Occipito Posterior Position

Occipito Posterior Position

Right Occipito-Posterior Position-Long Rotation

Although the vertex is a normal presentation, the course of labour can border on the abnormal when the Occipito occupies a posterior instead of an anterior part of the pelvis.

Diagnosis of (Right Occipito-Posterior)

Abdominal Examination

On inspection there is a saucer-shaped depression at or immediately below the umbilicus, the high head with the depression above it looks rather like a full bladder. On palpation: the head is high

The head feels unduly large; this is due to the larger circumference of the deflexed head.

The occiput and sinciput are on the same level.

The back is difficult to palpate because it is placed well out on the right side.

Limbs are felt on both sides of the midline.

On auscultation the fetal heart beat will be located in the right flank, somewhat muffled as the muscles there are thick. It may also be heard in the midline near the umbilicus or slightly to the left.

Diagnosis during labour

Posterior position should be suspected where there is no disproportion and a vertex presentation is held up at the brim in spite of good uterine action.

On vaginal examination: locating the anterior fontanelle to the left anterior is diagnostic of an R.O.P. The sagittal suture will be in the right oblique diameter of the pelvis... The large caput may make identification of sutures and fontanelles difficult

Outcome of Labour

Long internal rotation of the head commonly takes place and the baby is born normally.

Short internal rotation of the head takes place and the baby is born face to pubes.

Deep transverse arrest of the head occurs in the pelvis which has projecting ischial spines that inhibit forward rotation of the head. Labour may be prolonged because larger diameters of the skull present, the deflexed head does not dilate the cervix effectively. The necessity for interference is greater. Epidural analgesia may be used for backache.

Rotation of the head may have to be assisted manually or by forceps; application of forceps is frequently required because of delay in the second stage, or on account of fetal or maternal distress.

The fetal mortality and morbidity rates are higher because of intracranial injury and hypoxia.

Summary of Clinical Features

The head descends slowly, even when there are good contractions.

The uterine contractions are sometimes weak. Dilatation of the cervix is retarded.

The membranes usually rupture early.

Backache is frequently complained of.

Difficulty in micturition is common.

The urge to bear down at the end of the first stage is especially great, probably because the occiput is pressing on the rectum.

Nursing care

Although only 10 per cent of these patients will have a prolonged or difficult labour, such a possibility should be anticipated in every case so that further complications can be averted. Additional nursing care, including observation of the maternal and fetal conditions will be necessary.

Persistent occipito posterior position short-rotation

The occiput point to the sacro-iliac joint , left or right . In this condition, the occiput fails to rotate forwards. Instead the sinciput takes the lead reaching the pelvic floor first and rotate forwards. The occiput goes into the hallow of the sacrum and the baby is born facing the pubic bone – face to pubis

Causes

·              failure of the head to flex

·              small head with a large pelvis

·              anthropoid pelvis favours it

Diagnosis

·              head is slow to engage

·              fetal heart sound is heard in the flank or midline above the umbilicus

·              delayed second stage

·              large caput succedanuum

·              the pinna of the ear is pointing to the maternal sacrum , is indicative of posterior position

·              Excessive bulging of the anus and the perineum due to the biperietal diameter descending the perineum instead of the bi-tempora

·              At birth , the sinciput appear first under the symphysis pubis

Management

You should allow the sinciput to engage as far as the root of the nose, and then maintain flexion by restraining it from escaping. Allow the occiput to sweep the perineum and be born. Then grasp the head and extend it and bring the head down under the symphysis pubis because of the large diameter it may be necessary you give episiotomy. After observe the perineum for tear (bottle neck tear)

Complication:

3^rd degree tear, Intracranial hemorrhage, Excessive moulding

Brow presentation

In brow presentation the head is partially extended it is very rare and diagnosis is ever made until the woman is in labour.

Diagnosis

·              A depression is felt between the fetal head and the back

·              Presentation part is high

·              Head is unduely large

·              Cephalopelvic disproportion (CPD) may be present.

·              On Vaginal examination (VE) the examining fingers fell the orbital ridge, anterior fontanelle

·              Baby has large caput succedaneum

Face presentation

Face present when the attitude of the head is that of complete extension. The occiput of the fetus is in contact with the spine. Causes

·              Anencephaly, Contracted pelvis,Occipito posterior position,Pendulous abdomen

·              Polyhydramnious , Congenital abnormalities-  tumour  of the fetal neck(rare)

Diagnosis:

Abdominal palpation may not detect the presentation during pregnancy or early labour

Because of the bulk presenting parts. However the following points may guide the midwife to make the diagnosis;

·              Fetal sound is too loud at the same side as the limbs.

·              On V.E. the chin orbital ridges, malar bone ,bridge of the nose may be felt.

·              Ultra sound scanning, x-ray at 34 weeks confirm diagnosis.

Progress in labour

Mechanism of labor is not possible due to large diameter of 13.8 descending the perinum. Spontaneous delivery is rare except when the baby is extremely small. Usually ceasarean section is the mode of delivery. Sometimes the brow is converted to another presentation like face or vertex presentation by vaginal manipulation under anesthesia

Complication

Same as face presentation