This document provides an overview of occipito-posterior and shoulder presentations during labor. It defines occipito-posterior as a vertex presentation where the occiput is directed posteriorly. The positions, causes, diagnosis and management of occipito-posterior are discussed. Shoulder presentation is defined as an abnormal presentation with an abnormal lie that is transverse or oblique. The positions, causes, mechanism of labor and management including attempting version are summarized for shoulder presentation. Complications of both positions are also briefly mentioned.

1. OCCIPITO-POSTERIOR AND
SHOULDER PRESENTATION
Presented by: Mohamad Jamil Ghutmi MD
OBGYN hospitalist at Clemenceau Medical Center
Maternity team
2022

2. OCCIPITO-POSTERIOR POSITION

3. DEFINITION
• THIS IS VERTEX PRESENTATION WHERE THE OCCIPUT IS DIRECTED
POSTERIOR
• IT IS AN ABNORMAL POSITION NOT AN ABNOMAL PRESENTATION

6. POSITIONS OF OP
•ROP
•LOP
ROP IS MORE COMMON THAN LOP????
RT OBLIQUE DIAM IS LONGER DURING LIFE THAN LT OBLIQUE DIAM
(PELVIC COLON IS LOADED WITH FECAL MATTER ENCROACHING ON 1 CM
FROM LT OBLIQUE DIAM)

7. INCIDENCE
• DURING ANTENATAL PERIOD THE INCIDENCE IS HIGHER COMPARED TO
END OF PREGNANCY AS WELL AS DURING LABOR AS MANY CASES WILL
UNDERGOE SPONTANEOUS ANTERIOR ROTATION
• REMEMBER THAT THIS IS VERTEX PRESENTATION WHER LIE IS NORMAL
LT AND THEY ARE THE THIRD AND FOURTH POSITION OF VERTEX
PRESENTATION

8. CAUSES
MATERNAL:
1-TYPE OF PELVIS AS ANDROID, ANTHROPOID, AND KYPHOTIC PELVES
(FUNNEL PELVES = WIDE INLET AND NARROW OUTLET)
2-PENDULOUS ABDOMEN
FETAL :
• POSTERIOR INSERTION OF PLACENTA
• PREMATURITY
• IUFD
• EXTENDED ATTITUDE OF THE FETAL BACK

12. PENDULOUS
ABDOMEN

13. FATE OF OP
• LONG ANTERIOR ROTATION OF THE OCCIPUT TO BE DELIVERED AS OA
• SHORT POSTERIOR ROTATION OF THE OCCIPUT TO BE DLIVERED AS
FACE TO PUBIS
• INCONPLETE ANTERIOR ROTATION OF THE OCCIPUT TO BE ARRESTED AS
DEEP T ARREST WITH OBSTRUCTED LABOR UNLESS : FLEXION AND
ROTATION OF THE OCCIPUT ANT OR POST FOR DELIVERY TO OCCUR
• NO ROTATION AND HEAD WILL BE ARRESTED AS PERSITENT OP

19. GOOD OMMENS FOR ANTERIOR ROTATION
OF THE OCCIPUT
• GOOD UTERINE CONTRACTIONS
• FLEXION OF THE HEAD TO MAKE OCCIPUT LOWER MOST TO TOUCH
PELVIC FLOOR FIRST
• GOOD TONE OF PELVIC FLOOR
• AVERAGE SIZED FETUS
• GOOD PELVIC CAPACITY
• MEMBRANES INTACT TILL CERVIX IS MORE THAN HALF DILATED

20. COMPLICATIONS OF OP
THREE Ps
• P: POWERS ARE WEAK = UTERINE INERTIA ??
-HEAD IS DEFLEXED SO NOT WELL FIITTING ON THE LUS
• P: PROM ???? HEAD IS DELEXED SO NOT ACTING WELL AS A
BALLL VALVE MECHANISM SO WITH UTERINE
CONTRACTIONS HIND WATER WILL COMMUNICATE WITH
FORE WATER AND PROM WILL OCCUR
• P: PERINEAL TEARS AND LACERATIONS???

21. CAUSES OF PERINEAL TEARS AND
LACERATIONS:
• THE BULK OF THE OCCIPITAL END OF THE HEAD IS DIRECTED
TOWARDS THE PERINEUM
• THE DIAMETERS THAT DILATE THE INTROITUS AT THE SAME
TIME ARE THE O-F (11.25CM) DIAM AND BPD (9.5CM) (INSTEAD OF
B-T 7.5CM DIAM AND S-O-F 10.5CM)
• THE UPPER PART OF THE CHEST ENTERS WITH THE HEAD IN
THE PELVIS OVERSTRTCHING THE VAGINA AS THE POST WALL
OF THE PELVIS IS LONGER AS IT IS REPRESENTED BY THE
SACRUM.
• INCREASED INSTRUMENTAL DELIVERY BY FORCEPS AND
VENTOUSE OR MANUAL ROTATION AND FELXION

22. OTHER COMPLICATIONS INCLUDE
• INCREASED OPERATIVE INTERFERENCE BY CS OR FORCEPS OR
VENTOUSE
• PROLONGED LABOR WITH MATERNAL EXHAUSTION
• PROM PREDISPOSE TO ASCENDING INFECTION TO THE MOTHER
CAUSEING PUERPURAL PYREXIA OR SEPSIS AND TO THE FETUS CAUSING
FETAL INHALATION, PNEUMONITIS AS WELL AS FETAL DISTRESS WITH
LOW APGAR SCORE

23. DIAGNOSIS OF OP:
• IN RECENT OBSTETRICAL MANAGEMENT IT IS DIAGNOSED IN
THE ANTENATAL PERIOD BY US WHEN THE BACK OF THE FETUS
IS DIRECTED POSTERIORLY
• DURING LABOR WHEN THE CERVIX DILATES AND MEMBRANES
RUPTURE : THE OCCIPUT IS DIRECTED POSTERIORLY TO THE RT
OR TO THE LT
 THE POSTERIOR FONTANELLE IS DIRECTED POSTERIORLY
TOWARDS THE SACRUM TO THE RT(ROP) OR TO THE LT (LOP)
OR T (DEEP T ARREST) OR DIRECTLY POSTERIOR (DIRECT OP)
 THE ANTERIOR FONTANELLE IS DIRECTED ANTERIORLY
TOWARDS THE Sym Pub AND IT IS AT A LOWER LEVEL THAN PF
= DEFLEXED ATTITUDE OF THE VERTEX

24. MANAGEMENT OF OP:
• DURING PREGNANCY : POSITIONAL TREATMENT BY LYING ON THE SIDE
(LATERAL POSITION OPPOSITE TO THE DIRECTION OF THE BACK)
• DURING LABOUR:
• FIRST STAGE :
WATCHFULL EXPECTENCY WITH FOLLOW-UP AS REGARDS THE
CONDITION OF THE MEMBRANES, CERVICAL DILATATION, DESCENT OF
THE HEAD AND ONCE MEMBRANES RUPTURE IMMEDIATE PV TO
EXCLUDE CORD PROLAPSE
AVOID PREMATURE RUPTURE OF MEMBRANES (PROM)?????

25. • SECOND STAGE :
1. LOOK FOR THE GOOD OMENS OF ANTERIOR ROTATION OF
THE OCCIPUT
2. ALWAYS HELP FLEXION BY PUSHING THE SINCIPUT UP
DURING BEARING DOWN AND UTERINE CONTRACTIONS
3. IF IT ROTATES ANTERIORLY IT WILL BE DELIVERED AS OA
4. IF IT IS ARRESTED AS DEEP T ARREST :
DISIMPACTION, FLEXION , ROTATION ANTERIOR OR POSTERIOR
AND FORCEPS APPLICATION OR VENTOUSE
5. CS IS INDICATED IN MANY CASES
6. IF FETUS IS DEAD CRANIOTOMY

29. SHOULDER
PRESENTATION

32. DEFINITION
• ABNORMAL PRESENTATION OF SHOULDER WITH
ANORMAL LIE TRANSVERSE OR OBLIQUE

33. DENOMINATOR
• IS COMPLEX
• HEAD IS EITHER TO THE RIGHT OR TO THE LEFT
• BACK ANTERIOR OR POSTERIOR

34. POSITIONS
• FIRST: LEFT-DORSO-ANTERIOR
• SECOND: RIGHT-DORSO-ANTERIOR
• THIRD: RIGHT-DORSO-POSTERIOR
• FOURTH: LEFT-DORSO-POSTERIOR

35. CAUSES:
• DISTURBED UTERINE OVOID:
 SEPTATE UTERUS
 SUBMUCOUS FIBROID
 PLACENTA PRAEVIA
• DISTURBED FETAL OVOID:
 POLYHYDRAMNIOS
 IUFD
 MULTIPLE PREGNANCY
 PREMATURE LABOR

36. MECHANISM OF LABOR
• UNDELIVERABLE
• DURING PREGNANCY SOME CASES ARE CORRECTED
TO BECOME CEPHALIC : SPONTANEOUS
RECTIFICATION
• DURING PREGNANCY SOME CASES WILL BE
CORRECTED TO BECOME BREECH : SPONTANEOUS
VERSION
• DURING LABOR UNDELIVERABLE EXCEPTIN
VERY RARE CASES AS WITH HIGH PARITY+STRONG
UTERINE CONTRACTIONS+IUFD OR PREMATURITY
+WIDE BIRTH CANAL = SPONTANEOUS EXPULSION
OR SPONTANEOUS EVOLUTION

38. MANAGEGEMENT:
I-DURING PREGNANCY
WE CAN TRY:
• EXTERNAL CEPHALIC VERSION (TO BRING HEAD DOWN OR CEPHALIC)
• EXTERNAL PODALIC VERSION (TO BRING BREECH DOWN)
• THIS IS DONE BETWEEN 32W AND 36 W WHEN THERE IS ENOUGH LIQUOR
AND SPACE TO CORRECT THE LIE

40. II-DURING LABOR
• CS IS INDICATED AS NO MECHANISM FOR LABOR
• IN SECOND TWIN OR PREMATURE FETUS WE CAN DO INTERNAL PODALIC
VERSION TO BRING DOWN A LEG IF LIQUOR IS PRESERVED AND MEMBRANES
WERE INTACT
• IT IS CONTRAINDICATED TO DO VERSION IF LIQUOR IS DRAINED AND
MEMBRANES ARE RUPTURED WHY???? DANGER OF RUPTURE UTERUS

41. BRING DOWN A LEG

42. NEGLECTED
SHOULDER????????
• SHOULDER PRESENTATION NOT DIAGNOSED EXCEPT WHEN
LABOR IS ADVANCED
• LIQUOR IS DRAINED DUE TO PROM
• FETUS IS DEAD
• LOWER UTERINE SEGMENT IS STRETCHED WITH FORMATION
OF PATHOLOGICAL RETRACTION RING (BANDL’s
RING)= IMPENDING RUPTURE UTERUS
• MOTHER IS STRESSED, IRRITABLE WITH FACE FUSHED (
CLINICAL PICTURE OF OBSTRUCTED LABOR)

43. • SHOULDER IS IMPACTED IN THE PELVIS WITH A
PROLAPSED ARM
WHAT TO DO??????????
• CS DESPITE FETUS IS DEAD
• IT IS NOT NOT NOT ALLOWED TO DO INTERNAL
PODALIC VERSION AS LUS IS THIN AND LIQUOR IS
DRAINED AND IF DONE = RUPTURE UTERUS
• DELIVER THE FETUS WITH THE LEAST
MANIPULATION WHICH MEANS CS

45. THANK
YOU

46. REFERENCES
• ACOG. American College of Obstetricians and Gynecologists Practice
Bulletin. Dystocia and augmentation of labor. Clinical management
guidelines for obstetricians-gynecologists. No 49. American College of
Obstetricians and Gynecologists: Washington, DC; December 2003.
• Norwitz ER, Robinson JN, Repke JT. Labor and delivery. Gabbe SG, Niebyl
JR, Simpson JL, eds. Obstetrics: Normal and problem pregnancies. 3rd ed.
New York: Churchill Livingstone; 2003.
• ACOG. American College of Obstetricians and Gynecologists Practice
Bulletin. Intrapartum Fetal Heart Rate Monitoring. Clinical Management
Guidelines for Obstetricians-Gynecologists. No 36. American College of
Obstetricians and Gynecologists;: Washington, DC; December 2005.
• ACOG. American College of Obstetricians and Gynecologists Practice
Bulletin. Obstetric Analgesia and Anesthesia. Clinical Management
Guidelines for Obstetricians-Gynecologists. No 36. American College of
Obstetricians and Gynecologists;: Washington, DC; July 2002.

47. • Friedman EA. Primigravid labor; a graphicostatistical
analysis. Obstet Gynecol. 1955 Dec. 6(6):567-89.
• Friedman EA, Sachtleben MR. Dysfunctional labor. I.
Prolonged latent phase in the nullipara. Obstet Gynecol. 1961
Feb. 17:135-48.
• Friedman EA, Sachtleben MR. Dysfunctional labor. II.
Protracted active-phase dilatation in the nullipara. Obstet
Gynecol. 1961 May. 17:566-78.
• Kilpatrick SJ, Laros RK Jr. Characteristics of normal
labor. Obstet Gynecol. 1989 Jul. 74(1):85-7. Albers LL, Schiff
M, Gorwoda JG. The length of active labor in normal
pregnancies. Obstet Gynecol. 1996 Mar. 87(3):355-9.

48. • Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve
in nulliparous women. Am J Obstet Gynecol. 2002 Oct.
187(4):824-8.
• Menticoglou SM, Manning F, Harman C, et al. Perinatal
outcome in relation to second-stage duration. Am J Obstet
Gynecol. 1995 Sep. 173(3 Pt 1):906-12.
• Janni W, Schiessl B, Peschers U, et al. The prognostic impact
of a prolonged second stage of labor on maternal and fetal
outcome. Acta Obstet Gynecol Scand. 2002 Mar. 81(3):214-21.
• Cheng YW, Hopkins LM, Caughey AB. How long is too long:
Does a prolonged second stage of labor in nulliparous women
affect maternal and neonatal outcomes?. Am J Obstet
Gynecol. 2004 Sep. 191(3):933-8.
• Myles TD, Santolaya J. Maternal and neonatal outcomes in
patients with a prolonged second stage of labor. Obstet
Gynecol. 2003 Jul. 102(1):52-8.

49. • O'Connell MP, Hussain J, Maclennan FA, et al. Factors associated with a
prolonged second state of labour--a case-controlled study of 364
nulliparous labours. J Obstet Gynaecol. 2003 May. 23(3):255-7.
• Senecal J, Xiong X, Fraser WD. Effect of fetal position on second-stage
duration and labor outcome. Obstet Gynecol. 2005 Apr. 105(4):763-72.
• Herman A, Zimerman A, Arieli S, et al. Down-up sequential separation of
the placenta. Ultrasound Obstet Gynecol. 2002 Mar. 19(3):278-81.
• Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of
delayed versus early umbilical cord clamping on neonatal outcomes and
iron status at 4 months: a randomised controlled trial. BMJ. 2011 Nov
15. 343:d7157.
• Prendiville WJ, Elbourne D, McDonald S. Active versus expectant
management in the third stage of labour. Cochrane Database Syst Rev.
2000. CD000007.
• Zhang J, Yancey MK, Klebanoff MA, et al. Does epidural analgesia
prolong labor and increase risk of cesarean delivery? A natural
experiment. Am J Obstet Gynecol. 2001 Jul. 185(1):128-34.