Face presentation in labour: when the baby's face leads the way

Most babies enter the pelvis head first with the chin tucked towards the chest, so that the back or crown of the head leads. This is called a vertex or cephalic presentation. In a face presentation the neck is extended instead of flexed, so the baby's face comes first. Patient.info describes it as occurring when there is complete extension of the fetal head.

It sits at one end of a spectrum of head positions. At the other extreme is the usual flexed position. In between lies a brow presentation, where the head is only part way extended. Doctors group all of these as malpresentations, which Patient.info defines as all presentations of the baby other than the vertex.

The word presentation describes which part of the baby is leading towards the cervix. It is different from position, which describes how that leading part is turned in relation to the mother's pelvis. In face presentation, the key position question is where the chin is pointing.

It is rare. Patient.info states that face presentation occurs in 1 in 1,000 deliveries, while GPnotebook, another UK clinical reference, says 1 in 500, so it is best thought of as occurring in somewhere between one in 500 and one in 1,000 births.

Patient.info lists several factors that predispose to malpresentation in general: prematurity, multiple pregnancy, abnormalities of the uterus such as fibroids or a partial septate uterus, an abnormal baby, placenta praevia and a first baby. Not every face presentation has an identifiable cause, and the sources reviewed for this page do not single out specific causes for face presentation alone.

There is usually no way for a woman to tell. A face presentation is typically identified when the midwife or obstetrician carries out an examination in labour and finds that the face, rather than the top of the head, is leading. The sources reviewed describe the diagnosis in the context of labour examination rather than as a routine antenatal finding.

If it is suspected, an obstetrician is involved. The NHS notes that midwives monitor the baby's heartbeat during labour and may suggest electronic monitoring if there are any concerns about the baby or the mother, and that you can ask for electronic monitoring even if there are no concerns.

GPnotebook says that progress depends on the relative sizes of the baby and pelvis, that a mento-anterior face is the more favourable position, and that delivery may convert to a vertex position, in much the same way as an occipito-posterior position does, which can be assisted by manually flexing the head. It also notes that a face presentation is less favourable than the occipito-posterior position.

Patient.info says that with an adequate pelvic size and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour, whereas backward rotation to a mento-posterior position requires a caesarean section.

NICE's guideline on intrapartum care lists any non-cephalic presentation among the observations that mean a woman should be transferred to obstetric-led care, and says that assessment includes confirming the baby's wellbeing, presentation and position. Labour is then managed by an obstetric team, and the recommendation can move to caesarean section if labour is not progressing or there are concerns about the baby.

• If labour is progressing and the chin is to the front, the team may continue labour with close monitoring.

• If labour stalls, if the chin is to the back, or if there are concerns about the baby's wellbeing, an emergency caesarean section is the usual route.

• Pain relief options, including an epidural, are discussed in the same way as for any labour.

The NHS explains that a caesarean can be planned or done in an emergency if it is thought that a vaginal birth is too risky, and that most are done under spinal or epidural anaesthetic so the woman is awake. The operation normally takes about 40 to 50 minutes, most women can go home 1 to 2 days afterwards if there are no complications, and recovery takes longer than after a vaginal birth.

A caesarean in labour for face presentation is not a sign that anything was missed. It is the recognised route when the head cannot negotiate the pelvis safely. A woman who has had one should ask about the implications for a future pregnancy, including whether a vaginal birth after caesarean would be possible.

Face presentation is a variation in how the baby descends, and many babies with it are born healthy. The sources reviewed describe the management options but do not give outcome statistics, so this page does not quote figures for complications. Because the labour can be long, the main aims are to keep the mother and baby comfortable, monitor the baby's heart rate and make a timely decision about the mode of birth.

After the birth, the baby is checked in the usual way. If you have concerns about how your baby looks or feeds in the first days, raise them with the midwife, who can ask a paediatrician to review.

A face presentation is found in labour, so the management described here is carried out by the obstetric team in whichever maternity unit you are in. NICE's intrapartum guideline places this within obstetric-led care. If you are planning private maternity care, ask how a malpresentation found in labour would be managed and whether emergency caesarean facilities and neonatal support are on site.