REVIEW
Malpositions and
malpresentations of the
fetal head
Suparna Sinha
Vikram S Talaulikar
Sabaratnam Arulkumaran
Abstract
Nearly 95% of fetuses at term present with the vertex and with such a
presentation, the vast majority of women progress well in labour and
have a spontaneous vaginal delivery. Any presentations other than
vertex can lead to difficulties in labour and hence are called as malpre-
sentations.
Malpresentations of fetal head occur due to extension of the fetal
head causing brow or face to present during labour. Malpositions of
fetal head result when the occiput persists in a lateral or posterior po-
sition. Malpresentations and malpositions of fetal head are usually
diagnosed in labour and are associated with difficult labour and
increased risk of operative intervention. Regular systematic clinical ex-
aminations to monitor progress of labour and fetal wellbeing are
necessary once fetal malpresentations or malpositions are diagnosed.
Although vaginal delivery is possible in many cases, caesarean section
becomes necessary when the malposition or malpresentation persists
and labour fails to progress.
Keywords brow; face; malposition; malpresentation; occipitoposte-
rior; occipitotransverse
Introduction
The normal mechanism of labour involves a well flexed fetal
head that engages into maternal pelvis so that the occiput comes
to lie near one of the lateral aspects of maternal pelvis at the
onset of labour. As labour advances, progressive flexion and
descent of fetal head cause the occiput to rotate anteriorly when
the head reaches the pelvic floor. When this sequence of changes
in the position of fetal head is altered, a malposition or malpre-
sentation occurs.
To complete the process of labour successfully, a fetus has to
pass through the maternal bony pelvis. The widest parts of the
fetal body are its head (in the anteroposterior plane), and the
shoulders (laterally across the shoulder tips). About 95% of
fetuses at term, present by the vertex in labour and this is hence
Suparna Sinha MBBS MS MRCOG is a Specialty Registrar in Obstetrics
and Gynaecology at North West London NHS Trust, UK. Conflicts of
interest: none.
Vikram S Talaulikar MD MRCOG PhD is an Associate Specialist in
Reproductive Medicine at University College London Hospital, UK.
Conflicts of interest: none.
Sabaratnam Arulkumaran MD PhD FRCS FRCOG is Professor Emeritus
at St. George’s University of London, UK. Conflicts of interest: none.
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called a normal presentation. The vertex is a diamond-shaped
area defined by the two parietal eminences, the anterior fonta-
nelle and the posterior fontanelle (Figure 1). It presents the
smallest diameters of the fetal head to the maternal pelvis. The
vertex adopts the occipitoanterior (OA e right, left or direct)
position in about 90% of the cases in the late first stage of la-
bour at term and this is generally referred to as a normal
position.
As women choose to have fewer babies, the incidence of
malpresentations has fallen in modern times as many malpre-
sentations are associated with high parity. Most of the malposi-
tions or malpresentations of fetal head are diagnosed in labour.
While in many cases, vaginal delivery is possible, they are
associated with difficult labour and increased operative in-
terventions, with attendant risks to both the mother and the
baby.
Definitions
Presentation: refers to the part of the fetus which is presenting to
the pelvic inlet. Presentations other than vertex such as breech,
brow, face or shoulder are termed malpresentations.
Denominator: is the fetal reference point used in defining posi-
tion. It is usually a prominent bony landmark at the circumfer-
ence of the presenting part e.g. occiput for vertex, sacrum for
breech, mentum (chin) for face and acromion for shoulder pre-
sentation. For a brow presentation, the denominator is not fixed
and either the sinciput or occiput can be used.
Position: refers to the relationship of the denominator to the
fixed points on the maternal pelvis such as pubic symphysis. For
vertex presentations, the occiput can occupy the following po-
sitions in labour e occipitoanterior (OA), occipitotransverse
(OT) or occipitoposterior (OP).
Attitude: refers to the degree of flexion or extension of the fetal
head with respect to the trunk. A well-flexed fetal head presents
the most favourable diameters to the maternal pelvis (Figure 2).
If the fetal neck is deflexed, the leading part of the fetal head lies
more anteriorly and a brow presentation can occur, while if there
is complete extension of the fetal neck, the face becomes the
leading part producing face presentation (Figures 3 and 4).
Mechanism of normal labour
Descent: As the fetal head engages and descends, it assumes an
OT position; this facilitates the widest pelvic diameter available
for the widest part of the fetal head (Figure 5).
Flexion: While descending through the pelvis, the fetal head
flexes so that the fetal chin approximates to the fetal chest. This
functionally presents smaller diameters to pass through the
maternal pelvis. When flexion occurs, the posterior fontanelle
slides more into the centre of the birth canal, and the anterior
fontanelle becomes more remote and difficult to feel.
Internal rotation: With further descent, the occiput rotates
anteriorly.
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 REVIEW

Figure 1 Diamond shaped area of the fetal vertex bounded by each

parietal eminence and the anterior and posterior fontanelles.

Figure 3 Brow presentation with deflexed head.

to slow progress or arrest of labour. The presenting diameters

associated with these different presentations at term are listed in
Table 1 and shown in Figure 6.

Aetiology
The three Ps of normal labour - Power (uterine activity), Passage
(maternal pelvis and soft tissues) and Passenger (position and
size of fetal head) all play an important role in success of vaginal
delivery.
Figure 2 Vertex presentation with flexed attitude.
Maternal factors (passage and power)
! Contracted pelvis, android pelvis
Extension: The curve of the hollow of the sacrum favours ! Pelvic tumour/fibroid
extension of the fetal head as further descent occurs. ! Uterine malformation
! Oligohydramnios
Restitution and external rotation: With further uterine con- ! Placenta praevia
tractions and descent, the head is born by extension of the fetal ! Pendulous abdomen with lax abdominal muscles,
neck followed by restitution. The head then undergoes external ! Weak uterine contractions
rotation as the shoulders continue their internal rotation to come
to lie in the sagittal plane for delivery. The baby is then born by Fetal factors (passenger)
lateral flexion of the body. If the fetal head is not well flexed, the ! Prematurity
presenting diameters to the pelvis are larger and this causes ! Multiple pregnancy
malpositions or malpresentations. The larger diameters can lead ! Macrosomia

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Please cite this article in press as: Sinha S, et al., Malpositions and malpresentations of the fetal head, Obstetrics, Gynaecology and Reproductive
Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.01.001
 REVIEW
Figure 4 Face presentation with extension of the fetal neck.
! Fetal malformation e.g. hydrocephalus
! Intrauterine death
! Cord around neck
Clinical presentation and diagnosis of malpresentation
and malposition
Slow progress of labour is the commonest manifestation of fetal
malpresentations and malpositions in labour. The partogram is a
very useful tool which can help in timely diagnosis and action for
dystocia. Signs suggestive of malpresentations include a pendu-
lous abdomen and non-engagement of the presenting part at term
in a primigravida. Preterm or early rupture of membranes in term
labour and delay in the descent of the presenting part during
labour are notable.
Periodic abdominal examination should be performed in la-
bour to assess descent and position of fetal head. Engagement is
considered to have occurred when two-fifths or less of the fetal
head is palpable abdominally. The relative positions of sinciput
and occiput may suggest the attitude of the fetal head. Palpation
may also provide an estimate of the fetal size/weight and liquor
volume.
Vaginal examination often confirms the findings of malposi-
tion or malpresentation. The station of the fetal head should be
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identified in cm above or below the ischial spines. Placement of
sutures and fontanelles should be confirmed by sweeping the
fingers across the fetal head. The inverted Y shaped suture lines
or overlapping of parietal bones over the occipital bones in la-
bour helps to identify the posterior fontanelle. The anterior
fontanelle is felt as a soft diamond shaped depression at junction
of four bones. If the anterior fontanelle is felt easily near the
centre of the pelvis it is indicative of a deflexed head. If the
amount of caput makes examination difficult, it may be possible
to feel the fetal ear anteriorly. Care should be taken to feel the
pinna and the canal, as the ear can be folded and give a false
impression of its position.
Asynclitism
Ideally the sagittal suture should be parallel to the key diameters
of pelvis and this allows smooth progress of labour. When
neither of parietal bones precedes the sagittal suture, the head is
referred to as synclitic. When the anterior parietal bone precedes
the sagittal suture e it is anterior asynclitism and if the posterior
parietal bone precedes the sagittal suture it is posterior asyncli-
tism (Figure 7). Anterior asynclitism, in which the anterior pa-
rietal bone is more easily felt and the sagittal suture is further
back in the transverse plane, is generally normal. Posterior
asynclitism, however, may be a sign of disproportion. Asyncli-
tism is often associated with OT and OP positions. Ultrasound
(transabdominal and transperineal) has been advocated as a
more objective tool to support and validate the clinical diagnosis
of asynclitism in labour.
Signs of obstructed labour
If the presenting part is too large for the pelvis, arrest of labour
can occur. It is very important to be vigilant for signs of
obstructed labour and perform a timely operative delivery to
avoid adverse maternal or neonatal outcomes. The partogram is
a useful tool to monitor the progress of labour, and helps detect
an abnormal labour pattern before signs of obstruction appear.
Obstructed labour is characterized by signs such as arrest of
cervical dilatation/descent of fetal head, an oedematous poorly
applied cervix, increasing caput and moulding, formation of a
Bandl’s ring which may be visible or palpable per abdomen.
Excessive ‘Caput’ (soft tissue swelling of fetal scalp) and
‘Moulding’ (overriding of fetal skull bones) on vaginal exami-
nation may also suggest the possibility of obstructed labour due
to cephalopelvic disproportion. In case of a brow presentation,
the orbital ridges and sinciput will form the prominent findings,
while in case of face presentation, great care should be taken to
avoid damaging the orbits which may be felt along with nose,
mouth and malar bones. The degree of moulding is expressed as
1þ (apposition of the parietal bones at the suture but no
overlap), 2þ (overlap of parietal bones but reducible with
gentle pressure) or 3þ (overlap of bones with difficulty in
reducing with gentle pressure). The mother will be exhausted
and show signs of dehydration such as tachycardia, pyrexia and
oliguria. While in a nulliparous woman, obstruction may be
followed by uterine inertia (weak or no contractions), in
multiparous women violent uterine contractions can lead to
uterine rupture.
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 REVIEW

Mechanisms of normal labour

1. Engagement 2. Descent

3. Flexion 4. Internal rotation

5. Extension 6. External rotation

7. Expulsion

Figure 5

Obstetric outcomes associated with malpositions or 5.Primary dysfunctional labour/dystocia (slow progress)
malpresentations of the fetal head 6.Secondary arrest of cervical dilatation in labour
7.Prolonged second stage of labour
Fetal malpositions or malpresentations are associated with the
8.Obstructed labour with higher incidence of uterine rupture
following -
9.Operative interventions either in the form of instrumental
1. Prolonged pregnancy
delivery or caesarean section depending upon the stage of
2. Pre-labour rupture of membranes or rupture of membranes
labour and findings on clinical examination
early in labour
10. Increased incidence of trauma to the genital tract
3. Cord presentation or prolapse
11. Increased incidence of postpartum haemorrhage and puer-
4. Prolonged latent phase of labour
peral infection

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Please cite this article in press as: Sinha S, et al., Malpositions and malpresentations of the fetal head, Obstetrics, Gynaecology and Reproductive
Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.01.001
 REVIEW

Fetal head presentations, attitudes and anteroposterior Anterior and posterior asynclitism
diameters (Transverse diameter is the biparietal L9.5
cm) a Anterior parietal b Posterior parietal
bone presentation bone presentation
Presentation Attitude Anteroposterior Length
diameter PS PS

Vertex Flexed Vertex Sub 9.5 cm

occipitobregmatic
Vertex Semi-deflexed Sub occipitofrontal 10.5
vertex cm
Vertex Deflexed Occipitofrontal 11.5
(Occipitoposterior vertex cm
position)
Brow Semi- Mentovrtical 13 cm
extended S S
Face Extended Submentobregmatic 9.5 cm
PS, pubic symphysis; S, sacrum
Table 1

Figure 7
The presenting anteroposterior diameters
associated with different presentations of fetal head OP position therefore occurs in approximately 5e10% of vertex
deliveries. This is the most common malposition of the fetal
head. The OP position is associated with a prolonged labour,
increased use of oxytocin, epidural analgesia, and a higher
incidence of operative deliveries as well as third or fourth degree
perineal tears.
a d
Causes
1. Android or anthropoid type pelvis are more likely to result in
b an OP position due to narrow fore-pelvis
2. Use of intrapartum epidural analgesia (relaxation of the
pelvic floor muscles)
Weak uterine contractions and a relaxed pelvic floor may
c contribute to the failure of the occiput to rotate anteriorly.

Mechanism of labour
Unlike the OA position where the head is well flexed and pre-
sents the smallest suboccipitobregmatic (9.5 cm) diameter to the
pelvis, in OP positions the fetal head is deflexed and hence pre-
sents a larger anteroposterior (occipitofrontal - 11.5 cm) diameter
to the maternal pelvis. OP positions may be subclassified into
(a) Suboccipitobregmatic – 9.5 cm (vertex);
(b) Occipitofrontal – 11.5 cm (occipitoposterior); right OP, left OP or direct OP (Figure 8). ROP position is more
(c) Mentovertical – 13 cm (brow); and common than LOP because the left oblique diameter is reduced
(d) Submentobregmatic – 9.5 cm (face).
by the presence of sigmoid colon. In almost 90% cases with OP
position at onset of labour, the deflexion is corrected and com-
Figure 6 plete flexion occurs. The occiput meets the pelvic floor first and a
long anterior rotation of 3/8 circle occurs, bringing the occiput
anteriorly and the fetus is delivered normally. In about 5% cases,
12. Increased incidence of perinatal morbidity and mortality
either the occiput rotates 1/8 circle anteriorly and the head is
arrested in the transverse diameter (deep transverse arrest), or
Occipitoposterior position (OP)
alternatively the occiput and sinciput meet the pelvic floor
Usually (in four out of five cases), when the fetal head engages simultaneously, no internal rotation happens and the head per-
into maternal pelvis, the occiput lies laterally and then undergoes sists in the oblique diameter as persistent OP.
rotation anteriorly during labour. An OP position is thus present In the remaining 5%, the sinciput meets the pelvic floor first,
in only about 20% of fetuses in the early stages of labour. rotates 1/8 circle anteriorly and the occiput becomes direct
Moreover, even in these cases, most fetal heads undergo further posterior leading to face to pubis delivery. In such direct OP
spontaneous rotation to OA by the time of delivery. A persistent situations, the head can be delivered by flexion if the uterine

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 REVIEW
Occipitoposterior positions
a Right occipitoposterior b Left occipitoposterior
PS
S S
PS, pubic symphysis; S, sacrum
Figure 8
contractions are strong and there is no contracted pelvis. How-
ever, perineal lacerations are more likely to occur.
Diagnosis
Inspection of abdomen may reveal flattening below the level of
umbilicus. On palpation, limbs are easily felt anteriorly and it is
difficult to palpate the fetal back. The anterior shoulder is
palpated at some distance from the midline. The prominences of
sinciput and occiput can both be felt at the same level above the
pubic symphysis suggesting deflexion. Fetal heart sounds are
often heard in the flank away from the midline. Vaginal exami-
nation reveals the anterior fontanelle anteriorly and the posterior
fontanelle near the sacrum.
Prevention
A Cochrane review assessed the effects of adopting a hands and
knees maternal posture in late pregnancy or during labour, as
compared with no intervention, when the presenting part of the
fetus was in a lateral or posterior position. Three trials (2794
women) were included. The authors reported that the use of
hands and knees position for 10 minutes twice daily to correct OP
position of the fetus in late pregnancy could not be recommended
as an intervention. However, the use of position in labour was
associated with reduced backache.
Management
As many OP positions will spontaneously undergo rotation to OA
during the course of labour, if an OP position is diagnosed in
labour, an expectant management is recommended. Close watch
on progress of labour and fetal monitoring is required in view of
possibility of prolonged labour. Oxytocin should be used to
maintain good uterine activity (3e4 contractions every 10 mi-
nutes lasing more than 45 seconds). Previous studies have
shown that active management of labour with oxytocin
augmentation does help rotation to the OA position.
The mother may get the urge to push before full dilatation but
this must be discouraged. Delivery can occur spontaneously in
OP positions, but if instrumental delivery is required, careful
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c Direct occipitoposterior
PS PS
S
abdominal and vaginal examinations are needed to establish
whether this is safe and appropriate (Figure 9). In difficult cases,
use of ultrasonography to confirm position as well as senior help
should be sought. If instrumental delivery is appropriate, the
delivery can be assisted by either rotating to the OA position or
delivering in the OP position. A rotational delivery can be ach-
ieved manually or using an instrument. A manual rotation in-
volves flexing the fetal head to allow the rotation followed by a
traction delivery (using forceps or ventouse). A rotational
instrumental delivery is most commonly attempted using vac-
uum extraction which brings about autorotation of the vertex
with the descent. The vacuum cup should be placed over the
flexion point of the vertex (3 cm anterior to the posterior fonta-
nelle in the midline over the sagittal suture) and traction applied
along the pelvic axis synchronous with the uterine contractions
and maternal bearing down efforts. Kielland’s forceps can ach-
ieve rotation before traction and delivery but they should only be
used by those with adequate training and experience in the use of
rotational forceps. Non-rotational forceps can be used for delib-
erate delivery in the OP position when the head is very low but it
should be remembered that there is a higher likelihood of sig-
nificant perineal trauma with such deliveries. Caesarean section
delivery may be needed either in the first stage of labour for
failure to progress or cardiotocographic abnormalities, or in
second stage if vaginal delivery is deemed difficult. To avoid
difficulty in delivery at caesarean, the fetal head should be flexed
and rotated before delivering with the occiput facing anterior.
Role of ultrasound assessment of the fetal head position at
instrumental delivery
The role of ultrasound to assess fetal head position in the second
stage of labour and prior to conducting an operative vaginal
delivery has been investigated. While clinical determination of
fetal head position is subjective, ultrasonographic determination
of the fetal occiput position has better accuracy and reproduc-
ibility. The technique involves placing the ultrasound probe
horizontally on the maternal abdomen to obtain a transverse
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Face to pubis delivery with forceps

Figure 9

view of the fetal trunk at the level of the fetal upper abdomen.
The position of the fetal spine is then determined. The ultrasound
transducer is then moved downwards until the maternal supra-
pubic region is reached, visualising the fetal head. The land-
marks depicting fetal occiput position are the midline cerebral
echo, fetal thalami and cerebellum for OT and OA positions; and
the fetal orbits for OP position. The orbits will be directly under
the symphysis in the case of direct OP position, toward the upper
portion of the right inferior ramus of the pubis in left OP position,
and toward the upper portion of the left inferior ramus of the
pubis in right OP position.
Although the current evidence to recommend routine use of
ultrasound to determine fetal head position prior to operative
vaginal delivery is limited, it is reasonable to recommend that
ultrasound should be utilized if suitable equipment as well as
expertize is available and there is no urgency to deliver the fetus
(such as acute fetal or maternal compromise). A multicentre
randomized controlled study determined whether the use of
ultrasound can reduce the incidence of incorrect diagnosis of the
fetal head position at instrumental delivery and subsequent
morbidity in comparison to standard care. A cohort of 514
nulliparous women at term (37 weeks of gestation) with
singleton cephalic pregnancies, aiming to deliver vaginally,
were recruited prior to an induction of labour or in early labour.
The incidence of incorrect diagnosis was significantly lower in
the ultrasound group than the standard care group (4/257,
1.6%, versus 52/257, 20.2%; odds ratio 0.06; 95% confidence
interval 0.02e0.19; P < 0.001). The decision to delivery interval
was similar in both groups. The incidences of maternal and
neonatal complications, failed instrumental delivery and
caesarean section were not significantly different between the
two groups.
Occipitotransverse position (OT)
Occipitotransverse position will arise when the fetal head fails to
rotate to an OA position and remains in a transverse position.
The head initially may engage correctly but fails to rotate and
remains in a transverse position. Asynclitism is associated with
this malposition. A persistant OT position can cause either
obstructed labour in the first stage or a ‘deep transverse arrest’ in
the second stage of labour. If the second stage is reached and the
head is below the level of ischial spines, the fetal head can be
manually rotated or an instrumental rotational delivery using
either the vacuum or Kielland’s forceps is possible. This may be
inappropriate if there is any concern about fetal compromise.
Any trial of forceps should be performed in theatre and there
must be immediate provision for a failure of forceps delivery to
be converted to a Caesarean section.
Face presentation
The incidence of face presentation is reported to be between 1 in
500 and 1 in 1000 deliveries. A face presentation is a result of
complete extension of the fetal head and may start as an OP
position that extends further either before labour or as labour
progresses. Most face presentations are therefore secondary and
become evident in established labour. During labour, some of the
cases of face presentation will flex while the others will persist as
face. Although vaginal delivery is feasible in many cases,
Caesarean delivery is very common once a face presentation is
diagnosed during labour.
Causes
1. Tumours of the fetal neck eg. goitre or cystic hygroma
2. Anencephaly

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3. Loops of cord around the neck
4. Uterine abnormalities
5. Prematurity
6. Cephalopelvic disproportion
7. Fetal musculoskeletal abnormalities
8. Multiparity
9. Multiple pregnancy
Mechanism
The mentum (chin) is the denominator and the presenting
diameter is submentobregmatic (9.5 cm). Most face pre-
sentations are chin anterior (mentoanterior) in the maternal
pelvis and in such cases spontaneous/assisted vaginal delivery
can occur with the fetal head being born by flexion of the neck in
60e90% cases. Mentoposterior faces rotate to anterior sponta-
neously in 45% of cases but a persistent mentoposterior position
will not allow delivery of the skull under the pubic symphysis
and will necessitate a Caesarean section.
Diagnosis
A face presentation is usually diagnosed during labour. On
abdominal palpation, a large amount of head may be palpable on
the same side as the back without a cephalic prominence on the
same side as the limbs and, in some women, a sharp angulation
may be felt between the fetal occiput and back. The abdominal
examination findings alone are not reliable for making diagnosis,
and confirmation must be done by vaginal examination when the
orbits, nose, mouth and malar bones are palpable. The fetal
mouth sucking on the examiner’s finger is a classical sign! It is
important to distinguish face from breech presentations by
remembering that the malar prominences and mouth form a
triangle, whereas the ischial tuberosities and the anus form a
straight line.
Management
Malpresentations of fetal head such as face or brow are infre-
quently encountered and much of the practice recommendations
are derived from clinical experience and consensus of expert
opinion. When a face presentation is diagnosed during labour,
the woman should be informed of the findings. She should be
made aware that there may be facial swelling and bruising noted
in the baby soon after delivery, however, this is likely to resolve
without any permanent damage over the next few days. Regular
abdominal and gentle vaginal examinations should be under-
taken to monitor progress while avoiding injury to fetal orbits/
face. If progress is good and the position is mentoanterior (or
rotating round to mentoanterior) then vaginal delivery can be
anticipated. If progress is slow or arrests, or if the position re-
mains mentoposterior, a Caesarean section is indicated. Fetal
blood sampling, use of a fetal scalp electrode and ventouse de-
livery are contraindicated with a face presentation. If the baby
delivers vaginally, the fetal chin descends down the symphysis
pubis and the delivery of the head is completed by flexion of the
fetal neck bringing the occiput out last, and causing considerable
posterior perineal distension. In second stage with failure to
progress, a forceps delivery is possible although usually confined
to non-rotational forceps when the mentum is anterior and head
is low. It is vital to confirm before application of forceps that no
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head is palpable per abdomen as the vaginal findings can be
misleading (because the chin is in the pelvis and the occiput lies
posteriorly). It is important to remember that ‘the head is always
higher than you think’ and if the sacral hollow feels empty then
forceps should not be applied as the occiput must still be in the
abdomen. The biparietal diameter is usually approximately 7 cm
behind the advancing face so consequently, even when the face
is distending the vulva, the biparietal diameter has only just
entered the pelvis.
Even with favourable mentolateral or mentoanterior position,
if there is failure to progress, the safer option for the fetus is
caesarean section in the first stage. At Caesarean section, care
should be taken with delivery of the fetal head to avoid exten-
sions of the uterine incision.
Brow presentation
The incidence of brow is between 1 in 700 and 1 in 1500
deliveries.
Causes
1. Cephalopelvic disproportion
2. Prematurity
In brow presentations, the head is deflexed and presents to the
pelvis with the largest anteroposterior diameter. Many brow
presentations in early labour are transient, proceeding to com-
plete extension (face) or flexion (vertex) as labour progresses.
Mechanism
The fetal head stays between full extension and full flexion so
that the biggest diameter (the mentovertical - 13 cm) presents.
Vaginal delivery is not possible in an adequately grown term
baby. Spontaneous conversion to either vertex or face presenta-
tion by flexion or further extension, respectively, may occur with
advancing labour especially if the fetus is small.
Diagnosis
Brow presentations are usually only diagnosed once labour is
well established. Although on abdominal examination much of
the fetal head may be palpable, this finding alone is not reliable
for making a diagnosis. On vaginal examination, the head has
not descended below the ischial spines and the root of the nose,
supraorbital ridges and anterior fontanelle are palpable.
Management
The brow discovered in early labour may flex or extend, and
early recourse to Caesarean section on this finding alone should
be avoided. One should remain alert to the signs of obstructed
labour, preparations should be undertaken for Caesarean section,
and time allowed to see whether flexion or extension takes place.
Unless the head flexes, a vaginal delivery is not possible, and a
Caesarean section is required. Failure to progress in the next few
hours in labour with persistent brow is an indication for a
Caesarean section. In extreme prematurity, the fetus may
descend as a brow and deliver as a brow or may convert to a face
or vertex after it reaches the pelvic floor. Care is required when
undertaking Caesarean section to avoid extensions to the uterine
incision. The aim should be to flex the head with the delivering
hand before delivering it from the wound. A
8 ! 2018 Elsevier Ltd. All rights reserved.
 REVIEW
Practice points
C Although OP position is relatively common in early labour (10e
30%), the fetal head undergoes spontaneous anterior rotation in
most cases as labour advances. A persistent OP position is more
likely to be associated with delay/arrest of labour progress.
C Delivery can occur spontaneously in OP positions, however, if
instrumental delivery is required, careful abdominal and vaginal
examinations are needed to establish whether this is safe and
appropriate.
C Progressive deflexion of the fetal head can result in brow or face
malpresentations.
C Most face presentations are secondary and become evident in
established labour. During labour, some of the cases of face
presentation will flex while the others will persist as face.
Although vaginal delivery is feasible, Caesarean delivery is very
common once a face presentation is diagnosed during labour.
C The brow discovered in early labour may flex or extend, and early
recourse to Caesarean section on this finding alone should be
avoided. Failure to progress in the next few hours in labour with
persistent brow is an indication for a Caesarean section.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE --:-
Please cite this article in press as: Sinha S, et al., Malpositions and malpresentations of the fetal head, Obstetrics, Gynaecology and Reproductive
Medicine (2018), https://doi.org/10.1016/j.ogrm.2018.01.001
FURTHER READING
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9 ! 2018 Elsevier Ltd. All rights reserved.