What is the best approach for managing a face presentation in labor?

Management of Face Presentation in Labour

Face presentation should be managed expectantly with continuous fetal monitoring, allowing spontaneous vaginal delivery in mentum anterior positions while proceeding to cesarean section for persistent mentum posterior or transverse positions that fail to rotate, or when cephalopelvic disproportion is suspected. 1, 2

Initial Assessment and Diagnosis

• Confirm the diagnosis through vaginal examination identifying the orbital ridges, nose, mouth, and malar bones to distinguish face from breech presentation 1
• Document the position of the mentum (chin) relative to the maternal pelvis - anterior, transverse, or posterior 3, 4
• Assess for predisposing factors including multiparity (aOR 2.76), polyhydramnios (amniotic fluid index >18 cm, aOR 2.60), fetal macrosomia, prematurity, anencephaly, and cephalopelvic disproportion 1, 5
• Establish continuous electronic fetal monitoring as variable decelerations occur in 59% of cases and severe variable decelerations in 29%, with late decelerations in 24% 3

Expectant Management Strategy

The cornerstone of management is watchful waiting without intervention when disproportion is absent and the fetus is not anomalous. 1

• Allow spontaneous labor to progress without artificial rupture of membranes or oxytocin augmentation unless clear active phase arrest occurs after 6 cm dilation 1, 2
• Avoid manual rotation attempts as these increase maternal and fetal trauma without improving outcomes 1
• Monitor labor duration carefully - face presentation does not consistently alter labor duration in the absence of underlying cephalopelvic disproportion 1

Position-Specific Management

Mentum Anterior Position

• Anticipate spontaneous vaginal delivery in 88% of cases with mentum anterior presentation 3
• Prepare for delivery as the prognosis for vaginal birth is excellent when the chin remains anterior 1, 4

Mentum Transverse Position

• Continue expectant management as 45% will deliver vaginally, often after spontaneous rotation to mentum anterior 3
• Reassess every 1-2 hours during active labor for evidence of rotation or arrest 2

Mentum Posterior Position

• Proceed to cesarean section as only 25% deliver vaginally and these carry higher risk of low 5-minute Apgar scores 3
• Do not attempt forceps rotation from mentum posterior to anterior, as this significantly increases trauma 1, 2

Indications for Cesarean Section

Cesarean delivery is indicated in the following circumstances:

• Persistent mentum posterior position that fails to rotate spontaneously during labor 2, 3
• Evidence of cephalopelvic disproportion including arrest of descent or dilation in active phase 1, 5
• Fetal distress with non-reassuring fetal heart rate patterns that do not resolve with conservative measures 3
• Failed progress in labor despite adequate contractions and time 4
• Nulliparity with early diagnosis (before 5 cm dilation) carries higher cesarean risk and warrants lower threshold for operative delivery 4

Critical Pitfalls to Avoid

• Never attempt version and extraction or midforceps rotation - the majority of perinatal losses in face presentation result from traumatic operative vaginal deliveries 1
• Do not confuse face with breech presentation during vaginal examination, as management differs fundamentally 1
• Avoid aggressive intervention in latent phase - diagnosis before 5 cm dilation is associated with increased cesarean rates, but this reflects appropriate caution rather than indication for immediate intervention 4
• Do not underestimate postpartum hemorrhage risk - the rate of PPH ≥500 ml is significantly higher (14.8% vs 2.8%) in face presentations 5
• Recognize that internal fetal scalp electrode placement is safe when needed for monitoring, with no serious trauma reported in properly placed electrodes 3

Expected Outcomes

• Overall cesarean rate is 31.7-50% compared to 9.2-13.9% in vertex presentations 5, 4
• Neonatal outcomes are generally favorable with proper management - Apgar scores and arterial pH values are similar to vertex presentations when traumatic operative delivery is avoided 1, 4
• Vaginal delivery occurs in more than two-thirds of attempted cases when managed expectantly without aggressive intervention 4
• Incidence is rare at approximately 1 per 600-1250 deliveries at term 1, 3

Monitoring and Documentation

• Use internal monitoring techniques when available (79% of cases) for more accurate assessment of fetal status 3
• Document position changes throughout labor as mentum transverse may rotate to anterior or posterior 3
• Prepare for potential complications including brachial plexus injury and lower uterine segment lacerations, though these remain uncommon with appropriate management 5