Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate

OBJECTIVE: To identify the risk factors for failure of manual rotation in patients with occiput posterior or transverse positions during labor and to study the cesarean rate according to the success of the rotation. METHODS: Case-control study comparing failure and success of manual rotation. Cases were all fetuses for whom rotation failed. We used computerized randomization (without matching) to select one control with a successful rotation during the same period for each case with a failed rotation. Maternal, neonatal, and obstetric risk factors for failed rotation were studied with bivariable and multivariable analyses. Mode of delivery was analyzed according to success of the rotation. RESULTS: During the study period, manual rotations were performed in 796 patients. The procedure failed in 77 (9.7%) women. Attempted rotation before full dilatation tripled the risk of failure in comparison with rotation at full dilatation (adjusted odds ratio 3.4, 95% confidence interval 1.3-8.6), and rotation for failure to progress quadrupled that risk in comparison with prophylactic rotation (adjusted odds ratio 3.3, 95% confidence interval 1.2-8.5). Failure of manual rotation was associated with a higher cesarean delivery rate than was success (58.8% compared with 3.8%, P<.001). All women with unsuccessful manual rotations who delivered vaginally delivered in the occiput posterior position, and all women with successful manual rotation delivering vaginally delivered in the occiput anterior position. CONCLUSION: Manual rotation may be an effective technique for reducing the cesarean delivery rate in patients with an occiput posterior or transverse position during labor. The success or failure of attempted manual rotation depends upon obstetric conditions, including the indication for rotation and cervical dilatation.     

Management of occiput posterior position

A 27‐year‐old, para 1 at 40 1/7 weeks' gestation presented to the labor and delivery unit in labor. Her prenatal course was uncomplicated, and her previous obstetric history included a vaginal delivery of a full‐term 7‐pound, 9‐ounce male infant. She described her first birth as being “straightforward.” It was 10 hours in length, and she received an epidural for analgesia. Upon this admission, she stated that she had been having regular, painful contractions for the past 10 hours. Her cervix was 1 cm dilated, 50% effaced, and the fetus was at ?3 station. The membranes were intact. She was experiencing intensely painful contractions every 2 to 3 minutes, and reported severe back pain and exhaustion. Leopold's maneuvers revealed small parts on the left anterior side, and the fetal back was difficult to palpate, consistent with an occiput posterior (OP) position. Per hospital protocol, she was confined to bed rest and placed on continuous fetal and uterine monitoring. Five hours after admission, her membranes ruptured spontaneously with clear fluid. The fetus was then at ?2 station, and her cervix had dilated to 4 cm and was 80% effaced. She reported increased pain and requested an epidural, hoping to get some rest. After the epidural was placed, her contractions became irregular (every 3–10 min), and as a result, oxytocin augmentation was started. Approximately 1 hour later, the external uterine monitor began failing to record contractions, and an intrauterine pressure catheter was placed. Ten hours after admission, and 4 hours after oxytocin was started, her cervix had dilated to 7 cm. Despite several epidural boluses, she continued to experience severe back pain, and a belly binder was applied as a relief measure. Throughout her labor, she stayed in bed with position changes that were limited to left lateral and right lateral. Cervical dilatation did not progress beyond 7 cm, and no fetal descent occurred over the next 4 hours, despite progressive oxytocin augmentation and an adequate contraction pattern based on Montevideo units. The midwife collaborated with the attending obstetrician and a cesarean section was recommended for failure to progress. A healthy baby boy who was noted to be in direct OP position was born via cesarean section with Apgar scores of 9/9. He weighed 8 pounds, 10 ounces.     

持续性枕横位和枕后位病例的产程特点及影响

目的探讨持续性枕横位和枕后位的产程特点及对母儿结局的影响。方法回顾性分析64例持续性枕横位和51例持续性枕后位病例的各阶段产程时间、异常产程及产道损伤、产后出血、羊水粪染(Ⅱ°以上)、新生儿Apgar评分(5min评分≤7分)等情况,并与同期100例枕前位病例进行对比分析。结果持续性枕横位和枕后位的异常产程发生率、产道损伤、产后出血率均较对照组明显增加(P<0.05);羊水粪染及新生儿窒息发生率均较对照组明显增加,两组比较差异均有统计学意义(P<0.05)。结论重视对持续性枕横位和枕后位的早期诊断和及时处理对减少母儿并发症有重要意义。     

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation

Introduction: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry’s spatulas (TS), in the setting of failed manual rotation (MR).

Study design: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015.

The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions.

Results: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p?Conclusion: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.     

Diagnosis and intervention for occiput posterior malposition

OBJECTIVES: To evaluate diagnostic methods used to detect occiput posterior and to describe the efficacy of posturing to enhance rotation from occiput posterior to occiput anterior. DATA SOURCES: Keyword search using PubMed, CINAHL, Cochrane Review, and Dissertation Abstracts International. STUDY SELECTION: Studies published from 1996 to 2006 (except one published in 1983) that focused on the use of ultrasonography versus digital vaginal examination to diagnose fetal position and maternal posturing to enhance rotation from occiput posterior to occiput anterior. DATA EXTRACTION: Eight prospective studies regarding malposition diagnosis were reviewed and analyzed for error rates and predictors affecting ability to detect fetal position; five randomized controlled trials were evaluated for effects of various maternal postures on fetal rotation from occiput posterior to occiput anterior. DATA SYNTHESIS: If fetal malposition is accurately diagnosed in early labor, subsequent nursing management can focus on rotation toward occiput anterior position, leading to a safer delivery for mother and baby. CONCLUSIONS: Antepartum ultrasonography is more accurate than digital vaginal examination in diagnosing fetal malposition; however, its efficacy needs to be further explored using randomized controlled trials and cost-benefit analyses before routine use is recommended. Furthermore, Sims' posture on the same side as the fetal spine is recommended during labor to enhance rotation from occiput posterior to occiput anterior.     

Influence of persistent occiput posterior position on delivery outcome.

OBJECTIVE: To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia. METHODS: We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2-year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position. RESULTS: The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P <.001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago. CONCLUSION: Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.     

持续性枕后位的临床特点及分娩方式选择

目的探讨持续性枕后位的临床特点及分娩方式。方法采用回顾性分析方法，对1998年1月至2004年12月在重庆医科大学两所附属医院住院分娩的112例持续性枕后位（枕后位组）和112例枕前位（枕前位组）的临床资料进行分析，比较两组产程情况、分娩方式及母儿结局。结果两组头位分娩评分、第一产程、第二产程及总产程时间比较，差异有显著性意义（P〈0．05）。枕后位组产钳助产、剖宫产、会阴裂伤、产后出血、胎儿窘迫、新生儿窒息率等均明显高于枕前位组，差异均有显著性意义（P〈0．05）。枕后位组宫口扩张及胎头下降延缓和第二产程延长的发生率均高于枕前位组，差异均有显著性意义（P〈0．05）。剖宫产组富口扩张延缓、胎头下降停滞和第二产程延长的发生率明显高于阴道分娩组（P〈0．05）。而剖宫产组和阴道分娩组骨盆临界狭窄、潜伏期及活跃期延长的发生率比较，差异无显著性意义（P〉0．05）。结论持续性枕后位导致母儿并发症增加，及时处理并选择最佳分娩方式可减少母儿并发症的发生。     

The association between persistent occiput posterior position and neonatal outcomes

OBJECTIVE: To examine the effect of persistent occiput posterior position on neonatal outcome. METHODS: This is a retrospective cohort study of 31,392 term, cephalic, singleton births. Women with neonates born in persistent occiput posterior position at delivery were compared to those with occiput anterior position. Women with occiput transverse position were excluded. The association between occiput posterior position and neonatal outcomes, including 5-minute Apgar scores, umbilical cord gases, meconium-stained amniotic fluid, meconium aspiration syndrome, birth trauma, admission to the intensive care nursery, and length of stay were examined using chi(2) and Student t tests. Potential confounders (maternal age, ethnicity, parity, gestational age, epidural anesthesia, labor induction, length of labor, meconium, chorioamnionitis, birth weight, and year of delivery) were controlled for by using multivariable logistic regression and linear regression analyses. RESULTS: There were 2,591 (8.2%) neonates delivered in occiput posterior position of the total cohort of 31,392 deliveries. Compared with occiput anterior, neonates delivered in occiput posterior position had higher risks for adverse outcomes, including 5-minute Apgar score less than 7 (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.17-1.91), acidemic umbilical cord gases (OR 2.05, 95% CI 1.52-2.77), meconium-stained amniotic fluid (OR 1.29, 95% CI 1.17-1.42), birth trauma (OR 1.77, 95% CI 1.22-2.57), admission to the intensive care nursery (OR 1.57, 95% CI 1.28-1.92), and longer neonatal stay in the hospital (OR 2.69, 95% CI 2.22-3.25). CONCLUSION: Persistent occiput posterior position at delivery is associated with higher risks of adverse neonatal outcomes compared with neonates delivered in the occiput anterior position. This information may be important in counseling women who experience persistent occiput posterior position in labor. Level of Evidence: II-2.     

Operative vaginal delivery in case of persistent occiput posterior position after manual rotation failure: a 6-month follow-up on pelvic floor function

Purpose

To compare the short- and long-term perineal consequences (at 6 months postpartum) and short-term neonatal consequences of instrumental rotation (IR) to those induced by assisted delivery (AD) in the occiput posterior (OP) position, in case of manual rotation failure.

Methods

A prospective observational cohort study; tertiary referral hospital including all women presenting with persistent OP position who delivered vaginally after manual rotation failure with attempted IR or AD in OP position from September 2015 to October 2016. Maternal and neonatal outcomes of all attempted IR deliveries were compared with OP operative vaginal deliveries. Main outcomes measured were pelvic floor function at 6 months postpartum including Wexner score for anal incontinence and ICIQ-FLUTS for urinary symptoms. Perineal morbidity comprised severe perineal tears, corresponding to third and fourth degree lacerations. Fetal morbidity parameters comprised low neonatal Apgar scores, acidaemia, major and minor fetal injuries and neonatal intensive care unit admissions.

Results

Among 5265 women, 495 presented with persistent OP positions (9.4%) and 111 delivered after manual rotation failure followed by AD delivery: 58 in the IR group and 53 in the AD in OP group. The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.7% vs. 24.5%; p?<?0.001) without increasing neonatal morbidity. At 6 months postpartum, AD in OP position was associated with higher rate of anal incontinence (30% vs. 5.5%, p?=?0.001) and with more urinary symptoms, dyspareunia and perineal pain.

Conclusions

OP operative deliveries are associated with significant perineal morbidity and pelvic floor dysfunction at 6 months postpartum.

     

Correcting occiput posterior position during labor: the role of maternal positions

Occipito-posterior presentation represents 10 to 34% of cephalic presentations in early labor. Spontaneous rotation during labor to occipito-anterior mode occurs in most cases, but 5 to 8% of fetuses will persist in posterior position for the expulsive phase of delivery. Previous research has shown that this presentation carries an increased risk of unusually long labor, maternal and fetal exhaustion, instrument-assisted delivery, severe perineal injury, and cesarean section. The diagnosis of posterior variety is usually made quite late at the end of dilation. Several researchers have reported the benefits of determining presentation during labor by transabdominal ultrasonography. Some obstetrical techniques to correct these presentations at complete dilation have also been described. In the case of diagnosis of posterior variety, the usual attitude is expectant management. Postural techniques to promote physiological labor and delivery have been documented in the literature. De Gasquet has described a very precise technique to facilitate fetal rotation, but its effectiveness has never been assessed scientifically. A Cochrane review on the topic has shown that similar positions are well accepted by women and reduce back pain. On the other hand, the sample size of included studies appeared inadequate to assess their interest for use in childbirth, in general, and for adverse outcomes associated with posterior presentation varieties in particular. Attempts to correct the fetal malposition during the expansion phase would allow to reduce adverse outcomes during the expulsive phase of delivery. Further research is necessary to assess the efficacity of specific maternal positions during labor for the correction of fetal posterior presentation.