Malposition

 It is the vertex position where the occiput is placed

posteriorly over the sacro-ilical joint or directly over the
sacrum, it is called an occipito-posterior position.

 When the occiput is placed over the right sacroiliac joint,

the position is called right occipito posterior (R.O.P)
position and when placed over the left sacro-iliac joint, is
called left occipito posterior (L.O.P) position.

 When it points towards the sacrum it is called direct

occipito posterior position.
 Occipito-posterior position
 Occipito-posterior position is an abnormal position of the
vertex rather than an abnormal presentation.

 Occurs in approximately 10% of labours.

 A persistent occipito-posterior position results from

a failure of internal rotation prior to birth.

 Occurs in 5% of the births.

 ROP is five times more common than LOP

 Causes
 The direct cause is often unknown. But the following are
the responsible factors:

 Shape of the pelvic inlet: associated with

either an
anthropoid or android pelvis.

 Fetal factors: Marked deflexion of fetal head.

 Uterine factors: Abnormal uterine contraction

 Abdominal examination
Listen to the mother: Complain of backache and she may feel that
her baby’s bottom is very high up against her ribs.
Inspection: Palpation:
• Fetal limbs are felt more easily
•Abdomen looks flat, below the near midline on either side.
umbilicus. •Fetal back is felt far away from
midline on flank.
•Presence of saucer
shaped depression. • Anterior shoulder lies far
away
• The outline created by from midline.
high, unengaged head can • Head is not engaged.
look like a full bladder
• Cephalic prominence is not
felt
so much prominent
Most common cause of non engagement in a primigravida at term.
Comparison of abdominal contour in (A) posterior and (B) anterior
positions of the occiput
 Examination cont…
Auscultation Vaginal examination
•The fetal back is not well • Elongated bag of membranes
flexed so chest is thrust
forward, therefore the •Sagittal suture occupies any of
fetal heart can be heard the oblique diameters of pelvis.
in the midline.
•Posterior fontanelle is felt
•Heart rate may be heard near the sacro-iliac joint
more easily at the flank on
the same side as the back. •Anterior fontanelle is felt more
easily
 In late labour, the diagnosis is often difficult because of
caput formation.
 In such cases, the ear is to be located and the unfolded
pinna points towards the occiput.
 Fate of OPP
OPP
Engaging diameter :- occipito-frontal
11.5cm or sub-occipitofrontal 10cm.

Unfavorable (10%)
Favorable (90%)

3/8th rotation Mild deflexion Moderate deflexion Severe deflexion

occipit comes under Occiput rotate by Non-rotation Occiput rotate

symphysis pubis (rt/lt 1/8th circle posteriorly by 1/8th
occipito anterior) Oblique
posterior POPP/ occipito-
Deep
Normal vaginal delivery arrest sacral position
transverse
arrest
Face to pubis delivery Arrest
 Mechanism of labour
 Head engages through right oblique diameter in ROP
and left oblique diameter in LOP.

 The engaging transverse diameter of head is biparietal

(9.5 cm) and that of AP diameter is either SOF (10 cm)
or OF (11.5 cm).

 Because of deflexion engagement is delayed.

 Mechanism of labour cont…

 Lie: longitudinal
 The attitude of the head is deflexed
 Presentation: vertex
 Position: Right occipitoposterior
 Denomi nator: Occiput
 Presenti ng part: Middle or of left parietal
bone anterior area

 The OF right oblique

diameter
d of the pelvic
iameter brim.
11.5 cmThe occiput points to the
right sacroiliac
lies jointin and the
the sinciput to the left
iliopectineal eminence.
 Mechanism of labour cont…
 Flexion: Descent takes place with increasing flexion. The
occiput becomes the leading part.

 Internal rotation of head: Occiput reaches pelvic floor

first and rotates forwards 3/8th of a circle along a right
side of pelvis to lie under the symphysis pubis. The
shoulders follow, turning 2/8th of a circle from left to right
oblique diameter.

 Crowning: Occiput escapes under the symphysis pubis

and the head is crowned.

 Extension: Sinciput, face and chin sweep perineum and

head is born by a movement of extension.
 Mechanism of labour cont…
 Restitution: Occiput turns 1/8th of circle to the right.
 Internal rotation of shoulders: Shoulders enter the pelvis
in right oblique diameter; anterior shoulder reaches
pelvic floor first and rotates forwards 1/8th of circle to lie
under the symphysis pubis.
 External rotation of head: Occiput turns a further 1/8 of a
circle to the right.
 Lateral flexion: Anterior shoulder escapes under the
symphysis pubis, posterior shoulder sweeps perineum
and body is born by a movement of lateral flexion.
Mechanism of labour in right occipito posterior diameter
Mechanism of face to pubis delivery
 Further descent occurs until the root of nose hinges
under symphysis pubis.
 Flexion occurs —releasing successively the brow, vertex
and occiput out of the stretched perineum and then the
face is born by extension.
 Restitution: Head moves 1/8th of circle in opposite
direction of internal rotation thus turning the face to look
towards the mother’s left thigh in ROP and right thigh in
LOP.
 External rotation: Occiput further rotates to the same
direction of restitution to 1/8th of a circle placing finally
face looking directly towards the left thigh in ROP and
the right thigh in LOP.
 Persistent Occipito posterior
 It is an abnormal mechanism of the occipito posterior
position where there is malrotation of the occiput
posteriorly towards the sacral hollow.

 Delivery may occur spontaneously as face to pubis but

arrest may occur in this position and is called occipito
sacral arrest

 Cause: Failure of flexion

 Delivery of head in a persistent
occipitoposterior position

Allowing the sinciput to escape as far as the glabella and

the occiput sweeps the perineum, sinciput held back to
maintain flexion
 Delivery of head in a persistent
occipitoposterior position

Grasping the head to bring the face down from under the
symphysis pubis and Extension of the head
Upward moulding (dotted line) following
persistent occipito posterior position
 Deep transverse arrest
 The head is deep into the cavity, the sagittal suture is
placed in the transverse bipsinous diameter and there is
no prognosis in descent of the head even after ½ -1 hour
following full dilatation of cervix.

 May be end result of incomplete anterior rotation of the

oblique OPP, or it may be due to non rotation of the
commonly primary occipito transverse position of normal
mechanism of labour.
 Deep transverse arrest cont…
Causes:
 Faulty pelvic architecture
 Prominent ischial spine,
 Flat sacrum and convergent side walls,
 Deflexion of head,
 Weak uterine contraction,
 Laxity of the pelvic floor muscles.

Diagnosis
 Head is engaged
 Sagittal suture lies in transverse bispinous diameter,
 Anterior fontanelle is palpable,
 Faulty pelvic architecture may be detected.
 Deep transverse arrest cont…
Management:
 Vaginal delivery is found safe.

 Ventouse
 Manual rotation and application of forceps
 Forceps rotation and delivery with Keilland in
hands of an expert.
 Vaginal delivery is not safe: caesarean section.
 Craniotomy in dead pelvis.
 Diagnosis of OP position
First stage of labour:
 Signs are those of any posterior position of occiput,
namely a deflexed head and the fetal heart heard in the
flank or in the midline.
 Descent is slow

Second stage of labour:

 Delay is common.

 Vaginal examination: Anterior fontanelle is felt behind

symphysis pubis. If the pinna of the ear is felt pointing
towards the mothers sacrum, this indicates a posterior
position.
 Diagnosis of OP position cont..
The birth
 Sinciput will first emerge from under symphysis pubis as
far as the root of the nose and flexion should be
maintained by restraining it from escaping further than
the glabella, allowing the occiput to sweep the perineum
and be born.

 Extends the head by grasping it and bringing the

face
down from under the symphysis pubis.

 Perineal trauma and PPH are common. An episiotomy

may be required, owing to the larger presenting
diameter.
 Mode of delivery
 Long anterior rotation of the occiput: Spontaneous
or aided vaginal delivery usually occurs (90%)
 Short posterior rotation: Spontaneous or aided
vaginal
delivery may occur as face to pubis.
 Non-rotation or short rotation:
anterior
Spontaneous vaginal delivery is unlikely exceptin
circumstances.
favourable
 Moulding: The characteristic moulding of head occurs in
face to pubis delivery. There is compression of the
occipito-frontal diameter with elongation of the vault at
right angle to it. The frontal bones are displaced beneath
the parietal bones.
 Management of labour
 Diagnosis and evaluation: Fetal back on the flank
FHS not being easily
with early rupture of
located, membranes should suspicion.Internal
examination
arouseisthe
confirmatory.

 Pelvic assessment: Inclination of pelvis, configuration of

inlet, sacrum, ischial spines and the side walls are to be
noted.

 Early caesarean section: Pelvic inadequacy or

unfavourable
its configuration, along with obstetric
complications like, preeclampsia, post
pregnancy, big baby caesarean
 Management of labour cont..
First stage: In uncomplicated cases, the labour is allowed
to proceed in a manner similar to normal labour.
 Intravenous infusion is started.

 Progress of labour is judged

 Weak pain, persistence of deflexion and nonrotation of
the occiput are the triad too often coexistent. In such
situation, oxytocin infusion is started for augmentation of
labour.
 Indication of caesarean section arrest of labour,
incoordinate uterine action, fetal distress.
 Management of labour cont..
Second stage: In majority anterior rotation of the occiput is
completed and the delivery is either spontaneous or can be
accomplished by low forceps or ventouse.
 In minority: watchful expectancy for anterior rotation of the
occiput and descent of the head.
 In occipito-sacral position, spontaneous delivery of face to
pubis may occur.

Third stage:
 Tendency of PPH can be prevented by prophylactic IV
ergometrine 0.25 mg with the delivery of anterior shoulder.

 Following vaginal delivery meticulous inspection of the

cervix and lower genital tract should be made to detect any
injury.
 Care in labour
First stage of labour
 Continuous support

 Provide physical support: Back massage and other

comfort
measures and suggest changes of posture and position.

 Prevent the mother from being dehydrated or ketotic.

 Oxytocin infusion

 Change in position and the use of breathing techniques

or inhalational analgesia to enhance relaxation.

 Suggest the women the alternative method of pain relief.

 Care in labour cont…
Second stage of labour
 Confirm full dilatation of cervix by vaginal examination. If the
head is not visible at the onset of second stage of labour
encourage the women to remain in upright position.

 Closely monitor the maternal and fetal conditions throughout

the second stage.

 The length of second stage is generally increased when the

occiput is posterior and there is increased likelihood of
operative delivery.
 Complications
Obstructed labour

Cerebral hemorrhage

Maternal trauma

Neonatal trauma

Cord prolapse
 References
1. Fraser DM, Cooper MA. Myles Textbook for
Midwives.15th edition. Philadelphia:Churchill livingstone
elsevier;2009

2. Dutta DC. Textbook of obstetrics. 6th edition.

Calcutta:New central book agency;2004

3. Pillitteri A. Maternal and child health nursing. Care of

the childbearing and childrearing family. Sixth edition.
Philadelphia; Lippincott Williams & Wilkins: 2010.

4. Cunningham, Leveno, Bloom. William’s obstetrics. 23rd

edition. United states of America; Mcgraw Hill
companies: 2010.