Browse the corpus

Presentation in labor refers to the fetal part closest to the maternal pelvic inlet. Presentations are classified as cephalic, breech, shoulder, and compound, with cephalic being the most common. In cephalic presentations, the fetal head is the presenting part, further categorized into vertex, brow, face, and chin presentations. Face presentation is an abnormal form of cephalic presentation caused by hyperextension of the fetal neck. Therefore, the mentum (chin) leads. This rare presentation occurs in about 1 in 600 deliveries. Face presentation requires careful assessment of the chin position when diagnosed through digital examination. Mentum-anterior orientation may allow for vaginal delivery, but mentum-posterior often necessitates a cesarean section due to obstructed descent through the birth canal. Brow presentation, the rarest presentation (1 in 500 to 1 in 4000 deliveries), occurs when the fetal neck is extended less than in face presentation, and the brow leads. Persistent brow presentation generally requires a cesarean section, as the larger cephalic diameter prevents engagement in the pelvis for vaginal delivery. Both presentations are often diagnosed in the second stage of labor via physical examination or confirmed with ultrasonography. Cesarean delivery rates are higher for face and brow presentations, as they can cause prolonged labor, fetal distress, and complications, including significant neonatal swelling. This activity for healthcare professionals is designed to enhance the learner's competence in recognizing face and brow presentations, performing the recommended management and delivery techniques, and implementing an appropriate interprofessional management approach to improve patient outcomes. Objectives: Identify the mechanism of labor in the face and brow presentation. Assess potential complications during the face and brow presentations. Evaluate different management approaches for the face and brow presentations. Apply interprofessional team strategies to improve care coordination and outcomes in patients with face and brow presentations. Access free multiple choice questions on this topic.

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]

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]

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]

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.