Clinical notes

Summary is the presenting part. Because its occurrence A relatively simple osteopathic manipulative is rare (Obstetrical Statistical Cooperative technique for diagnosis and treatment of pa- gives a rate of 0.2 percent% the obstetrician tients with heart disease has been detailed. or general practitioner must rely on the large Responses of patients with varied types of volume of literature and clinical reports for cardiopathy have been cited and seem to war- guidance in management, rather than draw rant continued trials. upon his own experience with this malpresen- The observation that one specific area, the tation. The following report presents a case second thoracic vertebra and associated second and summarizes the etiology, diagnosis, man- rib on the left, has been the center of approach agement, and prognosis of face presentation. differs, but not too importantly, from the ob- servations of other authors. That the influence Report of case of treatment to this area is extended above and A gravida 3, para 2-0-0-2, Caucasian woman, below to other segments is well understood. age 23, was sent to the hospital in active labor. The diagnostic value of the tactile sense in Vaginal examination at the attending physi- attempts at early recognition of potential vic- cians office suggested a face presentation at tims of coronary disease has been discussed. delivery. Upon admission, a radiologic flat The study and maintenance of structural plate of the abdomen verified the face presen- integrity in treatment, not only of cardiopath- tation (Fig. 1). ies, but in a broad field of medical care, are Results of laboratory work done at admis- strongly emphasized. sion are as follows: blood type B, Rh positive, he positive (D) ; leukocyte count, 12,200/cu. mm.; hemoglobin, 14.1 gm./100 ml.; hema- 1. Wilson, P.T.: Osteopathic cardiology. Yearbook of Academy tocrit level, 43.2 vol. %. of Applied Osteopathy. 1956, pp. 27-32 2. Wilson, P.T.: Osteopathic cardiology. Yearbook of Academy Vaginal examination at this time revealed of Applied Osteopathy. 1958. pp. 9-11 the at a —2 station, with the cervix 3. Daiber, W .F.: Experiences in the management of coronary dis- ease. JAOA 60:345-55. Jan 61 dilated 5 cm. Fetal heart rate was 150 beats 4. Boone, D.W.: Clinical experience in conjestive heart failure. per minute; contractions were 5 minutes apart, In Manual of cardiology, Journal Printing Company, Kirksville Mo.. 1962. (As cited in chapter 82 of Osteopathic medicine. Ed. moderate in intensity, and lasted from 30 to by J.M. Hoag. McGraw-Hill Book Co., New York, 1969) 40 seconds. The fetus was in a right mento- 6. Burns, L., Chandler, L.C., and Rice, R.W.: Pathogenesis of visceral disease following vertebral lesions. American Osteopathic transverse position. Association, Chicago, 1948 6. Koch, R.S.: A somatic component in heart disease. JAOA 60: Labor progressed satisfactorily with the pa- 735-40, May 61 tient in no acute distress. Two hours after 7. Robuck. S.V.: Osteopathic manipulative therapy in organic heart disease. Yearbook of Academy of Applied Osteopathy. 1966, admission, vaginal examination revealed the pp. 11-26 cervix dilated completely with the fetus at a 8. Wolf, A.H.: Personal communication to the author 9. Romney, I.C.: Personal communication to the author —1 station. The fetal heart rate was 140 beats 10. Gibran, K.: The prophet. Alfred A. Knopf. New York. 1923 per minute; contractions occurred every 2 to 3 minutes and lasted approximately 45 seconds. The patient was taken into the delivery room at this time and a continuous lumbar epi- dural anesthetic was given. The initial dose was 5 cc. of 1.5 percent xylocaine hydrochlor- ide solution with 1/200,000 epinephrine. At 20- Face presentation minute intervals, 10 cc. of the solution was administered until a total of 25 cc. (375 mg.) ROBERT S. LEE, D.o. had been given. Mt. Clemens, Michigan An intravenous drip of 1/1,000 dilution of A face presentation in delivery occurs when synthetic oxytocin was started in order to the head is extended, instead of flexed, as it maintain the uterine contractions. The fetus descends through the , so that the chin rotated naturally from a right mentotrans-

804/92 verse to a right mento-anterior position; a 7 presentation by abdominal examination; it lb. 21/2 oz. viable male infant was delivered should, however, be suspected if upon palpation using Tucker McLean outlet forceps extraction the cephalic prominence is felt on the side oppo- procedure (Fig. 2). The infants Apgar rating site the small parts and the small parts are un- at one minute was 9. Both mother and infant usually prominent. 3 A final diagnosis normally had uneventful hospital stays and were dis- is made by vaginal examination, usually after charged five days postpartum. the membranes have ruptured. The face may feel like a breech since the anus can be mis- Etiology taken for the mouth, particularly late in labor Face presentation occurs about three times as when the parts become disfigured. However, often in multiparas as in primigravidas. 2 Fac- the distinctive triangular position of the nose tors that favor extension or prevent flexion of and malar bones and location of the orbital the head will cause face presentation. Such ridges help differentiate a breech from a face factors include cephalopelvic disproportion presentation. (with a large body), a small premature baby X-ray examination is used to confirm (or in the presence of an adequate or large pelvis, refute) the clinical impression; it can also anencephalic infants, loops in the cord or the establish cephalopelvic disproportion or the cord around the neck of the infant, short liga- presence of an anencephalic fetus. mentum nuchae, previa, and pelvic The face frequently occupies the right tumors. oblique diameter of the pelvis, resulting in either left mento-anterior or right mentopos- Diagnosis terior positions (Fig. 3). The initial position About 50 percent of face presentations are not of the chin is posterior in about 30 percent of diagnosed until the time of delivery. It is very cases. The chin will present first if the head difficult to make a positive diagnosis of face is completely extended, since the occiput will

Fig. 1. Roentgenogram showing face presentation. Note spinal curvature of infant. Fig. 2. Face presentation de- livery.

Journal AOA/vol. 71. May 1972 805/93 Clinical notes

lie against the back of the fetus. terior; two-thirds of this group result in spon- taneous rotation; that means in only one of Management ten face presentations must persistent mentum According to Eastman and Hellman, 1 there are posterior be confronted.) (5) In the one-third six steps in managing a face presentation: (1) of cases in which the chin remains in its pos- X-ray is used to establish or elim- terior position, a cesarean section is usually inate the presence of pelvic contraction. (2) A necessary, regardless of mothers status as a cesarean section is necessary when pelvic con- primigravida or multipara and assuming the traction and disproportion exist. (3) No treat- fetus is alive. (6) If the fetus is dead, it is best ment is required if the chin is anterior and the that its skull be perforated for delivery. Figure pelvis normal either spontaneous delivery or 4 shows proper management. uncomplicated, lower forceps delivery usually Manual conversion of the face to a vertex will occur. (4) In cases where the pelvis is presentation, manual or forceps rotation of the normal and the chin is posterior, a safe vaginal posterior chin to an anterior chin presenta- delivery often occurs through spontaneous tion, and version and extraction are other al- rotation of the fetus. This rotation happens in ternatives that may merit consideration under two-thirds of all cases of posterior chin pre- certain conditions. sentations. (Approximately one-third of all During the course of labor, careful monitor- face presentations occur with the chin pos- ing of the fetal heart tones (preferably by means of a fetal electrocardiographic device) is urged. Expeditious vaginal or abdominal delivery may be resorted to if evidence of fetal distress should appear. In selecting forceps for face presentation, one must choose an instrument that will hold the fetal head securely and at the same time be suitable for rotation. The advantage of the Kjelland forceps in this procedure is the ab- sence of the pelvic curve; Kjelland forceps are the forceps of choice when rotation or traction is needed. 5 When rotation is not neces- sary, however, a classic instrument is ac- ceptable and is preferred by many.6

Conclusions Until recently, face presentations in labor have been high risk situations for both mother and child. Although the fetal mortality in this malpresentation continues to hover around 10 percent (excluding anencephalics), there are additional considerations, such as a high inci- dence of premature babies and more cases necessitating intervention than in vertex de- liveries, that affect the fetal mortality rate? In fact, if abnormal and premature babies are not included, perinatal mortality in face pre- sentations approximates the fetal mortality rate of normal vertex presentations. 5 The mother is little more at risk than in the normal Fig. 3. Common positions in face presentations. vertex presentation.

806/94 I INITIAL DIAGNOSIS I I I 1 X-ray pelvimetry 3% Previous cesarean section 1 or hysterotomy 81% Adequate pelvis 16% Inadequate pelvis

Labor Primary cesarean Elect-ve repeat section section Conversion attempt 1 1 Unsuitable for Failed Successful

...c I 4. Vaginal vertex delivery

Spontaneous Low Mid Cesarean forceps forceps section 25% Under T 91% 2500 gm. 9% None None 1 64% Average 55% 21% 3% infant I

I I c/_ Over I ° 40003m. L None 40% 10%

Fig. 4. Management of face presentation. (Adapted from Greenhill`).

Summary 1. Eastman, N.J., and Hellman, L.M.: . Ed 13. Apple- Although a face presentation occurs in only ton-Century-Crofts, New York, 1966 2. Greenhill, J.P.: Obstetrics. Ed. 13. W.B. Saunders Co., Philadel- 0.2 percent of births, it is an important part phia, 1965 of obstetric training since it is often undiag- 3. Barber, H.R., and Graber, E.A.: Quick reference to ob-gyn procedures. J.B. Lippincott Co., Philadelphia, 1969 nosed until late in labor when the help of a spe- 4. Wilson, R.J.: Management of obstetric difficulties. Ed. 6. C.V. cialist may not be available. The circumstances Mosby Co., St. Louis, 1961 5. Douglas, R.G., and Stromme, W.B.: Operative obstetrics. Ed. 2. that lead to the malpresentation (such as cepha- Appleton-Century-Crofts, New York, 1965 lopelvic disproportion of anencephalic ) 6. Laufe, L.E.: Obstetrics forceps. Harper and Row, Inc., New York, 1968 usually result in normal spontaneous delivery. 7. Donald, I.: Practical obstetric problems. Ed. 4. J.B. Lippincott Some circumstances, however, such as a con- Co., Philadelphia, 1969 Beck, A.O., and Rosenthal. A.H.: Obstetrical practice. Ed. 7.. tracted pelvis, may require a cesarean section. Williams and Wilkins Co., Baltimore. 1951 A case report of face presentation is pre- Dede, J.A.. and Friedman, E.A.: Face presentation. Amer Obstet Gynec 87:615-24, 15 Oct 63 sented and procedures for management are Willson, J.R., Beecham, C.T., and Carrington, E.R.: Obstetrics reviewed. and gynecology. Ed. 3. C.V. Mosby Co., St. Louis, 1966

Journal AOA/vol. 71, May 1972 807/95