What is the antepartum management of occipital posterior (OP) position?

From the Guidelines

Antepartum management of occipital posterior position should focus on encouraging fetal rotation to a more favorable position before labor begins, with the primary recommendation being maternal positioning exercises, such as hands-and-knees positions for 10 minutes several times daily during the last few weeks of pregnancy. The goal of these exercises is to create space in the pelvis to facilitate fetal rotation, thereby reducing the risk of complications associated with persistent occipital posterior positions, such as longer and more painful labors, and higher rates of instrumental delivery and cesarean section 1. Some key points to consider in the management of occipital posterior position include:

• Avoiding reclining positions that tilt the pelvis backward, and instead sitting on birth balls or chairs while leaning forward
• Using gravity and maternal positioning to encourage the heaviest part of the fetal head (the occiput) to rotate anteriorly
• Considering chiropractic techniques like the Webster technique to optimize pelvic alignment, although evidence is limited 1
• Recognizing that while many fetuses in posterior position will spontaneously rotate during labor, persistent occipital posterior positions are associated with increased risks, making antepartum efforts to encourage optimal positioning worthwhile It is essential to note that no medications are indicated for this positional issue, and management should focus on non-pharmacological interventions to encourage fetal rotation and optimize pelvic alignment 1.

From the Research

Antepartum Management of Occipital Posterior (OP) Position

The antepartum management of occipital posterior (OP) position involves various techniques to promote the rotation of the fetal head to an anterior position. Some of the key points to consider include:

• Maternal postural techniques have been reported to promote the anterior position of the fetal head for delivery 2
• 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 3
• Manual rotation of the fetal head to occiput anterior improves the rate of occiput anterior deliveries 3
• Attempts to correct OP by manual rotation have better results when the head is in the mid-pelvis 4
• Posture change reduces cesarean section rate 4

Identification and Diagnosis

Identification and diagnosis of OP position is crucial for effective management. Some key points to consider include:

• Ultrasound (US) diagnosed OP position during labor can predict OP position at birth 5
• The exact position of the fetal head is of paramount importance prior to any operative vaginal delivery 5
• Digital vaginal examination can be used to identify the OP fetus during labor, but its accuracy is limited 3

Complications and Outcomes

Persistent OP position is associated with a higher rate of complications during labor and delivery, including:

• Prolonged first and second stages of labor 6
• Oxytocin augmentation 6
• Use of epidural analgesia 6
• Chorioamnionitis 6
• Assisted vaginal delivery 6
• Third and fourth degree perineal lacerations 6
• Cesarean delivery 6
• Excessive blood loss 6
• Postpartum infection 6