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Management of Brow, Face, and Compound Malpresentations

8/1/2013 - Thomas J. Bader, MD

Malpresentations are relatively uncommon in labor yet every obstetrician needs to be prepared to manage them. All malpresentations have two things in common:

(1) they are managed expectantly awaiting spontaneous resolution; and

(2) delivery is generally impossible without resolution.

A brow presentation can be thought of as “midway” between a face presentation (maximal nuchal extension) and an occiput presentation (maximal nuchal flexion). The anterior fontanelle and frontal sutures are prominent on vaginal exam. Management of a brow presentation is expectant. A persistent brow presentation usually requires a cesarean delivery, although successful vaginal delivery is possible. A brow presentation that converts to an occiput presentation (by nuchal flexion) is managed routinely. If the brow presentation converts to a face presentation (by nuchal extension), it is managed as a face presentation.

Face presentations are also managed expectantly. If the fetus is in a mentum anterior presentation, vaginal delivery is possible. Normal labor forces result in flexion of the fetal neck allowing expulsion of the fetus without increased morbidity.

If the fetus is in a mentum posterior presentation, vaginal delivery cannot be accomplished unless the fetal head rotates to a mentum anterior position. Rotation should be spontaneous; manual or forceps rotation is not recommended. If spontaneous rotation to a mentum anterior does occur, management continues to be expectant. If the presentation remains mentum posterior, a cesarean delivery is necessary.

Compound presentations occur when a fetal extremity presents in front of or next to the presenting part. Most compound presentations are either a hand or arm next to the fetal head. Management is expectant, because, in most cases, the extremity will retract as the head descends. If it does not retract, it can usually be swept out of the way with gentle manual pressure, with care taken to move the fetal part in a natural direction.

All three malpresentations are managed expectantly during labor and may result in a vaginal delivery. When the malpresentation is identified, the mother should be counseled of the necessity for cesarean delivery if the malpresentation persists.

Further Reading:

Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS, eds. Abnormal labor. In: Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill Inc; 2014.

Initial Approval: 8/2013; Revised: 11/2016

 

 

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