A System of Midwifery

by Edward Rigby

Face presentations. The face, like the cranium, may present in two ways, either with its right or left side forwards. The former is the most frequent occurrence, and bears a striking analogy to the first cranial position; indeed, we cannot too strongly impress upon the minds of our readers the advantages of accurately knowing the different features of the two cranial positions just described; for by this means the positions of the face will be rendered much more simple and easy of comprehension. Whether the right or the left side of the face presents (first or second facial position,) the root of the nose crosses the os uteri exactly in the same manner as the sagittal suture does in the two cranial positions; the chin is turned to the right acetabulum, and as the face descends through the pelvis during the progress of the labour, the chin moves somewhat more forwards, as the occiput does in the cranial positions.

At an early stage of labour the right eye and zygoma is that part of the face which is lowest in the pelvis, and which the finger first touches upon during examination, precisely as it was the right parietal protuberance in the first cranial position; and as in this case the caput succedaneum was situated upon the posterior and superior quarter of the right parietal bone, so here the livid bruise-like swelling, which the face brings with it into the world, is situated upon the right cheek, this part being the first which presses through the os externum; the chin passes under the right branch of the pubic arch, as the occiput in the first cranial position does under the left, the face during the whole process preserving a strictly oblique position, both as to the transverse diameter and axis of the pelvis.[78]

Second position of the face. The second position of the face is merely the reverse of the first: it is now the left side which is turned forwards, the left eye and zygomatic process being those parts which are lowest in the pelvis; the chin is turned to the left side and somewhat forward, and advances towards the left foramen ovale during the farther progress of the labour. As the face approaches the inferior aperture of the pelvis, it is the left cheek which first enters the os externum, and upon which the swelling is situated: likewise the chin passes beneath the left branch of the pubic arch.

It has been supposed by some authors, and we think correctly that the majority (if not all) of face presentations are originally cranial presentations: if this be the case, we can easily understand why the right side of the face presents more frequently than the left, for if the head in the first cranial position moves round upon its transverse diameter, and thus allows the face to turn downwards, we shall immediately have a first position of the face. We are the more inclined to adopt this opinion, not only from the greater number of cases where the right side of the face presents, but also from our having more than once met with cases where so long as the head of the child was moveable above the brim, the presentation was midway between one of the cranium, and of the face. On one side of the pelvis we could feel the anterior fontanelle; on the other we could, with some difficulty, reach the orbital process of the frontal bone: as the pains increased, and the head advanced lower, the side of the face came more within reach; so that by the time it had fairly entered the cavity of the pelvis, it had become a complete presentation of the face.[79]

We distinguish the face by the bridge of the nose, which from its crossing the os uteri may be detected at a very early period of labour: it is far better than the eye, for not only is this liable to mislead us in our examination, but it may also receive injury from the finger. Nor is the malar bone a guide, for this might easily be mistaken for the tuberosity of the ischium, or even for the shoulder. The nose not only tells us that the face is presenting but also in which position, for at one end we shall feel the soft cushiony extremity of it, at the other we shall reach the broad hard expanse of the forehead.

It was not until nearly the end of the last century that presentations of the face ceased to be accounted unnatural, and impossible to be terminated by natural means. Although the fact had been pointed out by Portal so early as 1685, that these presentations were very little removed from the usual one, it seems to have excited but little attention until the time of Deleurye in 1770. “I have,” says Portal, “delivered several women whose children came with the face foremost, and always without any great difficulty, it being only observed, that in such cases no violence must be used, but nature be left to its own course; which done, there is no danger either of mother or child.” (Portal’s Midwifery, transl. obs. 66:) La Motte in 1721, although so accurate an observer, could not divest himself of the general opinion that these were unfavourable positions, even although the face was usually expelled by the natural efforts, after he had fruitlessly endeavoured to rectify it, and although he himself confesses never to have “seen any that had not done well.”

Giffard has recorded two cases of face presentation (Cases in Midwifery, 1734, p. 59, 443.,) both of which he delivered by his extractor, which was one of the early forms of midwifery forceps; and in both, although the labour had lasted some time, the child was alive. He describes the position of the face in the second case, the chin being turned towards the right side. The only practical observation which he makes is, that turning is very difficult where the “waters are gone off, and the uterus closely envelopes the child.” This is probably given as an explanation for his deviating from the usual practice of turning in these cases. Deleurye in supporting Portal’s views observes, “one daily sees similar labours terminate naturally: it is true they are somewhat longer, but they terminate without the aid of art.” (Traité des Accouchemens, 1770, § 736.)

Lastly, the celebrated Boer of Vienna (1793) placed the matter in a still more decided point of view when he asserted, that “face presentations being merely a rare form of natural labour, should be left to be completed by the natural efforts, since neither the mothers nor their children were exposed to any more danger in this form of labour than they were in the most usual forms of all.” Having charge of the great lying-in hospital of Vienna, Boer had ample means of ascertaining the most accurate results on all points of practical midwifery, and his observations on labours where the face presented, are, therefore, peculiarly interesting, and tend strongly to contradict the prevailing opinion respecting the difficulty and danger of these presentations.

“Of eighty cases of face presentations which have occurred during a period of some years, and which I have myself observed and noted down, there were three, or at the most four, where the children were born dead. None of the patients suffered in the slightest degree from any of these labours; and, except one case, all were left entirely to nature: in one case only, on account of the weakness of the pains and doubtful character of the symptoms, I deemed it necessary to terminate the labour by the forceps.” (Boer’s Natürliche Geburtshülfe, erstes buch, p. 137.) In spite of this valuable practical fact, supported by experience on so great a scale, the opinion that face presentations were preternatural, continued to prevail upon the Continent, being supported by the authority of Baudelocque and Osiander. A similarly unfavourable opinion was entertained by Dr. Smellie in this country, although Dr. W. Hunter, in his lectures delivered prior to the publication of his plates on the gravid uterus (and, therefore, at an early date,) states, “in this case I do not turn the head round in order to deliver, but nineteen times in twenty leave it to itself to come as it will.” (W. Hunter, MS. Lectures.)

Dr. R. W. Johnson, who dedicated his New System of Midwifery, &c. to Dr. W. Hunter and others, in 1769, and probably attended his lectures, expresses a similar opinion, and says, that in these cases “nature herself will do the work.” (p. 267.) Dr. Alexander Hamilton, in 1784, also speaks favourably of these presentations. “The head will, however, in most cases, advance in that position by the force of the natural pains, though the delivery will be more slow or painful.” (Outlines of the Theory and Practice of Midwifery.)