Face Presentation

Face presentation is a fetus presenting with the head fully extended so that the face enters the pelvis first. Causes include anencephaly, fetal goitre or neck mass, tight nuchal cord, polyhydramnios, a contracted pelvis, multiparity and prematurity, but in many no cause is found. It matters because the outcome depends on the position of the chin: mentum anterior can deliver vaginally, while mentum posterior cannot and needs caesarean section.

• Risk factors: grand multiparity, contracted pelvis, anencephaly, fetal neck tumour, polyhydramnios, prematurity, large baby.
• A persistent mentum posterior face cannot be delivered vaginally.
• Face is usually found during labour.

Labour is often prolonged, with a head that feels very prominent on abdominal palpation and a groove between the head and the back. The fetal heart is heard on the side of the chest.

• A groove is felt between the occiput and the fetal back.
• Facial oedema and bruising in the baby after birth.
• Differential diagnosis: breech presentation, brow presentation, occiput posterior, anencephaly, hydrocephalus, fetal neck mass, extended head with transverse lie.
• Complications: prolonged and obstructed labour, fetal distress, caesarean section, facial and laryngeal oedema, airway obstruction in the newborn, bruised and swollen face, neonatal feeding difficulty, cord prolapse.

The diagnosis is made by vaginal examination, with confirmation by ultrasound.

• Vaginal examination: soft facial features (mouth, nose, malar bones, orbital ridges, chin), the mouth and the nose in a triangle, no fontanelle; mentum anterior, transverse or posterior position by the chin.
• Abdominal palpation: a groove between the head and back; fetal heart heard on the fetal chest.
• Ultrasound: hyperextended head, face toward the pelvic inlet, neck mass, anencephaly, and lie.
• Cardiotocography; assessment of pelvis and fetal weight.

The principle is to allow vaginal birth for mentum anterior or mentum transverse with a rotating chin, and to deliver by caesarean section for mentum posterior or any complication.

• Supportive: avoid fetal scalp electrodes and scalp blood sampling (use external cardiotocography), avoid unnecessary vaginal examinations, avoid pressure on the eyes, Ringer's lactate 1 litre IV over 2 hours, continuous monitoring; paediatric team to secure the airway at birth.
• Pharmacological: oxytocin 10 IU in 1 litre Ringer's lactate (10 mU/mL) started at 12 mL per hour (2 mU/minute) and doubled every 30 minutes to a maximum of 192 mL per hour (32 mU/minute) only for weak contractions with a mentum anterior face and a normal pelvis; analgesia (epidural or pethidine 50 to 100 mg IM 4-hourly); cefazolin 2 g IV before caesarean section; oxytocin 10 IU IM after birth, then 20 IU in 1 litre at 125 mL per hour for 4 hours; newborn vitamin K 1 mg IM and, for airway obstruction, oxygen and intubation by a skilled operator.
• Procedures: vaginal birth for mentum anterior with a normal pelvis (forceps may be used; avoid vacuum extraction); caesarean section for persistent mentum posterior, failure to progress after 2 hours in the second stage, fetal distress, cephalopelvic disproportion or a fetal neck mass; do not attempt manual conversion or rotation of a mentum posterior face.
• Special groups: face presentation with anencephaly in a live fetus allows vaginal birth after counselling, and a dead fetus allows vaginal birth by destructive means when needed; a uterine scar has caesarean section more readily.
• Red flags: mentum posterior, no progress after 2 hours of the second stage, fetal heart abnormal, cord prolapse, bandl ring.
• Follow-up: newborn airway and feeding observation for 24 to 48 hours, with facial swelling subsiding in 1 to 3 days; examine for neck mass and anomalies; review at 6 weeks.