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Obstetrics                                                                                                                                Dr. eman 

 

Face & brow 

presentation 

 
 
 

Face presentation 

Face presentation occurs in approximately 1:500 to 1000 deliveries.  
The general causes for malpresentations apply for face presentation: 

  There is a small chance of congenital abnormality such as anencephaly. 
  thyroid goitre and this need to be excluded by an ultrasound examination.  
  In the majority it is due to extension of the head in a normal fetus. 
  Prematurity. 

 
 
Diagnosis :
 The possibility of face presentation can be suspected on abdominal 
examination if the prominence of the head is palpable more prominently at a 
higher level on the opposite side of the fetal spine. In a thin woman a deep 
groove may be palpable between the occiput and the back.  
 
on vaginal examination when the nose, eyes and the hard gum margins are 
palpated. 
Difficulties may be encountered in recognizing the presentation when the 
membranes are intact especially if the presenting part is high or in the presence 
of oedema due to few hours of labour. 
 


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Obstetrics                                                                                                                                Dr. eman 

 

 

 

 

 

 


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Obstetrics                                                                                                                                Dr. eman 

 

mechanism of labour

 The transverse submento-bregmatic diameter enters the pelvis. 
 In the majority it rotates forwards to be in the mento-anterior position with the 
chin behind the symphysis pubis. The presenting lateral ( biparietal – 9.5 cm) 
and antero-posterior (submentobregmatic – 9.5 cm) diameters are conducive 
for vaginal delivery 
 
Descent is possible posterior in the pelvis when the position is mento-anterior 
because of large space in the lateral sacral area.  
The head is born with the chin emerging under the pubic arch followed by the 
forehead over the perineum 
 
If the face rotates to a mento-posterior position, although the diameters are the 
same as mento-anterior, the lateral dimensions of the frontal bones are large 
and do not permit descent behind the narrow retro-pubic arch and hence a CS is 
advisable. 
 
Even with favourable mento-lateral or anterior position if there is failure to 
progress the safer option for the fetus is CS in the first stage. In late second 
stage of labour with the face at the outlet in mento-anterior or lateral position 
outlet forceps delivery can be carried out by skilled personal if spontaneous 
delivery is not forthcoming.  
 

Brow presentation 

In brow presentation the head is half extended and presents to the pelvis with 
the largest anteroposterior diameter (mento-vertical-13 cm).  
The incidence is rare and is about 1 in 1500–3000 deliveries. 
 
The lower most part of the head that is palpable on vaginal examination is the 
forehead but it is termed as brow because the orbital ridges and the bridge of 
the nose are palpable . 
 
The presentation may correct itself in labour by flexion and present as a vertex 
or undergo further extension and presents a face and may result in vaginal 
delivery.  


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Obstetrics                                                                                                                                Dr. eman 

 

 
In early labour, preparations should be undertaken for CS and time allowed to 
see whether flexion or extension would take place. 
  
Failure to progress in the next few hours in labour with the persistence of brow 
presentation is an indication for CS and not for augmentation of labour with 
oxytocin 
 
In extreme prematurity the fetus may descend as a brow and deliver as a brow 
or may convert to a face or vertex after it reaches the pelvic floor.  
Although vaginal delivery is possible in preterm fetuses there is a possibility of 
spinal cord damage and a CS is preferred.  
 
Complications in labour include cord prolapse with membrane rupture and rare 
incidence of uterine rupture in neglected cases. 
 
In cases of intrauterine fetal death and in those with lethal malformation in the 
extreme preterm period, where injury to the fetus is not a concern, labour may 
be allowed if there is good progress in anticipation of vaginal delivery. 
 
At term, destructive operations and vaginal delivery may be possible for cases of 
fetal death or lethal anomaly but CS is still preferred in the developed world for 
fear of genital tract trauma in the hands of those who are not familiar with 
these techniques. 

 
Shoulder presentation: 

Causes 
1-In multiparous women with singleton pregnancies shoulder presentation is 
more common without any cause due to the laxity of the uterus. 
2-Preterm. 
3-congenital fetal or uterine malformation, fibroids, placenta praevia and 
polyhydramnios. 
The incidence at term is about1:400. 

On abdominal examination

-SFH is less than expected for gestation 
-Broader uterus  


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Obstetrics                                                                                                                                Dr. eman 

 

-Empty lower uterine segment 

 

 
Transverse lie with shoulder presentation in the antenatal period corrects itself 
to longitudinal lie with the onset of labour due to increased muscular tone of 
the uterus.if rupture of membranes take place with the fetus in the transverse 
lie, cord prolapse, shoulder presentation and arm prolapse are likely possibilities 
with progressive cervical dilatation.  

 

 
- In early labour with the membranes intact, one could wait in anticipation of 
spontaneous or assisted correction to longitudinal lie while making all the 
preparation for CS. If the membranes rupture and the fetus is still in the 
transverse lie, CS should be performed to avoid injury to the fetus or the uterus. 
- In cases where the diagnosis is made late the fetus may be impacted in the 
transverse lie and safe delivery may be only possible by a CS with a midline 
vertical incision. It may be possible to deliver the fetus through a lower segment 
transverse incision with acute uterine relaxation using a short acting drug (e.g. 
0.25 mg terbutaline in 5 cc saline given IV over 5 min) . 
- Following this treatment if the uterus does not contract despite oxytocics, a 
small dose of beta blocker such as Propranolol 1 mg IV may be needed to 


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Obstetrics                                                                                                                                Dr. eman 

 

contract the uterus and to avoid post-partum haemorrhage . Labour and 
spontaneous vaginal delivery is possible in extreme preterm and macerated 
fetuses. 
 

Compound presentation

In a compound presentation, an extremity prolapses alongside the presenting 
part, and both present simultaneously in the pelvis.

 

Incidence 1 every 1000. 

Causes of compound presentations are conditions that prevent complete 
occlusion of the pelvic inlet by the fetal head, including preterm labor. 

 

 

Management: 

In most cases, the prolapsed part should be left alone, because most often it will 
not interfere with labor. If the arm is prolapsed alongside the head, the 
condition should be observed closely to ascertain whether the arm retracts out 
of the way with descent of the presenting part. 
If it fails to retract and if it appears to prevent descent of the head, the 
prolapsed arm should be pushed gently upward and the head simultaneously 
downward by fundal pressure. 

Prognosis

In general, rates of perinatal mortality and morbidity are increased as a result of 
concomitant preterm delivery, prolapsed cord, and traumatic obstetrical 
procedures. 
 
By:TWANA NAWZAD 




رفعت المحاضرة من قبل: Mohammed Musa
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