Face Presentation and Birth Injury

Normally, children are born head-first with the chin tucked towards the chest (vertex presentation). In a face presentation, the chin is not tucked and the neck is hyperextended. This can inhibit the engagement of the head and complicate the labor process. In some cases, a baby in face presentation can be delivered vaginally, but in other cases vaginal delivery is difficult and dangerous. Face presentation increases the risk of facial edema, skull molding, breathing problems (due to tracheal and laryngeal trauma), prolonged labor, fetal distress, spinal cord injuries, permanent brain damage, and neonatal death. Usually, medical staff conduct a vaginal examination to determine the position of the baby. If they suspect an abnormal presentation, they can confirm with an ultrasound and take action to properly handle the delivery of a baby in the face presentation. This includes additional monitoring and in some cases requires a C-Section. Because ventilation issues are more common in babies with face presentation, staff should be ready to intubate immediately after delivery (1).

Baby in utero in face presentation.

Risk factors and causes of face presentation

Conditions that may increase the likelihood of a face presentation include the following (1, 2, 3, 4):

Diagnosing face presentation

Face presentation is diagnosed late in the first or second stage of labor by vaginal examination. The distinctive facial features of the chin, mouth, nose, and cheekbones can be felt.  Face presentation is sometimes confused with breech presentation (because both are characterized by soft tissues with an orifice), which is why it is imperative that a very skilled physician be present during any potentially risky delivery or malpresentation. Diagnosis can be confirmed by an ultrasound, which reveals a deflexed/hyperextended neck (1).

Face presentation and delivery

There are three types of face presentation:

  • Mentum anterior (MA). In this position, the chin is facing the front of the mother, 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 (MP). In this position, the chin is facing the mother’s back.  The baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this (however, the baby may spontaneously rotate into mentum anterior position) . Typically, a C-section is indicated, but there are certain circumstances under which vaginal delivery may be attempted (e.g. the mother is multiparous, the infant in face presentation is relatively small compared to her other children, fetal monitoring is reassuring, and the baby is progressing in labor). Regardless, the medical team should be prepared to perform a prompt C-section if there are any complications.
  • Mentum transverse (MT).  In this position, 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. If labor is progressing and the fetal heart monitor is reassuring when face presentation is present, physician intervention may not be necessary since many MP and MT positions convert to MA.  Oxytocin (Pitocin) augmentation may be used in a face presentation with a normal fetus and abnormally slow progress, as long as fetal heart rate patterns remain reassuring (although there are certain risks associated with this drug, including uterine tachysystole). Of course, in any face presentation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section.

There is an increased risk of trauma to the baby when the face presents first, and the physician should not internally manipulate (try to rotate) the baby.  In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to pull the baby from the uterine cavity.  Furthermore, 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 (1).

Abnormalities of the fetal heart rate 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 (5).

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 (1).

It is always critical that doctors obtain a mother’s informed consent, which means discussing delivery options (vaginal, C-section, enhanced with oxytocin, etc.) with her and explaining the potential risks and benefits of each.  Failure to do so constitutes negligence.

Baby facing sideways in pelvis / birth canal.

Complications and side effects of face presentation

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 uterine tachysystole/hyperstimulation (strong, frequent contractions). Hyperstimulation increases pressure on the blood vessels in the womb, which can deprive the baby of oxygen-rich blood.

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.

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Standards of care, medical malpractice, and face presentation

Informed consent must be given during all medical procedures. 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.

Because there are many complications associated with face presentation, it is essential that the baby be 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 of fetal distress, labor is not progressing, or the baby fails to convert (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 (1).

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.

Trusted birth injury attorneys

If your baby has HIE, cerebral palsy, periventricular leukomalacia (PVL), developmental delays, a seizure disorder, or any other birth injury, we may be able to help. Unlike other firms, the attorneys at ABC Law Centers (Reiter & Walsh, P.C.) focus solely on birth injury cases and have been helping children throughout the nation since 1997. During your free legal consultation, our attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you. Moreover, you pay nothing throughout the entire legal process unless we win or favorably settle your case.

“Reiter and Walsh goes above and beyond the norm in getting their clients the best possible results. Each client is treated with respect and compassion, and they are truly sensitive to what it means to help a family whose child has been injured.” -Client review from 11/23/2015

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Helpful resources

  1. Julien, S., Lockwood, C. J., & Barss, V. A. (2014). Face and brow presentations in labor. Up to date.
  2. Duff, P. (1981). Diagnosis and management of face presentation. Obstetrics and gynecology, 57(1), 105-112.
  3. S. BHAL NJ DAVIES T. CHUNG, P. (1998). A population study of face and brow presentation. Journal of Obstetrics and Gynaecology, 18(3), 231-235.
  4. Shaffer, B. L., Cheng, Y. W., Vargas, J. E., Laros Jr, R. K., & Caughey, A. B. (2006). Face presentation: predictors and delivery route. American journal of obstetrics and gynecology, 194(5), e10-e12.
  5. Benedetti, T. J., Lowensohn, R. I., & Truscott, A. M. (1980). Face presentation at term. Obstetrics and gynecology, 55(2), 199-202.

The above information is intended to be an educational resource. It is not meant to be, and should not be interpreted as, medical advice.