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doi:10.1111/jog.12369
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1573–1577, June 2014
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 Danıs¸man1 1
Department of Obstetrics and Gynecology, Ministry of Health, Dr. Zekai Tahir Burak Women’s Health Education and Research Hospital, and 2Department of Obstetrics and Gynecology, Ministry of Health, Etlik Zubeyde Hanim Women’s Health Teaching 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 diagnosed with a face presentation were studied. Factors that may have contributed to the etiology of the presentation including 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 presentation. Birthweight of 4000 g or more indicated an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk of face presentation when compared with the general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, respectively). With physical examination, only 70% were diagnosed correctly. Conclusion: Face presentation is a rare event and birthweight more than 4000 g was found to be associated with 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 a longitudinal lie and full extension of the fetal head on the neck with the occiput against the upper back. The reported incidence ranges 0.14–0.54%.1–4 Diagnosis is suspected by abdominal palpation but may not be detected on abdominal palpation only, especially if the mentum is anterior. While the limbs may be palpated on the side opposite to the occiput and the fetal heart is heard on the same side as the limbs are in a mentum anterior position, the fetal heart is difficult to hear as the fetal chest is in contact with the maternal spine in a mentum posterior position. On digital examination,
orbital ridge, orbits, saddle of the nose, mouth and chin can be palpated. However, face presentation is more often discovered by digital examination and confirmed by radiography or ultrasound with a view of hyperextended fetal neck. Causes of face presentation are numerous, generally stemming from any factor that favors extension or prevents head flexion. Congenital malformations, especially anencephaly,5 high parity leading to pendulous abdomen,6 very large fetus, contracted pelvis or cephalopelvic disproportion,2,4,7 marked enlargement of the neck or coils of cord about the neck in exceptional instances are noted factors. There are only a few recent reports on this clinical entity 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: [email protected] Declaration: All authors have contributed significantly to this study and all authors are in agreement with the content of the manuscript.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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O. L. Tapisiz et al.
mortality if not diagnosed early and managed properly. The aim of this study was to determine the factors associated with face presentation of term fetuses.
Methods A retrospective study including 34 480 consecutive term deliveries of uncomplicated pregnancies in the delivery unit of a research and education hospital within a 3-year period was conducted. All live, singleton term fetuses with cephalic presentation in which no lethal anomalies occurred and were diagnosed with a face presentation were included in the study. Multiple pregnancies were excluded from the analysis. The perinatal data were collected from patient files and either a resident or an expert made the diagnosis. An experienced obstetrician confirmed all diagnoses. Various factors that might have contributed to the etiology of the presentation, including age, parity and fetal size, were evaluated. Inlet contraction was defined as a diagonal conjugate of less than 11.5 cm. Ultrasonographic evaluation of the fetuses was recorded. The ethical committee approved this study protocol. Data were stored and analyzed using SPSS version 10.0 for Windows. Measurements of variables were expressed as means ± standard deviation for descriptive statistics and the level of statistical significance was set at 0.05. Parity and birthweights were compared between the face presentation group and all deliveries using Student’s t-test, χ2-test and Fisher’s exact test.
Results During the study period, 50 cases of face presentation at term were diagnosed among 34 480 consecutive deliveries with an incidence of 0.14%. Twenty-four cases (48%) were primigravida, whereas 6% (n = 3) were grand multiparous (>4 deliveries). Parity was not found to be significantly associated with face presentation. Table 1 shows the distribution of parity in the study group and all deliveries. The age of the patients ranged 16–40 years with a mean of 27.24 ± 6.09 years. Most of the patients received prenatal care and had at least one antenatal visit during their pregnancy. None of the patients had a history of cesarean delivery because of our elective cesarean section policy. None of the patients were manually rotated during delivery. All infants were delivered by cesarean section. The mean gestational age was 39.1 ± 1.6 weeks. The mean birthweight was 3356.8 ± 562 g, ranging 2100– 4340 g. The distribution of birthweights in the face presenting group and all deliveries is depicted in Table 2. Birthweight was found to be associated with face presentation. Birthweight of 4000 g or more had an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk for face presentation when compared with the general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, 95% confidence interval [CI] = 1.328–6.543 and 0.239–0.847, respectively) (Table 2).
Table 1 Comparison of parity in face presentation and whole obstetric population at the time of study
Primipara Multiparous Grand multiparous
Face presenting group
No. of patients (%)
All deliveries
No. of patients (%)
P
RR
95% CI
24 23 3
48 46 6
14 687 17 492 2 301
42.6 50.7 6.7
0.817 0.503 0.570
1.068 0.827 0.899
0.613–1.860 0.475–1.440 0.300–2.695
CI, confidence interval; RR, risk ratio.
Table 2 Comparison of birthweights in face presentation and whole obstetric population Birthweight (g)
Face presenting group
No. of patients (%)
All deliveries
No. of patients (%)
P
RR
95% CI
2000–2499 2500–2999 3000–3499 3500–3999 ≥4000
2 12 13 16 7
4 24 26 32 14
1 292 8 044 15 114 8 253 1 777
3.7 23.4 43.8 23.9 5.2
0.563 0.910 0.011 0.181 0.015
1.070 1.038 0.450 1.495 2.948
0.260–4.399 0.530–1.986 0.239–0.847 0.826–2.708 1.328–6.543
CI, confidence interval; RR, risk ratio.
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Face presentation of term fetuses
As all term pregnancies were included in the study, there were no preterm deliveries and/or premature rupture of membrane cases. Four cases of gestational diabetes mellitus (DM) were determined (8%), and there were no cases with pregestational DM. At the examination of fetal presentation and position on admission, 26% of the cases were wrongly diagnosed as vertex, 2% as breech and 2% as brow presentations; 70% were diagnosed correctly. In one patient, face presentation was determined only during the second stage of labor. In six patients, the diagnosis was made before onset of the active phase of labor. Twentyfour infants were in mentum posterior position, 12 mentum anterior and 14 mentum transverse. Eight cases (16%) were both primigravida and had a diagonal conjugate of less than 11.5 cm with a mean birthweight of 3453.73 ± 101 g. When compared with the other 42 cases without the inlet contraction, the mean birthweight was 3338.33 ± 601 g and there was no significant difference with respect to birthweight (P = 0.410). However, when compared with other primigravida patients, there was a significant difference in birthweights between these eight cases and the remaining 16 cases (3453.73 ± 101 vs 2833.12 ± 388, P = 0.001; 95% CI = 297.95–943.29). Diagnosis was based on vaginal examination. No abdominal X-ray was performed for confirmation. All patients had transabdominal ultrasound examination for determination of the fetal presentation, gestational age and estimated fetal weight. Face presentation was suspected in 23 (46%) of the cases. Among these cases, the view of hyperextension of the neck and deflexion was observed in 11 cases (22%). In 27 cases (54%), vertex presentation was reported. Face presentation was determined as the labor progressed in all of these cases by digital examination, whereas in 10 of 27 patients, a second confirmatory sonography was performed in the labor unit. There was no perinatal mortality. Non-reassuring fetal heart rate pattern was determined in 14 (28%) cases. Among these cases, three infants with late decelerations on tracing, in whom thick meconium in amnion were determined, and had low 1-min Apgar scores of 3, 5 and 6, respectively, needed neonatal intensive care unit support. There were no infants with a 1-min Apgar of less than 3. One infant in this series had spina bifida that was determined before delivery during ultrasonographic examination. He was a 2720-g male 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 male and 54% (n = 27) were female.
Discussion In the current study, face presentation with an incidence of 0.14% was found. Parity was not found to be associated with face presentation. Birthweight of 4000 g or more had an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk of face presentation when compared with the general obstetrics group. A number of predisposing factors have been implicated by various authors in the etiology of face presentation. Anencephaly, multiparity, fetal size and prematurity are the causative factors most frequently cited. Anencephaly and prematurity are out of the scope of this study as non-anomalous term infants were enrolled. Multiparity is another cited factor8–10 that was not borne out in this study. Especially grand multiparity, due to pendulous abdomen and increased maternal age, was suggested to be associated with face presentation.11 Cruikshank and White8 found that the incidence of grand multiparity was twice as high in cases of face presentation as in the general obstetric population. On the other hand, other reports, including this one, have found no significant differences between the two groups with regard to multiparity.5,7,12,13 In this study, we demonstrated that with respect to face presentation, grand multiparity has a relative risk of 0.899 with a 95% CI of 0.3–2.695 meaning that grand multiparity is not associated with face presentation in term infants without a lethal anomaly. This is similar to the findings of Zayed et al.14 Fetal size was found to be of etiologic importance in this study. Infants weighing more than 4000 g were found to have an approximately 2.9-fold increased risk of face presentation when compared with infants weighing less than 4000 g (95 % CI, 1.328–6.543). Infants weighing 3000–3500 g had an approximately 0.45-fold decreased risk (95% CI, 0.239–0.847). In previous reports suggesting fetal weight to be of etiologic importance,7,8,15 mainly large fetuses (>4000 g) were of concern when anomalous infants were excluded. Face presentation among term-size fetuses is common when there is some degree of pelvic inlet contraction. The incidence of inlet contraction was found to be 10–40% in some studies.2,4,7 In this study, inlet contraction was
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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O. L. Tapisiz et al.
determined in 16% of the cases, all being primigravida with a mean birthweight of 3453.73 ± 101 g, which was not significantly different. Prematurity was suggested to be associated with face presentation by various authors,7,9,16,17 but not all would agree.3,8,12 In our series, while there were no cases with pregestational DM, four cases of gestational DM were determined (8%) in the face presenting group. Among these four patients, three of them had babies weighing 4000 g or more; one of them delivered a baby with a birthweight of 3890 g. Early diagnosis is of utmost importance as perinatal mortality may be higher with late diagnosis.2 Diagnosis based on physical and vaginal examinations require experience. Campbell reported that, in practice, fewer than one in 20 infants with face presentation is diagnosed abdominally18 and in various studies it is stated that in fact only half of these infants are found to have a face presentation by any means prior to the second stage of labor4,5,15 and half of the remaining cases are undiagnosed until delivery.4,7 In our study, 70% of the cases were diagnosed correctly by physical examination. Most commonly, the presenting part was misdiagnosed as vertex, followed by breech and brow, which should be considered in differential diagnosis.19 Diagnosis must be confirmed by radiography or ultrasound. In this study, ultrasonography was used as confirmation and no X-ray was performed. The ultrasonographic evaluations were performed either during admission to the hospital or to the labor unit based on indications from the physicians. If deflection is included as a correct diagnosis, because further extension of an intermediate deflection to a fully extended position may occur as labor progresses due to resistance exerted by the pelvic bony and soft tissues, it may be difficult to demonstrate face or brow presentation directly on ultrasound imaging because of the location of the fetal head in the birth canal inferior to the maternal symphysis pubis resulting in suboptimal resolution.20 Although the advantages of a transvaginal scan with a better resolution of the presenting parts has been emphasized, the risk of injury to the fetal orbits and maternal discomfort was also noted. Additional to these techniques, translabial ultrasound has been demonstrated as an advantageous technique with the documentation of landmarks and the management of the second stage of labor.20,21 In our obstetrics practice, diagnostic ultrasound is widely used in the labor unit for the estimation of fetal weight, presentation and gestational age. Reported perinatal mortality, corrected for nonviable malformations and extreme prematurity, varies
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from 0.6%18 to 5%,7 and cesarean delivery has been reported in up to 67.1% of cases of face presentation.3,22 Except for mentum posterior cases, safe vaginal delivery is suggested to be accomplished,23 and a trial of labor with careful monitoring of fetal condition and progress is not contraindicated unless macrosomia or a 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 infants were term and were delivered by cesarean regardless of the position of the fetal chin. There were no maternal or fetal perinatal mortalities and morbidities. There was no laryngeal and/or tracheal edema resulting from pressures of the birth. The physicians decided to perform cesarean delivery as soon as they diagnosed face presentation without waiting for progression. This is probably because obstetricians harbor a fear that they may be criticized in hindsight for failure to perform an earlier cesarean delivery that ‘might have’ resulted in a better outcome. All over the world, the cesarean delivery rate has become higher and cesarean delivery liberally used as part of a trend in modern obstetrics, not only to achieve a safer delivery and patient satisfaction, but also to achieve the protection of the surgeon him/herself. The result is a more defensive approach to practice, including a lower threshold for resorting to cesarean delivery.25 A limitation of our study is that it is retrospectively designed and therefore only a collection of existing data about the issue. All in all, we believe that in the absence of a contracted pelvis, and with effective labor, successful vaginal delivery may be performed as written in the textbooks.26 In conclusion, face presentation has an incidence of 0.14% at term and infants weighing more than 4000 g have an approximately 2.9-fold increased risk for this malpresentation. Term infants of average size (3000– 3500 g) have a decreased risk in face presentation, with a relative risk of 0.45.
Disclosure None declared.
References 1. Johnson CE. Abnormal fetal presentations. Lancet 1964; 84: 317–323. 2. Copeland GN, Nicks FI, Christakos AC. Face and brow presentations. N C Med J 1968; 29: 507–510. 3. Duff P. Diagnosis and management of face presentation. Obstet Gynecol 1981; 57: 105–112.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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4. Magid R, Gillespie CF. Face and brow presentation. Obstet Gynecol 1957; 9: 450–457. 5. Salzmann B, Soled M, Gilmour T. Face presentation. Obstet Gynecol 1960; 16: 106–112. 6. Fuchs K, Peretz BA, Marcovici R, Paldi E, Timor-Tritsh I. The ‘grand multipara’ – is it a problem? A review of 5785 cases. Int J Gynaecol Obstet 1985; 23: 321–326. 7. Dede JA, Friedman EA. Face presentation. Am J Obstet Gynecol 1963; 87: 515–524. 8. Cruikshank DP, White CA. Obstetric malpresentations. Twenty years’ experience. Am J Obstet Gynecol 1973; 116: 1097–1104. 9. Hellman LM, Epperson JWW, Connally F. Face and brow presentation. Am J Obstet Gynecol 1950; 59: 831–842. 10. Groenig DC. Face presentation. Obstet Gynecol 1953; 2: 495– 499. 11. Schwartz Z, Dgani R, Lancet M, Kessler I. Face presentation. Aust NZ J Obstet Gynaecol 1986; 26: 172–176. 12. Morris N. Face and brow presentation. J Obstet Gynecol Br Emp 1953; 60: 44–51. 13. Parikh MA. Face presentation. J Obstet Gynecol India 1960; 10: 456–459. 14. Zayed F, Amarin Z, Obeidat N, Alchalabi H, Lataifeh I. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet 2008; 278: 427– 430. 15. Cucco UP. Face presentation. Am J Obstet Gynecol 1966; 94: 1085–1092. 16. Posner AC, Fridman S, Posner LB. Modern trends in the management of face and brow presentation. Surg Gynecol Obstet 1957; 104: 485–490.
17. Shaffer B, Cheng YW, Vargas JE, Laros RK, Caughey AB. Face presentation: Predictors and delivery route. Am J Obstet Gynecol 2006; 194: e10–e12. 18. Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol 1965; 5: 231–234. 19. Gomez HE, Denen EH. Face presentation. Obstet Gynecol 1956; 8: 103–106. 20. Lau WL, Cho LY, Leung WC. Intrapartum translabial ultrasound demonstration of face presentation during first stage of labor. J Obstet Gynaecol Res 2011; 37: 1868–1871. 21. Yeo L, Romero R. Sonographic evaluation in the second stage of labor to improve the assessment of labor progress and its outcome. Ultrasound Obstet Gynecol 2009; 33: 235– 238. 22. Bashiri A, Burstein E, Bar-David J, Levy A, Mazor M. Face and brow presentation: Independent risk factors. J Matern Fetal Neonatal Med 2008; 21: 357–360. 23. Ducarme G, Ceccaldi PF, Chesnoy V, Robinet G, Gabriel R. Face presentation: Retrospective study of 32 cases at term. Gynecol Obstet Fertil 2006; 34: 393–396. 24. Bhal PS, Davies NJ, Chung T. A population study of face and brow presentation. J Obstet Gynaecol 1998; 18: 231– 235. 25. NIH consensus development statement on cesarean childbirth. The Cesarean Birth Task Force. Obstet Gynecol 1981; 57: 537–545. 26. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Abnormal Delivery. Williams Obstetrics, 23rd edn. New York: The McGraw-Hill Companies, 2010; 464– 489.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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doi:10.1111/jog.12369
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1573–1577, June 2014
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 Danıs¸man1 1
Department of Obstetrics and Gynecology, Ministry of Health, Dr. Zekai Tahir Burak Women’s Health Education and Research Hospital, and 2Department of Obstetrics and Gynecology, Ministry of Health, Etlik Zubeyde Hanim Women’s Health Teaching 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 diagnosed with a face presentation were studied. Factors that may have contributed to the etiology of the presentation including 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 presentation. Birthweight of 4000 g or more indicated an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk of face presentation when compared with the general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, respectively). With physical examination, only 70% were diagnosed correctly. Conclusion: Face presentation is a rare event and birthweight more than 4000 g was found to be associated with 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 a longitudinal lie and full extension of the fetal head on the neck with the occiput against the upper back. The reported incidence ranges 0.14–0.54%.1–4 Diagnosis is suspected by abdominal palpation but may not be detected on abdominal palpation only, especially if the mentum is anterior. While the limbs may be palpated on the side opposite to the occiput and the fetal heart is heard on the same side as the limbs are in a mentum anterior position, the fetal heart is difficult to hear as the fetal chest is in contact with the maternal spine in a mentum posterior position. On digital examination,
orbital ridge, orbits, saddle of the nose, mouth and chin can be palpated. However, face presentation is more often discovered by digital examination and confirmed by radiography or ultrasound with a view of hyperextended fetal neck. Causes of face presentation are numerous, generally stemming from any factor that favors extension or prevents head flexion. Congenital malformations, especially anencephaly,5 high parity leading to pendulous abdomen,6 very large fetus, contracted pelvis or cephalopelvic disproportion,2,4,7 marked enlargement of the neck or coils of cord about the neck in exceptional instances are noted factors. There are only a few recent reports on this clinical entity 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: [email protected] Declaration: All authors have contributed significantly to this study and all authors are in agreement with the content of the manuscript.
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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O. L. Tapisiz et al.
mortality if not diagnosed early and managed properly. The aim of this study was to determine the factors associated with face presentation of term fetuses.
Methods A retrospective study including 34 480 consecutive term deliveries of uncomplicated pregnancies in the delivery unit of a research and education hospital within a 3-year period was conducted. All live, singleton term fetuses with cephalic presentation in which no lethal anomalies occurred and were diagnosed with a face presentation were included in the study. Multiple pregnancies were excluded from the analysis. The perinatal data were collected from patient files and either a resident or an expert made the diagnosis. An experienced obstetrician confirmed all diagnoses. Various factors that might have contributed to the etiology of the presentation, including age, parity and fetal size, were evaluated. Inlet contraction was defined as a diagonal conjugate of less than 11.5 cm. Ultrasonographic evaluation of the fetuses was recorded. The ethical committee approved this study protocol. Data were stored and analyzed using SPSS version 10.0 for Windows. Measurements of variables were expressed as means ± standard deviation for descriptive statistics and the level of statistical significance was set at 0.05. Parity and birthweights were compared between the face presentation group and all deliveries using Student’s t-test, χ2-test and Fisher’s exact test.
Results During the study period, 50 cases of face presentation at term were diagnosed among 34 480 consecutive deliveries with an incidence of 0.14%. Twenty-four cases (48%) were primigravida, whereas 6% (n = 3) were grand multiparous (>4 deliveries). Parity was not found to be significantly associated with face presentation. Table 1 shows the distribution of parity in the study group and all deliveries. The age of the patients ranged 16–40 years with a mean of 27.24 ± 6.09 years. Most of the patients received prenatal care and had at least one antenatal visit during their pregnancy. None of the patients had a history of cesarean delivery because of our elective cesarean section policy. None of the patients were manually rotated during delivery. All infants were delivered by cesarean section. The mean gestational age was 39.1 ± 1.6 weeks. The mean birthweight was 3356.8 ± 562 g, ranging 2100– 4340 g. The distribution of birthweights in the face presenting group and all deliveries is depicted in Table 2. Birthweight was found to be associated with face presentation. Birthweight of 4000 g or more had an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk for face presentation when compared with the general obstetrics group (P = 0.015 and 0.001, risk ratio = 2.948 and 0.450, 95% confidence interval [CI] = 1.328–6.543 and 0.239–0.847, respectively) (Table 2).
Table 1 Comparison of parity in face presentation and whole obstetric population at the time of study
Primipara Multiparous Grand multiparous
Face presenting group
No. of patients (%)
All deliveries
No. of patients (%)
P
RR
95% CI
24 23 3
48 46 6
14 687 17 492 2 301
42.6 50.7 6.7
0.817 0.503 0.570
1.068 0.827 0.899
0.613–1.860 0.475–1.440 0.300–2.695
CI, confidence interval; RR, risk ratio.
Table 2 Comparison of birthweights in face presentation and whole obstetric population Birthweight (g)
Face presenting group
No. of patients (%)
All deliveries
No. of patients (%)
P
RR
95% CI
2000–2499 2500–2999 3000–3499 3500–3999 ≥4000
2 12 13 16 7
4 24 26 32 14
1 292 8 044 15 114 8 253 1 777
3.7 23.4 43.8 23.9 5.2
0.563 0.910 0.011 0.181 0.015
1.070 1.038 0.450 1.495 2.948
0.260–4.399 0.530–1.986 0.239–0.847 0.826–2.708 1.328–6.543
CI, confidence interval; RR, risk ratio.
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© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Face presentation of term fetuses
As all term pregnancies were included in the study, there were no preterm deliveries and/or premature rupture of membrane cases. Four cases of gestational diabetes mellitus (DM) were determined (8%), and there were no cases with pregestational DM. At the examination of fetal presentation and position on admission, 26% of the cases were wrongly diagnosed as vertex, 2% as breech and 2% as brow presentations; 70% were diagnosed correctly. In one patient, face presentation was determined only during the second stage of labor. In six patients, the diagnosis was made before onset of the active phase of labor. Twentyfour infants were in mentum posterior position, 12 mentum anterior and 14 mentum transverse. Eight cases (16%) were both primigravida and had a diagonal conjugate of less than 11.5 cm with a mean birthweight of 3453.73 ± 101 g. When compared with the other 42 cases without the inlet contraction, the mean birthweight was 3338.33 ± 601 g and there was no significant difference with respect to birthweight (P = 0.410). However, when compared with other primigravida patients, there was a significant difference in birthweights between these eight cases and the remaining 16 cases (3453.73 ± 101 vs 2833.12 ± 388, P = 0.001; 95% CI = 297.95–943.29). Diagnosis was based on vaginal examination. No abdominal X-ray was performed for confirmation. All patients had transabdominal ultrasound examination for determination of the fetal presentation, gestational age and estimated fetal weight. Face presentation was suspected in 23 (46%) of the cases. Among these cases, the view of hyperextension of the neck and deflexion was observed in 11 cases (22%). In 27 cases (54%), vertex presentation was reported. Face presentation was determined as the labor progressed in all of these cases by digital examination, whereas in 10 of 27 patients, a second confirmatory sonography was performed in the labor unit. There was no perinatal mortality. Non-reassuring fetal heart rate pattern was determined in 14 (28%) cases. Among these cases, three infants with late decelerations on tracing, in whom thick meconium in amnion were determined, and had low 1-min Apgar scores of 3, 5 and 6, respectively, needed neonatal intensive care unit support. There were no infants with a 1-min Apgar of less than 3. One infant in this series had spina bifida that was determined before delivery during ultrasonographic examination. He was a 2720-g male 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 male and 54% (n = 27) were female.
Discussion In the current study, face presentation with an incidence of 0.14% was found. Parity was not found to be associated with face presentation. Birthweight of 4000 g or more had an increased risk of approximately 2.9-fold, whereas fetuses weighing 3000–3499 g were found to have a relatively decreased risk of face presentation when compared with the general obstetrics group. A number of predisposing factors have been implicated by various authors in the etiology of face presentation. Anencephaly, multiparity, fetal size and prematurity are the causative factors most frequently cited. Anencephaly and prematurity are out of the scope of this study as non-anomalous term infants were enrolled. Multiparity is another cited factor8–10 that was not borne out in this study. Especially grand multiparity, due to pendulous abdomen and increased maternal age, was suggested to be associated with face presentation.11 Cruikshank and White8 found that the incidence of grand multiparity was twice as high in cases of face presentation as in the general obstetric population. On the other hand, other reports, including this one, have found no significant differences between the two groups with regard to multiparity.5,7,12,13 In this study, we demonstrated that with respect to face presentation, grand multiparity has a relative risk of 0.899 with a 95% CI of 0.3–2.695 meaning that grand multiparity is not associated with face presentation in term infants without a lethal anomaly. This is similar to the findings of Zayed et al.14 Fetal size was found to be of etiologic importance in this study. Infants weighing more than 4000 g were found to have an approximately 2.9-fold increased risk of face presentation when compared with infants weighing less than 4000 g (95 % CI, 1.328–6.543). Infants weighing 3000–3500 g had an approximately 0.45-fold decreased risk (95% CI, 0.239–0.847). In previous reports suggesting fetal weight to be of etiologic importance,7,8,15 mainly large fetuses (>4000 g) were of concern when anomalous infants were excluded. Face presentation among term-size fetuses is common when there is some degree of pelvic inlet contraction. The incidence of inlet contraction was found to be 10–40% in some studies.2,4,7 In this study, inlet contraction was
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
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determined in 16% of the cases, all being primigravida with a mean birthweight of 3453.73 ± 101 g, which was not significantly different. Prematurity was suggested to be associated with face presentation by various authors,7,9,16,17 but not all would agree.3,8,12 In our series, while there were no cases with pregestational DM, four cases of gestational DM were determined (8%) in the face presenting group. Among these four patients, three of them had babies weighing 4000 g or more; one of them delivered a baby with a birthweight of 3890 g. Early diagnosis is of utmost importance as perinatal mortality may be higher with late diagnosis.2 Diagnosis based on physical and vaginal examinations require experience. Campbell reported that, in practice, fewer than one in 20 infants with face presentation is diagnosed abdominally18 and in various studies it is stated that in fact only half of these infants are found to have a face presentation by any means prior to the second stage of labor4,5,15 and half of the remaining cases are undiagnosed until delivery.4,7 In our study, 70% of the cases were diagnosed correctly by physical examination. Most commonly, the presenting part was misdiagnosed as vertex, followed by breech and brow, which should be considered in differential diagnosis.19 Diagnosis must be confirmed by radiography or ultrasound. In this study, ultrasonography was used as confirmation and no X-ray was performed. The ultrasonographic evaluations were performed either during admission to the hospital or to the labor unit based on indications from the physicians. If deflection is included as a correct diagnosis, because further extension of an intermediate deflection to a fully extended position may occur as labor progresses due to resistance exerted by the pelvic bony and soft tissues, it may be difficult to demonstrate face or brow presentation directly on ultrasound imaging because of the location of the fetal head in the birth canal inferior to the maternal symphysis pubis resulting in suboptimal resolution.20 Although the advantages of a transvaginal scan with a better resolution of the presenting parts has been emphasized, the risk of injury to the fetal orbits and maternal discomfort was also noted. Additional to these techniques, translabial ultrasound has been demonstrated as an advantageous technique with the documentation of landmarks and the management of the second stage of labor.20,21 In our obstetrics practice, diagnostic ultrasound is widely used in the labor unit for the estimation of fetal weight, presentation and gestational age. Reported perinatal mortality, corrected for nonviable malformations and extreme prematurity, varies
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from 0.6%18 to 5%,7 and cesarean delivery has been reported in up to 67.1% of cases of face presentation.3,22 Except for mentum posterior cases, safe vaginal delivery is suggested to be accomplished,23 and a trial of labor with careful monitoring of fetal condition and progress is not contraindicated unless macrosomia or a 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 infants were term and were delivered by cesarean regardless of the position of the fetal chin. There were no maternal or fetal perinatal mortalities and morbidities. There was no laryngeal and/or tracheal edema resulting from pressures of the birth. The physicians decided to perform cesarean delivery as soon as they diagnosed face presentation without waiting for progression. This is probably because obstetricians harbor a fear that they may be criticized in hindsight for failure to perform an earlier cesarean delivery that ‘might have’ resulted in a better outcome. All over the world, the cesarean delivery rate has become higher and cesarean delivery liberally used as part of a trend in modern obstetrics, not only to achieve a safer delivery and patient satisfaction, but also to achieve the protection of the surgeon him/herself. The result is a more defensive approach to practice, including a lower threshold for resorting to cesarean delivery.25 A limitation of our study is that it is retrospectively designed and therefore only a collection of existing data about the issue. All in all, we believe that in the absence of a contracted pelvis, and with effective labor, successful vaginal delivery may be performed as written in the textbooks.26 In conclusion, face presentation has an incidence of 0.14% at term and infants weighing more than 4000 g have an approximately 2.9-fold increased risk for this malpresentation. Term infants of average size (3000– 3500 g) have a decreased risk in face presentation, with a relative risk of 0.45.
Disclosure None declared.
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4. Magid R, Gillespie CF. Face and brow presentation. Obstet Gynecol 1957; 9: 450–457. 5. Salzmann B, Soled M, Gilmour T. Face presentation. Obstet Gynecol 1960; 16: 106–112. 6. Fuchs K, Peretz BA, Marcovici R, Paldi E, Timor-Tritsh I. The ‘grand multipara’ – is it a problem? A review of 5785 cases. Int J Gynaecol Obstet 1985; 23: 321–326. 7. Dede JA, Friedman EA. Face presentation. Am J Obstet Gynecol 1963; 87: 515–524. 8. Cruikshank DP, White CA. Obstetric malpresentations. Twenty years’ experience. Am J Obstet Gynecol 1973; 116: 1097–1104. 9. Hellman LM, Epperson JWW, Connally F. Face and brow presentation. Am J Obstet Gynecol 1950; 59: 831–842. 10. Groenig DC. Face presentation. Obstet Gynecol 1953; 2: 495– 499. 11. Schwartz Z, Dgani R, Lancet M, Kessler I. Face presentation. Aust NZ J Obstet Gynaecol 1986; 26: 172–176. 12. Morris N. Face and brow presentation. J Obstet Gynecol Br Emp 1953; 60: 44–51. 13. Parikh MA. Face presentation. J Obstet Gynecol India 1960; 10: 456–459. 14. Zayed F, Amarin Z, Obeidat N, Alchalabi H, Lataifeh I. Face and brow presentation in northern Jordan, over a decade of experience. Arch Gynecol Obstet 2008; 278: 427– 430. 15. Cucco UP. Face presentation. Am J Obstet Gynecol 1966; 94: 1085–1092. 16. Posner AC, Fridman S, Posner LB. Modern trends in the management of face and brow presentation. Surg Gynecol Obstet 1957; 104: 485–490.
17. Shaffer B, Cheng YW, Vargas JE, Laros RK, Caughey AB. Face presentation: Predictors and delivery route. Am J Obstet Gynecol 2006; 194: e10–e12. 18. Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol 1965; 5: 231–234. 19. Gomez HE, Denen EH. Face presentation. Obstet Gynecol 1956; 8: 103–106. 20. Lau WL, Cho LY, Leung WC. Intrapartum translabial ultrasound demonstration of face presentation during first stage of labor. J Obstet Gynaecol Res 2011; 37: 1868–1871. 21. Yeo L, Romero R. Sonographic evaluation in the second stage of labor to improve the assessment of labor progress and its outcome. Ultrasound Obstet Gynecol 2009; 33: 235– 238. 22. Bashiri A, Burstein E, Bar-David J, Levy A, Mazor M. Face and brow presentation: Independent risk factors. J Matern Fetal Neonatal Med 2008; 21: 357–360. 23. Ducarme G, Ceccaldi PF, Chesnoy V, Robinet G, Gabriel R. Face presentation: Retrospective study of 32 cases at term. Gynecol Obstet Fertil 2006; 34: 393–396. 24. Bhal PS, Davies NJ, Chung T. A population study of face and brow presentation. J Obstet Gynaecol 1998; 18: 231– 235. 25. NIH consensus development statement on cesarean childbirth. The Cesarean Birth Task Force. Obstet Gynecol 1981; 57: 537–545. 26. Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Rouse DJ, Spong CY. Abnormal Delivery. Williams Obstetrics, 23rd edn. New York: The McGraw-Hill Companies, 2010; 464– 489.
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