Arch Gynecol Obstet (2008) 278:427–430
DOI 10.1007/s00404-008-0600-0
O R I G I N A L A R T I CL E
Face and brow presentation in northern Jordan,
over a decade of experience
F. Zayed · Z. Amarin · B. Obeidat · N. Obeidat ·
H. Alchalabi · I. Lataifeh
Received: 19 November 2007 / Accepted: 4 February 2008 / Published online: 19 February 2008
© Springer-Verlag 2008
Abstract
Background Malpresentation is a deviation from the normal
presentation, which occurs in approximately 5% of labours
(Seeds and Cefalo in Clin Obstet Gynaecol 25:145–156,
1982). The commonest form of malpresentation at delivery is
breech presentation followed by face and brow presentation.
Objectives To review the incidence and management of
face and brow presentation in north of Jordan.
Materials and methods This was a retrospective review
of the experience of face and brow presentation deliveries
in the two main civil hospitals in north of Jordan between
1995 and 2005.
Results The incidence of face and brow presentation was
1 in 813 and 1 in 1,689 deliveries, respectively. There was
no signiWcant increase in the incidence of prematurity nor
very low birth weight and no higher incidence of postmatu-
rity among those delivered by face or brow in the same
period. All the foetuses presenting by the brow and by face
(mentoposterior) and only 16.7 % of foetuses presenting by
face (mentoanterior) were delivered by caesarian section.
Conclusion The incidence of face and brow presentation
was 1 in 813 and 1 in 1,689 deliveries, respectively. All the
babies presenting by brow presentation did undergo caesar-
ean section. The management of face and brow presentation
is heading towards a safe delivery and not merely to accom-
plish vaginal delivery.
F. Zayed (&) · Z. Amarin · B. Obeidat · N. Obeidat ·
H. Alchalabi · I. Lataifeh
Department of Obstetrics and Gynaecology,
King Abdullah University Hospital,
Jordan University of Science and Technology, Irbid, Jordan
e-mail: fhmzayed@just.edu.jo; fhmzayed@yahoo.com
F. Zayed
P. O. Box 962106, Amman 11196, Jordan
Keywords Face · Brow · Presentation · Northern Jordan
Introduction
Malpresentation is a deviation from the normal presenta-
tion, which occurs in approximately 5% of labours [1]. The
commonest form of malpresentation at delivery is breech
presentation followed by face and brow presentation. The
literature seems to vary in classifying the aetiological fac-
tors for face and brow presentation [2–4]. The deXexed
cephalic attitudes of the foetus in its face or brow presenta-
tion are rare and the incidence varies from one study to
another [1, 4, 5]. Obstetricians have to rely on the available
published literature for guidance in the diagnosis and man-
agement. Those malpresentations may be associated with
signiWcant maternal and perinatal morbidity especially
when diYcult manipulative maneuvers were favoured to
accomplish vaginal delivery [2, 6].
This is a retrospective analysis of the experience and
management of face and brow presentation between 1995
and 2005 in two main civil hospitals in Irbid, Jordan.
Materials and methods
A retrospective review was performed for deliveries includ-
ing face and brow presentation at Princess Badeea Hospital
and King Abdullah University Hospital in Irbid, Northern
Jordan. This study was carried out in about 11-year period
from January 1995 to December 2005, during which there
were a total of 64,192 consecutive births of pregnancies of
greater than 28 weeks’ gestation also checked with previ-
ous data [7], this gestational age was used as cut oV age for
perinatal statistics in Jordan till the last few years.
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428 Arch Gynecol Obstet (2008) 278:427–430

Data were retrieved from both the hospital notes for each
identiWed case of face and brow presentation to allow the
collection of maternal demographic data, together with
information regarding any relevant antenatal and intrapar-
tum events for each case.
Statatistical analysis using student t test and Mann–
Whitney test as appropriate and on discrete results chi
square or Fischer exact test when appropriate. The diVer-
ences were considered signiWcant at P value of <0.05.
Results
There were 79 cases of face presentation (60 mentoanterior
and 19 mentoposterior, originally there were 89 face pre-
sentation but 10 cases were excluded) and 38 cases of brow
presentation delivered during the 11-year period; an inci-
dence of 1 in 813 and 1 in 1,689 deliveries, respectively.
All the 79 face presentations and all the 38 cases of brow
presentation during the study period were retrieved for
analysis. Maternal age, in both forms of malpresentaion
were similar to those of the overall population. Singleton
pregnancies made up most of the cases of face and brow.
Table 1 summarizes the data on maternal age, parity, birth-
weight, gestational age, and Apgar score for foetuses deliv-
ered during the same period.
It was noticed that the incidence of multiparity and
grandmultiparity is similar in the face presentation and the
brow presentation, in multiparae 65.8 and 63.2% where the
vertex was 60%, but in grand multiparae it was 15.7, and
15.8% but in the vertex it was 18%, respectively. The same
applied in primiparous the incidence in face and brow pre-
sentation was similar 18.9 and 21%, respectively also the
vertex was 20%. The incidence of prematurity and low
birth weight babies was double in face presentation that of
the brow presentation, the prematurity was 6.3% versus
2.6% where the vertex was 5%, the postmaturity in the face
was similar the brow presentation 3.8 versus 5.3% where
the vertex was 5%.
In face presentation the total number was 89 as there
were 6 cases of anencephaly and one case of multiple fetal
anomaly as well as 3 cases of IUFD all delivered vaginally;
however, those10 cases were excluded from the study, the
remaining 79 cases were studied.
The Wrst stage for brow presentation was short compared
to face presentation and control cases, approximately 3, 7,

Table 1 Summary of data on parity, birth weight, gestation and mode of delivery in face and brow presentation in north of Jordan Hospital
population (1995–2005)
Face (MA) Face (MP) Face total Brow Vertex P value
n = 60 (%) n = 19 (%) n = 79 (%) n = 38 (%) n = 44,934 (%) P < 0.05

Maternal age (years) 27.8 28 27.9 32.9 30.2

Incidence 1:813 1:1689
Parity Mean 3.6 3.3 3.5 2.9
Primi 12 (20%) 3 (15.8%) 15 (18.9%) 8 (21%) 8,986 (20%) Ns
P1–5 38 (63.3%) 14 (73.7%) 52 (65.8%) 24 (63.2%) 26,960 (60%) Ns
P>5 10 (16.7%) 2 (10.5%) 12 (15.2%) 6 (15.8%) 8,986 (18%) Ns
Gest age Mean 37.9 39.5 39 39
<37 weeks 4 (6.7%) 1 (5.3%) 5 (6.3%) 1 (2.6%) 2,246 (5%) Ns
37–42 weeks 54 (90%) 17 (89.4%) 71 (89.8%) 35 (92.1%) 40,440 (90%)
>42 weeks 2 (3.3%) 1 (5.3%) 3 (3.8%) 2 (5.3%) 2,246 (5%) Ns
Birth wt (g) Mean 3,400 3,450 3,600 3,200
<1,500 3 (5%) 1 (5.3%) 4 (5.1%) 1 (2.6%) 3,145 (6%) Ns
1,500–4,000 54 (90%) 17 (89.4%) 71 (89.9%) 35 (92.1%) 40,665 (90.5%) Ns
>4,000 3 (5%) 1 (5.3%) 4 (5%) 2 (5.3%) 1,572 (3.5%)
Apgar score Mean 7–8.7 6.8–8.7 7.1–8.9 7.3–8.8
<7 10 (16.7%) 3 (15.8%) 13 (16.5%) 5 (13.2%) Ns
>7 50 (83.3%) 16 (84.2%) 66 (83.5%) 33 (86.8%) Ns
First stage (h) 8 3 7 3 6
Second stage (min) 70 25 55 10 50
Caesarean section 10 (16.7%) (19) 100% 29 (36.7%) 38 (100%) 8,986 (20%) S
Ns Not signiWcant; S signiWcant
P value face vs vertex 0.0066
P value brow vs vertex 0.0001

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Arch Gynecol Obstet (2008) 278:427–430
6 h, respectively and the same in the second stage 10, 55
and 50 min, respectively.
Ten cases of mentoanterior face presentation delivered
by caesarean section but all the cases of mentoposterior
presentation and all the cases of brow were delivered by
caesarean section.
The diagnosis of malpresentation was made in labour.
Discussion
Cruikshank et al. [5] showed in their review of several pub-
lished studies of face and brow presentation that the average
incidence of these malpresentations have been quoted as
average of 1 in 545 and 1 in 1,444 births, respectively; how-
ever Bhal et al. [8] showed in their study that face presenta-
tion has been reported as being more common than brow
presentation till 1990s. This diVerence, however, appears to
have become less marked according to Bhal et al. [8] over
the past two decades and they reported an incidence of 1 in
994 in face and 1 in 755 in brow presentations.
Bhal et al. [8] suggested that the increase in the reported
incidence of face presentation over the Wrst half of this cen-
tury maybe related to an increase in data collection and an
inclusion of foetuses with cranial vault anomalies. The sub-
sequent decline could have been associated with the intro-
duction of ultrasound screening for neural tube defects,
especially anencephaly which is widely considered as a
causative factor in face presentation [4, 9]. The incidence of
face and brow presentation in this study was 1 in 813 and 1
in 1,689 deliveries, respectively similar to Cruikshank meta
analysis and is still much higher than the incidence of brow
presentation in contrast to Bhal study.
The aetiology of face presentation studied by Cruikshank
et al. [5] included anencephaly, high parity, contracted pel-
vis, large infant, small infant, placenta praevia, polyhy-
dramnios uterine anomaly and nuchal cord; while in the
same study brow presentation they found that placenta prae-
via, polyhydramnios uterine anomaly and nuchal cord were
no longer part of the aetiology of this presentation, the high
parity and low birth weight and cephalopelvic disproportion
is a possible cause. Cruikshank et al. [5] in an analysis of 28
studies, no possible cause was found in 38% of face presen-
tation; ranged from 2% by Posner et al. [10] to 97% by
Light et al. [11]. The same applies to brow presentations
that no possible cause was found in 50% of cases ranged
from 3.8% by Morris [12] to 82% by Magid et al. [13]. The
incidence of prematurity and foetuses weighing less than
1,500 g among foetuses delivered by face presentation var-
ies from 5 to 34% [6, 14–18] and delivered as brow 1–29%
[5] respectively. In this study, the incidence of very low
birth weight in face and brow presentation was 5.1 and
2.6% respectively, compared with vertex which was 6%.
429
In brow presentation post mature foetuses appear to be a
signiWcant Wnding as mentioned by Cruikshank et al. [5]. In
this study the incidence of post mature and over 4 kg birth
weight babies with face and brow presentation was 3.8, 5.3,
5.1, and 5.3% respectively, which indicates the lack of
diVerence between the two malpresentations. Fetal size in
face presentation is a controversial factor as there have
been other reviews that have found a three-fold increase in
the incidence of macrosomia when compared with their
general population [19].
The literature showed that more than 60% of foetuses
delivered by face presentation were from multiparous
mothers [6, 8, 20, 21]; while nulliparous patients were more
common with brow presentation as reported in other studies
[5, 17]. In this study about two-thirds of the face and brow
presentation were from multiparous group. The incidence
of face in nulliparous was 18.9 compared to 21% in brow
presentation, where the incidence of multiparous in face
compared to brow was 65.8 versus 63.2% but in the grand
multiparous face presentation the incidence was 15.2 com-
pared with 15.8% for brow presentation. This implies that
in this study the incidence of face and brow are similar in
nulliparous, multiparous and grand multiparous. This
diVers from other studies in the dissimilarity between face
and brow presentation but agreed with other studies in that
about two-thirds of the face and brow presentation are in
the multiparous group.
Other possible aetiological factors also seen in this study
for both forms of malpresentation included the presence of
cord, multiple pregnancy, hydramnios, placenta praevia and
congenital anomaly of the uterus but were not prominent or
had little impact. This is in agreement with the Wndings of
Cruikshank et al. [5].
Brow presentation is virtually impossible to deliver vag-
inally due to the large presenting diameter (mentovertical
13 cm) unless the foetus is very small and the pelvis is
capacious [5]. This was conWrmed in this study where all
the brow presentations were delivered by caesarean section.
Almost all obstetricians agree that manipulative or destruc-
tive procedures, other than caesarean section or low forceps
deliveries in these circumstances are associated with mater-
nal and perinatal morbidity and mortality and no more
accepted in modern obstetrics [5, 19]
Approximately 84% of cases of face presentation (men-
toanterior) in this study achieved vaginal delivery; while all
mentoposterior were delivered by caesarean section. About
37% of all face presentation delivered by caesarean while
all brow presentation delivered by caesarean section. In
other studies some of brow presentation delivered vaginally
and some of mentoposterior face presentation were deliv-
ered vaginally. In this study none of the brow and of the
mentoposterior achieved vaginal delivery. This may be
explained by the trend in modern obstetrics to achieve safe
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430
delivery rather than to merely accomplish vaginal delivery
[22], resulting in liberal use of caesarean for the above pre-
sentations.
The incidence of fetal distress in labour is relatively high
in face and brow presentations [8, 18, 23–27]. In this study
the incidence of Apgar score of less than 7 was 16.7, 15.8,
and 13.2% in face (mentoanterior), face (mentoposterior)
and brow presentation, respectively. The least fetal distress
was in the brow group. This may be due to the early resort
to caesarean section and the highest fetal distress was in the
face (mentoanterior) group. This may be due to allowing
those cases to have vaginal delivery. Umbilical cord com-
pression or abnormal pressure on the extended neck, head
or eyes of the foetus may cause this increase in foetal dis-
tress as explained by [17, 19, 22].
The above Wndings indicate a need for close and continu-
ous CTG monitoring and perhaps early resort to caesarean
section especially in cases of brow presentation.
In this study comparing the Wrst stage of labour showed
shorter Wrst stage in brow presentation but that was due to
early recourse of caesarean section once diagnosed, and the
same apply to the second stage.
In conclusion, the reported incidence of these forms of
deXexed cephalic attitudes of face and brow presentation
has been diVerent over the last few decades. In spite of no
signiWcant diVerence in the characteristic features of face
and brow cases from vertex presentation, but we might
need more numbers to show the diVerence. The aim in the
management of face and brow presentation seem to have
shifted towards a safe delivery and not merely to accom-
plish vaginal delivery, on the expense of taking higher risks
of morbidity or mortality to the newborns.
Acknowledgments The authors would like to thank all the staV at
Princess Badeea Hospital and at King Abdullah University Hospital.
We are very grateful to other colleagues and residents in both hospitals
especially Dr. Alia Adwan who helped in attaining the data needed for
this study.
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