MAL POSITION-

OCCIPITO POSTERIOR

A.VIJI
 LEARNING OBJECTIVES

The Students will be able to

• define the malposition & Occipitoposterior

• enumerate the Incidence of Occipitoposterior

• list down the types of it

• Identify the etiology for occipitoposterior position

• discuss the Clinical diagnosis of Occipito posterior.

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 LEARNING OBJECTIVES (CONTD-)

• describe the types of mechanism of occipitoposterior position.

• explain about the mechanism of right occipito posterior position.

• discuss the management of labour

• explain about the mechanism & management of face to pubis &

Deep transverse arrest

• enlist the complications of Occipitoposterior position.

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 INTRODUCTION Malpositions are common cause of abnormal

labour. It complicates 20% of the labour . It is

associated with maternal & fetal morbidity &

mortality. Anticipation, Early identification and prompt

intervention can reduce the risk of complications and

improve outcome . Occipito posterior positions

occurs usually as a variations of the normal but can

also be due to abnormal pelvic configuration.

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 Fetal Position:
DEFINITIONS
Position refers to the relationship of
an arbitrarily chosen portion of the fetal
presenting part to the right or left side
of the maternal birth canal
• Accordingly, with each presentation
there may be two positions, right or left

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DEFINITION (CONTD-)

• The vertex is presenting, but the occiput lies in the

posterior rather than the anterior part of the pelvis.

• In Cephalic presentation when the occiput is in relation to

the posterior quadrants of the pelvis is said to be an

occipito posterior position

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 INCIDENCE

• At the onset of labour, 10% 0f Vertex Presentation are Occipito

posterior Position.
• 2/3rd of occipito posterior position of delivery are result if
malrotation of occipito anterior position.
• 80% of occipito posterior rotate to occipito anterior during labour.
• Among occipito posteroior positions incidence of ROP is 5 times
more than LOP.
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 CAUSES

MATERNAL FETAL

Obesity

Elderly primi(≥ 35)

Abnormal pelvic configuration

Android & Anthropoid pelvis Macrosomia -fetal weight is

more than 4 kg
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 ANDROID &ANTHROPOID
PELVIS

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 RESPONSIBLE FACTORS

Other factors
Placenta praevia
1.Shape of Pelvic Inlet
Pelvic tumours
2.Fetal factors Pendulous abdomen
Polyhydramnios
3.Uterine Factor Multiple pregnancy
 CLASSIFICATION

1. RIGHT OCCIPITO POSTERIOR

2. LEFT OCCIPITO POSTERIOR

3. DIRECT OCCIPITO POSTERIOR

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 DIAGNOSIS OF ROP

Diagnosis during Diagnosis during

Antenatal period labour period

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DIAGNOSIS DURING
ANTENATAL PERIOD Abdominal examination:

1.Listen to the mother

The mother may complain of

backache and she may feel that her
baby’s bottom is very high up against her
ribs. She may report feeling movements
across both sides of her abdomen.
 2.On inspection
DIAGNOSIS DURING ANTENATAL
PERIOD (CONTD-) There is a saucer-shaped
depression at or just below the
umbilicus. This depression is created by

OCCIPITO POSTERIOR
the ‘dip’ between the head and the lower
limbs of the fetus. The outline created by
the high, unengaged head can look like a
full bladder
OCCIPITO ANTERIOR
DIAGNOSIS DURING ANTENATAL PERIOD
(CONTD-) 3.Auscultation
The fetal back is not well flexed so
the chest is thrust forward, therefore
the fetal heart can be heard in the
midline. However, the heart may be
heard more easily at the flank on the
same side as the back.
 DIAGNOSIS DURING ANTENATAL PERIOD (CONTD-)

ABDOMINAL EXAMINATION

INSPECTION Abdomen
. appears flattened, or slightly
depressed, below the umbilicus
.
PALAPATION Umbilical Grip- Fetal breech posterior, Fetal limb
anterior
Pelvic Grip II- Sinciput and occiput is at same
.
level
AUSCULTATION Fetal Heart Rate Heard at Flank

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DIAGNOSIS DURING ANTENATAL PERIOD (CONTD-)

PELVIC EXAMINATION

Early Labour
- Sagital suture in oblique Late labour-
diameter. -Large caput present
- Anterior Fontanel easily felt I n -Perineum gaps much before head
anterior quadrant. distends it and premature straining
-Posterior Fontanel is posterior can occur
Quadrant

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 MECHANISM OF LABOUR IN OCCIPITO POSTERIOR

Normal Mechanism Abnormal Mechanism

of labour of labour
in occipito posterior in occipito Posterior
90% 10%

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Abnormal Mechanism Of Labour In Occipito Posterior

Deep Persistent Direct Occipito

transverse Occipito Posterior
arrest Posterior (Face to Pubis 6%)
1% 3%

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 RELATIONSHIP OF FETAL HEAD TO THE MATERNAL PELVIS

Malposition Occiput points towards Sagittal suture of fetus

in mothers pelvis

Left Occipito Posterior Left sacro iliac joint Left oblique diameter

Right Occipito Right sacro iliac joint Right obliqure diameter

posterior

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 MECHANISM OF LABOUR IN OCCIPITO POSTERIOR- ROP

• LIE - LONGITUDINAL
• ATTITUDE - DEFLEXION OF THE HEAD&BACK
• PRESENTATION - CEPHALIC/VERTEX
• DENOMINATOR - OCCIPUT
• POSITION - ANTERIOR PART OF THE
LEFTPARITAL BONE
• PRESENTING DIAMETERS-
OCCIPITO FRONTAL - 11.5CM BIPARITAL DIAMETER - 9.5CM
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 CARDINAL MOVEMENTS OF MECHANISM OF LABOUR

1. ENGAGEGEMENT
2. FLEXION
3. INTERNAL ROTATION OF THE HEAD
4. CROWNING
5.EXTENSION OF THE HEAD

6.RESTITUTION
7. INTERNAL ROTATION OF THE SHOULDER
8. EXTERNAL ROTATION OF THE HEAD
9.LATERAL FLEXION OF THE BODY
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MECHANISM OF LABOUR -ROP (CONTD-)

1. ENGAGEMENT- Occurs at right oblique diameter of the

pelvis.
2. FLEXION- Descend occurs with increasing flexion& the
occiput is the leading part.
3. INTERNAL ROTATION OF THE HEAD –
• Occiput leads & meets the pelvic floor first& rotates
anteriorly3/8 of the circle along right side of the pelvis to lie under
symphysis pubis
• - The Shoulders rotates 2/8 of the circle.
- A twist in the neck occur
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MECHANISM OF LABOUR -ROP (CONTD-)

•CROWNING- The occiput slips beneath the sub pubic arch & crowning
occurs & the widest diameters (biparietal) is born

•EXTENSION OF THE HEAD- After Crowning Occiput Escapes Under

The Symphysis Pubis & The Sinciput , Chin Sweeps the Perineum &
Head Is Born By Movement Of Extension.

•RESTITUTION- Occiput turns 1/8 of the circle towards the maternal

right

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MECHANISM OF LABOUR -ROP (CONTD-)

• INTERNAL ROTATION OF THE SHOULDER-

The shoulders rotates 1/8 of the circle towards the right anterior shoulder comes under the
symphysis pubis

• EXTERNAL ROTATION OF THE HEAD -The head of the fetus also rotates 1/8 of the circle
along with the shoulders towards mother right.

• LATERAL FLEXION OF THE BODY - The anterior shoulder slips under the symphysis pubis
& posterior shoulder sweeps the perineum remaining part of the fetus born by the movement
of lateral flexion towards mothers abdomen.

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 MANAGEMENT OF LABOUR

First Stage of Labour

Avoid Premature Rupture of the Membrane by-

- Avoid High Enema

- Rest in the bed
- No Straining
- Minimize Vaginal Examination

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MANAGEMENT OF LABOUR (CONTD-)

SECOND STAGE OF LABOUR

Proper care to be taken on perineum because liberal episiotomy
is needed. Since presenting diameter is occipito frontal 11.5 cm &
Biparital 9.5cm.
THIRD STAGE OF LABOUR
Because of prolongation of Labour,tendency of PPH can be
prevented by prophylactic Ergometrine 0.25mg after the delivery
of anterior shoulder.

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 POSSIBLE OUTCOME OF OCCIPITO POSTERIOR

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POSSIBLE OUTCOME OF OCCIPITO POSTERIOR (CONTD-)

1. Persistent occipito posterior-

Non rotation

2. Face to pubis - Mal rotation

3. Deep transverse arrest- Short

anterior rotation.

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 1. PERSISTENT OCCIPITO POSTERIOR POSITION

• In this position, vertex does not rotate but persist in

occipitoposterior position with the sagittal suture in the oblique

diameter of the pelvis is called as Persistent Occipito Posterior

position.

• Operative intervention is required in most.

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 2. FACE TO PUBIS - MAL ROTATION

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 FACE TO PUBIS - MAL ROTATION (CONTD-)

• It is otherwise called as short internal rotation.

• The head descends without increased flexion.

sinciput becomes the leading part . It reaches the pelvic floor

first and rotates forwards to lie under symphysis pubis.
• The baby is born facing the pubis as facing the pubis as face to
pubis delivery.
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 MECHANISM OF LABOUR IN FACE TO PUBIS

1.ENGAGEMENT- The head is engaged in the right oblique diameter.

2.FLEXION- Descend occurs with increasing flexion. On increased
flexion, occiput becomes the leading part.
3.INTERNAL ROTATION OF THE HEAD- In this head is rotated
backward in spite of forward. This rotation is 1/8 of circle due to this
sagittal suture comes to lie in Anterio – Posterior diameter.

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MECHANISM OF LABOUR IN FACE TO PUBIS (CONTD-)

4.CROWNING- With descends of fetus, the root of the nose comes under the
symphysis pubis.

5.DELIVERY OF HEAD- The sinciput comes under symphysis pubis. The head
is delivered by double mechanism of flexion & extension.
6.FLEXION- Occiput descends the perineum when head is in flexion and is
born upto nape of the neck.

7.EXTENSION- The head falls back towards the rectum with the face upward
by the extension, the head is born .

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MECHANISM OF LABOUR IN FACE TO PUBIS (CONTD-)

8.RESTITUTION- The head moves 1/8 of a circle to the right.

9.INTERNAL ROTATION OF SHOULDERS-

The internal rotation of shoulder occurs 1/8 of a circle along with external
rotation of head
10.LATERAL FLEXION- The anterior shoulder escapes under symphysis
pubis and is born followed by posterior shoulder after sweeping the perineum
with the lateral flexion, the whole of body is delivered.
.
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 DIAGNOSIS OF FACE TO PUBIS

• Delay in II stage of labour

• Per vaginal examination reveals that anterior fontanel under
symphysis pubis .
• Sagittal suture in the anterio- posterior diameter.
• There is a upward moulding
• Excessive bulging of the perineum and gaping of the anus
are evident.
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 MANAGEMENT

Management :Refer OCCIPITO POSTERIOR - LONG ROTATION

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 3. SHORT INTERNAL ROTATION-DEEP TRANSVERSE ARREST

• The vertex rotates anteriorly by 45 degree (1/8of a circle).

• This occur mostly in Android pelvis, the flat sacrum and reduced
sacral hollow do not permit posterior rotation.
• The labour is arrested with the sagittal suture in the transverse
diameter of the pelvis, resulting in TRANSVERSE ARREST /DEEP
TRANSVERSE ARREST.
• This may be due to A Straight Sacrum & A narrowed outlet.
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 MECHANISM OF LABOUR IN DEEP TRANVERSE ARREST

1.ENGAGEMENT- The head is engaged in the right oblique diameter.

2.FLEXION- Descend occurs with increasing flexion.

3.INTERNAL ROTATION OF THE HEAD-
The occiput reaches the pelvic floor and begins to rotate forward. It
rotates 1/8 of the circle anteriorly .Further flexion is not maintained &
Occipito frontal diameter caught at the narrow bispinous diameter of the
outlet. Arrest occurs.

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 MANAGEMENT OF DEEP TRANSVERSE ARREST
VAGINAL DELIVERY FOUND SAFE-
1.VACCUM EXTRACTION-
- Apply properly the cup of vaccum extractor to the occipiut , this will promote flexion of head.
- Traction will help and guide the head into pelvis till, it meets the pelvic floor where it will
rotate.
2.MANUAL ROTATION AND EXTRACTION BY FORCEPS-
- The procedures is performed under GA
- The head of the fetus is grasped bi temporarily and is pushed slightly up ward this process
is known as disimpaction.

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MANAGEMENT OF DEEP TRANSVERSE ARREST (CONTD-)

- Flexion of the head & rotation of the occiput anteriorly is done by the right

hand inserted vaginally.

- Rotating the anterior shoulder abdominally towards the midline by the left

hand or an assistant.

- Fix the head abdominally by an assistant , apply forceps & extract it.

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MANAGEMENT OF DEEP TRANSVERSE ARREST (CONTD-)

3.ROTATION AND EXTRACTION BY FORCEPS

-KIELLAND’S FORCEPS- Single application for rotation &extraction of head
as this forceps has a minimal pelvic curve.
-BARTON’S FORCEPS- This fprceps ois originally designed for fdeep
transverse arrest . It has a hinge with in blade between the blade.

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MANAGEMENT OF DEEP TRANSVERSE ARREST (CONTD-)

VAGINAL DELIVERY FOUND UNSAFE-

1.Caesarean section-
Even there certain conditions associated theses are
- Contracted Pelvis
- Placenta praevia
- Prolapsed cord
- Elderly primigravida
2.Craniotomy- This procedure is performed rarely and is done when the fetus is dead.

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 COMPLICATIONS

MATERNAL
 Prolonged Labour
 Pre labour Rupture of membrane
 Prolapse of the cord
 Anal Sphincter injuries
 Oxytocin augmentation
 Instrumental delivery
 Cesarean section

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COMPLICATIONS (CONTD-)

FETAL
 5 minute APGAR –Low
 Meconium Aspiration
 Hypoxic ischemic Encephalopathy
 Birth Trauma
 Admission Neonatal Intensive Care Unit

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 SUMMARY

So for we have discussed about Occipito posterior positions

and it outcome . This will help for early identification and prompt

intervention which turn into reduction of complications of occipito

posterior position

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