what does a face presentation mean

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

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Last Update: January 9, 2023 .

• Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the interprofessional team's role in safely managing delivery for both the mother and the baby.

• Identify the mechanism of labor in the face and brow presentation.
• Differentiate potential maternal and fetal complications during the face and brow presentations.
• Evaluate different management approaches for the face and brow presentation.
• Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference. Face presentation is an abnormal form of cephalic presentation where the presenting part is the mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]  In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation, with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, and black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, and polyhydramnios. [2] [4] [5]  These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. Palpating orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation is possible. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, the anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse. Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6]  Ultrasound imaging can show a reduced angle between the occiput and the spine or the chin is separated from the chest. However, ultrasound does not provide much predictive value for the outcome of labor. [7]

• Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements. 

Planes and Diameters of the Pelvis

The 3 most important planes in the female pelvis are the pelvic inlet, mid-pelvis, and pelvic outlet. Four diameters can describe the pelvic inlet: anteroposterior, transverse, and 2 obliques. Furthermore, based on the landmarks on the pelvic inlet, there are 3 different anteroposterior diameters named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these 3 diameters is obstetrical conjugate, which measures approximately 10.5 cm and is the distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5 cm and is the widest distance between the innominate line on both sides. The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. 

Fetal Skull Diameters

There are 6 distinguished longitudinal fetal skull diameters:

• Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the diameter presented in the vertex presentation. 
• Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm 
• Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5 cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the diameter in the face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5 cm 
• Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation. 

Cardinal Movements of Normal Labor

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (restitution)
• Expulsion (delivery of anterior and posterior shoulders)

Some key movements are impossible in the face or brow presentations. Based on the information provided above, it is obvious that labor be arrested in brow presentation unless it spontaneously changes to the face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery are explained in later sections.

• Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

• Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore, the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations. Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous. Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8]  External transducer devices are advised to prevent damage to the eyes. When internal monitoring is inevitable, monitoring devices on bony parts should be placed carefully. 

Consultations that are typically requested for patients with delivery of face/brow presentation include the following:

• Experienced midwife, preferably looking after laboring women 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (eg, epidural)
• Theatre team  - in case of failure to progress, an emergency cesarean section is required.
• Preparation

No specific preparation is required for face or brow presentation. However, discussing the labor options with the mother and birthing partner and informing members of the neonatal, anesthetic, and theatre co-ordinating teams is essential.

• Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and the pressure of the amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery. If the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

The pubis is described as mentum-anterior when the fetal chin is rotated towards the maternal symphysis. In these cases, further descent through the vaginal canal continues, with approximately 73% of cases delivering spontaneously. [9]  The fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot occur. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

• Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]  However, some complications are still associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor. Prolonged labor itself can provoke fetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications. Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

• Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5 cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head engages later, and labor progresses more slowly. Failure to progress in labor is also more common in both presentations compared to the vertex presentation. Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descending through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section. Manual attempts to change face presentation to vertex or manual or forceps rotation to mentum anterior are considered dangerous and discouraged.

• Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Face Presentation Birth: Is it Dangerous?

• Birth Injuries

The first thing everyone wants to see after a birth is a baby’s adorable face. But that’s not the first thing doctors should see when the child makes an entrance into the world. Arriving “face first” is called “face presentation birth”, and it can be dangerous. 

In this article, we’ll discuss the “baby born face up” complications and more:

• What is face presentation birth?
• Is face presentation birth dangerous?
• What are some complications from a face presentation birth?
• What can you do if your doctor mismanages your face presentation birth and injures the child?
• When can you take legal action , and how?

What is a Face Presentation Birth?

When we talk about “presentation”, we’re talking about how the baby positions itself in the womb as labor approaches. The part that faces downward will come through the birth canal first, whether it’s the head, the foot, or something else.  

The most common and favorable presentation for vaginal birth is the vertex presentation. It’s also known as the “head-down” position. 

But several other presentations can occur, including:

• Breech. The baby’s buttocks or feet are positioned to come out first
• Transverse . The baby lies horizontally across the uterus, with its shoulder or back presenting at the cervix .
• Compound. The baby’s hand, arm, or another body part alongside the head presents at the cervix alongside the head. 
• Shoulder . The baby is sideways in the uterus. One shoulder presents at the cervix.
• Face . The baby’s face is positioned to come out first.

Many of these presentations may require medical intervention or cesarean section delivery. Some can be dangerous for both mother and child–and the face-down position is one of them.

Is Face Presentation Birth Dangerous?

Yes, attempting a face presentation birth can be dangerous. Why? First of all, it means the baby’s head is pulled backward as it descends through the birth canal. You can imagine how uncomfortable this would be. In normal circumstances, a baby’s chin would point down at the chest.

But this position isn’t just uncomfortable for an infant. It’s risky, because the baby may get stuck while descending. It may also spell severe discomfort for the mother, who must endure long, difficult labor. 

A face presentation birth can result in a host of birth injuries, such as:

• Asphyxia (oxygen deprivation)
• Trauma to the face and head
• Spinal cord injuries
• Fetal heart rate issues
• Cerebral palsy and other brain injuries
• Breathing problems (due to tracheal and laryngeal injuries)
• Fetal distress
• Facial bruising or swelling
• Facial nerve injury
• Soft tissue injuries
• Prolonged labor
• Maternal injuries

Face Presentation Causes & Risk Factors

These conditions may increase the likelihood of a face presentation birth:

• A Very Big Baby (Fetal Macrosomia): Larger babies may have trouble fitting into the birth canal in the standard position, leading to alternative presentations.
• Prematurity: Premature infants are more likely to have non-standard presentations, including face presentation, because of their small size and muscle tone.
• A Very Low Birth Weight (VLBW ) : Similar to prematurity, lower birth weight can affect fetal position and presentation.
• Maternal Obesity: Obesity can be associated with a variety of complications in pregnancy and childbirth, including potentially affecting fetal position.
• Excessive Fetal Mobility: Sometimes, an unusually mobile fetus can adopt a face presentation position.
• Anencephaly: This severe birth defect can alter the usual mechanics of labor and fetal positioning.
• Anterior Neck Mass: This could cause the fetus to extend its neck, leading to a face presentation.
• Mother Has Given Birth Multiple Times (Multiparity ) : In multiparous women, the uterine and pelvic muscles may be more relaxed, leading to a higher likelihood of non-standard presentations.
• Excessive Amniotic Fluid (Polyhydramnios): Too much amniotic fluid can allow the baby more room to move, potentially leading to unusual positions.
• Maternal Pelvis Abnormalities: Irregularities in the size or shape of the maternal pelvis can affect how the baby positions itself for birth.
• Multiple Nuchal Cords: While not a necessarily direct cause, multiple loops of the umbilical cord around the baby’s neck can contribute to abnormal presentations.
• CPD ( Cephalopelvic Disproportion): When the baby’s head is too large or the mother’s pelvis is too small for vaginal birth in the typical head-first position, it can lead to a face presentation position.

These are some of the conditions that can increase a mother’s chances of having a face presentation birth.

Diagnosing and Treating Face Presentation

When a woman goes into labor, doctors perform a vaginal examination to find out what position the baby is in. If they suspect it’s not head down, they should conduct an ultrasound. 

The ultrasound makes confirming an abnormal presentation easy. It lets the medical team see exactly how the baby is lying in the womb. Isn’t modern medicine wonderful?

There’s just one problem: doctors can and do make mistakes. They can mismanage a face presentation birth and cause severe injuries. 

For example, let’s say a physician conducts a physical examination only. They could confuse face presentation with breech. If they don’t go a step further and confirm with an ultrasound, they might make the wrong decision about how to proceed. 

In most cases, a face presentation birth shouldn’t be attempted vaginally. A C-section is the safer alternative. But this depends on several factors, such as the type of face presentation. That’s what we’ll look at next. 

Types of Face Presentation

Face and brow presentations are types of malpositions where the baby is positioned abnormally. In a face presentation, the baby’s face is the first part to appear, while in a brow presentation, the area between the baby’s forehead and the top of the skull is the leading part.

These are the three main types of face presentation:

• Mentum Anterior (Chin First) Presentation. The baby’s chin leads the way through the birth canal. The forehead is closest to the mother’s spine.
• Mentum Posterior (Forehead First) Presentation. The baby’s forehead is positioned to come out first, with the chin closest to the mother’s spine.
• Mentum Transverse (Face in Transverse Position) Presentation. The baby’s face turns sideways in the birth canal. In other words, the baby lies with the face parallel to the mother’s pelvis, rather than being aligned with the head-down or head-up positions.

A baby can be injured in any of these types of face and brow presentation, and sometimes it’s due to negligence.

Legal Help for Mismanaged Face Presentation Birth

Standard protocol for face presentation birth prohibits doctors from doing these things (in most cases):

• Aggressive pushing or pulling maneuvers during delivery
• Attempt to rotate the baby with their hands 
• Try to pull the baby out with their hands
• Excessive manipulation of the baby’s head
• Use forceps or a vacuum to pull the baby out. 
• Ignoring signs of fetal distress
• Ignoring maternal discomfort or distress
• Rushed delivery

These actions heighten the risk of causing irreversible trauma. If a doctor decides to act against protocol and causes an injury, it constitutes negligence. Patients may be able to sue for the cost of treatment for the injury. 

Of course, suing a doctor or hospital (and subsequently their insurance company) is easier said than done. Birth injury lawsuits are some of the most complex cases that exist. That’s why you need to seek legal help from a birth injury law firm. (Not a law firm that sometimes takes on birth injury cases.) To discuss a potential case with our knowledgeable, compassionate lawyers, schedule a free consultation here .  

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Face Presentation and Birth Injury

Normally, babies are born head-first with their chin tucked towards their chest (vertex presentation). In a face presentation birth, the baby’s chin is not tucked and their neck is hyperextended. Unfortunately, this can impede the movement of their head and complicate their birth and engagement (when the largest part of the baby’s head or buttocks enters the mother’s pelvis). In some cases, a baby in face presentation can be delivered vaginally, but in most  cases, vaginal delivery is difficult and can injure the baby. 

In this piece, the birth injury team at ABC Law Centers will discuss risks, diagnosis, management, and legal help for children with complications from a face presentation birth. 

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Types of Face Presentation Birth

There are three types of face presentation that can occur at birth:

• Mentum anterior position (MA): The baby’s chin faces the mother’s front side, and will be the presenting part of the face. Babies in mentum anterior position are usually delivered vaginally, although in some cases a C-section may be necessary. 
• Mentum posterior position (MP): The baby’s chin is facing the mother’s back. The baby’s head, neck, and shoulders enter its mother’s pelvis at the same time, and the pelvis is usually not large enough to accommodate this. The baby might spontaneously rotate into mentum anterior position, discussed above. 
• Typically, a C-section is indicated, but there are certain circumstances under which vaginal delivery may be attempted . Regardless, the medical team should be prepared to perform a prompt C-section if there are any complications.
• Mentum transverse position (MT): The baby’s chin is facing the side of the birth canal. Doctors may recommend a trial of labor under certain circumstances, but they should promptly proceed to a C-section if there are issues. 

During any type of face presentation birth, if labor is progressing normally and the baby is not in distress, physician intervention may not be necessary since many MP and MT positions convert to MA.  

However, if progress in dilation and the baby’s descent slows or stops despite adequate contractions, or the baby is in fetal distress, doctors and the hospital  must perform an emergency C-section .

Risk Factors and Causes of Face Presentation Birth

Conditions that may increase the likelihood of a face presentation birth include the following:

• Prematurity
• Babies with a very low birth weight
• Fetal macrosomia (a baby that is larger than average)
• Cephalopelvic disproportion, or CPD (a mismatch in size between the mother’s pelvis and the baby’s head)
• Severe hydrocephalus that causes enlargement of the baby’s head
• Anterior neck mass
• Multiple nuchal cords (umbilical cord wrapped around baby’s neck more than once)
• Maternal pelvis abnormalities
• Maternal obesity
• Multiparity (the mother has previously given birth)
• Polyhydramnios (too much amniotic fluid)
• Previous cesarean delivery

In one study of women who were given a diagnosis of face presentation during birth, r esearchers found that the babies with a face presentation were more likely preterm and Black/African American . As of 2022, the rate of preterm births was recorded highest for Black/African American infants .

If any of the above-mentioned factors are present, it’s important for physicians to appropriately monitor and assess the patient’s pregnancy and labor to ensure that it is progressing well and that no complications arise. Additionally, they must discuss risk factors with their patients.

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Diagnosing Face Presentation

Face presentation is diagnosed late in the first or second stage of labor by vaginal examination. The distinctive facial features of the baby’s chin, mouth, nose, and cheekbones can be felt. Face presentation is sometimes confused with breech presentation , in which the baby’s feet come out first (both presentations are characterized by soft tissues with an orifice). That is why it’s important that a very skilled physician is present during any potentially risky delivery with abnormal fetal position or presentation . Diagnosis can be confirmed by an ultrasound , which reveals a deflexed/hyperextended neck.

Managing Face Presentation Delivery

Face presentation and birth trauma.

There is an increased risk of trauma to the baby when the face presents first. Therefore, the doctor should not internally manipulate (try to rotate) the baby. In addition, the physician must not use vacuum extraction or manual extraction (grasping the baby with hands) to pull the baby from the mother’s uterus. Midforceps ( forcep extraction when the baby’s station is above +2 cm, but the head is engaged) should never be used. Outlet forceps should only be used by experienced physicians who understand the circumstances under which this is appropriate.

Face presentation and abnormal fetal heart rate

Abnormalities of the fetal heart rate and fetal distress occur more frequently with face presentation. In one study , 59% of infants in face presentation had variable heart decelerations, and 24% had late decelerations. Of the babies who were born live, 37% had 1-minute Apgar scores lower than 7, and 13% had 5-minute Apgar scores lower than 7. The majority of the low 5-minute Apgar scores were babies that had been in mentum posterior position .

For these reasons, it is crucial that babies are continuously monitored during labor, ideally with an external heart monitoring device.  An internal device may cause facial or eye injuries if improperly placed. If internal monitoring is needed, the electrode should be cautiously placed over a bony structure such as the forehead, jaw or cheekbone to minimize the risk of trauma.

Informed consent and delivery options

It is always critical that doctors obtain a mother’s informed consent , which means discussing delivery options (vaginal, C-section, enhanced with labor drugs, etc.) with her and explaining the potential risks and benefits of each. This means that when a mother has a baby with face presentation, she must be given the option of a C-section versus a vaginal birth. One of the reasons a mother may opt for a C-section is to avoid the extensive facial bruising/trauma that is common in babies with face presentation. In addition to thoroughly explaining the risks and benefits of each type of delivery method, the physician must explain and obtain consent from the mother if forceps or oxytocin are used.

Oxytocin (Pitocin) is a labor drug that may be used in a face presentation with a normal fetus and abnormally slow progress, as long as the baby’s heart rate patterns remain reassuring. It’s important to note that there are certain risks associated with this drug, including uterine hyperstimulation . Hyperstimulation happens when contractions are too frequent or strong, which can injure the baby. Hyperstimulation also increases pressure on the blood vessels in the womb, which can deprive the baby of oxygen-rich blood.

Doctors must explain these risks and obtain consent before proceeding. However, in any face presentation, if progress in dilation and the baby’s descent stops despite adequate contractions, doctors must perform an emergency C-section. Failing to deliver in time puts the baby at risk of not getting enough oxygen. If the baby doesn’t get enough oxygen, it is at high risk of suffering a brain injury.

Face presentation and birth injury

It can be frightening to learn that your baby is not in the correct or ideal position for birth. However, your doctors should always communicate changes, risks, and delivery plans with you. If at any point, your doctor fails to communicate with you or monitor you properly and it causes your child to suffer a brain injury, that is considered medical malpractice or negligence. If you believe that your child suffered an injury at birth that could have been prevented, our birth injury lawyers can help. 

Complications and Side Effects of Face Presentation

Complications associated with face presentation include the following:

• Prolonged labor
• Facial trauma
• Facial edema (fluid build up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress/difficulty in ventilation due to airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• Low Apgar score

A baby may be at increased risk of complications if forceps or oxytocin are used during labor. Forceps can cause traumatic injury to the head, and oxytocin can deprive a baby of oxygen due to hyperstimulation (strong, frequent contractions). Trauma to the head and decreased oxygenation can cause permanent brain damage, such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy (CP) , as well as fetal deaths. Fortunately, a child with HIE or cerebral palsy can survive, but depending on the severity of their injury, they may have severe disability and need 24/7 care. 

Did your child have a traumatic birth?

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Face Presentation and Medical Malpractice

Because there are many complications associated with face presentation, it is essential that the baby is closely monitored and that delivery is handled by a physician with experience in this area. Furthermore, the physician must quickly proceed to a C-section delivery if there are any signs that the baby is in distress , labor is not progressing, or the baby fails to rotate to MA position. In addition, once a face presentation is diagnosed, the physician must check for “pelvic adequacy”. When the pelvis is inadequate (contracted/small), a C-section is recommended .

Since respiratory problems can occur in babies with face presentation, equipment and staff to perform intubation of the baby (placement of a breathing tube) should be readily available at the time of delivery.

Failure to follow any of these standards of care is negligence. If this negligence results in injury to the baby, it is medical malpractice . To learn more about bringing a medical malpractice claim for your child’s birth injury, complete the form below.

ABC Law Centers: Trusted Birth Injury Attorneys

If your baby has HIE, cerebral palsy, developmental delays , a seizure disorder , or any other birth injury , we may be able to help. Unlike other firms, the attorneys at ABC Law Centers (Reiter & Walsh, P.C.) focus only on birth injury cases and have been helping injured children throughout the nation since 1997. During your free legal consultation, our attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you. Moreover, you pay nothing throughout the entire legal process unless we win or favorably settle your case.

“Reiter and Walsh goes above and beyond the norm in getting their clients the best possible results. Each client is treated with respect and compassion, and they are truly sensitive to what it means to help a family whose child has been injured.” -Client review from 11/23/2015

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Helpful resources

• Face and brow presentations in labor – UpToDate  
• Diagnosis and management of face presentation -Obstetrics and gynecology
• A population study of face and brow presentation – Journal of Obstetrics and Gynecology
• Face presentation: predictors and delivery route – American journal of obstetrics and gynecology
• Face presentation at term

The above information is intended to be an educational resource. It is not meant to be, and should not be interpreted as, medical advice.

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• Face Presentation

Face it. We have a lot to learn about fetal positioning. The old paradigm is fetal positions are random. The new paradigm is that babies match the space available.

Face and brow presentations occur when baby’s spine extended until the head is shifted back so baby’s face comes through the pelvis first.

Baby may settle in a face or brow presentation before labor or they may become a face or brow presentation, usually when a posterior baby has it’s chin pushed further up by the pelvic floor during descent.

A baby who is in a face-first or forehead-first position often started as an extended (chin up)   occiput posterior   or   occiput transverse   position. Coming down on to the pelvic floor with the forehead leading then “converted” this baby’s head to the face first position.

The baby’s face may be bruised for a couple days after the birth. The brow presentation may cause a redness but only occasionally will cause a bruise.

Mobility of the pelvis and the freedom of maternal movements often help bring the face-first baby down through the pelvis with good strong, uterine surges.

But not always. Sometimes the labor can’t move baby down.   Cesareans   are more common, but a portion of the higher surgical rate is because time is not given to the mother to begin or continue labor, or to be out of bed for this labor. Monitoring becomes important. Expect a bit of an unusual heart rate to contraction pattern seen in these labors.

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What makes labor easier for a face-first baby and you?

Balance the body and the baby will thank you by curling into position to aim, not their face, but the crown of their head. 

Flexion is physiological. So support physiology and the baby will change their position. We may need a little physics.

In Labor with a Face or Brow Presentation

Back baby up!

Forward-leaning Inversion with a jiggle of the buttocks right through 1-2 contractions often backs baby up so they can tuck their chin. Then they can aim into the pelvis with an easier position.

A little effort can make labor a lot easier!

Only after baby’s crown is first, then do Side-lying Release in labor.

Before Labor with a face or brow presentation

Face presentation may reflect a psoas/pelvic floor imbalance with a collapse in the front body.

Free the piriformis, strengthen the buttocks, lengthen the hamstrings, squat for lengthening the pelvic floor, don’t worry about strengthening the pelvic floor right now. Alignment, walking, stabilizing and lengthening will tone the pelvic floor. Use it by breathing with your whole body.

Before labor, it’s safe to do Side-lying Release when baby’s face-first head isn’t in the pelvis yet.

Free the way

The psoas is the upper guide, the pelvic floor is the lower guide. release spasms and lengthen both.

Make room for the baby by releasing muscles that spasm, lengthen ligaments that are shortened, and support the abdominal muscles by attending to the muscles that interact with them, don’t go directly to the front first.

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• 2022 New Pearls of Exxcellence Articles

Management of Brow, Face, and Compound Malpresentations

Author: Meera Kesavan, MD

Mentor: Lisa Keder MD Editor: Daniel JS Martingano DO MBA PhD

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Fetal malpresentation, including brow, face, or compound presentations, complicates around 3-4% of all term births. Because these abnormal fetal presentations still are cephalic, many such cases result in vaginal deliveries, yet there are increased risks for adverse outcomes, including cesarean delivery resultant surgical complications, persistent malpresentation precluding vaginal delivery, and abnormal labor resulting in arrest of dilation or descent.

These fetal malpresentation are differentiated in the following ways:

• In face presentations, the presenting part is the mentum, which is further divided based on its position, including mentum posterior, mentum transverse or mentum anterior positions. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Mentum anterior malpresentations can potentially achieve vaginal deliveries, whereas mentum posterior malpresentations cannot.
• In brow presentations, there is less extension of the fetal neck as in face presentations making the leading fetal part being the area between the anterior fontanelle and the orbital ridges. These presentations are uncommon and are managed similarly to face presentations. Brow presentation can be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.
• Compound presentation is defined as the leading fetal part, including a fetal extremity, alongside a cephalic or breech presentation. Management of compound presentations is expected (and often incidentally noted following delivery) because the extremity will often either retract as the head descends or will feasibly allow for delivery in its current position, with manipulation attempts to reduce the compound presentation usually avoided.

Risk factors for brow and face presentations include fetal CNS malformations, congenital or chromosomal anomalies, advanced maternal age, low birthweight, abnormal maternal pelvic anatomy (e.g. contracted pelvis, cephalopelvic disporotion, platypelloid pelvis, etc.) and nulliparity. non-Hispanic White women have the highest risk for malpresentation, whereas non-Hispanic Black women have the lowest risk.

Diagnosis usually is made during the second stage of labor while performing routine vaingla examinations and involves palpation of the abnormal leading fetal part (forehead, orbital ridge, orbits, nose, etc.) Obstetric ultrasound can additionally provide complimentary information to support these diagnoses and distinguish from other fetal malpresentations or malpositions. In face presentation, the mentum (chin) and mouth are palpable.

Management considerations for face, brow, and compounds presentations are unique with compound presentations having higher rates of vaginal delivery and lower complications as compared to either brow or face presentations.

• For brow presentations, approximately 30-40% of brow presentations will convert to a face presentation, and about 20% will convert to a vertex presentation. Anterior positions have the possibility of vaginal deliveries and can be managed by usual labor management principles, whereas mentum posterior positions are indications for cesarean delivery.
• For face presentations, the likelihood of vaginal delivery depends on the orientation of the mentum, with mentum anterior being most suitable for vaginal delivery. If the fetus is mentum posterior, flexion of the neck is precluded and results in the inability of fetal descent.
• For compound presentations, management is expectant and manipulation of the leading extremities should be avoided. Most cases of compound presentation result in vaginal deliveries. For term deliveries, compound presentations with parts other than the hand are unlikely to result in safe vaginal delivery.

Labor management for brow and face presentation overall involves continuous fetal heart rate monitoring and repeat clinical assessments, given the increased potential of fetal complications as noted. Caution should be used with internal monitoring devices, which can cause ophthalmic injury or trauma to the presenting fetal parts, with the use of fetal scalp electrodes discouraged and intrauterine pressure catheters acceptable with appropriate clinical judgment and feasibility.

Midforceps, breech extraction, and manual manipulation are not recommended and increase the risk of maternal and neonatal morbidity. 

Neonatal outcomes for both face and brow presentations include facial edema, bruising, and soft tissue trauma. Complications of compound presentation specifically include umbilical cord prolapse and injury to the presenting limb. With appropriate management, neonatal and maternal morbidity for face, brow, and compound presentations are low.

Further Reading:

Bar-El L, Eliner Y, Grunebaum A, Lenchner E, et al. Race and ethnicity are among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol MFM. 2021 Sep;3(5):100405. doi: 10.1016/j.ajogmf.2021.100405. Epub 2021 Jun 4. PMID: 34091061.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol. 2017 Dec;217(6):633-641. doi: 10.1016/j.ajog.2017.07.025. Epub 2017 Jul 22. PMID: 28743440 . 

Pilliod RA, Caughey AB. Fetal Malpresentation and Malposition: Diagnosis and Management. Obstet Gynecol Clin North Am. 2017 Dec;44(4):631-643. doi: 10.1016/j.ogc.2017.08.003. PMID: 29078945 .

Zayed F, Amarin Z, Obeidat B, et al. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. PMID: 18283473 . 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018; Reaffirmed January 2020; Revised September 2021. Revised July 2023.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Medical Information

Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

• Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
• Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
• Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

• Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
• Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
• Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
• Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

• Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
• Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
• Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
• Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

• Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
• Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Delivery, Face and Brow Presentation

Introduction.

The term "presentation" refers to the part of the fetus or the fetal anatomical structure closest to the maternal pelvic inlet during labor. Presentations can be categorized into 4 primary classifications: cephalic, breech, shoulder, and compound. Of these, cephalic presentation is the most common and can be further subclassified into vertex, sinciput, brow, face, and chin.

The vertex presentation, where the fetal neck is flexed to the chin, minimizing the head's circumference, is the most common presentation in term labor. Face presentation is an abnormal cephalic presentation where the mentum (chin) is the presenting part. This presentation typically occurs due to hyperextension of the fetal neck, with the occiput (back of the head) touching the fetal back. The incidence of a face malpresentation is rare, occurring in approximately 1 in 600 of all presentations. [1] [2] [3]

Brow presentation occurs when the neck is less extended than in face presentation, with the presenting fetal part being the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest form of malpresentation, with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations result from extension of the fetal neck instead of flexion. Conditions that lead to hyperextension or prevent neck flexion can contribute to these presentations. Maternal risk factors include preterm delivery, a contracted maternal pelvis, a platypelloid pelvis, multiparity, or a history of previous cesarean delivery. Black pregnant patients have a higher incidence of face and brow presentation than other ethnic groups. Fetal risk factors for face or brow presentation include anencephaly, multiple loops of the umbilical cord around the neck, neck masses, macrosomia, and polyhydramnios. [2] [4] [5]  

These malpresentations are typically diagnosed during the second stage of labor via a digital examination. During the examination, it is possible to palpate the orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in cases of face presentation. Based on the chin's position, face presentation can be categorized as mentum anterior, posterior, or transverse. In brow presentation, the anterior fontanelle and face can be felt, but not the mouth and chin. Brow presentation can also be described based on the anterior fontanelle's position as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may sometimes be misidentified as frank breech. Bedside ultrasonography can be performed to confirm which malpresentation is present. [6] Ultrasonography can reveal a reduced angle between the occiput and the spine or show that the chin is separated from the chest. However, ultrasonography does not provide significant predictive value regarding the outcome of labor. [7]

Anatomy and Physiology

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Understanding some anatomical landmarks and their measurements is crucial before discussing the mechanism of labor in the face or brow presentation. 

Planes and Diameters of the Pelvis

The 3 most important planes in the female pelvis are the pelvic inlet, mid-pelvis, and pelvic outlet. Four diameters can describe the pelvic inlet: anteroposterior, transverse, and 2 obliques. Furthermore, based on the landmarks on the pelvic inlet, 3 different anteroposterior diameters named conjugates exist: the true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these 3 diameters is obstetrical conjugate, which measures approximately 10.5 cm and is the distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5 cm and is the widest distance between the innominate line on both sides. The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm. [8]  

Fetal Skull Diameters

The following are the 6 distinguished longitudinal fetal skull diameters:

• Suboccipitobregmatic : This fetal skull diameter is measured from the center of the anterior fontanelle (bregma) to the occipital protuberance, typically equaling 9.5 cm. This is the diameter presented in the vertex presentation. 
• Suboccipitofrontal : This fetal skull diameter is 10 cm, extending from the anterior part of the bregma to the occipital protuberance.
• Occipitofrontal : The occipitofrontal diameter extends from the root of the nose to the most prominent part of the occiput, measuring 11.5 cm
• Submentobregmatic : This diameter, present in the face presentation where the neck is hyperextended, extends from the center of the bregma to the angle of the mandible, measuring 9.5 cm.
• Submentovertical : This diameter, measuring 11.5 cm, extends from the midpoint between the fontanelles and the angle of the mandible.
• Occipitomental : The occipitomental diameter is the presenting diameter in brow presentation and extends from the midpoint between the fontanelles and the tip of the chin, measuring 13.5 cm. [9]

Cardinal Movements of Normal Labor

Anglo-American literature lists 7 cardinal movements: engagement, descent, flexion, internal rotation, extension, external rotation, and expulsion. German and older English literature lists only 4 rotational movements as the cardinal movements and excludes engagement, descent, and expulsion. Therefore, to define either 4 or 7 is acceptable, with the emphasis on the successful attainment of fetal descent being the primary purpose of these movements, including:

• Neck flexion
• Internal rotation
• Extension (delivers head)
• External rotation (restitution)
• Expulsion (delivery of anterior and posterior shoulders)  [10]

Some key movements are impossible in the face or brow presentations. [10] [11]  Based on the information provided above, it is obvious that labor be arrested in brow presentation unless it spontaneously changes to the face or vertex, as the occipitomental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery are explained in later cesarean deliveries.

Indications

As mentioned previously, a spontaneous vaginal delivery can be achieved in face presentation. However, the primary indication for vaginal delivery in such circumstances is maternal preference. Therefore, a thorough conversation with the patient, comparing the risks and benefits of vaginal and cesarean delivery with face presentation, is essential. Clinicians should have supportive and detailed discussions with patients and their family members to obtain informed consent and achieve a safe and successful labor experience.

Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal.

Therefore, cesarean delivery is recommended as the safest mode of delivery for mentum posterior face presentations. Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous. Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [12]  External transducer devices are advised to prevent damage to the fetal eyes. When internal fetal monitoring is inevitable, monitoring devices on bony parts should be placed carefully. 

Consultations that are typically requested for patients with delivery of face or brow presentation include the following:

• Maternal team : The obstetrical team may include experienced midwives, obstetricians, and labor nurses to care for laboring women.
• Neonatal team : These clinicians are focused on attending to neonatal needs following delivery (eg, resuscitation).
• Anesthesiology team : Anesthesiology clinicians are typically necessary to provide pain control (eg, epidural).
• Operating room team : In case of failure to progress, an emergency cesarean delivery is required.

Preparation

No specific preparation is required for face or brow presentation. However, discussing the labor options with the mother and birthing partner before delivery and obtaining consent for the chosen procedure is essential. Additionally, obstetric clinicians should inform and help coordinate neonatal, anesthesiology, and operating room team members.

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and the pressure of the amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery. If the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean delivery is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous patients with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, clinicians should have a low threshold to proceed to cesarean delivery in primigravida patients or those with large fetuses.

The fetus is described as mentum-anterior when the fetal chin is rotated towards the maternal symphysis. In these cases, further descent through the vaginal canal continues, with approximately 73% of cases delivering spontaneously. [13]  The fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation occurs. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

This presentation is considered unstable, as brow presentation is usually spontaneously converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot occur. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean delivery is required for safe delivery.

Complications

As cesarean delivery is becoming a more accessible mode of delivery in malpresentation, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [14]  However, some complications are still associated with the nature of labor in face presentation. Due to the fetal head position, engagement and descent of the head in the birth canal is more difficult, resulting in prolonged labor.

Prolonged labor itself can provoke fetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on cardiotocography, the recommended next step in management is an emergency cesarean delivery, which in itself carries a myriad of operative and postoperative complications. Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation. In general, cesarean delivery rates and neonatal intensive care unit admission rates are higher in face and brow presentations compared to cephalic presentation. Additionally, neonatal composite score is also increased in face presentation. [15]

Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, approximately 9.5 cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head engages later, and labor progresses more slowly. Failure to progress in labor is also more common in both presentations compared to the vertex presentation.

Furthermore, when the fetal chin is in a posterior position, further flexion of the fetal neck is prevented, as the fetal brows are pressing on the symphysis pubis. As a result, descending through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean delivery. Manual attempts to change face presentation to vertex or manual or forceps rotation to mentum anterior are considered dangerous and discouraged. [16]

Enhancing Healthcare Team Outcomes

In managing face and brow presentations, an interprofessional team approach is critical for ensuring patient-centered care, safety, and optimal outcomes. Experienced midwives and obstetricians play essential roles in early diagnosis and monitoring, performing detailed vaginal examinations, and assessing fetal positioning to anticipate complications. Sonographers skilled in antenatal scanning contribute valuable expertise, particularly when fetal anomalies like anencephaly or goiter may be factors.

Early involvement of anesthesiologists and neonatal teams is advised, as emergency cesarean delivery and immediate neonatal resuscitation may be necessary. Effective communication and coordinated care among these specialists support timely interventions, minimize risks, and enhance overall team performance in managing complex labor scenarios. By fostering a culture of collaboration, empathy, and shared responsibility, the healthcare team can optimize outcomes, support patient satisfaction, and uphold the standards of patient-centered care.

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