Occipito posterior

position

By Arambam.Aruna
Definition:
In a vertex presentation where the
occiput is placed posteriorly over
the sacro iliac joint or directly
over the sacrum, it is called an
occipito posterior position
INCIDENCE

- 10% at onset of labour.

- During pregnancy(30-40%)
- Early in labour(10-20%)
- Late in labour(1-2%)
POSITION

Right OP is common than left OP  The right oblique diameter is

because slightly longer than the left one.
- Dextro rotation of the uterus
- Diminished left oblique
diametre by the presence of
sigmoid colon
 Aetiology
 The shape of the pelvis:
(85%)anthropoid and android
pelvises are the most common
cause of occipito-posterior due
to narrow fore-pelvis.
 Others(15%)
 Maternal kyphosis: The
convexity of the foetal back fits
with the concavity of the
lumbar kyphosis.
 High pelvic inclination
 Abnormal uterine
contraction
 Anterior insertion of the
placenta: the foetus
usually faces the placenta
(doubtful).
 Fetal factor contributing  Other causes of
to deflexion of head e.g malpresentations: as
brachy cephaly – placenta praevia,
– pelvic tumours,
– pendulous abdomen,
– polyhydramnios,
– multiple pregnancy.
Idiopathic(10-30%)
 Type
 Primary: It occure late in
pregnancy before the onset of
labour. It occur in association
with anthropoid pelvis
 Secondary: It develops during
labour and in association with
android pelvis
 ANTENATAL DIAGNOSIS
ON INSPECTION:
- There is a saucer shaped depression
at or just below the umbilicus
- The depression is created by 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
ON PALPATION:
- The breech is easily palpated at
the fundus, the back is difficult
to palpate as it is adjacent to the
maternal spine.
- Limbs can be felt on both side
of midline
ON AUSCULTATION:

- The fetal head is not well flexed so the

chest is thrust forward, so F.H.S can
be heard at midline
- Sometime F.H.S can be heard more
easily at the flank on the same side of
the back
Mechanism of labour
SL.NO NAME

1 Flexion

2 Internal rotation of head

3 Crowning

4 Extension

5 Restitution

6 Internal rotation of shoulder

7 Internal rotation of head

8 Lateral flexion
Criteria:
- Lie – longitudinal
- Presentation- vertex
- Attitude- deflexed head
- Denominator- Occiput
- Position- ROP, LOP
- Presenting part- Middle or
anterior part of left parietal bone
The occipito frontal diameter
of 11.5cm lies in the right
oblique diameter of pelvic
brime. The occiput points
to the right sacro iliac
joint and sinciput to left
ileopectineal eminance
1. Flexion: Decend takes place with increase
flexion and occiput is the leading part
2. Internal rotation of head:
Occiput reaches the pelvic floor
1st and rotate forward 3/8th of a
circle along the right side of
pelvis to lie under symphysis
pubis. The shoulder follows
turning 2/8th of a circle from left
to right oblique diameter
Crowning: Occiput escape under the pubic
arch and the head is said to be crown
4. Extension: Sinciput face and chin is born by a movement of
extension and head is born

5. Restitution: Occiput turns 1/8th of the circle toward the right side
and head realign itself with the shoulder.
6. Internal rotation of the shoulder: shoulder enter the pelvis
in right oblique diameter , the anterior shoulder reaches the pelvic
floor 1st and rotate forward 1/8th of a circle along the left side
7. Lateral flexion – Anterior shoulder escape under the symphysis
pubis and posterior shoulder sweap the perineum and the baby is born
by a movement of lateral flexion
 Early diagnosis
Associated
Careful monitoring of labour
complication
Judicious and timely interference
- Contracted
pelvis
- Post CS
pregnancy
Watchful expectancy Early caesarean section - Big baby
- Pre-eclampsia
Persistant occipito
Anterior rotation
posterior position
of occiput(3/8)th

Adequate
spontaneous size of pelvis Mal rotation
Incomplete and
forward fetal status
rotation
Occipito sacreal
position
Ventous/ Non rotation
Deep transverse
Forcep
arrest
Pelvis
adequate
Oblique posterior Head below the level
arrest Of ischeal spine
Head above
ischeal spine
Pelvis
forcep delivery inadequate
Pelvic inadequate Pelvic adequate Baby death LSCS/manual
Rotation and
forcep delivery
forcep LSCS
LSCS
craniotomy
Ventous delivery
MECHANISM OF LABOUR IN UNFAVOURABLE
CONDITION
 In unfavourable condition , the occiput fails to rotate , the cause may
be
– deflexion of head
– weak uterine contraction
– faulty shape of pelvis
1. In complete forward
rotation i.e in case of mild
deflexion of head the
occiput rotates 1/8th of a
circle anteriorly and the
saggital suture comes to lie
in bispinous diameter and
further anterior rotation is
impossible and is called as
deep transverse arrest
2. NON ROTATION- Both sinciput and occiput touches the pelvic
floor simultaneously due to moderate deflexion of head resulting in
non rotation of occiput.this condition is called as oblique posterior
arrest
3. MAL ROTATION: In severe deflexion, the sinciput touches
the pelvic floor 1st resulting in anterior rotation of sinciput 1/8th of a
circle and putting the occiput in the sacreal hallow.This position is
term as occipito sacreal position
4. In favourable condition i,e
with the average size of baby , good
uterine contraction and with
adequate pelvis spontaneous
delivery may occur as face to pubis
delivery. In unfavourable condition
when arrest occure it is called as
occipito sacreal arrest
Management of OPP
Principle:
 strict vigilance with watchful expectancy hoping for descent and
anterior rotation of the occiput
 Timely diagnosis
 judicious and timely interference
MANUAL ROTATION:
PROCEDURE:
-Patient should be place in lithotomy position and general
anaesthesia should be given
- Strict aseptic technique and catheterize the bladder
- Vaginal examination and detect the direction of occiput

Step I
Griping the hand:
 The corresponding hand is introduce
in the vagina in a cone shape manner
after separating labia by 2 finger of
the other hand.
 In occipito transverse
position the four finger
are push in to the
sacreal hollow to be
placed over the
posterior parietal bone
and the thumb is place
over the anterior
parietal bone
In oblique posterior position the 4th finger of partially supinated are
place over the occiput and the thumb is place over the sinciput
STEP II
ROTATION OF THE HEAD
 Attempt is made to make the head flex. The head is to be rotated to
bring the occiput to the anterior side along the shortage route ,
simultaneously the back of fetus is rotated by the external hand from
the flanks to the midline
STEPIII
APPLICATION OF FORCEP
 Following the rotation of the head when the right hand is placed on
the left side of pelvis
 left blade of forcep is to be introduce. When the left hand is used, it is
place on the right side of pelvis after rotation as such the right blade is
to be introduce 1st and the left blade is then to be introduce
underlying the right blade
  Cord presentation and prolapse:
Complications A high head predispose to early
spontaneous rupture of the
 Premature rupture of membrane, which together with an
membranes or its rupture ill fitting presenting part, may
early in labour. result cord prolapse

 Increased incidence of
perinatal mortality.
 Prolonged labour due to
hypotonic or hypertonic inertia.
 Obstructed labour with higher
incidence of rupture uterus.
 Increased incidence of
instrumental and operative
delivery.
 Increased incidence of
trauma to the genital tract.
 Increased incidence of
postpartum haemorrhage
and puerperal infection
 Bibliography
- Fraser and Cooper. Myles textbook of midwives.14 th
edition.churchill livingstone
publication.philadelphia2007. page no 551-557
- Dutta D.C. Text book of obstetrics.6th edition. New
central book publication. kolkata 2006. page no
365-374