medical definition of face presentation

Face and Brow Presentation

• Author: Teresa Marino, MD; Chief Editor: Carl V Smith, MD  more...
• Sections Face and Brow Presentation
• Mechanism of Labor
• Labor Management

At the onset of labor, assessment of the fetal presentation with respect to the maternal birth canal is critical to the route of delivery. At term, the vast 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. The fetal spine typically lies along the longitudinal axis of the uterus. Nonvertex presentations (including breech, transverse lie, face, brow, and compound presentations) occur in less than 4% of fetuses at term. Malpresentation of the vertex presentation occurs if there is deflexion or extension of the fetal head leading to brow or face presentation, respectively.

In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an internal examination through the cervix. The occiput of a vertex is usually hard and has a smooth contour, while the face and brow tend to be more irregular and soft. Like the occiput, the mentum can present in any position relative to the maternal pelvis. For example, if the mentum presents in the left anterior quadrant of the maternal pelvis, it is designated as left mentum anterior (LMA).

In a brow presentation, the fetal head is midway between full flexion (vertex) and hyperextension (face) along a longitudinal axis. The presenting portion of the fetal head is between the orbital ridge and the anterior fontanel. The face and chin are not included. The frontal bones are the point of designation and can present (as with the occiput during a vertex delivery) in any position relative to the maternal pelvis. When the sagittal suture is transverse to the pelvic axis and the anterior fontanel is on the right maternal side, the fetus would be in the right frontotransverse position (RFT).

Face presentation occurs in 1 of every 600-800 live births, averaging about 0.2% of live births. Causative factors associated with a face presentation are similar to those leading to general malpresentation and those that prevent head flexion or favor extension. Possible etiology includes multiple gestations, grand multiparity, fetal malformations, prematurity, and cephalopelvic disproportion. At least one etiological factor may be identified in up to 90% of cases with face presentation.

Fetal anomalies such as hydrocephalus, anencephaly, and neck masses are common risk factors and may account for as many as 60% of cases of face presentation. For example, anencephaly is found in more than 30% of cases of face presentation. Fetal thyromegaly and neck masses also lead to extension of the fetal head.

A contracted pelvis or cephalopelvic disproportion, from either a small pelvis or a large fetus, occurs in 10-40% of cases. Multiparity or a large abdomen can cause decreased uterine tone, leading to natural extension of the fetal head.

Face presentation is diagnosed late in the first or second stage of labor by examination of a dilated cervix. On digital examination, the distinctive facial features of the nose, mouth, and chin, the malar bones, and particularly the orbital ridges can be palpated. This presentation can be confused with a breech presentation because the mouth may be confused with the anus and the malar bones or orbital ridges may be confused with the ischial tuberosities. The facial presentation has a triangular configuration of the mouth to the orbital ridges compared to the breech presentation of the anus and fetal genitalia. During Leopold maneuvers, diagnosis is very unlikely. Diagnosis can be confirmed by ultrasound evaluation, which reveals a hyperextended fetal neck. [ 1 , 2 ]

Brow presentation is the least common of all fetal presentations and the incidence varies from 1 in 500 deliveries to 1 in 1400 deliveries. Brow presentation may be encountered early in labor but is usually a transitional state and converts to a vertex presentation after the fetal neck flexes. Occasionally, further extension may occur resulting in a face presentation.

The causes of a persistent brow presentation are generally similar to those causing a face presentation and include cephalopelvic disproportion or pelvic contracture, increasing parity and prematurity. These are implicated in more than 60% of cases of persistent brow presentation. Premature rupture of membranes may precede brow presentation in as many as 27% of cases.

Diagnosis of a brow presentation can occasionally be made with abdominal palpation by Leopold maneuvers. A prominent occipital prominence is encountered along the fetal back, and the fetal chin is also palpable; however, the diagnosis of a brow presentation is usually confirmed by examination of a dilated cervix. The orbital ridge, eyes, nose, forehead, and anterior fontanelle are palpated. The mouth and chin are not palpable, thus excluding face presentation. Fetal ultrasound evaluation again notes a hyperextended neck.

As with face presentation, diagnosis is often made late in labor with half of cases occurring in the second stage of labor. The most common position is the mentum anterior, which occurs about twice as often as either transverse or posterior positions. A higher cesarean delivery rate occurs with a mentum transverse or posterior [ 3 ] position than with a mentum anterior position.

The mechanism of labor consists of the cardinal movements of engagement, descent, flexion, internal rotation, and the accessory movements of extension and external rotation. Intuitively, the cardinal movements of labor for a face presentation are not completely identical to those of a vertex presentation.

While descending into the pelvis, the natural contractile forces combined with the maternal pelvic architecture allow the fetal head to either flex or extend. In the vertex presentation, the vertex is flexed such that the chin rests on the fetal chest, allowing the suboccipitobregmatic diameter of approximately 9.5 cm to be the widest diameter through the maternal pelvis. This is the smallest of the diameters to negotiate the maternal pelvis. Following engagement in the face presentation, descent is made. The widest diameter of the fetal head negotiating the pelvis is the trachelobregmatic or submentobregmatic diameter, which is 10.2 cm (0.7 cm larger than the suboccipitobregmatic diameter). Because of this increased diameter, engagement does not occur until the face is at +2 station.

Fetuses with face presentation may initially begin labor in the brow position. Using x-ray pelvimetry in a series of 7 patients, Borrell and Ferstrom demonstrated that internal rotation occurs between the ischial spines and the ischial tuberosities, making the chin the presenting part, lower than in the vertex presentation. [ 4 , 5 ] Following internal rotation, the mentum is below the maternal symphysis, and delivery occurs by flexion of the fetal neck. As the face descends onto the perineum, the anterior fetal chin passes under the symphysis and flexion of the head occurs, making delivery possible with maternal expulsive forces.

The above mechanisms of labor in the term infant can occur only if the mentum is anterior and at term, only the mentum anterior face presentation is likely to deliver vaginally. If the mentum is posterior or transverse, the fetal neck is too short to span the length of the maternal sacrum and is already at the point of maximal extension. The head cannot deliver as it cannot extend any further through the symphysis and cesarean delivery is the safest route of delivery.

Fortunately, the mentum is anterior in over 60% of cases of face presentation, transverse in 10-12% of cases, and posterior only 20-25% of the time. Fetuses with the mentum transverse position usually rotate to the mentum anterior position, and 25-33% of fetuses with mentum posterior position rotate to a mentum anterior position. When the mentum is posterior, the neck, head and shoulders must enter the pelvis simultaneously, resulting in a diameter too large for the maternal pelvis to accommodate unless in the very preterm or small infant.

Three labor courses are possible when the fetal head engages in a brow presentation. The brow may convert to a vertex presentation, to a face presentation, or remain as a persistent brow presentation. More than 50% of brow presentations will convert to vertex or face presentation and labor courses are managed accordingly when spontaneous conversion occurs.

In the brow presentation, the occipitomental diameter, which is the largest diameter of the fetal head, is the presenting portion. Descent and internal rotation occur only with an adequate pelvis and if the face can fit under the pubic arch. While the head descends, it becomes wedged into the hollow of the sacrum. Downward pressure from uterine contractions and maternal expulsive forces may cause the mentum to extend anteriorly and low to present at the perineum as a mentum anterior face presentation.

If internal rotation does not occur, the occipitomental diameter, which measures 1.5 cm wider than the suboccipitobregmatic diameter and is thus the largest diameter of the fetal head, presents at the pelvic inlet. The head may engage but can descend only with significant molding. This molding and subsequent caput succedaneum over the forehead can become so extensive that identification of the brow by palpation is impossible late in labor. This may result in a missed diagnosis in a patient who presents later in active labor.

If the mentum is anterior and the forces of labor are directed toward the fetal occiput, flexing the head and pivoting the face under the pubic arch, there is conversion to a vertex occiput posterior position. If the occiput lies against the sacrum and the forces of labor are directed against the fetal mentum, the neck may extend further, leading to a face presentation.

The persistent brow presentation with subsequent delivery only occurs in cases of a large pelvis and/or a small infant. Women with gynecoid pelvis or multiparity may be given the option to labor; however, dysfunctional labor and cephalopelvic disproportion are more likely if this presentation persists.

Labor management of face and brow presentation requires close observation of labor progression because cephalopelvic disproportion, dysfunctional labor, and prolonged labor are much more common. As mentioned above, the trachelobregmatic or submentobregmatic diameters are larger than the suboccipitobregmatic diameter. Duration of labor with a face presentation is generally the same as duration of labor with a vertex presentation, although a prolonged labor may occur. As long as maternal or fetal compromise is not evident, labor with a face presentation may continue. [ 6 ] A persistent mentum posterior presentation is an indication for delivery by cesarean section.

Continuous electronic fetal heart rate monitoring is considered mandatory by many authors because of the increased incidence of abnormal fetal heart rate patterns and/or nonreassuring fetal heart rate patterns. [ 7 ] An internal fetal scalp electrode may be used, but very careful application of the electrode must be ensured. The mentum is the recommended site of application. Facial edema is common and can obscure the fetal facial anatomy and improper placement can lead to facial and ophthalmic injuries. Oxytocin can be used to augment labor using the same precautions as in a vertex presentation and the same criteria of assessment of uterine activity, adequacy of the pelvis, and reassuring fetal heart tracing.

Fetuses with face presentation can be delivered vaginally with overall success rates of 60-70%, while more than 20% of fetuses with face presentation require cesarean delivery. Cesarean delivery is performed for the usual obstetrical indications, including arrest of labor and nonreassuring fetal heart rate pattern.

Attempts to manually convert the face to vertex (Thom maneuver) or to rotate a posterior position to a more favorable anterior mentum position are rarely successful and are associated with high fetal morbidity and mortality and maternal morbidity, including cord prolapse, uterine rupture, and fetal cervical spine injury with neurological impairment. Given the availability and safety of cesarean delivery, internal rotation maneuvers are no longer justified unless cesarean section cannot be readily performed.

Internal podalic version and breech extraction are also no longer recommended in the modern management of the face presentation. [ 8 ]

Operative delivery with forceps must be approached with caution. Since engagement occurs when the face is at +2 position, forceps should only be applied to the face that has caused the perineum to bulge. Increased complications to both mother and fetus can occur [ 9 ] and operative delivery must be approached with caution or reserved when cesarean section is not readily available. Forceps may be used if the mentum is anterior. Although the landmarks are different, the application of any forceps is made as if the fetus were presenting directly in the occiput anterior position. The mouth substitutes for the posterior fontanelle, and the mentum substitutes for the occiput. Traction should be downward to maintain extension until the mentum passes under the symphysis, and then gradually elevated to allow the head to deliver by flexion. During delivery, hyperextension of the fetal head should be avoided.

As previously mentioned, the persistent brow presentation has a poor prognosis for vaginal delivery unless the fetus is small, premature, or the maternal pelvis is large. Expectant management is reasonable if labor is progressing well and the fetal well-being is assessed, as there can be spontaneous conversion to face or vertex presentation. The earlier in labor that brow presentation is diagnosed, the higher the likelihood of conversion. Minimal intervention during labor is recommended and some feel the use of oxytocin in the brow presentation is contraindicated.

The use of operative vaginal delivery or manual conversion of a brow to a more favorable presentation is contraindicated as the risks of perinatal morbidity and mortality are unacceptably high. Prolonged, dysfunctional, and arrest of labor are common, necessitating cesarean section delivery.

The incidence of perinatal morbidity and mortality and maternal morbidity has decreased due to the increased incidence of cesarean section delivery for malpresentation, including face and brow presentation.

Neonates delivered in the face presentation exhibit significant facial and skull edema, which usually resolves within 24-48 hours. Trauma during labor may cause tracheal and laryngeal edema immediately after delivery, which can result in neonatal respiratory distress. In addition, fetal anomalies or tumors, such as fetal goiters that may have contributed to fetal malpresentation, may make intubation difficult. Physicians with expertise in neonatal resuscitation should be present at delivery in the event that intubation is required. When a fetal anomaly has been previously diagnosed by ultrasonographic evaluation, the appropriate pediatric specialists should be consulted and informed at time of labor.

Bellussi F, Ghi T, Youssef A, et al. The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations. Am J Obstet Gynecol . 2017 Dec. 217 (6):633-41. [QxMD MEDLINE Link] .

[Guideline] Ghi T, Eggebø T, Lees C, et al. ISUOG Practice Guidelines: intrapartum ultrasound. Ultrasound Obstet Gynecol . 2018 Jul. 52 (1):128-39. [QxMD MEDLINE Link] . [Full Text] .

Shaffer BL, Cheng YW, Vargas JE, Laros RK Jr, Caughey AB. Face presentation: predictors and delivery route. Am J Obstet Gynecol . 2006 May. 194(5):e10-2. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour. Radiol Clin North Am . 1967 Apr. 5(1):73-85. [QxMD MEDLINE Link] .

Borell U, Fernstrom I. The mechanism of labour in face and brow presentation: a radiographic study. Acta Obstet Gynecol Scand . 1960. 39:626-44.

Gardberg M, Leonova Y, Laakkonen E. Malpresentations--impact on mode of delivery. Acta Obstet Gynecol Scand . 2011 May. 90(5):540-2. [QxMD MEDLINE Link] .

Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand . 2004 Jun. 83(6):511-8. [QxMD MEDLINE Link] .

Verspyck E, Bisson V, Gromez A, Resch B, Diguet A, Marpeau L. Prophylactic attempt at manual rotation in brow presentation at full dilatation. Acta Obstet Gynecol Scand . 2012 Nov. 91(11):1342-5. [QxMD MEDLINE Link] .

Johnson JH, Figueroa R, Garry D. Immediate maternal and neonatal effects of forceps and vacuum-assisted deliveries. Obstet Gynecol . 2004 Mar. 103(3):513-8. [QxMD MEDLINE Link] .

Benedetti TJ, Lowensohn RI, Truscott AM. Face presentation at term. Obstet Gynecol . 1980 Feb. 55(2):199-202. [QxMD MEDLINE Link] .

BROWNE AD, CARNEY D. OBSTETRICS IN GENERAL PRACTICE. MANAGEMENT OF MALPRESENTATIONS IN OBSTETRICS. Br Med J . 1964 May 16. 1(5393):1295-8. [QxMD MEDLINE Link] .

Campbell JM. Face presentation. Aust N Z J Obstet Gynaecol . 1965 Nov. 5(4):231-4. [QxMD MEDLINE Link] .

Contributor Information and Disclosures

Teresa Marino, MD Assistant Professor, Attending Physician, Division of Maternal-Fetal Medicine, Tufts Medical Center Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

Chitra M Iyer, MD, Perinatologist, Obstetrix Medical Group, Fort Worth, Texas.

Chitra M Iyer, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Society of Maternal-Fetal Medicine .

Disclosure: Nothing to disclose.

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7.9 Face presentation

7.9.1 diagnosis.

• Palpation of the mother's abdomen at the start of labour: palpate the occipital region; a cleft between the head and the back will be palpable, due to hyperextension of the head.
• On vaginal examination: no suture or fontanelle can be felt; orbits, nose, mouth, ears and chin palpable. Palpation of the chin is essential to confirm the diagnosis.

7.9.2 Management

Determine the orientation of the chin—anterior (at the mother's pubis) or posterior.

The chin is anterior

Vaginal delivery is possible. Labour may be slow, patience is required. If uterine contractions are inadequate, oxytocin may be used. Episiotomy is usually needed during delivery (Figures 7.4), given the maximum amount the perineum can stretch. If instrumental delivery is necessary, use forceps. Vacuum extraction is contra-indicated for a live fœtus.

Figures 7.4 - Chin anterior: delivery possible

The chin is posterior

Vaginal delivery is not possible (Figure 7.5). A caesarean section must be arranged. Refer if necessary.

Figure 7.5 - Chin posterior: impaction

If caesarean section is not feasible and referral is not possible, attempt the following manoeuvres:

• Flex the head to obtain a vertex presentation: with one hand in the vagina, grasp the top of the skull and flex the neck, using the other hand, on the abdomen, to apply pressure to the foetal chest and buttocks. Obviously, the presenting part must not be engaged, and it is often hard—or impossible—to keep the head flexed (Figures 7.6).

• Rotate the head to bring the chin anteriorly: push the face and chin back to free the shoulders from the pelvic inlet then, turn the head within the pelvic cavity, using a hand on the abdomen to help the rotation by applying pressure to the shoulders. In this way, the chin is brought to the front (Figures 7.7).

• Version: internal podalic version, then total breech extraction (Figure 7.8).

All these manoeuvres are difficult and pose a significant risk of uterine rupture. They must be done when the uterus is not contracting. Whenever possible, caesarean section should be performed instead.

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Malpresentations and malpositions

Peer reviewed by Dr Laurence Knott Last updated by Dr Colin Tidy, MRCGP Last updated 22 Jun 2021

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In this article :

Malpresentation, malposition.

Usually the fetal head engages in the occipito-anterior position (more often left occipito-anterior (LOA) rather than right) and then undergoes a short rotation to be directly occipito-anterior in the mid-cavity. Malpositions are abnormal positions of the vertex of the fetal head relative to the maternal pelvis. Malpresentations are all presentations of the fetus other than vertex.

Obstetrics - the pelvis and head

Continue reading below

Predisposing factors to malpresentation include:

Prematurity.

Multiple pregnancy.

Abnormalities of the uterus - eg, fibroids.

Partial septate uterus.

Abnormal fetus.

Placenta praevia.

Primiparity.

Breech presentation

See the separate Breech Presentations article for more detailed discussion.

Breech presentation is the most common malpresentation, with the majority discovered before labour. Breech presentation is much more common in premature labour.

Approximately one third are diagnosed during labour when the fetus can be directly palpated through the cervix.

After 37 weeks, external cephalic version can be attempted whereby an attempt is made to turn the baby manually by manipulating the pregnant mother's abdomen. This reduces the risk of non-cephalic delivery 1 .

Maternal postural techniques have also been tried but there is insufficient evidence to support these 2 .

Many women who have a breech presentation can deliver vaginally. Factors which make this less likely to be successful include 3 :

Hyperextended neck on ultrasound.

High estimated fetal weight (more than 3.8 kg).

Low estimated weight (less than tenth centile).

Footling presentation.

Evidence of antenatal fetal compromise.

Transverse lie 4

When the fetus is positioned with the head on one side of the pelvis and the buttocks in the other (transverse lie), vaginal delivery is impossible.

This requires caesarean section unless it converts or is converted late in pregnancy. The surgeon may be able to rotate the fetus through the wall of the uterus once the abdominal wall has been opened. Otherwise, a transverse uterine incision is needed to gain access to a fetal pole.

Internal podalic version is no longer attempted.

Transverse lie is associated with a risk of cord prolapse of up to 20%.

Occipito-posterior position

This is the most common malposition where the head initially engages normally but then the occiput rotates posteriorly rather than anteriorly. 5.2% of deliveries are persistent occipito-posterior 5 .

The occipito-posterior position results from a poorly flexed vertex. The anterior fontanelle (four radiating sutures) is felt anteriorly. The posterior fontanelle (three radiating sutures) may also be palpable posteriorly.

It may occur because of a flat sacrum, poorly flexed head or weak uterine contractions which may not push the head down into the pelvis with sufficient strength to produce correct rotation.

As occipito-posterior-position pregnancies often result in a long labour, close maternal and fetal monitoring are required. An epidural is often recommended and it is essential that adequate fluids be given to the mother.

The mother may get the urge to push before full dilatation but this must be discouraged. If the head comes into a face-to-pubis position then vaginal delivery is possible as long as there is a reasonable pelvic size. Otherwise, forceps or caesarean section may be required.

Occipito-transverse position

The head initially engages correctly but fails to rotate and remains in a transverse position.

Alternatives for delivery include manual rotation of fetal head using Kielland's forceps, or delivery using vacuum extraction. This is inappropriate if there is any fetal acidosis because of the risk of cerebral haemorrhage.

Therefore, there must be provision for a failure of forceps delivery to be changed immediately to a caesarean. The trial of forceps is therefore often performed in theatre. Some centres prefer to manage by caesarean section without trial of forceps.

Face presentations

Face presents for delivery if there is complete extension of the fetal head.

Face presentation occurs in 1 in 1,000 deliveries 5 .

With adequate pelvic size, and rotation of the head to the mento-anterior position, vaginal delivery should be achieved after a long labour.

Backwards rotation of the head to a mento-posterior position requires a caesarean section.

Brow positions

The fetal head stays between full extension and full flexion so that the biggest diameter (the mento-vertex) presents.

Brow presentation occurs in 0.14% of deliveries 5 .

Brow presentation is usually only diagnosed once labour is well established.

The anterior fontanelle and super orbital ridges are palpable on vaginal examination.

Unless the head flexes, a vaginal delivery is not possible, and a caesarean section is required.

Further reading and references

• Hofmeyr GJ, Kulier R, West HM ; External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015 Apr 1;(4):CD000083. doi: 10.1002/14651858.CD000083.pub3.
• Hofmeyr GJ, Kulier R ; Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;10:CD000051. doi: 10.1002/14651858.CD000051.pub2.
• Management of Breech Presentation ; Royal College of Obstetricians and Gynaecologists (Mar 2017)
• Szaboova R, Sankaran S, Harding K, et al ; PLD.23 Management of transverse and unstable lie at term. Arch Dis Child Fetal Neonatal Ed. 2014 Jun;99 Suppl 1:A112-3. doi: 10.1136/archdischild-2014-306576.324.
• Gardberg M, Leonova Y, Laakkonen E ; Malpresentations - impact on mode of delivery. Acta Obstet Gynecol Scand. 2011 May;90(5):540-2. doi: 10.1111/j.1600-0412.2011.01105.x.

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Next review due: 21 Jun 2026

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Face presentation at term: incidence, risk factors and influence on maternal and neonatal outcomes

• Maternal-Fetal Medicine
• Published: 09 April 2024
• Volume 310 , pages 923–931, ( 2024 )

Cite this article

• Yongqing Zhang 1   na1 ,
• Tiantian Fu 1   na1 ,
• Luping Chen 1 ,
• Yinluan Ouyang 1 ,
• Xiujun Han 1 &
• Danqing Chen   ORCID: orcid.org/0000-0002-0201-7215 1  

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The incidence, diagnosis, management and outcome of face presentation at term were analysed.

A retrospective, gestational age-matched case–control study including 27 singletons with face presentation at term was conducted between April 2006 and February 2021. For each case, four women who had the same gestational age and delivered in the same month with vertex position and singletons were selected as the controls (control group, n = 108). Conditional logistic regression was used to assess the risk factors of face presentation. The maternal and neonatal outcomes of the face presentation group were followed up.

The incidence of face presentation at term was 0.14‰. After conditional logistic regression, the two factors associated with face presentation were high parity (adjusted odds ratio [aOR] 2.76, 95% CI 1.19–6.39)] and amniotic fluid index > 18 cm (aOR 2.60, 95% CI 1.08–6.27). Among the 27 cases, the diagnosis was made before the onset of labor, during the latent phase of labor, during the active phase of labor, and during the cesarean section in 3.7% (1/27), 40.7% (11/27), 11.1% (3/27) and 44.4% (12/27) of cases, respectively. In one case of cervical dilation with a diameter of 5 cm, we innovatively used a vaginal speculum for rapid diagnosis of face presentation. The rate of cesarean section and postpartum haemorrhage ≥ 500 ml in the face presentation group was higher than that of the control group (88.9% vs. 13.9%, P  < 0.001, and 14.8% vs. 2.8%, P  = 0.024), but the Apgar scores were similar in both sets of newborns. Among the 27 cases of face presentation, there were three cases of adverse maternal and neonatal outcomes, including one case of neonatal right brachial plexus injury and two cases of severe laceration of the lower segment of the uterus with postpartum haemorrhage ≥ 1000 ml.

Conclusions

Face presentation was rare. Early diagnosis is difficult, and thus easily neglected. High parity and amniotic fluid index > 18 cm are risk factors for face presentation. An early diagnosis and proper management of face presentation could lead to good maternal and neonatal outcomes.

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Acknowledgements

The authors wish to acknowledge Menglin Zhou, Zhengyun Chen and Guohui Yan for their valuable assistance for the manuscript.

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Department of Obstetrics, School of Medicine, Women’s Hospital, Zhejiang University, 1st Xueshi Road, Hangzhou, 310006, Zhejiang, People’s Republic of China

Yongqing Zhang, Tiantian Fu, Luping Chen, Yinluan Ouyang, Xiujun Han & Danqing Chen

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YZ: conceptualization, methodology, writing—original draft. TF: conceptualization, formal analysis, writing—original draft. LC: data collection, follow-up. YO: investigation, resources. XH: investigation, formal analysis, supervision. DC: conceptualization, writing—review and editing, supervision. All authors read and approved the final manuscript.

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Zhang, Y., Fu, T., Chen, L. et al. Face presentation at term: incidence, risk factors and influence on maternal and neonatal outcomes. Arch Gynecol Obstet 310 , 923–931 (2024). https://doi.org/10.1007/s00404-024-07406-4

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Face and brow presentations in labor.

INTRODUCTION  —  The vast majority of fetuses at term are in cephalic presentation. Approximately 5 percent of these fetuses are in a cephalic malpresentation, such as occiput posterior or transverse, face ( figure 1A-B ), or brow ( figure 2 ) [ 1 ].

Diagnosis and management of face and brow presentations will be reviewed here. Other cephalic malpresentations are discussed separately. (See "Occiput posterior position" and "Occiput transverse position" .)

Prevalence  —  Face and brow presentation are uncommon. Their prevalences compared with other types of malpresentations are shown below [ 1-9 ]:

● Occiput posterior – 1/19 deliveries

● Breech – 1/33 deliveries

● Face – 1/600 to 1/800 deliveries

● Brow – 1/500 to 1/4000 deliveries

● Transverse lie – 1/833 deliveries

● Compound – 1/1500 deliveries

The prevalence of face presentation at Parkland Memorial Hospital in Texas (United States) has decreased to 1/2000 deliveries in recent years [ 10 ], possibly because of fewer deliveries of fetuses with anomalies such as anencephaly [ 11,12 ]; however, others have not observed a decline [ 9,12,13 ].

Clinical significance  —  During labor in the occiput anterior presentation, the neck normally flexes to bring the chin to the chest, resulting in the relatively small suboccipito-bregmatic diameter (average length 9.5 cm) as the widest cephalic diameter that needs to negotiate the pelvis. This diameter is generally able to traverse the obstetric conjugate (average length 10.5 cm) ( figure 3 ), which is the shortest anteroposterior pelvic diameter. By comparison, the neck is extended in brow and face presentations, which present larger fetal cephalic diameters that need to negotiate the pelvis ( figure 4 ). Thus, protraction or arrest of descent is more likely, which increases the chances of maternal and neonatal morbidity from vaginal birth and the frequency for cesarean birth. Brow and mentum posterior face presentations are most likely to exhibit cephalopelvic dystocia unless the fetus is very small or the maternal pelvis is very large or both. (See 'Neonatal outcome' below and 'Neonatal outcome' below.)

Fetal heart rate abnormalities are more common than with occiput anterior position [ 2,14 ]. They may be due to more head compression or a higher frequency of cord compression.

Risk factors  —  Maternal or fetal anatomic factors that prevent flexion or favor extension of the fetal neck increase the risk for face/brow presentation. These factors include anencephaly, severe hydrocephalus with cephalomegaly, anterior neck mass, multiple nuchal cords, cephalopelvic disproportion, preterm birth/low birth weight, macrosomia, contracted maternal pelvis, platypelloid pelvis ( figure 5 ), multiparity, polyhydramnios, previous cesarean birth, and Black race [ 2,5,8,9,11-13 ].

In multiparous patients, poor abdominal muscle tone may permit the uterine fundus and fetal trunk to swing anteriorly, which may extend the cervical spine, leading to a face or brow presentation [ 13 ]. Alternatively, late engagement of the vertex in multiparous patients, often after the onset of labor, may be the predisposing factor [ 12 ].

A contracted maternal pelvis predisposes to malpresentation [ 12 ]. The increased risk of face/brow presentation in Black patients may be due to differences in pelvic dimensions between White and Black females and a higher rate of preterm birth in Black individuals [ 13,15-17 ]. The differences in pelvic dimensions may be related to environmental differences (eg, locomotion, load carrying, health, nutrition) [ 18 ].

Although preterm birth has been linked to face/brow presentation, possibly because a very small fetus can descend with the neck partially extended, the association between preterm birth and face presentation is weak [ 9,13 ].

Pregnancies with polyhydramnios may be at risk secondary to impaired swallowing due to a fetal anomaly (particularly anencephaly) [ 12 ] or to obstruction of the fetal trachea and esophagus from a hyperextended fetal neck [ 5 ].

FACE PRESENTATION

Definition  —  Face presentation refers to a fetal presentation in which the fetal face from forehead to chin is the leading fetal body part descending into the birth canal ( figure 1B ). The fetal neck is highly extended (sharply deflexed), such that the occiput may touch the back.

Diagnosis  —  The intrapartum diagnosis of face presentation is made by vaginal examination in the late first or the second stage of labor [ 5 ]. Palpation of the orbital ridge and orbits, saddle of the nose, mouth, and chin is diagnostic of face presentation. The fontanelles and sutures are not generally palpable [ 19 ]. At diagnosis, nearly 60 percent of face presentations are mentum anterior, 26 percent are mentum posterior, and 15 percent are mentum transverse, and may be designated as left or right ( figure 1A ) [ 11 ].

Intrapartum transabdominal, translabial, and/or transvaginal sonography of a face presentation will show a hyperextended fetal neck, with the orbits and nasal bridge at the center of the presenting part in the mid-sagittal plane [ 20 ]. Although imaging studies can be performed to confirm the diagnosis if it is uncertain, imaging is not mandatory, and results do not have prognostic value for predicting the outcome of labor [ 21 ].

Differential diagnosis  —  Face presentation may be misdiagnosed as a frank breech presentation on digital examination since the latter is more commonly encountered (and therefore expected). Both presentations are characterized by soft tissues with an orifice; however, careful palpation will identify the bony facial structures and lead to the correct diagnosis. With ultrasound readily available in most delivery units, confirmation of the type of malpresentation (breech or face) is easily obtained if needed.

Labor and delivery management

Fetal heart rate monitoring  —  The fetal heart rate is monitored continuously, ideally with an external device. An internal device may cause facial or ophthalmic injuries if improperly placed [ 22-24 ]. If internal monitoring is required, the electrode should be carefully applied over a bony structure such as the forehead, mandible, or zygomatic bones to minimize the risk of trauma [ 25 ].

Abnormalities of the fetal heart rate occur more frequently with face presentations [ 4,25,26 ]. In one series, severe variable and late decelerations developed in 29 and 24 percent of labors, respectively [ 25 ]. Only 14 percent of pregnancies had normal tracings. Moreover, 13 percent of the newborns had a low five-minute Apgar score.

Interpretation and management of abnormal fetal heart rate tracings are not affected by fetal presentation and are reviewed separately. We perform amnioinfusion for patients with variable decelerations (category 2 tracing), regardless of presentation, as long as vaginal birth is anticipated. (See "Intrapartum category I, II, and III fetal heart rate tracings: Management" .)

Mentum anterior  —  In mentum anterior face presentation, the fetal chin needs to pass under the symphysis pubis. For this to occur, the extended fetal neck may need to extend even more. After the chin clears the symphysis, further descent and fetal expulsion can occur [ 5 ]. Over 75 percent of mentum anterior fetuses are born vaginally [ 2,3,13,26,27 ].

The parturient may begin pushing at full dilation. Labor progress should be closely monitored as arrest of descent may occur, although not inevitably as in persistent mentum posterior position.

Oxytocin augmentation and cesarean birth are performed for standard obstetric indications [ 26 ]. (See "Labor: Overview of normal and abnormal progression" .)

Attempts at version or vacuum- or midforceps-assisted delivery should be avoided as they are associated with unnecessary maternal trauma and neonatal injury [ 28 ].

An outlet forceps-assisted delivery when the face is distending the perineum is not contraindicated if delivery must be facilitated but should only be performed by experienced clinicians familiar with the particular considerations involved. For example, in contrast to the occiput anterior position, engagement does not occur until the face is at +2 station [ 5 ]; the chin rather than the occiput is the focal point for orientation; and if Kielland forceps are applied, the left blade is applied to the right side of the head and the right blade to the left side [ 29,30 ]. The technique of forceps delivery is beyond the scope of this review.

Mentum posterior  —  In the mentum posterior face presentation, the fetal neck is already maximally extended and cannot extend further to allow the occiput to pass under the symphysis. Therefore, the mentum posterior face presentation will not deliver vaginally unless spontaneous rotation to mentum anterior occurs ( figure 6 ), often late in the second stage of labor [ 14 ], or the fetus is very small, or the pelvis is very large. If the fetal status is reassuring and there is normal labor progress, mentum posterior presentation can be managed expectantly to see if spontaneous rotation will occur [ 14 ].

Patients with abnormal labor progression are delivered by cesarean. We individualize management when labor is progressing. For example, in multiparous patients with an adequate pelvis and fetus estimated to weigh less than their prior newborns, we would follow labor progress closely and maintain a low threshold for abandoning attempts at vaginal birth if labor does not progress normally in the first or second stage. However, if the fetus is estimated to be larger than their prior newborns, or in nulliparous patients, we would recommend cesarean birth early in the labor course. There is consensus that assisted vaginal delivery is contraindicated for mentum posterior presentations [ 14,31,32 ].

In the past, manual version of the mentum posterior face to an occiput anterior or mentum anterior position was attempted using internal and external manipulation [ 33,34 ]. Although some clinicians have been successful with no serious neonatal or maternal complications, others have reported maternal deaths from uterine rupture, cord prolapse resulting in neonatal asphyxia, and cervical spine trauma resulting in severe neonatal neurologic sequelae [ 28 ]. Given the safety and ready availability of cesarean birth, we believe internal version should be reserved for occasions when cesarean birth is unable to be accomplished due to lack of surgical facilities and inability to arrange maternal transport, or absolute maternal refusal to allow a cesarean birth [ 34 ].

Mentum transverse  —  There are minimal published data on management of the mentum transverse position. Our management is the same as for mentum posterior.

Neonatal outcome  —  Prior to 1955, increased rates of intrapartum fetal death and perinatal mortality (approximately 10 percent) were reported for face presentation [ 5 ]. Perinatal mortality decreased to 2 to 3 percent by 1980, likely due to the increased use of cesarean birth, as well as other advances in obstetric and neonatal care [ 5 ]. Recent perinatal mortality data are not available.

Neonates who were in face presentation often have significant facial edema, facial bruising/ecchymosis, and skull molding [ 35 ]. This usually resolves within the first 24 to 48 hours of life. Personnel and equipment for performing endotracheal intubation should be readily available at birth [ 25 ]. Difficulty in ventilation during resuscitation has been reported and attributed to tracheal and laryngeal trauma and edema.

Facial trauma and spinal cord injury have also been described in case reports and are often associated with version, extraction, and midforceps rotations [ 2,23-25,36 ]. Appropriate management of face presentation, as described above, typically does not result in increased serious maternal or neonatal morbidity [ 2 ].

BROW PRESENTATION

Definition  —  Brow presentation refers to a presentation in which the fetal surface presenting in the birth canal extends from the anterior fontanelle to the brow (orbital ridge), but does not include the mouth and chin ( figure 2 ). The fetal neck is extended, but not to the degree of a face presentation.

Diagnosis  —  The diagnosis of brow presentation is made by vaginal examination in the second stage of labor [ 5 ]. Palpation of the forehead, orbital ridge, orbits, and saddle of the nose, but not the mouth and chin, is diagnostic of brow presentation. The anterior fontanelle is palpable, but the sagittal suture generally is not [ 19 ]. The brow may be anterior or posterior and described by the position or the anterior fontanelle as frontal anterior, transverse, or posterior [ 14 ].

There is increasing evidence that ultrasound is more accurate than vaginal examination for determining fetal position and can be used to determine or confirm abnormal presentation [ 37,38 ]. On transabdominal examination, if the occiput is anterior, the main finding is a reduction in occiput-spinal angle, usually around 90 degrees rather than over 120 degrees; if the occiput is posterior, the chin is separate from chest, and the cervical spine is curved (convex) anteriorly [ 19 ]. If a transperineal examination is performed, the fetal orbits are seen at the same level as the pubic symphysis.

Labor and delivery management  —  The fetal heart rate is monitored continuously during labor, ideally with an external device, since fetal heart rate abnormalities are more common than with occiput anterior position. An internal device may cause facial or ophthalmic injuries if improperly placed [ 22-24 ]. If internal monitoring is required, the electrode should be cautiously applied over a bony structure, such as the forehead, to minimize the risk of trauma [ 25 ].

Patients with a clinically adequate or proven pelvis can undergo a trial of labor since many brow presentations are transitional. In one review, when brow presentation was diagnosed early in labor, 67 to 75 percent of fetuses spontaneously converted to a more favorable presentation and delivered vaginally. When diagnosed late in labor, 50 percent spontaneously converted and delivered vaginally: in 30 percent, the neck extended further resulting in mentum anterior face presentation; in 20 percent, the neck flexed resulting in an occiput posterior presentation [ 2,5,39 ]. Conversion to occiput anterior is rare.

If the brow presentation persists, labor progress is usually protracted or arrests, necessitating cesarean birth. Oxytocin augmentation is not recommended in this setting, given the association between brow presentation and cephalopelvic disproportion [ 5,26,33 ]. Version or vacuum- or forceps-assisted delivery are not recommended, as the risks for maternal and fetal injury are high [ 5,14,31,32 ]. However, in settings where cesarean birth is not readily available, vacuum-assisted flexion of the fetal head may be considered [ 40 ].

In a minority of cases, spontaneous vaginal birth may be possible if the fetus is extremely small or macerated or the maternal pelvis is unusually large.

Neonatal outcome  —  Recognition and appropriate management of brow presentation, as described above, typically do not result in increased serious maternal or neonatal morbidity.

SOCIETY GUIDELINE LINKS  —  Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor" .)

SUMMARY AND RECOMMENDATIONS

Issues common to face and brow presentations

● Risk factors – Face and brow presentations are associated with multiparity, cephalopelvic disproportion, preterm birth, polyhydramnios, and fetal anomalies (eg, anencephaly, anterior neck mass). (See 'Risk factors' above.)

● Clinical significance – The deflexed neck in face or brow presentation inhibits head engagement and subsequent fetal descent. (See 'Clinical significance' above.)

● Cautions – The fetal heart rate is monitored continuously during labor, ideally with an external device, because of the increased prevalence of fetal heart rate decelerations. An internal device may cause facial or ophthalmic injuries if improperly placed. If internal monitoring is required, the electrode should be carefully applied over a bony structure to minimize the risk of trauma. (See 'Labor and delivery management' above.)

● Definition – In face presentation, the fetal face from forehead to chin is the leading fetal body part descending into the birth canal ( figure 1B ). The fetal neck is sharply deflexed and the occiput may touch the back. Nearly 60 percent of face presentations are mentum anterior, 26 percent are mentum posterior, and 15 percent are mentum transverse, and may be designated as left or right ( figure 1A ). (See 'Definition' above.)

● Diagnosis – The diagnosis of face presentation is made by vaginal examination. Palpation of the orbital ridge and orbits, saddle of the nose, mouth, and chin is diagnostic of face presentation ( figure 1A ). Ultrasound can be used to confirm or clarify the type of malpresentation if the clinical examination findings are unclear. (See 'Diagnosis' above.)

● Management

• Mentum anterior – Over 75 percent of mentum anterior fetuses deliver vaginally; this rate is similar to that for all fetuses in cephalic presentations. For face presentation with the mentum anterior, we suggest a trial of labor rather than cesarean birth ( Grade 2C ). Oxytocin augmentation may be administered in the setting of a normal fetus with protracted labor, as long as the fetal heart rate pattern remains reassuring. (See 'Labor and delivery management' above.)

• Mentum posterior – The mentum posterior face presentation will not deliver vaginally unless spontaneous rotation occurs, which is infrequent and occurs late in the second stage of labor, or the fetus is very small or the pelvis very large or both. As mentum posterior presentations are rare, we individualize management of such situations. In a multiparous patient with an adequate pelvis and fetus estimated to weigh less than her prior newborns, we follow labor progress closely and maintain a low threshold for abandoning attempts at vaginal birth if labor does not progress normally in the first or second stage. We recommend cesarean birth rather than manual rotation ( Grade 1C ).

If the fetus is estimated to be larger than the patient’s prior newborns or the patient is nulliparous, we perform cesarean birth early in the labor course. (See 'Labor and delivery management' above.)

● Definition – In brow presentation, the fetal surface presenting in the birth canal extends from the anterior fontanelle to the brow (orbital ridge), but does not include the mouth and chin ( figure 2 ). The fetal neck is extended, but not to the degree of a face presentation. (See 'Definition' above.)

● Diagnosis – The diagnosis of brow presentation is made by vaginal examination. Palpation of the forehead, orbital ridge, orbits, and saddle of the nose, but not the mouth and chin, is diagnostic of brow presentation ( figure 2 ). Ultrasound can be used to confirm or clarify the type of malpresentation if the clinical examination findings are unclear. (See 'Diagnosis' above.)

● Management – Patients with a fetus in brow presentation and a clinically adequate or proven pelvis can undergo a trial of labor, with close monitoring and delivery by cesarean for standard indications. The brow presentation is often a transitional state: 50 percent will spontaneously convert to a face or occipital presentation. Fetuses with persistent brow presentation should be delivered by cesarean since vaginal birth is not possible unless the fetus is very small, the pelvis is very large, or both. Operative vaginal delivery is contraindicated for brow presentation. (See 'Labor and delivery management' above.)

ACKNOWLEDGMENT  —  The UpToDate editorial staff acknowledges Svena Julien, MD, who contributed to earlier versions of this topic review.

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1 : Malpresentations--impact on mode of delivery.

2 : Diagnosis and management of face presentation.

3 : [Face presentation: retrospective study of 32 cases at term].

4 : A population study of face and brow presentation.

5 : Face and brow presentation: a review.

6 : Compound presentation of the fetus.

7 : Brow presentations.

8 : Face presentation at term: a forgotten issue.

9 : Face and brow presentation in northern Jordan, over a decade of experience.

10 : Face and brow presentation in northern Jordan, over a decade of experience.

11 : Obstetric malpresentations: twenty years' experience.

12 : Face and brow presentation: independent risk factors.

13 : Face presentation: predictors and delivery route.

14 : Management of fetal malpresentation.

15 : Racial differences in pelvic anatomy by magnetic resonance imaging.

16 : Assessment of race from the pelvis.

17 : Metric analysis of sex differences in South African black and white pelves.

18 : Shape variation in the human pelvis and limb skeleton: Implications for obstetric adaptation.

19 : The use of intrapartum ultrasound to diagnose malpositions and cephalic malpresentations.

20 : Intrapartum translabial ultrasound demonstration of face presentation during first stage of labor.

21 : ISUOG Practice Guidelines: intrapartum ultrasound.

22 : Eyelid laceration in a neonate by fetal monitoring spiral electrode.

23 : Penetrating ocular injury with a fetal scalp monitoring spiral electrode.

24 : Neonatal eyelid penetration from insertion of a fetal scalp electrode: a case report.

25 : Face presentation at term.

26 : Face presentation.

27 : Face presentation in modern obstetrics--a study with special reference to fetal long term morbidity.

28 : Spinal cord injuries at birth: a multicenter review of nine cases.

29 : Spinal cord injuries at birth: a multicenter review of nine cases.

30 : Spinal cord injuries at birth: a multicenter review of nine cases.

31 : Spinal cord injuries at birth: a multicenter review of nine cases.

32 : Spinal cord injuries at birth: a multicenter review of nine cases.

33 : Persistent brow presentation: a new approach to management.

34 : Intrapartum bimanual tocolytic-assisted reversal of face presentation: preliminary report.

35 : Intrapartum bimanual tocolytic-assisted reversal of face presentation: preliminary report.

36 : Birth-related spinal cord injuries: a multicentric review of nine cases.

37 : Intrapartum translabial ultrasound demonstrating brow presentation during the second stage of labor.

38 : The effectiveness of intrapartum ultrasonography in assessing cervical dilatation, head station and position: A systematic review and meta-analysis.

39 : Brow presentation with vaginal delivery.

40 : Vaginal delivery of two cases of brow presentation using multiple Kiwi Omnicups.

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Diagnosis and management of face presentation

• PMID: 7005774

Face presentation is an unusual complication of pregnancy; it occurs once in every 500 to 600 deliveries. Prematurity, fetal macrosomia, anencephaly, and cephalopelvic disproportion (CPD) are the major obstetric factors that predispose the fetus to face presentation. Although the mechanisms of labor in face presentation are different from those of simple vertex presentation, there is no consistent alteration in the duration of labor in the absence of underlying CPD. When disproportion does not exist and gross anomalies are not present, the prognosis for spontaneous vaginal delivery is excellent. The majority of perinatal losses reported in face presentation have resulted from traumatic operative vaginal deliveries, specifically version and extraction and midforceps rotations. Recent experience at this institution with a limited series of face presentations demonstrates that, with careful intrapartum surveillance, delivery can be accomplished with no increase in risk to either mother or fetus.

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• A simple measure to enhance atraumatic vaginal delivery of vertex-presenting fetuses in prematurity. Sherer DM. Sherer DM. Am J Perinatol. 1992 May;9(3):162-3. doi: 10.1055/s-2007-999312. Am J Perinatol. 1992. PMID: 1575835
• Face and brow presentation in northern Jordan, over a decade of experience. Zayed F, Amarin Z, Obeidat B, Obeidat N, Alchalabi H, Lataifeh I. Zayed F, et al. Arch Gynecol Obstet. 2008 Nov;278(5):427-30. doi: 10.1007/s00404-008-0600-0. Epub 2008 Feb 19. Arch Gynecol Obstet. 2008. PMID: 18283473
• [Normal delivery in deflected presentations. Presentation of the face, presentation of the forehead]. Jahier J. Jahier J. Rev Prat. 1975 Jan 11;25(3):163-6, 169-70, 175-6. Rev Prat. 1975. PMID: 1118709 French. No abstract available.
• Labor with abnormal presentation and position. Stitely ML, Gherman RB. Stitely ML, et al. Obstet Gynecol Clin North Am. 2005 Jun;32(2):165-79. doi: 10.1016/j.ogc.2004.12.005. Obstet Gynecol Clin North Am. 2005. PMID: 15899353 Review.
• Controversies: selective vaginal delivery for breech presentation. Erkkola R. Erkkola R. J Perinat Med. 1996;24(6):553-61. J Perinat Med. 1996. PMID: 9120738 Review.
• Management of face presentation, face and lip edema in a primary healthcare facility case report, Mbengwi, Cameroon. Fomukong NH, Edwin N, Edgar MML, Nkfusai NC, Ijang YP, Bede F, Shirinde J, Cumber SN. Fomukong NH, et al. Pan Afr Med J. 2019 Aug 8;33:292. doi: 10.11604/pamj.2019.33.292.18927. eCollection 2019. Pan Afr Med J. 2019. PMID: 31692903 Free PMC article.

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Face Presentation and Birth Injury

Normally, babies are born head-first with their chin tucked towards their chest (vertex presentation). In a face presentation birth, the baby’s chin is not tucked and their neck is hyperextended. Unfortunately, this can impede the movement of their head and complicate their birth and engagement (when the largest part of the baby’s head or buttocks enters the mother’s pelvis). In some cases, a baby in face presentation can be delivered vaginally, but in most  cases, vaginal delivery is difficult and can injure the baby. 

In this piece, the birth injury team at ABC Law Centers will discuss risks, diagnosis, management, and legal help for children with complications from a face presentation birth. 

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Types of Face Presentation Birth

There are three types of face presentation that can occur at birth:

• Mentum anterior position (MA): The baby’s chin faces the mother’s front side, and will be the presenting part of the face. Babies in mentum anterior position are usually delivered vaginally, although in some cases a C-section may be necessary. 
• Mentum posterior position (MP): The baby’s chin is facing the mother’s back. The baby’s head, neck, and shoulders enter its mother’s pelvis at the same time, and the pelvis is usually not large enough to accommodate this. The baby might spontaneously rotate into mentum anterior position, discussed above. 
• Typically, a C-section is indicated, but there are certain circumstances under which vaginal delivery may be attempted . Regardless, the medical team should be prepared to perform a prompt C-section if there are any complications.
• Mentum transverse position (MT): The baby’s chin is facing the side of the birth canal. Doctors may recommend a trial of labor under certain circumstances, but they should promptly proceed to a C-section if there are issues. 

During any type of face presentation birth, if labor is progressing normally and the baby is not in distress, physician intervention may not be necessary since many MP and MT positions convert to MA.  

However, if progress in dilation and the baby’s descent slows or stops despite adequate contractions, or the baby is in fetal distress, doctors and the hospital  must perform an emergency C-section .

Risk Factors and Causes of Face Presentation Birth

Conditions that may increase the likelihood of a face presentation birth include the following:

• Prematurity
• Babies with a very low birth weight
• Fetal macrosomia (a baby that is larger than average)
• Cephalopelvic disproportion, or CPD (a mismatch in size between the mother’s pelvis and the baby’s head)
• Severe hydrocephalus that causes enlargement of the baby’s head
• Anterior neck mass
• Multiple nuchal cords (umbilical cord wrapped around baby’s neck more than once)
• Maternal pelvis abnormalities
• Maternal obesity
• Multiparity (the mother has previously given birth)
• Polyhydramnios (too much amniotic fluid)
• Previous cesarean delivery

In one study of women who were given a diagnosis of face presentation during birth, r esearchers found that the babies with a face presentation were more likely preterm and Black/African American . As of 2022, the rate of preterm births was recorded highest for Black/African American infants .

If any of the above-mentioned factors are present, it’s important for physicians to appropriately monitor and assess the patient’s pregnancy and labor to ensure that it is progressing well and that no complications arise. Additionally, they must discuss risk factors with their patients.

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Diagnosing Face Presentation

Face presentation is diagnosed late in the first or second stage of labor by vaginal examination. The distinctive facial features of the baby’s chin, mouth, nose, and cheekbones can be felt. Face presentation is sometimes confused with breech presentation , in which the baby’s feet come out first (both presentations are characterized by soft tissues with an orifice). That is why it’s important that a very skilled physician is present during any potentially risky delivery with abnormal fetal position or presentation . Diagnosis can be confirmed by an ultrasound , which reveals a deflexed/hyperextended neck.

Managing Face Presentation Delivery

Face presentation and birth trauma.

There is an increased risk of trauma to the baby when the face presents first. Therefore, the doctor should not internally manipulate (try to rotate) the baby. In addition, the physician must not use vacuum extraction or manual extraction (grasping the baby with hands) to pull the baby from the mother’s uterus. Midforceps ( forcep extraction when the baby’s station is above +2 cm, but the head is engaged) should never be used. Outlet forceps should only be used by experienced physicians who understand the circumstances under which this is appropriate.

Face presentation and abnormal fetal heart rate

Abnormalities of the fetal heart rate and fetal distress occur more frequently with face presentation. In one study , 59% of infants in face presentation had variable heart decelerations, and 24% had late decelerations. Of the babies who were born live, 37% had 1-minute Apgar scores lower than 7, and 13% had 5-minute Apgar scores lower than 7. The majority of the low 5-minute Apgar scores were babies that had been in mentum posterior position .

For these reasons, it is crucial that babies are continuously monitored during labor, ideally with an external heart monitoring device.  An internal device may cause facial or eye injuries if improperly placed. If internal monitoring is needed, the electrode should be cautiously placed over a bony structure such as the forehead, jaw or cheekbone to minimize the risk of trauma.

Informed consent and delivery options

It is always critical that doctors obtain a mother’s informed consent , which means discussing delivery options (vaginal, C-section, enhanced with labor drugs, etc.) with her and explaining the potential risks and benefits of each. This means that when a mother has a baby with face presentation, she must be given the option of a C-section versus a vaginal birth. One of the reasons a mother may opt for a C-section is to avoid the extensive facial bruising/trauma that is common in babies with face presentation. In addition to thoroughly explaining the risks and benefits of each type of delivery method, the physician must explain and obtain consent from the mother if forceps or oxytocin are used.

Oxytocin (Pitocin) is a labor drug that may be used in a face presentation with a normal fetus and abnormally slow progress, as long as the baby’s heart rate patterns remain reassuring. It’s important to note that there are certain risks associated with this drug, including uterine hyperstimulation . Hyperstimulation happens when contractions are too frequent or strong, which can injure the baby. Hyperstimulation also increases pressure on the blood vessels in the womb, which can deprive the baby of oxygen-rich blood.

Doctors must explain these risks and obtain consent before proceeding. However, in any face presentation, if progress in dilation and the baby’s descent stops despite adequate contractions, doctors must perform an emergency C-section. Failing to deliver in time puts the baby at risk of not getting enough oxygen. If the baby doesn’t get enough oxygen, it is at high risk of suffering a brain injury.

Face presentation and birth injury

It can be frightening to learn that your baby is not in the correct or ideal position for birth. However, your doctors should always communicate changes, risks, and delivery plans with you. If at any point, your doctor fails to communicate with you or monitor you properly and it causes your child to suffer a brain injury, that is considered medical malpractice or negligence. If you believe that your child suffered an injury at birth that could have been prevented, our birth injury lawyers can help. 

Complications and Side Effects of Face Presentation

Complications associated with face presentation include the following:

• Prolonged labor
• Facial trauma
• Facial edema (fluid build up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress/difficulty in ventilation due to airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• Low Apgar score

A baby may be at increased risk of complications if forceps or oxytocin are used during labor. Forceps can cause traumatic injury to the head, and oxytocin can deprive a baby of oxygen due to hyperstimulation (strong, frequent contractions). Trauma to the head and decreased oxygenation can cause permanent brain damage, such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy (CP) , as well as fetal deaths. Fortunately, a child with HIE or cerebral palsy can survive, but depending on the severity of their injury, they may have severe disability and need 24/7 care. 

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Face Presentation and Medical Malpractice

Because there are many complications associated with face presentation, it is essential that the baby is closely monitored and that delivery is handled by a physician with experience in this area. Furthermore, the physician must quickly proceed to a C-section delivery if there are any signs that the baby is in distress , labor is not progressing, or the baby fails to rotate to MA position. In addition, once a face presentation is diagnosed, the physician must check for “pelvic adequacy”. When the pelvis is inadequate (contracted/small), a C-section is recommended .

Since respiratory problems can occur in babies with face presentation, equipment and staff to perform intubation of the baby (placement of a breathing tube) should be readily available at the time of delivery.

Failure to follow any of these standards of care is negligence. If this negligence results in injury to the baby, it is medical malpractice . To learn more about bringing a medical malpractice claim for your child’s birth injury, complete the form below.

ABC Law Centers: Trusted Birth Injury Attorneys

If your baby has HIE, cerebral palsy, developmental delays , a seizure disorder , or any other birth injury , we may be able to help. Unlike other firms, the attorneys at ABC Law Centers (Reiter & Walsh, P.C.) focus only on birth injury cases and have been helping injured children throughout the nation since 1997. During your free legal consultation, our attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you. Moreover, you pay nothing throughout the entire legal process unless we win or favorably settle your case.

“Reiter and Walsh goes above and beyond the norm in getting their clients the best possible results. Each client is treated with respect and compassion, and they are truly sensitive to what it means to help a family whose child has been injured.” -Client review from 11/23/2015

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• Face and brow presentations in labor – UpToDate  
• Diagnosis and management of face presentation -Obstetrics and gynecology
• A population study of face and brow presentation – Journal of Obstetrics and Gynecology
• Face presentation: predictors and delivery route – American journal of obstetrics and gynecology
• Face presentation at term

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Author: Roberto Grujičić, MD • Reviewer: Sophie Stewart Last reviewed: July 12, 2023 Reading time: 17 minutes

The human face is the most anterior portion of the human head . It refers to the area that extends from the superior margin of the forehead to the chin, and from one ear to another. 

The basic shape of the human face is determined by the underlying facial skeleton (i.e. viscerocranium ), the facial muscles and the amount of subcutaneous tissue present. 

The face plays an important role in communication and the expression of emotions and mood. In addition, the basic shape and other features of the face provide our external identity. 

This article will discuss the anatomy and structure of the human face.

Bones of the face

Muscles of face, superior part of face , middle part of face, inferior part of face, innervation, blood supply , facial clefts, related articles.

The facial skeleton is also known as the viscerocranium . It is composed of fourteen bones, six paired and two unpaired bones. 

The bones of the viscerocranium include:

• Two nasal bones
• Two maxillae
• Two inferior nasal conchae
• Two palatine bones
• Two zygomatic bones
• Two lacrimal bones

The main function of these bones is to give shape to the human face and to protect the internal structures. In addition, these bones provide openings for the passage of neurovascular structures and bony features for the attachment of facial muscles. 

The facial muscles are also known as the muscles of the facial expression or the mimetic muscles. These muscles are a group of approximately 20 superficial skeletal muscles of the face and scalp divided into five different groups according to their location and function. These groups include: 

• Buccolabial (oral) group : Levator labii superioris , levator labii superioris alaeque nasi, risorius , levator anguli oris , zygomaticus major , zygomaticus minor , depressor labii inferioris , depressor anguli oris , mentalis , orbicularis oris and buccinator muscles. 
• Nasal group : Nasalis and procerus muscles.
• Orbital group : Orbicularis oculi and corrugator supercilii muscles.
• Epicranial group : Occipitofrontalis and platysma muscles.
• Auricular group : Auricularis anterior, auricularis superior, auricularis posterior muscles. 

All facial muscles originate from the bony and fibrous structures of the skull and insert into the skin . The prime function of the facial muscles is to provide a wide range of facial expressions which is important for expressing emotions and mood (e.g. smiling, grinning, frowning). In addition, these muscles help in opening and closing the mouth and eyes, and thus protect the delicate structures of the face.

Regions of face

The human face can be divided into three main parts the superior part of the face, middle part of the face, and the inferior part of the face. 

The superior part of the human face extends from the hairline to the inferior margin of the orbit . The lateral margins of this portion extend to the temporal region. The superior part of the face can be divided into three separate regions including the frontal , orbital and temporal regions. 

These regions are characterized by the following: 

• The frontal region , also known as the forehead, is the most superior region of the face that spreads from the hairline to the eyebrows. It is composed mainly of the frontal bone and the overlying muscles including the procerus, occipitofrontalis, depressor supercilii and corrugator supercillii muscles. The muscles are covered by several fat pads (central, middle and lateral) and skin. 
• The orbital region contains the eyes and orbits. Eyes are paired spherically-shaped organs situated in the orbits. The orbits are composed of several cranial bones including the frontal bone superiorly, nasal bone medially, maxilla inferomedially and the zygomatic bone inferolaterally. Each eyeball is cushioned by superior, inferior, and lateral fat pads. The orbit is surrounded by a single muscle known as the orbicularis oculi muscle , while the eyes are enveloped and covered by the eyelids which function to protect the eyes from external factors. The orbicularis oculi muscle closes the eyelids on contraction while the levator palpebrae muscle opens the eyelids. The edges of the eyelids are lined with eyelashes. 
• The temporal region is composed of the frontal, sphenoid and temporal bones. It is covered mainly by the temporalis muscle and overlying skin. 

The middle part of the face region extends from the lower eyelid superiorly to the superior margin of the upper lip inferiorly. This portion of the face is marked by four regions including the nasal , infraorbital , zygomatic and auricular regions. 

• The nasal region is located in the central portion of the human face and, as its name suggests, it features the nose. The nose is the central pyramid-shaped structure, situated in the midline . The base of the nose is formed mainly by the nasal bone and covered by the nasalis muscle. The apex of the nose ends inferiorly in a rounded ‘tip’. The area between the base and apex is the dorsum of the nose which is formed by nasal cartilage . Superficially, the dorsum of the nose is covered by fat pads and skin. 
• The infraorbital region overlies the maxilla, while the zygomatic regions overlie the zygomatic bone. These regions are located lateral to the nose and mark the superior portion of the cheek. The cheek is a prominence that overlies the zygomatic arch and is comprised of muscles and fat. The zygomatic arch is composed of two bones (zygomatic and maxilla). The muscular layer of the cheeks contains several muscles that include the masseter , levator labii superioris alaeque nasi, levator labii superioris, zygomaticus minor, zygomaticus major, risorius, levator anguli oris and buccinator muscles. The muscles of the cheeks are covered by fat pads and overlying skin. 

The auricular region is the most lateral region of the face. It contains the external ear (auricle). The internal structure of the auricle is made from cartilage and covered by skin. The ears are surrounded by three auricular muscles (anterior, posterior, and superior).

Take a closer look at the regions of the face in the study unit below!

The inferior part of the face is bordered superiorly by the superior margin of the upper lip and inferiorly by the inferior border of the chin. The lateral borders of the inferior part of the face are formed by the angles of the mandible on each side. This part can be divided into oral, mental, buccal and parotideomasseteric regions. 

• The oral region surrounds the lips, the most prominent structures in the inferior part of the face. They are divided into two parts: the upper lip and lower lip. The upper lip is associated with the maxilla, while the lower lip, with the mandible. The lips are surrounded mainly by the orbicularis oris muscle which functions in altering the shape of the lips when we speak or eat. The other muscles that facilitate the movements of lips are the risorius, mentalis, depressor labii inferioris, and depressor anguli oris muscles. The movements of the lips allow for  actions such as speech, eating, and kissing. 
• The mental region is located inferior to the mouth. It features the chin, a central structure that overlies mental protuberance of the mandible. 
• The buccal region is located just inferior to the infraorbital and zygomatic region, and comprises the inferior portion of the cheek. It mainly refers to the area marked by the buccinator muscle. The inferior border of the buccal region is the jawline, formed by the inferior border of the mandible. 
• The parotideomasseteric region is located lateral to the buccal region. This region is named after the underlying parotid gland and masseter muscle. 

Test your knowledge on the regions of the head and face with this quiz.

The three divisions of the trigeminal nerve (CN V) are responsible for the somatic sensation of the entire face according to the three embryological origins.

The ophthalmic nerve (CN V1) which comes from the frontonasal prominence supplies the anterior scalp, forehead, and nasal dorsum.

Deriving from the maxillary prominence the maxillary nerve (CN V2) provides mainly the anterior cheek, the lateral face, the upper lip, the side of the nose, and the lower eyelid.

The mandibular nerve (CN V3) originates from the mandibular prominence and supplies the lower lip,chin, and posterior cheek.

The face is richly perfused by a subdermal plexus formed mainly by musculocutaneous arteries coming from the superficial temporal and facial arteries . The facial artery branches off the external carotid artery , winds around the inferior border of the mandible and ascends along the side of the nose. The superficial temporal artery similarly arises from the external carotid artery and gives off numerous branches which supply different parts of the face including the transverse facial artery and the middle temporal artery. 

The venous blood of the face drains from the subdermal plexus to the deep venous plexus via communicating veins.

Clinical relations

The pathological traits of facial growth are many and quite frequent. Lasting complications include facial disfigurement, difficulties hearing, speaking, eating, swallowing, and breathing. The most common and well-known facial anomalies, known as facial clefts, are listed below:

• Cleft lip : A partial or complete lack of fusion of the maxillary prominence with the medial nasal prominence on one or both sides. Depending on the severity of the lack of fusion, this can result in a partial or complete, unilateral or bilateral cleft lip.
• Cleft palate : Cleft palates are divided into primary and secondary depending on whether they are in front of or behind the incisive foramen respectively. The primary (or anterior) cleft deformities include lateral cleft lip, upper cleft jaw, and a cleft between the primary and secondary palates. Behind the incisive foramen, the clefts can either be of the secondary palate or known as a cleft uvula. Cleft palates result from a lack of fusion between the palatine shelves. Rarely, a cleft will run from the lip to the secondary palate.
• Oblique facial clefts: When the maxillary prominence fails to merge with the lateral nasal prominence the nasolacrimal duct is exposed.
• Median (or midline) cleft : This type of anomaly occurs with the incomplete fusion of the two medial nasal prominences in the midline. This particular defect can have much more serious consequences than the others it is associated with cognitive disabilities and brain abnormalities.
• Standring, S. (2016). Gray's Anatomy (41st ed.). Edinburgh: Elsevier Churchill Livingstone.
• Netter, F. (2019). Atlas of Human Anatomy (7th ed.). Philadelphia, PA: Saunders.
• Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2014). Clinically Oriented Anatomy (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
• Nguyen JD, Duong H. Anatomy, Head and Neck, Cheeks. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. 
• Nguyen JD, Duong H. Anatomy, Head and Neck, Face. [Updated 2021 Jun 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Articles within this topic:

• Buccinator muscle
• Corrugator supercilii muscle
• Depressor anguli oris muscle
• Depressor labii inferioris muscle
• Facial artery
• Facial lymph nodes
• Facial muscles
• Facial vein
• Frontalis muscle
• Great auricular nerve
• Head anatomy
• Inferior orbital fissure
• Internal carotid artery
• Levator anguli oris muscle
• Levator labii superioris muscle
• Lingual artery
• Major arteries, veins and nerves of the body
• Maxillary artery
• Mentalis muscle
• Nasalis muscle
• Occipital artery
• Occipitalis muscle
• Occipital nerves
• Occipitofrontalis muscle
• Orbicularis oculi
• Orbicularis oris muscle
• Posterior auricular artery
• Procerus muscle
• Retromandibular vein
• Risorius muscle
• Superficial arteries and veins of the face and scalp
• Superficial nerves of the face and scalp
• Superficial temporal artery
• Supraorbital artery
• Supratrochlear artery
• Temporal muscle
• Zygomaticus major muscle
• Zygomaticus minor muscle

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• Patient Care & Health Information
• Diseases & Conditions
• Bell's palsy

Bell's palsy is a condition that causes sudden weakness in the muscles on one side of the face. Often the weakness is short-term and improves over weeks. The weakness makes half of the face appear to droop. Smiles are one-sided, and the eye on the affected side is hard to close.

Bell's palsy also is known as acute peripheral facial palsy of unknown cause. It can occur at any age. The exact cause is not known. Experts think it's caused by swelling and irritation of the nerve that controls the muscles on one side of the face. Bell's palsy could be caused by a reaction that occurs after a viral infection.

Symptoms usually start to improve within a few weeks, with complete recovery in about six months. A small number of people continue to have some Bell's palsy symptoms for life. Rarely, Bell's palsy occurs more than once.

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• Facial paralysis

The nerve that controls facial muscles passes through a narrow corridor of bone on its way to the face. Facial weakness or paralysis may cause one corner of the mouth to droop, and the mouth may not be able to retain saliva on the paralyzed side of the face. The condition also may make it difficult to close the eye on the affected side of the face.

Symptoms of Bell's palsy come on suddenly and may include:

• Mild weakness to total paralysis on one side of the face — occurring within hours to days.
• Facial droop and trouble making facial expressions, such as closing an eye or smiling.
• Pain around the jaw or pain in or behind the ear on the affected side.
• Increased sensitivity to sound on the affected side.
• Loss of taste.
• Changes in the amount of tears and saliva produced.

Rarely, Bell's palsy can affect the nerves on both sides of the face.

When to see a doctor

Seek medical help right away if you experience any type of paralysis because you may be having a stroke. Bell's palsy is not caused by a stroke, but the symptoms of both conditions are similar.

If you have facial weakness or drooping, see your healthcare professional to find out the cause and the severity of the illness.

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Although the exact reason Bell's palsy occurs isn't clear, it's often related to having a viral infection. Viruses that have been linked to Bell's palsy include viruses that cause:

• Cold sores and genital herpes, also known as herpes simplex.
• Chickenpox and shingles, also known as herpes zoster.
• Infectious mononucleosis, caused by the Epstein-Barr virus.
• Cytomegalovirus infections.
• Respiratory illnesses, caused by adenoviruses.
• German measles, also known as rubella.
• Mumps, caused by the mumps virus.
• Flu, also known as influenza B.
• Hand-foot-and-mouth disease, caused by a coxsackievirus.

The nerve that controls facial muscles passes through a narrow corridor of bone on its way to the face. In Bell's palsy, that nerve becomes inflamed and swollen — usually related to a viral infection. Besides affecting facial muscles, the nerve affects tears, saliva, taste and a small bone in the middle of the ear.

Risk factors

Bell's palsy occurs more often in people who:

• Are pregnant, especially during the third trimester, or who are in the first week after giving birth.
• Have an upper respiratory infection, such as the flu or a cold.
• Have diabetes.
• Have high blood pressure.
• Have obesity.

It's rare for Bell's palsy to come back. But when it does, there's often a family history of repeated attacks. This suggests that Bell's palsy might have something to do with genes.

Complications

Mild symptoms of Bell's palsy typically disappear within a month. Recovery from more-complete facial paralysis can vary. Complications may include:

• Irreversible damage to your facial nerve.
• Irregular regrowth of nerve fibers. This may result in involuntary contraction of certain muscles when you're trying to move other muscles, known as synkinesis. For example, when you smile, the eye on the affected side may close.
• Partial or complete blindness of the eye that won't close. This is caused by excessive dryness and scratching of the clear protective covering of the eye, known as the cornea.
• Kellerman RD, et al. Acute facial paralysis. In: Conn's Current Therapy 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 3, 2022.
• AskMayoExpert. Bell palsy. Mayo Clinic; 2022. Accessed March 3, 2022.
• Ferri FF. Bell palsy. In: Ferri's Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed March 3, 2022.
• Bell's palsy. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/health-information/disorders/bells-palsy#. Accessed Feb. 1, 2024.
• Ronthal M. Bell's palsy: Pathogenesis, clinical features, and diagnosis in adults. https://www.uptodate.com/contents/search. Accessed Feb. 1, 2024.
• Ronthal M. Bell's palsy: Prognosis and treatment in adults. https://www.uptodate.com/contents/search. Accessed March 7, 2022.
• Facial nerve palsy. Merck Manual Professional Version. https://www.merckmanuals.com/professional/neurologic_disorders/neuro-ophthalmologic_and_cranial_nerve_disorders/facial_nerve_palsy.html?qt=&sc=&alt=. Accessed March 7, 2022.
• Singh A, et al. Bell's palsy: A review. Cureus. 2022; doi:10.7759/cureus.30186.

Associated Procedures

• Electromyography (EMG)

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Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.

Chapter 217 general appearance.

Steven L. Berk and Abraham Verghese .

"The art of the practice of medicine is to be learned only by experience, tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become expert." Osler (1919) .

The general appearance of a patient may provide diagnostic clues to the illness, severity of disease, and the patient's values, social status, and personality. The astute physician will begin to gather this information immediately upon meeting the patient. By observing gait, facial features and expression, handshake, and quality of voice, the physician may begin to detect unique qualities and potential problems. Physicians who have the ability to remember a patient's name and face for many years are those who pay intense attention to the initial encounter.

No detail is unimportant. The following should be evaluated systematically:

• Facies and expression ( Table 217.1 )
• Gait ( Table 217.2 )
• Clothing and paraphernalia ( Table 217.3 ): Are clothes appropriate for the time of year? What does jewelry or makeup say about the patient? Is a particular scarf, hat, or patch covering an area of deformity or disease?
• Stature and habitus ( Table 217.4 ): Observe the patient's body build. Very short stature will be seen in dwarfism, pseudohypoparathyroidism, Turner's syndrome, or prepubertal steroid therapy. Tall and lanky individuals with long, thin extremities suggest Marfan's syndrome
• Posture and decubitus ( Table 217.5 ): The normal state of resting tone in muscle groups results in healthy, upright posture with tone greatest in antigravity muscles. Alteration in this tone may result in the characteristic postures of Parkinson's disease, stroke, or cerebellar abnormalities. Decubitus refers to the observed posture of the patient in bed. Does the patient prefer to lie on one side, such as occurs in the lateral decubitus position of a patient with abdominal disease? Is the patient lying very still in bed, as might occur in peritonitis, or is there flailing such as that seen with renal colic?
• Odor of breath and body ( Table 217.6 ): Does the breath suggest poor hygiene or anaerobic infection? Does the comatose patient have the fruity odor of diabetic ketoacidosis?

Table 217.1

Clues to Disease from Facies and Expression.

Table 217.2

Clues to Disease from Gait.

Table 217.3

Clues to Disease from Clothing and Paraphernalia.

Table 217.4

Clues to Disease from Stature and Habitus.

Table 217.5

Clues to Disease from Posture and Decubitus.

Table 217.6

Clues to Disease from Odor of Breath and Body.

• Basic Science

The physician is much like a detective, searching for clues in the history and physical examination, reserving judgment during the quest for conclusive data. Read, for example, the following passage that emphasizes Sherlock Holmes" powers of observation:

" "Pon my word Watson, you are coming along wonderfully. You have really done very well indeed. It is true that you have missed everything of importance, but you have hit upon the method, and you have a quick eye for colour. Never trust to general impressions, my boy, but concentrate yourself upon details. My first glance is always at a woman's sleeve. In a man it is perhaps better first to take the knee of the trouser. As you observe, this woman had plush upon her sleeves, which is a most useful material for showing traces. The double line a little above the wrist, where the typewritist presses against the table, was beautifully defined. The sewing machine, of the hand type, leaves a similar mark, but only on the left arm, and on the side of it farthest from the thumb, instead of being right across the broadest part, as this was. I then glanced at her face, and observing the dint of a pince-nez at either side of her nose, I ventured a remark upon short sight and typewriting which seemed to surprise her." "It surprised me." "But, surely it was obvious. I was then much surprised and interested on glancing down to observe that, though the boots which she was wearing were not unlike each other, they were really odd ones; the one having a slightly decorated toe-cap, and the other a plain one. One was buttoned only in the two lower buttons out of five, and the other at the first, third and fifth. Now, when you see that a young lady, otherwise neatly dressed, has come away from home with odd boots, half-buttoned, it is no great deduction to say that she came away in a hurry."

General appearance demands less data collection than any of the other represented items of database content. Yet information gleaned from the patient appearance is particularly valuable, since it is usually the first bit of objective data. Examining the general appearance of the patient may be likened to surveying the forest before walking among the trees. Writings of 50 or more years ago contain the very-best descriptions relating patient appearance to disease. Osler's detailed description of the patient with typhoid fever is a classic example. The sensitivity and specificity of patient appearance have withstood the test of time. Excellent clinicians continue to use this technique with high yield.

• Clinical Significance

What can be learned by looking into a patient's face and eyes? The eyes have been called the windows of the soul, the face the mirror of the mind. Authors and poets have described the importance of such observation. Physicians will long remember some of their patients" faces, the pain, anger, or pleading that can be so vividly expressed by the human face. Clues to endocrine and physiologic abnormalities may also become apparent—the rounded facies of Cushing's disease, the prominent jaw and frontal bossing of acromegaly, or the exophthalmos of hyperthyroidism. Icteric sclera may tell more about a patient's alcohol problem than can be stated. Pallor may quickly explain shortness of breath. Lateral thinning of the eyebrows may suggest hypothyroidism; periorbital edema may represent the nephrotic syndrome; and a butterfly rash may predict lupus erythematosus.

A simple handshake may help assess the circulatory system, suggest active inflammation in the patient with arthritis, or differentiate the cold and moist hands of the anxious patient from the warm and moist ones of the thyrotoxic patient.

The patient's voice may suggest fear, depression, or mania. Speech can also be the first clue to dysarthria or aphasia. The thickened, low pitch of hypothyroidism or hoarseness of laryngeal carcinoma can be detected by a careful listener.

Observation of a shuffling gait will require a particular review of symptoms for signs of Parkinsons's disease and a physical examination particularly directed toward the assessment of mobility. Similarly, gait may suggest a mild hemiparesis secondary to stroke, or the ataxia of cerebellar disease.

An illustration of what the patient's appearance can reveal is shown by the following case:

The patient is from a rural area, brought to the clinic by family members. He is cachectic and thin; his clothes fit loosely. His face shows great sadness and fear. His speech is difficult, his mouth dry, and a fecal odor is evident on his breath. He is pale, his sclera are icteric, and his head bobs and body jars with each heartbeat. On shaking hands, his skin is warm and his nails have subungual hemorrhages. A hole has been cut out of his shoe where the large toe protrudes.

This patient is extremely ill, and only a detailed history and physical examination will provide the necessary data for diagnosis and treatment. However, important information has already been collected and can be used to make hypotheses and chart a further course. The patient has a chronic debilitating disease. Perhaps his fears of medical care have delayed presentation and resulted in advanced disease. The odor of his breath suggests poor oral hygiene and the head bobbing suggests advanced aortic regurgitation. This presentation could be consistent with subacute endocarditis. Subungual hemorrhages provide further support for this hypothesis. His pale complexion and scleral icterus may be caused by a hemolytic anemia secondary to endocarditis; but a chronic hemolytic anemia might cause gout, requiring the modified shoe.

These hypotheses are generated by data obtained from the patient's general appearance. The possibilities will require confirmation by more detailed history (has there been fever, chills, weight loss, night sweats), physical examination (is there an aortic regurgitant murmur, splenomegaly or podagra), and laboratory data (blood cultures, complete blood count, peripheral smear, uric acid). But we have used the patient's general appearance to begin the scientific process that will eventually lead to accurate diagnosis.

• Cheraskin E, Ringsdorf WM Jr. Predictive medicine: a study in strategy. Mountain View, CA: Pacific Press Publishing, 1973.
• Feingold M, Gellis SS. Syndrome identification and consultation. Am J Dis Child. 1971; 121 :82–83. [ PubMed : 5539824 ]
• Osler W. The principles and practice of medicine. New York: D Appleton, 1892;2–39.
• Osler W. The teacher. Johns Hopkins Hosp Bull 1919;30.
• Roberts HJ. Difficult diagnosis: a guide to the interpretation of obscure illness. Philadelphia: W.B. Saunders, 1959.
• Cite this Page Berk SL, Verghese A. General Appearance. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 217.
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Patient discussion about face

Q. Can scabies be on the face? About a week ago, several bumps, red and itchy, appeared on my face. I have had scabies on other parts of my body and although it feels quite similar, it doesn’t really look the same. Can it be scabies? Is it other thing? A. If you indeed have scabies on your face, it may come from two sources: either from your scalp, where it hides when you treat the rest of your body, or your pillow. First you should be sure it's scabies (have you seen a doctor?) If it's scabies, try to wash all your pillows and change them, and then treat your face.

Q. Is there any way you can lose weight on your face? I am a male and I got chubby cheeks like girls and I don’t like it...is there any way you can lose weight on your face? A. Hi Christopher, I’m not sure if there is, but you should like your face just the way it is, try some make-up and see how it goes, or rub your cheeks in a circular motion with your hands for about 45 seconds a day. Chubby cheeks can also come from liver problems, water retention from a high salt diet, excessive toxic buildup in the body, and of course poor choices in diet. Try exercise, facial massages, ice packs can help, or natural diuretic herbs like dandilion root extract.

Q. how i can have afat face? after loosing weight my face has lost weight and is thin how can i treat it? A. You want to make your face look fuller? Except for the obvious (although not the most recommended...) way to gain wait, you can use make-up, You can try to draw attention to the center of your face: use some blush on your chick's apples, a little on your chin and add a little touch to the end of your nose. It'll shorten your face. You can also see the tips in this movie (http://www.expertvillage.com/video/14409_lips-full-makeup.htm there are other movies in this site).

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