newborn face presentation

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Management of face presentation, face and lip edema in a primary healthcare facility case report, Mbengwi, Cameroon

Nzozone henry fomukong.

1 Microhealth Global Medical Centre, Mbengwi, Cameroon

2 Department of Medicine and Surgery, Faculty of Health Sciences University of Buea, Buea, Cameroon

Ngouagna Edwin

Mandeng ma linwa edgar, ngwayu claude nkfusai.

3 Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon

4 Cameroon Baptist Convention Health Services (CBCHS), Yaoundé, Cameroon

Yunga Patience Ijang

5 Department of Public Health, School of Health Sciences, Catholic University of Central Africa, Box 1110, Yaoundé, Cameroon

Joyce Shirinde

6 School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria Private Bag X323, Gezina, Pretoria, 0001, Pretoria, South Africa

Samuel Nambile Cumber

7 Institute of Medicine, Department of Public Health and Community Medicine (EPSO), University of Gothenburg, Box 414, SE - 405 30 Gothenburg, Sweden

8 Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

Face presentation is a rare obstetric event and most practitioners will go through their carriers without ever meeting one. Face presentation can be delivered vaginally only if the foetus is in the mentum anterior position. More than half of the cases of face presentation are delivered by caesarean section. Newborn infants with face presentation usually have severe facial oedema, facial bruising or ecchymosis. These syndromic facial features usually resolved within 24-48 hours.

Introduction

Face presentation is a rare unanticipated obstetric event characterized by a longitudinal lie and full extension of the foetal head on the neck with the occiput against the upper back [ 1 - 3 ]. Face presentation occurs in 0.1-0.2% of deliveries [ 3 - 5 ] but is more common in black women and in multiparous women [ 5 ]. Studies have shown that 60 per cent of face presentations have one or more of the following risk factors: small fetus, large fetus, high parity, previous caesarean section (CS), contracted pelvis, fetopelvic disproportion, cord around the neck multiple pregnancy, hypertensive disorders of pregnancy, polyhydramnios, uterine or nuchal cord anomaly. But 40 per cent of face presentations occur with none of these factors [ 6 , 7 ]. A vaginal birth at term is possible only if the fetus is in the mentum anterior position. More than half of cases of face presentation are delivered by caesarean section [ 4 ]. Newborn infants with face presentation usually have severe facial edema, facial bruising or ecchymosis [ 8 ]. Repeated vaginal examination to assess the presenting part and the progress of labor may lead to bruises in the face as well as damage to the eyes.

Patient and observation

Case presentation: a 21 year old primigravida at 40 weeks gestation from the last normal menstrual period referred to our facility for prolonged second stage of labor after visiting two health centres. She labored for a total of 14hrs, membrane ruptured spontaneously 12hrs before referral. Amniotic fluid was documented by midwife to be clear. She attended antenatal clinics in Mbengwi health centre 5 times, was diagnosed of hepatitis B during antenatal consultations, received no treatment. She did not do any ultrasound due to financial constraints. On examination, she was healthy, in painful distress, blood pressure 131/76mmhg, pulse 85 beats/min, temperature 37.2 o C SPO2 98%. On abdominal exams, uterus was gravid, fundal height 35cm, lie longitudinal, fetal heart rate 137bpm, cephalic presentation, engaged 2/5, with moderate contractions of 2 in 10 minutes. On vaginal examination, cervix was fully dilated, membranes ruptured, presenting part was face, mentum anterior. The conclusion made was mento-anterior face presentation ( Figure 1 ). Paturient was counseled, labor was augmented with 1 amp of oxytocin in 500ml of glucose 5% and started at 10drops/mins. Ten minutes later she delivered a male baby with Apgar score 6/10, 8/10 on the first and fifth minute. The baby weighed 3.2kg, length was 50cm, and head circumference was 41cm. Syndromic facial appearance with marked edema at the baby's lips, face and scalp was evident and he had bruising on the right nasolabial groove and right cheeks ( Figure 2 ). Physical examination of the infant's respiratory system, cardiovascular system, and his abdominal examination were normal, as was his neurological examination. Placenta was delivered by controlled cord traction 5mins later with all cotyledons. Delivery was complicated by a second degree perineal tear. Perineal tear was repaired with absorbable suture under local anaesthesia. Estimated blood lost was 350ml. baby received Hepatitis B immunoglobulins, hepatitis B vaccine and vitamin K were administered to the baby. 24 hours later, facial swellings resolved ( Figure 3 ), baby breast feeds well. Baby and mother were discharged on day 3 postpartum all fine.

Men-tum anterior face presentation

Bruising, marked lip and facial edema

Baby 24 hours later with all syndromic facial features resolved

Ethics : informed consent: written informed consent was obtained from the patient's parents for the publication of this case report.

Face presentation is a rare obstetric event and most practitioner will go through their carriers without ever meeting one [ 3 ]. We presented a case of face presentation noticed in the delivery room on digital examination in a patient with no risk factors. In a poor resource setting as ours where ultrasound is not readily available, this event is often scary and confusing to most midwives and nurses. This may prompt repeated vaginal exams for confirmation of presentation. This intend will lead to bruising of the baby's face and delay effective management [ 8 ]. Exact knowledge about the fetal position and level is important for providing the correct management of this malpresentation. When face presentation is diagnosed, around 60% of cases are in the mentum anterior position, 25% are mentum posterior and 15% are mentum transverse [ 5 ]. The patient presented the most common form of face presentation (mentum anterior). Labor was augmented, vaginal delivery was attempted and successfully conducted. Facial bruising, lip and face edema are very common complication of face presentation. These complications usually resolve within 24-48 hours [ 9 , 10 ] in this case facial edema completely resolved within 24hours ( Figure 3 ) and baby breastfeed well.

Repeated vaginal exams should be avoided when presenting part is unsure. Vaginal delivery should be attemped only on mentum anterior face presentation, in other cases, emergency ceserian section should be performed. Syndromic facial features in babies born from face presentation resolve completely within 24-48 hours.

Competing interests

The authors declare no competing interests.

Acknowledgements

We thank the participant of this study.

Authors’ contributions

NHF, NE, MMLE, NCN, YPI, FB, JS and SNC conceived the case series, assisted with the study design and participant enrollment, designed the study protocol and collected the data. NE, MMLE, NCN and SNC assisted in interpretation of results and wrote the manuscript. All authors read and approved the final manuscript.

Medical Information

Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

• Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
• Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
• Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

• Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
• Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
• Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
• Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

• Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
• Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
• Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
• Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

• Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
• Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Birth Injuries in Newborns

• Head Injuries During Birth |
• Injuries to the Skin and Soft Tissues |
• Bleeding In and Around the Brain |
• Nerve Injuries |
• Bone Injuries |

Birth injury is harm that can happen to a baby during the birthing process, usually in the process of passing through the birth canal.

Many newborns have swelling or minor bruising as a result of the birthing process.

Most injuries resolve without treatment.

Infrequently, more serious injuries occur, such as damage to nerves or a broken bone.

Birth injuries are most commonly due to the natural forces of labor and delivery.

Injuries are more likely to occur during a difficult delivery, which may occur because of fetal size, fetal position, forceps or vacuum-assisted delivery, or other factors.

A very large baby is at increased risk of birth injury. Doctors recommend cesarean delivery (C-section) when they estimate the baby weighs more than 11 pounds (more than 10 pounds when the mother has diabetes).

Injury is also more likely when the fetus is lying in an unusual position in the uterus before birth (see figure Position and Presentation of the Fetus ).

In some deliveries, doctors use forceps (a surgical instrument with rounded edges that fit around the fetus's head) or a vacuum extractor device. When used appropriately, there is a low risk of injury with these delivery methods.

Overall, the rate of birth injuries is much lower now than in previous decades because of improved prenatal assessment with ultrasonography , the limited use of forceps, and because doctors often do a C-section if they foresee an increased risk of birth injury.

(See also Overview of General Problems in Newborns .)

Position and Presentation of the Fetus

Head Injuries During Birth

Head molding is not an injury, but parents may be concerned about it. Molding refers to the normal change in shape of the baby's head that results from pressure on the head during delivery. In most births, the head is the first part to enter the birth canal. Because a fetus's skull bones are not rigidly fixed in position, the head elongates as it is pushed through the birth canal, which allows the fetus to pass through more easily. Molding does not affect the brain and does not cause problems or require treatment. The head shape gradually becomes more rounded over several days.

Minor head injury is the most common birth-related injury. Swelling and bruising of the scalp is common but not serious and generally resolves within a few days. Scalp scratches can occur when instruments (such as fetal monitors that attach to the scalp, forceps, or vacuum extractors ) are used during a vaginal delivery.

Bleeding between the scalp and skull bones can lead to an accumulation of blood either above or below the thick fibrous layer (periosteum) that covers the skull bones.

A cephalohematoma is blood accumulation between the scalp and the periosteum. Cephalohematomas feel soft and can increase in size after birth. They disappear on their own over weeks to months and almost never require any treatment. However, they should be evaluated by a pediatrician if they become red or start to drain liquid. Occasionally some of the blood hardens (calcifies) and leaves a hard lump in the scalp. Rarely, the calcified lump needs to be removed surgically.

A subgaleal hemorrhage is an accumulation of blood between the periosteum and the skull bones. Blood in this area can spread and is not confined to one area like a cephalohematoma. It can cause significant blood loss and shock , which may require a blood transfusion . A subgaleal hemorrhage may result from the use of forceps or a vacuum extractor, or may result from a blood clotting problem .

Fracture of one of the bones of the skull may occur before or during the birth process. Skull fractures are not common. Unless the skull fracture forms an indentation (depressed fracture), it generally heals rapidly without treatment.

Did You Know...

Injuries to the Skin and Soft Tissues

The newborn’s skin may have minor injuries after delivery, especially to the scalp, but also to other areas that receive pressure during contractions or that first emerge from the birth canal during delivery. Instruments needed for delivery, such as forceps , can injure the skin. Swelling and bruising may occur around the eyes and on the face during face-first deliveries and on the genitals after breech deliveries (see Fetal Presentation, Position, and Lie (Including Breech Presentation) ). No treatment for these injuries is needed.

Use of instruments during delivery and stress on the newborn (such as caused by birth asphyxia ) can injure the fat under the skin (called subcutaneous fat necrosis of the newborn). This skin injury can look like red, firm, raised areas on the trunk, arms, thighs, or buttocks. This type of injury usually resolves on its own over weeks to months.

Bleeding In and Around the Brain

Bleeding in and around the brain (intracranial hemorrhage) is caused by the rupture of blood vessels and may be caused by

Birth injury

Significant illness in the newborn that decreases delivery of blood or oxygen to the brain

A blood clotting problem

Prematurity increases the risk of intracranial hemorrhage.

Sometimes, intracranial hemorrhage occurs after a normal delivery in an otherwise well newborn. The cause of bleeding in these cases is unknown.

Bleeding in the brain is much more common among very preterm infants. Newborns who have bleeding disorders (such as hemophilia ) are also at increased risk of bleeding in the brain.

Most infants with bleeding do not have symptoms. However, some infants may have severe symptoms and be sluggish (lethargic), feed poorly, and/or have seizures.

Bleeding can occur in several places in and around the brain:

Subarachnoid hemorrhage is bleeding below the innermost of the two membranes that cover the brain. This is the most common type of intracranial hemorrhage in newborns, usually occurring in full-term newborns. Newborns with a subarachnoid hemorrhage may occasionally have apnea (periods when they stop breathing), seizures , or lethargy during the first 2 to 3 days of life but usually ultimately do well.

Subdural hemorrhage is bleeding between the outer and the inner layers of the brain covering. It is now much less common because of improved childbirth techniques. A subdural hemorrhage can put increased pressure on the surface of the brain. Newborns with a subdural hemorrhage may develop problems such as seizures.

Epidural hematoma is bleeding between the outer layer (dura mater) of tissue covering the brain (meninges) and the skull. An epidural hematoma may be caused by a skull fracture. If the hematoma increases the pressure in the brain, the soft spots between skull bones (fontanelles) may bulge. Newborns with an epidural hematoma may have apnea or seizures.

Intraventricular hemorrhage is bleeding into the normal fluid-filled spaces (ventricles) in the brain.

Intraparenchymal hemorrhage occurs into the brain tissue itself.

Intraventricular hemorrhages and intraparenchymal hemorrhages usually occur in very preterm newborns and occur more typically as a result of an underdeveloped brain rather than a birth injury. Most of these hemorrhages do not cause symptoms, but large ones may cause apnea or a bluish gray discoloration to the skin, or the newborn's entire body may suddenly stop functioning normally. Newborns who have a large hemorrhage, especially one that extends into the parenchyma, have a poor prognosis, but those with small hemorrhages usually survive and do well.

Newborns who have a hemorrhage may be admitted to a neonatal intensive care unit (NICU) for imaging tests (such as a CT scan or MRI) and monitoring, supportive care (such as warmth), fluids given by vein (intravenously), and other treatments to maintain body function.

Nerve Injuries

Nerve injuries may occur before or during delivery. These injuries usually cause weakness of the muscles controlled by the affected nerve. Nerve injuries may involve the

Facial nerve: Lopsided facial expression

Brachial plexus: Arm and/or hand weakness

Phrenic nerve (rare): Difficulty breathing

Spinal cord (rare): Paralysis

Other nerves, such as the radial nerve in the arm, the sciatic nerve in the lower back, or the obturator nerve in the leg, also may be injured during delivery. Most children completely recover from these injuries.

Facial nerve injury

Facial nerve injury is evident when the newborn cries and the face appears lopsided (asymmetric). The facial nerve is the nerve injured most often. This injury is caused by pressure against the nerve due to

The way the fetus was positioned in the uterus before birth

The nerve being pressed against the mother's pelvis during delivery

Forceps used to assist the delivery

No treatment of facial nerve injury is needed, and the muscle weakness usually resolves by 2 to 3 months of age. However, sometimes facial nerve weakness is caused by a congenital disorder rather than an injury and does not resolve.

Brachial plexus injury

The brachial plexus is a group of large nerves located between the neck and shoulder, leading to each arm. During a difficult delivery, one or both of the baby's arms can be stretched and injure the nerves of the brachial plexus (see Plexus Disorders ) and cause weakness or paralysis of part or all of the baby's arm and hand. Weakness of the shoulder and elbow is called Erb palsy, and weakness of the hand and wrist is called Klumpke palsy.

About half of the cases of brachial plexus injuries are related to difficult deliveries, typically involving large babies, and about half occur in babies with no difficulties during delivery. Brachial plexus injury is less frequent in babies delivered by cesarean delivery (C-section).

Extreme movements at the shoulder should be avoided to allow the nerves to heal. Many milder injuries resolve over a few days. If the injury is more severe or lasts for more than 1 or 2 weeks, physical therapy or occupational therapy for proper positioning and gentle movement of the arm are recommended. If there is no improvement over 1 or 2 months, doctors typically recommend the baby be evaluated by a pediatric neurologist and/or orthopedist at a pediatric specialty hospital to see whether surgery may be beneficial.

Phrenic nerve injury

The phrenic nerve, which is the nerve going to the diaphragm (the muscular wall that separates the organs of the chest from those of the abdomen and assists in breathing), is occasionally damaged, resulting in paralysis of the diaphragm on the same side.

In this injury, the newborn may have difficulty breathing and sometimes requires assistance with breathing.

Injury of the phrenic nerve usually resolves completely within a few weeks.

Spinal cord injury

Spinal cord injuries due to overstretching during delivery are extremely rare (see also Spinal Cord Injury in Children ). These injuries can result in paralysis below the site of the injury. Damage to the spinal cord is often permanent.

Some spinal cord injuries that occur high up in the neck are fatal because they prevent the newborn from breathing properly.

Bone Injuries

Bones may be broken (fractured) before or during delivery even when the delivery is normal.

A fracture of the collarbone (clavicle) is relatively common, occurring in 1 to 2% of newborns. Sometimes these fractures are not recognized until several days after birth when a lump of tissue forms around the fracture. Newborns with clavicle fractures are sometimes irritable and may not move the arm on the affected side. These fractures do not require treatment. Healing is complete over a few weeks.

Fractures of the upper arm bone (humerus) or upper leg bone (femur) sometimes occur. Newborns may have pain with movement in the first few days. Doctors usually apply a loose splint to limit movement. These fractures usually heal well.

Fractures of multiple bones can occur in newborns with certain rare genetic conditions in which the bones are very fragile (for example, osteogenesis imperfecta ).

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• Face Presentation

Pictoral Midwifery, Comyns Berkely, 4th Edition. 1941

Face it. We have a lot to learn about fetal positioning. The old paradigm is fetal positions are random. The new paradigm is that babies match the space available.

Face and brow presentations occur when baby’s spine extended until the head is shifted back so baby’s face comes through the pelvis first.

Baby may settle in a face or brow presentation before labor or they may become a face or brow presentation, usually when a posterior baby has it’s chin pushed further up by the pelvic floor during descent.

A baby who is in a face-first or forehead-first position often started as an extended (chin up)   occiput posterior   or   occiput transverse   position. Coming down on to the pelvic floor with the forehead leading then “converted” this baby’s head to the face first position.

The baby’s face may be bruised for a couple days after the birth. The brow presentation may cause a redness but only occasionally will cause a bruise.

Mobility of the pelvis and the freedom of maternal movements often help bring the face-first baby down through the pelvis with good strong, uterine surges.

But not always. Sometimes the labor can’t move baby down.   Cesareans   are more common, but a portion of the higher surgical rate is because time is not given to the mother to begin or continue labor, or to be out of bed for this labor. Monitoring becomes important. Expect a bit of an unusual heart rate to contraction pattern seen in these labors.

• When is Breech an Issue?
• Belly Mapping® Breech
• Flip a Breech
• When Baby Flips Head Down
• Breech & Bicornuate Uterus
• Breech for Providers
• What if My Breech Baby Doesn't Turn?
• Belly Mapping ®️ Method
• After Baby Turns
• Head Down is Not Enough
• Sideways/Transverse
• Asynclitism
• Oblique Lie
• Left Occiput Transverse
• Right Occiput Anterior
• Right Occiput Posterior
• Right Occiput Transverse
• Left Occiput Anterior
• OP Truths & Myths
• Anterior Placenta
• Body Balancing

What makes labor easier for a face-first baby and you?

Balance the body and the baby will thank you by curling into position to aim, not their face, but the crown of their head. 

Flexion is physiological. So support physiology and the baby will change their position. We may need a little physics.

In Labor with a Face or Brow Presentation

Back baby up!

Forward-leaning Inversion with a jiggle of the buttocks right through 1-2 contractions often backs baby up so they can tuck their chin. Then they can aim into the pelvis with an easier position.

Shake the Apples in Forward-leaning Inversion with hands

A little effort can make labor a lot easier!

Only after baby’s crown is first, then do Side-lying Release in labor.

Before Labor with a face or brow presentation

Face presentation may reflect a psoas/pelvic floor imbalance with a collapse in the front body.

Free the piriformis, strengthen the buttocks, lengthen the hamstrings, squat for lengthening the pelvic floor, don’t worry about strengthening the pelvic floor right now. Alignment, walking, stabilizing and lengthening will tone the pelvic floor. Use it by breathing with your whole body.

Before labor, it’s safe to do Side-lying Release when baby’s face-first head isn’t in the pelvis yet.

Free the way

The psoas is the upper guide, the pelvic floor is the lower guide. release spasms and lengthen both.

Make room for the baby by releasing muscles that spasm, lengthen ligaments that are shortened, and support the abdominal muscles by attending to the muscles that interact with them, don’t go directly to the front first.

Contact to Listing Owner

Excellent Care from the Moment of Birth

Normal Peeling

Normal skin pigment, slate grey patches (mongolian spots), salmon patch.

• "Stork Bite" Mark

Port Wine Stain

Hypopigmented macule, sebaceous hyperplasia, erythema toxicum, subcutaneous fat necrosis, skin irritation, transient neonatal pustular melanosis, cutis marmorata telangiectasia congenita, mottling (cutis marmorata), early hemangioma, congenital hemangioma, epidermal nevus, sebaceous nevus, junctional melanocytic nevus, cafe au lait spot, cutis aplasia, sucking blister, fingernail scratches.

Forceps Mark

Vacuum Mark

Scalp electrode site.

The downy hair seen over the shoulder is lanugo. Although this is present to a much greater degree in premature infants, term babies also have variable amounts of lanugo present at birth, as evidenced in this photo.

photo by Janelle Aby, MD

A dry, flaky, peeling appearance of the skin is very common in newborns. Although this can be distressing to parents, it does not need treatment and will spontaneously resolve.

This is another example of a post-dates infant with dry, peeling skin. On the day of birth, the skin of this baby had a very leathery appearance. This photograph was taken on the second day, when the skin had dried out and the peeling was more visible. The red blotches visible on the chest, right forearm, and legs are erythema toxicum and are unassociated with the peeling.

The hands and feet are especially common places to observe peeling. Often associated with infants who are post dates, many term babies exhibit this kind of peeling as well. In this patient, the skin and nails (look at the thumbnail) are stained yellow from the presence of meconium in utero. This photo was taken a few hours after birth, so the moist appearance of the skin is still visible. By the following day, the skin was more dry and the difference between the peeled and non-peeled areas of the hand was less visible.

In contrast, this type of peeling is not normal. Notice how the skin uder the peeled areas is red and fissured and how the fingers on the right hand appear edematous. This newborn had an uncomplicated pregnancy and delivery, but this skin appearance in the delivery room prompted transfer to the NICU for further evaluation. For this baby, Aquaphor was liberally applied to the skin, and the infant was kept in an isolette to minimize fluid losses.

This is the same infant as in the previous photo. Here, deeper fissuring can be seen in the area under the chin. Involvement of both pediatric dermatologists and geneticists is appropriate when dealing with  congenital icthyosis .

The increased pigment seen at the base of the nails is this African-American infant is entirely normal. When the parents' skin tone is dark, the overall skin tone of the baby will typically be much lighter than the parents at birth. In some areas, though, the increased melanin can be seen -- around the nails, over the helix of the external ear, around the umbilicus, and over the genitalia.

This infant was born to African American parents. Although the pediatrician's physical examination was unremarkable except for the general hypopigmentation, eye findings consistent with oculocutaneous albinism were noted by the ophthalomologist. These included transillumination of the irises, blonde fundi and vessels running through the macula. Nystagmus was not present at birth, but may be present in this condition as visual acuity is often low.

These dark blue-grey lesions are most commonly seen in darker-skinned infants. The sacrum is the most commonly affected area. These lesions tend to fade over several years but may not completely disappear. No evaluation is needed. They can be easily differentiated from bruises by the absence of other colors associated with bruises -- red, purple, green, brown or yellow.

This baby has more intense and widespread lesions, but the diagnosis and management are the same.

Slate grey patches can even involve an entire extremity. It is important to be able to distinguish the typical appearance of the patch even in an unusual location, so that trauma is not suspected. Patches involving a single leg or which are circumferential around both ankles have also been seen in our nursery. Documentation of these unusual birthmarks in the medical record is helpful.

This is another atypical example. These slate grey patches are typical in appearance, but unusual in location, as this finding is almost always observed on the back or extremities.

This photograph was taken approximately 6 hours after birth. In this case, the infant was initially thought to have sustained a bruise from delivery because this hand presented in a position on top of the head. The homogenous appearance and discrete borders, though, are inconsistent with a fresh bruise.

The pink patches in the middle of the forehead and over the left eye are salmon patches. Also known as nevus simplex or "angel kisses", these are a common capillary malformations that are present at birth. Eyelid spots generally fade over several months. Lesions on the glabella may take several years to resolve, and occasionally the outlines can be seen into adulthood, especially when the face is flushed.

This is another newborn with salmon patches. When lesions are present only on the eyelids, they are sometimes mistaken for bruising, but the examiner should realize that the eyelids are in a very protected position. Although the lids may be quite edematous, bruising in this location would be highly unusual, even in a baby with bruising elswhere on the face.

Here is a third example. In this patient, small spots can be seen over the eyelids and near the tip of the nose in addition to the large spot on the forehead.

"Stork Bite" Mark

Salmon patches may also be found on the nape of the neck in newborns. Nicknamed "Stork Bite Marks", these lesions become less intense with time, but are frequently visible into adulthood.

In contrast, these congenital pink patches are port wine stains. They are typically more intense and purple-red in color than salmon patches. In some cases, as seen here, a port wine stain may affect a large surface area. The discoloration is not, of itself, a problem, but it may be a clue to an underlying condition. Port wine stains on the face may be associated with  Sturge-Weber syndrome , and those on the extremities may be associated with  Klippel-Trenaunay-Weber syndrome , in which overgrowth of an extremity may occur.

Lesions that occur over the spine may also indicate an occult spinal dysraphism, so imaging should be considered. This is the same infant as in the previous photo. Although the lesion in this infant is not localized to the back, a spinal ultrasound was done; it was normal.

photo by provided by the parents

Hypopigmented macules are typically very subtle, and benign, findings in the newborn. In this patient, the macule partially overlaps the slate-grey patch (9 o'clock position) on the upper thigh.

Many hypopigmented macules are transient, and are caused by abnormal local vasoconstriction, as in the patient above. In this case the lesion became more visible with gentle stroking of the skin, but otherwise was almost invisible.

If it is important to differentiate vasoconstriction from true hypopigmentation, a wood's lamp can be used. If an abnormality of pigment exists, the lesion will appear bright under a wood's lamp, while areas of abnormal vasoconstriction will appear the same as the surrounding skin.

Ash leaf spots, associated with tuberous sclerosis, are rare in newborns; usually they appear in children more than 5 years old.

The white papules on this baby's chin and cheeks are milia. Milia are keratin filled epithethial cysts which occur in up to 40% of newborns. Spontaneous exfoliation and resolution is expected within a few weeks.

Parents will occasionally mistake these lesion for neonatal acne, but milia are present at birth and have no inflammatory component. Acne, even though caused by maternal hormones, does not generally appear until after  2 weeks of age.

In contrast to milia, the raised lesions on the nose in this newborn are sebaceous hyperplasia. The lesions are more yellow than milia and are the result of maternal androgen exposure in utero.

Sometimes referred to as "the miniature puberty of the newborn," maternal hormone exposure may also cause vaginal withdrawl bleeding in infant girls and neonatal acne.

Sebaceous hyperplasia is a benign finding and spontaneously resolves with time. No evaluation is needed.

This is the "rash" most commonly observed in the nursery. Lesions generally start on day 1 or 2 and increase in number over the next several days, followed by spontaneous resolution in about a week. Even newborns who have hundreds of spots are not symptomatic and need no futher evaluation.

With a closer view, the typical lesion can be seen. A central, yellowish papule is surrounded by a halo of erythema.

Another example of this ubiquitous rash. More than half of all newborns will have this to some degree.

This red lesion is subcutaneous fat necrosis. On palpation, there is a firm nodule in the subcutaneous tissue under the area of redness that is freely mobile with respect to the bony structures underneath it.

Subcutaneous fat necrosis is more common in infants who have had difficult deliveries, cold stress, or perinatal asphyxia.

Lesions are typically asymptomatic and resolve spontaneously within several weeks, usually without scarring or atropy.

Infants with extensive lesions or with renal disease should have calcium levels followed once or twice weekly. Hypercalcemia associated with subcutaneous fat necrosis is rare, but is a potentially lethal complication.

These raised yellow lesions are the result of irritated skin. Some newborns will have particularly sensitive skin, and may develop a "rash" of this type even in the absence of diarrhea or other known offending agents.

Symptomatic care and good diaper hygiene (with thorough drying before the diaper is replaced) is recommended.

All the lesions seen here are consistent with this diagnosis. The hallmark of this rash is the hyperpigmented spots that remain (seen here on the chest) after the fragile pustules (seen on the scrotum and thigh) have resolved.

Because the rash starts in utero, lesions may be in any stage at birth.

Despite the anxiety-provoking appearance of a newborn covered in pustules in the delivery room, no evaluation is needed when non-inflammatory pustules occur in combination with hyperpigmented macules in an otherwise well infant.

The back of the infant in the previous photo. Less pustules are noted here, but there are more hyperpigmented macules. These are expected to fade over several months. The pustules are fragile and last only a day or two.

This infant was born with only the hyperpigmented macules present. Although the etiology is unknown, it has been observed that African Americans infants are more frequently affected with this condition, occurring in up to 4%. Spontaneous resolution is expected.

Here is a close-up of the lesions present in the previous photo.

This is another infant with the hyperpigmented macules typical of neonatal pustulare melanosis. In this photo, the "collarette of scale" that often surrounds the individual lesions can be appreciated (look carefully at the neck and the infant's left axilla/arm).

Petechiae were first noted in this infant in the groin, where they are most numerous. With a careful examination, spots can also be seen on the abdomen and left upper chest. While petechiae may be due to pressure during birth, widespread petechiae deserve some evaluation; a CBC and platlet count in this infant was normal.

Blanching the abdomen reveals more petechiae than were appreciated on casual examination.

The same infant as in the previous photo, with more petechiae highlighted by blanching.

Another infant has petechiae primarily around the chin, neck, and upper chest. Given the relatively localized area affected in a newborn born vertex, no evaluation was done. These improved substantially over the next 2 days.

This infant had a somewhat difficult delivery, and as a result, sustained bruises on the head and the left arm. This picture was taken on the third day of life. By this time, the bruises were significantly improved from the appearance at birth.

On the initial physical examination, this infant was thought to have sustained bruising of the right arm during delivery. On closer inspection, however, the discolored areas are also depressed, suggesting some underlying atrophy of the skin.

This is cutis marmorata tealngiectasia congenita, a rare congenital vascular malformation. The presentation seen here with one limb affected is most common. Associated defects may occur in up to 50% of affected patients, but the cutaneous lesions tend to improve with time.

In another patient, this dark purple lesion was noted on initial exam. Port wine stain and bruising were considered in the differential diagnosis, but the angulated shape made these possibilities less likely. In addition, there is a suggestion of dark erythema streaking from the lesion across the wrist.

See the following photo for more findings that helped lead to the diagnosis of cutis marmorata telangiectasia congenita.

When the underside of the forearm was examined, mottled streaks of erythema were noted.

Although mottling occurs commonly in newborns exposed to cool temperatures, it is transient (disappears with rewarming) and more generalized than this. Compare the mottled appearance of the forearm to the normal appearance of the upper arm to appreciate the difference.

This photo is a good example of how this condition got its name. Cutis marmorata is the term used for mottling of the skin; in this case, the mottling is of the congenital, telangiectatic variety.

Again, the skin lesions are expected to improve with time, but lesions should be followed for possible ulceration.

The lacy erythema present on the thigh of this newborn is mottling. Not to be confused with cutis marmorata telangiectasia congenita, cutis marmorata (mottling) is a transient and common finding in newborns. It is particular visible when the infant is cold and disappears with warming. The mottling in this photo is mild.

In the newborn nursery, the raised, red appearance of a strawberry hemangioma is not usually seen. Instead, the precursors of these lesions are found. Although this photo is somewhat blurry, the lesion at this stage contains a central area of telangiectasia surrounded by a halo of pallor.

This lesion is much more subtle and is completely flat, but the circular area of pallor with central vascular markings can still be seen on the upper arm of this newborn.

This example is a little more noticeable than the previous one, but is still a subtle finding. The small, circular, pale area on the left side of the baby's abdomen (right side of the photograph) is the hemangioma. In this position, no problems would be expected. Lesions located in an area of chronic irritation (diaper area) or near vital structures (eye) can be problematic and may require treatment when they grow and become raised, but typically the best cosmetic result is obtained if the lesion is left to grow and involute spontaneously.

A much more unusual presentation of hemangioma is shown here. This vascular lesion on the heel was present at birth. Initially, this was thought to possibly be a hemangioendothelioma, a lesion with malignant potential. Eventually however, that diagnosis was excluded. This particular infant did not develop  Kasabach-Merritt  syndrome, though that was a concern, and the lesion began spontaneously involuting after about 6 months of age.

This is another fairly large congenital hemangioma. In this case, the hemangioma appears to have more deep, rather than superficial, involvement. Again, unless complications arise, the best course of action seems to be watchful waiting.

This lesion was present at birth. Initially, there was concern that this was a group of vesicles, but on careful examination, the lesion is firm and papular without any evidence of inflammation. This is consistent with an epidermal nevus. With time, epidermal nevi usually become more wart-like and scaly. Patients with epidermal nevi may have associated CNS, bone, and eye abnormalities, but this is more likely in those with extensive lesions. This baby was otherwise well.

A sebaceous nevus (also known as sebaceous nevus of Jadassohn) is a yellow-orange, waxy, pebbly lesion present on the face or scalp of some newborns. Hair follicles are not present within the lesion itself, but lesions on the scalp may be covered over by surrounding hair, so careful examination is important.

Here is another example of sebaceous nevus on the lateral margin of the eyelid. The significance of this finding is primarily related to the fact that it is sensitive to the androgens produced during puberty, causing the lesion to become larger and more wart-like, so elective removal may be considered at that time. Almost all of the changes that occur within these lesions are benign, but there are a few reports of basal cell carcinomas in older adults, so observation throughout life is important.

Here is a typical appearance of a junctional melanocytic nevus. The lesion is completely flat and is medium to dark brown in color. It may be present at birth, as it was in this infant. It may become slightly raised as the infant grows and may become a compound nevus if intradermal melanocytes develop. It is considered a benign lesion.

This is a less typical appearance for a congenital melanocytic nevus. On initial examination, the central portion of this lesion appeared to be peeling (minimal peeling can be seen in this photograph). It is also more common to have a dark center with a light rim than it is to have this "halo" appearance.

Cafe au lait spots are lighter in color than melanocytic nevi, but they also may be congenital macules. They are caused by an increased amount of melanin in both melanocytes and epidermal cells, and may increase in number with age. Most children with cafe au lait spots do not have neurofibromatosis, but the presence of six or more of these spots that are larger than 0.5cm diameter is considered to be a major clue to the diagnosis.

Here is another example of cafe au lait spot. Again in this patient, the spot was an isolated physical finding, so no further evaluation was necessary.

On examination of this infant, there were 3 areas of abnormality -- the nodule under the left eye, the red "excoriated" area lateral to the nodule, and the hairless, circular lesion anterior to the ear. The etiology of the nodule is unknown at this time, but the other two areas were felt to be consistent with cutis aplasia. Cutis aplasia is often thought of in association with trisomy 13, but it can also be an isolated finding in an otherwise well newborn, as in this case.

This lesion is fairly typical of the appearance of a sucking blister at birth. While the blister created by the infant sucking on his extremity in the womb may still be intact at the time of delivery, often it appears as a flat, scabbed, healing area (as shown here). Sucking blisters are solitary lesions that occur only in areas accessible to the infant's mouth. They are benign and resolve spontaneously. The appearance and location of the lesion is usually sufficient for diagnosis, but if the infant is observed sucking on the affected area, the diagnosis is certain.

These tags are rather typical in appearance, but in a highly unusual location. Both were pedunculated tags with very thin stalks, although the one on the baby's right is much longer. Because of the narrow diameter of the stalk, the decision was made to clip these with scissors instead of tying them off.

A sharp, sterile scissors was used to remove the two tags. This photo, taken immediately after the procedure, shows an excellent result. There was no bleeding from the longer tag on the baby's right side; there was very slight bleeding from the spot on the baby's left, but after pressure was briefly applied, it quickly stopped.

When babies are born, the nails are frequently rather jagged and sharp. Because normal behavior for a newborn includes bringing fists and hands up to the face, self-inflicted fingernail scratches are not uncommon.

In this infant, two linear scratches can be clearly seen on the patient's left cheek, but there are also several other subtle scratches visible (one under the right eye, one on the right cheek, one under the right nares, and one inside the left nares.

In an effort to prevent scratches, the hands of a newborn are frequently covered with long sleeves, mittens or socks. Fingernails can also be carefully trimmed with a nail file or clippers (a feat most easily accomplished when the baby is asleep).

The semi-circular red mark on this infant's right cheek is a forceps mark. When forceps are needed to assist with a delivery, this type of superficial red mark can occasionally been seen on the sides of the infant's face. In most cases, the marks are small (<2cm) erythematous streaks. These marks have no consequence and will spontaneously resolve. In rare cases when the skin is abraded, antibiotic ointment may facilitate healing.

Vacuum extraction can also leave marks on the infant's head. Typically, the bruising is similar to that which occurs normally during the process of delivery except for the fact that it is well circumscribed. In some cases, however, the bruising can be more severe with associated blisters or sloughing of the skin, or with underlying cephalohematoma or subglaeal hemorrhage. In this infant, the bruising is fairly mild, but can be easily seen because it extends beyond the hairline in the front. This finding spontaneously resolved.

When a scalp electrode is used for internal monitoring prior to delivery, a small circular scab can often be seen at the site where the monitor was. In this child, the scalp electrode site is the slightly red area with central darkness in the middle of the photograph, just to the right of the part in the hair. This amount of erythema is consistent with normal healing, but as this site is a break in the skin, infection in this area is possible (The lighter red spots on the scalp are consistent with bruising).

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Face presentation

Latest Posts , Labour & Delivery

She still had intact membranes. The midwife asked me to come as she was starting to get pressure. She concluded the conversation by saying: “I think it is a face presentation”.

I attended at once. She had ruptured her membranes just prior to my arrival. I did an internal examination and sure enough, it was a face presentation with chin being anterior. Her cervix was now fully dilated.

She could feel pressure with contractions so I encouraged them to push. With pushing over two contractions she delivered her baby face first and chin up. With the next contraction, she delivered the rest of the baby. She had a boy weighing 3.8Kg and born in good condition. She had an intact perineum. No stitches were needed.

The incidence of face presentation is reported to be between 1 in 500 deliveries to 1 in 1400 deliveries. It happens when the baby’s head is very extended backwards. Fortunately, it was a mento-anterior face presentation as a mento-posterior face presentation usually needs a Caesarean section. Also, that it was her third vaginal delivery and that the patient could push so well meant it was a very straightforward but different delivery.

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Abnormal Fetal Position and Presentation

Under normal circumstances, a baby is in the vertex (cephalic) position before delivery. In the vertex position, the baby’s head is at the lower part of the abdomen, and the baby is born head-first. However, some babies present differently before delivery. In these cases, abnormal presentations may place the baby at risk of experiencing umbilical cord problems and/or a birth trauma (1). Types of abnormal fetal positions and presentations include the following. We’ll cover each in more detail on this page.

What is the difference between fetal presentation and position?

In the womb, a fetus has both a presentation and a position . Presentation refers to the baby’s body that leads, or is expected to lead, out of the birth canal (9). For example, if a baby’s rear is set to come out of the birth canal first, the baby is said to be in “breech presentation.” Position refers to the direction the baby is facing in relation to the mother’s spine (9). A baby could be lying face-first against a mother’s spine, or face up towards the mother’s belly.

What way should a baby come out during birth?

Vertex presentation is the ‘normal’ way that a baby is positioned for birth and the lowest-risk presentation for vaginal birth (1). In vertex presentation, the baby is positioned head-first with their occiput (the part of the head close to the base of the skull) entering the birth canal first. In this position, the baby’s chin is tucked into their chest and they are facing the mother’s back (occipito-anterior position). Any position other than vertex position is abnormal and can make vaginal delivery much more difficult or sometimes impossible (2). If a baby’s chin isn’t tucked into their chest, they may come out face-first (face presentation), which can cause birth injury (1).

What happens if a baby isn’t in the standard vertex position during birth?

Before delivery, it is critical that the fetus is in the standard vertex presentation and within the normal range for weight and size. This helps ensure the safety of both baby and mother during labor. When the baby’s size or position is abnormal, physician intervention is usually warranted (1). This may mean simple manual procedures to help reposition the baby or, in many cases, a planned C-section delivery . The failure of healthcare professionals to identify and quickly resolve issues related to fetal size, weight, and presentation is medical malpractice . There are numerous complications related to abnormal weight, size, abnormal position, or abnormal presentation.

Compound presentation

In the safest presentation (vertex presentation), the baby is born head first, with the rest of the body following. In a compound presentation, however, there are multiple presenting parts. Most commonly, this means that the baby’s head and an arm come out first at the same time. Sometimes compound presentation can occur with twins where the head of the first twin presents with the extremity of the second twin (3).

Risk factors for compound presentation include (3):

• Prematurity
• Intrauterine growth restriction (IUGR)
• Multiple gestations ( twins , triplets, etc.)
• Polyhydramnios
• A large pelvis
• External cephalic version
• Rupture of membranes at high station

Compound presentations can be detected via ultrasound before the mother’s water breaks. During labor, compound presentation is identified as an irregular finding during a cervical examination (3).

If a mother has polyhydramnios, the risk of compound presentation is higher, as the flow of amniotic fluid when the membranes rupture can sweep extremities into the birth canal, or cause a cord prolapse , which is a medical emergency (3). If compound presentation continues, it is likely to cause dystocia (the baby becoming stuck in the birth canal), which is also a medical emergency (3). Often, the safest way to deliver a baby with compound presentation is C-section, because complications like dystocia and cord prolapse carry risks of severe adverse outcomes, including cerebral palsy , intellectual and developmental disabilities, and hypoxic-ischemic encephalopathy (HIE) (3).

Limb presentation

Limb presentation during childbirth means that the part of the baby’s body that emerges first is a limb – an arm or a leg. Babies with limb presentation cannot be delivered safely via vaginal delivery; they must be delivered quickly by emergency C-section (4). Limb presentation poses a large risk for dystocia (the baby getting stuck on the mother’s pelvis), which is a medical emergency.

Occipitoposterior (OP) position

Approximately 1 out of 19 babies present  in a posterior position rather than an anterior position. This  is called an occipitoposterior (OP) position or occiput posterior position (3)  In OP position, the baby is head-first with the back part of the head turned towards the mother’s back, rotated to the right  (right occipitoposterior position, or ROP), or to the left (left occipitoposterior position, or LOP) of the sacroiliac joint. Occipitoposterior position increases the baby’s risk of experiencing prolonged labor , prolapsed umbilical cord , and use of delivery instruments, such as forceps and vacuum extractors (5). These conditions can cause brain bleeds , a lack of oxygen to the brain, and birth asphyxia .

When OP position is present, if a manual rotation cannot be quickly and effectively performed in the face of fetal distress, the baby should be delivered via C-section (5).  A C-section can help prevent oxygen deprivation caused by prolonged labor, umbilical cord prolapse, or forceps and vacuum extractor use.

A nurse explains posterior position

Breech presentation

Breech presentation is normal throughout pregnancy. However, by the 37th week, the baby should turn to the cephalic position in time for labor. Breech presentation occurs when a baby’s buttocks or legs are positioned to descend the birth canal first. Breech positions are dangerous because when vaginal delivery is attempted, a baby is at increased risk for prolapsed umbilical cord, traumatic head injury, spinal cord fracture, fatality, and other serious problems with labor (6).

There are 4 types of breech positions:

• Footling breech presentation : In footling position, one or both feet enter the birth canal first, with the buttocks at a higher position than the feet.
• Kneeling breech presentation : This is when the baby has one or both legs extended at the hips and flexed at the knees.
• Frank breech presentation : This is when the baby’s buttocks present first, the legs are flexed at the hip and extended at the knees, and the feet are near the ears.
• Complete breech presentation : In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with the feet beside the buttocks.

When a baby is in breech position, physicians often try to maneuver the baby into a head-first position. This should only be attempted if fetal heart tracings are normal (the baby is not in distress ) (7). The only type of breech position that may allow for a vaginal delivery is frank breech , and the following conditions must be met:

• The baby’s heart rate is being closely monitored and the baby is not in distress.
• Cephalopelvic disproportion (CPD) is not present; x-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
• The hospital is equipped for and the physician is skilled in performing an emergency C-section .

If these conditions are not present, vaginal birth should not be attempted. Most experts recommend C-section delivery for all types of breech positions because it is the safest method of delivery and it helps avoid birth injuries (6). Mismanaged breech birth can result in the following conditions:

• Brain bleeds, intracranial hemorrhages
• Spinal cord fractures
• Hypoxic-ischemic encephalopathy (HIE)
• Cerebral palsy
• Intellectual disabilities
• Developmental delays

Face presentation

A face presentation occurs when the face is the presenting part of the baby. In this position, the baby’s neck is deflexed (extended backward) so that the back of the head touches the baby’s back. This prevents head engagement and descent of the baby through the birth canal. In some cases of face presentation, the trauma of a vaginal delivery causes face deformation and fluid build-up (edema) in the face and upper airway, which often means the baby will need a breathing tube placed in the airway to maintain airway patency and assist breathing (1).

Image by healthhand.com

There are three types of face presentation:

• Mentum anterior (MA) : In this position, the chin is facing the front of the mother.
• Mentum posterior (MP) : The chin is facing the mother’s back, pointing down towards her buttocks in mentum posterior position. In this position, the baby’s head, neck, and shoulders enter the pelvis at the same time, and the pelvis is usually not large enough to accommodate this. Also, an open fetal mouth can push against the bone (sacrum) at the upper and back part of the pelvis, which also can prevent descent of the baby through the birth canal.
• Mentum transverse (MT) : The baby’s chin is facing the side of the birth canal in this position.

Trauma is very common during vaginal delivery of a baby in face presentation, so parents must be warned that their baby may be bruised and that a C-section is available to avoid this trauma.

Babies presenting face-first can sometimes be delivered vaginally, as long as the baby is in MA position (1). Safe vaginal delivery of a term-sized infant in persistent MP position is impossible due to the presenting part of the baby compared to the size of the mother’s pelvis (1). Babies in MP position must be delivered by C-section. Babies in MT position must also be delivered by C-section. Some babies in the MP and MT positions will spontaneously convert to the MA position during the course of labor, which makes vaginal delivery a possibility. If the baby is in the MA position and vaginal delivery is able to proceed, engagement of the presenting part of the baby probably will not occur until the face is at a +2 station (1).

The management of face presentation requires close observation of the progress of labor due to the high incidence of CPD with face presentation. In face presentation, the diameter of the presenting part of the head is, on average, 0.7 cm greater than in the normal vertex position (1).

In any face presentation situation, if progress in dilation and descent ceases despite adequate contractions, delivery must occur by C-section. In fact, when face presentation occurs, experts recommend liberal use of C-section (1).

Since there is an increased risk of trauma to the baby when the face presents, the physician should not try to rotate the baby internally. In addition, the physician must not use vacuum extractors or manual extraction (grasping the baby with hands) to extract the baby from the uterine cavity. Outlet forceps should only be used by experienced physicians; these forceps increase the risk of trauma and brain bleeds. In almost all clinical circumstances a cesarean delivery is the safest method of delivery.

Listed below are complications that can occur if face presentation is mismanaged by the medical team:

• Prolonged labor
• Facial trauma
• Facial and upper airway edema (fluid build-up in the face, often caused by trauma)
• Skull molding (abnormal head shape that results from pressure on the baby’s head during childbirth)
• Respiratory distress or difficulty in ventilation (the baby being able to move air in and out of lungs) due to upper airway trauma and edema
• Spinal cord injury
• Abnormal fetal heart rate patterns
• 10-fold increase in fetal compromise
• Brain bleeds
• Intracranial hemorrhages
• Permanent brain damage

Brow presentation

Brow presentation is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backward. As the term “brow presentation” suggests, the brow (forehead) is the part that is situated to go through the pelvis first. Vaginal delivery can be difficult or impossible with brow presentation, because the diameter of the presenting part of the head may be too big to safely fit through the pelvis.

Risk factors and conditions associated with brow presentation

Brow presentation has been linked to several risk factors and co-occurring conditions. These include:

• Multiparity (having previously given birth)
• Premature delivery
• Fetal anomalies such as anencephaly (an absence of major parts of the brain and skull) or anterior neck mass (a growth on the front of the neck)
• Previous c-section delivery
• Polyhydramnios (excessive amniotic fluid: infants swallow amniotic fluid while in utero, but this may be difficult if their neck is extended)

Diagnosis of brow presentation

Brow presentation can often be diagnosed through a vaginal examination during labor. If there are no conclusive signs from the physical examination alone, an ultrasound can also be used. Warning signs of brow presentation may include signs of fetal distress or lack of labor progression.

Management of brow presentation

Infants who assume a brow presentation early in labor may spontaneously move into a more optimal position during the delivery process. Additionally, safe delivery in brow presentation may be possible if the infant is unusually small and/or the mother’s pelvic opening is unusually large. For these reasons, physicians occasionally recommend vaginal delivery of infants in brow presentation.

Doctors attempting vaginal delivery of a baby in brow presentation must be very careful to watch for signs of fetal distress (such as an abnormal heart rate), and to monitor the progression of labor. Prolonged labor can cause extended periods of fetal oxygen deprivation, which can cause birth asphyxia and permanent injury. Signs of fetal distress can indicate that a baby is in danger of sustaining serious brain damage if action is not quickly taken to prevent this. If an infant in brow presentation begins to show signs of distress, or if labor progress stops or slows significantly, physicians should be ready to move on to a cesarean delivery.

Labor induction or augmentation with the drug Pitocin (synthetic oxytocin) is very dangerous in cases of brow presentation. Pitocin can lead to excessive uterine contractions, which can put pressure on the infant’s head and cut off their oxygen supply; this is especially risky when safe fetal descent is already compromised, such as in cases of brow presentation.

Complications of brow presentation

If brow presentation is diagnosed in a timely fashion and is appropriately managed, there are typically no serious negative effects on the mother or baby. However, if medical professionals fail to recognize brow presentation and intervene as necessary, there can be lasting consequences. Infants may suffer  oxygen deprivation  due to prolonged labor, or  traumatic injuries from a difficult delivery. Some of the most severe conditions resulting from mismanaged brow presentation births include:

• Hypoxic-ischemic encephalopathy
• Periventricular leukomalacia
• Seizure disorders
• Developmental disabilities

Shoulder presentation (transverse lie)

Shoulder presentation (transverse lie) is when the arm, shoulder or trunk of the baby enter the birth canal first. When a baby is in a transverse lie position during labor, C-section is almost always used as the delivery method (8).  Mothers who have polyhydramnios (too much amniotic fluid), are pregnant with more than one baby, have placenta previa, or have a baby with intrauterine growth restriction (IUGR) are more likely to have a baby in the transverse lie position (8). Once the membranes rupture, there is an increased risk of umbilical cord prolapse in this position; thus, a C-section should ideally be performed before the membranes break (8). Failure to quickly deliver the baby by C-section when transverse lie presentation is present can cause severe birth asphyxia due to cord compression and trauma to the baby. This can cause hypoxic-ischemic encephalopathy (HIE), seizures, permanent brain damage, and cerebral palsy.

Legal help for birth injuries from abnormal position or presentation

The award-winning birth injury attorneys at ABC Law Centers: Birth Injury Lawyers have over 100 years of joint experience handling birth trauma cases related to abnormal position or presentation. If you believe your loved one’s birth injury resulted from an instance of medical malpractice, you may be entitled to compensation from a medical malpractice or personal injury case. During your free legal consultation, our birth injury attorneys will discuss your case with you, determine if negligence caused your loved one’s injuries, identify the negligent party, and discuss your legal options with you.

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• Julien, S., and Galerneau, F. (2017). Face and brow presentations in labor. Retrieved from https://www.uptodate.com/contents/face-and-brow-presentations-in-labor .
• World Health Organization, UNICEF, and United Nations Population Fund. Malpositions and malpresentations. Retrieved from http://hetv.org/resources/reproductive-health/impac/Symptoms/Malpositions__malpresetations_S69_S81.html .
• Barth, W. (2016). Compound fetal presentation. Retrieved from https://www.uptodate.com/contents/compound-fetal-presentation .
• Gabbe, S.G., … Grobman, W.A. (2017). Compound Presentation. Retrieved from https://expertconsult.inkling.com/read/gabbe-obstetrics-normal-problem-pregnancies-7e/chapter-17/compound-presentation .
• Argani, C.H. and Satin, A.J. (2018) Occiput posterior position. Retrieved from https://www.uptodate.com/contents/occiput-posterior-position .
• Hofmeyr, G.J. (2018). Overview of issues related to breech presentation. Retrieved from https://www.uptodate.com/contents/overview-of-issues-related-to-breech-presentation .
• Hofmeyr, G.J. (2017). Delivery of the fetus in breech presentation. Retrieved from https://www.uptodate.com/contents/delivery-of-the-fetus-in-breech-presentation .
• Strauss, R.A. (2017). Transverse fetal lie. Retrieved from https://www.uptodate.com/contents/transverse-fetal-lie .
• Moldenhauer, J.S. (2018). Abnormal Position and Presentation of the Fetus. Retrieved from https://www.merckmanuals.com/home/women-s-health-issues/complications-of-labor-and-delivery/abnormal-position-and-presentation-of-the-fetus .

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• Giuseppe De Bernardo ,
• Maria Svelto ,
• Maurizio Giordano ,
• Desiree Sordino
• Department of Emergency, NICU , Azienda Ospedaliera di Rilievo Nazionale Santobono Pausilipon , Napoli , Italy
• Correspondence to Dr Giuseppe De Bernardo, debernardo.giuseppe{at}alice.it

https://doi.org/10.1136/bcr-2016-219114

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A few hours after birth, a newborn was admitted to Santobono-Pausilipon III level Hospital. Suspected eye injury was reported. During childbirth, the baby showed a face presentation and to help with the delivery, a vacuum extractor (VE) method was used. Body weight of the baby at the time of birth was 3200 g, length 50 cm and head circumference 35 cm. Apgar scores were 7 I and 8 V . The newborn was subjected to examinations by an ophthalmologist and a neurologist and tested by a CT. The ophthalmological examination of the right eye revealed an extensive conjunctiva haemorrhage, dioptric media was transparent, anterior chamber was normal, optical disc had defined margins and retinal haemorrhages were absent. A neurological examination reported extensive haematoma of the right half-face and excoriations of the right eyelid ( figure 1 A, B). Bregmatic fontanelle was normotensive, archaic reflexes were present and symmetrical. CT scan results confirmed the absence of damage on the right eye or nerve. The infant's wound was treated with betamethasone–chloramphenicol ointment applied four times a day, mupirocin ointment three times a day for a total of 9 days with good results ( figure 2 A, B). Follow-up to 3 months showed complete recovery of the infant without sequelae ( figure 2 C). Childbirth with a face presentation ranges from 0.5 to 3 per 1000 deliveries; its cause and mechanism are not yet understood. 1  The use of VE presents higher rates for traumatic and non-traumatic intracranial haemorrhages compared with infants born by caesarean section (CS) or by a non-assisted vaginal delivery. 2 Therefore, the use of VE method has been proven high-risk procedure, CS choice should be considered. 3

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(A, B) Lesions at the time of admission.

(A) The lesions after 6 days of therapy and (B) after 9 days of the therapy. (C) Follow-up at 3 months from discharge.

Learning points

The use of vacuum extractor presents higher rates of complications compared with caesarean section (CS).

CS should be considered in cases of face presentation.

• Langlois C ,
• Garabedian C , et al
• Högberg U ,
• Schwartz Z ,
• Lancet M , et al

Contributors GDB made substantial contributions to the conception of the work and acquired data. MS analysed and interpreted data with GDB. GDB, MS and MG drafted the work. MG and DS revised it critically for important intellectual content.

Competing interests None declared.

Patient consent Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

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• What a newborn really looks like

Do you wonder what your newborn baby will look like? Some physical features of newborns can surprise people who've only seen these tiny babies in the movies or magazines.

Being born affects how a baby looks. Pregnancy and birth can cause a baby's skin, face, arms and legs, or genitals to look different than you might expect.

Your healthcare team will examine the newborn just after the baby is born as well as before you take your baby home. If you have any questions, make sure to ask a person on your healthcare team.

Every baby is different, but here's a peek at some real newborns so that you know what to expect.

Your newborn's eyes

As a baby goes through the birth canal, pressure on the face can cause the baby's eyelids to look puffy or swollen. This swelling should go down over a day or two after birth.

Sometimes right after birth, a baby's eyes seem cross-eyed, meaning they look more toward the baby's nose. As your baby's eye muscles strengthen over time, this cross-eyed condition usually gets better.

Also, a baby's eye color may not be set at birth. You might notice your baby's eye color changing over the first six months.

Your newborn's head

An infant's skull bones can shift and overlap. This allows a baby to move through the birth canal. In general, being in labor for a long time means a baby's head might be more cone shaped than a baby who experienced a shorter labor.

A baby's head also may look taller if tools such as a vacuum extractor were used in the birth. In the few days after birth, the cone shape usually becomes rounder. Babies born buttocks or feet first or by C-section are more likely to have round heads at birth.

A newborn's soft spots

There are two soft areas at the top of your baby's head where the skull bones haven't yet grown together. These spots, called fontanels, allow for the skull to reshape as needed to pass through the birth canal. Later, these areas provide the space needed by a baby's rapidly growing brain. These areas can look like bumps or dents in the baby's scalp. You might notice these spots pulsing when your baby cries or strains.

Fontanels are covered by a thick fibrous layer. The larger soft spot is a diamond shape about the size of a quarter coin. This is about an inch in diameter (about 2.5 centimeters). The smaller soft spot is at the back of the head. That area is about the size of a dime. This is just over half an inch (1.79 centimeters).

Fontanels are safe to touch and typically close when the skull bones fuse together by age 2 years old.

Your newborn's umbilical cord

The umbilical cord attaches the baby to the placenta during pregnancy. After the baby is born, a healthcare professional will clamp the cord close to the baby's body.

The stump of a newborn's umbilical cord is usually a yellow-green color at birth.

The clamped bit of umbilical cord will dry out over a few weeks after birth. It will change in color to brown and then to black. It typically falls off around 1 to 3 weeks after birth.

In the meantime, caregivers should keep the stump clean and dry. Fold your baby's diaper under the stump so that air can help dry out the base. Stick to sponge baths while the area is healing. There's no need to swab the stump with rubbing alcohol.

Your newborn's skin

After birth, babies can have all sorts of spots, rashes, bruises or blotches. Dry, peeling skin is typical in newborns, especially on hands and feet in the first few weeks. The top layer of skin is usually flaky in the first weeks after birth. Daily moisturizing can help keep your baby comfortable.

You might notice white bumps on your newborn's face that look like tiny pimples. These harmless spots, known as milia, typically disappear on their own. Don't try and pinch these bumps, scrub your baby's face, or use lotions or oils on milia. Mild soap and water once a day usually helps clear up milia over time, usually in a few weeks.

Your newborn's skin also might be covered by fine, downy hair at birth. This is known as lanugo. It can be found especially on the back and shoulders and is most common in premature babies. It typically wears off within several weeks.

Other skin marks that caregivers may see on a newborn are bruises on a baby's head from the mother's pelvis. If tools were used during birth, such as forceps, the baby may have a scrape or bruise. These marks generally should all go away within about two weeks.

Your newborn's birthmarks

Birthmarks are areas of skin that are present at birth or develop later. Some are permanent and some fade as a child grows.

They can range from blue-gray to brown to red in color. A common birthmark is called a salmon patch. This is a pink to red patch at the back of a newborn's neck, on the eyelids or forehead, or between the baby's eyes.

Salmon patch birthmarks are sometimes nicknamed stork bites or angel kisses. These marks tend to get brighter during crying.

Some marks disappear in a few months, while others fade over a few years or persist. Marks at the back of the neck usually last longer than marks on the face.

Babies of African or Asian ethnicity may be born with birthmarks that are flat, blue-green or blue-gray marks typically found on the lower back or buttocks. Sometimes these marks are mistaken for bruises. But, in general, this type of mark fades during early childhood.

Your newborn's breasts and genitals

As the pregnant body prepares for birth and breastfeeding, some hormones can cross the placenta. These hormones can affect a newborn.

Babies may have swollen breast tissue at birth, and this tissue may produce a fluid.

Vaginal tissue may be swollen, or newborns may have a harmless vaginal discharge for a few weeks after birth.

The loose skin that holds the testes, called the scrotum, may be swollen. The swelling may be caused by hormones or the pressure in the birth canal, especially if a baby is born feet first, called breech.

The swelling is due to fluid in the scrotum, a condition called hydrocele. Typically, this fluid will be reabsorbed over time.

Right after birth, a healthcare professional will examine your baby and talk with you about any concerns. If you have questions then or later, ask your baby's healthcare professional.

Your first look at your newborn

Every baby is different. But in general, newborns look wrinkly. And they may be damp or even a bit bloody.

At birth, a baby's legs and feet might look bowed or bent. This is because of the lack of space in the uterus. You can expect the baby's legs to straighten on their own as the baby grows and starts to move around.

Your healthcare professional will do a full examination of the baby and explain the findings. Be sure to ask any questions you may have.

No matter how the baby looks, your baby is born ready to be cared for and held. If everyone is healthy, your healthcare team may put your baby right on your chest for skin-to-skin contact. Some caregivers immediately feel a bond. Others are too exhausted or overwhelmed. Not everyone feels the same way. Caregivers can expect their feelings to grow over time.

• Cook WJ, et al., eds. Mayo Clinic Guide to Your Baby's First Years: Newborn to Age 3. Mayo Clinic Press; 2020.
• Kliegman RM, et al. The newborn infant. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. http://www.clinicalkey.com. Accessed Aug. 29, 2023.
• Coin specifications. United States Mint. https://www.usmint.gov/learn/coin-and-medal-programs/coin-specifications. Accessed Aug. 30, 2023.
• McKee-Garrett TM. Assessment of the newborn infant. https://www.uptodate.com/contents/search. Accessed Aug. 29, 2023.
• Palazzi DL, et al. Care of the umbilicus and management of umbilical disorders. https://www.uptodate.com/contents/search. Accessed Aug. 30, 2023.

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Management of face presentation, face and lip edema in a primary healthcare facility case report, Mbengwi, Cameroon

Affiliations.

• 1 Microhealth Global Medical Centre, Mbengwi, Cameroon.
• 2 Department of Medicine and Surgery, Faculty of Health Sciences University of Buea, Buea, Cameroon.
• 3 Department of Microbiology and Parasitology, Faculty of Science, University of Buea, Buea, Cameroon.
• 4 Cameroon Baptist Convention Health Services (CBCHS), Yaoundé, Cameroon.
• 5 Department of Public Health, School of Health Sciences, Catholic University of Central Africa, Box 1110, Yaoundé, Cameroon.
• 6 School of Health Systems and Public Health, Faculty of Health Sciences, University of Pretoria Private Bag X323, Gezina, Pretoria, 0001, Pretoria, South Africa.
• 7 Institute of Medicine, Department of Public Health and Community Medicine (EPSO), University of Gothenburg, Box 414, SE - 405 30 Gothenburg, Sweden.
• 8 Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa.
• PMID: 31692903
• PMCID: PMC6815474
• DOI: 10.11604/pamj.2019.33.292.18927

Face presentation is a rare obstetric event and most practitioners will go through their carriers without ever meeting one. Face presentation can be delivered vaginally only if the foetus is in the mentum anterior position. More than half of the cases of face presentation are delivered by caesarean section. Newborn infants with face presentation usually have severe facial oedema, facial bruising or ecchymosis. These syndromic facial features usually resolved within 24-48 hours.

Keywords: Cameroon; Face presentation; pregnancy delivery.

© Nzozone Henry Fomukong et al.

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Conflict of interest statement

The authors declare no competing interests.

Men-tum anterior face presentation

Bruising, marked lip and facial…

Bruising, marked lip and facial edema

Baby 24 hours later with…

Baby 24 hours later with all syndromic facial features resolved

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• Face presentation. Schwartz Z, Dgani R, Lancet M, Kessler I. Schwartz Z, et al. Aust N Z J Obstet Gynaecol. 1986 Aug;26(3):172-6. doi: 10.1111/j.1479-828x.1986.tb01560.x. Aust N Z J Obstet Gynaecol. 1986. PMID: 3468936
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FactChecking the Biden-Trump Debate

En el primer debate de la campaña 2024, los dos candidatos soltaron una ráfaga de declaraciones falsas y engañosas.

By Robert Farley , Eugene Kiely , D'Angelo Gore , Jessica McDonald , Lori Robertson , Catalina Jaramillo , Saranac Hale Spencer and Alan Jaffe

Posted on June 28, 2024

Para leer en español, vea esta traducción de El Tiempo Latino.

The much-anticipated first debate of 2024 between President Joe Biden and former President Donald Trump featured a relentless barrage of false and misleading statements from the two candidates on immigration, the economy, abortion, taxes and more.

• Both candidates erred on Social Security, with Biden incorrectly saying that Trump “wants to get rid” of the program, and Trump falsely alleging that Biden will “wipe out” Social Security due to the influx of people at the border.
• Trump misleadingly claimed that he was “the one that got the insulin down for the seniors,” not Biden. Costs were lowered for some under a limited project by the Trump administration. Biden signed a law capping costs for all seniors with Medicare drug coverage.
• Trump warned that Biden “wants to raise your taxes by four times,” but Biden has not proposed anything like that. Trump was also mostly wrong when he said Biden “wants the Trump tax cuts to expire.” Biden said he would extend them for anyone making under $400,000 a year.
• Biden repeated his misleading claim that billionaires pay an average federal tax rate of 8%. That White House calculation factors in earnings on unsold stock as income.
• Trump repeated his false claim that “everybody,” including all legal scholars, wanted to end Roe v. Wade’s constitutional right to abortion.
• Trump falsely claimed that “the only jobs” Biden “created are for illegal immigrants and bounced back jobs that bounced back from the COVID.” Total nonfarm employment is higher than it was before the pandemic, as is the employment level of native-born workers.
• Biden claimed that Trump oversaw the “largest deficit of any president,” while Trump countered that “we now have the largest deficit” under Biden. The largest budget deficit was under Trump in fiscal year 2020, but that was largely because of emergency spending due to COVID-19.
• Biden misleadingly said that “Black unemployment is the lowest level it has been in a long, long time.” The rate reached a record low in April 2023, and it was low under Trump, too, until the pandemic.
• Biden said Trump called U.S. veterans killed in World War I “suckers and losers,” which Trump called a “made up quote.” The Atlantic reported that, based on anonymous sources. A former Trump chief of staff later seemed to confirm Trump said it.
• Trump claimed that Biden “caused the inflation,” but economists say rising inflation was mostly due to disruptions to the economy caused by the pandemic.
• Trump grossly inflated the number of immigrants who have entered the country during the Biden administration — putting the number at 18 million to 20 million — and he said, without evidence, that many of them are from prisons and mental institutions.
• Trump claimed that “we had the safest border in history” in the “final months” of his presidency. But apprehensions of those trying to cross illegally in the last three full months of his presidency were about 50% higher than in the three months before he took office.
• Biden criticized Trump for presiding over a loss of jobs when he was president, but that loss occurred because of the COVID-19 pandemic.
• Trump falsely claimed that “some states” run by Democrats allow abortions “after birth.” If it happened, it would be homicide, and that’s illegal.
• Trump made the unsupported claim that the U.S. border with Mexico is “the most dangerous place in the world,” and suggested that it has opened the country to a violent crime wave. The data show a reduction in violent crime in the U.S.
• Trump overstated how much food prices have risen due to inflation. Prices are up by about 20%, not double or quadruple. 
• Trump boasted his administration “had the best environmental numbers ever.” Trump reversed nearly 100 environmental rules limiting pollution. Although greenhouse gas emissions did decline from 2019 to 2020, the EPA said that was due to the impacts of the pandemic on travel and the economy.   
• Biden said he joined the Paris Agreement because “if we reach the 1.5 degrees Celsius, and then … there’s no way back.” Limiting global warming to 1.5 degrees would reduce the damages and losses of global warming, but scientists agree that climate action is still possible after passing the threshold.
• Trump said immigrants crossing the border illegally were living in “luxury hotels.” New York City has provided hotel and motel rooms to migrant families, but there is no evidence that they are being placed in “luxury” hotels. 
• Trump falsely claimed that there was “no terrorism, at all” in the U.S. during his administration. There were several terrorist acts carried out by foreign-born individuals when he was president.
• While talking about international trade, Trump falsely claimed that the U.S. currently has “the largest deficit with China.” In 2023, the trade deficit in goods and services with China was the lowest it has been since 2009.
• Trump wrongly claimed that prior to the pandemic, he had created “the greatest economy in the history of our country.” That’s far from true using economists’ preferred measure — growth in gross domestic product.
• As he has many times before, Trump wrongly claimed, “I gave you the largest tax cut in history.” That’s not true either as a percentage of gross domestic product or in inflation-adjusted dollars.
• Trump contrasted his administration with Biden’s by misleadingly noting that when he left office, the U.S. was “energy independent.” The U.S. continues to export more energy than it imports.

The debate was hosted by CNN in Atlanta on June 27.

Social Security

Biden claimed that Trump “wants to get rid” of Social Security, even though the former president has consistently said he will not cut the program and has advised Republicans against doing so.

Earlier this year, Biden and his campaign based the claim on Trump saying in a  March 11 CNBC interview  that “there is a lot you can do in terms of entitlements in terms of cutting and in terms of also the theft and the bad management of entitlements.” As  we’ve said , in context, instead of reducing benefits, Trump was talking about cutting waste and fraud in those programs — although there’s not enough of that to make the program solvent over the long term.

“I will never do anything that will jeopardize or hurt Social Security or Medicare,” Trump later said in a  March 13 Breitbart interview . “We’ll have to do it elsewhere. But we’re not going to do anything to hurt them.”

During the GOP presidential primary, Trump also  criticized  some of his Republican opponents for proposing to raise the retirement age for Social Security, which budget experts  have said  would reduce scheduled benefits for those affected.

Some critics of Trump have  argued  that he cannot be expected to keep his promise because of his past budget proposals. But,  as we’ve written , Trump did not propose cuts to Social Security retirement benefits.

Meanwhile, Trump claimed during the debate that Biden “is going to single handedly destroy Social Security” because of illegal immigration. “These millions and millions of people coming in, they’re trying to put them on Social Security. He will wipe out Social Security,” Trump said of Biden.

As  we  and  others  have explained before, immigrants who are not authorized to be in the U.S. aren’t eligible for Social Security. In fact, because many such individuals pay into Social Security via payroll taxes but cannot receive benefits, illegal immigrants bolster rather than drain the finances of the program.

In referring to what seniors pay for insulin, Trump misleadingly claimed, “I heard him say before ‘insulin.’ I’m the one that got the insulin down for the seniors. I took care of the seniors.” Insulin costs went down for some beneficiaries under a limited project under Trump; Biden signed a more expansive law affecting all seniors with Medicare drug coverage.

Under Trump, out-of-pocket costs were lowered to $35 for some Medicare Part D beneficiaries under a two-year pilot project in which some insurers could voluntarily reduce the cost for some insulin products. KFF, a nonpartisan health policy research organization,  explained  earlier this month that under this model, in effect from 2021 to 2023, “participating Medicare Part D prescription drug plans covered at least one of each dosage form and type of insulin product at no more than $35 per month,” and “less than half of all Part D plans chose to participate in each year.”

But in 2022, Biden  signed a law  that required all Medicare prescription drug plans to cap all insulin products at $35. The law also capped the out-of-pocket price for insulin that’s covered under Medicare Part B, which covers drugs administered in a health care provider’s office. The caps went into effect last year.

STAT, a news site that covers health care issues,  reported  that the idea for a $35 cap for seniors initially came from Eli Lilly, the pharmaceutical company, which proposed it in 2019.

Trump on Biden Tax Plan

“He’s the only one I know he wants to raise your taxes by four times,” Trump said of Biden. “He wants to raise everybody’s taxes by four times. He wants the Trump tax cuts to expire. So everybody … [is] going to pay four to five times –  nobody ever heard of this before.”

Trump regularly warns of massive tax hikes for “everybody,” should Biden be reelected. That doesn’t jibe with anything Biden has proposed.

In his more than three years as president, Biden’s  major tax changes  have included setting a  minimum corporate tax rate  of 15% and lowering taxes for some families by  expanding the child tax credit  and, for a time, making it fully refundable, meaning families could still receive a refund even if they no longer owe additional taxes.

As  we wrote  in 2020, when Trump made a similar claim, Biden proposed during that campaign to raise an additional $4 trillion in taxes over the next decade, although the increases would have fallen mainly on very high-income earners and corporations. The plan would not have doubled or tripled people’s taxes at any income level (on average), according to analyses of Biden’s plan by the  Penn Wharton Budget Model ,  the Tax Policy Center  and  the Tax Foundation .

In March 2023, the TPC’s Howard Gleckman  wrote  that Biden proposed a 2024 budget that would, on average, increase after-tax incomes for low-income households and “leave them effectively unchanged for middle-income households.” The Tax Policy Center noted, “The top 1 percent, with at least roughly $1 million in income, would pay an average of $300,000 more than under current law, dropping their after-tax incomes by 14 percent.”

This March, Biden released his  fiscal year 2025 budget , which contains many of the same proposals and adds a few new wrinkles. But it still  does not contain  any “colossal tax hikes” on typical American families, as Trump has said.

Biden’s latest plan proposes — as he has in the past — to increase the corporate income tax rate from 21% to 28%, and to  restore  the top individual tax rate of 39.6% from the current rate of 37%. It would also increase the corporate minimum tax rate from 15% to 21% for companies that report average profits in excess of $1 billion over a three-year period. And the plan would impose a 25% minimum tax on very wealthy individuals. The plan also proposes to extend the expanded child tax credit enacted in the American Rescue Plan through 2025, and to make the child tax credit fully refundable on a permanent basis.

Trump is also mostly wrong that Biden “wants the Trump tax cuts to expire.”

As he has said since the 2020 campaign, Biden’s FY 2025 budget vows not to increase taxes on people earning less than $400,000.

In order to keep that pledge, Biden would have to extend most of the individual income tax provisions enacted in the Tax Cuts and Jobs Act that are set to expire at the end of 2025. And that’s what Biden says he would do — but  only for  individual filers earning less than $400,000 and married couples making less than $450,000. (In order to pass the TCJA with a simple Senate majority, Republicans wrote the law to have most of the individual income tax changes  expire after 2025 .)

The Biden budget plan “would raise marginal income tax rates faced by higher earners and corporations while expanding tax credits for lower-income households,” according to a Tax Foundation  analysis  of the tax provisions in Biden’s budget. “The budget would redistribute income from high earners to low earners. The bottom 60 percent of earners would see increases in after-tax income in 2025, while the top 40 percent of earners would see decreases.”

Biden on Taxes Paid by Billionaires

In arguing that wealthy households should pay a minimum tax, Biden repeated his misleading claim that billionaires pay an average federal tax rate of 8%.

“We have a thousand … billionaires in America, and what’s happening?”  Biden said . “They’re in a situation where they in fact pay 8.2% in taxes.”

That’s not the average rate in the current tax system; it’s a figure  calculated  by the White House and factors in earnings on unsold stock as income. When only considering income, the top-earning taxpayers, on average, pay higher tax rates than those in lower income groups, as  we’ve written  before.

The top 0.1% of earners pay an average rate of 25.1% in federal income and payroll taxes,  according to  an analysis by the Tax Policy Center in October 2022 for the 2023 tax year.

The point that Biden tried to make is that earnings on assets, such as stock, currently are not taxed until that asset is sold, which is when the earnings become subject to capital gains taxes. Until stocks and assets are sold, the earnings are referred to as “unrealized” gains. Unrealized gains, the White House  has argued , could go untaxed forever if wealthy people hold on to them and transfer them on to heirs when they die.

Roe v. Wade

As he has  before , Trump wildly exaggerated the popularity of ending Roe v. Wade — even going so far as to claim that it was “something that everybody wanted.”

“51 years ago, you had Roe v. Wade and everybody wanted to get it back to the states,”  he said , referring to the 1973 Supreme Court ruling that established a constitutional right to abortion, which was  overturned  in 2022.

Trump:  Everybody, without exception: Democrats, Republicans, liberals, conservatives. Everybody wanted it back — religious leaders. And what I did is I put three great Supreme Court justices on the court and they happened to vote in favor of killing Roe v. Wade, and moving it back to the states. This is something that everybody wanted. Now 10 years ago or so they started talking about how many weeks and how many this and getting into other things. But every legal scholar throughout the world — the most respected — wanted it brought back to the states. I did that.

In fact, a majority of Americans have disagreed with ending Roe v. Wade, including plenty of legal scholars, as we’ve explained  before . While some scholars criticized aspects of the legal reasoning in Roe, it did not necessarily mean they wanted the ruling overturned. Legal experts told us that Trump’s claim was “utter nonsense” and “patently absurd.”

Trump Wrong on Jobs

After Biden talked about job creation during his administration, Trump falsely claimed that “the only jobs [Biden] created are for illegal immigrants and bounced back jobs that bounced back from the COVID.”

In fact, as of May,  total nonfarm employment  in the U.S. had gone up about 6.2 million from the pre-pandemic peak in February 2020, according to figures from the Bureau of Labor Statistics. The increase is about 15.6 million if you count from when Biden took office in January 2021 until now — but that would include some jobs that were temporarily lost during the pandemic and then came back during the economic recovery.

Furthermore, there is no evidence that only “illegal immigrants” have seen employment gains.

Since Biden became president in January 2021, employment of U.S.-born workers has increased more than employment of foreign-born workers, a category that includes anyone who wasn’t a U.S. citizen at birth, as we’ve written before . BLS says the  foreign-born  population includes “legally-admitted immigrants, refugees, temporary residents such as students and temporary workers, and undocumented immigrants.” There is no employment breakdown for just people in the U.S. illegally.

In looking at employment since the pre-pandemic peak, the employment level of  foreign-born workers  was up by about 3.2 million, from roughly 27.7 million in February 2020 to nearly 30.9 million in May. Employment for the  U.S.-born population  increased by about 125,000 — from nearly 130.3 million in February 2020 to 130.4 million, as of May.

Conflicting Budget Deficit Claims

Biden and Trump accused each other of presiding over the largest budget deficit in the U.S.

After talking about Trump’s plans for additional tax cuts, Biden said Trump already had the “largest deficit of any president in American history.” When he got a chance to respond, Trump said, “We now have the largest deficit in the history of our country under this guy,” referring to Biden.

Biden is correct: The  largest budget deficit  on record was about $3.1 trillion in fiscal year 2020 under Trump. However, that was  primarily  because of trillions of dollars in emergency funding that both congressional Republicans and Democrats approved to address the COVID-19 pandemic. Before the pandemic, the largest budget deficit under Trump was about $1 trillion in fiscal 2019.

Meanwhile, the most recent budget deficit under Biden was about $1.7 trillion in fiscal 2023. As of June, the nonpartisan Congressional Budget Office  projected  that the deficit for fiscal 2024, which ends on Sept. 30, would be about $2 trillion.

Black Unemployment

Biden boasted that on his watch, “Black unemployment is the lowest level it has been in a long, long time.”

It’s true that the unemployment rate for Black or African American people reached a record low of 4.8% in April 2023, but it is currently 6.1%,  according to  the Bureau of Labor Statistics, which has data going back to 1972.

Also, the unemployment rate was low under Trump, too, until the pandemic.

Under Trump, the  unemployment rate for Black Americans  went down to 5.3% in August 2019 – the lowest on record at that time. It shot up to 16.9% in April 2020, when the economic effects of the pandemic took hold. When Trump left office in January 2021, amid the pandemic, the rate was 9.3%.

The rate has been 6% or less in only 29 months since 1972, and it happened only under two presidents: 21 times under Biden and eight times under Trump.

‘Suckers and Losers’

Biden  said  Trump called U.S. veterans killed in World War I “suckers and losers,” which Trump called a “made up quote … that was in a third-rate magazine.”

It was first reported by a magazine — the Atlantic — but Trump’s former chief of staff,  John F. Kelly , a retired four-star Marine general, later seemed to confirm it.

Biden was referring to a trip Trump made to France in November 2018, where he reportedly declined to visit the  Aisne-Marne American Cemetery  near the location of the Battle of Belleau Wood. “He was standing with his four-star general and he told him, ‘I don’t want to go in there because they’re a bunch of losers and suckers.’”

The Atlantic  wrote  about this alleged incident in 2020, citing unnamed sources. The magazine wrote that Trump made his remark about “losers” when he declined to visit the Aisne-Marne American Cemetery, and his remark about “suckers” during that same trip.

The Atlantic, Sept. 3, 2020:  In a conversation with senior staff members on the morning of the scheduled visit, Trump said, “Why should I go to that cemetery? It’s filled with losers.” In a separate conversation on the same trip, Trump referred to the more than 1,800 marines who lost their lives at Belleau Wood as “suckers” for getting killed.

In October 2023, Kelly – who was on that trip and visited the Aisne-Marne Cemetery — gave a  statement to CNN  that seemed to confirm those remarks. CNN published Kelly’s statement.

CNN, Oct. 3, 2023:  “What can I add that has not already been said?” Kelly said, when asked if he wanted to weigh in on his former boss in light of recent comments made by other former Trump officials. “A person that thinks those who defend their country in uniform, or are shot down or seriously wounded in combat, or spend years being tortured as POWs are all ‘suckers’ because ‘there is nothing in it for them.’ A person that did not want to be seen in the presence of military amputees because ‘it doesn’t look good for me.’ A person who demonstrated open contempt for a Gold Star family – for all Gold Star families – on TV during the 2016 campaign, and rants that our most precious heroes who gave their lives in America’s defense are ‘losers’ and wouldn’t visit their graves in France.”

Trump said, “We had 19 people who said I didn’t say it.” One of those who said that he didn’t hear Trump make those remarks is John Bolton, Trump’s former national security adviser who was also on the trip and said he was there when the decision was made not to visit the cemetery.

“I didn’t hear that,” Bolton  told the New York Times  in 2020 after the magazine story first appeared. “I’m not saying he didn’t say them later in the day or another time, but I was there for that discussion.”

Biden Misleads on Jobs

Biden ignored the economic impact of the COVID-19 pandemic when he criticized Trump for employment going down over Trump’s time in office.

“He’s the only president other than Herbert Hoover that lost more jobs than he had when he began,” Biden said.

Job growth during Trump’s term was positive until the economy lost 20.5 million jobs in April 2020, as efforts to slow the spread of the novel coronavirus led to business closures and layoffs. By the time Trump left office in January 2021, employment had partly rebounded, but was still 9.4 million jobs below the February 2020 peak,  according to the Bureau of Labor Statistics .

Trump repeatedly claimed that Biden “caused the inflation” and that “I gave him a country with no essentially no inflation. It was perfect. It was so good.”

It’s true that inflation was relatively modest when Trump was president. The  Consumer Price Index rose 7.6%  under Trump’s four years — continuing a long period of low inflation. And inflation has been high over the entirety of Biden’s time in office. The  Consumer Price Index  for all items rose 19.3% between January 2021 and May.

For a time, it was the worst inflation in decades. The 12 months ending in June 2022 saw a 9% increase in the CPI (before seasonal adjustment), which the  Bureau of Labor Statistics said  was the biggest such increase since the 12 months ending in November 1981.

Inflation has moderated more recently. The CPI  rose  3.3% in the 12 months ending in May, the most recent figure available.

Although Trump claims that Biden is entirely responsible for massive inflation, economists  we have spoken to  say Biden’s policies are only partly to blame. The economists placed the lion’s share of the blame for inflation on disruptions to the economy caused by the pandemic, including supply shortages, labor issues and increased consumer spending on goods. Inflation was then worsened by Russia’s attack on Ukraine, which drove up oil and gas prices, experts told us.

Indeed, inflation has been a  worldwide problem  post-pandemic.

However, many economists say Biden’s policies — particularly aggressive stimulus spending early in his presidency to offset some of the economic damage caused by the pandemic — played a modest role.

Jason Furman , a former economic adviser to President Barack Obama and now a Harvard University professor, told us in June 2022 that he estimated about 1 to 4 percentage points worth of the inflation was due to Biden’s stimulus spending in the  American Rescue Plan  — a $1.9 trillion pandemic relief measure that included $1,400 checks to most Americans; expanded unemployment benefits; and money for schools, small businesses and states.  Mark Zandi , chief economist of Moody’s — whose work is often cited by the White House — said the impact of the stimulus measure now “has largely faded.”

Economists note that the American Rescue Plan came after two other pandemic stimulus laws enacted under Trump that were  worth  a  total  of $3.1 trillion. That spending, too, could have contributed to inflation.

Immigrants Entering U.S. Under Biden

Trump grossly inflated the number of immigrants who have entered the country during the Biden administration — putting the number at 18 million to 20 million. The number, by our calculation, is about a third of that. Trump also claimed, without evidence, that many of those immigrants are from prisons and mental institutions.

“It could be 18, it could be 19, and even 20 million people,” Trump said of the immigrants who have entered the U.S. during the Biden administration. Later in the debate, Trump asked Biden why there had been no accountability “for allowing 18 million people many from prisons, many from mental institutions” into the country.

That’s a greatly exaggerated number. We took a deep dive into the immigration numbers  in February , and again in  mid-June , and we came up with an estimate of at most a third of Trump’s number.

Here’s the breakdown:

Department of Homeland Security data show nearly 8 million encounters at the U.S.-Mexico border between February 2021, the month after Biden took office, and May, the last month of available  statistics . That’s a figure that includes both the 6.9 million apprehensions of migrants caught between legal ports of entry – the number typically used for illegal immigration – and nearly 1.1 million encounters of migrants who arrived at ports of entry without authorization to enter the U.S.

DHS also has comprehensive data, through February, of the initial processing of these encounters. That information shows 2.9 million were removed by Customs and Border Protection and 3.2 million were released with notices to appear in immigration court or report to Immigration and Customs Enforcement in the future, or other classifications, such as parole. (Encounters do not represent the total number of people, because some people attempt multiple crossings. For example, the recidivism rate was 27% in fiscal year 2021,  according to the most recent figures  from CBP.) 

As  we’ve explained before , there are also estimates for “gotaways,” or migrants who crossed the border illegally and evaded the authorities. Based on an average annual apprehension rate of 78%, which DHS provided to us, that would mean there were an estimated 1.8 million gotaways from February 2021 to February 2024. The gotaways plus those released with court notices or other designations would total about 5 million.

There were also 407,500 transfers of unaccompanied children to the Department of Health and Human Services and 883,000 transfers to ICE. The ICE transfers include those who are then booked into ICE custody, enrolled in “ alternatives to detention ” (which include technological monitoring) or released by ICE. We don’t know how many of those were released into the country with a court notice. But even if we include those figures, it still doesn’t get us to anywhere near 18 to 20 million.

And we should note that these figures do not reflect whether a migrant may ultimately be allowed to stay or will be deported, particularly since there is a yearslong backlog of immigration court cases.

Also, as we have  written   repeatedly , Trump has provided no credible support for his incendiary claim that countries are emptying their prisons and mental institutions and sending those people to the U.S. Experts tell us they have seen no evidence to substantiate it.

Earlier this month, we looked into  Trump’s claim as it relates to Venezuela, because Trump has repeatedly cited a drop in crime there to support his claim about countries emptying their prisons and sending inmates to the U.S. Reported crime is trending down in Venezuela, but crime experts in the country say there are numerous reasons for that — including an enormous out-migration of citizens and a consolidation of gang activity — and they have nothing to do with sending criminals to the U.S.

“We have no evidence that the Venezuelan government is emptying the prisons or mental hospitals to send them out of the country, whether to the USA or any other country,” Roberto Briceño-León, founder and director of the independent Venezuelan Observatory of Violence, told us.

Border Under Trump

Trump claimed that “we had the safest border in history” in the “final months” of his presidency, according to Border Patrol. But according to  data  provided by Customs and Border Protection, apprehensions of those trying to cross illegally into the U.S. in the last three full months of Trump’s presidency were about 50% higher than in the  three months  before he took office.

In fact, as we wrote in our piece, “ Trump’s Final Numbers ,” illegal border crossings, as measured by  apprehensions at the southwest border , were 14.7% higher in Trump’s final year in office compared with the last full year before he was sworn in.

But these statistics tell only part of the story. The number of apprehensions fluctuated wildly during Trump’s presidency, from a  monthly  low of 11,127 in April 2017 to a high of 132,856 in May 2019.

Back in April,  we wrote  about a misleading chart that Trump showed to the crowd during a speech in Green Bay, Wisconsin. “See the arrow on the bottom? That was my last week in office,” Trump said. “That was the lowest number in history.” But Trump was wrong on both points.

The arrow was pointing to apprehensions in April 2020, when apprehensions plummeted during the height of the pandemic.

“The pandemic was responsible for a near-complete halt to all forms of global mobility in 2020, due to a combination of border restrictions imposed by countries around the world,”  Michelle Mittelstadt , director of communications for the Migration Policy Institute, told us.

After apprehensions reached a pandemic low in April 2020, they rose every month after that. In his last months in office, apprehensions had more than quadrupled from that pandemic low and were higher than the month he took office.

Trump falsely claimed that “some states” run by Democrats allow abortions “after birth.” As  we have written , that’s simply false. If it happened, it would be  homicide , and that’s  illegal .

“No such procedure exists,” the American College of Obstetricians and Gynecologists  says  on its website.

The former president  has wrongly said  that abortions after birth were permitted under Roe v. Wade — the Supreme Court ruling that established a constitutional right to abortion until it was  reversed  in 2022. It was not.

Under Roe, states could outlaw abortion after fetal viability, but with exceptions for risks to the life or health of the mother. Many Republicans  have objected  to the health stipulation, saying it would allow abortion for any reason. Democrats say exceptions are needed to protect the mother from medical risks. We should note, late-term abortions  are rare . According to the  Centers for Disease Control and Prevention , less than 1% of abortions in the U.S. in 2020 were performed after 21 weeks gestational time.

In June 2022, after Trump had appointed three conservative justices to the Supreme Court, the court  overturned  Roe in a 5-4 ruling. Biden  supports  restoring Roe as “the law of the land,” as he said in his State of the Union address in March.

Trump Calls Border ‘The Most Dangerous Place’

In his focus on the U.S. border with Mexico, Trump  made  the unsupported claim that it is “the most dangerous place in the world.”

It’s true that unauthorized border crossings  can be dangerous  — 895 people died while doing so in fiscal year 2022, which is the most recent year for which the Customs and Border Protection has  data . Most of those deaths were heat related.

And the International Organization for Migration called calendar year 2022 “the deadliest year on record” for migration in the Americas, with a total of 1,457 fatalities throughout South America, Central America, North America and the Caribbean. The organization began tracking deaths and disappearances related to migration in 2014.

“Most of these fatalities are related to the lack of options for safe and regular mobility, which increases the likelihood that people see no other choice but to opt for irregular migration routes that put their lives at risk,” the organization said in its  2022 report .

Trump suggested that the border crossings imperil Americans when he went on to say, “these killers are coming into our country, and they are raping and killing women.”

But, as  we’ve written before , FBI data show a downward trend in violent crime in the U.S., and there’s no evidence to support the claim that there’s been a crime wave driven by immigrants.

Crime analyst Jeff Asher, co-founder of the New Orleans firm  AH Datalytics , told us in May that there’s no evidence in the data to indicate a migrant crime wave.

Similarly, Jeffrey Butts, director of the Research and Evaluation Center at the John Jay College of Criminal Justice,  told the New York Times  in February there was no evidence of a migrant crime wave in New York City after Texas Gov. Greg Abbott began busing migrants there in April 2022.

“I would interpret a ‘wave’ to mean something significant, meaningful and a departure from the norm,” Butts said at the time. “So far, what we have are individual incidents of crime.”

Also, it’s worth noting that the Institute for Economics and Peace’s  Global Peace Index  — which measures the safety of 163 countries based on 23 indicators, including violent crime, deaths from internal conflict and terrorism — said the “least peaceful country” is Afghanistan, followed by Yemen, Syria, South Sudan and the Democratic Republic of the Congo.

In discussing inflation, the former president embellished the degree to which food prices have increased.

“It’s killing people. They can’t buy groceries anymore,” Trump said. “You look at the cost of food, where it’s doubled, tripled and quadrupled. They can’t live.”

According to the Bureau of Labor Statistics, the Consumer Price Index for food has  gone up 17.5%  — not 100% to 300% — since January 2021. The Consumer Price Index specifically for groceries, or “food at home,” has  risen 20.8% .

Climate Change

During a short exchange about climate change, Trump boasted that during his tenure “we had the best environmental numbers ever.” It is not clear what he was referring to exactly, but he said if elected president he wanted to have “absolutely immaculate clean water and I want absolutely clean air — and we had it.” He might have been referring to a talking point that Andrew Wheeler, Trump’s former Environmental Protection Agency administrator, had recommended Trump mention during the debate: “CO2 emissions went down” during his administration, as  the Hill reported . 

Greenhouse gas emissions, which are responsible for global warming,  did decline  from 2019 to 2020. But that was “largely due to the impacts of the coronavirus (COVID-19) pandemic on travel and economic activity,” according to the EPA. Emissions increased by 5.7% from 2020 to 2022, once the economy started getting reactivated again, the agency said. 

According to an  analysis by the New York Times , Trump’s administration reversed nearly 100 environmental rules, including 28 regulations on air pollution and emissions, and eight rules that limited water pollution. Reportedly, Trump  recently asked  oil executives and lobbyists to donate to his campaign, promising he would roll back other environmental rules that hurt fossil fuel interests. 

“He’s not done a damn thing for the environment,” Biden said in response, pointing out that Trump had  pulled the U.S. out of the Paris Agreement . “I immediately joined it because if we reach the 1.5 degrees Celsius … there’s no way back,” Biden said. 

As  we’ve reported , although reaching 1.5 degrees Celsius, or 2.7 degrees Fahrenheit, of warming comes with a number of very serious impacts, it is not a point of no return. Scientists agree that every increment of global warming increases these negative impacts, but 1.5 degrees is not a magic number after which everything is doomed, they say. 

Immigrants Living in Hotels

During the debate, Trump  mentioned   twice  that while immigrants crossing the border illegally were “living in luxury hotels,” in New York City and other cities “our veterans are living in the street.”

While it is true that New York City has  provided   hotel   rooms  to migrant families as a temporary shelter solution, there is no evidence that immigrants are being placed in “luxury” hotels. 

In 2023, Mayor Eric Adams  signed  a $275 million contract with the Hotel Association of New York City to house 5,000 migrants. The deal was intended to help  struggling hotels  impacted by the pandemic and did not expect to include luxury hotels. “There are no gold-plated rooms that are being given away contrary to any reports that you may have seen,” the association president  told NY1  at the time. In January, the city  signed  another $77 million contract to shelter migrant families in hotels. 

In April, social media posts falsely claimed immigrants had stormed New York City Hall to demand luxury hotel accommodations. But as the  Associated Press reported , the immigrants were there for a hearing about racial inequities in shelter and immigrant services. 

In 2023, the number of veterans experiencing homelessness increased 7.4% from 2022, according to  data  from the Department of Housing and Urban Development. But homelessness among veterans has been declining in recent years, with a 4% overall reduction within the last three years alone. 

Terrorist Attacks Under Trump

While talking about Iran and terrorism, Trump falsely claimed that “you had no terror, at all, during my administration.” As  we’ve written , there were several acts of terrorism carried out by foreign-born individuals when Trump was in office.

For example, in October 2017, Sayfullo Saipov  used  a truck to run down people in New York City. He killed eight people,  including  Americans and tourists, in an attack carried out on behalf of the Islamic State.

Then in December 2017, Akayed Ullah  detonated  a homemade pipe bomb he was wearing inside a New York City subway station. Ullah  told  authorities he did it in response to U.S. airstrikes against the Islamic State in Syria and other places.

Then in  December 2019 , Second Lt. Mohammed Saeed Alshamrani, a member of the Royal Saudi Air Force, shot 11 people at Florida’s Naval Air Station Pensacola, killing three U.S. sailors. Trump’s own attorney general, William Barr,  called  it an act of terrorism in January 2020. “The evidence shows that the shooter was motivated by jihadist ideology,” Barr said in a statement.

China Trade Deficit

When discussing U.S. trade relations with China, Trump said “we have the largest deficit with China.” That’s false, as  we’ve written .

In 2023, the U.S. had a trade deficit with China in goods and services of roughly $252 billion,  according to  revised figures the Bureau of Economic Analysis  released  in early June. The deficit in goods trading was about $279 billion which was partially offset by a roughly $27 billion surplus in the trading of  services  — which can include travel, transportation, finance and intellectual property.

The trade gap with China last year was the lowest it had been since 2009, when it was $220 billion.

In fact, according to BEA data going back to 1999, the highest total U.S.-China trade deficit in goods and services was about $378 billion in 2018 — when Trump was president. Under Biden, the highest trade deficit with China was $366 billion in 2022.

Not ‘Greatest Economy’ Under Trump

Trump falsely said that prior to the pandemic, the U.S. had “the greatest economy in the history of our country. … Everything was locked in good.”

Trump’s boast about creating the “greatest economy in history” is ubiquitous in his campaign speeches. And it’s not true, at least not by the objective measure typically used to gauge the health of the economy.

As  we have written , economists generally measure a nation’s health by the growth of its  inflation-adjusted gross domestic product . Under Trump, growth was modest. Real GDP in Trump’s four years grew annually by 2.5% in 2017, 3% in 2018 and 2.5% in 2019 — before the economy went into a tailspin during the pandemic in 2020, when real GDP declined by 2.2%,  according to  the Bureau of Economic Analysis.

So, in the best year under Trump, U.S. real GDP grew annually by 3%. By contrast, the nation’s economy grew at a faster annual rate  48 times  and under every president before and after Trump dating to 1930, except Barack Obama and Herbert Hoover. The economy grew at more than 3% six of Ronald Reagan’s eight years, including 7.2% in 1984, and it grew 5% or more 10 times under Franklin D. Roosevelt, including 18.9% in 1942.  Under Biden , the GDP grew by 5.8% in 2021 — a post COVID-19 bounce-back — by 1.9% in 2022 and 2.5% in 2023.

Trump’s Was Not Largest Tax Cut in History

As he has many times before, Trump wrongly claimed, “I gave you the largest tax cut in history.” But saying this over and over, as Trump has for years, doesn’t make it any more true.

As  we have been writing  even before the 2017  Tax Cuts and Jobs Act  was enacted into law, while the law provided tax relief to nearly all Americans, it was not the largest tax cut in U.S. history either as a percentage of gross domestic product (the measure preferred by economists) or in inflation-adjusted dollars.

According to a Tax Policy Center  analysis , the law reduced the individual income taxes owed by Americans by about $1,260 on average in 2018. It also reduced the top corporate tax rate from  35% to 21% , beginning in January 2018.

The law signed by Trump was initially projected to cost $1.49 trillion over 10 years,  according to the nonpartisan Joint Committee on Taxation . It could end up costing substantially more if individual tax provisions are extended past 2025. Over the first four years, the average annual cost was estimated to be $185 billion. That was about 0.9% of  gross domestic product  in 2018.

That’s nowhere close to President Ronald Reagan’s 1981 tax cut, which was 2.89% of GDP over a four-year average. That’s according to a  2013 Treasury Department analysis  on the revenue effects of major tax legislation. Five more tax measures since 1940 had an impact larger than 1% of GDP, and the Committee for a Responsible Federal Budget  includes  a 1921 measure as also being larger than the 2017 plan. That’s eighth place for Trump’s “biggest tax cut in our history.”

In inflation-adjusted dollars, the Trump-era tax cut is also less than the American Taxpayer Relief Act of 2012, which comes in at No. 1 with a $320.6 billion cost over a four-year average. And it’s less than tax reductions in 2010 ($210 billion) and 1981 ($208 billion).

Energy Independence

Trump boasted, as he  often does , that “on Jan. 6 [2021], we were energy independent,” implying that’s no longer the case under Biden. But by Trump’s definition, the country remains energy independent.

To be clear, under Trump, the U.S. never stopped  importing  sources of energy,  including crude oil , from other countries. What he likely means is that the country either  produced  more energy than it consumed, or  exported  more energy than it imported. During Trump’s presidency, after years trending in that direction, the U.S. did hit a tipping point where exports of primary energy exceeded energy imports from foreign sources in 2019 and 2020 — the first times that had happened since 1952,  according to  the U.S. Energy Information Administration. 

But contrary to Trump’s suggestion, that has continued in the Biden presidency. The U.S., during Biden’s presidency, has  exported  more energy,  including petroleum , than it imported, and it has  produced  more energy than it consumed. Also, the U.S. is producing record amounts of  oil  and  natural gas  under Biden.

Editor’s note: FactCheck.org does not accept advertising. We rely on grants and individual donations from people like you. Please consider a donation. Credit card donations may be made through  our “Donate” page . If you prefer to give by check, send to: FactCheck.org, Annenberg Public Policy Center, 202 S. 36th St., Philadelphia, PA 19104. 

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Column: Yes, Biden looked and sounded awful. But the debate didn’t change the stark choice we face

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Here’s a terrible thought I could not shake as I watched Thursday’s debate: President Biden looked like a corpse.

Sure, anyone might look pale while standing next to the floridly orange former President Trump, but Biden’s pallor was alarming.

When he was not speaking, Biden’s eyes had a faraway look, and, more distressingly, his mouth was slack. Compared with the overanimated Trump — who scowled, sneered and screwed up his mouth in a pout — Biden’s face looked as if it had been dipped in Botox and frozen.

And his voice! What has happened to our loquacious president’s voice? It was so whispery and phlegmy that I wanted to yell, “Just clear your throat, for God’s sake!”

Biden’s performance Thursday was revelatory, for all the wrong reasons.

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For years, Republicans have tried to make us believe Biden is feeble. They’ve deceptively edited videos to make him look clueless, magnified his every small bumble and exploited his lifelong stutter , which old age seems to have exacerbated.

On Thursday, tragically, he did their work for them .

Trump was, of course, Trump: He spewed a volcano of lies , misstatements, exaggerations and fear-mongering. It seemed as if virtually nothing that came out of his mouth was true, especially his insistence that the United States under Biden has become a worldwide laughingstock, that Putin would never have invaded Ukraine on his watch, that Hamas would never have attacked Israel.

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I recorded the debate and did not watch it until after it was finished. I refused to look at my phone — which was dinging like crazy — because I did not want to be influenced by anyone else’s opinion of what had gone down. I wanted my impressions to be mine alone, free of whatever conventional wisdom was rapidly congealing in the cybersphere. And on Friday morning, I tried not to look at headlines, though it was obvious that Biden had a terrible, terrible night.

I conducted a thought experiment: If I read the transcript , would I be as alarmed by Biden’s performance as I was while watching it on TV? Would his sepulchral presentation be apparent? Would he seem like a man in command of facts and history? Would he, to put it bluntly,make sense?

The answer is a resounding but bittersweet yes, because his substance will ultimately be less important than his geriatric demeanor.

Take the exchange on abortion, which will be a key issue in November, as it has in every election since the Supreme Court overturned Roe vs. Wade two years ago.

Here is Biden: “The idea that the politicians, that the founders wanted the politicians to be the ones making decisions about women’s health, is ridiculous. That’s the last — no politician should be making that decision. A doctor should be making those decisions. That’s how it should be run. That’s what you’re going to do. And if I’m elected, I’m going to restore Roe v. Wade.”

Trump came back with his crazy spigot on blast: “So that means he can take the life of the baby in the ninth month and even after birth, because some states — Democrat-run — take it after birth. Again, the governor — former governor of Virginia: ‘Put the baby down, then we decide what to do with it.’ So he’s in — he’s willing to, as we say, rip the baby out of the womb in the ninth month and kill the baby. Nobody wants that to happen.”

(For years, Trump has been misrepresenting a 2019 statement by then-Virginia Gov. Ralph Northam, a Democrat and pediatric neurologist, about what happens when a nonviable fetus with severe deformities is delivered.)

Trump’s statements are often ludicrous to the point of being nonsensical, but he speaks with the conviction of a pathological liar. During a back-and-forth on immigration, for instance, he spoke forcefully, but I have no idea what he was talking about:

“He decided to open up our border, open up our country to people that are from prisons, people that are from mental institutions, insane asylum, terrorists,” Trump said. “We have the largest number of terrorists coming into our country right now. ... We had the safest border in history. In that final couple of months of my presidency, we had, according to Border Patrol, who is great — and, by the way, who endorsed me for president. But I won’t say that. But they endorsed me for president. Brandon , just speak to him.”

I’m sorry, what?

“I’m not saying no terrorist ever got through,” Biden said of the border. “But the idea they’re emptying their prisons, we’re welcoming these people, that’s simply not true. There’s no data to support what he said. Once again, he’s exaggerating. He’s lying.”

Tell me again, who is confused?

Regarding the economy, the No. 1 issue for most voters, CNN’s Jake Tapper asked Biden, “What do you say to voters who feel they are worse off under your presidency than they were under President Trump?”

“We’ve got to take a look at what I was left when I became president, what Mr. Trump left me,” Biden replied. “We had an economy that was in free fall. The pandemic was so badly handled. Many people were dying. All he said was,’It’s not that serious, just inject a little bleach in your arm. You’ll be all right.’ The economy collapsed. There were no jobs. The unemployment rate rose to 15%. It was terrible.

“And so, what we had to do is try to put things back together again. ... We created 15,000 new jobs. We brought out in a position where we have 800,000 new manufacturing jobs .” (Biden meant to say a total of 15 million new jobs , which his campaign often boasts about.)

Trump’s response to the question was, again, lies and nonsense:

“We had the greatest economy in the history of our country,” he boasted, wrongly . “We have never done so well. Every — everybody was amazed by it. Other countries were copying us. We got hit with COVID. And when we did, we spent the money necessary so we wouldn’t end up in a Great Depression, the likes of which we had in 1929. By the time we finished — so we did a great job. We got a lot of credit for the economy, a lot of credit for the military, and no wars and so many other things. Everything was rocking good.”

Yes, Thursday’s debate was painful to watch. Biden, who has maintained that his age, 81, is irrelevant, can no longer make that claim. His decline is distressing.

And yet whether he bows out of the race or not, the choice facing voters in November is stark: Do we want democracy, or do we want dictatorship? The answer should be obvious.

@robinkabcarian

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Robin Abcarian is an opinion columnist at the Los Angeles Times. She writes about news, politics and culture. Her columns appear on Wednesday and Sunday. Twitter: @AbcarianLAT

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