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Posterior & Full Face Presentation Babies

Malpresentation of Babies: Full-Face & Sunny Side Up Presentations

Labour and birth are intense events for most people and as we know, unfortunately, regardless of how prepared we are, there is always some chance of complication, no matter how small. Some of these are related to the position the baby is in when being delivered. In this article, I will be addressing two of these positions, and sharing the stories of people who have experienced them. The first of these positions, or presentations, is called a ‘full face’ presentation which is rare, while the second is known a ‘sunny side up’ presentation and is quite common. What these are, their potential risk factors and what will happen if a baby is delivered in one of them will all be covered.



What is full face presentation?

Most of the time, babies pass through the birth canal with their chin tucked in towards their chest, and headfirst. This position makes it easier for them to pass through and exit the birth canal, as it ensures the circumference of their head is as small as possible.


Full face presentation, or face presentation, is a malpresentation of the baby during labour and birth, in which the baby’s head is tilted backwards, as if they were looking up. This means that the baby passes through the birth canal face-first with their neck hyperextended. Consequently, the circumference of the head as it is birthed is larger, compared to a normally positioned baby. Full face presentations only account for 1 in 600 births, or 0.17% of birth, meaning they are a rare occurrence. The images below depict what this presentation looks like.


Image above from Cafe Mom (https://cafemom.com/parenting/205632-face_presentation_birth_photo). Diagram from Pictorial Midwifery, Comyns Berkeley, 4th Edition. 1941. Via Spinning Babies (https://www.spinningbabies.com/pregnancy-birth/baby-position/other-fetal-positions/face-presentation/)



Diagnosing full face presentation

Face presentation can occur in several ways. The baby may move into this position prior to the onset labour, or it can be moved into this presentation during labour. Often, it is diagnosed during the second stage of labour, or late in the first. This can be done by conducting a vaginal examination and confirmed using an ultrasound.


Risk factors for having full face presentation

There are several different risk factors, both for the mother and the baby, that may increase the likelihood of a birth having a face presentation. According to a study published in the Pan African Medical Journal, 60% of full-face presentation deliveries had one or of the following risk factors: multiparous women, small baby, large baby, high parity, mother having had a previous birth via caesarean section, mother having a contracted pelvis, fetopelvic disproportion, cord around the neck, hypertensive disorders of pregnancy or nuchal cord anomaly. The same study notes that the remaining 40% of face presentation deliveries had none of these risk factors.



Risks of having full face presentation birth

Births with full face presentation are more likely to end up as happening via a caesarean section – more than half. This is because vaginal birth with this presentation can only go ahead if the baby is in a certain position – the mentum anterior position, where the baby’s chin is facing the front of the mother. Additionally, because these births require more monitoring, the baby risks facial and eye injury if too many vaginal examinations occur, therefore it is advised that these exams should not be conducted repeatedly. Babies that are born are likely to suffer facial trauma and oedema, abnormally shaped head (known as skull moulding), low Apgar score, prolonged labour, spinal cord injury, abnormal foetal heart rate and foetal distress. Risk of complications is increased if medical interventions such artificial oxytocin, forceps or vacuum, or manual extraction. Caregivers should not use these interventions.



What can be done?

Attempting certain labour positions may help resolve a face presenting baby. Spinning Babies recommend the forward-leaning inversion while ‘shaking the apple tree’ during one or two contractions, to encourage the baby to tuck its chin by giving it more space in the pelvis. The position is pictured here on the left.


Image from Spinning Babies

https://www.spinningbabies.com/pregnancy-birth/baby-position/other-fetal-positions/face-presentation/


Experiences with a Full-face Presentation Birth

Here is a link to Amy’s experience having a full face presentation birth, which ended up as a caesarean section as her baby was not in the mentum anterior position:

https://www.ican-online.org/blog/2012/02/amys-birth-story-inverted-t-cesarean-for-face-presentation-out-of-hospital-vbac/


What is Sunny Side Up Presentation?

Sunny side up presentation is the colloquial name for a baby presenting in the occiput posterior position, or simply the posterior position. The difference between a sunny side up baby and a full-face presentation baby is that the baby’s spine in the sunny side up position is not hyperextended, and the baby’s back is along the mother’s spine (whereas a face presenting baby’s body can be in several different positions). Once again, like a face presenting baby, delivery can be more difficult as both positions increase the circumference of the baby’s head as it passes through the birth canal. The chance of a posterior baby at birth is significantly higher than that of having a full-face presentation, and it is the most common malposition.


The diagram on the left depicts a baby in the occiput posterior position (Credit: Johnathan Dimes for BabyCenter: https://www.babycenter.com/pregnancy/your-body/posterior-position_1454005). The photograph on the right shows a baby in the sunny side up position at birth (Credit: Kelly Bardon).


Diagnosing Sunny Side Up Presentation

A sunny side up baby can be diagnosed by your healthcare provider, most accurately done using an ultrasound. Your abdomen may also appear flat below the navel, and you may feel more of the baby’s movements.


Risk factors for having Sunny Side Up Presentation

There are several factors that can increase the odds of your baby moving into a posterior position. Avoidable risk factors include, poor posture, crossing your legs, not enough physical activity and sitting in cars or other seats with reclined backs. Unavoidable risks include being African American, maternal age being 35 or older, gestational age being 41 weeks or above, baby’s birth rate being above 4kg, artificial rupture of membranes being conducted and epidural anaesthesia.



Risks of having Sunny Side Up Presentation

There are several risks associated with having a sunny side up presentation. Some of these include having a prolonged labour, baby’s head catching on mother’s tailbone, hypoxia, and birth trauma. There is also an increased chance of requiring an emergency caesarean section, or intervention using forceps or vacuum, which in turn have their own risk. Additionally, there is a chance of prolapsed or compressed umbilical cord, birth asphyxia or brain bleed. Further, mothers are more likely to be induced or have their labour augmented, experience post-partum haemorrhage, tears, and endometritis.



What can be done?

Like with face presenting babies, sunny side up babies can also be attempted to be repositioned using labour or pre-labour positions. Some of these positions are all fours, feet apart sitting on a birth ball, sitting leaning forward

It is also important to maintain good posture during pregnancy and avoid slouching to decrease the chances of your baby moving into a less desirable position. Although more than 30% of babies may be in the sunny side up position pre-labour and at the beginning of labour, it is important to remember that most babies will move into the anterior position by the time they are born, reducing the number of babies born sunny side up to around 5%.


K’s Experience with Sunny Side Up Presentation

K has had two sunny side up babies! Her experience for her first child started off well, with labour progressing well and being bearable until she reached seven centimetres dilation at home, and then decided to go to the hospital. Unfortunately, she had a terrible experience with the midwife who worked with her, who forced her to lay in the bed and banned her from getting up as it apparently would mess with the monitors. K believes this was one of the reasons her baby was unable to readjust into a better position, and I am inclined to agree. Because of this, her labour slowed, and she struggled a lot with pain from here on. She ended up with an episiotomy, traumatic ventouse and was prepped for an emergency caesarean section in case the ventouse failed. Sadly, she and her husband assumed it was a normal experience as this was their first time having a child.


With her second baby, because K worked for the hospital, they allowed her to do a social induction. This is where a mother is allowed to induce for her convenience, or for the convenience of the caregiver/medical team. In hindsight, K says she regrets this decision greatly. She was induced at 39 weeks, using several methods, which ended up being so painful for her that she needed an epidural, and once again ended up on her back with her baby sunny side up, requiring the ventouse and episiotomy. Looking back K says knowing what she knows now, she never would have agreed to an induction.


Despite these intense and traumatic experiences, K has done 8 years of medical training after her experience, as well as doula training, and is expecting another baby in two weeks! She feels far more prepared and is planning to birth at a birth centre with a designated midwife and hoping for an intervention free and mobile labour and birth!



Conclusion

Malpresentation of babies during birth can range from quite rare to common, depending on the presentation. Though this can be a scary experience, it is important to remember that not all is lost! There are steps that can be taken during pregnancy and labour to prevent them from occurring, or to encourage the baby to move into a more desirable position.



My name is Manju Lahrech and I am a qualified doula who has trained at the Doula Training Academy. If you would like more information about my doula services please contact me:

Phone: 0415 815 246

Email: manju@padmabirthing.com

Instagram: @padmabirthing

Website: www.padmabirthing.com



References for Full Face Presentation:

https://www.spinningbabies.com/pregnancy-birth/baby-position/other-fetal-positions/face-presentation/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815474/

https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/abnormal-position-or-presentation/face-presentation/

https://www.ncbi.nlm.nih.gov/books/NBK567727/

https://casereports.bmj.com/content/2017/bcr-2016-219114

https://cafemom.com/parenting/205632-face_presentation_birth_photo

https://www.spinningbabies.com/pregnancy-birth/baby-position/other-fetal-positions/face-presentation/


References for Sunny Side Up Presentation:

https://www.healthline.com/health/pregnancy/sunny-side-up-baby#other-positions

https://www.braceability.com/blogs/articles/is-your-baby-sunny-side-up

https://www.abclawcenters.com/abc-video/posterior-position/

http://www.midwiferygroup.ca/downloads/position/Posterior%20Babies.pdf

https://www.msdmanuals.com/en-au/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus

https://www.lynnharrislaw.com/blog/2020/06/08/posterior-birth-complications-205577

https://pubmed.ncbi.nlm.nih.gov/16966125/


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