what does a face presentation mean

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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

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Krish Tangella MD, MBA

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Alexandra Warren

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INTRODUCTION

Diagnosis and management of face and brow presentations will be reviewed here. Other cephalic malpresentations are discussed separately. (See "Occiput posterior position" and "Occiput transverse position" .)

Prevalence  —  Face and brow presentation are uncommon. Their prevalences compared with other types of malpresentations are shown below [ 1-9 ]:

● Occiput posterior – 1/19 deliveries

● Breech – 1/33 deliveries

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Face presentation

Latest Posts , Labour & Delivery

She still had intact membranes. The midwife asked me to come as she was starting to get pressure. She concluded the conversation by saying: “I think it is a face presentation”.

I attended at once. She had ruptured her membranes just prior to my arrival. I did an internal examination and sure enough, it was a face presentation with chin being anterior. Her cervix was now fully dilated.

She could feel pressure with contractions so I encouraged them to push. With pushing over two contractions she delivered her baby face first and chin up. With the next contraction, she delivered the rest of the baby. She had a boy weighing 3.8Kg and born in good condition. She had an intact perineum. No stitches were needed.

The incidence of face presentation is reported to be between 1 in 500 deliveries to 1 in 1400 deliveries. It happens when the baby’s head is very extended backwards. Fortunately, it was a mento-anterior face presentation as a mento-posterior face presentation usually needs a Caesarean section. Also, that it was her third vaginal delivery and that the patient could push so well meant it was a very straightforward but different delivery.

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Delivery, 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 – an abnormal form of cephalic presentation where the presenting part is 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, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, 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]  The 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 predicting value in the outcome of the labor. [7]

Anatomy and Physiology

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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 three 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 two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three 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 three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a 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 13.5cm 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 six 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 presenting diameter in 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 11.5cm
• Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended. 
• Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm 
• 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 of the key movements are not possible in the face or brow presentations.  

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to 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 will be 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] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully. 

People who are usually involved in the delivery of face/ brow presentation are:

• Experienced midwife, preferably looking after laboring woman 1:1
• Senior obstetrician 
• Neonatal team - in case of need for resuscitation 
• Anesthetic team - to provide necessary pain control (e.g., epidural)
• Theatre team  - in case of failure to progress and an emergency cesarean section will be required.

Preparation

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

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of 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.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] 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 take place. 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, there are still some complications 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 foetal 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 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to 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, descend 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, manual or forceps rotation to mentum anterior are considered dangerous and are 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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Labour and Delivery pp 99–105 Cite as

Face Presentation

• Shubhra Agarwal 2 &
• Suchitra Pandit 3  
• First Online: 02 August 2023

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Face presentation is defined as a cephalic presentation in which the presenting part is face and it occurs due to factors that lead to extension of of fetal head. It is a rare obstetric presentation and may not be encountered even in the entire carrier of an obstetrician.

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Shaffer BL. Face presentation: predictors and delivery route. Am J Obstet Gynecol. 2006;194:e10–2.

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Schwartz Z, Dgani R, Lancet M, Kessler I. Face presentation. Aust N Z J Obstet Gynaecol. 1986;26:172–6.

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Westgren M, et al. Face presentation in modern obstetrics-a study with special reference to fetal long term morbidity. Z Geburtshilfe Perinatol. 1984;188(2):87–9.

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Agarwal, S., Pandit, S. (2023). Face Presentation. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_6

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

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Diagnosis and management of face presentation

• PMID: 7005774

Face presentation is an unusual complication of pregnancy; it occurs once in every 500 to 600 deliveries. Prematurity, fetal macrosomia, anencephaly, and cephalopelvic disproportion (CPD) are the major obstetric factors that predispose the fetus to face presentation. Although the mechanisms of labor in face presentation are different from those of simple vertex presentation, there is no consistent alteration in the duration of labor in the absence of underlying CPD. When disproportion does not exist and gross anomalies are not present, the prognosis for spontaneous vaginal delivery is excellent. The majority of perinatal losses reported in face presentation have resulted from traumatic operative vaginal deliveries, specifically version and extraction and midforceps rotations. Recent experience at this institution with a limited series of face presentations demonstrates that, with careful intrapartum surveillance, delivery can be accomplished with no increase in risk to either mother or fetus.

Publication types

• Delivery, Obstetric
• Labor Presentation*
• Labor, Obstetric

• Face Presentation

Pictoral Midwifery, Comyns Berkely, 4th Edition. 1941

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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• Body Balancing

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.

Shake the Apples in Forward-leaning Inversion with hands

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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Face Presentation and Birth Injury

Normally, children are born head-first with the chin tucked towards the chest (vertex presentation). In a face presentation, the chin is not tucked and the neck is hyperextended. This can inhibit the engagement of the head and complicate the labor process. In some cases, a baby in face presentation can be delivered vaginally, but in other cases vaginal delivery is difficult and dangerous. Face presentation increases the risk of facial edema, skull molding, breathing problems (due to tracheal and laryngeal trauma), prolonged labor, fetal distress, spinal cord injuries, permanent brain damage, and neonatal death. Usually, medical staff conduct a vaginal examination to determine the position of the baby. If they suspect an abnormal presentation, they can confirm with an ultrasound and take action to properly handle the delivery of a baby in the face presentation. This includes additional monitoring and in some cases requires a C-Section. Because ventilation issues are more common in babies with face presentation, staff should be ready to intubate immediately after delivery (1).

Risk factors and causes of face presentation

Conditions that may increase the likelihood of a face presentation include the following (1, 2, 3, 4):

• Prematurity
• Very low birth weight
• Fetal macrosomia (large baby)
• Cephalopelvic disproportion, or CPD (a mismatch in size between the mother’s pelvis and the baby’s head)
• Anencephaly (a birth defect in which the baby is missing part of the brain and skull)
• Severe hydrocephalus with enlargement of the 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

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 chin, mouth, nose, and cheekbones can be felt.  Face presentation is sometimes confused with breech presentation (because both are characterized by soft tissues with an orifice), which is why it is imperative that a very skilled physician be present during any potentially risky delivery or malpresentation . Diagnosis can be confirmed by an ultrasound, which reveals a deflexed/hyperextended neck (1).

Face presentation and delivery

There are three types of face presentation:

• Mentum anterior (MA) . In this position, the chin is facing the front of the mother, 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 (MP) . In this position, the chin is facing the mother’s back.  The baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this (however, the baby may spontaneously rotate into mentum anterior position) . Typically, a C-section is indicated, but there are certain circumstances under which vaginal delivery may be attempted (e.g. the mother is multiparous, the infant in face presentation is relatively small compared to her other children, fetal monitoring is reassuring, and the baby is progressing in labor). Regardless, the medical team should be prepared to perform a prompt C-section if there are any complications.
• Mentum transverse (MT) .  In this position, 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. If labor is progressing and the fetal heart monitor is reassuring when face presentation is present, physician intervention may not be necessary since many MP and MT positions convert to MA.  Oxytocin (Pitocin) augmentation may be used in a face presentation with a normal fetus and abnormally slow progress, as long as fetal heart rate patterns remain reassuring (although there are certain risks associated with this drug, including uterine tachysystole ). Of course, in any face presentation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section.

There is an increased risk of trauma to the baby when the face presents first, and the physician should not internally manipulate (try to rotate) the baby.  In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to pull the baby from the uterine cavity.  Furthermore, 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 (1).

Abnormalities of the fetal heart rate 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 (5).

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 (1).

It is always critical that doctors obtain a mother’s informed consent , which means discussing delivery options (vaginal, C-section, enhanced with oxytocin, etc.) with her and explaining the potential risks and benefits of each.  Failure to do so constitutes negligence.

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 uterine tachysystole/hyperstimulation (strong, frequent contractions). Hyperstimulation increases pressure on the blood vessels in the womb, which can deprive the baby of oxygen-rich blood.

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.

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Standards of care, medical malpractice, and face presentation

Informed consent must be given during all medical procedures. 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.

Because there are many complications associated with face presentation, it is essential that the baby be 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 of fetal distress , labor is not progressing, or the baby fails to convert (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 (1).

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 .

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If your baby has HIE, cerebral palsy, periventricular leukomalacia (PVL), 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 solely on birth injury cases and have been helping 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.

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• Julien, S., Lockwood, C. J., & Barss, V. A. (2014). Face and brow presentations in labor. Up to date.
• Duff, P. (1981). Diagnosis and management of face presentation. Obstetrics and gynecology, 57(1), 105-112.
• S. BHAL NJ DAVIES T. CHUNG, P. (1998). A population study of face and brow presentation. Journal of Obstetrics and Gynaecology, 18(3), 231-235.
• Shaffer, B. L., Cheng, Y. W., Vargas, J. E., Laros Jr, R. K., & Caughey, A. B. (2006). Face presentation: predictors and delivery route. American journal of obstetrics and gynecology, 194(5), e10-e12.
• Benedetti, T. J., Lowensohn, R. I., & Truscott, A. M. (1980). Face presentation at term. Obstetrics and gynecology, 55(2), 199-202.

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 in delivery room: what is strategy?

Description.

A few hours after birth, a newborn was admitted to Santobono-Pausilipon III level Hospital. Suspected eye injury was reported. During childbirth, the baby showed a face presentation and to help with the delivery, a vacuum extractor (VE) method was used. Body weight of the baby at the time of birth was 3200 g, length 50 cm and head circumference 35 cm. Apgar scores were 7 I and 8 V . The newborn was subjected to examinations by an ophthalmologist and a neurologist and tested by a CT. The ophthalmological examination of the right eye revealed an extensive conjunctiva haemorrhage, dioptric media was transparent, anterior chamber was normal, optical disc had defined margins and retinal haemorrhages were absent. A neurological examination reported extensive haematoma of the right half-face and excoriations of the right eyelid ( figure 1 A, B). Bregmatic fontanelle was normotensive, archaic reflexes were present and symmetrical. CT scan results confirmed the absence of damage on the right eye or nerve. The infant's wound was treated with betamethasone–chloramphenicol ointment applied four times a day, mupirocin ointment three times a day for a total of 9 days with good results ( figure 2 A, B). Follow-up to 3 months showed complete recovery of the infant without sequelae ( figure 2 C). Childbirth with a face presentation ranges from 0.5 to 3 per 1000 deliveries; its cause and mechanism are not yet understood. 1  The use of VE presents higher rates for traumatic and non-traumatic intracranial haemorrhages compared with infants born by caesarean section (CS) or by a non-assisted vaginal delivery. 2 Therefore, the use of VE method has been proven high-risk procedure, CS choice should be considered. 3

(A, B) Lesions at the time of admission.

(A) The lesions after 6 days of therapy and (B) after 9 days of the therapy. (C) Follow-up at 3 months from discharge.

Learning points

• The use of vacuum extractor presents higher rates of complications compared with caesarean section (CS).
• CS should be considered in cases of face presentation.

Contributors: GDB made substantial contributions to the conception of the work and acquired data. MS analysed and interpreted data with GDB. GDB, MS and MG drafted the work. MG and DS revised it critically for important intellectual content.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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face presentation

Definition of face presentation

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“Face presentation.” Merriam-Webster.com Dictionary , Merriam-Webster, https://www.merriam-webster.com/dictionary/face%20presentation. Accessed 14 Apr. 2024.

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face presentation noun

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What does the noun face presentation mean?

There is one meaning in OED's entry for the noun face presentation . See ‘Meaning & use’ for definition, usage, and quotation evidence.

How common is the noun face presentation ?

Where does the noun face presentation come from.

Earliest known use

The earliest known use of the noun face presentation is in the late 1700s.

OED's earliest evidence for face presentation is from around 1781, in the writing of W. Perfect.

face presentation is formed within English, by compounding.

Etymons: face n. , presentation n. III.7a

Nearby entries

• facepalm, v. 1996–
• facepalm, int. & n. 1996–
• face physic, n. 1611–1715
• face piece, n. 1779–
• face plan, n. 1875–
• face plant, n. 1981–
• face-plant, v. 1986–
• faceplate, n. 1827–
• face-play, n. 1850–
• face-playing, n. 1773–
• face presentation, n. ?1781–
• face print, n. 1866–
• face-pulling, adj. & n. 1898–
• facer, n. c1500–
• face reading, n. 1926–
• face recognition, n. 1947–
• face-saver, n. 1910–
• face-saving, n. & adj. 1901–
• face screen, n. 1788–
• face-shaft, n. 1835–
• face shield, n. 1842–

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Meaning & use

Entry history for face presentation, n..

Originally published as part of the entry for face, n.

face, n. was revised in September 2009.

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Watch CBS News

What is Eid al-Fitr? 6 questions about the holiday and how Muslims celebrate it, answered

By Ken Chitwood

Updated on: April 9, 2024 / 8:03 AM EDT / The Conversation

Ken Chitwood  is a senior research fellow, Muslim Philanthropy Initiative at Indiana University–Purdue University Indianapolis and journalist-fellow at the Dornsife Center for Religion and Civic Culture at the  University of Southern California Dornsife College of Letters, Arts and Sciences .

Eid al-Fitr, one of Islam's principal festivals, will be celebrated April 9, 2024, according to the Fiqh Council of North America . At the middle of June, Muslims will celebrate Eid al-Adha. Ken Chitwood, a scholar of global Islam, explains the two Islamic festivals.

1. What is Eid?

Eid literally means a "festival" or "feast" in Arabic. There are two major eids in the Islamic calendar per year – Eid al-Fitr earlier in the year and Eid al-Adha later.

Eid al-Fitr is a three-day-long festival and is known as the "Lesser" or "Smaller Eid" when compared to Eid al-Adha, which is four days long and is known as the "Greater Eid."

2. Why is Eid celebrated twice a year?

The two Eids recognize, celebrate and recall two distinct events that are significant to the story of Islam.

Eid al-Fitr means "the feast of breaking the fast." The fast, in this instance, is Ramadan , which recalls the revealing of the Quran to Prophet Muhammad and requires Muslims to fast from sunrise to sundown for a month.

3. How do Muslims celebrate Eid al-Fitr?

Eid al-Fitr features two to three days of celebrations that include special morning prayers. People greet each other with "Eid Mubarak," meaning "Blessed Eid" and with formal embraces. Sweet dishes are prepared at home and gifts are given to children and to those in need. In addition, Muslims are encouraged to forgive and seek forgiveness. Practices vary from country to country.

In many countries with large Muslim populations, Eid al-Fitr is a national holiday. Schools, offices and businesses are closed so family, friends and neighbors can enjoy the celebrations together. In the U.S. and the U.K., Muslims may request to have the day off from school or work to travel or celebrate with family and friends.

In countries like Egypt and Pakistan, Muslims decorate their homes with lanterns, twinkling lights or flowers. Special food is prepared and friends and family are invited over to celebrate.

In places like Jordan, with its Muslim majority population, the days before Eid al-Fitr can see a rush at local malls and special "Ramadan markets" as people prepare to exchange gifts on Eid al-Fitr.

In Turkey and in places that were once part of the Ottoman-Turkish empire such as Bosnia and Herzegovina, Albania, Azerbaijan and the Caucasus, it is also known as the, "Lesser Bayram" or "festival" in Turkish.

4. How do Muslims celebrate Eid al-Adha?

The other festival, Eid al-Adha, is the "feast of the sacrifice." It comes at the end of the Hajj , an annual pilgrimage by millions of Muslims to the holy city of Mecca in Saudi Arabia that is obligatory once in a lifetime, but only for those with means.

Eid al-Adha recalls the story of how God commanded Ibrahim to sacrifice his son Ismail as a test of faith. The story, as narrated in the Quran, describes Satan's attempt to tempt Ibrahim so he would disobey God's command. Ibrahim, however, remains unmoved and informs Ismail, who is willing to be sacrificed.

But, just as Ibrahim attempts to kill his son, God intervenes and a ram is sacrificed in place of Ismail. During Eid al-Adha, Muslims slaughter an animal to remember Ibrahim's sacrifice and remind themselves of the need to submit to the will of God.

5. When are they celebrated?

Eid al-Fitr is celebrated on the first day of the 10th month in the Islamic calendar.

Eid al-Adha is celebrated on the 10th day of the final month in the Islamic calendar.

The Islamic calendar is a lunar calendar, and dates are calculated based on lunar phases. Since the Islamic calendar year is shorter than the solar Gregorian calendar year by 10 to 12 days, the dates for Ramadan and Eid on the Gregorian calendar can vary year by year.

6. What is the spiritual meaning of Eid al-Fitr?

Eid al-Fitr, as it follows the fasting of Ramadan, is also seen as a spiritual celebration of Allah's provision of strength and endurance.

Amid the reflection and rejoicing, Eid al-Fitr is a time for charity, known as Zakat al-Fitr. Eid is meant to be a time of joy and blessing for the entire Muslim community and a time for distributing one's wealth.

Charity to the poor is a highly emphasized value in Islam. The Quran says ,

"Believe in Allah and his messenger, and give charity out of the (substance) that Allah has made you heirs of. For those of you who believe and give charity – for them is a great reward."

This piece incorporates materials from an article first published on Aug. 28, 2017. The dates have been updated. This article is republished from The Conversation under a Creative Commons license.

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James and Jennifer Crumbley, a school shooter's parents, are sentenced to 10-15 years

Quinn Klinefelter

(From left) James Crumbley, his attorney Mariell Lehman, Jennifer Crumbley and her attorney Shannon Smith sit in court in Pontiac, Mich., for Tuesday's sentencing on four counts of involuntary manslaughter for the deaths of four Oxford High School students who were shot and killed by the Crumbleys' son. Bill Pugliano/Getty Images hide caption

(From left) James Crumbley, his attorney Mariell Lehman, Jennifer Crumbley and her attorney Shannon Smith sit in court in Pontiac, Mich., for Tuesday's sentencing on four counts of involuntary manslaughter for the deaths of four Oxford High School students who were shot and killed by the Crumbleys' son.

James and Jennifer Crumbley, whose son murdered four classmates and shot seven other people at Oxford High School in 2021, were each sentenced Tuesday in a Pontiac, Mich. courtroom to between 10 and 15 years in prison.

Both Crumbleys were found guilty in separate trials on four counts of involuntary manslaughter. Each of those charges carried a maximum penalty of 15 years, and the sentences are to be served concurrently.

In court, the Crumbleys looked visibly shaken, breathing heavily as they read from prepared statements prior to learning their fate.

James Crumbley spoke directly to the parents of the students his son had murdered. Several family members attended the sentencing.

"I am sorry for your loss as a result of what my son did," he said. "I cannot express how much I wish that I had known what was going on with him or what was going to happen. Because I absolutely would have done a lot of things differently."

James Crumbley, father of school shooter, found guilty of involuntary manslaughter

In her statement, Jennifer Crumbley said she, her husband and her son, Ethan, were an average family.

"We weren't perfect but we loved our son and each other tremendously," Crumbley said. "This could be any parent up here in my shoes. Ethan could be your child, could be your grandchild, your niece, your nephew, your brother, your sister. Your child could make the fatal decision not just with a gun but a knife, a vehicle, intentionally or unintentionally."

The teenagers who lost their lives during the shooting rampage were Justin Shilling and Madisyn Baldwin, both 17, Tate Myre, 16, and 14-year-old Hana St. Juliana. Six other students and a teacher were injured.

When it was time for their families to speak, several members described how the murders still haunted them.

Nicole Beausoleil, whose daughter Madisyn Baldwin was shot at point blank range, told the Crumbleys buying their son a gun when he was already spiraling into despair made them just as responsible as the shooter.

"Not only did your son kill my daughter but you both did as well. The words 'involuntary' should not be a part of your offense. Everything you did that day, months prior and days after were voluntary acts (helping) your son to commit a murder. Not just one, but multiple," Beausoleil said.

A rare prosecution

The Crumbleys are believed to be the first parents of a mass school shooter to have been charged and convicted of such crimes. Many legal experts say it could set a precedent for charging parents with serious crimes because of actions taken by their child.

Their son, Ethan Crumbley, pleaded guilty to murder and previously was sentenced to life without parole for the school shooting he carried out when he was 15.

Prosecutors never claimed the parents knew about their son's plans to go on a killing spree at Michigan's Oxford High School. However, they argued the Crumbleys ignored signs their son was seriously troubled and bought him a powerful Sig Sauer 9mm handgun as an early Christmas present.

They never told counselors about the gun they gifted their child when they were called to a meeting at the school the day of the shooting, not even when they were shown drawings the teen made. The images featured a pistol resembling the Sig Sauer alongside a figure with bullet wounds and phrases like "blood everywhere" and "help me, the thoughts won't stop."

Jennifer Crumbley convicted of involuntary manslaughter over son's school shooting

Instead, the Crumbleys left their son at school and returned to work. A few hours later, Ethan emerged from a school bathroom with the gun and began firing his first of 32 shots.

Prosecutors told the jury if the Crumbleys had taken a "tragically few steps," four Oxford students would likely still be alive.

They showed evidence that the murder weapon was never properly secured away from their troubled son.

In court, Oakland County Prosecutor Karen McDonald used the murder weapon to demonstrate how to use a cable lock to keep the gun from being fired.

The process took about 10 seconds.

A 'chilling' lack of remorse

The prosecution had asked for the Crumbleys to serve 10 to 15 years in prison, citing what they called a "chilling lack of remorse" on the part of both parents after the shooting.

Prosecutors noted that Jennifer Crumbley testified during her trial that "I've asked myself if I would've done anything differently. And I wouldn't have."

And they pointed to repeated profanity-laced threats James Crumbley made against Oakland County Prosecutor Karen McDonald on jailhouse phone calls he knew were being recorded, as well as in an electronic message.

'Mistakes any parent could make'

James Crumbley's attorney countered that his client had not physically threatened the prosecutor, he merely "vented" his anger over what he saw as an unjust incarceration.

The Crumbleys said they, too, were victims of their son, who they claimed had "manipulated" them into the purchase of a gun they had no idea he would use to kill.

They argued they made "mistakes any parent could make," given the information they had.

Defense attorneys for the couple noted an Oxford High counselor determined Ethan could remain in school the day of the shooting because he did not seem to pose a danger to himself or anyone else.

The couple maintained they thought their son was a normal teenager simply depressed over the loss of his grandmother, a pet dog and a friend who had moved away.

In a pre-sentencing interview with state officials, Jennifer Crumbley said that with the benefit of hindsight, "There are so many things I would change if I could go back in time."

Defense claims extra prison time unnecessary

The Crumbleys had asked to be sentenced to time served.

Defense attorneys argued the parents had already spent more than two and a half years in prison locked in a cell for 23 hours a day, and that further prison time was not necessary because the Crumbleys were not a threat to the public.

Defense attorney Shannon Smith also said more time would not deter others from committing a similar offense because "there is no person who would want the events of Nov. 30, 2021, to repeat themselves."

Smith added that, far from being the uncaring, remorseless mother prosecutors had portrayed to the public and the media, Jennifer Crumbley was focused on her son and distraught over the devastation her son caused.

In a sentencing memo, Jennifer Crumbley's parents and others pleaded with the court for leniency. A young woman, who said she was 18 when she became Crumbley's cellmate for a year and a half, also wrote to the judge.

She said Crumbley had greeted her with a basket of snacks and served as a mother figure to her.

The woman also wrote that inmates screamed threats at Crumbley, who tearfully told them she was sorry and "wished she could change everything her son had done."

Though Judge Cheryl Matthews sentenced the Crumbleys to the stiffest penalty possible, she said that the sentences were not designed to send a message to other parents or prosecutors that they should hold families responsible for children's crimes.

"These convictions are not about poor parenting. These convictions confirm repeated acts, or lack of acts, that could have halted an oncoming runaway train. About repeatedly ignoring things that would make a reasonable person feel the hair on the back of their neck stand up," Matthews said.

Moments after they were sentenced, the Crumbleys began filling out paperwork in the courtroom for an appeal.

Their son, Ethan, who pleaded guilty in October 2022 to murder and terrorism charges, is also likely to appeal his sentence of life without the possibility of parole.

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What does the gag order mean in Trump's hush money case?

By Luc Cohen

NEW YORK (Reuters) - The gag order imposed on Donald Trump by a judge in next week's New York criminal trial bars the former U.S. president from talking publicly about certain people involved in the case and their families. 

Trump has pleaded not guilty to falsifying business records to cover up a $130,000 payment before the 2016 election to stop porn star Stormy Daniels from talking about a sexual encounter she says she and Trump had in 2006. Trump denies an encounter. 

Here's why Justice Juan Merchan imposed the gag order and what it bars the Republican presidential candidate from doing: 

WHAT DOES THE GAG ORDER DO?

The March 26 order prevents Trump from making public statements about witnesses concerning their potential testimony and about prosecutors, court staff and their family members if those statements are meant to interfere with the case. 

On April 1, Merchan extended the gag order to cover his own family members and family members of Manhattan District Attorney Alvin Bragg, whose office charged Trump. The order does not restrict Trump's statements about Merchan and Bragg.

WHAT HAPPENS IF TRUMP VIOLATES THE GAG ORDER? 

Trump could face fines or jail time if he violates the order. 

WHY DID THE JUDGE IMPOSE THE GAG ORDER? 

Prosecutors sought the order because they said Trump had a long history of verbally attacking people involved in legal proceedings. 

Merchan agreed that some of Trump's statements had been threatening and inflammatory and said there was a risk such comments could derail the proceedings. 

The judge expanded the order to cover his family after Trump disparaged his daughter online, calling her a "Rabid Trump Hater" due to her work for a political consultancy firm with Democratic clients. 

WHAT DOES TRUMP SAY ABOUT THE ORDER?

Trump's lawyers had urged Merchan not to impose the gag order, arguing his political opponents had attacked him based on the case and that he should have a right to respond. 

After the order was imposed, his campaign said in a statement that it violated his right to free speech. 

"Plenty of people have gagged me recently because when I talk in New York I explain to the people and they understand these cases are all rigged," Trump said in a video posted on Thursday to his Truth Social website. "It sounds fair, doesn't it, to be gagged? But it's not." 

DOES THE ORDER PREVENT TRUMP FROM TALKING ABOUT THE CASE? 

No. Merchan wrote that Trump has a constitutional right to speak to voters freely and to defend himself publicly. The order only applies to statements about specific individuals. 

HAS TRUMP COMPLIED WITH THE ORDER? 

So far, neither prosecutors nor the judge have accused Trump of violating the gag order. Before the March 26 order, Trump repeatedly criticized one of the prosecutors - Matthew Colangelo - by name in a press conference and on social media. Trump has not mentioned him since the order was imposed.

He has not made additional comments about Merchan's daughter since the order was expanded, but also has not deleted the March 28 post on his Truth Social media platform where he refers to her by name. 

HAS TRUMP FACED OTHER GAG ORDERS? 

Yes. Merchan's gag order is similar to restrictions a federal judge imposed last year in a criminal case over Trump's efforts to overturn his 2020 election loss to Democratic President Joe Biden. 

Trump has pleaded not guilty in that case as well.

In a separate, civil fraud case over Trump's business practices, another New York state judge fined him $15,000 last year for twice violating a gag order against publicly commenting about court staff. Trump is appealing a $454.2 million judgment in that case.

(Reporting by Luc Cohen in New York; Editing by Noeleen Walder and Howard Goller)

US does not expect to be drawn into war but predicts attack by Iran against Israel

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Kanishka Singh is a breaking news reporter for Reuters in Washington DC, who primarily covers US politics and national affairs in his current role. His past breaking news coverage has spanned across a range of topics like the Black Lives Matter movement; the US elections; the 2021 Capitol riots and their follow up probes; the Brexit deal; US-China trade tensions; the NATO withdrawal from Afghanistan; the COVID-19 pandemic; and a 2019 Supreme Court verdict on a religious dispute site in his native India.

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Iran warns israel against retaliation, global powers urge restraint.

Iran warned Israel and the United States on Sunday of a much larger response if there is any retaliation for its mass drone and missile attack on Israeli territory overnight, as Israel said "the campaign is not over yet".

The governor of Russia's Kurgan region on Sunday urged people to evacuate flooded areas immediately, saying rain was exacerbating the already tough situation there and the coming night would be difficult.

‘Shōgun’ Episode 8’s Tea Ceremony Has a Deeper Meaning

It's a beautiful and respected tradition.

Editor's note: The below contains spoilers for Shōgun Episode 8.

The Big Picture

• Mariko and Buntaro's tea ceremony reveals hidden tensions and offers a glimpse into their troubled relationship.
• Shōgun carefully reenacts the Japanese tea ceremony with attention to detail and symbolism, emphasizing the characters' emotions.
• Mariko's refusal of Buntaro's offer to commit seppuku together marks a turning point in their relationship, signaling irreparable damage.

This week's episode of Shōgun , " The Abyss of Life ," is a shocking one. Filled with death, distrust, and politicking, it finally offers some insight into what Lord Yoshii Toranaga ( Hiroyuki Sanada ) intends to do about his surrender , taking things to surprising extremes. However, there's also room for some beauty, too. In one of the best scenes of the whole series, Toda "Buntaro" Hirokatsu ( Shinnosuke Abe ) prepares tea for Lady Mariko ( Anna Sawai ) in a typical Japanese tea ceremony. It's very unlike his character but works perfectly in the context of the episode. This tradition has been depicted countless times in pop culture, but Shōgun portrays it in a very special and emotional light .

Shogun (2024)

When a mysterious European ship is found marooned in a nearby fishing village, Lord Yoshii Toranaga discovers secrets that could tip the scales of power and devastate his enemies.

Buntaro and Mariko’s Tea Ceremony Happens at a Crucial Moment

In "The Abyss of Life," Toranaga travels to Edo to mourn his son, Nagakado ( Yuki Kura ). There, the whole controversy around his decision to surrender to the Council of Regents and face his sentence in Osaka continues. After a meeting with Padre Martin Alvito ( Tommy Bastow ), Toranaga's general, Toda Hiromatsu ( Tokuma Nishioka ), is briefly convinced that Toranaga has a secret plan and states as such to Buntaro and Kashigi Yabushige ( Tadanobu Asano ). Shortly before this meeting, Buntaro cordially tells Mariko he "would like to prepare tea for his wife, " and this is the context in which their tea ceremony takes place.

The couple meets in a room in what appears to be their home in Edo. Mariko enters first by crawling through a small door on the side, and Buntaro enters through a different door connected directly to the house. They briefly say a few poetry verses, with Buntaro sitting at an angle across from Mariko, who is sitting facing him. He prepares her the tea and she commends his performance, to which he replies that it is only for her. Buntaro explains his frustration regarding Toranaga and says that, despite what Hiromatsu claims, he thinks everyone will die in Osaka. He then says he finally wants to grant Mariko her wish to commit seppuku , and that they should do it together that night as a protest against Toranaga's surrender.

This time, though, Mariko refuses. She says that, even after years of marriage, Buntaro still fails to see that what he has denied her for years isn't death , but "a life beyond his reach," and that she would rather "live a thousand years" than die with him like this. She politely bows before her husband and exits the room. Buntaro is left behind alone and cries in the face of denial and frustration.

‘Shōgun’ Carefully Recreates the Tea Ceremony With Attention to Detail

The episode's tea ceremony is a beautiful Japanese tradition that has stood for centuries, also known as chanoyu . It can involve either two individuals or a small group of people, and it's meant to strengthen the bond between the host (who is preparing the tea) and their guests (who are drinking it). This tradition began when Japanese Buddhist priests brought the custom of drinking green tea from China in the 12th century and evolved until the mid-16th century, when it took the form it has today.

In Shōgun, it's clear the ceremony is quite an intimate affair. It's the first time Buntaro talks to Mariko like a proper husband would. The ceremony isn't often confined to just two people, but it's often portrayed this way because of what chanoyu is supposed to invoke : the principles of harmony (Wa), respect (Kei), purity (Sei), and tranquility (Jaku). With those four principles in mind, each tea ceremony becomes a unique event, and can never be repeated. Those involved, their roles in the ceremony, the purpose, and the things they talk about will never happen this same way again, a principle known as "ichi-go ichi-e" (“one time, one meeting”).

Even the smallest gestures are carefully thought of in a tea ceremony. For example, before entering the tea house, Mariko is outside in the tea garden, and rinses her hands and mouth with water, as a guest is supposed to. She then enters the room through a small door, which represents the humility of the guest towards the host and the ceremony itself. Inside, she sees a scroll in a small alcove with the writing "Beauty of Nature" and a small vase of flowers. The host chooses such ornaments for the guests' enjoyment to take in while they are alone in the room. Then, the host enters through a different door and takes their place across from the guest. When the tea is ready, the tea is put in a bowl carefully selected by the host, with an adorned or uneven design that allows them to choose their favorite side, considered the "front" of the bowl. The host turns the front of the bowl toward the guest, who accepts it, appreciates the art and, before drinking the tea holding the bowl with two hands, turns it toward the host, so everyone can see it at different important moments of the ceremony — which we also see Mariko and Buntaro doing.

Everything is supposed to make those involved feel like they are far away, sometimes even in another realm and deep in the forest, so their minds can be at ease, and they can speak truthfully and openly to each other . The tea itself can either be "thin" ("usucha") or "thick" ("koicha"), depending on the guests, and it's carefully prepared by the host. If it's thin, each guest receives an individual bowl of tea and a small cake or sweet, while thick tea has the guests drinking from a single bowl while receiving a light meal, and it's also a more formal affair. In Shōgun , Buntaro and Mariko talk openly about their positions as husband and wife and as vassals of Toranaga, something that is also supposed to happen in a tea ceremony.

What Does 'Shōgun's Tea Ceremony Mean for Mariko and Buntaro?

Mariko and Buntaro have never had a calm or easy relationship. From the moment she was set to marry him, Mariko felt displeased, and Buntaro, knowing about her family's tragic past, had always treated her poorly and even abusively. The arrival of John Blackthorne ( Cosmo Jarvis ) only made things worse, as now Mariko is supposed to spend her time alongside another man, even if it's under Toranaga's orders.

Each tea ceremony is unique, and Mariko and Buntaro's is supposed to represent a change of direction in their relationship at a key moment in the series, as well as an olive branch Buntaro is trying to extend when he feels lost in the wake of Toranaga's decision to surrender to Lord Ishido ( Takehiro Hira ). Now, Buntaro offers Mariko the openness he has always denied her, as well as her wish to commit seppuku , which she always wanted as a way of honoring her family. It's a tender moment for him, although it's still not about them as a couple, but rather about him and how he feels.

Ultimately, Mariko refuses Buntaro's offer to commit seppuku. Although she has always had the desire to do it, it is related to keeping her family's honor, not protesting Toranaga. She offers Buntaro the openness and sincerity the tea ceremony demands by saying that things between them are as they are because she never wanted him as a husband. While Shōgun 's tea ceremony allows Mariko and Buntaro to get certain things about their relationship out in the open, it also serves as a turning point when Mariko tells Buntaro that things will never be the same between them again.

Shōgun is streaming on Hulu in the U.S. New episodes are released weekly on Tuesdays.

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What to know about the real estate tycoon sentenced to death in Vietnam’s largest fraud case

A Vietnamese real estate tycoon has been sentenced to death in the country’s biggest ever financial fraud case, a shocking development in an intensifying anti-corruption drive in the southeast Asian nation. Truong My Lan, a high-profile businesswoman who chaired a sprawling real estate company, was arrested in 2022. The 67-year-old was accused of fraud amounting to $12.5 billion, nearly 3% of the country’s 2022 GDP.

Business woman Truong My Lan attends a trial in Ho Chi Minh City, Vietnam on Thursday, April 11, 2024. The real estate tycoon may face the death penalty if convicted of allegations that she siphoned off an amount of $12.5 billion, nearly 3 percent of Vietnam’s 2022 GDP, in its largest financial fraud case. (Thanh Tung/VnExpress via AP)

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Business woman Truong My Lan, center, attends a trial in Ho Chi Minh City, Vietnam on Thursday, April 11, 2024. The real estate tycoon may face the death penalty if convicted of allegations that she siphoned off an amount of $12.5 billion, nearly 3 percent of Vietnam’s 2022 GDP, in its largest financial fraud case. (Thanh Tung/VnExpress via AP)

Business woman Truong My Lan, front center, attends a trial in Ho Chi Minh City, Vietnam on Thursday, April 11, 2024. The real estate tycoon may face the death penalty if convicted of allegations that she siphoned off an amount of $12.5 billion, nearly 3 percent of Vietnam’s 2022 GDP, in its largest financial fraud case. (Thanh Tung/VnExpress via AP)

HANOI, Vietnam (AP) — A Vietnamese real estate tycoon was sentenced to death Thursday in the country’s biggest ever financial fraud case, a shocking development in an intensifying anti-corruption drive in the southeast Asian nation.

Truong My Lan, a high-profile businesswoman who chaired a sprawling company that developed luxury apartments, hotels, offices and shopping malls, was arrested in 2022. The 67-year-old has been convicted for fraud amounting to $12.5 billion — nearly 3% of the country’s 2022 GDP — and for illegally controlling a major bank and allowing loans that resulted in losses of $27 billion, state media outlets reported.

Death sentences are not uncommon in Vietnam, but it is rare in financial crime cases and for someone this well known.

Here is a look at the key details of the case:

WHO IS TRUONG MY LAN?

Lan was born in 1956 and started out helping sell cosmetics with her mother, a Chinese entrepreneur, in Ho Chi Minh city’s oldest market, according to state media outlet Tien Phong.

She and her family established the Van Thinh Phat company in 1992, when Vietnam shed its state-run economy in favor of a more market-oriented one that was open to foreigners. Over the years VTP grew to become one of Vietnam’s richest real estate firms.

Today the company is linked to some of Ho Chi Minh’s most valuable downtown properties including the glittering 39-story Times Square Saigon, the five-star Windsor Plaza Hotel, the 37-story Capital Place office building and the five-star Sherwood Residence hotel where Lan lived until her arrest.

Lan met her husband, Hong Kong investor Eric Chu Nap-kee, in 1992. He was sentenced Thursday to nine years in prison. They have two daughters.

WHAT IS SHE ACCUSED OF?

Lan was involved in the 2011 merger of the beleaguered Saigon Joint Commercial Bank, or SCB, with two other lenders in a plan coordinated by Vietnam’s central bank.

She is accused of using the bank as her cash cow, illegally controlling it between 2012 to 2022, and using thousands of “ghost companies” in Vietnam and abroad to give loans to herself and her allies, according to government documents.

Business woman Truong My Lan, center, attends a trial in Ho Chi Minh City, Vietnam on Thursday, April 11, 2024. (Thanh Tung/VnExpress via AP)

The loans resulted in losses of $27 billion, state media VnExpress reported Thursday.

She was accused of paying bribes to government officials — including a former central official who has been sentenced to life in prison for taking $5.2 million in bribes — and violating banking regulations, government documents said.

The court sentenced her to death, saying her actions “not only violate the property management rights of individuals but also pushed SCB into a state of special control, eroding people’s trust in the leadership of the (Communist) party and state.”

WHY IS THIS HAPPENING NOW?

Lan’s arrest in October 2022 is among the most high-profile in an growing anti-corruption drive in Vietnam .

Weeks after her trial started in early March, former President Vo Van Thuong resigned after being implicated in the so-called Blazing Furnace anti-graft campaign, conducted by Communist Party General Secretary Nguyen Phu Trong, the country’s most powerful politician since the campaign began in 2013.

The 79-year-old ideologue views corruption as a grave threat facing the party and has vowed that the campaign will be a “blazing furnace” where no one is untouchable.

While Lan’s arrest and the scale of her fraud shocked the nation, the case also raised questions about whether other banks or businesses had engaged in similar practices, dampening Vietnam’s economic outlook and making foreign investors jittery.

This is happening as Vietnam tries to argue its case for being the ideal home for businesses trying to move away from neighboring China.

Analysing Chelsea’s latest accounts: What £205m amortisation figure, £404m wage bill mean for PSR

Chelsea face a battle to comply with the Premier League ’s profit and sustainability rules (PSR) and could be forced to sell players before June 30 after their financial state was laid bare in a sobering set of accounts.

The club’s accounts for the year ending June 30, 2023 saw them post a pre-tax loss of £90.1million ($112m), while wages climbed from £340.2m (2022) to £404m in 2023.

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Only Manchester City ’s annual wage bill (£423m) is higher than Chelsea’s. Last season, City won the Premier League, Champions League and FA Cup . Chelsea men’s team finished 12th in the league, though the women’s side won the Women’s Super League and the women’s FA Cup.

Chelsea’s accounts also show that between July 1, 2022 and June 30, 2023, they spent a total of £745.2m on new players. Their accounts note that a further £454.1m has been spent on players since June 30, 2023. They raised £203m from player sales and made a net profit of £62.9m on player trading overall, thanks to the sales of Timo Werner to RB Leipzig , Kalidou Koulibaly to Al Hilal and Jorginho and Kai Havertz to Arsenal .

Since a consortium led by Todd Boehly and Clearlake Capital bought the club in May 2022, Chelsea have splurged a combined £1.2bn on new signings.

This has resulted in their amortisation — how transfers are accounted for in club’s financial reports, with the cost of acquiring players, including fee and salary, spread out over the length of their contracts — soaring to £205m, up from £162.5m in 2022.

Due to the £454.1m spent on players after June 30, 2023 — such as Moises Caicedo , Cole Palmer and Axel Disasi — Chelsea’s amortisation figure for the 2023-24 period will likely have increased further. The club’s £205m figure is already a Premier League high, with Manchester United in second on £152m. Manchester City’s stands at £145.4m.

Chelsea may have spent £1bn - but how much of that have they seen on the pitch?

What does this all mean for Chelsea’s PSR calculations?

Analysis from football finance expert Kieran Maguire

“Chelsea need to start selling again, but if you have got a £400m wage bill, then that means you have players on very big wages and there are a limited number of clubs willing to take those players off your hands, or a limited number of clubs a player would be willing to transfer to.

“They are still good at selling players, and that is the one thing they have always had in their favour. Mason Mount will grab back £60million, but Chelsea are under more pressure now regarding June 30, especially as we have seen the PSR commissions say, with respect to Nottingham Forest , that if you sell later in the year, tough, you know what the rules are.

“My concern is more for the three-year reporting period ending in this season because they have not had the benefits of European football. We had all been told that the wage bill will go down under Clearlake Capital, but the fact it shot up has taken me back.

“It will drop this season because they will not be paying European bonuses, for example. The amortisation charge is completely out of control and that is with their eight-year contracts applied. It is £50million more than Manchester City. They are going to have to work extremely hard to keep within PSR by June 30.”

When asked by  The Athletic about their accounts, Chelsea maintained confidence that they will remain compliant with the Premier League’s PSR for the period ending in 2023-24 season. Chelsea added that they expect their wage bill to be different in the 2023-24 accounts after moving players out last summer.

How does it look going forward?

“The main issue is that these accounts are worse than everyone expected. I can’t see any positives. They can’t grow matchday revenue this season because Stamford Bridge is full. TV income will be down around £70million because of not playing in Europe and unless they win every match until the end of the season, then finishing eighth or ninth is £3million per place, so they may get a little bit more.

“Qualifying for the Europa League and Conference League does not make money, it is only the Champions League that puts plusses on the bottom line. If you get to the final of the Europa League or the semi-final, then that is about OK, but you aren’t making much money before that.

“There must be a lot of pressure on the club. The fact there was a £90million loss and that was after selling the hotel to themselves. Under EFL rules, you are not allowed to put that (hotel sale) into your PSR calculations.

“If they can’t do that for the Premier League, then it will make a bad situation even worse.”

Confused, drifting, a mess: What next for the Chelsea 'project'?

What else do the accounts tell us?

The accounts show that Chelsea borrowed £428.5m interest-free, although no information is given regarding who lent the money.

Chelsea also sold a hotel to BlueCo 22 Limited — a company which lists Boehly and other Chelsea board members as its directors  — for £76.3m, which would have gone towards reducing the £90.1m loss.

It is unclear whether the Premier League will allow for money generated from the hotel sale to another company associated with the club to be used towards the PSR numbers. Chelsea say this was done in line with Premier League rules and was run past the league.

The accounts also reveal that the club considers Blues Investment Holdings to be its ultimate parent company. Blues Investment Holdings is incorporated in the Cayman Islands, which is a British-owned territory that is best known for its status as a tax haven. Manchester United’s parent company is also registered there.

Chelsea’s overall revenue increased from £481.3m in 2022 to £512.5m in 2023, with the majority of this rise coming from their commercial department. Their commercial income grew to £210.1m for the year ended June 30, 2023, having totalled £177.1m in the previous year.

These figures come off the back of it being revealed on Friday that Chelsea spent £75.1m on agent fees between February 1, 2023 and February 2, 202 4. This was more than any other Premier League side, with Manchester City spending £60m during the same period.

(Clive Brunskill/Getty Images)

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Dan Sheldon is a football news reporter for The Athletic, covering Manchester City and Manchester United. He spent four years writing about Southampton FC, two of which were at the Southern Daily Echo. Follow Dan on Twitter @ dansheldonsport

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Golf Fans Had Lots of Jokes About Jason Day's Huge Pants at the Masters

• Author: Andy Nesbitt

In this story:

Tiger Woods is off and running at the 2024 Masters (with a very ho-hum birdie on the first hole ), but it's one of his playing partners that has stolen a lot of the attention on social media early during their first round.

And it has nothing to do with his play.

Instead, golf fans had lots of jokes about the very baggy pants Jason Day is wearing Thursday at Augusta National. Day, who is paired with Woods and Max Homa, had everyone doing a double take when he walked up to the first tee just before 4 p.m. ET wearing these slacks:

Tiger & Jason Day pic.twitter.com/DhrsqWc2XX — CJ Fogler account may or may not be notable (@cjzero) April 11, 2024

Fans had a lot of fun with that:

Jason Day on the first tee #themasters pic.twitter.com/mCxNYJI67c — SammyD (@The_SammyD) April 11, 2024

“Fore, please. Jason Day now driving.” #themasters pic.twitter.com/TCNbAzp1Ob — robmillertime (@robmillertime) April 11, 2024

Jason Day's pants pic.twitter.com/kYRFCyok0K — Mitch Robson (@_mitchrobson) April 11, 2024

Tiger must have smiled nostalgically when he saw Jason Day's pants today pic.twitter.com/27Kvms1m5R — Garrett Morrison (@garrett_TFE) April 11, 2024

Jason Day at #TheMasters pic.twitter.com/4AAMLyIBEo — Dan (Nationally Invited) (@X_Fan_Dan25) April 11, 2024

I think it’s great that Jason Day up-cycled an outfit from his inaugural PGA TOUR season in 2008 pic.twitter.com/KXfbV5idTR — Amanda Rose (@AmandaGolf59) April 11, 2024

Jason Day showing up with parachute pants is insane pic.twitter.com/KVzpr00Rx9 — Frankie Borrelli (@FrankieBorrelli) April 11, 2024

Solid start from Jason Day pic.twitter.com/rzFl4dPSNY — Bryce Ritchie (@BRitchieGolf) April 11, 2024

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