Occipito-posterior Position

By Prof Aly Kholeif

Occipito-posterior Position
Definition:
Normal presentation (Vertex) but an abnormal position. The back is directed posteriorly

Incidence:
During pregnancy & early in labor: 30-40 % Late in labor: 10-15%

Etiology:
Android (funnel) pelvis is the most important (why?) Lumbar kyphosis

Occipito-posterior Position
Diagnosis:
Abdominally: (During pregnancy & early in labour) Loss of curvature or some flattening of the abdominal contour The fundal level is usually higher The fetal back is not easily defined Delayed engagement of the fetal head (Deflexion) U/S diagnoses such position easily Vaginally: ( Late in labour) Anterior fontanelle is felt easily towards iliopectineal eminence Posterior fontanelle is felt with difficulty towards sacroiliac joint

Occipito-posterior Position
Fate of Occipito-Posterior: (Mechanism of labor) I. Spontaneous vaginal delivery (mostly) through long anterior rotation or short posterior rotation II. Failure of spontaneous vaginal delivery due to short anterior rotation (deep transverse arrest) or persistent occipito-posterior Factors affecting the mechanism of labor----------- good omens: 1. good uterine action 2. Intact membranes 3. Good shape and size of the pelvis 4. Average sized fetal head 5. Low degree of deflexion of fetal head (causes of deflexion)

Fate of Occipito-Posterior Position

1. Long anterior rotation of the occiput (90%) and delivered spontaneously

2. Short posterior rotation of the occiput and also, delivered spontaneously (Face to pubis)

Fate of Occipito-Posterior Position

3. Incomplete anterior rotation (deep transverse arrest), No spontaneous delivery

4. Non-rotation of the occiput(persistent O P), No spontaneous delivery

Occipito-posterior Position
Complications:

Prolonged labour Premature rupture of membranes Perineal tears (mostly in face to pubis) Syndrome of occipito-posterior: Sluggish uterine action, premature rupture of membranes and perineal tears

Occipito-posterior Position

1. 2.

Management: Prevention of premature rupture of membranes Wait for spontaneous long anterior or short posterior rotation for spontaneous delivery Failure of spontaneous delivery due to deep transverse arrest or persistent OP are managed through: i-Manual rotation and forceps, or ii- Rotation & extraction with vacuum extractor, or iii- More safely through CS

3.

Face Presentation
Definition: Its a cephalic presentation with completely extended fetal head Etiological Types: Primary face: before the onset of labor, fetal causes(anencephaly, fetal thyroid tumors, loop of umbilical cord around the neck) Secondary face: more common, after the onset, secondary to occipito-posterior

Face Presentation
Positions: The mentum is the demnemonitor
1. 2. 3. 4.

Right Mento-Posterior (RMP) Left Mento-Posterior (LMP) Left Mento-Anterior (LMA, the commonest) Right Mento-Anterior (RMA)

RMP

LMP

LMA

RMA

Face Presentation
Mechanism of labour: Engaging diameters Mento-anterior----spontaneous delivery Mento-posterior----mostly undeliverable (WHY?) : The thorax descends at the same time with the head filling the sacral concavity together with arrest of the head above the symphysis pubis

Face Presentation
Management: Mento-anteriorwait &see for spontaneous delivery Mento-posterior---unless there are strong contractions, roomy pelvis and small sized or premature fetus, spontaneous delivery is impossible and CS is a must.

Brow Presentation
Definition: Its a cephalic presentation with the head midway between flexion and extension. Engaging diameters Positions: 1. Fronto-anterior 2. Fronto-posterior Mechanism of labour: No spontaneous vaginal delivery in brow presentation

Brow Presentation
Differential Diagnosis with face presentation Types of brow presentation: 1. Transient brow 2. Persistent brow

No spontaneous delivery in almost all cases, so CS is indicated