Fetal Occiput Posterior Position Research Articles

The Impact of Maternal Position in Labor on Occiput-Posterior Position of Fetus and Pregnancy Outcomes in Pregnant Women Without Epidural Analgesia.

Fetal occiput posterior (OP) position is associated with more maternal and neonatal complications. This study aimed to investigate the effect of maternal position during labor on fetal OP position and pregnancy outcomes. This randomized clinical trial study included 180 primigravida women in labor with a single fetus and approved OP position. Participants were randomly allocated into three groups: semi-prone position (n=45), knee-chest position (n=45), and supine position (n=90). All participants were placed in the defined positions 15-30 min in labor until delivery. Data collected using Visual Analogue Scale and researcher made checklist. The ANOVA, Tukey post hoc, and the chi-square test were used to analyze. Among all participants who had OP, after intervention 16.3% in the semi-prone position, 14/3 % in the knee-chest position, and 33.7% of the control groups remained with OP at birth (X3=7/87, P=0.019). The rate of natural delivery was significantly higher in the semi-prone position and knee-chest position. The duration of active phase of labor and low back pain were significantly reduced in the semi-prone and knee-chest position compared to the control groups (P<0.05). There were no differences in the duration of the third stage of labor, APGAR score, and the rate of neonatal addition to neonatal intensive care unit, using oxytocin, and perineal tears (P>0.05). The semi-prone and knee-chest positions increase the spontaneous rotation of occiput to the anterior position, vaginal delivery rates as well as a reduction in duration of active phase of labor and low back pain after delivery.

Latent phase duration and associated outcomes: a contemporary, population-based observational study

Little is known about the latent phase of labor, including whether its duration influences subsequent labor processes or birth outcomes. This study aimed to describe the duration of the latent phase of labor from self-report of the onset of painful contractions to a cervical dilation of 5 cm in a large, Swedish population and evaluate the association between the duration of the latent phase of labor and perinatal processes and outcomes that occurred during the active phase of labor, second stage of labor, birth and immediately after delivery, stratified by parity. This was a population-based cohort study of 67,267 pregnancies with deliveries between 2008 and 2020 in the Stockholm-Gotland Regions, Sweden. Nulliparous and parous women without a history of cesarean delivery in spontaneous labor with a term (≥37 weeks of gestation), singleton, live, and vertex fetus without major malformations were included. Imputation was used if the notation of the end of the latent phase of labor (ie, cervical dilation of 5 cm) was missing in the partograph. Multivariable logistic regression was used to estimate the association with adjusted odds ratios and 95% confidence intervals, controlling for potential covariates. Including the time from painful contraction onset to a cervical dilation of 5 cm, the median durations of the latent phase of labor were 16.0 (interquartile range, 10.0-26.6) hours for nulliparous women and 9.4 (interquartile range, 5.9-15.3) hours for multiparous women. The durations of the latent phase of labor beyond the median were associated with increased odds of labor dystocia diagnosis during the first stage active phase or second stage of labor and interventions commonly associated with dystocia (amniotomy, oxytocin augmentation, epidural, and cesarean delivery). The duration of the latent phase of labor of ≥90th percentile vs less than the median in nulliparous women demonstrated an increased risk of adverse neonatal outcomes (Apgar score of <7 at 5 minutes and neonatal intensive care unit admission), chorioamnionitis, and fetal occiput posterior. In multiparous women, longer duration of the latent phase of labor was associated with an increased risk of neonatal intensive care unit admission and chorioamnionitis but was not associated with an Apgar score of <7 at 5 minutes. The duration of the latent phase of labor was not associated with additional markers of maternal risk. The duration of the latent phase of labor in nulliparous women was longer than that of multiparous women at each point of distribution. A longer duration of the latent phase of labor was associated with more frequent dystocia diagnoses and related interventions during the first stage active phase or second stage of labor, including cesarean delivery, nulliparous fetal occiput posterior position, chorioamnionitis, and markers of neonatal morbidity. More research is needed to identify potential mediating paths between the duration of the latent phase of labor and neonatal morbidity.

How reliable is fetal occiput and spine position assessment prior to induction of labor?

To assess the reliability of fetal occiput and spine position determination in nulliparous women prior to induction of labor (IOL), and to evaluate identification of fetal occiput and spine positions prior to IOL in the prediction of labor outcome. A series of 136 nulliparous women were recruited prospectively, immediately after the decision to perform IOL was made. Transabdominal ultrasound was performed to determine fetal head and spine positions. After at least 1 h, and prior to IOL, fetal occiput and spine positions were reassessed. Fetal occiput and spine positions were then compared between women who underwent vaginal delivery and those who delivered by Cesarean section. On the first and second assessments, respectively, fetal occiput position was anterior in 55 (40.4%) and 62 (45.6%) women, transverse in 52 (38.2%) and 49 (36.0%) women, and posterior in 29 (21.3%) and 25 (18.4%) women, while fetal spine position was anterior in 58 (42.6%) and 52 (38.2%) women, transverse in 42 (30.9%) and 50 (36.8%) women, and posterior in 36 (26.5%) and 34 (25.0%) women. Discordance between the first and second assessments of fetal occiput position was identified in 34 (25.0%) women, whereas discordance of fetal spine position was observed in 40 (29.4%) women. The incidence of fetal occiput posterior position in women undergoing Cesarean section was comparable to that in the vaginal-delivery group (19 (18.8%) vs 6 (17.1%); P = 0.826), which was similarly the case for fetal posterior spine position (27 (26.7%) vs 7 (20%); P = 0.428). Women with fetal occiput posterior position had a longer induction-to-delivery interval in comparison to those with non-occiput posterior fetal position (1786 ± 805 vs 1347 ± 784 min; P = 0.013). Fetal occiput and spine positions are dynamic in a considerable proportion of women undergoing IOL, and their assessment does not seem to correlate with mode of delivery. Occiput and spine position assessment in women prior to IOL is unlikely to be clinically useful. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Intrapartum ultrasound monitoring of malposition and malrotation during labor neuraxial analgesia: maternal outcomes

Objective: This study analyzes the important role of ultrasonography (IUS) related to the maternal outcomes in women with fetal persistent occiput posterior position (POPP) and asynclitism (A) in labor neuraxial analgesia (LNA).Study design: Prospective assessment of 148 primiparous women diagnosed with the prolonged second stage of labor. Transabdominal and transperineal IUS were used to detect fetal head position and to evaluate the angle of progression (AOP) and pubic arch angle (PAA). Statistical data about maternal aspects, modalities of delivery and maternal outcomes were observed.Results: In all parturients included in the study, the operative delivery rate was 73%. In patients delivered via cesarean section, the PAA was ≤ of 96.5°. There was statistical correlation between doses of LNA and Apgar score at first minute (r0.8).Conclusions: There is a greater frequency of Fetal POPP and asynclitism related with maternal complications. The results of our study confirmed the importance of determination of angle of progression (AoP) and PAA in the prolonged second stage of labor. Unfavorable AoP and PAA, in presence of POPP and A, are related with high percentage of operative delivery. If the prolonged labor and delivery in these patients exceed time limit proposed by American College of Obstetricians and Gynecologists guidelines, it may be viewed as a possible malpractice. In cases of POPP with asynclitism, in the second stage of labor detected by IUS it is advisable to discontinue the anesthetic drugs administration in LNA; because the labor pain is related to the dystocia, an operative delivery is necessary to avoid maternal and fetal complications.

Case Report of Spontaneous Skull Fracture in a Newborn With Cesarean Birth for Persistent Occiput Posterior Position

Spontaneous newborn skull fracture is rarely cited in nursing literature as a potential outcome of persistent fetal occiput posterior position. Although most newborns seem unaffected by the condition initially, some may show symptoms several hours after the birth, when nursing assessments are less frequent. This case report illustrates delayed newborn symptoms that led to an unexpected diagnosis of spontaneous skull fracture.

Study on the influence of the supine adjustment on the posterior position of the fetal occipital position in the parturient with epidural analgesia

Objective To investigate the effect of supine regulating on maternal fetal occiput posterior position during the delivery after epidural analgesia. Methods Totally600 cases of parturient with intravaginal posterior occipital position with 3cm voluntary labor analgesia were selected,who were born in Dalian maternity hospital from October 2015 to October 2016.The (Visual Analogue Scale/Score)VAS pain score at 15min after epidural labor analgesia was as effective as less than 3 points. They were randomly divided into the control group and the observation group by random number table method, with 300 cases in each group.The control group monitored parturient respiration, pulse, blood pressure, heart rate and fetal heart rate according to routine treatment.The control group monitored parturient respiration, pulse, blood pressure, heart rate and fetal heart rate according to routine treatment.In the observation group, except for routine treatment according to the labor process, after the opening of 5cm, the pregnant women were instructed to take the lateral prone position, so that the maternal side and the fetal side of the spinal column should be the same side. To observe the difference between the two groups in the rate of spontaneous vaginal delivery, delivery rate, cesarean section rate, fetal cardioversion rate, time of birth process and neonatal Apgar score. Results Totally 283 cases delivery through vagina and 17 cases of cesarean section in observation group, while 257 cases of vaginal delivery and 43 cases of cesarean section in the control group.The successful rate of fetal position transfer in the observation group was 74.6% (211/283) which was significantly higher than 45.9% (118/257) of the control group (χ2=62.782, P<0.01), natural labor rate was also 87.3% (262/300) which increased significantly according to 64.7% (194/300) (χ2=42.251, P<0.01),the rate of midwifery (7.0%, 21/300) and cesarean section (5.7%, 17/300) were significantly lower than 21.0% (63/300)and 14.3% (43/300) of the control group (χ2=24.419, 12.519,P<0.01), the second stage of labor was (1.60±0.56) h which was significantly shortened than (2.19±0.53) h also(t=-12.589,P<0.01).In the observation group, the ratio of the posterior occipital position to the occipital transverse position after the opening of 8-10 cm and the complete dilation of the cervical were 7.4% (21/283) and 13.1% (37/283), which were also significantly increased than 3.4% (9/264), 6.8% (18/264) of the control group (χ2=4.240, 5.911, P<0.05). Conclusions Supine adjustment after the cervix dilatation larger than 5cm is more conducive to fetal rotation and to avoid the adverse complications, reduce the rate of vaginal delivery and cesarean section rate, improve the rate of natural childbirth, shorten delivery time, improve the quality of delivery. Key words: Labor analgesia; Supine adjustment; Posterior occipital position

Efficiency of the modified Sims maternal position in the rotation of persistent occiput posterior position during labor: A randomized clinical trial.

Fetal occiput posterior position in labor is associated with more painful and prolonged labor, and an increase in both maternal and fetal morbidity. The aim of this study is to assess whether the modified Sims position on the side of the fetal spine increases the rotation to occiput anterior position in women with epidural analgesia and a fetus in persistent occiput posterior (POP) position. This is an open, randomized controlled, clinical trial. One hundred and twenty women in labor with fetuses in POP position were included. The diagnosis was performed through digital vaginal examination and confirmed with an ultrasound scan. Women were randomized into the free position group or the modified Sims on the side of the fetal spine. The primary outcome was rotation to occiput anterior, and secondary outcomes were type of delivery, postpartum perineal condition, perinatal results, and maternal satisfaction. In pregnant women undergoing labor in the Sims position, fetuses in POP rotated to occiput anterior in 50.8% of cases, whilst in the free position group, the rotation occurred in 21.7% (P=.001). The rate of vaginal deliveries was higher in the Sims group compared with the free position group (84.7% vs 68.3%, P=.035). The modified Sims position is a maternal posture intervention efficient in POP rotation, which decreases cesarean delivery rate. It is a simple and noninvasive intervention, reproducible, and well tolerated by pregnant women.

571: Predictors of failed operative vaginal delivery: A prospective population-based cohort study

To identify factors associated with failed attempted OVD (aOVD) in a prospective population-based cohort study, evaluate whether these factors can be used to accurately predict failed OVD, and build a predictive score for failed aOVD. This was a planned secondary analysis of data collected for a prospective population-based cohort study of 2,138 deliveries with an aOVD at term from 2008-2013. Its design was to estimate severe composite maternal and neonatal morbidity after aOVD according to the fetal head station [mid- (391/2,138; 18.3%), low- (1,550/2,138; 72.5%), and outlet-pelvic (197/2,138; 9.2%)]. Women in the case group were defined as women who had aOVD but required ultimately cesarean delivery, and women who delivered vaginally after aOVD were defined as controls. A risk score for failed aOVD was derived using univariate and multivariate logistic regression analyses. Ability of the tool to predict failed aOVD was assessed using the area under the receiver operating characteristic curve (AUC). Failed aOVD occurred in 39 women (1.8%): 35 (8.9%) mid-, and 4 (0.3%) low-pelvic aOVD (P<.0001). Women with failed aOVD had more often gestational age (GA)≥40 weeks (P=.003), fetal occiput-posterior position (P<.0001), mid station at application (P<.0001), aOVD performed by senior obstetrician (P<.0001), vacuum (P<.0001), and less often with active phase of second stage longer than 30 min (P=.005). Failed aOVD was associated with severe maternal morbidity (P=.0008) without increasing risk of severe neonatal morbidity (P=.07). The risk score for failed aOVD included the following predictors: vacuum (+1), fetal occiput-posterior position (+1), and aOVD for arrested progress (+1), active phase of second stage longer than 30 min (-1), GA≥40 weeks with midpelvic aOVD (+1). The AUC was 0.83 (95% CI 0.75-0.91) (Fig.1). A cut-off point of 2 had Se of 66.7%, Sp of 93.6%, and PPV of 93.2% for cesarean delivery after failed aOVD. If failed aOVD was considered as women who had aOVD but required sequential use of 2 instruments or ultimately cesarean delivery (n=117; 5.5%), the AUC was 0.77 (95%CI 0.73-0.80) (Fig.2). Using a cut-off point of 2, failed aOVD was predicted with Se, Sp, and PPV of 35.3%, 94.2%, and 90.9%, respectively. Risk factors identified before an aOVD should be easily used to accurately predict whether an aOVD will fail.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Facteurs de risque de césarienne pour non-engagement persistant à dilatation complète

ObjectivesIdentify the factors associated with caesarean delivery for unengaged fetal head beyond 3hours of passive second stage of labor, among primiparous patients. MethodsA case-control study conducted in level III universitary center between October 2012 and September 2015. Only primiparous at term, with a singleton, cephalic fetus and a passive second stage of labor prolonged over 3hours before pushing were included. During the second stage of labor, patients who had caesarean for abnormal fetal heart rate were excluded. Risk factors of cesarean were analyzed with univariate analysis and after statistical adjustment using multivariate logistic regression. ResultsThe mean passive second stage duration was significantly longer among patients who had a caesarean (3h37±21min vs 3h13±19min [P=0,0001]). After multivariate logistic regression, factors associated with a risk of caesarean were body mass index higher than 30kg/m2 (OR=25.9 [3.1–215.9]). fetal macrosomia suspected by 3rd trimester ultrasound (OR=4.4 [1.2–16.4]), induction by prostaglandins (OR=5.7 [2.1–15.5]), a stagnation of cervical dilatation during the 1st stage (OR=[1.3–6.8]), and fetal occiput posterior position beyond 3hours (OR=30.7 [3.3–280.9]). ConclusionsRisk of caesarean delivery for unengaged fetal head beyond 3hours of passive second stage of labor is associated with maternal, fetal and obstetrical factors. Those factors might be taken into account before accept or not a 3rd hour at full cervical dilation.

Predictors of Failed Operative Vaginal Delivery in a Contemporary Obstetric Cohort.

To identify factors associated with failed operative vaginal delivery in contemporary parturients and evaluate whether these factors can be used to accurately predict failed operative vaginal delivery. This was a case-control study of women undergoing a trial of operative vaginal delivery from a low or outlet station between 2005 and 2014. Women in the case group were defined as women who had an attempted operative vaginal delivery but ultimately required cesarean delivery. Women in the control group were defined as women who delivered vaginally. Bivariable and multivariable analyses were performed to determine factors that were independently associated with failed operative vaginal delivery. A receiver operating characteristic curve was created and area under the curve calculated to estimate the predictive capacity of these associations. Of 4,352 women who met inclusion criteria, 2,527 underwent an attempt at operative vaginal delivery using forceps and 1,825 using vacuum. Failure occurred in 272 (6.3%). In bivariable analysis, nulliparity, white race, induction of labor, chorioamnionitis, second stage 2 hours or greater, fetal occiput-posterior position, low station at application (compared with outlet), larger estimated fetal weight, and arrest or exhaustion as an indication for operative vaginal delivery (compared with a fetal indication) were significantly associated with a failed operative vaginal delivery. In multivariable analysis, factors that remained independently associated with operative vaginal delivery failure were race-ethnicity, arrest or exhaustion as an indication for operative vaginal delivery, occiput-posterior position, and a low pelvic application. The area under the curve for this regression was 0.74 (95% confidence interval 0.69-0.77) demonstrating less than optimal prediction of operative vaginal delivery failure. Risk factors identified before an operative vaginal delivery attempt cannot be used to accurately predict whether an operative vaginal delivery attempt will fail.

Rebozo Technique for Fetal Malposition in Labor.

Fetal occiput posterior position is associated with increased maternal and fetal morbidities. Currently, clinicians have limited evidence-based techniques or tools to remedy fetal occiput posterior position. The traditional Mexican rebozo technique of pelvic massage, sifting, or jiggling offers a potentially valuable tool to help correct fetal malposition. This article reviews the adaptation of 3 rebozo techniques that can be used in labor to encourage optimum fetal positioning; outlines hospital considerations for safety, fetal heart rate monitoring, and universal precautions; and reviews the implementation plan to introduce and sustain use of the rebozo in a large academic medical center.

DOĞUM EYLEMİNDE BEL AĞRISININ HAFİFLETİLMESİNDE İNTRADERMAL STERİL SU ENJEKSİYONU

OZET Dogum agrisi; bilinen ve tanimlanan en siddetli agri kaynaklarindan biridir ve algilanmasi bireyden bireye farklilik gosterir. Intrapartum bakimin en buyuk amaci kadinlarin dogumda yasadigi agriyi en iyi sekilde yonetmektir. Tum dogumlarin yaklasik %15-74’unde kadinlar bel bolgesinde ciddi agri yasamaktadir. Bel agrisinin etiyolojisinde fetal oksiput posterior pozisyon, kadinlarin bireysel lumbopelvik ozellikleri ve uterustan kaynaklanan nedenler yer almaktadir. Intradermal steril su bloklari enjeksiyonu dogumda bel agrisini ve belli olcude de abdominal agriyi azaltmaktadir. Intradermal su enjeksiyonu 0.05-0.1 ml steril suyun sakrum cevresinde dort ayri noktaya enjeksiyonu ile dort su kabarciginin olusturulmasi esasina dayanir. Agrinin azalmasinda Kapi Kontrol Teorisinin ve Lokal Endorfin salgisinin etkili oldugu dusunulmektedir. Bes randomize calismada intadermal steril su bloklari uygulamasi ile transkutanoz elektriksel sinir stimulasyonu, annenin hareketi ve pozisyonu, masaj, banyo gibi alternatif nonfarmakolojik metotlarin dogumda bel bolgesindeki agriya etkisi karsilastirilmistir. Calismalarin hepsinde intradermal steril su blogu uygulamasinin diger yontemlere gore bel agrisini onemli derecede azalttigi bulunmustur. Sonuc olarak intradermal steril su enjeksiyonu fetus ve anne uzerinde herhangi bir yan etki olusturmadigi sonucuna ulasildigindan dogumda yasanan bel agrisini azaltmada kullanilabilir. Anahtar Kelimeler: Intradermal steril su enjeksiyonu; dogum; bel agrisi. ABSTRACT Intradermal Sterile Water Injections for The Relief of Low Back Pain in Labour Pain of labor known and identified sources of pain is one of the most severe and perception varies from individual to individual. The aim of intrapartum care of women at birth, the largest in the best way to manage her pain. Estimates of the experience of low back pain in labor range between 15 and 74 percent of womens at all labors. Possible etiologies of low back pain include a fetal occiput posterior position, the woman's lumbopelvic characteristics, and referred pain from the uterus. Intradermal sterile water blocks injections, decrease back pain during labor, and, to a certain extent, the abdominal pain of labor. Intradermal water injections in four different points around the sacrum injection of 0.05-0.1 ml of sterile water and four are based on the creation of the water bubble. At reduction of pain are thought to be effective of The Gate Control Theory and the local secretion of Endorphins. Five randomized trials compared the effect of intradermal sterile water blocks or an alternative nonpharmacological method such as transcutaneous electrical nevre stimulation, maternal movement and positioning, massage, bath for low back pain in labor. All five studies found that intradermal sterile water blocks significantly decreased severe low back pain. In summary, intradermal sterile water injections may significantly reduce the perception of severe low back pain in labor without side-effects on the fetus or mother. Keywords: Intradermal sterile water injections; labor; back pain.

The Fetal Occiput Posterior Position

The fetal occiput posterior position poses challenges in every aspect of intrapartum care-prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes.

Instrumental rotation for persistent fetal occiput posterior position: a way to decrease maternal and neonatal injury?

ObjectiveTo evaluate immediate perineal and neonatal morbidity associated with instrumental rotations performed with Thierry’s spatulas for the management of persistent posterior occiput (OP) positions.MethodsRetrospective study including all persistent occiput posterior positions with vaginal OP delivery, from August 2006 to September 2007. Occiput anterior deliveries following successful instrumental rotation were included as well. We compared maternal and neonatal immediate outcomes between spontaneous deliveries, rotational and non rotational assisted deliveries, using χ2 and Anova tests.Results157 patients were enrolled, comprising 46 OP spontaneous deliveries, 58 assisted OP deliveries and 53 deliveries after rotational procedure. Instrumental rotation failed in 9 cases. Mean age and parity were significantly higher in the spontaneous delivery group, while labor duration was shorter. There were no significant differences in the rate of severe perineal tears and neonatal adverse outcomes between the 3 groups.ConclusionInstrumental rotation using Thierry’s spatulas was not associated with a reduced risk of maternal and neonatal morbidity for persistent OP deliveries. Further studies are required to define the true interest of such procedure in modern obstetrics.

Maternal Temperature Elevation and Occiput Posterior Position at Birth Among Low‐Risk Women Receiving Epidural Analgesia

To evaluate the relationship between maternal temperature elevation and occiput posterior position at birth as well as the association of fetal head position and temperature elevation on method of birth among women receiving epidural analgesia. We conducted a secondary analysis of data from the Fetal Orientation during Childbirth by Ultrasound Study (FOCUS), which used serial ultrasounds to evaluate the effect of epidural anesthesia on fetal position at birth in low-risk women. The current analysis was limited to the 1428 study participants who received epidural analgesia. In our population, 47% (n = 669) of women had a maximum intrapartum temperature greater than or equal to 99.6°F (37.6°C). The prevalence of fetal occiput posterior position at admission did not differ between women who later developed temperature elevations (24.4%) and those who did not (23.6%, P= .70). Women who developed an elevated temperature greater than or equal to 99.6°F (37.6°C) had an increased risk of occiput posterior fetal head position at birth regardless of the amount of temperature elevation (odds ratio [OR]= 2.0; 95% confidence interval [CI], 1.5-2.8); the association persisted after control for potentially confounding factors (adjusted OR = 1.5; 95% CI, 1.1-2.1). The cesarean birth rate among women with both temperature elevation and occiput posterior position at birth was more than 12 times the rate of women with neither risk factor (adjusted OR = 12.6; 95% CI, 7.5-21.2). Intrapartum temperature elevation among women receiving epidural analgesia, even if only to 99.6°F (37.6°C), is associated with approximately a 2-fold increase in the occurrence of occiput posterior fetal head position at birth. Additionally, although this observational study cannot establish causal links, our findings suggest that the relationship between epidural-related intrapartum temperature elevation and occiput posterior position at birth could contribute to an increased cesarean birth rate among women receiving epidural analgesia for pain relief in labor.

Pelvic floor dysfunction 6 years post-anal sphincter tear at the time of vaginal delivery

This study aims to estimate fecal, urinary incontinence, and sexual function 6 years after an obstetrical anal sphincter tear. Among 13,213 women who had a vaginal delivery of a cephalic singleton at term, 196 women sustained an anal sphincter tear. They were matched to 588 controls. Validated questionnaires grading fecal and urinary incontinence, and sexual dysfunction were completed by the participants. Severe fecal incontinence was more frequently reported by women who had sustained an anal sphincter tear compared to the controls. Women with an anal sphincter tear had no increased risk of urinary incontinence, but reported significantly more pain, difficulty with vaginal lubrication, and difficulty achieving orgasm compared to the controls. A fetal occiput posterior position during childbirth was an independent risk factor for both severe urinary incontinence and severe sexual dysfunction. Fecal incontinence is strongly associated with an anal sphincter tear. A fetal occiput posterior position represents a risk factor for urinary incontinence and sexual dysfunction.

The Fetal Occiput Posterior Position: State of the Science and a New Perspective

The fetal occiput posterior position poses challenges in every aspect of intrapartum care-prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe nine prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. A search was conducted of the databases of PubMed and the Cochrane Library. Additional valuable information was obtained from obstetric and midwifery textbooks, books and websites for the public, conversations with maternity care professionals, and years of experience as a doula. Nine prevailing concepts are as follows: (1) prenatal maneuvers rotate the occiput posterior fetus to occiput anterior; (2) it is possible to detect the occiput posterior fetus prenatally; (3) a fetus who is occiput anterior at the onset of labor will remain in that position throughout labor; (4) back pain in labor is a reliable sign of an occiput posterior fetus; (5) the occiput posterior fetus can be identified during labor by digital vaginal examination; (6) an ultrasound scan is a reliable way to detect fetal position; (7) maternal positions facilitate rotation of the occiput posterior fetus; (8) epidural analgesia facilitates rotation; (9) manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries. Concepts 1, 2, 3, 4, 5, and 8 have little scientific support whereas concepts 6, 7, and 9 are supported by promising evidence. Many current obstetric practices with respect to the occiput posterior position are unsatisfactory, resulting in failure to identify and correct the problem and thus contributing to high surgical delivery rates and traumatic births. The use of ultrasound examination to identify fetal position is a method that is far superior to other methods, and has the potential to improve outcomes. Research studies are needed to examine the efficacy of midwifery methods of identification, and the effect of promising methods to rotate the fetus (simple positional methods and digital or manual rotation). Based on the findings of this review, a practical approach to care is suggested.

The Association Between Persistent Fetal Occiput Posterior Position and Perinatal Outcomes: An Example of Propensity Score and Covariate Distance Matching

In a retrospective cohort study of 18,880 full-term, cephalic singletons born in San Francisco, California, during 1976-2001, the authors used multivariable logistic regression (MVLR) and propensity score analysis (PSA) to examine the association between persistent fetal occiput posterior (OP) position and perinatal outcomes. The principles and applications of these techniques are compared and discussed. Pregnancies with OP positions at delivery were compared with those with occiput anterior positions. Perinatal outcomes were examined as adjusted odds ratios determined by MVLR and PSA and as risk differences determined by propensity score matched bootstrapping based on covariate distance. Persistent OP position was associated with operative delivery and maternal morbidity. The odds ratio estimates based on PSA were somewhat larger than those obtained with standard MVLR, and the confidence intervals were narrower. When statistical inference was evaluated with the permutation test, the results were more consistent with the PSA. These analyses demonstrate that PSA is likely to provide more precise estimates of exposure associations and more reliable statistical inferences than MVLR. The authors show that PSA can be extended with Mahalanobis distance matching to obtain estimates of risk difference between exposed and unexposed subjects that avoid violations of the experimental treatment assignment (positivity) assumption that is required for valid causal inference.

Changes in Fetal Position During Labor and Their Association With Epidural Analgesia

To evaluate whether epidural analgesia is associated with a higher rate of abnormal fetal head position at delivery. We conducted a prospective cohort study of 1,562 women to evaluate changes in fetal position during labor by using serial ultrasound examinations. Ultrasound examinations were performed at enrollment, epidural administration, 4 hours after the initial ultrasonography if epidural had not been administered, and late in labor (> 8 cm). Information about fetal head position at delivery was obtained from the provider. Regardless of fetal head position at enrollment (occiput transverse, occiput posterior, or occiput anterior), most fetuses were occiput anterior at delivery (enrollment position: occiput transverse 78%, occiput posterior 80%, occiput anterior 83%, P = .1). Final fetal position was established close to delivery. Of fetuses that were occiput posterior late in labor, only 20.7% were occiput posterior at delivery. Changes in fetal head position were common, and 36% of women had an occiput posterior fetus on at least one ultrasound examination. Women receiving epidural did not have more occiput posterior fetuses at the enrollment (23.4% epidural versus 26.0 no epidural, P = .9) or the epidural/4-hour ultrasound examination (24.9% epidural, 28.3% no epidural), but did have more occiput posterior fetuses at delivery (12.9% epidural versus 3.3% no epidural, P = .002); the association remained in a multivariate model (adjusted odds ratio 4.0, 95% confidence interval 1.4-11.1). Fetal position changes are common during labor, with the final fetal position established close to delivery. Our demonstration of a strong association of epidural with fetal occiput posterior position at delivery represents a mechanism that may contribute to the lower rate of spontaneous vaginal delivery consistently observed with epidural.

Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth

Objective To evaluate the efficacy of hands and knees position and pelvic rocking exercises on the incidence of fetal occiput posterior position at birth.Design Multicentre randomised controlled trial.Setting Seven maternity...