Face presentation at term: A forgotten issue

Omer L. Tapisiz1, Hakan Aytan1, Sadiman Kiykac Altinbas2, Feyza Arman1,Gorkem Tuncay1, Mustafa Besli1, Leyla Mollamahmutoglu1 and Nuri Danısman1

1Department of Obstetrics and Gynecology, Ministry of Health, Dr. Zekai Tahir Burak Women’s Health Education andResearch Hospital, and 2Department of Obstetrics and Gynecology, Ministry of Health, Etlik Zubeyde Hanim Women’s HealthTeaching and Research Hospital, Ankara, Turkey

Abstract

Aim: To determine factors associated with face presentation of term fetuses delivered.Methods: Of 34 480 consecutive, term deliveries of uncomplicated pregnancies within a 3-year period, all live,singleton term fetuses with cephalic presentation in which no lethal anomalies occurred that were diagnosedwith a face presentation were studied. Factors that may have contributed to the etiology of the presentationincluding age, parity and fetal size were evaluated. Ultrasonographic evaluation was recorded.Results: Fifty cases were diagnosed with an incidence of 0.14%. Parity was not associated with face presen-tation. Birthweight of 4000 g or more indicated an increased risk of approximately 2.9-fold, whereas fetusesweighing 3000–3499 g were found to have a relatively decreased risk of face presentation when compared withthe general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, respectively). With physicalexamination, only 70% were diagnosed correctly.Conclusion: Face presentation is a rare event and birthweight more than 4000 g was found to be associatedwith face presentation. Parity is not an associated factor.Key words: face presentation, birthweight, parity, term pregnancy.

Introduction

Face presentation is a rare event characterized by alongitudinal lie and full extension of the fetal head onthe neck with the occiput against the upper back. Thereported incidence ranges 0.14–0.54%.1–4 Diagnosis issuspected by abdominal palpation but may not bedetected on abdominal palpation only, especially if thementum is anterior. While the limbs may be palpatedon the side opposite to the occiput and the fetal heart isheard on the same side as the limbs are in a mentumanterior position, the fetal heart is difficult to hear asthe fetal chest is in contact with the maternal spine in amentum posterior position. On digital examination,

orbital ridge, orbits, saddle of the nose, mouth and chincan be palpated. However, face presentation is moreoften discovered by digital examination and confirmedby radiography or ultrasound with a view of hyperex-tended fetal neck. Causes of face presentation arenumerous, generally stemming from any factor thatfavors extension or prevents head flexion. Congenitalmalformations, especially anencephaly,5 high parityleading to pendulous abdomen,6 very large fetus,contracted pelvis or cephalopelvic disproportion,2,4,7

marked enlargement of the neck or coils of cord aboutthe neck in exceptional instances are noted factors.

There are only a few recent reports on this clinicalentity that may result in increased fetal morbidity and

Received: May 10 2013.Accepted: December 2 2013.Reprint request to: Dr Omer L. Tapisiz, 1425. Cadde, Hayat Sebla Evleri, C Blok no. 74, Cukurambar, Ankara, Turkey.Email: omertapisiz@yahoo.com.trDeclaration: All authors have contributed significantly to this study and all authors are in agreement with the content of themanuscript.

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doi:10.1111/jog.12369 J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1573–1577, June 2014

© 2014 The Authors 1573Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

mortality if not diagnosed early and managed properly.The aim of this study was to determine the factorsassociated with face presentation of term fetuses.

Methods

A retrospective study including 34 480 consecutiveterm deliveries of uncomplicated pregnancies in thedelivery unit of a research and education hospitalwithin a 3-year period was conducted. All live, single-ton term fetuses with cephalic presentation in which nolethal anomalies occurred and were diagnosed with aface presentation were included in the study. Multiplepregnancies were excluded from the analysis. The peri-natal data were collected from patient files and either aresident or an expert made the diagnosis. An experi-enced obstetrician confirmed all diagnoses. Variousfactors that might have contributed to the etiology ofthe presentation, including age, parity and fetal size,were evaluated. Inlet contraction was defined as adiagonal conjugate of less than 11.5 cm. Ultra-sonographic evaluation of the fetuses was recorded.The ethical committee approved this study protocol.

Data were stored and analyzed using SPSS version10.0 for Windows. Measurements of variables wereexpressed as means ± standard deviation for descrip-tive statistics and the level of statistical significance wasset at 0.05. Parity and birthweights were comparedbetween the face presentation group and all deliveriesusing Student’s t-test, χ2-test and Fisher’s exact test.

Results

During the study period, 50 cases of face presentationat term were diagnosed among 34 480 consecutivedeliveries with an incidence of 0.14%. Twenty-fourcases (48%) were primigravida, whereas 6% (n = 3)were grand multiparous (>4 deliveries). Parity was notfound to be significantly associated with face presenta-tion. Table 1 shows the distribution of parity in thestudy group and all deliveries. The age of the patientsranged 16–40 years with a mean of 27.24 ± 6.09 years.Most of the patients received prenatal care and had atleast one antenatal visit during their pregnancy. Noneof the patients had a history of cesarean deliverybecause of our elective cesarean section policy. None ofthe patients were manually rotated during delivery. Allinfants were delivered by cesarean section.

The mean gestational age was 39.1 ± 1.6 weeks. Themean birthweight was 3356.8 ± 562 g, ranging 2100–4340 g. The distribution of birthweights in the face pre-senting group and all deliveries is depicted in Table 2.Birthweight was found to be associated with face pre-sentation. Birthweight of 4000 g or more had anincreased risk of approximately 2.9-fold, whereasfetuses weighing 3000–3499 g were found to have arelatively decreased risk for face presentation whencompared with the general obstetrics group (P = 0.015and 0.001, risk ratio = 2.948 and 0.450, 95% confidenceinterval [CI] = 1.328–6.543 and 0.239–0.847, respec-tively) (Table 2).

Table 1 Comparison of parity in face presentation and whole obstetric population at the time of study

Facepresentinggroup

No. ofpatients(%)

Alldeliveries

No. ofpatients(%)

P RR 95% CI

Primipara 24 48 14 687 42.6 0.817 1.068 0.613–1.860Multiparous 23 46 17 492 50.7 0.503 0.827 0.475–1.440Grand multiparous 3 6 2 301 6.7 0.570 0.899 0.300–2.695

CI, confidence interval; RR, risk ratio.

Table 2 Comparison of birthweights in face presentation and whole obstetric population

Birthweight(g)

Facepresentinggroup

No. ofpatients(%)

Alldeliveries

No. ofpatients(%)

P RR 95% CI

2000–2499 2 4 1 292 3.7 0.563 1.070 0.260–4.3992500–2999 12 24 8 044 23.4 0.910 1.038 0.530–1.9863000–3499 13 26 15 114 43.8 0.011 0.450 0.239–0.8473500–3999 16 32 8 253 23.9 0.181 1.495 0.826–2.708≥4000 7 14 1 777 5.2 0.015 2.948 1.328–6.543

CI, confidence interval; RR, risk ratio.

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1574 © 2014 The AuthorsJournal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

As all term pregnancies were included in thestudy, there were no preterm deliveries and/or pre-mature rupture of membrane cases. Four cases of ges-tational diabetes mellitus (DM) were determined(8%), and there were no cases with pregestationalDM.

At the examination of fetal presentation and positionon admission, 26% of the cases were wrongly diag-nosed as vertex, 2% as breech and 2% as brow presen-tations; 70% were diagnosed correctly. In one patient,face presentation was determined only during thesecond stage of labor. In six patients, the diagnosis wasmade before onset of the active phase of labor. Twenty-four infants were in mentum posterior position, 12mentum anterior and 14 mentum transverse. Eightcases (16%) were both primigravida and had a diagonalconjugate of less than 11.5 cm with a mean birthweightof 3453.73 ± 101 g. When compared with the other42 cases without the inlet contraction, the meanbirthweight was 3338.33 ± 601 g and there was no sig-nificant difference with respect to birthweight(P = 0.410). However, when compared with other pri-migravida patients, there was a significant difference inbirthweights between these eight cases and theremaining 16 cases (3453.73 ± 101 vs 2833.12 ± 388,P = 0.001; 95% CI = 297.95–943.29).

Diagnosis was based on vaginal examination. Noabdominal X-ray was performed for confirmation. Allpatients had transabdominal ultrasound examinationfor determination of the fetal presentation, gestationalage and estimated fetal weight. Face presentation wassuspected in 23 (46%) of the cases. Among these cases,the view of hyperextension of the neck and deflexionwas observed in 11 cases (22%). In 27 cases (54%),vertex presentation was reported. Face presentationwas determined as the labor progressed in all of thesecases by digital examination, whereas in 10 of 27patients, a second confirmatory sonography was per-formed in the labor unit.

There was no perinatal mortality. Non-reassuringfetal heart rate pattern was determined in 14 (28%)cases. Among these cases, three infants with latedecelerations on tracing, in whom thick meconium inamnion were determined, and had low 1-min Apgarscores of 3, 5 and 6, respectively, needed neonatal inten-sive care unit support. There were no infants with a1-min Apgar of less than 3. One infant in this series hadspina bifida that was determined before deliveryduring ultrasonographic examination. He was a 2720-gmale infant with a 1- and 5-min Apgar score of 7 and 9,respectively. There were no other perinatal morbidities.

Among 50 neonates, 46% (n = 23) of them were maleand 54% (n = 27) were female.

Discussion

In the current study, face presentation with an inci-dence of 0.14% was found. Parity was not found to beassociated with face presentation. Birthweight of4000 g or more had an increased risk of approximately2.9-fold, whereas fetuses weighing 3000–3499 g werefound to have a relatively decreased risk of face pre-sentation when compared with the general obstetricsgroup.

A number of predisposing factors have beenimplicated by various authors in the etiology of facepresentation. Anencephaly, multiparity, fetal size andprematurity are the causative factors most frequentlycited.

Anencephaly and prematurity are out of the scope ofthis study as non-anomalous term infants wereenrolled.

Multiparity is another cited factor8–10 that was notborne out in this study. Especially grand multiparity,due to pendulous abdomen and increased maternalage, was suggested to be associated with face presen-tation.11 Cruikshank and White8 found that the inci-dence of grand multiparity was twice as high in casesof face presentation as in the general obstetric popula-tion. On the other hand, other reports, including thisone, have found no significant differences between thetwo groups with regard to multiparity.5,7,12,13 In thisstudy, we demonstrated that with respect to face pre-sentation, grand multiparity has a relative risk of 0.899with a 95% CI of 0.3–2.695 meaning that grand multi-parity is not associated with face presentation in terminfants without a lethal anomaly. This is similar to thefindings of Zayed et al.14

Fetal size was found to be of etiologic importance inthis study. Infants weighing more than 4000 g werefound to have an approximately 2.9-fold increased riskof face presentation when compared with infantsweighing less than 4000 g (95 % CI, 1.328–6.543).Infants weighing 3000–3500 g had an approximately0.45-fold decreased risk (95% CI, 0.239–0.847). In pre-vious reports suggesting fetal weight to be of etiologicimportance,7,8,15 mainly large fetuses (>4000 g) were ofconcern when anomalous infants were excluded. Facepresentation among term-size fetuses is common whenthere is some degree of pelvic inlet contraction. Theincidence of inlet contraction was found to be 10–40%in some studies.2,4,7 In this study, inlet contraction was

Face presentation of term fetuses

© 2014 The Authors 1575Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology

determined in 16% of the cases, all being primigravidawith a mean birthweight of 3453.73 ± 101 g, which wasnot significantly different. Prematurity was suggestedto be associated with face presentation by variousauthors,7,9,16,17 but not all would agree.3,8,12 In our series,while there were no cases with pregestational DM, fourcases of gestational DM were determined (8%) in theface presenting group. Among these four patients,three of them had babies weighing 4000 g or more; oneof them delivered a baby with a birthweight of 3890 g.

Early diagnosis is of utmost importance as perinatalmortality may be higher with late diagnosis.2 Diagnosisbased on physical and vaginal examinations requireexperience. Campbell reported that, in practice, fewerthan one in 20 infants with face presentation is diag-nosed abdominally18 and in various studies it is statedthat in fact only half of these infants are found to havea face presentation by any means prior to the secondstage of labor4,5,15 and half of the remaining cases areundiagnosed until delivery.4,7 In our study, 70% of thecases were diagnosed correctly by physical examina-tion. Most commonly, the presenting part was misdiag-nosed as vertex, followed by breech and brow, whichshould be considered in differential diagnosis.19

Diagnosis must be confirmed by radiography orultrasound. In this study, ultrasonography was used asconfirmation and no X-ray was performed. Theultrasonographic evaluations were performed eitherduring admission to the hospital or to the labor unitbased on indications from the physicians. If deflectionis included as a correct diagnosis, because furtherextension of an intermediate deflection to a fullyextended position may occur as labor progresses due toresistance exerted by the pelvic bony and soft tissues, itmay be difficult to demonstrate face or brow presenta-tion directly on ultrasound imaging because of thelocation of the fetal head in the birth canal inferior tothe maternal symphysis pubis resulting in suboptimalresolution.20 Although the advantages of a transvaginalscan with a better resolution of the presenting parts hasbeen emphasized, the risk of injury to the fetal orbitsand maternal discomfort was also noted. Additional tothese techniques, translabial ultrasound has been dem-onstrated as an advantageous technique with the docu-mentation of landmarks and the management of thesecond stage of labor.20,21 In our obstetrics practice,diagnostic ultrasound is widely used in the labor unitfor the estimation of fetal weight, presentation andgestational age.

Reported perinatal mortality, corrected for non-viable malformations and extreme prematurity, varies

from 0.6%18 to 5%,7 and cesarean delivery has beenreported in up to 67.1% of cases of face presentation.3,22

Except for mentum posterior cases, safe vaginal deliv-ery is suggested to be accomplished,23 and a trial oflabor with careful monitoring of fetal condition andprogress is not contraindicated unless macrosomia ora small pelvis is identified. In the published work,vaginal delivery rates differ from 56% to 84%(mentum anterior cases).14,24 In this study, all infantswere term and were delivered by cesarean regardlessof the position of the fetal chin. There were no mater-nal or fetal perinatal mortalities and morbidities. Therewas no laryngeal and/or tracheal edema resultingfrom pressures of the birth. The physicians decided toperform cesarean delivery as soon as they diagnosedface presentation without waiting for progression. Thisis probably because obstetricians harbor a fear thatthey may be criticized in hindsight for failure toperform an earlier cesarean delivery that ‘might have’resulted in a better outcome. All over the world, thecesarean delivery rate has become higher and cesar-ean delivery liberally used as part of a trend inmodern obstetrics, not only to achieve a safer deliveryand patient satisfaction, but also to achieve the protec-tion of the surgeon him/herself. The result is a moredefensive approach to practice, including a lowerthreshold for resorting to cesarean delivery.25 A limi-tation of our study is that it is retrospectively designedand therefore only a collection of existing data aboutthe issue. All in all, we believe that in the absence of acontracted pelvis, and with effective labor, successfulvaginal delivery may be performed as written in thetextbooks.26

In conclusion, face presentation has an incidence of0.14% at term and infants weighing more than 4000 ghave an approximately 2.9-fold increased risk for thismalpresentation. Term infants of average size (3000–3500 g) have a decreased risk in face presentation, witha relative risk of 0.45.

Disclosure

None declared.

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Face presentation of term fetuses

© 2014 The Authors 1577Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology