Face Presentation and Birth Injury

Normally, babies are born head-first with their chin tucked towards their chest (vertex presentation). In a face presentation birth, the baby’s chin is not tucked and their neck is hyperextended. Unfortunately, this can impede the movement of their head and complicate their birth and engagement (when the largest part of the baby’s head or buttocks enters the mother’s pelvis). In some cases, a baby in face presentation can be delivered vaginally, but in most  cases, vaginal delivery is difficult and can injure the baby. 

In this piece, the birth injury team at ABC Law Centers will discuss risks, diagnosis, management, and legal help for children with complications from a face presentation birth. 

There are three types of face presentation that can occur at birth:

• Mentum anterior position (MA): The baby’s chin faces the mother’s front side, and will be the presenting part of the face. Babies in mentum anterior position are usually delivered vaginally, although in some cases a C-section may be necessary. 
• Mentum posterior position (MP): The baby’s chin is facing the mother’s back. The baby’s head, neck, and shoulders enter its mother’s pelvis at the same time, and the pelvis is usually not large enough to accommodate this. The baby might spontaneously rotate into mentum anterior position, discussed above. 
• Typically, a C-section is indicated, but there are certain circumstances under which vaginal delivery may be attempted . Regardless, the medical team should be prepared to perform a prompt C-section if there are any complications.
• Mentum transverse position (MT): The baby’s chin is facing the side of the birth canal. Doctors may recommend a trial of labor under certain circumstances, but they should promptly proceed to a C-section if there are issues. 

During any type of face presentation birth, if labor is progressing normally and the baby is not in distress, physician intervention may not be necessary since many MP and MT positions convert to MA.  

However, if progress in dilation and the baby’s descent slows or stops despite adequate contractions, or the baby is in fetal distress, doctors and the hospital  must perform an emergency C-section.

Conditions that may increase the likelihood of a face presentation birth include the following:

• Prematurity
• Babies with a very low birth weight
• Fetal macrosomia (a baby that is larger than average)
• Cephalopelvic disproportion, or CPD (a mismatch in size between the mother’s pelvis and the baby’s head)
• Severe hydrocephalus that causes enlargement of the baby’s head
• Anterior neck mass
• Multiple nuchal cords (umbilical cord wrapped around baby’s neck more than once)
• Maternal pelvis abnormalities
• Maternal obesity
• Multiparity (the mother has previously given birth)
• Polyhydramnios (too much amniotic fluid)
• Previous cesarean delivery

In one study of women who were given a diagnosis of face presentation during birth, researchers found that the babies with a face presentation were more likely preterm and Black/African American. As of 2022, the rate of preterm births was recorded highest for Black/African American infants.

If any of the above-mentioned factors are present, it’s important for physicians to appropriately monitor and assess the patient’s pregnancy and labor to ensure that it is progressing well and that no complications arise. Additionally, they must discuss risk factors with their patients.

Face presentation is diagnosed late in the first or second stage of labor by vaginal examination. The distinctive facial features of the baby’s chin, mouth, nose, and cheekbones can be felt. Face presentation is sometimes confused with breech presentation, in which the baby’s feet come out first (both presentations are characterized by soft tissues with an orifice). That is why it’s important that a very skilled physician is present during any potentially risky delivery with abnormal fetal position or presentation. Diagnosis can be confirmed by an ultrasound, which reveals a deflexed/hyperextended neck.

There is an increased risk of trauma to the baby when the face presents first. Therefore, the doctor should not internally manipulate (try to rotate) the baby. In addition, the physician must not use vacuum extraction or manual extraction (grasping the baby with hands) to pull the baby from the mother’s uterus. Midforceps (forcep extraction when the baby’s station is above +2 cm, but the head is engaged) should never be used. Outlet forceps should only be used by experienced physicians who understand the circumstances under which this is appropriate.

Abnormalities of the fetal heart rate and fetal distress occur more frequently with face presentation. In one study, 59% of infants in face presentation had variable heart decelerations, and 24% had late decelerations. Of the babies who were born live, 37% had 1-minute Apgar scores lower than 7, and 13% had 5-minute Apgar scores lower than 7. The majority of the low 5-minute Apgar scores were babies that had been in mentum posterior position .

For these reasons, it is crucial that babies are continuously monitored during labor, ideally with an external heart monitoring device.  An internal device may cause facial or eye injuries if improperly placed. If internal monitoring is needed, the electrode should be cautiously placed over a bony structure such as the forehead, jaw or cheekbone to minimize the risk of trauma.

It is always critical that doctors obtain a mother’s informed consent, which means discussing delivery options (vaginal, C-section, enhanced with labor drugs, etc.) with her and explaining the potential risks and benefits of each. This means that when a mother has a baby with face presentation, she must be given the option of a C-section versus a vaginal birth. One of the reasons a mother may opt for a C-section is to avoid the extensive facial bruising/trauma that is common in babies with face presentation. In addition to thoroughly explaining the risks and benefits of each type of delivery method, the physician must explain and obtain consent from the mother if forceps or oxytocin are used.

Oxytocin (Pitocin) is a labor drug that may be used in a face presentation with a normal fetus and abnormally slow progress, as long as the baby’s heart rate patterns remain reassuring. It’s important to note that there are certain risks associated with this drug, including uterine hyperstimulation. Hyperstimulation happens when contractions are too frequent or strong, which can injure the baby. Hyperstimulation also increases pressure on the blood vessels in the womb, which can deprive the baby of oxygen-rich blood.

Doctors must explain these risks and obtain consent before proceeding. However, in any face presentation, if progress in dilation and the baby’s descent stops despite adequate contractions, doctors must perform an emergency C-section. Failing to deliver in time puts the baby at risk of not getting enough oxygen. If the baby doesn’t get enough oxygen, it is at high risk of suffering a brain injury.

It can be frightening to learn that your baby is not in the correct or ideal position for birth. However, your doctors should always communicate changes, risks, and delivery plans with you. If at any point, your doctor fails to communicate with you or monitor you properly and it causes your child to suffer a brain injury, that is considered medical malpractice or negligence. If you believe that your child suffered an injury at birth that could have been prevented, our birth injury lawyers can help. 

Complications associated with face presentation include the following:

• Prolonged labor
• Facial trauma
• Facial edema (fluid build up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress/difficulty in ventilation due to airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• Low Apgar score

A baby may be at increased risk of complications if forceps or oxytocin are used during labor. Forceps can cause traumatic injury to the head, and oxytocin can deprive a baby of oxygen due to hyperstimulation (strong, frequent contractions). Trauma to the head and decreased oxygenation can cause permanent brain damage, such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy (CP), as well as fetal deaths. Fortunately, a child with HIE or cerebral palsy can survive, but depending on the severity of their injury, they may have severe disability and need 24/7 care. 

Because there are many complications associated with face presentation, it is essential that the baby is closely monitored and that delivery is handled by a physician with experience in this area. Furthermore, the physician must quickly proceed to a C-section delivery if there are any signs that the baby is in distress, labor is not progressing, or the baby fails to rotate to MA position. In addition, once a face presentation is diagnosed, the physician must check for “pelvic adequacy”. When the pelvis is inadequate (contracted/small), a C-section is recommended.

Since respiratory problems can occur in babies with face presentation, equipment and staff to perform intubation of the baby (placement of a breathing tube) should be readily available at the time of delivery.

Failure to follow any of these standards of care is negligence. If this negligence results in injury to the baby, it is medical malpractice. To learn more about bringing a medical malpractice claim for your child’s birth injury, complete the form below.