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2. MALPOSITION
Malposition refers to any
position of the vertex other than the
flexed occipito-anterior one.
OCCIPITO POSTERIOR POSITION
In a vertex presentation where the occiput
is placed posteriorly over the sacroiliac
joint or directly over sacrum is called
occipito-posterior postion.”

4. • In majority of cases (90 %), ANTERIOR
ROTATION of occiput occurs and follows the
course like that of an occipito anterior
position and it is favorable position
• But as the posterior position occasionaly
gives rise to dytocia, so it is described
along with malpositions

7. ⚫When the occiput is placed over right sacro iliac
joint it is called Right occipito-posterior(ROP)
/3RD vertex
⚫When the occiput is placed over left sacroilliac joint,
Left occipito -posterior(LOP) or also called 4th
position of vertex.
⚫When placed directly over sacrum, it is called
Direct occipito-posterior.
TYPES OF O-P POSITION

8. Right occipito posterior is 5 times more
common than the left occipito posterior
Dextro-rotation of the uterus and the presence of
sigmoid colon on the left, disfavor Left Occipito
Posterior Position

9. All the three positions can be:
• Primary - (before the onset of labor )
• Secondary - ( developing after onset of
labor

10. INCIDENCE
At onset of labour:- About 10 %
Expected to be more during late pregnancy and
less during late second stage of labour due to
spontaneous long anterior rotation of occiput.

11. CAUSES
 Shape of the pelvic inlet
 Fetal factors
 Uterine factor

12.  Shape of the pelvic inlet
More than 50 % cases are associated
with the Anthropoid Or Android Pelvic
The wide occiput can comfortably be
placed in the wider posterior segment of
the pelvis

14.  FETAL FACTORS
Marked deflexion of the fetal head
Cuases of deflexion:-
1. High pelvic inclination
2. Anterior attachment of placenta
3. Primary brachycephaly
4. Pelvic tumors

15. • High pelvic inclination
–Inclination of brim is high due to
sacralization of lumbar vertebra and the
upper sacrum is relatively vertical and
convex
–Occiput will be placed to posterior
segment of pelvis

16. • Anterior attachment of placenta
–favors posterior position of occiput. But
convexity of maternal and fetal spine is
opposite, which leads to deflexion of
fetal head.

17. • Primary bradycephaly (flatened
area at back of the skull)
–Diminishes the effective movement of flexion

18.  Uterine factor
Abnormal uterine contraction which may be
cause or effect, lead to persistent deflexion
and occipito posterior postion

19. DIAGNOSIS
 ABDOMINAL EXAMINATION
On inspection - abdomen looks flat below the
level of umbelicus

20.  On Palpation :-
Fundal height :- corresponds with period of
amenorrhoea.
Fundal grip : breech
Lateral grip:
• Fetal limbs are more easily palpable anteriorly
near the midline
• Fetal back is felt far away from the midline in
the flank and often difficult to outline clearly.
• Anterior shoulder lies far away from midline

23. Pelvic grip:
• Head is not engaged
• Sinciput is not felt as in well flexed occipito
anterior
 On auscultation:-
FHS is often difficult to locate, heard on
the flank and iintensity is low

24.  VAGINAL EXAMINATION
Finding depends upon degree of flexion of head.
Confirmation made during 2nd stage of labor:-
Elongated bag of membranes which is
likely to rupture during examination
Sagital suture occupies any obligue
diameters of the pelvis
Posterior fontanelle felt near the sacroiliac
joint
Anterior fontanelle is felt more easily
because of deflexion of the head at a level
lower than posterior fontanelle

26. Sometimes the position is not recognized until
there is delay in the second stage of labour.
The diagnosis by vaginal examination may be
difficult due to the formation of caput over the
presenting part.
In this case the fingers may be passed higher to
feel the free margin of the ear which will point to
the occiput

27. MECHANISM OF LABOUR
• IN FAVOURABLE: Good uterine contraction
results in good flexion of head. normal descent occur up
to pelvic floor.
– Flexion and descent
– Long anterior Internal rotation of the head
(head 3/8 and shoulder 2/8)
– Further descent and delivery of head as
occipito anterior position
– Restitution
– External rotation
– Birth of the shoulders and trunk

28. COURSE OF LABOR
⚫Avg duration of both 1st& 2nd stage of labor is
increased.
⚫FIRST STAGE-
 Engagement is delayed due to persistence of
deflexion of head and increased anterio- posterior
diameter of engagement
 Driving force transmitted through the fetal axis is
not alignment with axis of inlet.

29. CONTD…
 Early rupture of membrane occur as deflexed
head does not fit well in spherical LUS.
 Abnormal uterine contraction
SECOND STAGE-delayed due to long internal or
due to malrotation , with at times arrest of head.
THIRD STAGE- increased incidence of postpartum
hemorrhage & trauma to genital tract due to long
emerging diameter

30. UNFAVOURABLE CASES:
Causes are-
 Deflexion of the head
 Weak uterine contraction
 Flat sacrum
 Prominent ischial spine
 Convergent side walls
 Weak pelvic floor muscles
 Big baby
 Early drainage of liquor

31. • IN UNFAVOURABLE CASES:
– Incomplete forward rotation: deep transverse
arrest
– Non rotation
– Malrotation: backward rotation (face to pubis
delivery or sacral arrest)

33. • Mechanism of “face to pubis” delivery
– Further descent occurs until the root of the
nose
– Flexion occurs
– Restitution
– External rotation

34. Fate of
OPP OPP
Engaging diameter :- occipito-
frontal 11.5cm orsub-occipitofrontal
10cm.
Favorable (90%)
Unfavorable (10%)
3/8th rotation
occiput comes under
symphysis pubis (rt/lt
occipitoanterior)
Normal vaginal delivery
Mild deflexion Severe deflexion
Moderatedeflexion
Occiput rotate by
1/8th circle
Deep
transverse
arrest
Non-rotation
Oblique
posterior
arrest
Occiput rotate
posteriorly by 1/8th
POPP/ occipito-
sacral position
Face to pubis
delivery
Arrest

35. MANAGEMENT
• Early diagnosis
• Strict vigilance and watchful expectancy for
decent and long anterior rotation
• Early cesarean section: Anticipating prolonged
labour, no progress of labour, persistentce of
deflexion and non- rotation, Arrest labour,
incoordinated uterine contraction, fetal distress

36. Management of the first stage:
 The 1st stage is managed as in a normal case.
Nothing can be done to correct the Malposition or to
influence the rotation of the head at this stage.
 A partograph is maintained to monitor :Uterine
contraction (frequency, duration and strength), Fetal
heart and dilatation of the cervix.

37. CONTD…
If progressive cervical dilatation does not
occur augmentation with an oxytocin drip may be
tried.
If still no progress obtained in a few
hours caesarian section (C/S) is performed.
Also if there is fetal distress C/S is done

38. Management of the 2nd stage:
 In most cases when uterine contractions are strong and the
woman is able to make good bearing down efforts the
occiput rotates forward and normal delivery takes place.
 In other cases the baby may be delivered face-to-
pubes with out difficulty but there is a great risk of a
perineal tear.
 In other cases there is failure of the presenting part to
rotate and descend and such cases delivered by C/S
or rotation can be enhanced by assistance .

39. Management Of Arrested Transverse / Obligue
Occipito Posterior Position
Ventouse- is suitable in cases where the pelvis is
adequate & non-rotation of the occiput due to
weak contraction or lack of tone of pelvic floor.
Alternative methods like manual rotation, forceps
rotation and extraction, cesarean section and
craniotomy

40. Occipito sacral arrest
⚫Below the
spine
Station of head
Above the
level of ischial
spine
C/S
Ventouse or
forceps with
deep
episiotomy

41. DEEP TRANSVERSE ARREST
• The head has descended deep in to the cavity up
to the level of ischial spines & sagital suture is
placed in bispinous diameter. There is no progress
in descent of the head even after 0.5 to 1 hour
even after full dilatation of the cervix
• It is only diagnosed during second stage of labor
and usually results in obstructed labor.

42. CAUSES
• Contracted pelvis
• Deflexion of the head
• Weak uterine contraction
• Laxity of pelvic floor muscles

43. DIAGNOSIS
• Head is engaged
• Sagital suture lies in transverse bispinous
diameter
• Anterior fontanelle is palpable
• Faulty pelvic architecture

44. MANAGEMENT
• If Vaginal delivery not safe: Cesarean
section eg pelvic inadequacy, big baby
• If Vaginal delivery safe: ventouse,
mannual rotation, forcep rotation
and extraction

45. Management of DTA
DTA or oblique posterior
arrest
Assisteddelivery
Pelvis adequate Inadequate pelvis
-Manual rotation of occiput to
anteriorposition followed by forceps
extraction
- vacuum delivery
- forcepsrotation
Dead baby
Craniotomy
C/S

46. MANNUAL ROTATION OF OPP
• The mannual rotation can be
accomplished with whole hand method or
with half hand method.
Steps:-
Put the patient under general anesthesia
Provide lithotomy position
Maintain full surgical asepsis
Catheterizaion should be done
Identify direction of occiput by PV Exa.

47. • WHOLE HAND METHOD:-
Step I: Gripping of the head
Step II: Rotation of the Head
Step III: Application of forceps

48. Step I: Gripping of the head
In ROP or ROT the Left hand and in LOP or
LOT the Right hand is usually used.
The correctsponding hand is introduced into
the vagina in cone shapped manner after
seperating the labia by two fingers of other
hand.

49. In Occipito transverse position, the four
fingers are pushed in the sacral hollow to be
placed over the posterior parital bone and
the thumb is placed over the anterior parital
bone.
In oblique posterior position, four fingers of
patially supinated hand are placed over the
occiput and the thumb is placed over the
sinciput.

50. Step II: Rotation of the head
Slight disimpaction may be needed for
good grip.
By the movement of pronation of the hand,
the head is rotated to bring the occiput
anterior along the shortest route.
Simultaneouslty, the back of the fetus is
rotated by the external hand from the flank to
the midline.

51. This is an essential prerequisite, for
anterior rotation of head.
A little over rotation is desirable
anticipating slight recurrence of
malposition before the application of
forceps.

52.  In the Alternative
method, the four
fingers of the
pronated right hand
are placed over the
sinciput and the
thumb over the
occiput in ROP. The
head is rotated in the
supination movement
of the hand.

53. Step III: Application of the forceps
Following Rotation, when the right hand is
placed over the left side of the pelvis, left
blade of the forcep is introduced.
When the left hand is used, it is placed on
the right side of the pelvis after rotation, as
such the right blade is to be introduced
first and the left blade is then to be
introduced underneath the right blade.

54. While introducing the blades, it is
preferable that an assistant fixes the head
by suprapubic pressure in a manner of
first pelvic grip.
As it is a mid forceps application, axis
traction device should be used.

55. DIFFICULTIES:-
Failure to grip the head adequetly due to
lack of space
Failure to dislodge the head from the
impacted position
Inadequate anesthesia
Wrong case selection

56. DANGERS-
Accidental slipping of the head above the
pelvic brim and prolapse of the cord
It is better to be perform cesarean section
in such a situation.

57. • HALF HAND METHOD:-
Steps:
The rotation is done only by using the
right hand.
The four fingers are introduced into the
vagina and tangential pressure is applied
on the head at the level of diameter of
engagement.

58. The pressure is applied on the side and
the parietal eminence of the head.
In ROP or ROTpositions, the fingers are
placed anterior to the head and the
pressure is applied by the ulnar border of
the hand.
In LOP or LOT positions, the fingers are
placed posteriorly and the pressure is
applied by the radial border of the hand.

59. The force is applied intermittently till the
occiput is placed behind the symphysis
pubis.