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Management of Brow, Face, and Compound Malpresentations

8/1/2018 - Meera Kesavan, MD

Mentor: Lisa Keder MD

Editor: Elizabeth Ferries-Rowe, MD

 

Five percent of fetuses present in brow, face, or compound presentations, many of which result in vaginal delivery. Patients should be counseled about increased risk for cesarean delivery due to fetal distress, labor arrest, or persistent malpresentations.

Risk factors for brow and face presentations include anencephaly, hydrocephalus, fetal neck masses, cephalopelvic disproportion, polyhydramnios, prematurity, low birth weight, and contracted pelvis. Diagnosis involves palpation of the forehead, orbital ridge, orbits, and the nose. In face presentation, the chin and mouth are palpable. Vaginal delivery is difficult because the largest transverse diameter passing through the maternal pelvis is greater than the suboccipitobregmatic diameter that presents in a typical vertex delivery.

Approximately 1/1500 deliveries are brow presentations. The fetal presenting part extends from the anterior fontanelle to the orbital ridge. Brow presentations are described by the position of the anterior fontanelle with regard to the maternal pelvis.  Thirty percent of brow presentations will convert to a face presentation and 20% will convert to a vertex presentation. 

Face presentations account for 1/600- 1/800 deliveries. This occurs when the fetal neck is extended and face from forehead to chin is the leading body part.  The likelihood of vaginal delivery depends on orientation of the mentum (chin). With mentum anterior, occuring in 60 % of face presentations, vaginal delivery is often possible.  Normal labor forces result in neck flexion in the second stage of labor as the chin passes under the pubic symphysis allowing expulsion of the fetus. If the fetus is mentum posterior, flexion of the neck is anatomically impossible. Spontaneous rotation to mentum anterior occurs frequently.

Labor management for brow and face presentation involves careful monitoring of the fetal heart rate and labor course because fetal heart rate abnormalities and prolonged or arrested labor occur more commonly than in vertex presentations. In face presentations with mentum anterior, oxytocin may be used. For persistent mentum posterior, cesarean delivery is indicated. Caution should be used with internal monitoring devices, which can cause opthalmic injury or trauma to the forehead, mandible, or zygomatic areas. Midpelvic forceps, version with 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. With appropriate management, neonatal and maternal morbidity is low. Vaginal delivery is more likely to be successful in small or preterm infants.

Compound presentations occur when a fetal extremity precedes or is adjacent to the presenting part. This occurs in about 1/1500 of deliveries. Most compound presentations are either a hand or arm next to the fetal head. Risk factors include prematurity, polyhydramnios, and multiple gestation. Management for compound hand presentation is expectant because the extremity will often retract as the head descends. Manipulation of the extremity should be avoided. For term deliveries, compound presentations with parts other than the hand are unlikely to result in safe vaginal delivery. Complications of compound presentation include cord prolapse and injury to the presenting limb.

 

Further Reading:

Cunningham FG, Leveno KJ, Bloom SL, et al, Abnormal labor. Williams Obstetrics. 24th ed. New York, NY: McGraw-Hill Inc; 2014.

Lannie SM, Gherman R, Gonik B, et al, Malpresentations, Obstetrics: Normal and Problem Pregnancies  Elsevier, 7th edition, 2017

Pilliod RA, Caughey AB. Fetal Malpresentation and Malposition: Diagnosis and Management., Obstet Gynecol Clin North Am. 2017 Dec;44(4):631-643. doi: 10.1016/j.ogc.2017.08.003.

 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018.

 

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