the following are the types of cephalic presentation except

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

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

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Last Update: January 9, 2023 .

• Continuing Education Activity

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

• Describe the mechanism of labor in the face and brow presentation.
• Summarize potential maternal and fetal complications during the face and brow presentations.
• Review different management approaches for the face and brow presentation.
• Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
• 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

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

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

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

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

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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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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

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

Occiput posterior position

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

Breech presentation

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

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

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

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

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

Other presentations

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

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

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

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

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Delivery, Face and Brow Presentation

Affiliations.

• 1 Vilnius University, Lithuania, Imperial London Healthcare NHS Trust
• 2 University of Health Sciences, Rawalpindi Medical College
• PMID: 33620804
• Bookshelf ID: NBK567727

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.

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.

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.

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. 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.

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• Continuing Education Activity
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Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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Leopold Maneuvers |Steps

Last updated on December 28th, 2023

In this post, you will learn about Leopold Maneuvers, its purpose, and how to perform four maneuvers systematically.

What are Leopold Maneuvers?

Leopold maneuvers are a systematic four-step physical examination performed to evaluate the fetal lie, presentation, and position of the fetus in the uterus.

These obstetric maneuvers are performed after 26 weeks of gestation.  It is when the fetus is matured enough that when you palpate the abdomen its outline can be easily distinguished. 

According to studies, the accuracy of the Leopold maneuvers varies between 94% to 95% in a cephalic presentation when compared with ultrasonography. However, when the fetus is not in a cephalic presentation, the clinician’s ability to correctly determine the fetal position significantly decreases.

History of Leopold Maneuvers

The four classic obstetric grips known as Leopold maneuvers were first described and named after a German Gynecologist Dr. Christian Gerhard Leopold (1846–1911).

Since then it has become an essential clinical skill to assess the presentation, lie, and position of the baby within the uterus.

Purpose of Leopold Maneuver

The purpose of Leopold maneuvers are to determine:

• Fetal position (fetal position is described as fetal presentation in relation to mother’s pelvis. For example, right occiput anterior [ROA], left occiput anterior [LOA], left sacrum anterior [LSA], and more…)
• Fetal lie (fetal lie is described as where the fetus lies in relation to the mother’s back. For example, longitudinal lie, transverse lie, and oblique lie)
• Fetal presentation (first fetal part that presents into the maternal pelvis)
• Fetal attitude (fetal attitude can be determined after head is engaged)
• Fetal malposition
• Approximate fetal weight and amount of amniotic fluid

Prerequisites before the procedure

• Explain the Leopold maneuvers and their purpose to the pregnant mother
• Obtain verbal consent
• Ask the client to empty her bladder
• Position patient in supine and legs partially flexed from knees
• Ensure the patient is comfortable and relaxed
• Expose the tummy (from the xiphoid process to pubic symphsis) and cover lower part of the body with a sheet to provide privacy
• Ensure your hands are warm prior to palpation

Leopold maneuver steps

Step 1: fundal grip.

The first step of the Leopold maneuver is known as the fundal grip . Here, you palpate the uppermost part of the abdomen. This maneuver answers the question “ What fetal part (i.e., head or buttocks) occupies the fundus (i.e., top of the uterus)? “

Hence, you will know the fetal lie by performing fundal grip or first Leopold maneuver. Additionally, at this step, fundal height is also measured.

Fundal height will give you information about gestational age. It can be measured using a measuring tape – McDonald’s rule or just by palpating with finger breadths.

Purpose of the first Leopold maneuver or the fundal grip is to determine fetal lie and fundal height .

How to perform the first Leopold maneuver – Fundal grip

• Stand client’s right side facing towards her face
• Warm-up both the hands
• Place both the hands over the fundal area
• Then, palpate from one hand while applying steady firm pressure with the other hand to make it easier to identify fetal parts

• If you feel broad, firm, irregular soft mass indicates fetal buttocks is in the fundus. It means presentation is cephalic and the lie is longitudinal . This is the normal findings which promotes normal vaginal delivery.
• If you feel smooth, globular mass which is ballotable [bounces between the palpating hands – beacuse head can move independly from its body] indicates fundus occupies the fetal head. It means presentation is breech – a malpresentation which must be documented and confirmed with ultrsonography for planning the safest mode of delivery for the mother and baby.
• If you feel the upper pole is empty, indicates a transverse lie .

Step 2: Lateral or Umbilical grip

The second Leopold maneuver is called lateral or the umbilical grip . The second step answers “ On which maternal side does the fetal back is located? ” The fetal’s back is the best location to auscultate its heart sound.

Hence, the aim of this step is to locate the fetal back and limbs . Additionally, you can determine the position (i.e., ROA, LOA, etc) of the fetus at this step.

How to perform the second Leopold maneuver – Lateral or Umbilical grip

• Stand facing the client as the first maneuver
• Place both hands on either side of the abdomen between flanks and umblicus
• Then, while steadily supporting with the right hand, palpate with the left hand. Palpate using deep gentle pressure in slightly circular motion – It will helps to easily identify the fetal parts .
• Repeat the steps on the other side as well using opposite hands

• If you feel continuous smooth structure indicates its fetal back. It is the best place to monitor fetal heart rate. You may use a fetoscope, stethoscope, or doppler to monitor fetal heart rate (FHR).
• If you feel irregular multiple knoblike structures indicates its fetal limbs
• Also, you will be able identify fetal body parts from amniotic fluids and the fetal position, whether its ROA, LOA, and more
• If the lie is transverse, head or breech may be palpable from one of the sides of maternal torso.

Step 3: Pawlik’s grip

The third Leopold maneuver is known as the Pawlik’s grip which answers the question “ what is the presenting part? “ This step was modified by Czech Gynecologist  Karel Pawlík (1849–1914). Hence, named Pawlik’s grip.

Sometimes the third Leopold maneuver is also referred as the first pelvic grip.

The aim of this maneuver is to evaluate presenting part into the pelvis and engagement .

How to perform the third Leopold maneuver – Pawlik’s grip

• Stand facing the client’s face same as the first and second maneuvers
• Wide open your right hand – thumb on one side and four fingers on the other side, grasp the lower pole of the uterus just above the symphsis pubis. Use your left hand to grasp the fundus at the same time.
• Then, try to move presenting fetal part between your thumb and four fingers.
• This maneuver usually causes some discomfort to the mother. So, be gentle and cautious during this step.

• If the lie is longitudinal and presentation is vertex, and head not engaged – you will feel the head of the fetus between your fingers. And it will be ballotable.
• If the presenting part is engaged (i.e, presenting part has already decended into the pelvic inlet), you will feel the less distinct mass.
• If the presenting part is breech, the mass will feel much softer and smaller. Also, it won’t move independently of the body.
• If the lie is transverse, like the empty fundus, the lower pole of the uterus will also be empty. Hence no fetal parts will be palpable.

Step 4: Pelvic grip

The fourth Leopold maneuver is known as pelvic grip. This final step of the Leopold maneuver answers the question “ Is the fetal head engaged in the pelvis and what is the attitude? “

This step will help you to confirm the presenting part of the fetus and its descent into the pelvis. If the presentation is vertex, you can determine the relation of the cephalic prominence to the fetal back to evaluate the fetal attitude .

Additionally, you can determine the degree of engagement. Hence, confirming the findings of the third maneuver.

How to perform the fourth Leopold maneuver – Deep pelvic grip

• In this step, stand facing towards client’s feet. This is the only maneuver performed facing towards the woman’s feet.
• Place hands below the umbilicus, parallel to inguinal, and walk fingers aroung presenting part towards the midline and symphysis pubis.

• If the fingers of both hands meet (converge) below presenting part indicates presenting part is floating (i.e., not engaged yet)
• If the fingers of both hands diverge below the presenting part indicates presenting part is now engaged.
• In vertex presentation, if cephalic prominence is felt on the opposite side of the back indicates that the fetal head is well flexed.
• If the head is deflexed or extended as in brow and face presentation – you can palpate cephalic prominence on the same side as the back, but you will feel a groove between the cephalic prominence and fetal back.
• You should be able to confirm the findings od Pawlik’s grip

Contraindication

Leopold maneuvers should not be performed during uterine contractions.

Complications

Leopold maneuvers do not have any significant complications. It may cause mild discomfort to the mother especially during the third maneuver. And some very rare cases, it may trigger uterine contractions.

Leopold maneuvers are a systematic method of palpating a pregnant woman’s abdomen to assess fetal position in utero. It helps determine presentation, lie, position, and attitude.

Leopold maneuvers are an easy and cost-effective method of assessing pregnant women. However, the accuracy of the findings is heavily dependent on the skills and competency of the examiner.

Berghella, V. (2007). Obstetric Evidence Based Guidelines . Taylor & Francis.

Evans, A. (2007). Manual of obstetrics (7th ed.). Lippincott Williams & Wilkins.

Kennedy, B., Ruth, D., & Martin, E. (2009). Intrapartum management modules (4th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.

Ricci, S., & Kyle, T. (2009). Maternity and Pediatric Nursing . Wolters Kluwer Health/Lippincott Williams & Wilkins.

Saxena, R. (2014). Bedside Obstetrics & Gynecology . Jaypee Brothers Medical Publisher (P) Ltd.

Simkin, P., & Hanson, L. (2017). Labor Progress Handbook (4th ed.). Wiley Blackwell.

Weber, J., Kelley, J., Sprengel, A., & Weber, J. (2010). Lab Manual to Accompany Health Assessment in Nursing (7th ed.). Lippincott Williams & Wilkins.Weber, J. R., & Kelley, J. H. (2017). Health Assessment in Nursing (6th ed.). Lippincott Williams and Wilkins.

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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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.

• Face presentation
• Active phase of labor
• Prematurity
• Deflexed head
• Congenital malformations
• Dolichocephalic skull
• Mento-anterior
• Crichton’s method

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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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Suchitra Pandit

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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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Obstetrics Simplified - Diaa M. EI-Mowafi

Face Presentation

It is a cephalic presentation in which the head is completely extended.

About 1:300 labours.

• It is less common.
• It occurs during pregnancy.
• Anencephaly: due to absence of the bony vault of the skull and the scalp while the facial portion is normal.
• Loops of the cord around the neck.
• Tumours of the foetal neck e.g. congenital goitre.
• Hypertonicity of the extensor muscles of the neck.
• Dolicocephaly: long antero-posterior diameter of the head, so as the breadth is less than 4/5 of the length.
• Dead or premature foetus.
• Idiopathic.
• It is more common. 
• It occurs during labour.
• Contracted pelvis particularly flat pelvis which allows descent of the bitemporal but not the biparietal diameter leads to extension of the head.
• Pendulous abdomen or marked lateral obliquity of the uterus.
• Further deflexion of brow or occipito - posterior positions.
• Other causes of malpresentations as polyhydramnios and placenta praevia.
• Right mento-posterior (RMP).           
• Left mento-posterior (LMP).
• Left mento-anterior (LMA).
• Right mento-anterior (RMA), are the more common positions.
• Right mento-transverse (lateral), left mento-transverse, direct mento-posterior and direct mento-anterior are rare and usually transient positions.

The first position (RMP) corresponds to the first normal position (LOA) as the back should be to the left and anterior in the first position. Mento-anterior are more common than mento-posterior as most cases arise from more deflexion of the head in occipito-posterior position usually in flat contracted pelvis.

During pregnancy (difficult)

• The back is difficult to feel.
• The limbs are felt more prominent in mento-anterior position.
• The chin may be felt on the same side of the limbs as a horseshoe-shaped rim in mento-anterior position.
• In mento-posterior, a groove may be felt between the occiput and the back particularly after rupture of the membranes.
• Second pelvic grip: the occiput is at a higher level than the sinciput.
• The FHS are heard below the umbilicus through the foetal chest wall in mento-anterior position.
• Ultrasound or X-ray: confirms the diagnosis and may identify associated foetal anomalies as anencephaly.

During labour

Vaginal examination shows the following identifying features for face:

• supra-orbital ridges,
• the malar processes,
• the nose (rubbery and saddle shaped),
• the mouth with hard areolar ridges.

Late in labour, the face becomes oedematous (tumefaction) so it can be misdiagnosed as a buttock (breech presentation) where the two cheeks are mistaken with buttocks and the mouth with anus and the malar processes with the ischial tuberosities. The following points can differentiate in-between:

Mechanism of Labour

Mento-anterior position

• Engagement by submento-bregmatic diameter 9.5 cm.
• Increased extension.
• Internal rotation of chin 1/8 circle anteriorly.
• Flexion: is the movement by which the head is delivered in mento-anterior position when the submental region hinges below the symphysis. The vulva is much distended by the submento-vertical diameter 11.5 cm.
• Restitution.
• External rotation.

Engagement is delayed because:

• The biparietal diameter does not pass the plane of pelvic inlet until the chin is below the level of the ischial spines and the face begins to distend the perineum.
• Moulding does not occur as in vertex presentation.

Mento-posterior position

• so the head is delivered as mento-anterior.
• Deep transverse arrest of the face: when the chin rotates 1/8 circle anteriorly.
• Persistent mento-posterior: when no rotation occurs.
• Direct mento-posterior: When the chin rotates 1/8 circle posteriorly.

In the last 3 conditions no further progress occurs and labour is obstructed.

Direct mento-posterior, unlike direct occipito-posterior, cannot be delivered because:

• Delivery should occur by extension while the head is already maximally extended.
• As the length of the sacrum is 10 cm and that of neck is only 5 cm, the shoulders enter the pelvis and become impacted while the head still in the pelvis, thus the labour is obstructed.

Management of Labour

Exclude: - Foetal anomalies and - Contracted pelvis.

Mento-anterior

• First stage: as in occipito-posterior.
• Spontaneous delivery usually occurs.
• Forceps delivery may be indicated in prolonged 2nd stage.
• Episiotomy is necessary because of over distension of the vulva.

Mento-posterior

• First stage: as mento-anterior.
• Wait for long anterior rotation of the mentum 3/8 circle and the head will be delivered as mento-anterior. During this period oxytocin is used to compete inertia which is common in such conditions as long as there is no contraindication. Failure of this long rotation is more common than in occipito-posterior position so earlier interference is usually indicated.
• Caesarean section: which is the safest and the current alternative in modern obstetrics.
• Manual rotation and forceps extraction as mento-anterior, or
• Rotation and extraction by Kielland forceps.
• In the last 2 methods the head should be engaged but they are hazardous to both the mother and foetus so they are nearly out of modern obstetrics.
• Craniotomy: if the foetus is dead.

The face of the foetus is oedematous after delivery so the mother is assured that this will be spontaneously relieved within few days.

Complications

See complications of malpresentations and malposition.

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NLE Nursing Sample Test Questions- Community Health Nursing

This is a practice test in preparation for the Comprehensive Board Examination for Nurses. The following topics were covered in this practice test.

• Department of Health Plans and Policies
• Home Delivery
• Millennium Development Goals
• Dengue Haemorrhagic Fever
• Immunizations
• Pulmonary Tuberculosis

The test set is randomly designed in such a way that it includes easy questions as well as difficult questions. Please choose the best answer.

Community Health Nursing Practice Questions

Situation 1: The Department of Health is strengthening its programs regarding maternal and child health nursing. As a newly appointed community health nurse in town, you are oriented and well versed on these.

1. With regards to the Women’s Health and Safe Motherhood Project, the following strategies are included to prevent maternal mortality, except one:

a. Establishment of BEmoNC and CEmoNC networks b. TBA facilitated home deliveries c. Improved Family Planning counseling d. Emphasis on Facility-based deliveries.

2. The following qualifications reflect possible delivery in the Rural Health Unit, except for one:

a. Cephalic presentation b. Adequate pelvis c. History of caesarian section delivery d. Less than five pregnancies

3. You are assigned to provide baby care to the newly delivered healthy baby. What procedure are you going to do first?

a. Examine the newborn and check for defects, deformities and birth injuries. b. Provide warmth to the newborn and have a quick check for breathing c. Clamp and cut the cord after cord pulsations have stopped. d. Facilitate the bonding between the mother and the newborn through early skin–to–skin contact.

4. The basis for the improvement in strategies in maternal and neonatal care is on Millennium Development Goals, which are:

a. MDGs 1 & 2 b. MDGs 2 & 4 c. MDGs 3 & 5 d. MDGs 4 & 5

5. The following are the intermediate results that can lower the risk for dying from pregnancy and childbirth with the integration of the MNCHN services in the community:

a. Every delivery is facility-based and managed by skilled birth attendants b. Every pregnancy is adequately managed during pre and postpartum courses c. Every pregnancy is wanted, planned, and supported d. Only answers A & C.

Situation II: You have observed that there are reports of dengue hemorrhagic fever in the barangay. You are to perform a community awareness lecture about the said disease.

6. Which is the best preventive measure for dengue hemorrhagic fever?

a. Frequent fogging in the vicinity to kill mosquitoes b. Use of mosquito nets and mosquito coils c. Use of mosquito repellent lotions d. Cleaning of surroundings and proper disposal of coconut shells, tires, and containers

7. What are the signs and symptoms of DHF assessed as Grade II?

a. Herman’s signs, bone, and joint pains, fever with a headache, and abdominal pain b. Hypotension, anorexia, nausea and vomiting, fever, and rapid weak pulse c. Herman’s signs, fever with a headache, epistaxis, and melena d. Narrowing pulse pressure, restlessness, and cold clammy perspiration

8. For planning and implementation during the course of DHF, the following are the necessary nursing considerations:

a. Educate client to avoid dark-colored foods and the use of hard-bristled toothbrush, razor, and other sharp objects b. Monitoring the intake and output of client c. Encouraging client to increase fluid intake d. All of the above

9. What diagnostic procedure will confirm that the client is having DHF?

a. Blood smear b. Urine and Stool examinations c. Cerebrospinal fluid examination d. Sputum examination

10. Dengue hemorrhagic fever can be fatal. The following manifestations are present in DHF, except for one.

a. Thrombocytosis b. Prolonged bleeding time c. Thrombocytopenia d. Positive Rumpel Leade test

Situation III: IMCI or the Integrated Management for Childhood Illnesses is an important tool for public health nurses for managing cases of children seeking health care.

11. What should you look for in assessing the child’s condition?

a. Does the child vomit everything? b. Is the child able to breastfeed or drink? c. Is the child lethargic or unconscious? d. Is the child having some breathing difficulties?

12. If the child is having fever for 9 days every day and has a stiff neck but without runny nose, what color health management will it suggest?

a. Green b. Yellow c. Pink d. Violet

13. In a child reported to having diarrhea, assessment is an essential guide for knowing if the child is experiencing dehydration. What body part should you assess?

a. Buttocks b. Abdomen c. Eyelids d. Arms

14. Child Isabel is already 12 weeks old. What immunizations should Isabel have received?

a. BCG, OPV-0, DPT+HIB-1, Hepatitis B1, and OPV-1 b. BCG, OPV-0, DPT+HIB-1, Hepatitis B1, DPT+HIB-2, Hepatitis B2, OPV-1 and OPV-2 c. BCG, OPV-0, DPT+HIB-1, Hepatitis B1, OPV-1, and Measles d. BCG, OPV-0, DPT+HIB-1, and OPV-1

15. In preparing sugar water for the treatment of low blood sugar in a child, includes the following proportion:

a. 200 ml of clean water plus 2 level tbsp. of sugar b. 400 ml of clean water plus 4 level tsp of sugar c. 200 ml of clean water plus 4 level tsp of sugar d. 200 ml of clean water plus 4 level tbsp of sugar

Situation IV: The Aquino Health Agenda (AHA) is focusing on the achievement of Universal Health Care for All Filipinos.

16. The AHA strategic thrusts are the keys for ensuring that all Filipinos especially the poor will receive the benefits of the health reform. These involve:

a. Attainment of Millennium Development Goals 2 and 3. b. Financial risk protection through expansion in National Health Insurance Program enrolment and benefit c. Improved service delivery for health care needs through upgraded quality health care facilities d. B & C only

17. Last April 2011, the Department of Health together with the LGUs conducted a nationwide campaign on:

a. Reproductive Health Bill b. Disaster and Preparedness c. Measles-Rubella d. Isang Milyong Sepilyo

18. Which is incorrect regarding the training and deployment of unemployed nurses as “RNHeals” to the rural area?

a. To supply the needs of poor Filipino people in far-flung areas b. To contribute to the eradication of poverty and hunger c. To assist in the promotion of gender and equality d. To address the proliferation of “volunteer nurses”

19. According to the AHA, the following instruments are vital in implementing the three strategic thrusts. Which one refers to the access to professional health providers capable in the provision of their health needs at the appropriate level of care?

a. Service Delivery b. Governance for Health c. Human Resources for Health d. Health Information

20. Encouragement of community integration and self-reliance enhancement in the community is valued, too in this health agenda. Which of these statements indicate the correct meaning of community health team?

a. It is a group of people composed of NGOs and private organizations b. It is led by the midwife in the priority population areas c. The rural health physician is the one who directly tracks the eligible population d. None of the above

Communicable Diseases

21. It refers to the description of disease occurrence which is constantly present in a given area.

a. Pandemic b. Sporadic c. Endemic d. Epidemic

22. Mang Ernie came to the RHU because he was bitten by their dog. What nursing consideration is your priority?

a. Administration of Anti- rabies vaccine b. Provision of dim, quiet and non-stimulating room for the client c. Assessment of the wound for classification, severity, and other signs and symptoms d. Provision of isolation precautions

23. You are about to provide health teachings about pulmonary tuberculosis in your area of assignment. What diagnostic procedure is usually done early in the morning to confirm PTB?

a. Chest X-ray b. Sputum Examination c. Bronchoscopy d. All of the above

24. Scarlet fever is a febrile contagious condition. Which laboratory procedure is not included in confirming scarlet fever?

a. ASO titer b. Sputum Examination c. Throat culture d. Differential count of white blood cells

25. What skin manifestation can be observed to a child having the 3- day measle?

a. Generalized flushing of the skin b. Rashes that appears on the chest spreading gradually upward and downward c. Macupapular rashes on the cheeks (slightly elevated) d. Rose-red papules on the face

Answers and Rationale

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