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

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

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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Premature baby, baby products, health & safety, what is brow presentation what are its complications.

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What Is Brow Presentation?

What leads to brow presentation, diagnosis of brow presentation, how to avoid c-section if baby is in brow presentation, what complications can arise due to brow presentation.

Polyhydramnios : Excess amniotic fluid can make it difficult for the baby’s head to take a flexed position
Size and shape of the pelvis: Abnormally shaped and sized pelvis can make it difficult for the baby to pick up a vertex presentation. Android pelvis, which has a triangular or heart-shaped inlet with a narrower front part, is usually behind most of the brow presentations. Similarly, contracted pelvis, a pelvis that is abnormally small, can cause brow presentation
Fetal abnormality: Fetal abnormalities such as hydrocephalus, anencephaly and neck masses accounts for the majority of brow presentations
Premature birth/low birth weight baby: If the baby is born prematurely or if the baby is having low birth weight , the chances of brow presentation increases
Big baby : If the baby is larger than normal size, the baby tends to extend its head instead of curling inward
Multiple pregnancies: Multiple pregnancies also increase the risk of brow presentation
Multiple nuchal cords: If the umbilical cord wraps around the baby’s neck, obviously, it cannot tuck its chin into the chest. In such cases, the baby tends to be brow or face presentations
Laxity of the uterus: If the uterine wall loses its firmness, the baby may not able to hold its chin tucked to the chest firmly and the baby tends to be in brow presentation
Cephalopelvic disproportion (CPD): If the mother’s pelvis and the baby’s head are not proportionate to each other, brow presentation can happen

Manual rotation: Doctor inserts his hand through the cervix and tries to flex the baby’s head
The baby’s head should be engaged in the pelvis and should be in a front anterior position
The pelvis should have sufficient room to permit the ventouse cup to be inserted posteriorly and to reach the occiput
Ability and experience of the obstetrician
How favorable is the position of the baby’s head inside the pelvis
Available space inside the pelvis
Increased chances of spinal cord injury are associated with brow presentation
Fetal distress
Abnormal shape of the baby’s head after delivery
Prolonged labor
Increased chances of using forceps which in turn increases the chances of facial trauma
Obstructed labor

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Medical Information

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

Introduction:.

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

Delivery Process:

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

Face Presentation:

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

Brow Presentation:

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

Delivery Techniques and Intervention:

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

Conclusion:

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

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

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

Variations in Fetal Position and Presentation |

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

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

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

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

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

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

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

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

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

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

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

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

Occiput posterior position

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

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

Breech presentation

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

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

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

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

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

Labor starts too soon (preterm labor).

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

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Delivery, Face and Brow Presentation

Introduction.

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.

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.

Indications

Contraindications

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.

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

Technique or Treatment

Mechanism of Labor in Face Presentation

Mechanism of Labor in Brow Presentation

Complications

Clinical Significance

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

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Domingues AP,Belo A,Moura P,Vieira DN, Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2015 May; [PubMed PMID: 26107576]

. Intrapartum care for healthy women and babies. 2022 Dec 14:(): [PubMed PMID: 32212591]

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What is brow presentation?

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because your baby is premature
an abnormality that prevents your baby from tucking in her chin
having too much amniotic fluid ( polyhydramnios )

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Delivery, Face and Brow Presentation

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1 Vilnius University, Lithuania, Imperial London Healthcare NHS Trust
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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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7.10 Brow presentation

Brow presentation constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible (except with preterm birth or extremely low birth weight).

This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.

7.10.1 Diagnosis

Head is high; as with a face presentation, there is a cleft between the head and back, but it is less marked.
the chin (it is not a face presentation),
the posterior fontanelle (it is not a vertex presentation).

Figures 7.9 - Brow presentation

Any mobile presenting part can subsequently flex. The diagnosis of brow presentation is, therefore, not made until after the membranes have ruptured and the head has begun to engage in a fixed presentation. Some brow presentations will spontaneously convert to a vertex or, more rarely, a face presentation.

During delivery, the presenting part is slow to descend: the brow is becoming impacted.

7.10.2 Management

Foetus alive.

Perform a caesarean section. When performing the caesarean section, an assistant must be ready to free the head by pushing it upward with a hand in the vagina.
Convert the brow presentation to a face presentation: between contractions, insert the fingers through the cervix and move the head, encouraging extension (Figures 7.10).
Attempt internal podalic version ( Section 7.9 ).

Both these manoeuvres pose a significant risk of uterine rupture. Vacuum extraction, forceps and symphysiotomy are contra-indicated.

Foetus dead

Perform an embryotomy if the cervix is sufficiently dilated (Chapter 9, Section 9.7 ) otherwise, a caesarean section.

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Delivery presentations

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

Your baby must pass through your pelvic bones to reach the vaginal opening. The ease at which this passage will take place depends on how your baby is positioned during delivery. The best position for the baby to be in to pass through the pelvis is with the head down and the body facing towards the mother's back. This position is called occiput anterior (OA).

In breech position, the baby's bottom is facing down instead of the head. Your health care provider will most often detect this in an office visit before your labor begins. Most babies will be in the head-down position by about 34 weeks.

Part of your prenatal care after 34 weeks will involve making sure your baby is in the head-down position.

If your baby is breech, it is not safe to deliver vaginally. If your baby is not in a head-down position after your 36th week, your provider can explain your choices and their risks to help you decide what steps to take next.

Occiput Posterior (OP)

In occiput posterior position, your baby's head is down, but it is facing the mother's front instead of her back.

It is safe to deliver a baby facing this way. But it is harder for the baby to get through the pelvis. If a baby is in this position, sometimes it will rotate around during labor so that the head stays down and the body faces the mother's back (OA position).

The mother can walk, rock, and try different delivery positions during labor to help encourage the baby to turn. If the baby does not turn, labor can take longer. Sometimes, the provider may use forceps or a vacuum device to help get the baby out. If the baby stays in the OP position during labor, you have a higher risk of needing to deliver your baby by cesarean delivery (C-section).

Transverse Position

A baby in the transverse position is sideways. Often, the shoulders or back are over the mother's cervix. This is also called the shoulder, or oblique, position.

The risk for having a baby in the transverse position increases if you:

Go into labor early
Have given birth 3 or more times
Have placenta previa

Unless your baby can be turned into head-down position, a vaginal birth will be too risky for you and your baby. A doctor will deliver your baby by cesarean birth ( C-section ).

Less Common Presentations

With the brow-first position, the baby's head extends backward (like looking up), and the forehead leads the way. This position may be more common if this is not your first pregnancy.

Your provider rarely detects this position before labor. An ultrasound may be able to confirm a brow presentation.
More likely, your provider will detect this position while you are in labor during an internal exam.

With face-first position, the baby's head is extended backwards even more than with brow first position.

Most of the time, the force of contractions causes the baby to be in face-first position.
It is also detected when labor does not progress.

In some of these presentations, a vaginal birth is possible, but labor will generally take longer. After delivery, the baby's face or brow will be swollen and may appear bruised. These changes will go away over the next few days.

Alternative Names

Pregnancy - delivery presentation; Labor - delivery presentation; Occiput posterior; Occiput anterior; Brow presentation

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.

Thorp JM, Grantz KL. Clinical aspects of normal and abnormal labor. In: Lockwood CJ, Copel JA, Dugoff L, et al, eds. Creasy and Resnik's Maternal-Fetal Medicine: Principles and Practice . 9th ed. Philadelphia, PA: Elsevier; 2023:chap 40.

Vora S, Dobiesz VA. Emergency childbirth. In: Roberts JR, Custalow CB, Thomsen TW, eds. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care . 7th ed. Philadelphia, PA: Elsevier; 2019:chap 56.

Review Date 11/21/2022

Updated by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. 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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Malpresentations and malpositions

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 22 Jun 2021

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Usually the fetal head engages in the occipito-anterior position (more often left occipito-anterior (LOA) rather than right) and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.

Obstetrics - the pelvis and head

Continue reading below

Predisposing factors to malpresentation include:

Prematurity.

Multiple pregnancy.

Abnormalities of the uterus - eg, fibroids.

Partial septate uterus.

Abnormal fetus.

Placenta praevia.

Primiparity.

Breech presentation

See the separate Breech Presentations article for more detailed discussion.

Breech presentation is the most common malpresentation, with the majority discovered before labour. Breech presentation is much more common in premature labour.

Approximately one third are diagnosed during labour when the fetus can be directly palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made to turn the baby manually by manipulating the pregnant mother's abdomen. This reduces the risk of non-cephalic delivery 1 .

Maternal postural techniques have also been tried but there is insufficient evidence to support these 2 .

Many women who have a breech presentation can deliver vaginally. Factors which make this less likely to be successful include 3 :

Hyperextended neck on ultrasound.

High estimated fetal weight (more than 3.8 kg).

Low estimated weight (less than tenth centile).

Footling presentation.

Evidence of antenatal fetal compromise.

Transverse lie 4

When the fetus is positioned with the head on one side of the pelvis and the buttocks in the other (transverse lie), vaginal delivery is impossible.

This requires caesarean section unless it converts or is converted late in pregnancy. The surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a fetal pole.

Internal podalic version is no longer attempted.

Transverse lie is associated with a risk of cord prolapse of up to 20%.

Occipito-posterior position

This is the most common malposition where the head initially engages normally but then the occiput rotates posteriorly rather than anteriorly. 5.2% of deliveries are persistent occipito-posterior 5 .

The occipito-posterior position results from a poorly flexed vertex. The anterior fontanelle (four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures) may also be palpable posteriorly.

It may occur because of a flat sacrum, poorly flexed head or weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation.

As occipito-posterior-position pregnancies often result in a long labour, close maternal and fetal monitoring are required. An epidural is often recommended and it is essential that adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged. If the head comes into a face-to-pubis position then vaginal delivery is possible as long as there is a reasonable pelvic size. Otherwise, forceps or caesarean section may be required.

Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse position.

Alternatives for delivery include manual rotation of fetal head using Kielland's forceps, or delivery using vacuum extraction. This is inappropriate if there is any fetal acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be provision for a failure of forceps delivery to be changed immediately to a caesarean. The trial of forceps is therefore often performed in theatre. Some centres prefer to manage by caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 1,000 deliveries 5 .

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Brow positions

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.

Brow presentation occurs in 0.14% of deliveries 5 .

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

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Brow Presentation

First Online: 02 August 2023

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Syeda Batool Mazhar 2 &
Zahra Ahmed Muslim 2

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Brow presentation is the rarest of all malpresentations. Anencephaly, neck masses in fetus, polyhydramnios, multiple loops of cord around neck are the fetal factors leading to brow presentation. Contracted pelvis, preterm labour, platypelloid pelvis are some of the contributory maternal factors for brow presentation. Diagnosis is usually made during second stage of labour during prevaginal examination when anterior frontanelle and face are palpated. Cesarean section is performed in brow presentation as it is unusual to get conversion in average sized fetus once membranes have ruptured.

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Mazhar, S.B., Muslim, Z.A. (2023). Brow Presentation. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_8

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2022 New Pearls of Exxcellence Articles

Management of Brow, Face, and Compound Malpresentations

Author: Meera Kesavan, MD

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

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

These fetal malpresentation are differentiated in the following ways:

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

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

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

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

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

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

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

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

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Obstetrics Simplified - Diaa M. EI-Mowafi

Brow Presentation

It is a cephalic presentation in which the head is midway between flexion and extension.

About 1:1000 labour.

As face presentation.

It is difficult.
The occiput and sinciput may be felt at the same level.
Ultrasonography and X-ray may be helpful.
frontal bones,
supra-orbital ridges, and
root of the nose but not the chin.

Mechanism of Labour

The engagement diameter is the mento-vertical 13.5 cm which is longer than any diameter of the inlet so there is no mechanism of labour and labour is obstructed.
may occur during conversion of vertex into face presentation. So if brow is flexed to become vertex or extended to become face it may be delivered.
Exclude contracted pelvis, if present do caesarean section.
The case is considered as transient brow, observed carefully and given a chance for spontaneous conversion into either face or vertex.
The rest of management as other malpresentation.
Caesarean section is done if the foetus is living.
Craniotomy if the foetus is dead.
Dystocia : Guidelines, reviews

Vishal's account
Complications

Brow Presentation – An Overview

What Is Brow Presentation?

How can you get to know if your baby is in this position, what are the causes of brow presentation, how is the diagnosis made, complications of brow presentation delivery, alternatives for labor during brow presentation, precautions to take before and after labour, how will brow presentation affect your baby during labor.

Pregnancy is a beautiful experience that is also fraught with a host of complications and risks. One of them concerns the normal orientation of your baby inside your uterus, which is essential for a smooth delivery. This article will explain all about abnormal forehead presentation and its associated causes, complications, diagnosis, treatment and precautions.

Babies assume a fixed position in the uterus, that is with their chins tucked firmly into their chests. This position is ideal to exit the uterus smoothly. However, in some cases, the baby’s head and neck will extend backwards away from their chest. This is known as a brow presentation or forehead presentation. It is an extremely rare condition, occurring once in 1500 births. Brow presentation might obstruct vaginal births from occurring as there is less space for the baby to drop down towards the pelvic girdle. However, if brow presentation occurs early in labour, there is still time for them to flex their neck back to the right position. If not, labour might be hindered, causing stress for both, the mother and the baby. In these instances, your doctor might recommend a caesarean section. A brow baby tends to occur in women pregnant for the second or third time, or due to physical defects like an abnormally developed spine.

Brow babies are rarely detected before labor begins, but around half of them will shift to a face-first or crown-first presentation suitable for delivery. A brow presentation delivery will take much longer than normal, which is usually when the condition is discovered.

There are several potential reasons for your baby to assume this orientation. Some of them are:

Fetal Size: Babies born preterm, or with low birth weights, raise the likelihood of them presenting brow first. This is also observed in large babies, who usually flex their head outwards rather than in towards their chest. Brow presentation can also be caused if your pelvic girdle and your baby’s head are disproportionate to each other.
Polyhydramnios: Polyhydramnios is the condition in which there is too much amniotic fluid in your uterus. Thus, it might be tricky for your baby to fix their heads in the correct position.
Multiple Pregnancy: Carrying twins or more in your womb decreases the amount of space available, making your babies take alternative positions to fit properly.
Maternal Defects: If your pelvis is not the right shape and size, it might be difficult for your fetus to assume normal presentations. The most common cause of brow presentation is the triangle-shaped android pelvis and the atypically small contracted pelvis. Another maternal defect is a lax uterus, which is not firm enough to hold the baby in place, resulting in different presentations.
Fetal Defects: If your baby has conditions such as anencephaly and hydrocephalus, their abnormally large heads will not be able to take the right position.

To diagnose brow presentation, an experienced doctor will be able to help. Ultrasound scans are compulsory for monitoring the situation. Your doctor might even conduct a digital examination to check the orientation of the baby’s facial features. If they find that the baby’s head does not rotate enough for a natural birth, they might recommend a caesarean section.

Several risks come with brow presentation birth. Some of them are:

Labor time might be extended as the baby would have a hard time getting past the pelvis.
Forceps might be required, which could cause cranial damage.
Baby’s head shape might be altered due to difficulty while moving through the birth canal.
Baby may go through stress during delivery as it would be difficult birth and may require a caesarean.
Injuries may occur to the baby’s spinal cord due to trauma.
Increased risk of cerebral hemorrhage in the baby as the head may take in damage.

As explained already, a baby in brow presentation might not have enough space to move downwards towards the cervix. If this happens, there are a few methods your doctor might implement to reduce the complications of natural birth. These methods require medical skill and enough space within the cervix to be attempted.

Ventouse Birth: In this case, your doctor will use a small vacuum extraction device known as a ventouse to pull the baby’s head towards their chest. This method can be used even after you have begun to push.
Manual Rotation: After the cervix undergoes complete dilation, your doctor might attempt to move the baby’s head into the correct position using their hands.

As there are several complications linked with brow presentations, here are some precautions for you to take before and after labour to have a successful pregnancy.

Choose a doctor who is accomplished in obstetrics and gynaecology, so they are experienced in dealing with any potential outcome.
Visit your doctor regularly, especially at the end of your third trimester.
If you have been diagnosed with brow presentation, do not hesitate to go for a caesarean if strongly recommended by your doctor, as it dramatically reduces the risks involved.

Babies might end up with abnormally shaped heads if they go through vaginal birth with a brow presentation. However, as their heads are malleable, they will return to a normal shape in a few days. Extended labor might cause stress in your baby who has been stuck in an uncomfortable position the whole time. This might also lead to vertebral problems, so consult a paediatric osteopath if you are concerned.

Brow presentation can happen to anyone, so not encountering it in your first pregnancy does not mean you will not see during later pregnancies. Consume a balanced, nutritious diet, stay hydrated and get enough sleep. Avoiding tension and anxiety will help you stay strong for when your baby arrives.

Also Read : Preparing for Labour & Delivery – Smart Ways to Prepare for Childbirth

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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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After Baby Turns
Head Down is Not Enough
Sideways/Transverse
Asynclitism
Oblique Lie
Left Occiput Transverse
Right Occiput Anterior
Right Occiput Posterior
Right Occiput Transverse
Left Occiput Anterior
OP Truths & Myths
Anterior Placenta
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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Malpresentation and Malposition of the Fetus

A malpresentation or malposition of the fetus is when the fetus is in any abnormal position, other than vertex (head down) with the occiput anterior or posterior.

The following are considered malpresentations or malpositions:

Unstable lie

Transverse presentation
Oblique presentation

Face presentation

Brow presentation

Shoulder presentation

High head at term

Prolapsed arm

The cause of a malpresentation can often not be clearly identified but it can be associated with the following:

Preterm pregnancy
Uterine anomalies
Pelvic tumors eg f ibroids
Placenta previa
Grandmultiparty
Contracted maternal pelvis
Multiple gestation
Too much amniotic fluyid (polyhydramnios)
Short umbilical cord
Fetal anomalies (e.g. anencephaly, hydro-cephalus)
Abnormal fetal motor ability

There is an increased risk of neonatal and maternal complications associated with a malpresentation including neonatal and maternal trauma. If delivery is indicated, doing a cesarean delivery can significantly decrease the risk of complications.

Transverse lie

Oblique lie

In most cases of a normal vertex (head down) presentation, the baby's head is flexed with the chin close to the baby's chest. In these cases, the presenting part is the occiput, the posterior part of the baby's head. If the baby's head is more but not completekly extended then the baby's brow presents towards the vagina. A brow presentation is rare, maybe happening in about 1 in 2,000 births, more likely in pwomen with their second or subsequent births. A baby with a brow presentation can only deliver vaginally if the head flexes or extends.

Prolapsed arm

Abnormal Fetal Position and Presentation

Under normal circumstances, a baby is in the vertex (cephalic) position before delivery. In the vertex position, the baby’s head is at the lower part of the abdomen, and the baby is born head-first. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma (1). Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.

What is the difference between fetal presentation and position?

In the womb, a fetus has both a presentation and a position . Presentation refers to the baby’s body that leads, or is expected to lead, out of the birth canal (9). For example, if a baby’s rear is set to come out of the birth canal first, the baby is said to be in “breech presentation.” Position refers to the direction the baby is facing in relation to the mother’s spine (9). A baby could be lying face-first against a mother’s spine, or face up towards the mother’s belly.

What way should a baby come out during birth?

Vertex presentation is the ‘normal’ way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). In vertex presentation, the baby is positioned head-first with their occiput (the part of the head close to the base of the skull) entering the birth canal first. In this position, the baby’s chin is tucked into their chest and they are facing the mother’s back (occipito-anterior position). Any position other than vertex position is abnormal and can make vaginal delivery much more difficult or sometimes impossible (2). If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury (1).

What happens if a baby isn’t in the standard vertex position during birth?

Before delivery, it is critical that the fetus is in the standard vertex presentation and within the normal range for weight and size. This helps ensure the safety of both baby and mother during labor. When the baby’s size or position is abnormal, physician intervention is usually warranted (1). This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery . The failure of healthcare professionals to identify and quickly resolve issues related to fetal size, weight, and presentation is medical malpractice . There are numerous complications related to abnormal weight, size, abnormal position, or abnormal presentation.

Compound presentation

In the safest presentation (vertex presentation), the baby is born head first, with the rest of the body following. In a compound presentation, however, there are multiple presenting parts. Most commonly, this means that the baby’s head and an arm come out first at the same time. Sometimes compound presentation can occur with twins where the head of the first twin presents with the extremity of the second twin (3).

Risk factors for compound presentation include (3):

Prematurity
Intrauterine growth restriction (IUGR)
Multiple gestations ( twins , triplets, etc.)
Polyhydramnios
A large pelvis
External cephalic version
Rupture of membranes at high station

Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during a cervical examination (3).

If a mother has polyhydramnios, the risk of compound presentation is higher, as the flow of amniotic fluid when the membranes rupture can sweep extremities into the birth canal, or cause a cord prolapse , which is a medical emergency (3). If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency (3). Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy , intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE) (3).

Limb presentation

Limb presentation during childbirth means that the part of the baby’s body that emerges first is a limb – an arm or a leg. Babies with limb presentation cannot be delivered safely via vaginal delivery; they must be delivered quickly by emergency C-section (4). Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis), which is a medical emergency.

Occipitoposterior (OP) position

Approximately 1 out of 19 babies present in a posterior position rather than an anterior position. This is called an occipitoposterior (OP) position or occiput posterior position (3) In OP position, the baby is head-first with the back part of the head turned towards the mother’s back, rotated to the right (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP) of the sacroiliac joint. Occipitoposterior position increases the baby’s risk of experiencing prolonged labor , prolapsed umbilical cord , and use of delivery instruments, such as forceps and vacuum extractors (5). These conditions can cause brain bleeds , a lack of oxygen to the brain, and birth asphyxia .

When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section (5). A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. Breech presentation occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor (6).

There are 4 types of breech positions:

Footling breech presentation : In footling position, one or both feet enter the birth canal first, with the buttocks at a higher position than the feet.
Kneeling breech presentation : This is when the baby has one or both legs extended at the hips and flexed at the knees.
Frank breech presentation : This is when the baby’s buttocks present first, the legs are flexed at the hip and extended at the knees, and the feet are near the ears.
Complete breech presentation : In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with the feet beside the buttocks.

When a baby is in breech position, physicians often try to maneuver the baby into a head-first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress ) (7). The only type of breech position that may allow for a vaginal delivery is frank breech , and the following conditions must be met:

The baby’s heart rate is being closely monitored and the baby is not in distress.
Cephalopelvic disproportion (CPD) is not present; x-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
The hospital is equipped for and the physician is skilled in performing an emergency C-section .

If these conditions are not present, vaginal birth should not be attempted. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries (6). Mismanaged breech birth can result in the following conditions:

Brain bleeds, intracranial hemorrhages
Spinal cord fractures
Hypoxic-ischemic encephalopathy (HIE)
Cerebral palsy
Intellectual disabilities
Developmental delays

Face presentation

A face presentation occurs when the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in the airway to maintain airway patency and assist breathing (1).

Image by healthhand.com

There are three types of face presentation:

Mentum anterior (MA) : In this position, the chin is facing the front of the mother.
Mentum posterior (MP) : The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, 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. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
Mentum transverse (MT) : The baby’s chin is facing the side of the birth canal in this position.

Trauma is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.

Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position (1). Safe vaginal delivery of a term-sized infant in persistent MP position is impossible due to the presenting part of the baby compared to the size of the mother’s pelvis (1). Babies in MP position must be delivered by C-section. Babies in MT position must also be delivered by C-section. Some babies in the MP and MT positions will spontaneously convert to the MA position during the course of labor, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is able to proceed, engagement of the presenting part of the baby probably will not occur until the face is at a +2 station (1).

The management of face presentation requires close observation of the progress of labor due to the high incidence of CPD with face presentation. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position (1).

In any face presentation situation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. In fact, when face presentation occurs, experts recommend liberal use of C-section (1).

Since there is an increased risk of trauma to the baby when the face presents, the physician should not try to rotate the baby internally. In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to extract the baby from the uterine cavity. Outlet forceps should only be used by experienced physicians; these forceps increase the risk of trauma and brain bleeds. In almost all clinical circumstances a cesarean delivery is the safest method of delivery.

Listed below are complications that can occur if face presentation is mismanaged by the medical team:

Prolonged labor
Facial trauma
Facial and upper airway 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 or difficulty in ventilation (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
Spinal cord injury
Abnormal fetal heart rate patterns
10-fold increase in fetal compromise
Brain bleeds
Intracranial hemorrhages
Permanent brain damage

Brow presentation

Brow presentation is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis.

Risk factors and conditions associated with brow presentation

Brow presentation has been linked to several risk factors and co-occurring conditions. These include:

Multiparity (having previously given birth)
Premature delivery
Fetal anomalies such as anencephaly (an absence of major parts of the brain and skull) or anterior neck mass (a growth on the front of the neck)
Previous c-section delivery
Polyhydramnios (excessive amniotic fluid: infants swallow amniotic fluid while in utero, but this may be difficult if their neck is extended)

Diagnosis of brow presentation

Brow presentation can often be diagnosed through a vaginal examination during labor. If there are no conclusive signs from the physical examination alone, an ultrasound can also be used. Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants who assume a brow presentation early in labor may spontaneously move into a more optimal position during the delivery process. Additionally, safe delivery in brow presentation may be possible if the infant is unusually small and/or the mother’s pelvic opening is unusually large. For these reasons, physicians occasionally recommend vaginal delivery of infants in brow presentation.

Doctors attempting vaginal delivery of a baby in brow presentation must be very careful to watch for signs of fetal distress (such as an abnormal heart rate), and to monitor the progression of labor. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain damage if action is not quickly taken to prevent this. If an infant in brow presentation begins to show signs of distress, or if labor progress stops or slows significantly, physicians should be ready to move on to a cesarean delivery.

Labor induction or augmentation with the drug Pitocin (synthetic oxytocin) is very dangerous in cases of brow presentation. Pitocin can lead to excessive uterine contractions, which can put pressure on the infant’s head and cut off their oxygen supply; this is especially risky when safe fetal descent is already compromised, such as in cases of brow presentation.

Complications of brow presentation

If brow presentation is diagnosed in a timely fashion and is appropriately managed, there are typically no serious negative effects on the mother or baby. However, if medical professionals fail to recognize brow presentation and intervene as necessary, there can be lasting consequences. Infants may suffer oxygen deprivation due to prolonged labor, or traumatic injuries from a difficult delivery. Some of the most severe conditions resulting from mismanaged brow presentation births include:

Hypoxic-ischemic encephalopathy
Periventricular leukomalacia
Seizure disorders
Developmental disabilities

Shoulder presentation (transverse lie)

Shoulder presentation (transverse lie) is when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, C-section is almost always used as the delivery method (8). Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position (8). Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position; thus, a C-section should ideally be performed before the membranes break (8). Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic-ischemic encephalopathy (HIE), seizures, permanent brain damage, and cerebral palsy.

Legal help for birth injuries from abnormal position or presentation

The award-winning birth injury attorneys at ABC Law Centers have over 100 years of joint experience handling birth trauma cases related to abnormal position or presentation. If you believe your loved one’s birth injury resulted from an instance of medical malpractice, you may be entitled to compensation from a medical malpractice or personal injury case. During your free legal consultation, our birth injury 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.

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Julien, S., and Galerneau, F. (2017). Face and brow presentations in labor. Retrieved from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor .
World Health Organization, UNICEF, and United Nations Population Fund. Malpositions and malpresentations. Retrieved from http://hetv.org/resources/reproductive-health/impac/Symptoms/Malpositions__malpresetations_S69_S81.html .
Barth, W. (2016). Compound fetal presentation. Retrieved from https://www.uptodate.com/contents/compound-fetal-presentation .
Gabbe, S.G., … Grobman, W.A. (2017). Compound Presentation. Retrieved from https://expertconsult.inkling.com/read/gabbe-obstetrics-normal-problem-pregnancies-7e/chapter-17/compound-presentation .
Argani, C.H. and Satin, A.J. (2018) Occiput posterior position. Retrieved from https://www.uptodate.com/contents/occiput-posterior-position .
Hofmeyr, G.J. (2018). Overview of issues related to breech presentation. Retrieved from https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation .
Hofmeyr, G.J. (2017). Delivery of the fetus in breech presentation. Retrieved from https://www.uptodate.com/contents/delivery-of-the-fetus-in-breech-presentation .
Strauss, R.A. (2017). Transverse fetal lie. Retrieved from https://www.uptodate.com/contents/transverse-fetal-lie .
Moldenhauer, J.S. (2018). Abnormal Position and Presentation of the Fetus. Retrieved from https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus .

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COMMENTS

Delivery, Face and Brow Presentation
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.
What Is Brow Presentation? What Are Its Complications?
One such complication that can come at the last minute of any delivery is the presentation of the baby. Normally, babies bow down their chin well tucked into the chest during their journey through the birth canal. This position is called flexed position or vertex presentation. This is the ideal position that makes delivery easier as the baby ...
What is brow presentation?
Brow presentation is a rare complication, which affects only one in every 500 to one in every 1,400 births. So the chances of it happening are low. If a brow presentation is picked up in early labour, your baby may still flex her head in time for the birth. Alternatively, she may tip her head further back and be born face first.
Face and Brow Presentation: Overview, Background, Mechanism ...
In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant patient's spine) with the face and body angled to one side and the neck flexed. Abnormal presentations include face, brow, breech, and shoulder.
Delivery, Face Presentation, and Brow Presentation ...
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.
Fetal Presentation, Position, and Lie (Including Breech Presentation
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.
Face and brow presentations in labor
The vast majority of fetuses at term are in cephalic presentation. Approximately 5 percent of these fetuses are in a cephalic malpresentation, such as occiput posterior or transverse, face ( figure 1A-B ), or brow ( figure 2) [ 1 ]. Diagnosis and management of face and brow presentations will be reviewed here.
Delivery, Face and Brow Presentation
Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large. Equipment. Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios.
What is brow presentation?
Brow presentation happens when your baby's neck and head are slightly extended (deflexed), as if your baby is looking up. The ideal position for your baby to be born in is with her chin tucked into her chest (flexed position), so her head is well down. At this angle, the smallest diameter of your baby's head descends first, which helps her to ...
Delivery, Face and Brow Presentation
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.
7.10 Brow presentation
7.10.1 Diagnosis. 7.10.2 Management. Foetus alive. Foetus dead. Brow presentation constitutes an absolute foeto-pelvic disproportion, and vaginal delivery is impossible (except with preterm birth or extremely low birth weight). This is an obstetric emergency, because labour is obstructed and there is a risk of uterine rupture and foetal distress.
Delivery presentations: MedlinePlus Medical Encyclopedia
Delivery presentations. Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery. Your baby must pass through your pelvic bones to reach the vaginal opening. The ease at which this passage will take place depends on how your baby is positioned during delivery. The best position for the baby to be ...
Malpresentations and Malpositions Information
Brow positions. The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents. Brow presentation occurs in 0.14% of deliveries 5. Brow presentation is usually only diagnosed once labour is well established. The anterior fontanelle and super orbital ridges are palpable on vaginal examination.
Brow Presentation
Brow Presentation: Brow is a cephalic deflection malpresentation with the partially deflexed fetal head midway between complete flexion (vertex) and full extension (face) (Fig. 2 ). The frontal bone is the designated point for its position in maternal pelvis. On vaginal examination, the brow, orbits, and root of the nose are palpable.
Management of Brow, Face, and Compound Malpresentations
Brow presentation can be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse. Compound presentation is defined as the leading fetal part, including a fetal extremity, alongside a cephalic or breech presentation. Management of compound presentations is expected (and often incidentally ...
Brow Presentation
Brow Presentation. It is a cephalic presentation in which the head is midway between flexion and extension. About 1:1000 labour. As face presentation. It is difficult. The occiput and sinciput may be felt at the same level. Ultrasonography and X-ray may be helpful. root of the nose but not the chin. The engagement diameter is the mento-vertical ...
Brow Presentation
Brow presentation might obstruct vaginal births from occurring as there is less space for the baby to drop down towards the pelvic girdle. However, if brow presentation occurs early in labour, there is still time for them to flex their neck back to the right position. If not, labour might be hindered, causing stress for both, the mother and the ...
Face Presentation
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.
Malpresentation and Malposition of the Fetus
Brow presentation . In most cases of a normal vertex (head down) presentation, the baby's head is flexed with the chin close to the baby's chest. In these cases, the presenting part is the occiput, the posterior part of the baby's head. If the baby's head is more but not completekly extended then the baby's brow presents towards the vagina.
Abnormal Fetal Position/Presentation and Birth Injury
Brow presentation is similar to face presentation, but the baby's neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term "brow presentation" suggests, the brow (forehead) is the part that is situated to go through the pelvis first.
Intrapartum ultrasound for the diagnosis of cephalic malpositions and
brow, and face presentations represent the 3 classical variants of cephalic mal-presentation and are characterized by a progressive deﬂection from vertex pre-sentation. These classic variants of mal-presentation are quite rare, with reported incidences of 1 in 600 to 1 in 2000 for face presentation1 and 1 in 380 to 1 in 800 for brow ...
Malpositions and malpresentations of the fetal head
Attitude - refers to the degree of flexion or extension of the fetal head with respect to the trunk. A well flexed fetal head presents the most favorable diameters to the maternal pelvis ().If the fetal neck is deflexed, the leading part of the fetal head lies more anteriorly and a brow presentation can occur while if there is complete extension of the fetal neck, the face then becomes the ...

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

Delivery Process:

Face Presentation:

Brow Presentation:

Delivery Techniques and Intervention:

Conclusion:

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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For Patients

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

Position and Presentation of the Fetus

Occiput posterior position

Breech presentation

Other presentations

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Delivery, Face and Brow Presentation

Anatomy and Physiology

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Delivery, Face and Brow Presentation

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7.10 Brow presentation

7.10.1 Diagnosis

7.10.2 Management

Foetus dead

Delivery presentations

Occiput Posterior (OP)

Transverse Position

Less Common Presentations

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Review Date 11/21/2022

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