B.
Sc DEGREE COURSE IN NURSING
(BASIC)
Midwifery and Obstetrical Nursing
Unit: VIII- Assessment and management of
Abnormal Labor
FACE PRESENTATION
Dr. Latha Venkatesan,Principal
Mrs. Indhumathi. R, Professor
27.4.2020- Afternoon
LEARNING OBJECTIVES
The Students will be able to:
• define Face presentation.
• enlist the types of face presentation
• identify the etiology of face presentation
• describe the Clinical diagnosis of face
presentation.
• explain about the mechanism of face
presentation.
• discuss the management of labour
• enlist the complications of Face Presentation
INTRODUCTION
• At term, majority of fetuses present in
the vertex presentation, where the fetal head is
flexed so that the chin is in contact with the fetal
thorax.
• Malpresentation of the vertex
presentation occurs if there is deflexion or
extension of the fetal head leading to brow or
face presentation, respectively.
DEFINITION
• It is a cephalic presentation
in which the head is
completely extended.
• Incidence
• About 1:500 labours.
• Face is a rare variety of
cephalic presentation
CHARECTERISTICS OF FACE
PRESENTATION
The fetal head and neck are hyperextended,
causing the occiput to come in contact with the
upper back of the fetus
The presenting part of the fetus is the fetal face
The attitude of the fetus shows complete flexion
of the limbs with extension of the spine.
The denominator is mentum
TYPES OF FACE PRESENTATION
Primary face Secondary face
presentation presentation
• It is less common.
• It occurs during • It is more common.
pregnancy. • It occurs during
• It is usually due to labour.
foetal causes • It may be due to
maternal causes
CAUSES OF FACE PRESENTATION
Maternal
Fetal
MATERNAL CAUSES
Further deflexion of
Multiparity with
brow or occipito -
pendulous abdomen
posterior positions.
Contracted pelvis Pelvic tumors
(Flat pelvis) Placenta previa
INTRODUCTION
FETAL CAUSES
Anencephaly
Loops of the cord around the neck.
Tumours of the foetal neck e.g.
congenital goitre.
Hypertonicity of the extensor muscles of
the neck.
Dolicocephaly: long antero-posterior
diameter of the head
Dead or premature foetus.
POSITIONS OF FACE PRESENTATION
RMP • Right mento-posterior
LMP • Left mento-posterior
• Left mento-anterior
LMA • Mento-anterior are more common than
mento-posterior
RMA • Right mento-anterior
RMT • Right mento-transverse
Cont…..
• The most common position is left
mentoanterior (LMA)
As the ROP position is 5 times more common
than LOP and as the conversion of face occurs
from deflexed OP, LMA is the commonest.
Overall anterior positions are more frequent
than the posterior one.
Left and right anterior and posterior
positions.
Lt mento-ant Rt mento-ant Rt mento-ant
DIAGNOSIS
• DURING PREGNANCY
• Antenatal diagnosis is rarely made.
• Diagnosis is made only during labor but in about
half, the detection is made at the time of delivery.
• The back is difficult to feel.
• The limbs are felt more prominent in mento-
anterior position.
• The FHS are heard below the umbilicus through
the foetal chest wall in mento-anterior position.
DIAGNOSIS( DURING LABOUR)
VAGINAL EXAMINATION
The nose can be felt during PV
The sucking effect of mouth
The malar processes
The Chin
The supra orbital ridges
FULLY DILATED CERVIX IN FACE
PRESENTATION
SONOGRAPHY/RADIOGRAPHY
This should be done to confirm the
diagnosis, to exclude bony congenital
malformation of the fetus and to note the size of
the baby
MANAGEMENT DURING LABOUR
• proper clinical assessment
• review antenatal chart
• insert large pore I.V. line
• take the necessary investigation
• keep patient fasting during labour
• start I. V. fluids to prevent maternal
dehydration and ketosis
• use Partogram for labour progress
assessment
Cont….
• continuous fetal monitoring
• provide adequate analgesia
• regular observation of maternal and fetal
condition and the labour progress
• be ready for operative intervention
either vaginally or abdominally
MECHANISM OF LABOUR IN FACE
PRESENTATION
CHARECTERISTICS
Lie Longitudinal
Presentation Face
Position Left mento anterior
Attitude Extension of head
Denominator Mentum
Presenting part Left malar bone
STEPS IN MECHANISM OF LABOUR IN
FACE PRESENTATION
1. Engagement
2. Descent
3. Extension
4. Internal Rotation of Head
5. Delivery of head
6. Restitution
7. Internal Rotation of shoulder and external
rotation of head
8. Lateral flexion
MECHANISM
Mentum facing the iliopectineal eminence and glabella
to the opposite sacro- iliac joint
The engaging diameter of the head is submento-
bregmatic 9.5cm. Descent takes place with increased
extension till the chin touches the pelvic floor.
Internal rotation of the Mentum occurs 1/8th of the circle
until the Mentum comes under symphysis pubis.
Crowning takes place where no longer the fetal head recedes back
during the uterine contractions
Head is born by the movement of flexion. Sinciput, vertex and occiput
sweeps the perineum.
Restitution occurs in which face turns to the left side of the mother
Shoulder enters the pelvis in left oblique diameter, internal rotation of the
shoulder and external rotation of the head takes place.
Anterior shoulder escapes the symphysis pubis and posterior shoulder
sweeps the perineum. The body is born by the movement of lateral
flexion.
VAGINAL DELIVERY
MENTOANTERIOR
First stage:
• In uncomplicated cases, a wait and watch
policy is adopted.
• Labor is conducted in the usual procedure
and the special instructions, as laid down in
occipito posterior positions, are to be followed
VAGINAL DELIVERY MENTO ANTERIOR
• Second stage
• Wait for spontaneous delivery
• Liberal episiotomy
• In case of delay, forceps delivery is done.
VAGINAL DELIVERY MENTOPOSTERIOR
• First stage
• In uncomplicated cases vaginal delivery is
allowed with strict vigilance hoping for
spontaneous anterior rotation of the chin.
VAGINAL DELIVERY MENTO POSTERIOR
• Second stage
• If anterior rotation of the chin occurs, spontaneous or
forceps delivery with episiotomy
• In incomplete or malrotation - early decision on mode
of delivery.
• LSCS is preferred method.
• Manual rotation of chin anteriorly followed by forceps.
INDICATIONS FOR ELECTIVE LSCS
Contracted
pelvis
Associate
d
Big baby
complicati
ng factors
COMPLICATIONS OF FACE
PRESENTATION
MATERNAL FETAL
• prolonged and complicated • Edema of brow
labour
• Maternal distress … • Marked moulding
dehydration … keto acidosis
• No engagement of • Cord prolapse
presenting part
• Fetal distress
• Obstructed labour
• APH, PPH • Fetal death
• Maternal Death
PROGNOSIS
In mentoanterior, the maternal
risk is not much increased.
Increased morbidity due to
operative delivery and vaginal
manipulation.
In neglected cases, the risks of
impacted mentoposterior leading
to obstructed labor
SUMMARY
• Normally, children are born head-first with the
chin tucked towards the chest (vertex
presentation).
• In a face presentation, the chin is not tucked
and the neck is hyperextended.
• This can inhibit the engagement of the head
and complicate the labor process.
• In some cases, a baby in face presentation
can be delivered vaginally, but in other cases
vaginal delivery is difficult and dangerous.
REFERENCE
[Link],V.R.&Brown,L.K.(2003).Myles TextBook for
Midwives.(15th ed). Philadelphia:ELNBSChurchill
Livingstone.
[Link],A.,& Gloria, L.(2001).Maternity Nursing An
Introductory text (8th ed).Philadelphia: W.B. Saunders
Company.
[Link].D.c.(2006). Textbook of Obstetrics (3rd ed).
Calcutta: New Central Book Agency.
[Link] Seshadri.,Gita Arjun.(2015).Essentials Of
Obstetrics(1st ed).New Delhi:Wolters Kluwer(India).
[Link],D.L,Perry.S.E.,Marilyn,J.,Hockenberry.,Lowdermil
k,D.L.,Wilson,D.(2006).Maternal Infant Nursing Care.(4th
ed). Missouri:Mosby.
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