Face presentation Definition: It is a cephalic presentation in which the head is completely extended..

Incidende : Face presentation has an incidence of 1 in 500 labours.common .

5. Dead or premature foetus. 6. Idiopathic Aetiology : (A) Primary face: -It is less common. - occurs during pregnancy. -It is usually due to foetal causes which may be: 1. Anencephaly: due to absence of the bony vault of the skull and the scalp while the facial portion is normal. 2. Loops of the cord around the neck. 3. Tumours of the foetal neck e.g. congenital goitre. 4. Hypertonicity of the extensor muscles of the Neck 5. Dead or premature foetus. 6. Idiopathic

- occurs during labour. (B) Secondary face: - It is more common. - It may be due to: 1-Contracted pelvis particularly flat pelvis which allows descent of the bitemporal but not the biparietal diameter leads to extension of the head. 2. Pendulous abdomen or marked lateral obliquity of the uterus. 3. Further deflexion of brow or occipito - posterior positions. 4. Other causes of malpresentations as polyhydramnios and placenta praevia

Positions: - Right mento-posterior (RMP) Positions: - Right mento-posterior (RMP). - Left mento - posterior (LMP). - Left mento-anterior (LMA). - Right mento-anterior (RMA), are the more common positions. Right mento- transverse (lateral), left mento-transverse, direct mento-posterior and direct mento-anterior are rare and usually transient positions.

Diagnosis: (A) During pregnancy (difficult): 1. The back is difficult to feel . 2. The limbs are felt more prominent in mento-anterior position. 3. The chin may be felt on the same side of the limbs as a horseshoe-shaped rim in mento-anterior position. In mento-posterior, a groove may be felt between the occiput and the back 5. Second pelvic grip: the occiput is at a higher level than the sinciput. 6. The FHS are heard below the umbilicus through the foetal chest wall in mentoanterior position. 7. Ultrasound or X-ray: confirms the diagnosis and may identify associated foetal anomalies as anencephaly

(B) During labour: In addition to the previously mentioned findings (B) During labour: In addition to the previously mentioned findings.Vaginal examination shows the following identifying features for face:- - supra - orbital ridges, - the malar processes, - the nose ( rubbery and saddle shaped), - the mouth with hard areolar ridges. - the chin.

Mechanism of Labour (A) Mento - anterior position: 1. Descent. 2. Engagement by submento-bregmatic diameter 9.5cm. 3. Increased extension. 4. Internal rotation of chin 1/8 circle anteriorly. 5-Flexion : is the movement by which the head is delivered in mento-anterior position when the submental region hinges below the symphysis. The vulva is much distended by the submento-vertical diameter 11.5 cm. 6. Restitution 7. External rotation

(B) Mento - posterior position: 1- Long anterior rotation 3/8 circle ( 2/3 of cases): so the head is delivered as mento-anterior. 2- In about 1/3 of cases one of the following may occur: i- Deep transverse arrest of the face: when the chin rotates 1/8 circle anteriorly. ii- Persistent mento-posterior: when no rotation occurs. iii- Direct mento-posterior: When the chin rotates 1/8 circle posteriorly.

In the last 3 conditions (i) , (ii) and (iii) no further progress occurs and labour is obstructed. Direct mento-posterior, unlike direct occipito-posterior, cannot be delivered because: 1. Delivery should occur by extension while the head is already maximally extended. As the length of the sacrum is 10 cm and that of neck is only 5 cm, the shoulders enter the pelvis and become impacted while the head still in the pelvis, thus the labour is obstructed

Management of Labour: Exclude: - Foetal anomalies and - Contracted pelvis. (A) Mento-anterior: First stage: as in occipito-posterior. Second stage: - Spontaneous delivery usually occurs. - Forceps delivery may be indicated in prolonged 2nd stage. - Episiotomy is necessary because of over distension of the vulva.

(B) Mento-posterior: First stage: as mento-anterior (B) Mento-posterior: First stage: as mento-anterior. Second stage: (I) Wait for long anterior rotation of the mentum 3/8 circle and the head will be delivered as mento-anterior. During this period oxytocin is used to compete inertia which is common in such conditions as long as there is no contraindication. Failure of this long rotation is more common than in occipito-posterior position so earlier interference is usually indicated.

(II) Failure of long anterior rotation 3/8 circle or - development of foetal or maternal distress at any time, is managed by: 1. Caesarean section: which is the safest and the current alternative in modern obstetrics. 2. Manual rotation and forceps extraction as mento-anterior , or 3. Rotation and extraction by kielland forceps. In the last 2 methods the head should be engaged but they are hazardous to both the mother and foetus so they are nearly out of modern obstetrics. 4. Craniotomy : if the foetus is dead.

The face of the foetus is oedematous after delivery so the mother is assured that this will be spontaneously relieved within few days.

BROW PRESENTATION Definition: It is a cephalic presentation in which the head is midway between flexion and extension

Incidence : About 1:1000 labour. Aetiology: As face presentation

Diagnosis: (A) During pregnancy: - It is difficult Diagnosis: (A) During pregnancy: - It is difficult. - The occiput and sinciput may be felt at the same level. - Ultrasonography and X-ray may be helpful

(B) During labour: In addition to the previous findings, vaginal examination reveals the following features: - frontal bones, - supra-orbital ridges, and - root of the nose but not the chin.

Mechanism of Labour: I- Persistent brow: The engagement diameter is the mento -vertical 13.5 cm which is longer than any diameter of the inlet so there is no mechanism of labour and labour is obstructed

II- Transient brow: may occur during conversion of vertex into face presentation. So if brow is flexed to become vertex or extended to become face it may be delivered

Management: (A) Early in the first stage: 1-Exclude contracted pelvis, if present do caesarean section.. 2-The case is considered as transient brow, observed carefully and given a chance for spontaneous conversion into either face or vertex. . 3. The rest of management as other malpresentation

(B) In the second stage: The case is considered as persistent brow so: 1. Caesarean section is done if the foetus is living. 2. Craniotomy if the foetus is dead.

Complex (Compound) Presentation Definition: It is the presence of a limb alongside the presenting part usually the arm presents with the head. Incidence: About 1:800 labours

Aetiology: Interference of adaptation of the presenting part to the pelvic brim which may be: (A) Foetal causes : (1) Malpresentations. (2) Prematurity. (3) Multiple pregnancy. (4) Polyhydramnios

(B) Maternal causes: (1) Contracted pelvis. (2) Pelvis tumours.

Management: Exclude: - contracted pelvis and - cord prolapse Management: Exclude: - contracted pelvis and - cord prolapse. (A) First stage: Nothing is done as in most cases the arm will be displaced spontaneously away from the head.

(2) Caesarean section : is indicated in - Nonengagement of the head. (B) Second stage: (1) Forceps extraction with or without reposition of the arm: reposition of the arm is tried first, if difficult apply forceps without reposition but do not include the arm in the blades. This is done if the head is engaged. (2) Caesarean section : is indicated in - Nonengagement of the head. - Contracted pelvis. - Other indications for caesarean section. (3)Craniotomy: if the foetus is dead and labour is obstructed