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8/1/2018

Management of Brow, Face, and Compound Malpresentations

Fetal malpresentations - including brow, face, or compound presentations - complicate 3-4% of term births. Because brow, face, and compound presentations are cephalic, many cases result in vaginal deliveries, yet there are increased risks for adverse outcomes such as persistent malpresentation, arrest disorder, and resultant Cesarean delivery.

Brow, face, and compound presentations are differentiated in the following ways:

• In face presentations, the presenting part is the mentum, which is further classified by position, including mentum posterior, mentum transverse or mentum anterior. Face presentation 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 (versus 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 expectant 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 central nervous system malformations, congenital and chromosomal anomalies, advanced maternal age, low birthweight, abnormal maternal pelvic anatomy (e.g. contracted pelvis, cephalopelvic disproportion, 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 vaginal examinations and involves palpation of the abnormal leading fetal part (forehead, orbital ridge, orbits, nose, etc.). Obstetric ultrasound can provide complementary information to support the diagnosis and distinguish from other fetal malpresentations or malpositions. In face presentation, the mentum (chin) and mouth are palpable.

Management considerations for face, brow, and compound 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 descen
• For compound presentations, management is expectant and manipulation of the leading extremities should be avoided. Most cases of compound presentation result in vaginal deliveries because the most common compound presentations involve the fetal hand next to the presenting part. For term deliveries, compound presentations with parts other than the hand are unlikely to result in safe vaginal delivery and are indications for cesarean delivery. 

Labor management for brow and face presentation involves continuous fetal heart rate monitoring and repeated clinical assessments, given the increased potential for fetal complications. 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. 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.

 

Further Reading:

Bar-El L, Eliner Y, Grunebaum A, Lenchner E, et al. Race and ethnicity are among the predisposing factors for fetal malpresentation at term. Am J Obstet Gynecol MFM. 2021 Sep;3(5):100405. doi: 10.1016/j.ajogmf.2021.100405. Epub 2021 Jun 4. PMID: 34091061.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol. 2017 Dec;217(6):633-641. doi: 10.1016/j.ajog.2017.07.025. Epub 2017 Jul 22. PMID: 28743440. 

Ghi T, Dall'Asta A. Sonographic evaluation of the fetal head position and attitude during labor. Am J Obstet Gynecol. 2024 Mar;230(3S):S890-S900. doi: 10.1016/j.ajog.2022.06.003. Epub 2023 May 19. PMID: 37278991.

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.

Zayed F, Amarin Z, Obeidat B, et al. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. PMID: 18283473. 

 

Initial Approval: August 2013; Revised: 11/2016; Revised July 2018; Reaffirmed January 2020; Revised September 2021. Revised July 2023. Minor Revision January 2025.

 

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