Cephalic presentation

A cephalic presentation or head presentation or

head-first presentation is a situation at childbirth Cephalic presentation
where the fetus is in a longitudinal lie and the head
enters the pelvis first; the most common form of
cephalic presentation is the vertex presentation, where
the occiput is the leading part (the part that first enters
the birth canal).[1] All other presentations are abnormal
(malpresentations) and are either more difficult to
deliver or not deliverable by natural means.

Contents
Engagement
Classification
Vertex presentation
Face presentation
Brow presentation
Oskie presentation
Reasons for predominance
Diagnosis
Management
References
External links

Engagement Vertex presentation, occiput anterior, William

Smellie, 1792
The movement of the fetus to cephalic presentation is
called head engagement. It occurs in the third trimester. Specialty Obstetrics
In head engagement, the fetal head descends into the
pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are
further flattened and the head may be felt vaginally.[2] Head engagement is known colloquially as the baby
drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and
renewed ease in breathing. However, it severely reduces bladder capacity resulting in a need to void more
frequently.[3]

Classification
In the vertex presentation the head is flexed and the occiput leads the way. This is the most common
configuration and seen at term in 95% of singletons.[1] If the head is extended, the face becomes the leading
part. Face presentations account for less than 1% of presentations at term. In the sinicipital presentation the
large fontanelle is the presenting part; with further labor the head will either flex or extend more so that in
the end this presentation leads to a vertex or face presentation.[1] In the brow presentation the head is
slightly extended, but less than in the face presentation. The chin presentation is a variant of the face
presentation with maximum extension of the head.

Non-cephalic presentations are the breech presentation (3.5%) and the shoulder presentation (0.5%).[1]

Vertex presentation

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture,
posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the
parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the
pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged, and more
operative interventions are deemed necessary.[4] The prevalence of the persistent occiput posterior is given
as 4.7%.[4]

The vertex presentations are further classified according to the position of the occiput, both right, left, or
transverse and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT)

Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse
(ROT)

Straight occipito-
Right occipito-anterior Left occipito-anterior
anterior

Right occipito-
Left occipito-transverse
transverse
 Right occipito-posterior Straight occipito- Left occipito-posterior
posterior

The Occipito-Anterior position is ideal for birth; it means that the baby is lined up so as to fit through the
pelvis as easily as possible. The baby is head down, facing the spine, with its back anterior. In this position,
the baby's chin is tucked onto its chest, so that the smallest part of its head will be applied to the cervix first.
The position is usually "Left Occiput Anterior", or LOA. Occasionally, the baby may be "Right Occiput
Anterior", or ROA.[5]

Face presentation

Factors that predispose to face presentation are prematurity, macrosomia,

anencephaly and other malformations, cephalopelvic disproportion, and
polyhydramnios.[6][7] In an uncomplicated face presentation duration of labor
is not altered. Perinatal losses with face presentation occur with traumatic
version and extraction and midforceps procedures[7] Duff indicates that the
prevalence of face presentations is about 1/500–600.,[7] while Benedetti et al.
found it to be 1/1,250 term deliveries.[8]

Face presentations are classified according to the position of the chin

(mentum):

Left Mento-Anterior (LMA), Left Mento-Posterior (LMP), Left Mento-

Transverse (LMT)
Right Mento-Anterior (RMA), Right Mento-Posterior (RMP), Right
Mento-Transverse (RMT) A mento-posterior face
presentation, William
Smellie, 1792
Brow presentation

While some consider the brow presentation as an intermediate stage towards the face presentation,[1] others
disagree. Thus Bhal et al. indicated that both conditions are about equally common (1/994 face and 1/755
brow positions), and that prematurity was more common with face while postmaturity was more common
with brow positions.[9]

Oskie presentation

The Oskie presentation is similar to the Occipito-Anterior position, where the baby is head down, facing
the spine, with back on the ventral side of the uterus; however, in this position, while the torso is aligned
with the mother's longitudinal axis, the legs of the fetus are extended straight along the frontal axis of the
mother, as if the baby is creating a right angle with its body. For the Oskie position to occur the baby's head
must be far down the pelvis in order to allow room for leg extension, typically the arms are bent, tucked
against the baby's body. There are no known complications for labor and delivery. This presentation is rare
and is not well researched.

Reasons for predominance

The piriform (pear-shaped) morphology of the uterus has been given as the major cause for the finding that
most singletons favor the cephalic presentation at term.[1] The fundus is larger and thus a fetus will adapt its
position so that the bulkier and more movable podalic pole makes use of it, while the head moves to the
opposite site. Factors that influence this positioning include the gestational age (earlier in gestation breech
presentations are more common as the head is relatively bigger), size of the head, malformations, amount of
amniotic fluid, presence of multiple gestations, presence of tumors, and others.

Two-thirds of all vertex presentations are LOA, possibly because of the asymmetry created by the
descending colon that is on the left side of the pelvis.

Diagnosis
Usually performing the Leopold maneuvers will demonstrate the presentation and possibly the position of
the fetus.[10] Ultrasound examination delivers the precise diagnosis and may indicate possible causes of a
malpresentation. On vaginal examination, the leading part of the fetus becomes identifiable after the
amniotic sac has been broken and the head is descending in the pelvis.

Management
Many factors determine the optimal way to deliver a baby. A vertex presentation is the ideal situation for a
vaginal birth, although occiput posterior positions tend to proceed more slowly, often requiring intervention
in the form of forceps, vacuum extraction, or Cesarean section.[4] In a large study, a majority of brow
presentations were delivered by Cesarean section, however, because of 'postmaturity', factors other than
labour dynamics may have played a role.[9] Most face presentations can be delivered vaginally as long as
the chin is anterior; there is no increase in fetal or maternal mortality.[11] Mento-posterior positions cannot
be delivered vaginally in most cases (unless rotated) and are candidates for Cesarean section in
contemporary management.[11]

References
1. Hellman LM, Pritchard JA. Williams Obstetrics, 14th edition. Appleton-Century-Crofts (1971)
Library of Congress Catalogue Card Number 73-133179. pp. 322–2.
2. "Starting labour" (http://www.pregnancy-bliss.co.uk/headengagement.html). pregnancy-
bliss.co.uk. Retrieved 14 January 2009.
3. "Lightening During Pregnancy as an Early Sign of Labor" (http://www.givingbirthnaturally.co
m/lightening-during-pregnancy.html). Giving Birth Naturally. Retrieved 22 August 2010.
4. Gardberg M, Tuppurainen M (1994). "Persitent occiput posterior presentation — a clinical
problem". Acta Obstet Gynecol Scand. 198 (4): 117–9. PMID 7975796 (https://pubmed.ncbi.
nlm.nih.gov/7975796).
5. "Optimum Foetal Positioning" (http://www.homebirth.org.uk/ofp.htm). Homebirth.org.
 6. Bashiri A, Burstein E, Bar-David J, Levy A, Mazor M (2008). "Face and brow presentation:
independent risk factors". J Matern Fetal Neonatal Med. 21 (6): 357–60.
doi:10.1080/14767050802037647 (https://doi.org/10.1080%2F14767050802037647).
PMID 18570114 (https://pubmed.ncbi.nlm.nih.gov/18570114). S2CID 6986584 (https://api.se
manticscholar.org/CorpusID:6986584).
7. Duff, P (1981). "Diagnosis and Management of Face Presentation". Obstet Gynecol. 57 (1):
105–12. PMID 7005774 (https://pubmed.ncbi.nlm.nih.gov/7005774).
8. Benedetti TJ, Lowensohn RL, Tuscott AM (1980). "Face Presentation at Term". Obstet
Gynecol. 55 (2): 199–202. PMID 7352081 (https://pubmed.ncbi.nlm.nih.gov/7352081).
9. Bhal PS, Davies NJ, Chung T (1998). "A population study of face and brow presentation". J
Obstet Gynaecol. 18 (3): 231–5. doi:10.1080/01443619867371 (https://doi.org/10.1080%2F0
1443619867371). PMID 15512065 (https://pubmed.ncbi.nlm.nih.gov/15512065).
10. Lydon-Rochelle M, Albers L, Gotwocia J, Craig E, Qualls C (September 1993). "Accuracy of
Leopold Maneuvrers in Screening for Malpresentation: A Prospective Study". Birth. 20 (3):
132–5. doi:10.1111/j.1523-536X.1993.tb00437.x (https://doi.org/10.1111%2Fj.1523-536X.19
93.tb00437.x). PMID 8240620 (https://pubmed.ncbi.nlm.nih.gov/8240620).
11. Ducarme G, Ceccaldi PF, Chesnoy V, Robinet G, Gabriel R (2006). "Face presentation:
retrospective study of 32 cases at term". Gynecol Obstet Fertil. 34 (5): 393–6.
doi:10.1016/j.gyobfe.2005.07.042 (https://doi.org/10.1016%2Fj.gyobfe.2005.07.042).
PMID 16630740 (https://pubmed.ncbi.nlm.nih.gov/16630740).

External links
Classification ICD-10: O80.0 (ht D
tps://icd.who.int/bro
wse10/2019/en#/O
80.0) · ICD-9-CM:
650 (http://www.icd
9data.com/getICD9
Code.ashx?icd9=6
50) · DiseasesDB:
1631 (http://www.di
seasesdatabase.co
m/ddb1631.htm)

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