Back to Search Results

8/1/2018

Management of Brow, Face, and Compound Malpresentations

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 regarding 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 1/500-1/600 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, occurring 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 ophthalmic 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 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. 25th ed. New York, NY: McGraw-Hill Inc; 2018.

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. PMID: 29078945. 

 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018; Reaffirmed January 2020; Revised September 2021.

 

********** Notice Regarding Use ************

The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

Copyright 2021 The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. All rights reserved.  No re-print, duplication or posting allowed without prior written consent.

 

Back to Search Results