DELIVERING THE MALROTATED HEAD

BY DR.KAVITA PRIYA M.D. CENTRAL HOSPITAL DHANBAD

OCCIPITO POSTERIOR POSITION

MALROTATED HEAD??

OCCIPITO POSTERIOR

INCIDENCE OF ALL VERTEX PRESENTATIONS

DEFINITION IN A VERTEX PRESENTATION IF

OCCIPUT IS PLACED

• POSTERIORLY OVER EITHER SACRO-ILIAC JOINT OR

• DIRECTLY OVER THE SACRUM

The vertex is presenting, but the occiput lies in theposterior rather than the anterior part of the pelvis.

As a consequence, the foetal head is deflexed andlarger diameters of the foetal skull present

OCCIPITOPOSTERIOR

RIGHT OCCIPITOPOSTERIOR

Occiput faces Right sacroiliac joint

ROP

RIGHT OCCIPITOTRANVERSE

Anterior fontanelleon left sideSaggital suture liesin transverse diameter of inlet

ROT

LEFT OCCIPITOPOSTERIOR

Occiput faces left sacroiliac joint

LOP

LEFT OCCIPITOTRANVERSE

Anterior fontanelleon right sideSaggital suture isin transverse diameter of inlet

LOT

RIGHT OCCIPITO

TRANVERSE

LEFT OCCIPITO TRANVERSE

OCCIPITO LATERAL

OCCIPITOSACRAL

FACE AGAINST PUBES,OCCIPUT AGAINST SACRUM

DIRECT OP

Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP) because:The left oblique diameter is reduced by the presence of sigmoid colon.The right oblique diameter is slightly longer than the left one.Dextro-rotation of the uterus favours occipito-posterior in right position.

KNOWTHYOP

Antenatal diagnosis

Listen to the mother

The mother may complain of

backache She may feel

that her baby’s bottom is very high up against

her ribs. She may report feeling

movements across both sides of

her abdomen

On inspection

There is a saucer-shaped depression at or just or below the umbilicus. This depression is created by the ‘dip’between the head and the head

& the lower limbs of the fetus.

The outline created by the high,

unengaged head can look like a full bladder

Suprapubicflattening

On palpationWhile the breech is easily palpated at the fundus,

the back is difficult to palpate as it is well out to thematernal side, sometimes almost adjacent to the

maternal spine.

Limbs can be felt

on both sides of

the midline.

On palpation.

.

The head is usually high, a posterior position beingthe most common cause of non-engagement in a

primigravida at term.

This is because the large presenting diameter,

the occipitofrontal

(11.5cm),kkkkkkkkkkkkkk

is unlikely toenter the pelvic

kkkkkkkkkkkkkkkkkkkkkkkkk brim until labour begins and

flexion kkkkkkkkkkkkkkkkkk

occurs. The occiput and sinciput are on the same

level

On auscultation The fetal back is not well

flexed so the chest is thrust forward, therefore the fetal heart

can be heard in the midline. However, the heart

may be heard more easily at the flank

on the kkksame side as the back.

Vaginal Examination

1)Elongated bag of waters

2)Sagittal suture in oblique dia

3)Posterior fontanelle near SI jt.

4)Anterior fontanelle felt more easily due to

deflexion of head

Early

Membranes may rupture during

examination

Diagnosis of Occipito-posterior Positions in

Late LabourOn many occasions after the

fi rst stage of labourhas been completed and

after the membranes have ruptured

the occiput may be either in an anterior or a

posterior position. To arrive at a

diagnosis by palpating the sutures in the vagina is

neither easy nor certain due to formation of caput. The ultimate diagnosis of an

occipitoposterior position is made

by feeling the ear of the foetus.

UNFOLDED EAR

POINTS TOWARDS

THE OCCIPUT

Unfolded pinna points

towards the

occiput

Diagnosis of Occipito-posterior Positions..

by

recrectal examination.

In an In occipito-anterior position it is possible to feel the anterior

fontanelle. If the anterior fontanelle cannot be felt,

then the position is probablyan occipito-posterior one.

USG can be very

informative…

THE POP MOM

SHORT STATUREHIG

H BM

I

PRIMI

PREVIOUS LSCS

1

THE POP BABY

LARGEBABY

 Brachycephaly describes a very wide head shape with a flattening across the whole back of the head.

Pendulous abdomen

Anthropoid brim – DIRECT OPAndroid brim – Tranverse dia being near sacrum - BPD fits itFlat sacrum - Deflexed head OPAnterior placenta encourages foetus to flex around it

ROT position of head & right obliquity + dextrorotated uterus -- deflexed head & OP

WHY OCCIPITO POSTERIOR?

P ASSENGER OWER

ELVIS SYCHE

LABOUR engagement descent flexion internal rotation extension external rotation expulsion

Descent & Flexion Descent and flexion go hand in hand, should be associated in thought as they are in reality. Flexion is not in any sense an active movement. It is always a movement of accommodation, on meeting resistance.

There is substitution of a shorter

diameter for a previous longer one.

.

WHAT’S USUAL?i Flexion

•As soon as the descending

head meets resistance, whether from the cervix, walls of the pelvis, or pelvic floor, then flexion of the head normally results .• The shorter  suboccipitobregmatic diameter is substituted for the longer occipitofrontal diameter.

FOETUS

PELVIC FLOOR

FLEXION & INTERNAL ROTATION

WHAT’S USUAL?i•In occipito anterior position the head rotates anteriorly by 1/8th of a circle at the pelvic floor or – rarely - in the cervix or at crowning.•In occipito lateral position rotation is by 2/8th of a circle.

INTERNAL ROTATION

DESCENT

FLEXION

ROTATION

INTERNAL

ROTATION

INTERNAL

ROTATION

BUT IN OCCIPITO POSTERIOR ….

FLEXION is incomplete due to 1) anterior placentation convexities of maternal & foetalspine appose foetal spine

straightens & head deflexes 2) High pelvic inclination

& IN OCCIPITO POSTERIOR ….

INTERNAL ROTATIONmay occur in favourable

conditions• Occiput rotates anteriorly by

3/8th of a circle head lies behind the pubic symphysis

• Shoulder rotates 2/8th of a circle Shouders lie in right oblique dia

(ROP) or in left oblique dia (LOP)• Neck suffers torsion of 1/8th of a

circle

INTERNAL ROTATIONin occipitoposterior i

& THEN IN FAVOURABLE OCCIPITO

POSTERIOR DESCENT & delivery of head occurs as for OA

RESTITUTION 1/8th of a circle in direction opposite to internal rotation

EXTERNAL ROTATION as for OA EXPULSION

{

This is favourable OCCIPITO POSTERIOR in which one long rotation converts course of labour to that for OCCIPITO ANTERIOR

favourable

unfavourable

LABOUR IN OP

Diameter of engagement= oblique diameter Engaging dia = occipitofrontal(11.5cm)/suboccipitofrontal(10cm)

FAVOURABLE OUTCOME PREREQUISITES

AVERAGE SIZED BABYGGRESSIVE CONTRACTIONSDEQUATE PELVIS

GYNECOID PELVISis a

favourable pelvis

A GYNECOID

a wide fore

Front of head with small bitemporal diameter fits into narrow hindpelvis & back of head with its wider transverse dia into the forepelvis - occipito anterior position

has& anarrower hind

•Android Pelvis (Male type)•Pelvic brim is triangular•Convergent Side Walls (widest posteriorly)•Prominent ischial spines•Narrow subpubic arch•More common in white women•Favours occipitoposterior

ANDROID PELVIS

ANTHROPOID PELVISAnthropoid Pelvis

Pelvic brim is an anteroposterior ellipse

Gynecoid pelvis turned 90 degrees

Narrow ischial spinesMuch more common in black womenFavours Direct OP/OA

UNFAVOURABLE FACTORS

Deficient contractionselayed engagementeflection persistsescent arrest

unfavourable

favourable

LABOUR IN OP

Diameter of engagement= oblique diameter Engaging dia = occipitofrontal(11.5cm)/suboccipitofrontal(10cm)

UNFAVOURABLE?? COURSE OF LABOUR WHEN THE HEAD IS MALROTATED

INTERNAL ROTATION MAY NOT OCCUR ….

•Occiput rotates only 1/8th of a circle saggital suture lies in bispinous diameter

DEEP TRANVERSE ARREST

INTERNAL ROTATION MAY NOT OCCUR ….

•Occiput & sinciput reach pelvic floor together & neither moves

NON ROTATION

INTERNAL ROTATION MAY NOT OCCUR ….

Sinciput reaches pelvic floor first sinciput rotates anteriorly by 1/8th circle

Occiput lies in sacral hollowPOP or PERSISTENT OCCIPITO POSTERIOR POSITION

PERSISTENT OCCIPITO

POSTERIORD e fi n i t i o n I t i s t h e c o n d i t i o n t h a t r e s u l t s i n s k u l l p r e s e n t a t i o n f r o m t h e r o t a t i o n o f t h e o c c i p u t b a c k w a r d t o w a r d s t h e s a c r u m . T h i s o c c u r s o n l y w h e n t h e h e a d e n t e r s t h e p e l v i s w i t h t h e o c c i p u t m o r e o r l e s s p o s t e r i o r t o t h e t r a n s v e r s e d i a m e t e r o f t h e p e l v i s .

POP CONTROVERSY!!• Study of GARDBERG et al1/3rd cases only occiput was posterior at start of labour2/3rd cases occiput was initially anterior & rotates backward malrotation POP • Study of Souka et al # rotation of the fetal head is highly

unlikely when labor begins with the head

anterior# persistent posterior position

nonrotated head in initial posterior /transverse

position.

GARDBERG STUDY•408 pregnant women

at 37+wks & vertex position had USG at onset of labour

•Foetal position, placental localization, maternal BMI were noted 61(15%)OPs

RESULTS !!• 68% POPs were initially Occipito Anterior Malrotation

Persistent Occipito Posterior

• 32% were Occipito Posterior at outset

• Operative intervention• 87% OPs rotated OA• POPs more in those initially OPs

87.5

RESULTS ….• POPs had less posterior placenta

• POPs had more operative interventions

• High maternal BMI

1Babywt

2 LSCS Forceps

3 Post placenta

F

Low 1min APGAR

USG can be very informative in POP

Intrapartum sonography useful

in investigating the development of

the persistent occipito posterior position.

Gardberg et al 1998 USG easy method to assess foetal head position before labour. Peregrine et al 2007

USG can be very

informative…

PASSENGER• MALPOSITION & MALROTATION• ROP, LOP• POP f a i l u re o f spontaneous ro ta t ion to an te r io r o r t ransverse pos i t i on p r io r to vag ina l de l i ve ry o cc ipu t ro ta tes backwards towards sac rum

malrotation

PERSISTENT OCCIPITO

POSTERIOR –What is it??? It is the true

malrotation into an occipito-sacral position but in wider sense it includes deep transverse arrest & oblique post. arrest

DEEP TRANSVERSE ARREST

• Head enters brim transversely in 60% cases• Caldwell & Moloy & D’esopo 1934• Transverse head in brim & midcavity• Steel & Javert• Transverse arrest is hence more usually of a

head that was TRANSVERSE throughout labour

WHY DEEP?• DEEP DEPTH INWARDS FROM

PELVIC OUTLET AT WHICH ARREST OCCURS

• DEEP DEPTH DOWNWARDS FROM PELVIC BRIM

• ARREST CAN OCCUR AT ANY LEVEL

DEEPTRANSVERSE

ARREST

Fate of OCCIPITOPOSTERIORLABOUR OP

Engaging diameter :- occipito-frontal 11.5cm or sub-occipitofrontal 10cm.

Favourable (90%)Unfavourable (10%)

3/8th rotation

occiput comes under symphysis pubis (rt/lt occipito anterior)

Normal vaginal delivery

Mild deflexion Moderate deflexion Severe deflexion

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

HOW TO MANAGE AN OP ?

RECOGNITIONOTATIONELIEF

from OP...

HAND KNEE POSITION IN LABOURMaternal hands-and-knees positioning has been associated with successful rotation to OA in at least one trial (Stremler 2005)

EFFECT OF HAND & KNEES P POSTURING &

PELVIC ROCKING EXERCISES ON INCIDENCE OF O P

OP POSITION AT BIRTH. RANDOMISED CONTROLLED

TRIAL TRIAL WITH 2547 WOMEN. KARIMINIA ET AL 2003.

NO PROVEN BENEFIT.COCHRANE DATABASE

X

FIRST STAGE OF LABOUR

E xclude contracted pelvisxclude cord presentation

xpect & augment a slow labour , give oxytocin

pidural/ painkillers forbackache

caregiver support reduces rate of LSCS

PREVENT RUPTURE OF MEMBRANES

AVOIDact

ivi

ty

straining

enemaUnnecessary

vaginal

examinations

EPIDURAL IN OP Pain relief

• more operative vaginal delivery with epidural

• decreases risk of 2 n d degree vaginal tear

• increases 2 n d stage delay

• decreases blood loss > 500ml

• increases vaginal delivery if pushing is delayed ti l l foetus reaches lower station even after full dilation

COCHRANE DATABASE

EPIDURAL IN OP

In 90% OPs long anterior rotation occiput becomes anterior spontaneous or aided vaginal delivery

Second stage delay

HOW LONG IS TOO LONG??

• >2 HOURS DURATION / <1CM PER HOUR DESCENT OF HEAD WITHOUT ANAESTHESIA•>3 HOURS DURATION WITH REGIONAL ANAESTHESIA ACOG

2003

Second stage delay

HOW LONG IS TOO LONG??

•Extended 2nd stage is safe if FHR is reassuring•Not an indication for LSCS, operative vaginals•Studies based on CORD BLOOD GAS & APGARS•REF:Cheng et al 2004, Myles et al COCHRANE

DATABASE

POPPPOPP

Spontaneous face to pubis delivery

Arrest

Head above the ischial spine / big baby

C/S (best) Manual rotation + forceps

Adequate pelvis Inadequate pelvis Dead baby

Head below the spines

Forceps with deep episiotomy

C/SCraniotomy

FACE TO PUBIS DELIVERY

l

The sinciput will first emerge from under the symphysis pubis as far as the root of the noseMaintain flexion by restraining it fromescaping further than the glabella, allowing the occiput to sweep the perineum and be born. .

POP DELIVERYl

Extend the head by grasping it and bringing the face down from under the symphysis pubis. Perineal trauma is common Watch for signs of rupture in the centre of the perineum(‘button-hole’ tear). An episiotomy may be required,owing to the larger presenting diameters.

Step 1 Step 2

POP DELIVERY

Step 3

Step 4

Steps 1 - 4

POPDELIVERY

Easiest and often the best method of delivering an infant with the head in the direct OP position. If the head is low in the pelvis it is likely to be deliverable with very little traction and the fetus is spared the risks of manipulation. A large episiotomy is necessary.

FORCEPS FOR DIRECT OP POSITION

1.

• APPLY BLADES AS FOR OCCIPITO ANTERIOR

• BLADES SHOULD BE AT SAME DISTANCE FROM SINCIPUT & OCCIPUT TO PREVENT SLIPPING DURING TRACTION

• GIVE HORIZONTAL TRACTION TILL ROOT OF NOSE IS UNDER SYMPHYSIS PUBIS

• CHANGE DIRECTION TO UPWARDS & FORWARDS TO DELIVER OCCIPUT

• DELIVER NOSE & CHIN BY DOWNWARD MOVEMENT

Arrest of Labour

First stage > 2h active labour : no cervical changeSecond stage > 1h of pushing : no descent ACOG 2003

Management of DTADTA or oblique posterior arrest

Assisted delivery

Pelvis adequate Inadequate pelvis

-Manual rotation of occiput to anterior position followed by forceps extraction- vacuum delivery- forceps rotation

Dead baby

Craniotomy C/S

DEEP TRANSVERSE ARREST

1) Manual rotation followed by vaginal delivery/forceps

2) Vacuum extraction-Ventouse3) Forceps rotation + extraction

MANUAL ROTATION

Technique -Tarnier and Chantreuil

– Cervix atleast 7cm dilatation, – Bladder emptied, – Dorsal recumbent (flat) position– Hand introduced during relaxation– Rotation effected during uterine contraction– Foetal heart rate (FHR) is monitored continuously

throughout these procedures. – In case of failure, the manoeuvre can be performed

again if the FHR is reassuring.

MANUAL ROTATION OUTCOME MANUAL

ROTATIONCONTROL

SPONTAN. VAGINAL. B 77% 26% OCCIPITO ANTERIOR 93% 15% LSCS NIL 23%

VENTOUSE

23% 50% REICHMAN ET AL 2008

To perform digital rotation, a physician or midwife applies upward pressure with the fingertips against the parietal bone of the fetal skull near the posterior fontanelle after the woman is fully dilated and the baby is engaged in the pelvis. Manual rotation is a variant using the practitioner's whole hand.

DIGITAL ROTATION

1) GA 2) Disimpaction: the head is grasped bitemporally and pushed slightly upwards. 3)Flexion of the head. 4)Rotation of the occiput anteriorly by the right hand vaginally 5)Rotation of the anterior shoulder abdominally towards the middle line by the left hand or an assistant 6)Fix the head abdominally by an assistant, apply forceps and extract it.

MANUAL ROTATION + FORCEPS

MANUAL ROTATION

• Indications–Occiput Posterior and Failure to Progress

• Safety–Low risk procedure –requires training)

• Efficacy–Significantly reduces cesareans in OP

Shaffer (2006)

MANUAL ROTATION– Flex fetal head

• Place hand in posterior Pelvis behind occiput

• Wedge head into flexion– Rotate head

• Perform during contraction with mother pushing

• OP: Examiner pronates dominant hand on exam

• ROP: Examiner pronates left hand clockwise

• LOP: Examiner pronates right hand counter clockwise SHAFFER 2006

VENTOUSEProper application as near as possible to the occiput will promote flexion of the head.Traction will guide the head into the pelvis till it meets the pelvic floor where it will rotate.

IT’S ALWAYS MORE

POSTERIOR THAN YOU THINK!!!

A poem by Aldo Vacca

Vacuum extraction may drive some to distractionWhile others may find comfort in a drinkThough life's replete with cliches, the answer is in the catch phrase:"It's always more posterior than you think”

“There is clinical confusion at the vacuum cups' profusionMade of plastic, rubber, steel or alloyed zincBut design, not the make-up is the feature that will make cupsMove a little more posterior than you think

Need and good intention are the mother of inventionNew cups appear as quick as you can blinkWhen the head is mal-rotated, the flexion point is situatedA good deal more posterior than you think

To find the point that's flexing should never be perplexingIt's on the vertex, in the midline not the brinkThree centimeters or an inch plus, from the landmark well used by usAnd often more POSTERIORthan you think

Some cups I've heard it muttered, look like metal "cookie cutters"Or a tool that's used to clear the kitchen sinkIn jest it's called a "Hoover" but the trick is to maneuver cupsTo place them more posterior than you think

FORCEPS IN DTAKielland's Forceps:

•  This forceps was originally designed to deliver the fetal head at or above the pelvic brim, lying in the transverse axis of the pelvis and rotating it when it had reached the pelvic cavity.

 

FORCEPS IN DTAKielland's Forceps:

 

• The forceps is used today for rotation and extraction of the head which is arrested in the deep transverse or occipito-posterior position. 

KIELLAND FORCEPS

.

KIELLAND

Christian Caspar Gabriel Kielland 1871-1941

KIELLAND’S FORCEPS

• The blades have very little pelvic curve and are virtually an axis traction forceps. The shallowness of the curve allows safe rotation in the vagina. Downward traction encourages rotation of the head. 

KIELLAND’S FORCEPS•The Claw Lock allows

the blades to slide on each other and correct or encourage synclitism of the fetal head as required.

HAZARDy.

The range of movement allowed by the lock makes it possible to apply lethal compression to the fetal head if the instrument is used improperly.

.

OTHER FORCEPS FOR OP Barton’s forceps:

Originally was designed for deep transverse arrest.It has a hinge in one blade between the blade proper and shank to facilitate application.The axis of the handle to that of the blades is 55o i.e. the angle of the pelvic inlet to the outlet.It is used for rotation only then conventional forceps is applied for extraction unless it has an axis traction piece so it can be used for rotation and extraction.

.

OTHER FORCEPS FOR OPScanzoni double application:•The conventional forceps is applied to rotate

the occiput anteriorly .•Then the forceps is removed and reapplied so

that the pelvic curve of the forceps is directed anteriorly and extract the head.

• This method is obsolete as it is hazardous to the mother and foetus.

LSCS IN OCCIPITOPOSTERIOR

# POP PER SE IS NOT AN INDICATION FOR LSCS # It is indicated in:

• Failure of the above methods.• Other indications for C.S. as;

–contracted pelvis, –placenta praevia,–prolapsed pulsating cord before full cervical

dilatation, and–elderly primigravida.

COMPLICATIONS

•PROLONGED LABOUR•VAGINAL OPERATIVE DELIVERY•PERINEAL INJURY•PPH•TENTORIAL TEAR •BIRTH ASPHYXIA•FOETAL TRAUMA

One last dreaded complication

is medicolegal…

THANK YOU