In a term singleton pregnancy with a face presentation and no maternal or fetal contraindications, what is the safest initial management for delivery?

Face Presentation Delivery Management

In a term singleton pregnancy with face presentation and no contraindications, the safest initial management is expectant management with a trial of labor, provided the fetal chin is in the mentum anterior position, with cesarean section reserved for mentum posterior positions or failure to progress. 1, 2

Initial Assessment and Position Determination

The critical first step is determining the position of the fetal chin (mentum):

• Mentum anterior (MA): The chin is directed toward the maternal symphysis pubis, allowing vaginal delivery in most cases 1, 3
• Mentum posterior (MP): The chin is directed toward the maternal sacrum, which is incompatible with vaginal delivery and requires cesarean section 3

The diagnosis is frequently made late in labor—only 3.7% are diagnosed before labor onset, with 44.4% not identified until cesarean section is already underway 4. Digital vaginal examination can identify facial landmarks (orbital ridges, nose, mouth), though a vaginal speculum may facilitate rapid diagnosis during active labor 4.

Management Algorithm by Chin Position

For Mentum Anterior Position:

• Proceed with trial of labor under continuous electronic fetal monitoring 1
• Position the patient in left lateral decubitus to optimize uteroplacental perfusion 5
• Avoid operative vaginal delivery (forceps/vacuum), as these are associated with the majority of perinatal losses and traumatic injuries in face presentation 1
• Allow spontaneous descent and delivery—the prognosis for vaginal delivery is excellent when cephalopelvic disproportion is absent 1
• Labor duration is typically not prolonged unless underlying disproportion exists 1

For Mentum Posterior Position:

• Proceed directly to cesarean section, as vaginal delivery is mechanically impossible 3
• Some experienced practitioners report success manually rotating MP to mentum anterior, though this is not standard practice and requires significant expertise 2

Key Risk Factors and Contraindications

Evaluate for conditions that increase cesarean section likelihood:

• Fetal macrosomia: Significantly increases risk of cephalopelvic disproportion 1, 4
• High parity: Associated with 2.76-fold increased odds of face presentation 4
• Polyhydramnios (AFI >18 cm): Associated with 2.60-fold increased odds 4
• Cephalopelvic disproportion: When present, cesarean section is mandatory regardless of chin position 6, 1

Critical Pitfalls to Avoid

Never attempt operative vaginal delivery (forceps or vacuum extraction) in face presentation—these interventions are contraindicated and cause catastrophic fetal trauma, accounting for most historical perinatal losses 7, 1. Forceps are only appropriate for vertex presentations with the head engaged in the pelvis 7.

Do not use oxytocin augmentation if cephalopelvic disproportion cannot be confidently excluded, as this increases risk of uterine rupture and fetal injury 6.

Avoid premature cesarean section for mentum anterior positions without trial of labor, as recent series demonstrate excellent outcomes with expectant management and careful surveillance 1, 2.

Expected Outcomes and Counseling

• Cesarean section rate for face presentation is 88.9% overall, significantly higher than vertex presentations 4
• Postpartum hemorrhage ≥500 mL occurs in 14.8% of cases 4
• Neonatal outcomes are generally favorable with appropriate management—Apgar scores are comparable to vertex presentations when traumatic operative delivery is avoided 1, 4
• Newborns typically present with severe facial edema, bruising, and ecchymosis that resolve within 24-48 hours 3
• Serious complications (brachial plexus injury, severe uterine laceration) occur in approximately 11% of cases, emphasizing the need for experienced management 4

Preparation for Delivery

• Ensure availability of neonatal resuscitation team given facial edema and potential airway concerns 5
• Prepare for potential cesarean section even with mentum anterior, as 88.9% ultimately require operative delivery 4
• Counsel the patient that while vaginal delivery is possible with mentum anterior, cesarean section may become necessary if labor fails to progress 1, 4