Face Presentation and Birth Injury
Normally, children are born head-first with the chin tucked towards the chest. In a face presentation, the chin is not tucked, inhibiting the engagement of the head and slowing down the labor process. This presentation runs risks like face and skull trauma/swelling, prolonged labor, fetal distress and breathing-related complications including HIE. Usually, medical staff use a finger to examine 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 typically the performance of a C-Section. Because ventilation issues are more common in babies with face presentation, staff should be ready to intubate immediately after delivery.
Under normal circumstances, a baby is born head first, with the top part of the head exiting the birth canal first. In this position, the head is flexed, and the chin is tucked in towards the chest. A face presentation, on the other hand, occurs when the baby’s face is the first part of the baby to present at the opening of the birth canal. When a baby is in face presentation this means that the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. Face presentation inhibits head engagement and descent of the baby through the birth canal. If face presentation is mismanaged, serious birth complications can occur, such as facial and skull trauma and swelling, prolonged labor, fetal compromise, abnormal fetal heart rate patterns, and even death of the baby. Trauma during labor can cause swelling (with fluid build-up, called edema) in the upper airway. This can result in respiratory distress in the baby, which can cause complications, such as overventilation injuries, hypoxia and hypoxic ischemic encephalopathy (HIE). Traumatic injury to the head or oxygen deprivation during labor and delivery can lead to brain bleeds (hemorrhages), HIE, cerebral palsy and hydrocephalus.
What Causes Face Presentation?
Causative factors associated with face presentation are similar to those that can lead to any malpresentation of the baby (such as breech position), and those that prevent the head from flexing or that favor head extension. Conditions that may increase the likelihood of a face presentation include the following:
- Multiple gestations (pregnant with more than one baby, e.g., twins, triplets, etc.)
- Grand multiparity (woman has given birth 5 or more times)
- Fetal malformations (Hydrocephalus and neck masses may account for as many as 60% of cases of face presentation.)
- Prematurity / low birth weight
- Polyhydramnios (too much fluid in the womb)
- Cephalopelvic disproportion (CPD) (mismatch in size between mother’s pelvis and baby’s head or body)
- Macrosomia (large baby)
- Multiple nuchal cords (umbilical cord wrapped around baby’s neck)
- Contracted maternal pelvis (pelvis is abnormally small in such a way that interferes with normal delivery)
- Previous C-section
Diagnosing Face Presentation
Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix. On digital exam, the distinctive facial features of the mouth, nose and cheek bones can be felt. The facial presentation has a triangular configuration from the mouth to the bony ridges near the cheekbones, compared to the breech presentation of the anus and female genitalia. Face presentation is sometimes confused with breech presentation, 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.
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.
- Mentum posterior (MP). The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, 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. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
- Mentum transverse (MT). The baby’s chin is facing the side of the birth canal in this position.
Informed consent and delivery options must always be given when there is a face presentation. Trauma almost always occurs with vaginal delivery so parents must be warned that their baby will be very bruised and that a C-section is available to avoid the trauma.
Babies with face presentation can be delivered vaginally under certain circumstances:
- MA Position: If the baby is in MA position, it may be possible to deliver vaginally.
- MP Position: For term-sized babies in persistent MP position, vaginal delivery is unsafe due to the size of the presenting part of the baby compared to the size of the mother’s pelvis. In this case, the baby must be delivered by C-section. About 35% of babies in MP position spontaneously convert to MA position during the course of labor, which makes vaginal delivery possible.
- MT Position: Terms-sized babies in persistent MT position must be delivered by C-section. However, many babies in the MT position convert to the MA position during the labor process, which makes vaginal delivery possible.
If the baby is in the MA position and vaginal delivery is thus able to proceed, engagement of the presenting part of the baby probably won’t occur until the face is at a +2 station (in a vertex presentation, engagement occurs at a 0 station). In a +2 station, the baby’s head is 2 centimeters below the ischial spines, which are located just above the tailbone. In other words, the head has entered the pelvis and is 2 cm away from crowning.
Indeed, the management of face presentation requires close observation of the progress of labor due to the high incidence of CPD when face presentation is present. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position.
If labor is progressing when face presentation is present, physician intervention may not be necessary since many MP and MT positions convert to MA. Rotation to MA may not occur until the presenting part of the baby is on the pelvic floor (at the area of the soft tissues that enclose the pelvic outlet). Of course, in any face presentation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. Oxytocin augmentation may be used in the setting of face presentation with a normal fetus and abnormally slow progress, as long as fetal heart rate patterns remain reassuring. However, when face presentation occurs, experts recommend liberal use of C-section.
There is an increased risk of trauma to the baby when the face presents, 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 extract 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. Outlet forceps are used when the scalp is visible without separating the labia, and the head is in a straight forward or backward position, or in a very slight rotation from one of these positions. When forceps are used, there is an increased risk of trauma.
Abnormalities of the fetal heart rate occur more frequently with face presentation. In one large study, 53% of face presentations had severely poor heart rate tracings (variable and late decelerations) during labor, and only 14% of babies in the study had normal heart tracings. Moreover, 13% of the babies being studied had a low five-minute Apgar score (this scoring quickly assesses the health of a newborn; the baby’s skin color / complexion, pulse rate, reflex irritability, muscle tone and breathing are assessed). For these reasons, it is crucial that babies be 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 cheek bone to minimize the risk of trauma.
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 (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
- Spinal cord injury
- Abnormal fetal heart rate patterns
- 10-fold increase in fetal compromise
- Decreased Apgar score
- Increased number of fetal deaths
A baby may further 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 of the mother’s uterus (womb), which can increase the strength and frequency of 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 HIE, cerebral palsy, brain hemorrhages, periventricular leukomalacia (PVL) and hydrocephalus.
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 typical 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.
Since difficulty in ventilation 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 | Reiter & Walsh, P.C.’s Experience Handling Face Presentation Cases
If your baby has HIE, periventricular leukomalacia (PVL), developmental delays, a seizure disorder, cerebral palsy or any other birth injury, email or call the award winning attorneys at Reiter & Walsh ABC Law Centers. Unlike other firms, the attorneys at Reiter & Walsh focus solely on birth injury cases and have been helping children throughout the nation since 1
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Video: Birth Injuries, Neonatal Brain Damage and Medical Malpractice
Watch a video of birth injury lawyer Jesse Reiter discussing traumatic deliveries, such as mismanaged face presentation, and how birth trauma and birth asphyxia can cause lifelong conditions such as cerebral palsy.
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