Face presentation is a rare abnormal lie where the fetal head is completely hyperextended. Instead of the usual vertex presenting first, the occiput is pressed against the fetal back, making the face the leading part felt in the birth canal. The mentum, or chin, serves as the designating point for positioning and diagnosis.
Complete extension of the fetal neck creates this state. When examining a patient, midwives must distinguish face presentation from brow presentation, where the head is only partially deflected. In face presentation, the mentum leads, whereas the brow presents when the head stops midway between flexion and extension.
Most cases of face presentation develop during labour rather than early pregnancy. Any factor that prevents normal flexion of the fetal head can trigger this malpresentation.
Detecting face presentation early improves labour outcomes. During antenatal abdominal palpation, a midwife might feel a deep groove between the fetal back and the remarkably prominent occiput, sometimes called the Cobb's sign. The fetal heart tones are often auscultated loudly over the chest side.
During vaginal examination in labour, the findings can sometimes be confused with a breech presentation because soft parts feel similar. The midwife must carefully palpate facial landmarks: the orbital ridges, the nose, the mouth, and the malar bones. Finding the firm alveolar margins of the jaws helps confirm a face, distinguishing it from a soft sacrum or an irregular brow.
The success of a vaginal delivery in face presentation depends heavily on the position of the chin.
In a mento-anterior (MA) position, the chin rotates forward toward the pubic symphysis. As the labour progresses, the head descends, and the face fits under the pubic arch. The head then undergoes flexion, allowing the chin, mouth, nose, and brow to sweep successively over the perineum.
In a mento-posterior (MP) position, the chin points toward the maternal sacrum. This position constitutes a major obstruction. Because the human neck cannot stretch enough to allow the head to clear the sacral promontory and pubic bone simultaneously, persistent mento-posterior positions result in obstructed labour requiring surgical intervention.
Management of face presentation requires vigilance in a well-equipped maternity unit. Midwives must monitor maternal and fetal well-being continuously using a partograph.
If the presentation is mento-anterior and progress is steady, vaginal delivery may proceed with caution. However, oxytocin augmentation is generally avoided because forcing a deeply extended head against a resistant pelvis increases trauma.
If a persistent mento-posterior position is diagnosed or if fetal distress occurs, a prompt caesarean section is performed. Manual rotation or instrumental delivery by inexperienced birth attendants is discouraged due to high risks of severe fetal trauma and uterine rupture.
Face presentations carry higher risks for both mother and baby compared to normal vertex births. Prolonged labour is common due to inefficient adaptation of the face to the pelvic floor.
Maternal risks include severe perineal lacerations, exhaustion, and increased rates of operative delivery, which elevate the chance of postpartum hemorrhage and infection. Fetal risks stem from prolonged pressure on the head and neck. Babies born after a face presentation frequently exhibit marked facial edema, bruising, and distortion of the features, which usually resolve within a few days. Intracranial hemorrhage remains a serious risk in neglected cases.