presentation definition in obstetrics

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Delivery, face and brow presentation.

Julija Makajeva ; Mohsina Ashraf .

Affiliations

Last Update: January 9, 2023 .

Continuing Education Activity

Face and brow presentation is a malpresentation during labor when the presenting part is either the face or, in the case of brow presentation, it is the area between the orbital ridge and the anterior fontanelle. This activity reviews the evaluation and management of these two presentations and explains the role of the interprofessional team in managing delivery safely for both the mother and the baby.

Describe the mechanism of labor in the face and brow presentation.
Summarize potential maternal and fetal complications during the face and brow presentations.
Review different management approaches for the face and brow presentation.
Outline some interprofessional strategies that will improve patient outcomes in delivery cases with face and brow presentation issues.
Introduction

The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common presentation in term labor is the vertex, where the fetal neck is flexed to the chin, minimizing the head circumference.

Face presentation – an abnormal form of cephalic presentation where the presenting part is mentum. This typically occurs because of hyperextension of the neck and the occiput touching the fetal back. Incidence of face presentation is rare, accounting for approximately 1 in 600 of all presentations. [1] [2] [3]

In brow presentation, the neck is not extended as much as in face presentation, and the leading part is the area between the anterior fontanelle and the orbital ridges. Brow presentation is considered the rarest of all malpresentation with a prevalence of 1 in 500 to 1 in 4000 deliveries. [3]

Both face and brow presentations occur due to extension of the fetal neck instead of flexion; therefore, conditions that would lead to hyperextension or prevent flexion of the fetal neck can all contribute to face or brow presentation. These risk factors may be related to either the mother or the fetus. Maternal risk factors are preterm delivery, contracted maternal pelvis, platypelloid pelvis, multiparity, previous cesarean section, black race. Fetal risk factors include anencephaly, multiple loops of cord around the neck, masses of the neck, macrosomia, polyhydramnios. [2] [4] [5]

These malpresentations are usually diagnosed during the second stage of labor when performing a digital examination. It is possible to palpate orbital ridges, nose, malar eminences, mentum, mouth, gums, and chin in face presentation. Based on the position of the chin, face presentation can be further divided into mentum anterior, posterior, or transverse. In brow presentation, anterior fontanelle and face can be palpated except for the mouth and the chin. Brow presentation can then be further described based on the position of the anterior fontanelle as frontal anterior, posterior, or transverse.

Diagnosing the exact presentation can be challenging, and face presentation may be misdiagnosed as frank breech. To avoid any confusion, a bedside ultrasound scan can be performed. [6] The ultrasound imaging can show a reduced angle between the occiput and the spine or, the chin is separated from the chest. However, ultrasound does not provide much predicting value in the outcome of the labor. [7]

Anatomy and Physiology

Before discussing the mechanism of labor in the face or brow presentation, it is crucial to highlight some anatomical landmarks and their measurements.

Planes and Diameters of the Pelvis

The three most important planes in the female pelvis are the pelvic inlet, mid pelvis, and pelvic outlet.

Four diameters can describe the pelvic inlet: anteroposterior, transverse, and two obliques. Furthermore, based on the different landmarks on the pelvic inlet, there are three different anteroposterior diameters, named conjugates: true conjugate, obstetrical conjugate, and diagonal conjugate. Only the latter can be measured directly during the obstetric examination. The shortest of these three diameters is obstetrical conjugate, which measures approximately 10.5 cm and is a distance between the sacral promontory and 1 cm below the upper border of the symphysis pubis. This measurement is clinically significant as the fetal head must pass through this diameter during the engagement phase. The transverse diameter measures about 13.5cm and is the widest distance between the innominate line on both sides.

The shortest distance in the mid pelvis is the interspinous diameter and usually is only about 10 cm.

Fetal Skull Diameters

There are six distinguished longitudinal fetal skull diameters:

Suboccipito-bregmatic: from the center of anterior fontanelle (bregma) to the occipital protuberance, measuring 9.5 cm. This is the presenting diameter in vertex presentation.
Suboccipito-frontal: from the anterior part of bregma to the occipital protuberance, measuring 10 cm
Occipito-frontal: from the root of the nose to the most prominent part of the occiput, measuring 11.5cm
Submento-bregmatic: from the center of the bregma to the angle of the mandible, measuring 9.5 cm. This is the presenting diameter in face presentation where the neck is hyperextended.
Submento-vertical: from the midpoint between fontanelles and the angle of the mandible, measuring 11.5cm
Occipito-mental: from the midpoint between fontanelles and the tip of the chin, measuring 13.5 cm. It is the presenting diameter in brow presentation.

Cardinal Movements of Normal Labor

Neck flexion
Internal rotation
Extension (delivers head)
External rotation (Restitution)
Expulsion (delivery of anterior and posterior shoulders)

Some of the key movements are not possible in the face or brow presentations.

Based on the information provided above, it is obvious that labor will be arrested in brow presentation unless it spontaneously changes to face or vertex, as the occipito-mental diameter of the fetal head is significantly wider than the smallest diameter of the female pelvis. Face presentation can, however, be delivered vaginally, and further mechanisms of face delivery will be explained in later sections.

Indications

As mentioned previously, spontaneous vaginal delivery can be successful in face presentation. However, the main indication for vaginal delivery in such circumstances would be a maternal choice. It is crucial to have a thorough conversation with a mother, explaining the risks and benefits of vaginal delivery with face presentation and a cesarean section. Informed consent and creating a rapport with the mother is an essential aspect of safe and successful labor.

Contraindications

Vaginal delivery of face presentation is contraindicated if the mentum is lying posteriorly or is in a transverse position. In such a scenario, the fetal brow is pressing against the maternal symphysis pubis, and the short fetal neck, which is already maximally extended, cannot span the surface of the maternal sacrum. In this position, the diameter of the head is larger than the maternal pelvis, and it cannot descend through the birth canal. Therefore the cesarean section is recommended as the safest mode of delivery for mentum posterior face presentations.

Attempts to manually convert face presentation to vertex, manual or forceps rotation of the persistent posterior chin to anterior are contraindicated as they can be dangerous.

Persistent brow presentation itself is a contraindication for vaginal delivery unless the fetus is significantly small or the maternal pelvis is large.

Continuous electronic fetal heart rate monitoring is recommended for face and brow presentations, as heart rate abnormalities are common in these scenarios. One study found that only 14% of the cases with face presentation had no abnormal traces on the cardiotocograph. [8] It is advised to use external transducer devices to prevent damage to the eyes. When internal monitoring is inevitable, it is suggested to place monitoring devices on bony parts carefully.

People who are usually involved in the delivery of face/ brow presentation are:

Experienced midwife, preferably looking after laboring woman 1:1
Senior obstetrician
Neonatal team - in case of need for resuscitation
Anesthetic team - to provide necessary pain control (e.g., epidural)
Theatre team - in case of failure to progress and an emergency cesarean section will be required.
Preparation

No specific preparation is required for face or brow presentation. However, it is essential to discuss the labor options with the mother and birthing partner and inform members of the neonatal, anesthetic, and theatre co-ordinating teams.

Technique or Treatment

Mechanism of Labor in Face Presentation

During contractions, the pressure exerted by the fundus of the uterus on the fetus and pressure of amniotic fluid initiate descent. During this descent, the fetal neck extends instead of flexing. The internal rotation determines the outcome of delivery, if the fetal chin rotates posteriorly, vaginal delivery would not be possible, and cesarean section is permitted. The approach towards mentum-posterior delivery should be individualized, as the cases are rare. Expectant management is acceptable in multiparous women with small fetuses, as a spontaneous mentum-anterior rotation can occur. However, there should be a low threshold for cesarean section in primigravida women or women with large fetuses.

When the fetal chin is rotated towards maternal symphysis pubis as described as mentum-anterior; in these cases further descend through the vaginal canal continues with approximately 73% cases deliver spontaneously. [9] Fetal mentum presses on the maternal symphysis pubis, and the head is delivered by flexion. The occiput is pointing towards the maternal back, and external rotation happens. Shoulders are delivered in the same manner as in vertex delivery.

Mechanism of Labor in Brow Presentation

As this presentation is considered unstable, it is usually converted into a face or an occiput presentation. Due to the cephalic diameter being wider than the maternal pelvis, the fetal head cannot engage; thus, brow delivery cannot take place. Unless the fetus is small or the pelvis is very wide, the prognosis for vaginal delivery is poor. With persistent brow presentation, a cesarean section is required for safe delivery.

Complications

As the cesarean section is becoming a more accessible mode of delivery in malpresentations, the incidence of maternal and fetal morbidity and mortality during face presentation has dropped significantly. [10]

However, there are still some complications associated with the nature of labor in face presentation. Due to the fetal head position, it is more challenging for the head to engage in the birth canal and descend, resulting in prolonged labor.

Prolonged labor itself can provoke foetal distress and arrhythmias. If the labor arrests or signs of fetal distress appear on CTG, the recommended next step in management is an emergency cesarean section, which in itself carries a myriad of operative and post-operative complications.

Finally, due to the nature of the fetal position and prolonged duration of labor in face presentation, neonates develop significant edema of the skull and face. Swelling of the fetal airway may also be present, resulting in respiratory distress after birth and possible intubation.

Clinical Significance

During vertex presentation, the fetal head flexes, bringing the chin to the chest, forming the smallest possible fetal head diameter, measuring approximately 9.5cm. With face and brow presentation, the neck hyperextends, resulting in greater cephalic diameters. As a result, the fetal head will engage later, and labor will progress more slowly. Failure to progress in labor is also more common in both presentations compared to vertex presentation.

Furthermore, when the fetal chin is in a posterior position, this prevents further flexion of the fetal neck, as browns are pressing on the symphysis pubis. As a result, descend through the birth canal is impossible. Such presentation is considered undeliverable vaginally and requires an emergency cesarean section.

Manual attempts to change face presentation to vertex, manual or forceps rotation to mentum anterior are considered dangerous and are discouraged.

Enhancing Healthcare Team Outcomes

A multidisciplinary team of healthcare experts supports the woman and her child during labor and the perinatal period. For a face or brow presentation to be appropriately diagnosed, an experienced midwife and obstetrician must be involved in the vaginal examination and labor monitoring. As fetal anomalies, such as anencephaly or goiter, can contribute to face presentation, sonographers experienced in antenatal scanning should also be involved in the care. It is advised to inform the anesthetic and neonatal teams in advance of the possible need for emergency cesarean section and resuscitation of the neonate. [11] [12]

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Disclosure: Julija Makajeva declares no relevant financial relationships with ineligible companies.

Disclosure: Mohsina Ashraf declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. [Updated 2023 Jan 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Original Author(s): Minesh Mistry Last updated: 12th November 2018 Revisions: 7

1 Introduction
2 Preparation
3 General Inspection
4 Abdominal Inspection
5.1 Fundal Height
5.3 Presentation
5.4 Liquor Volume
5.5 Engagement
6 Fetal Auscultation
7 Completing the Examination

The obstetric examination is a type of abdominal examination performed in pregnancy.

It is unique in the fact that the clinician is simultaneously trying to assess the health of two individuals – the mother and the fetus.

In this article, we shall look at how to perform an obstetric examination in an OSCE-style setting.

Introduction

Introduce yourself to the patient
Wash your hands
Explain to the patient what the examination involves and why it is necessary
Obtain verbal consent

Preparation

In the UK, this is performed at the booking appointment, and is not routinely recommended at subsequent visits
Patient should have an empty bladder
Cover above and below where appropriate
Ask the patient to lie in the supine position with the head of the bed raised to 15 degrees
Prepare your equipment: measuring tape, pinnard stethoscope or doppler transducer, ultrasound gel

General Inspection

General wellbeing – at ease or distressed by physical pain.
Hands – palpate the radial pulse.
Head and neck – melasma, conjunctival pallor, jaundice, oedema.
Legs and feet – calf swelling, oedema and varicose veins.

Abdominal Inspection

In the obstetric examination, inspect the abdomen for:

Distension compatible with pregnancy
Fetal movement (>24 weeks)
Surgical scars – previous Caesarean section, laproscopic port scars
Skin changes indicative of pregnancy – linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum (‘stretch marks’), striae albicans (old, silvery-white striae)

Fig 1 – Skin changes in pregnancy. A) Linea nigra. B) Striae gravidarum and albicans.

Ask the patient to comment on any tenderness and observe her facial and verbal responses throughout. Note any guarding.

Fundal Height

Use the medial edge of the left hand to press down at the xiphisternum, working downwards to locate the fundus.
Measure from here to the pubic symphysis in both cm and inches. Turn the measuring tape so that the numbers face the abdomen (to avoid bias in your measurements).
Uterus should be palpable after 12 weeks, near the umbilicus at 20 weeks and near the xiphisternum at 36 weeks (these measurements are often slightly different if the woman is tall or short).
The distance should be similar to gestational age in weeks (+/- 2 cm).
Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure
Move the hands and palpate down the abdomen
One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side

Fig 2 – Assessing fetal lie and presentation.

Presentation

Palpate the lower uterus (below the umbilicus) to find the presenting part.
Firm and round signifies cephalic, soft and/or non-round suggests breech. If breech presentation is suspected, the fetal head can be often be palpated in the upper uterus.
Ballot head by pushing it gently from one side to the other.

Liquor Volume

Palpate and ballot fluid to approximate volume to determine if there is oligohydraminos/polyhydramnios
When assessing the lie, only feeling fetal parts on deep palpation suggests large amounts of fluid
Fetal engagement refers to whether the presenting part has entered the bony pelvis
Note how much of the head is palpable – if the entire head is palpable, the fetus is unengaged.
Engagement is measured in 1/5s

Fig 3 – Assessing fetal engagement.

Fetal Auscultation

Hand-held Doppler machine >16 weeks (trying before this gestation often leads to anxiety if the heart cannot be auscultated).
Pinard stethoscope over the anterior shoulder >28 weeks
Feel the mother’s pulse at the same time
Should be 110-160bpm (>24 weeks)

Completing the Examination

Palpate the ankles for oedema and test for hyperreflexia (pre-eclampsia)
Thank the patient and allow them to dress in private
Summarise findings
Blood pressure
Urine dipstick
Hands - palpate the radial pulse.
Skin changes indicative of pregnancy - linea nigra (dark vertical line from umbilicus to the pubis), striae gravidarum ('stretch marks'), striae albicans (old, silvery-white striae)
One side will feel fuller and firmer - this is the back. Fetal limbs may be palpable on the opposing side

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

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What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

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Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70. https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

Where to go next

illustration of twin babies head down in utero

Presentation (Obstetrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

2 Types of Presentations
4 References

Presentation in Obstetrics refers to the relationship between the leading fetal part and the pelvic inlet: cephalic, breech, or shoulder presentation. A malpresentation is an abnormal (non-vertex) presentation.

Types of Presentations

Thus the various presentations are:

Vertex —commonest and associated with least complications
Sinciput (forehead)
Brow (Eye brows)
Complete breech
Footling breech
Frank breech
Child birth
Fetal relations

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

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Emergency Obstetrics and Pediatrics

2-02. definitions — common obstetric terms.

a. Abortion — the termination of pregnancy before the fetus reaches the stage of viability which is usually less than 21 to 22 weeks gestation (or less than 600 gm in weight).

b. Afterbirth — placenta, membrane, and umbilical cord which are expelled after the infant is delivered.

c. After pains — pain due to contractions of the uterus after the placenta has been expelled, following childbirth.

d. Amniotic fluid — approximately one liter of fluid in a sac which surrounds the fetus. This fluid protects and cushions the fetus during its development.

e. Amniotic sac (bag of waters) — thin bag which totally encloses the fetus during the development in the uterus.

f. Amniotomy — artificial rupture of the amniotic sac membranes; also, a method of inducing contractions.

g. Analgesic — medication which lessens the normal perception of pain.

h. Anesthesia — medication that causes partial or total loss of sensation with or without loss of consciousness.

i. Apgar scoring — rating system for newborn babies, measuring the baby’s general condition on a scale from 1 to 10.

j. Bloody show — small amount of blood-tinged discharge due to rupture of small capillaries in the cervix.

k. Breech — birth with baby’s buttocks or feet coming first.

l. Catherization — emptying the bladder by insertion of a small pliable tube through the urethra.

m. C-section (cesarean section) — delivery of the baby and the placenta through an incision made into the abdominal wall of the uterus.

n. Cephalic delivery — in normal circumstances, presentation of the head first.

o. Cervix — neck of the uterus; “mouth of the womb” which dilates and effaces during labor (dilates to 10 centimeters to accommodate the head of the baby passing through the cervix during the birth process).

p. Colostrum — thin, yellowish fluid preceding breast milk; usually present by the second day after the birth of the baby. Sugar content of this fluid is the same as breast milk. Colostrum contains as much or more protein material and salts as breast milk but less fat. Colostrum carries protective antibodies.

q. Contractions — also called labor, the term contractions refers to the muscles of the uterus contracting rhythmically and forcefully just before birth. Terms associated with contractions are as follows:

(1) Intensity — strength of the muscle contractions.

(2) Duration — length of time from start to end of the contraction.

(3) Frequency — time from the beginning of one contraction to the beginning of the next contraction.

(4) Braxton Hicks contractions — also called false labor, this refers to irregular uterine contractions occurring after the 28th week of pregnancy; felt mainly in the abdomen; changes in the woman’s activity will usually cause these contractions to go away.

r. Crowning — appearance of the baby’s head at the vaginal opening.

s. Dilation (or dilatation) — opening of the cervix. The cervix opens from 1 to 10 centimeters during the birth process.

t. Effacement — shortening and thinning of the cervix. During childbirth, the cervix becomes a part of the body of the uterus. Measurements are from 0 to 100 percent.

u. Episiotomy — incision through perineum, enlarging the vaginal outlet.

v. Engagement — refers to the entrance of the presenting part into the pelvis.

w. Fetus — developing baby; the developing offspring in the uterus from the second month of pregnancy to birth.

x. Multigravida — a woman who has been pregnant two or more times.

y. Perineum — area between the vaginal opening and the anus.

z. Placenta — also called afterbirth, a special organ of pregnancy which nourishes the fetus. It is expelled following the birth of the baby.

aa. Placenta abruptio — premature separation of the placenta from the uterine wall, this separation resulting in bleeding from the separation site.

bb. Placenta previa — placenta that is implanted in the lower uterine segment, possibly totally or partially covering the opening of the cervix.

cc. Prenatal — refers to the period of time prior to the birth of the baby.

dd. Presenting part — also called presentation, this is the part of the baby that will deliver first.

ee. Primigravida — a woman having her first pregnancy.

ff. Primipara — a woman who has produced one infant of 500 grams or 20 weeks gestation, regardless of whether the infant delivered dead or alive.

gg. Prolapsed cord — the umbilical cord appears in the vaginal orifice before the head of the infant.

hh. Puerperium — the time period following the delivery until about six weeks.

ii. Quickening — feeling of life within the uterus. This is usually noticed during the 16th to the 19th week of gestation.

jj. ROM — rupture of membranes.

kk. Station — the location of the presenting part in relation to the level of the ischial spines (midpelvis). Measures from -5 to +5.

ll. Umbilical cord — cord connecting the baby and the placenta; cord contains blood vessels, usually 19 blood vessels. mm. Uterus — also called womb, a pear-shaped muscular organ which holds and nourishes the developing fetus.

nn. Vagina — also called birth canal, a muscular tube that connects the uterus to the external genitalia; the passage for normal delivery of the fetus.

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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

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Krish Tangella MD, MBA

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Chapter 27: Compound Presentations

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Prolapse of hand and arm or foot and leg.

MANAGEMENT OF COMPOUND PRESENTATIONS
Full Chapter
Supplementary Content

A presentation is compound when there is prolapse of one or more of the limbs along with the head or the breech, both entering the pelvis at the same time. Footling breech or shoulder presentations are not included in this group. Associated prolapse of the umbilical cord occurs in 15 to 20 percent of cases.

Easily detectable compound presentations occur probably once in 500 to 1000 confinements. It is impossible to establish the exact incidence because:

Spontaneous correction occurs frequently, and examination late in labor cannot provide the diagnosis

Minor degrees of prolapse are detected only by early and careful vaginal examination

Classification of Compound Presentation

Upper limb (arm–hand), one or both

Lower limb (leg–foot), one or both

Arm and leg together

Breech presentation with prolapse of the hand or arm

By far the most frequent combination is that of the head with the hand ( Fig. 27-1 ) or arm. In contrast, the head–foot and breech–arm groups are uncommon, about equally so. Prolapse of both hand and foot alongside the head is rare. All combinations may be complicated by prolapse of the umbilical cord, which then becomes the major problem.

FIGURE 27-1.

Compound presentation: head and hand.

The etiology of compound presentation includes all conditions that prevent complete filling and occlusion of the pelvic inlet by the presenting part. The most common causal factor is prematurity. Others include high presenting part with ruptured membranes, polyhydramnios, multiparity, a contracted pelvis, pelvic masses, and twins. It is also more common with inductions of labor involving floating presenting parts. Another predisposing factor is external cephalic version. During the process of external version, a fetal limb (commonly the hand–arm, but occasionally the foot) can become “trapped” before the fetal head and thus become the presenting part when labor ensues.

Diagnosis is made by vaginal examination, and in many cases, the condition is not noted until labor is well advanced and the cervix is fully dilated.

The condition is suspected when:

There is delay of progress in the active phase of labor

Engagement fails to occur

The fetal head remains high and deviated from the midline during labor, especially after the membranes rupture

In the absence of complications and with conservative management, the results should be no worse than with other presentations.

Mechanism of Labor

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Citation, DOI, disclosures and article data

At the time the article was created Yuranga Weerakkody had no recorded disclosures.

At the time the article was last revised Joshua Yap had no financial relationships to ineligible companies to disclose.

Funic presentation
Cord (funic) presentation

A cord presentation (also known as a funic presentation or obligate cord presentation ) is a variation in the fetal presentation where the umbilical cord points towards the internal cervical os or lower uterine segment.

It may be a transient phenomenon and is usually considered insignificant until ~32 weeks. It is concerning if it persists past that date, after which it is recommended that an underlying cause be sought and precautionary management implemented.

Associations

Recognized associations include:

marginal cord insertion from the caudal end of a low-lying placenta

uterine fibroids

uterine adhesions

congenital uterine anomalies that may prevent the fetus from engaging well into the lower uterine segment

cephalopelvic disproportion

polyhydramnios

multifetal pregnancy

long umbilical cord

Color Doppler interrogation is extremely useful and shows cord between the fetal presenting part and the internal cervical os. However, unlike a vasa previa , the placental insertion is usually normal.

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As the complicating umbilical cord prolapse can lead to catastrophic consequences, most advocate an elective cesarean section delivery for persistent cord presentation in the third trimester 3 .

Complications

It can result in a higher rate of umbilical cord prolapse .

For the presence of umbilical cord vessels between the fetal presenting part and the internal cervical os on ultrasound consider:

vasa previa

1. Ezra Y, Strasberg SR, Farine D. Does cord presentation on ultrasound predict cord prolapse? Gynecol. Obstet. Invest. 2003;56 (1): 6-9. doi:10.1159/000072323 - Pubmed citation
2. Kinugasa M, Sato T, Tamura M et-al. Antepartum detection of cord presentation by transvaginal ultrasonography for term breech presentation: potential prediction and prevention of cord prolapse. J. Obstet. Gynaecol. Res. 2007;33 (5): 612-8. doi:10.1111/j.1447-0756.2007.00620.x - Pubmed citation
3. Raga F, Osborne N, Ballester MJ et-al. Color flow Doppler: a useful instrument in the diagnosis of funic presentation. J Natl Med Assoc. 1996;88 (2): 94-6. - Free text at pubmed - Pubmed citation
4. Bluth EI. Ultrasound, a practical approach to clinical problems. Thieme Publishing Group. (2008) ISBN:3131168323. Read it at Google Books - Find it at Amazon

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Labour and Delivery pp 99–105 Cite as

Face Presentation

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Face presentation is defined as a cephalic presentation in which the presenting part is face and it occurs due to factors that lead to extension of of fetal head. It is a rare obstetric presentation and may not be encountered even in the entire carrier of an obstetrician.

Face presentation
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Shaffer BL. Face presentation: predictors and delivery route. Am J Obstet Gynecol. 2006;194:e10–2.

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Schwartz Z, Dgani R, Lancet M, Kessler I. Face presentation. Aust N Z J Obstet Gynaecol. 1986;26:172–6.

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Westgren M, et al. Face presentation in modern obstetrics-a study with special reference to fetal long term morbidity. Z Geburtshilfe Perinatol. 1984;188(2):87–9.

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Agarwal, S., Pandit, S. (2023). Face Presentation. In: Garg, R. (eds) Labour and Delivery. Springer, Singapore. https://doi.org/10.1007/978-981-19-6145-8_6

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The definition of antisemitism is a contested term. In 2016 the US adopted the The International Holocaust Remembrance Alliance (IHRA) definition as a non-legally binding working definition of antisemitism. To date (2024) the United Nations has not adopted this definition

A critique of the IHRA definition concerns clarity in distinguishing antisemitism from opposition to Israel's political policies (see New Antisemitism). Alternative definitions of antisemitism attempt to address this critique.

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"Antisemitism is a certain perception of Jews, which may be expressed as hatred toward Jews. Rhetorical and physical manifestations of antisemitism are directed toward Jewish or non-Jewish individuals and/or their property, toward Jewish community institutions and religious facilities"

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The third "D" is the test of delegitimization: when Israel's fundamental right to exist is denied - alone among all peoples in the world - this too is anti-Semitism.

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Presentation (obstetrics)
Presentation (obstetrics) In obstetrics, the presentation of a fetus about to be born specifies which anatomical part of the fetus is leading, that is, is closest to the pelvic inlet of the birth canal. According to the leading part, this is identified as a cephalic, breech, or shoulder presentation. A malpresentation is any presentation other ...
Delivery, Face and Brow Presentation
The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common ...
Fetal Positions For Birth: Presentation, Types & Function
Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left. This is called left occiput anterior or right ...
Fetal Presentation, Position, and Lie (Including Breech Presentation
During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks.
Face and brow presentations in labor
The vast majority of fetuses at term are in cephalic presentation. Approximately 5 percent of these fetuses are in a cephalic malpresentation, such as occiput posterior or transverse, face ( figure 1A-B ), or brow ( figure 2) [ 1 ]. Diagnosis and management of face and brow presentations will be reviewed here.
Compound fetal presentation
Compound presentation is a fetal presentation in which an extremity presents alongside the part of the fetus closest to the birth canal. The majority of compound presentations consist of a fetal hand or arm presenting with the head [ 1 ]. This topic will review the pathogenesis, clinical manifestations, diagnosis, and management of this ...
Obstetric Examination
The obstetric examination is a type of abdominal examination performed in pregnancy. ... Presentation. Palpate the lower uterus (below the umbilicus) to find the presenting part. Firm and round signifies cephalic, soft and/or non-round suggests breech. If breech presentation is suspected, the fetal head can be often be palpated in the upper uterus.
Fetal Presentation, Position, and Lie (Including Breech Presentation
When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps Operative Vaginal Delivery Operative vaginal delivery is delivery using a vacuum extractor or forceps. A vacuum extractor consists of a small cup made of a rubberlike material that is connected to a vacuum.
Fetal presentation: Breech, posterior, transverse lie, and more
In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. ... . 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm ...
Normal labor and delivery
Types. Cephalic presentation: head (most common); Breech presentation: buttocks or feet. Frank breech: flexed hips and extended knees (buttocks presenting); Complete breech: thighs and legs flexed (cannonball position); Single footling breech: hip of one leg is flexed and the knee of the other is extended (one foot presenting); Double footling breech: both thighs and legs are extended (feet ...
Presentation (Obstetrics)
Overview. Presentation in Obstetrics refers to the relationship between the leading fetal part and the pelvic inlet: cephalic, breech, or shoulder presentation. A malpresentation is an abnormal (non-vertex) presentation.. Types of Presentations. Thus the various presentations are: Cephalic (Head first): Vertex—commonest and associated with least complications
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The Trusted Provider of Medical Information since 1899
Abnormal Fetal Lie and Presentation
Fetal presentation is a reference to the part of the fetus that is overlying the maternal pelvic inlet. The most common relationship between fetus and mother is the longitudinal lie, cephalic presentation. A breech fetus also is a longitudinal lie, with the fetal buttocks as the presenting part.
Face and Brow Presentation: Overview, Background, Mechanism ...
In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an ...
Presentation
presentation, in childbirth, the position of the fetus at the time of delivery. The presenting part is the part of the fetus that can be touched by the obstetrician when he probes with his finger through the opening in the cervix, the outermost portion of the uterus, which projects into the vagina. In nearly all deliveries the presenting part ...
2-02. Definitions
dd. Presenting part — also called presentation, this is the part of the baby that will deliver first. ee. Primigravida — a woman having her first pregnancy. ff. Primipara — a woman who has produced one infant of 500 grams or 20 weeks gestation, regardless of whether the infant delivered dead or alive. gg.
Delivery, Face Presentation, and Brow Presentation ...
Face Presentation: Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head). ... Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to ...
Compound Presentations
Definition. A presentation is compound when there is prolapse of one or more of the limbs along with the head or the breech, both entering the pelvis at the same time. Footling breech or shoulder presentations are not included in this group. Associated prolapse of the umbilical cord occurs in 15 to 20 percent of cases.
reVITALize: Obstetrics Data Definitions
The reVITALize obstetric data definitions are formally endorsed by the following organizations: To add your organization to this list, please contact [email protected]. Labor in a woman who has had one or more previous cesarean births. Planned labor after cesarean occurs in a woman intending to achieve a vaginal birth.
Management of malposition and malpresentation in labour
A malpresentation is diagnosed when any part of the baby is presenting to the maternal pelvis other than the vertex of the fetal head. A malposition is diagnosed when the fetal head is in any position other than occipito-anterior (OA) flexed vertex. Both malpresentation and malposition are associated with prolonged or obstructed labour, fetal and maternal morbidity, and potential mortality, if ...
Cord presentation
Citation, DOI, disclosures and article data. A cord presentation (also known as a funic presentation or obligate cord presentation) is a variation in the fetal presentation where the umbilical cord points towards the internal cervical os or lower uterine segment. It may be a transient phenomenon and is usually considered insignificant until ~32 ...
Labor with Abnormal Presentation and Position
Abnormal presentation and position are encountered infrequently during labor. Breech and transverse presentations should be converted to cephalic presentations by external cephalic version or delivered by cesarean section. Face, brow, and compound presentations are usually managed expectantly. Persistent occiput transverse positions are managed by rotation to anterior positions and delivered ...
Face Presentation
Face presentation is defined as a cephalic presentation in which the presenting part is face and it occurs due to factors that lead to extension of of fetal head. It is a rare obstetric presentation and may not be encountered even in the entire carrier of an obstetrician. Keywords. Face presentation; Active phase of labor; Prematurity; Deflexed ...
Definitions of Antisemitism
This guide supports the Hillel presentation on Antisemitism The definition of antisemitism is a contested term. The International Holocaust Remembrance Alliance (IHRA) definition is a commonly cited example. This definition was adopted by the US as a non-legally binding working definition of antisemitism in 2016

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

Variations in Fetal Position and Presentation

Position and Presentation of the Fetus

Occiput posterior position

Breech presentation

Other presentations

Drugs Mentioned In This Article

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation and position

Head down, facing down (anterior position)

Head down, facing up (posterior position)

Frank breech

Complete breech

Incomplete breech

Single footling breech

Double footling breech

Transverse lie

Oblique lie

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

Perineal massage

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Presentation (Obstetrics)

Types of Presentations

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Advanced Search:

Fetal Presentation, Position, and Lie (Including Breech Presentation)

Variations in Fetal Position and Presentation

Position and Presentation of the Fetus

Occiput posterior position

Breech presentation

Other presentations

Was This Page Helpful?

Test your knowledge

Emergency Obstetrics and Pediatrics

A Distance Learning Course

Medical Information

Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Delivery Process:

Face Presentation:

Brow Presentation:

Delivery Techniques and Intervention:

Conclusion:

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Chapter 27: Compound Presentations

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Classification of Compound Presentation

FIGURE 27-1.

Mechanism of Labor

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