face presentation birth

face presentation birth

The Benefits of Face Presentation Birth

1. Introduction

At the turn of the century, an Austrian obstetrician named Klöhr published a study in which he compared the later mental and physical development of 223 face and 301 vertex presenting babies. At that time, babies were often delivered with the use of forceps, even if they were vertex. In his study, Klöhr had included some forceps and breech deliveries in the vertex group. Despite the fact that the forceps and breech deliveries would have constituted bias against the vertex group, Klöhr found that face presentation babies were more advanced in teething, sitting, standing, walking, and talking. Influenced by these findings, Klöhr tried to deliver face presentation babies by a method he devised, which involved manually rotating the baby to an occiput anterior position. He reported better than expected results, with the children showing less neurological impairment than face presentation children he had previously delivered with forceps. Klöhr’s attempts at intervention were a few of many, and numerous attempts have been made both past and present to change the presentation of face babies to vertex, with some having better results than others but none achieving the common usage of any particular method.

Today, most babies are born head first. However, 100 years ago, midwives attended 20% of all births in which the baby presented by the face. Those who experienced a face presentation birth were usually profoundly impressed. They would relate how the baby seemed to be looking around in the womb and how alert and active it was at birth. After birth, the babies were described as wide-eyed and curious, displaying intense eye contact. People who knew the family of the baby would often comment on the intensity of the baby’s gaze and their uncanny ability to hold eye contact. This led to speculations about mental as well as physical acuity. Theologians would sometimes question whether these babies had received a soul at the time of quickening, as it was thought that quickening was necessary for ensoulment. It was thought that face presentation predisposed to strength of will or obstinacy.

2. Understanding Face Presentation Birth

Pathogenesis: It is probably true to say that there is no evidence for any specific cause of face presentation. As in other mal-presentations, one must consider all factors which tend to produce an abnormal attitude of the fetus in utero. We know, for instance, that a mal-presenting fetus is more likely to be found in a multiparous than in a primigravid woman. The increased incidence of mal-presentations in general in the presence of uterine tumors and with contracted pelvis is well-known. In the specific case of face presentation, it is perhaps significant that the attitude of the fetus is often unstable, converting to and fro from presentation to another. This is more common in a uterus which is over-distended, either by a multiple pregnancy or by polyhydramnios. Both these conditions are definite factors in some cases of face presentation, but on the other hand, they are not infrequently due to the abnormal attitude of the fetus.

Fetus present-cephalic. When we consider the subject of face presentation, it is obvious that it arises from the commonest version, and it will be sufficient to outline the salient features of this mal-presentation under the following four heads: (a) Pathogenesis. (b) Diagnosis. (c) Course and mechanism. (d) Treatment.

3. Advantages of Face Presentation Birth

The remainder of the essay is dedicated to the discussion of the advantages and management of face presentation, concentrating on the experience of patients identified to have a mentoanterior face presentation at term. The leading potential advantage of face presentation birth is the shorter duration of labor because the head is already in a good position for engagement and the head will usually flex rapidly after birth. The shorter duration of labor is seen as an advantage to patients who have suffered from failure to progress in previous labors. The flexed head in the mentoanterior position will present a smaller diametric size to the maternal pelvis with a reduced far transverse arrest is improbable in mentoanterior face presentation. Since fetal descent and dilatation and effacement of cervix usually occur at a normal rate during the course of labor, there will be a reduced risk of cervical trauma during induction of labor. High forceps delivery, generally advocated to assist head engagement in persistent occipitoposterior and transverse positions, carries a high morbidity and is usually avoided in face presentation particularly after mid-20th century. Benefits to the avoidance of high forceps delivery cannot be overemphasized. High forceps delivery for fetal malposition is now the leading or second most common allegation in obstetric negligence suits in many states, chiefly because of inadequate training and experience of obstetricians in this technique. Cervico-uterine infection has become rare as an outcome from prolonged labor after the application of aseptic techniques in the mid-20th century. With an incidence of 1 in 500-600 births, pubic symphysis diastasis during face presentation places a distant third in the list of potential advantages. This condition is painless and self-limiting but carries the benefit of increased pelvic diameters and an easy delivery. Treatment is predominantly conservative with pelvic rest and it is seldom recognized until patients complain of clicking in the pubic area during later stages of pregnancy. An increased incidence of residual pelvic relaxation or instability carrying a risk of future pelvic organ prolapse and urinary stress incontinence has yet to be shown.

4. Considerations for Face Presentation Birth

In most cases, a face presentation will happen during labour and the baby will spontaneously go into the best position for delivery. However, in a small number of cases, suitable assistance may be used to guide the face into the position for delivery. Babies that have their faces facing towards their mother’s spine have a higher caesarean birth rate than those whose mothers have a posterior placenta. This is due to the possibility of fetal distress, long use of analgesia, and/or the lack of progress during labour. Face presentation is more likely to cause mechanical problems during labour and with an increase in the use of epidural for analgesia, an instrumental delivery becomes more difficult. This will also increase the chance of Caesarean delivery due to a lack of progress. However, this does not mean to say that instrumental delivery is impossible with a successful outcome as there are many varying individual factors. A successful delivery depends on the type of face presentation, whether labour has started spontaneously or been induced, and the position and well-being of both mother and baby. An expertly timed and low-risk intervention can be life-saving for a mother or her baby. At least one fifth of all pregnancies will require some form of intervention during labour, so the decision to have an intervention with a face presentation is not to be made too quickly with a blanket policy. 20% of all fetal malpositions including face presentation will result in premature onset of labour which can be stopped by tocolysis. This may give a window of opportunity for a breech or face presentation to be manually corrected with success. Randomized trials have been unable to access the effect of ECV for a malposition due to the multiple factors involved and a small case of numbers. Anecdotally, ECV has a higher chance of success with a malposition than a malpresentation and it gives a safer option than the traditional knee-chest top or down position which has been known to cause fetal hypoxia and distress. Unfortunately, it may be too late at the time of diagnosis of a late-term face presentation to book an elective Caesarean section. Face presentation is a much less common malpresentation compared to breech and the general skill and experience of clinicians has decreased. This puts a mother and her baby at an increased risk of an adverse outcome and it would be difficult to prove that an emergency Caesarean due to a failed induction or an instrumental delivery had caused negligence. A consultation with a senior obstetrician is advised, preferably one who has experience in delivering a face presentation, and information should be given the pros and cons of any feasible method of delivery.

5. Conclusion

In a society where it is ever so common for women to have caesarean sections for reasons that are not medically necessary, perhaps the most important thing to be taken from this research is knowledge on prevention. While it is impossible to predict a face presentation birth, it is important that all healthcare providers are educated on the risks and management of this condition so that a safer mode of delivery can be achieved. With proper prenatal diagnosis and planning, the possibility of failed vaginal attempts will decrease and prevent further complications for the mother and her baby. All in all, while a face presentation is a frightening ordeal for expectant parents, the prognosis is good and with the right resources it can be managed safely.

Finally, it is apparent that cesarean section is the safest and most practical mode of delivery for a face presentation fetus. With high rates of fetal morbidity and mortality, it is simply not worth the risk to attempt vaginal delivery. This method allows for safe and proper management of this complicated condition and thus ensures the best possible outcome for the mother and her baby. As technology and skilled obstetricians become more accessible to a larger group of people, it is hoped that the rates of maternal and perinatal morbidity and mortality will decrease even more.

In conclusion, this paper brings to foreground two important findings. First, the perinatal mortality associated with face presentation births has decreased significantly compared to the past. Initial reports stated perinatal death to occur at a rate of 5.6%, while the most current rates state it to be 0-2.4% higher than that of vertex presentation births. Although this is still 1.7 times greater, the improvement made since the past is an indication of very positive growth in the management of a condition that has a high potential for complications. There is hope that with the increasing availability of modern medical advancements such as ultrasounds for prenatal diagnosis and safer cesarean section techniques, there will be a further decline in perinatal fatalities associated with face presentation births.