- Email: [email protected]
Management of Occiput Posterior Position
Management of Occiput Posterior Position Jocelyn Hart, CNM, MS, and Amy Walker, CNM, MS
A 27-year-old, para 1 at 40 1/7 weeks’ gestation presented to the labor and delivery unit in labor. Her prenatal course was uncomplicated, and her previous obstetric history included a vaginal delivery of a full-term 7-pound, 9-ounce male infant. She described her first birth as being “straightforward.” It was 10 hours in length, and she received an epidural for analgesia. Upon this admission, she stated that she had been having regular, painful contractions for the past 10 hours. Her cervix was 1 cm dilated, 50% effaced, and the fetus was at –3 station. The membranes were intact. She was experiencing intensely painful contractions every 2 to 3 minutes, and reported severe back pain and exhaustion. Leopold’s maneuvers revealed small parts on the left anterior side, and the fetal back was difficult to palpate, consistent with an occiput posterior (OP) position. Per hospital protocol, she was confined to bed rest and placed on continuous fetal and uterine monitoring. Five hours after admission, her membranes ruptured spontaneously with clear fluid. The fetus was then at –2 station, and her cervix had dilated to 4 cm and was 80% effaced. She reported increased pain and requested an epidural, hoping to get some rest. After the epidural was placed, her contractions became irregular (every 3–10 min), and as a result, oxytocin augmentation was started. Approximately 1 hour later, the external uterine monitor began failing to record contractions, and an intrauterine pressure catheter was placed. Ten hours after admission, and 4 hours after oxytocin was started, her cervix had dilated to 7 cm. Despite several epidural boluses, she continued to experience severe back pain, and a belly binder was applied as a relief measure. Throughout her labor, she stayed in bed with position changes that were limited to left lateral and right lateral. Cervical dilatation did not progress beyond 7 cm, and no fetal descent occurred over the next 4 hours, despite progressive oxytocin augmentation and an adequate contraction pattern based on Montevideo units. The midwife collaborated with the attending obstetrician and a cesarean section was recommended for failure to progress. A healthy baby boy who was noted to be in direct OP position was born via cesarean section with Apgar scores of 9/9. He weighed 8 pounds, 10 ounces.
OCCIPUT POSTERIOR POSITION Occiput posterior is the most common abnormal fetal position.1 The prevalence of OP position in term, vertex, singleton labors has been shown to range from 10% to 25% during the early stage of labor and 10% to 15% during the active phase, and is more common in nulliparas than multiparas.2 OP positions at birth occur approximately 5% of the time, and may result from malrotation of an original occiput anterior (OA) position or a persistent OP that has failed to rotate anteriorly.3 The OP position is associated with a higher rate of complications
Address correspondence to Amy Walker, CNM, MS, Montachusett Women’s Health, 100 Hospital Rd., Suite 1B, Leominster, MA 01453. E-mail: [email protected]
508 © 2007 by the American College of Nurse-Midwives Issued by Elsevier Inc.
during labor and birth, including prolonged labor, dystocia, chorioamnionitis, third and fourth degree lacerations, operative vaginal delivery, and cesarean section.2 Women who are in labor with a fetus in an OP position use epidural analgesia for pain management more frequently than women whose fetuses rotate to OA during the course of labor. The rate of spontaneous vaginal delivery may be as low as 26% for nulliparous women and 57% for multiparous women with persistent OP fetuses.2
ETIOLOGY OF OCCIPUT POSTERIOR Most obstetric textbooks explain that the majority of fetuses in vertex presentation begin descent through the pelvic inlet with the sagittal suture in the transverse pelvic diameter (OT). As the fetal head descends, it encounters resistance from the cervix, walls of the pelvis, and levator muscles, causing further flexion of the head. The head then internally rotates so that the occiput gradually moves from a left or right position anteriorly toward the symphysis pubis, or less commonly, toward the hollow of the pelvis for an OP position.1 The shape of the pelvis may influence the position of the occiput. Android and anthropoid pelvises are more prone to facilitating rotation into the OP position because the narrower bitemporal diameter of the fetal head can be better accommodated by the relatively small forepelvis. The mechanism of labor when the fetus is in the OP position is usually identical to that observed when the vertex is in the transverse or anterior position, except that in order for the birth to occur with the fetus in the OA position, the occiput has to internally rotate to the symphysis pubis 135°, instead of 90° or 45°, which are the arcs of rotation that occur if the fetus is in the OT or OA position.4 With effective contractions, adequate flexion of the head, and a fetus of average size, 87% of OP fetuses rotate to anterior positions when they reach the pelvic floor.1 If this is true, persistent OP is the result of labor starting in an OP position and failing to rotate to OA.1 However, this explanation may not be entirely correct according to a 1998 study by Gardberg, who used ultrasound to record the position of the occiput in 408 women in labor who were at term, singleton, with vertex presentations. In his study, two-thirds of OP births occurred through malrotation of an OA fetus during the active phase of labor.3 Volume 52, No. 5, September/October 2007 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2006.10.018
COMPLICATIONS ASSOCIATED WITH PERSISTENT OCCIPUT POSTERIOR POSITION The complications associated with persistent OP position can be attributed to relative cephalopelvic disproportion.1 Contractions will be less efficient and first stage will take longer because the vertex in an OP position is a less effective dilating wedge than when it is in the OA position. As the woman nears full dilatation, persistent anterior lip, cervical edema, and rarely cervical lacerations may occur as the force of the contractions is exerted anteriorly on the portion of cervix trapped between the fetal head and the symphysis pubis.5 If the occiput remains in the direct OP position, the anterior–posterior diameter of the OP fetal vertex that presents in the pelvic outlet is greater than the anterior–posterior diameter that presents when the fetus is in the OA position. If flexion of the head is inadequate, an even greater presenting anterior–posterior diameter will result.1 This disproportion results in a greater risk of vaginal and perineal lacerations and operative birth.2 Longer labors associated with OP position can cause fatigue of the uterine muscle and predispose the woman to a postpartum hemorrhage.2 Furthermore, a long and painful labor can rob the woman of much joy and excitement in childbirth. Ponkey et al.2 compared the outcomes of 360 women whose fetus was in an OP position just prior to birth to the outcomes of 6094 women whose fetus was in an OA position just prior to birth. There were no differences between the groups with regard to demographic characteristics, parity, weight, or body mass index. The women with a fetus in OP position had a higher incidence of labor ⬎12 hours (49.7% vs. 26.2%; P ⬍ .001), assisted vaginal delivery (24.6% vs. 9.4%), cesarean section (37.7% vs. 6.6%), and third or forth degree lacerations (18.2% vs. 6.7%; P ⬍ .001).2 Persistent OP position can cause complications in the neonate as well. Cheng et al.6 compared the outcomes of 31,392 women who were at term and had cephalic singleton births. They found that women with infants born in OP position had higher risks for 5-minute Apgar score ⬍7 (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17–1.91), acidemic cord gases (OR 2.05, 95% CI 1.52–2.77), meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17–1.42), birth trauma (OR 1.77, 95% CI 1.22–2.57), admission to the neonatal intensive care unit (OR 1.57, 95% CI 1.28 –1.92), and longer stay in the hospital (OR 2.69, 95% CI 2.22–3.25). The authors hypothesize that these results are most likely caused by
Jocelyn Hart, CNM, MS, is a recent graduate of Columbia University’s Midwifery program. She practices at the Morris Heights Women’s Health and Birthing Center in the Bronx. Amy Walker, CNM, MS, practices full scope midwifery at Montachusett Women’s Health in Leominster, Massachusetts. Ms. Wallker is recent graduate from the Columbia University Nurse Midwifery Program.
Journal of Midwifery & Women’s Health • www.jmwh.org
longer labors because of the relative cephalopelvic disproportion with an OP fetus, or higher rates of chorioamnionitis, a “downstream effect” observed in women with OP fetuses.6 Given the fact that women with OP fetuses experience longer labors and higher rates of interventions including operative delivery, it is not surprising that their neonates would suffer adverse outcomes as well. PREVENTION AND RISK FACTORS There has been much attention on prevention of OP throughout pregnancy and/or attempting to rotate a fetus suspected to be in the OP position before labor. While studies have had conflicting results on this topic, theoretically entering labor with a fetus in a left occiput anterior (LOA) position provides less of a chance that the fetus will rotate to OP than if the fetus is in a right occiput anterior (ROA) position.4 In their book Understanding and Teaching Optimal Foetal Positioning, Sutton and Scott warn that too many hours spent in reclining positions may promote an OP fetus.7 The authors theorize that when a pregnant woman assumes a reclining position, the angle between the pelvic brim and the spine is reduced from approximately 120° to 90°, decreasing the space in the anterior pelvis. In order to balance in this position, the pregnant woman may also cross her legs, which compounds the problem.7 The authors advise that, near term, pregnant women should avoid: 1) relaxing while semi-reclined; 2) sitting with legs crossed; and 3) deep squatting.7 Recommended postures and exercises to encourage rotation or maintain anterior positioning include upright and forward postures, hands-and-knees, using an ergonomic kneeling chair or birth ball, swimming, and yoga.7 Perhaps the greatest risk factor for OP presentation is the “couch potato” lifestyle. People are far less physically active and fit now more than any other time in the history of the human race. Our leisure time is spent sitting in slouching positions watching television, at the computer, reading, etc.7 When a woman rests in a semi-sitting/reclined position, OP position is encouraged. The fetal back is heavier than the small parts and therefore will shift to rest along the maternal back, as in a hammock. It is very possible that a fetus may maintain an OP position until labor starts and enter the pelvic brim in this position.7 Unfortunately, except for hands-andknees positioning, studies have not yet been performed on these postures and exercises. However there is much anecdotal support for their use. Other studies have examined antenatal use of handsand-knees positioning in combination with pelvic rocks and/or abdominal stroking toward the side opposite the fetal occiput. Andrews and Andrews8 found that the immediate effects of hands-and-knees posturing on OP position with 10 minutes in the hands-and-knees position with or without pelvic rocks and/or abdominal stroking 509
in comparison to 10 minutes of sitting was effective in promoting fetal rotation. Abdominal stroking can also be used during labor and should be done between contractions. A study by Kariminia et al.9 determined the incidence of OP position at birth in women using hands-and-knees with slow pelvic rocking for 10 minutes, twice daily, from 37 weeks’ gestation until labor. They found no significant difference in the number of babies born in persistent OP position between the intervention group (n ⫽ 105/1292, 8.1%) and the control group (n ⫽ 98/1255, 7.8%). DIAGNOSIS OF OCCIPUT POSTERIOR DURING LABOR A fetus may begin labor in OP position or it may rotate to OP spontaneously after labor has begun. Recognition and correction as early as possible is important to facilitate labor progress and increase the woman’s comfort. Women who enter labor after 40 weeks are more likely to have a fetus in OP positions.5 It is thought that the fetal head applies ineffective pressure to the cervix when in the OP position, delaying initiation of labor and slowing cervical dilation.5 Prolonged rupture of membranes or early rupture of membranes is also more common.5 Uneven pressure is put on the amniotic membranes, causing increased stress and earlier rupture. OP labor often begins with an unengaged fetal head. In a nulliparous labor, this should alert the midwife to the possibility that the fetus is in an OP position.5 During labor, be alert for variable decelerations. They may be caused by head compression from the additional pressure exerted on the fetal occiput and do not require treatment as long as variability is maintained and the baseline rate is normal.10 Leopold’s maneuvers can be very helpful in the diagnosis of OP. Eighty-five percent of OP positions will be right occiput posterior4 with the fetal small parts palpable against the left side of the maternal abdominal wall. If the fetus is direct OP with back lying against the maternal back, the contour of the mother’s abdomen may be somewhat knobby because of the anterior direction of the fetal small parts, and a depression near the umbilicus is often observed.5 The fetal heart tones will most easily be auscultated near the maternal flank (usually the right side) because of the location of the fetal back. In a study by Lydon-Rochelle et al.11 the authors assessed the accuracy of Leopold’s maneuvers on non-laboring women in their third trimester of pregnancy. Their data showed both high sensitivity (n ⫽ 23/26, 88%) and high specificity (n ⫽ 116/124, 94%) in determining cephalic versus noncephalic fetal presentation. While it is important to consider that this study was solely looking at fetal presentation and not position, this data provides a strong argument for the reliability of Leopold’s maneuvers. Vaginal exam will also be an important tool to determine position. If the fetus is in the ROP position, on 510
vaginal exam, the anterior fontanel will be in the anterior portion of the pelvis.5 However, caput succedaneum formation is common in the OP fetus and the fontanels and sutures can be difficult to palpate. Zahalka et al.12 compared use of transvaginal sonography with transabdominal sonography and digital vaginal exam to determine fetal position in the second stage of labor in 60 women when the head was between ⫹2 and ⫹3 on a 0 –3 scale. The authors found that transvaginal sonography was more accurate than either transabdominal sonography or digital exam. Fetal head position was accurately determined in all cases by transvaginal ultrasound. Position could not be determined in 7 cases with digital exam and 9 cases with transabdominal sonography (P ⬍ .03; P ⬍ .008), though when position could be determined, transabdominal ultrasound was more accurate than digital exam.12 They also found a 60° or greater difference in position between the digital exam and transabdominal sonography in 13 of 60 cases (21.7%) and between digital exam and transvaginal sonography in 14 of 60 cases (23.3%).12 They found a difference in position greater than or equal to 90° in 9 of 60 cases (15%) comparing digital exam and transabdominal sonography and in 12 of 60 cases (20%) when comparing transvaginal sonography and digital exam (P ⬍ .02).12 The goal of the study was to give practitioners a more accurate tool to determine fetal position prior to using forceps or vacuum, and the authors conclude with the recommendation that transvaginal sonography be used routinely in the labor room.12 Transvaginal sonography is most accurate for determining the position of the occiput during labor.3 However, routine use of such technology is not cost-effective or even necessary. Development of fundamental manual and observational skills are essential and should be adequate. In addition to clinical signs, it is important to pay close attention to the mother’s subjective experience. Many women experiencing OP labors will report severe back pain as the occiput puts pressure on the sacral nerves. They may report, “My back feels like it’s being sawed in half” and experience back pain whether a contraction is present or not. The urge to push well before complete cervical dilation—in some cases as early as 2 cm—is common and caused by overstimulation of the sacral nerves.5 This can make labor support extremely challenging, as many women are unable to resist bearing down for hours of labor. If at any point the clinician has reasonable clinical evidence that a fetus is OP, measures should be taken immediately to facilitate rotation. MANAGEMENT OF OP Management of OP position should be expectant and foster the goal of spontaneous vaginal delivery, preferably with anterior rotation. To facilitate rotation of the fetal head, active participation of the mother with posiVolume 52, No. 5, September/October 2007
tion changes during the first and second stages is necessary. In the event these actions fail, assisted vaginal delivery or cesarean section may be required. If the membranes are intact, try to preserve them as long as possible. Loss of amniotic fluid reduces the fetus’s buoyancy, making rotation more difficult. The fluid also serves as a cushion and without it, the woman’s perception of contraction pain may intensify to the point that she cannot cope.5 Anecdotally, there are many labor positions that may aid rotation (as well as a few to avoid in an OP labor, such as semi-sitting and supine).13 Recommended positions include the open knee-chest position, which is best used in latent phase labor or prior to engagement. It provides for release of pressure between the fetal head and the cervix and allows rotation or flexion to occur more easily and should be used for at least 35 to 40 minutes.13 The abdominal lift acts in a similar fashion but can be used through first stage and into second. The woman hugs her belly and gently lifts the fetus up. This position helps to align the long axis of the fetus with the axis of the pelvic inlet, improves rotation and can alleviate back pain.13 The lunge is another good first stage position to assist rotation. The woman stands facing forward with a chair at her side. She raises her foot (on the same side the occiput is facing) and places it on the chair. Maintaining an upright posture, she shifts her weight (lunges) into her foot on the chair. She remains in that position for a few seconds and then comes back upright, repeating this pattern for several contractions.13 It is critical that a support person be close by to help her balance. While randomized controlled trials on the efficacy of such positions have not been conducted, many midwives have found these positions to be helpful. More research in this area is needed. Although hands-and-knees positioning has not been shown to be effective in reducing the incidence of OP position when done antenatally, it may be effective when used in labor. The hands-and-knees position works to align the fetus with the pelvic inlet and increases the internal transverse diameter of the pelvis. It also allows for easy movement, such as swaying and rocking, which rotates the sacroiliac joint and results in elevation of the sacrum and coccyx to increase the anterior–posterior diameter of the pelvic midpelvis and outlet, which can facilitate fetal descent.14 This position also provides easy access for sacral-counter pressure that many women find helpful. Furthermore, the spinal-pelvic angle remains open, creating a discrepancy in the level of the spines which allows the fetal head to pass through more easily.14 A multi-center randomized controlled trial of hands-and-knees positioning for OP position during labor had women in the intervention group perform 30 to 60 minutes of the hands-and-knees position during labor followed by position of maternal preference. Although this was a small study of 147 participants, they found that Journal of Midwifery & Women’s Health • www.jmwh.org
more women (n ⫽ 11/70; 16%) experienced fetal head rotation into the OA position in the intervention group compared to the control group (n ⫽ 5/77; 7%) following the 1-hour intervention. (RR 2.4; 95% CI 0.88 – 6.62; number needed to treat 11).15 Of the women in the intervention group, 41 of 70 (59%) birthed with the fetal head in the OA position as compared to 36 of 77 (47%) in the control group.15 While these values are not statistically significant, there is a positive trend toward fetal head rotation with the intervention group indicating that hands-and-knees position can be helpful when a woman is experiencing an OP labor. If the woman has an epidural or is unable to get out of bed, side-lying can be helpful in turning the fetus from OP to OT. The woman should lie on the same side as the fetal occiput and back (“baby’s back toward bed”). Ask her to lie on this side for 15 to 30 minutes to encourage rotation. She should then ideally kneel and lean forward for 15 to 30 minutes to encourage rotation from OT to OA.13 If the woman is in semi-prone position (exaggerated Sims), she should lie on the side opposite the fetal occiput for 15 to 30 minutes. In this position, her pelvis is rotated so that the anterior side is pointing more toward the bed which alters the forces of gravity on the fetus and encourages OP to OT to OA rotation.13 Spontaneous vaginal delivery without rotation can be anticipated in approximately 40% of persistent OP positions, if the pelvic outlet is roomy and/or the woman is multiparous.1 However, a reduced pelvic outlet capacity and/or strong, resistant vaginal muscles may cause prolonged late first stage and/or second stage.1 There are several positions that widen the pelvic outlet which can create more room for the larger diameter of the OP presenting fetal head. These positions should not be attempted until the fetus is well engaged because they widen the pelvic outlet by shrinking the inlet.13 The double hip squeeze, in which pressure is applied to the anterior iliac crests, and the squatting position are two examples. Use of a birthing chair has also been shown to widen the pelvic outlet.14 Manual rotation can be attempted when full dilatation has been reached if rotation secondary to position change has failed. While studies on manual rotation are limited, a recent retrospective cohort study looked at all women who had an attempt of manual rotation from OP or OT position at the University of California at San Francisco between the years 1976 and 2001.16 Seventy-four percent (n ⫽ 549/742) of the women had a successful manual rotation and delivered vaginally in the OA position.16 The analysis found that women ⬍35 years of age and those who were multiparous were more likely to experience successful manual rotation. Factors associated with cesarean delivery after attempted manual rotation included nulliparity, ⱖ35 years of age, induction of labor, and epidural analgesia. Of women who had a successful manual rotation, only 2.1% birthed by cesarean section.16 511
Before attempting manual rotation, the posterior ear is first located to confirm the position. It is prudent to wait a few moments for spontaneous rotation of the occiput, which occasionally happens as a result of this first step.1 If no rotation occurs, the head is grasped with the fingers over one ear and the thumb over the other and rotation is attempted with the next contraction.1 Pain management should be addressed for any woman in labor, but especially for women with OP labors. The randomized trial of hands-and-knees positioning for OP position in labor found that this position change resulted in a significant reduction in persistent back pain.15 Not only did many of these women use hands-and-knees position for labor after the study period, but 84% of the women surveyed (both in the intervention and control group) stated that they would use this position in a future labor.15 Back pain may be alleviated when the woman assumes a position that leaves her abdomen “hanging.” Positions include forward-bending with palms braced against a wall or using a bed sheet or rebozo to cradle the uterus and “lift” it out of the abdomen. Although epidural analgesia may provide excellent pain control, it also causes diminished abdominal muscular tone and relaxes the levator muscles of the pelvic floor, predisposing the fetus to incomplete rotation.17 The use of epidural analgesia has been associated with a higher rate of persistent OP position and may actually increase the occurrence of OP at birth, contributing to higher rates of assisted vaginal birth and cesarean section.17 Thus non-pharmacological comfort measures, especially those that allow and encourage free movement by the laboring woman, are recommended. These include warm or cold packs placed on the sacral or suprapubic area, counter-pressure applied to the sacral area, low back massage, sterile water papules, use of a transcutaneous electro-nerve stimulator unit, and whirlpool baths to help with relaxation.13 While non-intervention based care is a hallmark of midwifery, identifying the correct time to call for medical back-up is important. In the developed world, cesarean section is most often the appropriate action for true labor dystocia secondary to failure of fetal rotation, especially in the presence of an abnormal fetal heart pattern.18 The World Health Organization created a set of guidelines specifically for use in the developing world, where the rate of maternal morbidity is much higher.19 These guidelines state that assisted vaginal delivery by vacuum or forceps is indicated when labor arrests at full dilatation and the leading bony edge of the fetal head is at 0 station.18 If the leading bony edge of the head is between 0 station and –2 station, the guidelines call for delivery by vacuum extraction with symphysiotomy.18 Symphysiotomy is an arguably more extreme measure than cesarean section, and therefore not an option in 512
places with access to safe cesarean birth. The risks of the procedure include urethral and bladder injury, infection, pain, and long-term difficulty walking.18 However, in parts of the developing world, there may be limited options for care. Globally, obstructed labor, which may be caused by fetal malpresentation, malposition, or pelvic deformity, accounts for approximately 8% of maternal deaths.20 This statistic is most likely an understatement, because deaths from complications of obstructed labor are counted separately. Complications can include uterine rupture, infection, and postpartum hemorrhage.20 CONCLUSION Clearly, management of OP position is clinically challenging, even for the most experienced of midwives. Discussion with a woman who has a previous history of OP position in labor may be helpful during prenatal care. The midwife can teach the woman how to recognize the position of her fetus and postures to maintain during pregnancy to prevent the development of OP; studies have not shown that these positions correct an OP position, but they may have some effect in preventing an OP position. She should also be taught symptoms of OP in early labor and techniques she can use before coming to the hospital or birth center to encourage rotation. Once she is in your care, management of a woman with an OP fetus should support physical activity throughout labor. If one position fails to provide the desired result, try another. Use a variety or non-pharmacological pain-relief techniques, including back massage. Resist the urge to perform artificial rupture of membranes. Delaying placement of an epidural in women who have a preference for an unmedicated birth may be of benefit. In this instance, one-on-one support and extensive use of non-pharmacologic methods will be required. Management of OP position is a special challenge in the hospital where one-on-one midwifery care may be impossible and the woman may be confined to bed. But in cases of suspected cephalopelvic disproportion, labor dystocia, or extremely slow progress, always rule out OP position and try to correct it before moving on to other measures. REFERENCES 1. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC III, Hauth JC, Wenstrom KD. Williams obstetrics (22nd ed.). New York: McGraw-Hill Professional, 2005. 2. Ponkey S, Cohen A, Heffner L, Lieberman E. Persistent fetal occiput posterior position: Obstetric outcomes. Obstet Gynecol 2003;101:915–20. 3. Gardberg M, Laakkonen E, Salevaara M. Intrapartum sonography and persistent occiput posterior position: A study of 408 deliveries. Obstet Gynecol 1998;91:746 –9.
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4. Oxorn H, Foote W. Human labor and birth (5th ed.). Norwalk (CT): Appleton-Century-Crofts, 1986.
mination of fetal head position in the second stage of labor. Am J Obstet Gynecol 2005;193:381– 6.
5. Biancuzzo M. How to recognize and rotate an occiput posterior fetus. Am J Nurs 1993;3:38 – 41.
13. Simkin P, Ancheta R. The labor progress handbook. Oxford: Blackwell Science, 2004.
6. Cheng Y, Shaffer B, Caughey A. The association between persistent occiput posterior position and neonatal outcomes. Obstet Gynecol 2006;107:837– 44. 7. Sutton J, Scott P. Understanding and teaching optimal foetal positioning. Tauranga (New Zealand): Birth Concepts, 1995. 8. Andrews CM, Andrews EC. Nursing, maternal postures, and fetal position. Nurs Res 1983;32:336 – 41. 9. Kariminia A, Chamberlain ME, Keogh J, Shea A. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. Br Med J 2004; 328:490 –5. 10. Ingemarsson E, Ingemarsson I, Solum T, Westgren M. Influence of occiput posterior position on the fetal heart rate pattern. Obstet Gynecol 1980;55:301–3.
14. Kelly FW, Terry R, Naglieri R. A review of alternative birthing positions. J Am Osteopath Assoc 1999;99:470 – 4. 15. Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth 2005;32:243–51. 16. Shaffer B, Cheng Y, Vargas J, Laros R, Caughey A. Manual rotation of the fetal occiput: Predictors of success and delivery. Obstet Gynecol 2006;194:e7–9. 17. Lieberman E, Davidson K, Lee-Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol 2005;105:974 – 82. 18. Department of Reproductive Health and Research, World Health Organization. Malpositions and malpresentations. In: Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Geneva: World Health Organization, 2003, pp. 172– 84.
11. Lydon-Rochelle M, Albers L, Gorwoda J, Craig E, Qualls C. Accuracy of Leopold maneuvers in screening for malpresentation: A prospective study. Birth 1993;20:132–5.
19. Department of Reproductive Health and Research, World Health Organization. Maternal mortality in 2000. Geneva: World Health Organization, 2004.
12. Zahalka N, Sadan O, Malinger G, Liberati M, Boaz M, Glezerman M, et al. Comparison of transvaginal sonography with digital examination and transabdominal sonography for the deter-
20. Division of Reproductive Health, World Health Organization. Maternal mortality: World health day—Safe motherhood. Geneva: World Health Organization, 1998. pp. 1–3.
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A 27-year-old, para 1 at 40 1/7 weeks’ gestation presented to the labor and delivery unit in labor. Her prenatal course was uncomplicated, and her previous obstetric history included a vaginal delivery of a full-term 7-pound, 9-ounce male infant. She described her first birth as being “straightforward.” It was 10 hours in length, and she received an epidural for analgesia. Upon this admission, she stated that she had been having regular, painful contractions for the past 10 hours. Her cervix was 1 cm dilated, 50% effaced, and the fetus was at –3 station. The membranes were intact. She was experiencing intensely painful contractions every 2 to 3 minutes, and reported severe back pain and exhaustion. Leopold’s maneuvers revealed small parts on the left anterior side, and the fetal back was difficult to palpate, consistent with an occiput posterior (OP) position. Per hospital protocol, she was confined to bed rest and placed on continuous fetal and uterine monitoring. Five hours after admission, her membranes ruptured spontaneously with clear fluid. The fetus was then at –2 station, and her cervix had dilated to 4 cm and was 80% effaced. She reported increased pain and requested an epidural, hoping to get some rest. After the epidural was placed, her contractions became irregular (every 3–10 min), and as a result, oxytocin augmentation was started. Approximately 1 hour later, the external uterine monitor began failing to record contractions, and an intrauterine pressure catheter was placed. Ten hours after admission, and 4 hours after oxytocin was started, her cervix had dilated to 7 cm. Despite several epidural boluses, she continued to experience severe back pain, and a belly binder was applied as a relief measure. Throughout her labor, she stayed in bed with position changes that were limited to left lateral and right lateral. Cervical dilatation did not progress beyond 7 cm, and no fetal descent occurred over the next 4 hours, despite progressive oxytocin augmentation and an adequate contraction pattern based on Montevideo units. The midwife collaborated with the attending obstetrician and a cesarean section was recommended for failure to progress. A healthy baby boy who was noted to be in direct OP position was born via cesarean section with Apgar scores of 9/9. He weighed 8 pounds, 10 ounces.
OCCIPUT POSTERIOR POSITION Occiput posterior is the most common abnormal fetal position.1 The prevalence of OP position in term, vertex, singleton labors has been shown to range from 10% to 25% during the early stage of labor and 10% to 15% during the active phase, and is more common in nulliparas than multiparas.2 OP positions at birth occur approximately 5% of the time, and may result from malrotation of an original occiput anterior (OA) position or a persistent OP that has failed to rotate anteriorly.3 The OP position is associated with a higher rate of complications
Address correspondence to Amy Walker, CNM, MS, Montachusett Women’s Health, 100 Hospital Rd., Suite 1B, Leominster, MA 01453. E-mail: [email protected]
508 © 2007 by the American College of Nurse-Midwives Issued by Elsevier Inc.
during labor and birth, including prolonged labor, dystocia, chorioamnionitis, third and fourth degree lacerations, operative vaginal delivery, and cesarean section.2 Women who are in labor with a fetus in an OP position use epidural analgesia for pain management more frequently than women whose fetuses rotate to OA during the course of labor. The rate of spontaneous vaginal delivery may be as low as 26% for nulliparous women and 57% for multiparous women with persistent OP fetuses.2
ETIOLOGY OF OCCIPUT POSTERIOR Most obstetric textbooks explain that the majority of fetuses in vertex presentation begin descent through the pelvic inlet with the sagittal suture in the transverse pelvic diameter (OT). As the fetal head descends, it encounters resistance from the cervix, walls of the pelvis, and levator muscles, causing further flexion of the head. The head then internally rotates so that the occiput gradually moves from a left or right position anteriorly toward the symphysis pubis, or less commonly, toward the hollow of the pelvis for an OP position.1 The shape of the pelvis may influence the position of the occiput. Android and anthropoid pelvises are more prone to facilitating rotation into the OP position because the narrower bitemporal diameter of the fetal head can be better accommodated by the relatively small forepelvis. The mechanism of labor when the fetus is in the OP position is usually identical to that observed when the vertex is in the transverse or anterior position, except that in order for the birth to occur with the fetus in the OA position, the occiput has to internally rotate to the symphysis pubis 135°, instead of 90° or 45°, which are the arcs of rotation that occur if the fetus is in the OT or OA position.4 With effective contractions, adequate flexion of the head, and a fetus of average size, 87% of OP fetuses rotate to anterior positions when they reach the pelvic floor.1 If this is true, persistent OP is the result of labor starting in an OP position and failing to rotate to OA.1 However, this explanation may not be entirely correct according to a 1998 study by Gardberg, who used ultrasound to record the position of the occiput in 408 women in labor who were at term, singleton, with vertex presentations. In his study, two-thirds of OP births occurred through malrotation of an OA fetus during the active phase of labor.3 Volume 52, No. 5, September/October 2007 1526-9523/07/$32.00 • doi:10.1016/j.jmwh.2006.10.018
COMPLICATIONS ASSOCIATED WITH PERSISTENT OCCIPUT POSTERIOR POSITION The complications associated with persistent OP position can be attributed to relative cephalopelvic disproportion.1 Contractions will be less efficient and first stage will take longer because the vertex in an OP position is a less effective dilating wedge than when it is in the OA position. As the woman nears full dilatation, persistent anterior lip, cervical edema, and rarely cervical lacerations may occur as the force of the contractions is exerted anteriorly on the portion of cervix trapped between the fetal head and the symphysis pubis.5 If the occiput remains in the direct OP position, the anterior–posterior diameter of the OP fetal vertex that presents in the pelvic outlet is greater than the anterior–posterior diameter that presents when the fetus is in the OA position. If flexion of the head is inadequate, an even greater presenting anterior–posterior diameter will result.1 This disproportion results in a greater risk of vaginal and perineal lacerations and operative birth.2 Longer labors associated with OP position can cause fatigue of the uterine muscle and predispose the woman to a postpartum hemorrhage.2 Furthermore, a long and painful labor can rob the woman of much joy and excitement in childbirth. Ponkey et al.2 compared the outcomes of 360 women whose fetus was in an OP position just prior to birth to the outcomes of 6094 women whose fetus was in an OA position just prior to birth. There were no differences between the groups with regard to demographic characteristics, parity, weight, or body mass index. The women with a fetus in OP position had a higher incidence of labor ⬎12 hours (49.7% vs. 26.2%; P ⬍ .001), assisted vaginal delivery (24.6% vs. 9.4%), cesarean section (37.7% vs. 6.6%), and third or forth degree lacerations (18.2% vs. 6.7%; P ⬍ .001).2 Persistent OP position can cause complications in the neonate as well. Cheng et al.6 compared the outcomes of 31,392 women who were at term and had cephalic singleton births. They found that women with infants born in OP position had higher risks for 5-minute Apgar score ⬍7 (adjusted odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17–1.91), acidemic cord gases (OR 2.05, 95% CI 1.52–2.77), meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17–1.42), birth trauma (OR 1.77, 95% CI 1.22–2.57), admission to the neonatal intensive care unit (OR 1.57, 95% CI 1.28 –1.92), and longer stay in the hospital (OR 2.69, 95% CI 2.22–3.25). The authors hypothesize that these results are most likely caused by
Jocelyn Hart, CNM, MS, is a recent graduate of Columbia University’s Midwifery program. She practices at the Morris Heights Women’s Health and Birthing Center in the Bronx. Amy Walker, CNM, MS, practices full scope midwifery at Montachusett Women’s Health in Leominster, Massachusetts. Ms. Wallker is recent graduate from the Columbia University Nurse Midwifery Program.
Journal of Midwifery & Women’s Health • www.jmwh.org
longer labors because of the relative cephalopelvic disproportion with an OP fetus, or higher rates of chorioamnionitis, a “downstream effect” observed in women with OP fetuses.6 Given the fact that women with OP fetuses experience longer labors and higher rates of interventions including operative delivery, it is not surprising that their neonates would suffer adverse outcomes as well. PREVENTION AND RISK FACTORS There has been much attention on prevention of OP throughout pregnancy and/or attempting to rotate a fetus suspected to be in the OP position before labor. While studies have had conflicting results on this topic, theoretically entering labor with a fetus in a left occiput anterior (LOA) position provides less of a chance that the fetus will rotate to OP than if the fetus is in a right occiput anterior (ROA) position.4 In their book Understanding and Teaching Optimal Foetal Positioning, Sutton and Scott warn that too many hours spent in reclining positions may promote an OP fetus.7 The authors theorize that when a pregnant woman assumes a reclining position, the angle between the pelvic brim and the spine is reduced from approximately 120° to 90°, decreasing the space in the anterior pelvis. In order to balance in this position, the pregnant woman may also cross her legs, which compounds the problem.7 The authors advise that, near term, pregnant women should avoid: 1) relaxing while semi-reclined; 2) sitting with legs crossed; and 3) deep squatting.7 Recommended postures and exercises to encourage rotation or maintain anterior positioning include upright and forward postures, hands-and-knees, using an ergonomic kneeling chair or birth ball, swimming, and yoga.7 Perhaps the greatest risk factor for OP presentation is the “couch potato” lifestyle. People are far less physically active and fit now more than any other time in the history of the human race. Our leisure time is spent sitting in slouching positions watching television, at the computer, reading, etc.7 When a woman rests in a semi-sitting/reclined position, OP position is encouraged. The fetal back is heavier than the small parts and therefore will shift to rest along the maternal back, as in a hammock. It is very possible that a fetus may maintain an OP position until labor starts and enter the pelvic brim in this position.7 Unfortunately, except for hands-andknees positioning, studies have not yet been performed on these postures and exercises. However there is much anecdotal support for their use. Other studies have examined antenatal use of handsand-knees positioning in combination with pelvic rocks and/or abdominal stroking toward the side opposite the fetal occiput. Andrews and Andrews8 found that the immediate effects of hands-and-knees posturing on OP position with 10 minutes in the hands-and-knees position with or without pelvic rocks and/or abdominal stroking 509
in comparison to 10 minutes of sitting was effective in promoting fetal rotation. Abdominal stroking can also be used during labor and should be done between contractions. A study by Kariminia et al.9 determined the incidence of OP position at birth in women using hands-and-knees with slow pelvic rocking for 10 minutes, twice daily, from 37 weeks’ gestation until labor. They found no significant difference in the number of babies born in persistent OP position between the intervention group (n ⫽ 105/1292, 8.1%) and the control group (n ⫽ 98/1255, 7.8%). DIAGNOSIS OF OCCIPUT POSTERIOR DURING LABOR A fetus may begin labor in OP position or it may rotate to OP spontaneously after labor has begun. Recognition and correction as early as possible is important to facilitate labor progress and increase the woman’s comfort. Women who enter labor after 40 weeks are more likely to have a fetus in OP positions.5 It is thought that the fetal head applies ineffective pressure to the cervix when in the OP position, delaying initiation of labor and slowing cervical dilation.5 Prolonged rupture of membranes or early rupture of membranes is also more common.5 Uneven pressure is put on the amniotic membranes, causing increased stress and earlier rupture. OP labor often begins with an unengaged fetal head. In a nulliparous labor, this should alert the midwife to the possibility that the fetus is in an OP position.5 During labor, be alert for variable decelerations. They may be caused by head compression from the additional pressure exerted on the fetal occiput and do not require treatment as long as variability is maintained and the baseline rate is normal.10 Leopold’s maneuvers can be very helpful in the diagnosis of OP. Eighty-five percent of OP positions will be right occiput posterior4 with the fetal small parts palpable against the left side of the maternal abdominal wall. If the fetus is direct OP with back lying against the maternal back, the contour of the mother’s abdomen may be somewhat knobby because of the anterior direction of the fetal small parts, and a depression near the umbilicus is often observed.5 The fetal heart tones will most easily be auscultated near the maternal flank (usually the right side) because of the location of the fetal back. In a study by Lydon-Rochelle et al.11 the authors assessed the accuracy of Leopold’s maneuvers on non-laboring women in their third trimester of pregnancy. Their data showed both high sensitivity (n ⫽ 23/26, 88%) and high specificity (n ⫽ 116/124, 94%) in determining cephalic versus noncephalic fetal presentation. While it is important to consider that this study was solely looking at fetal presentation and not position, this data provides a strong argument for the reliability of Leopold’s maneuvers. Vaginal exam will also be an important tool to determine position. If the fetus is in the ROP position, on 510
vaginal exam, the anterior fontanel will be in the anterior portion of the pelvis.5 However, caput succedaneum formation is common in the OP fetus and the fontanels and sutures can be difficult to palpate. Zahalka et al.12 compared use of transvaginal sonography with transabdominal sonography and digital vaginal exam to determine fetal position in the second stage of labor in 60 women when the head was between ⫹2 and ⫹3 on a 0 –3 scale. The authors found that transvaginal sonography was more accurate than either transabdominal sonography or digital exam. Fetal head position was accurately determined in all cases by transvaginal ultrasound. Position could not be determined in 7 cases with digital exam and 9 cases with transabdominal sonography (P ⬍ .03; P ⬍ .008), though when position could be determined, transabdominal ultrasound was more accurate than digital exam.12 They also found a 60° or greater difference in position between the digital exam and transabdominal sonography in 13 of 60 cases (21.7%) and between digital exam and transvaginal sonography in 14 of 60 cases (23.3%).12 They found a difference in position greater than or equal to 90° in 9 of 60 cases (15%) comparing digital exam and transabdominal sonography and in 12 of 60 cases (20%) when comparing transvaginal sonography and digital exam (P ⬍ .02).12 The goal of the study was to give practitioners a more accurate tool to determine fetal position prior to using forceps or vacuum, and the authors conclude with the recommendation that transvaginal sonography be used routinely in the labor room.12 Transvaginal sonography is most accurate for determining the position of the occiput during labor.3 However, routine use of such technology is not cost-effective or even necessary. Development of fundamental manual and observational skills are essential and should be adequate. In addition to clinical signs, it is important to pay close attention to the mother’s subjective experience. Many women experiencing OP labors will report severe back pain as the occiput puts pressure on the sacral nerves. They may report, “My back feels like it’s being sawed in half” and experience back pain whether a contraction is present or not. The urge to push well before complete cervical dilation—in some cases as early as 2 cm—is common and caused by overstimulation of the sacral nerves.5 This can make labor support extremely challenging, as many women are unable to resist bearing down for hours of labor. If at any point the clinician has reasonable clinical evidence that a fetus is OP, measures should be taken immediately to facilitate rotation. MANAGEMENT OF OP Management of OP position should be expectant and foster the goal of spontaneous vaginal delivery, preferably with anterior rotation. To facilitate rotation of the fetal head, active participation of the mother with posiVolume 52, No. 5, September/October 2007
tion changes during the first and second stages is necessary. In the event these actions fail, assisted vaginal delivery or cesarean section may be required. If the membranes are intact, try to preserve them as long as possible. Loss of amniotic fluid reduces the fetus’s buoyancy, making rotation more difficult. The fluid also serves as a cushion and without it, the woman’s perception of contraction pain may intensify to the point that she cannot cope.5 Anecdotally, there are many labor positions that may aid rotation (as well as a few to avoid in an OP labor, such as semi-sitting and supine).13 Recommended positions include the open knee-chest position, which is best used in latent phase labor or prior to engagement. It provides for release of pressure between the fetal head and the cervix and allows rotation or flexion to occur more easily and should be used for at least 35 to 40 minutes.13 The abdominal lift acts in a similar fashion but can be used through first stage and into second. The woman hugs her belly and gently lifts the fetus up. This position helps to align the long axis of the fetus with the axis of the pelvic inlet, improves rotation and can alleviate back pain.13 The lunge is another good first stage position to assist rotation. The woman stands facing forward with a chair at her side. She raises her foot (on the same side the occiput is facing) and places it on the chair. Maintaining an upright posture, she shifts her weight (lunges) into her foot on the chair. She remains in that position for a few seconds and then comes back upright, repeating this pattern for several contractions.13 It is critical that a support person be close by to help her balance. While randomized controlled trials on the efficacy of such positions have not been conducted, many midwives have found these positions to be helpful. More research in this area is needed. Although hands-and-knees positioning has not been shown to be effective in reducing the incidence of OP position when done antenatally, it may be effective when used in labor. The hands-and-knees position works to align the fetus with the pelvic inlet and increases the internal transverse diameter of the pelvis. It also allows for easy movement, such as swaying and rocking, which rotates the sacroiliac joint and results in elevation of the sacrum and coccyx to increase the anterior–posterior diameter of the pelvic midpelvis and outlet, which can facilitate fetal descent.14 This position also provides easy access for sacral-counter pressure that many women find helpful. Furthermore, the spinal-pelvic angle remains open, creating a discrepancy in the level of the spines which allows the fetal head to pass through more easily.14 A multi-center randomized controlled trial of hands-and-knees positioning for OP position during labor had women in the intervention group perform 30 to 60 minutes of the hands-and-knees position during labor followed by position of maternal preference. Although this was a small study of 147 participants, they found that Journal of Midwifery & Women’s Health • www.jmwh.org
more women (n ⫽ 11/70; 16%) experienced fetal head rotation into the OA position in the intervention group compared to the control group (n ⫽ 5/77; 7%) following the 1-hour intervention. (RR 2.4; 95% CI 0.88 – 6.62; number needed to treat 11).15 Of the women in the intervention group, 41 of 70 (59%) birthed with the fetal head in the OA position as compared to 36 of 77 (47%) in the control group.15 While these values are not statistically significant, there is a positive trend toward fetal head rotation with the intervention group indicating that hands-and-knees position can be helpful when a woman is experiencing an OP labor. If the woman has an epidural or is unable to get out of bed, side-lying can be helpful in turning the fetus from OP to OT. The woman should lie on the same side as the fetal occiput and back (“baby’s back toward bed”). Ask her to lie on this side for 15 to 30 minutes to encourage rotation. She should then ideally kneel and lean forward for 15 to 30 minutes to encourage rotation from OT to OA.13 If the woman is in semi-prone position (exaggerated Sims), she should lie on the side opposite the fetal occiput for 15 to 30 minutes. In this position, her pelvis is rotated so that the anterior side is pointing more toward the bed which alters the forces of gravity on the fetus and encourages OP to OT to OA rotation.13 Spontaneous vaginal delivery without rotation can be anticipated in approximately 40% of persistent OP positions, if the pelvic outlet is roomy and/or the woman is multiparous.1 However, a reduced pelvic outlet capacity and/or strong, resistant vaginal muscles may cause prolonged late first stage and/or second stage.1 There are several positions that widen the pelvic outlet which can create more room for the larger diameter of the OP presenting fetal head. These positions should not be attempted until the fetus is well engaged because they widen the pelvic outlet by shrinking the inlet.13 The double hip squeeze, in which pressure is applied to the anterior iliac crests, and the squatting position are two examples. Use of a birthing chair has also been shown to widen the pelvic outlet.14 Manual rotation can be attempted when full dilatation has been reached if rotation secondary to position change has failed. While studies on manual rotation are limited, a recent retrospective cohort study looked at all women who had an attempt of manual rotation from OP or OT position at the University of California at San Francisco between the years 1976 and 2001.16 Seventy-four percent (n ⫽ 549/742) of the women had a successful manual rotation and delivered vaginally in the OA position.16 The analysis found that women ⬍35 years of age and those who were multiparous were more likely to experience successful manual rotation. Factors associated with cesarean delivery after attempted manual rotation included nulliparity, ⱖ35 years of age, induction of labor, and epidural analgesia. Of women who had a successful manual rotation, only 2.1% birthed by cesarean section.16 511
Before attempting manual rotation, the posterior ear is first located to confirm the position. It is prudent to wait a few moments for spontaneous rotation of the occiput, which occasionally happens as a result of this first step.1 If no rotation occurs, the head is grasped with the fingers over one ear and the thumb over the other and rotation is attempted with the next contraction.1 Pain management should be addressed for any woman in labor, but especially for women with OP labors. The randomized trial of hands-and-knees positioning for OP position in labor found that this position change resulted in a significant reduction in persistent back pain.15 Not only did many of these women use hands-and-knees position for labor after the study period, but 84% of the women surveyed (both in the intervention and control group) stated that they would use this position in a future labor.15 Back pain may be alleviated when the woman assumes a position that leaves her abdomen “hanging.” Positions include forward-bending with palms braced against a wall or using a bed sheet or rebozo to cradle the uterus and “lift” it out of the abdomen. Although epidural analgesia may provide excellent pain control, it also causes diminished abdominal muscular tone and relaxes the levator muscles of the pelvic floor, predisposing the fetus to incomplete rotation.17 The use of epidural analgesia has been associated with a higher rate of persistent OP position and may actually increase the occurrence of OP at birth, contributing to higher rates of assisted vaginal birth and cesarean section.17 Thus non-pharmacological comfort measures, especially those that allow and encourage free movement by the laboring woman, are recommended. These include warm or cold packs placed on the sacral or suprapubic area, counter-pressure applied to the sacral area, low back massage, sterile water papules, use of a transcutaneous electro-nerve stimulator unit, and whirlpool baths to help with relaxation.13 While non-intervention based care is a hallmark of midwifery, identifying the correct time to call for medical back-up is important. In the developed world, cesarean section is most often the appropriate action for true labor dystocia secondary to failure of fetal rotation, especially in the presence of an abnormal fetal heart pattern.18 The World Health Organization created a set of guidelines specifically for use in the developing world, where the rate of maternal morbidity is much higher.19 These guidelines state that assisted vaginal delivery by vacuum or forceps is indicated when labor arrests at full dilatation and the leading bony edge of the fetal head is at 0 station.18 If the leading bony edge of the head is between 0 station and –2 station, the guidelines call for delivery by vacuum extraction with symphysiotomy.18 Symphysiotomy is an arguably more extreme measure than cesarean section, and therefore not an option in 512
places with access to safe cesarean birth. The risks of the procedure include urethral and bladder injury, infection, pain, and long-term difficulty walking.18 However, in parts of the developing world, there may be limited options for care. Globally, obstructed labor, which may be caused by fetal malpresentation, malposition, or pelvic deformity, accounts for approximately 8% of maternal deaths.20 This statistic is most likely an understatement, because deaths from complications of obstructed labor are counted separately. Complications can include uterine rupture, infection, and postpartum hemorrhage.20 CONCLUSION Clearly, management of OP position is clinically challenging, even for the most experienced of midwives. Discussion with a woman who has a previous history of OP position in labor may be helpful during prenatal care. The midwife can teach the woman how to recognize the position of her fetus and postures to maintain during pregnancy to prevent the development of OP; studies have not shown that these positions correct an OP position, but they may have some effect in preventing an OP position. She should also be taught symptoms of OP in early labor and techniques she can use before coming to the hospital or birth center to encourage rotation. Once she is in your care, management of a woman with an OP fetus should support physical activity throughout labor. If one position fails to provide the desired result, try another. Use a variety or non-pharmacological pain-relief techniques, including back massage. Resist the urge to perform artificial rupture of membranes. Delaying placement of an epidural in women who have a preference for an unmedicated birth may be of benefit. In this instance, one-on-one support and extensive use of non-pharmacologic methods will be required. Management of OP position is a special challenge in the hospital where one-on-one midwifery care may be impossible and the woman may be confined to bed. But in cases of suspected cephalopelvic disproportion, labor dystocia, or extremely slow progress, always rule out OP position and try to correct it before moving on to other measures. REFERENCES 1. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC III, Hauth JC, Wenstrom KD. Williams obstetrics (22nd ed.). New York: McGraw-Hill Professional, 2005. 2. Ponkey S, Cohen A, Heffner L, Lieberman E. Persistent fetal occiput posterior position: Obstetric outcomes. Obstet Gynecol 2003;101:915–20. 3. Gardberg M, Laakkonen E, Salevaara M. Intrapartum sonography and persistent occiput posterior position: A study of 408 deliveries. Obstet Gynecol 1998;91:746 –9.
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4. Oxorn H, Foote W. Human labor and birth (5th ed.). Norwalk (CT): Appleton-Century-Crofts, 1986.
mination of fetal head position in the second stage of labor. Am J Obstet Gynecol 2005;193:381– 6.
5. Biancuzzo M. How to recognize and rotate an occiput posterior fetus. Am J Nurs 1993;3:38 – 41.
13. Simkin P, Ancheta R. The labor progress handbook. Oxford: Blackwell Science, 2004.
6. Cheng Y, Shaffer B, Caughey A. The association between persistent occiput posterior position and neonatal outcomes. Obstet Gynecol 2006;107:837– 44. 7. Sutton J, Scott P. Understanding and teaching optimal foetal positioning. Tauranga (New Zealand): Birth Concepts, 1995. 8. Andrews CM, Andrews EC. Nursing, maternal postures, and fetal position. Nurs Res 1983;32:336 – 41. 9. Kariminia A, Chamberlain ME, Keogh J, Shea A. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. Br Med J 2004; 328:490 –5. 10. Ingemarsson E, Ingemarsson I, Solum T, Westgren M. Influence of occiput posterior position on the fetal heart rate pattern. Obstet Gynecol 1980;55:301–3.
14. Kelly FW, Terry R, Naglieri R. A review of alternative birthing positions. J Am Osteopath Assoc 1999;99:470 – 4. 15. Stremler R, Hodnett E, Petryshen P, Stevens B, Weston J, Willan AR. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth 2005;32:243–51. 16. Shaffer B, Cheng Y, Vargas J, Laros R, Caughey A. Manual rotation of the fetal occiput: Predictors of success and delivery. Obstet Gynecol 2006;194:e7–9. 17. Lieberman E, Davidson K, Lee-Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol 2005;105:974 – 82. 18. Department of Reproductive Health and Research, World Health Organization. Malpositions and malpresentations. In: Managing complications in pregnancy and childbirth: A guide for midwives and doctors. Geneva: World Health Organization, 2003, pp. 172– 84.
11. Lydon-Rochelle M, Albers L, Gorwoda J, Craig E, Qualls C. Accuracy of Leopold maneuvers in screening for malpresentation: A prospective study. Birth 1993;20:132–5.
19. Department of Reproductive Health and Research, World Health Organization. Maternal mortality in 2000. Geneva: World Health Organization, 2004.
12. Zahalka N, Sadan O, Malinger G, Liberati M, Boaz M, Glezerman M, et al. Comparison of transvaginal sonography with digital examination and transabdominal sonography for the deter-
20. Division of Reproductive Health, World Health Organization. Maternal mortality: World health day—Safe motherhood. Geneva: World Health Organization, 1998. pp. 1–3.
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