Malposition of the fetus is a major cause of dystocia and a frequent indication for obstetric intervention during labor. Among these abnormalities, persistent occiput posterior position is the most common, occurring in approximately 5.2% of deliveries. Breech presentation is observed in approximately 3.1% of cases, while transverse lie is less frequent, with an incidence of approximately 0.12% (1). Face presentation is the rarest form, occurring in only 0.014% of deliveries (2). Face presentation refers to a fetal position in which the face, from the forehead to the chin, constitutes the presenting part during descent through the birth canal. This condition is characterized by marked hyperextension of the fetal head, such that the occiput may lie near the fetal back. Face presentation is classified into mentum anterior, mentum posterior, and mentum transverse. Among these, approximately three-quarters of mentum anterior cases may be considered for vaginal delivery, whereas mentum posterior presentation most often requires cesarean delivery (3, 4).

The primary method for the clinical diagnosis of a face presentation is a vaginal digital examination. A definitive diagnosis is achieved by palpating facial cranial landmarks—such as the orbital ridges, orbits, nasal bridge, oral fissure, and chin—during the first or second stage of labor. Ultrasonography serves as a valuable adjunct or alternative modality for confirmation (5, 6). Sonographic findings typically include hyperextension of the fetal cervical spine, an S-shaped spinal curvature, and an occipitocervical angle of less than 90° (1, 7, 8). However, pelvic bone shadows and soft tissue artifacts limit the quantitative accuracy of ultrasonography. Furthermore, the scarcity of cases restricts clinicians’ palpation experience, while continuous fetal movement further complicates diagnosis. Consequently, the rate of missed and misdiagnosed cases remains high, with approximately 44.4% confirmed only during cesarean delivery, underscoring the considerable diagnostic challenge of this condition (2).

Established risk factors for face presentation include fetal anomalies (e.g., anencephaly), multiparity, and polyhydramnios. Additionally, any condition that impedes fetal head flexion or promotes neck extension—such as multiple nuchal cord loops, cephalopelvic disproportion, or pelvic contracture—can increase the risk of face presentation (9). Improper management of face presentation can result in serious maternal and fetal complications, including uterine rupture, severe perineal lacerations, fetal spinal injury, and neonatal mortality (2, 10), posing significant challenges for obstetricians. Data indicate that 89% of clinicians prefer cesarean delivery in such cases, a rate approximately three times higher than that for vertex presentations (2, 11). This preference is partly due to the complexity of face presentations—often accompanied by prolonged labor and altered fetal heart rate patterns—and more critically due to limited experience and confidence among obstetricians in managing this rare condition (11). Current research primarily focuses on the incidence, risk factors, and adverse maternal and neonatal outcomes associated with face presentation (2, 11–13). However, studies on the rapid diagnosis of sudden face presentations, intrapartum management, and multidisciplinary coordination remain scarce, despite their substantial clinical relevance. The multidisciplinary team (MDT) is an effective medical model that integrates the advantages of multiple clinical specialists for the comprehensive diagnosis and treatment of diseases (14).

The vaginal dilator is a widely used medical device in obstetrics and gynecology, with well-documented applications in the management of vaginismus, post-pelvic radiotherapy care, and postoperative rehabilitation (15–17). Based on their material composition, vaginal dilators are classified into three categories: silicone, plastic, and metal. Silicone dilators, valued for their pliable texture and high biocompatibility, are primarily employed in functional dilation therapy for vaginismus and in the prevention and treatment of vaginal stenosis following pelvic radiotherapy. Plastic dilators, often designed as disposable specula, are intended mainly for diagnostic examination rather than for therapeutic vaginal dilation (Figure 1). At present, metal dilators are rarely used because of their substantial weight, high thermal conductivity, and the need for repeated sterilization. Although characterized by simplicity, cost-effectiveness, and non-invasiveness, the vaginal dilator has seldom been reported in the context of diagnosing face presentation.

This report presents a case of a term pregnant woman who developed a sudden face presentation at the end of the first stage of labor and subsequently underwent successful vaginal delivery, with the aim of informing clinical practice and encouraging further research on managing this uncommon fetal presentation.

Factors that impede fetal head flexion, such as multiparity and fetal malposition, are established risks for face presentation (9, 19, 20). In this case, the patient’s multiparity and the initial right occiput posterior (ROP) position likely predisposed the fetus to incomplete flexion. We propose that the subsequent spontaneous rupture of membranes and rapid fetal descent from station −3 to 0 precipitated acute hyperextension of the fetal cervical spine, leading to the face presentation.

The mechanism of face presentation differs substantially from that of vertex delivery. In a face presentation, the fetal head extends and descends using the lever formed between the foramen magnum and occiput. Upon encountering pelvic resistance, the fetal head hyperextends—bringing the occiput posteriorly and the chin anteriorly—thus allowing descent with the face as the presenting part (Figure 4). The delivery mechanism in face presentation involves descent with the head in extension, which engages a larger and less malleable diameter than in vertex presentation. This can prolong labor and increase the risk of both maternal and fetal complications. Potential adverse outcomes include severe perineal lacerations, fetal distress, and, in cases of excessive hyperextension, fetal spinal cord injury (10, 21–23). These risks underscore the need for timely and accurate diagnosis (see Table 1).

Digital vaginal examination is the standard for diagnosing face presentation, but its accuracy is limited by operator experience and can be confounded by caput succedaneum, as observed in this case, where two examinations were inconclusive. While intrapartum ultrasound is a reliable alternative, it may not be immediately available, potentially delaying management (6). We employed a sterile vaginal dilator for direct visualization of the presenting part. This allowed for definitive identification of facial landmarks and confirmation of a left mentum anterior (LMA) position in under 1 min, demonstrating a practical method for rapid diagnosis when palpation is uncertain.

The use of a vaginal dilator for diagnosis is a simple technique that requires minimal equipment and may be particularly useful in settings where immediate ultrasound is unavailable. Its utility is likely greatest in the late first or second stage of labor when the cervix is sufficiently dilated and the presenting part is engaged. Certain limitations exist during early labor—if cervical dilation is inadequate or the fetal station is high, speculum examination may become technically difficult and less reliable. Following diagnosis, our institutional protocol for obstetric emergencies was activated, ensuring that anesthesia, neonatology, and operating room staff were on standby for a potential emergency cesarean delivery. This multidisciplinary readiness is a key component of safe management for high-risk intrapartum events.

During the second stage, the “bimanual guidance method” was used to control delivery of the head. This technique, involving one hand on the fetal chin and occiput to moderate extension and the other supporting the perineum, is intended to prevent rapid, uncontrolled delivery and potential spinal hyperextension. An episiotomy was performed to reduce perineal resistance as the head crowned. The neonate exhibited normal limb movement without significant facial edema or ecchymosis (Figure 4), and no complications were noted at the 47-day follow-up.

Effective communication and a coordinated team response were noted by the patient as important factors in alleviating her anxiety during this unexpected event, reinforcing the value of a patient-centered approach during obstetric emergencies. As an expression of gratitude, she presented the team with a banner of appreciation.

This case report describes the successful vaginal delivery of a term fetus in a face presentation that was diagnosed intrapartum using direct visualization with a vaginal dilator. This technique proved to be a rapid and effective adjunct when digital examination was inconclusive. We also describe a bimanual guidance method for fetal spinal protection during delivery.

While the outcomes were favorable, this report is limited to a single case. The efficacy and safety of these techniques, particularly the use of a vaginal dilator for diagnosis, require evaluation in larger studies to determine their role in the management of face presentation.