The Persistent Occipitoposterior Position: A Guide to Delivery
– Occipito-posterior position is a malposition in which the baby’s back is directed posteriorly during a vertex presentation
– Occipito-posterior position occurs in approximately 10% of labors
– Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP)
– Causes of occipito-posterior position include the shape of the pelvis (anthropoid and android pelvises are common causes), maternal kyphosis, anterior insertion of the placenta, and other malpresentations such as placenta previa, pelvic tumors, pendulous abdomen, polyhydramnios, and multiple pregnancy
– Diagnosis during pregnancy can be done through inspection, palpation, and auscultation
– Complications of occipito-posterior position include premature rupture of membranes, cord presentation and prolapse, prolonged labor, obstructed labor, increased incidence of instrumental and operative delivery, trauma to the genital tract, postpartum hemorrhage, and perinatal mortality
– The persistent occipitoposterior position occurs in about 3% of cases
– Long internal rotation, occurring in about 90% of cases, allows for delivery to proceed as in normal labor
– Direct occipitoposterior position occurs in about 6% of cases and can be managed by spontaneous delivery or with the aid of outlet forceps
– Deep transverse arrest occurs in 1% of cases and requires vacuum extraction or manual rotation and extraction with forceps
– Vacuum extraction can be used for rotation of the head, while manual rotation and extraction with forceps is done under general anesthesia
– Different types of forceps, such as Kielland’s forceps and Barton’s forceps, can be used for rotation and extraction of the head in persistent occipitoposterior position
– The Scanzoni double application method, which is considered hazardous, involves applying forceps twice for rotation and extraction
– If other methods fail, a Caesarean section may be necessary. Other indications for a C-section include contracted pelvis, placenta previa, prolapsed pulsating cord, and elderly primigravida
– Craniotomy may be performed if the fetus is dead
– Vacuum extraction and Caesarean section are the commonly used methods in modern obstetrics for managing persistent occipitoposterior position