Occipito posterior position 20.06.2020 final.ppt

ppt on occipito posterior position -etiology and management

1. OCCIPITOPOSTERIOR
POSITION

2. OBJECTIVES
•Definition
•Factors which favour OP
•Diagnosing OP position
•Course of labour
•Complications
•Management

3. DEFINITION
Malposition where the occiput is in the
posterior quadrant of the maternal pelvis

4. WHATISTHEINCIDENCEOFOP ?
•At the onset of labour, 20 -25 % of vertex
presentations engage in the oblique posterior
position
•A small minority engage in the direct occipito
sacral position

5. WHYISROP MORECOMMONTHANLOP?
1.Dextrorotation of the uterus
2.Presence of sigmoid on the left

6. WHATARETHEIMPORTANTAETIOLOGICALFACTORS?
•Primary
•Secondary -After onset of labour
1. Shape of the pelvic brim
•Long AP diameter as in anthropoid pelvis
•Heart shaped brim as in android pelvis
2. High assimilation pelvis ed angle of pelvic
inclination

7. FACTORSFAVOURINGOP
1.Type of pelvis –
Android &
Anthropoid
2.High assimilation
pelvis

8. OTHERFACTORSFAVOURINGOP
3.Nulliparity
4.Obesity
5.CPD esp if EFW > 4 KG
6.Anterior attachment of placenta as the
foetus tends to face the placenta

9. HOWISTHEDIAGNOSISOFOP MADE?
1.Subumbilical flattening
2.Back in the flanks
3.Position of anterior shoulder
4.Limbs on either side of midline
5.Deflexed head
6.FHR sometimes heard opp. to side of
back due to the chest being thrown
forwards due to deflexion

10. DIAGNOSISOFOP
Inspection –subumbilical ‘flattening’

11. Palpation
Back in the flanks
Limbs felt in both sides of
midline
Occiput & sinciput in the
same level (deflexed head)
Auscultation
FH heard out in the flank

12. DENOMINATOR -Occiput
ENGAGING DIAMETER
Occipito -frontal

13. Vaginal Exam:
Sagittal suture in the
oblique diameter of
pelvis
Post fontanelle
(Occiput )in the
posterior quadrant of
pelvis

14. VAGINALEXAMINATION-DIAGNOSINGOP

16. INTRAPARTUMUSG
Useful when position is in doubt due large caput
Probe placed transversely above Pubic Symp
Face towards probe
Follow spine to find position of occiput
Determine degree of flexion

17. WHATARETHEPOSSIBLECOURSESOF
LABOURINOP ?
1.Long anterior rotation through 135
o
2.Short posterior rotation(45
o
) or reverse
rotation
3.Non-rotation or persistant occipito posterior
4.Short anterior rotation(45
o
) & deep
transverse arrest

19. MOULDING
Compression of the occipito-frontal
diameter as the deflexed head descends
through the pelvis

20. COURSE OF LABOUR IN OP
•Delayed engagement
•Early rupture of membranes
•Poor uterine contractions as head is not well
applied
•Prolonged 1 & 2
nd
stages of labour
•Birth injuries
•PPH & Perineal tears

21. WHATARETHECAUSESOFDELAYINOP ?
•Correction of deflexion
•Long anterior rotation
•Sometimes occurs in a single contraction
•BPD occupies sacrocotyloid diameter, hence less
space to rotate
•Head is not well applied to the cervix. The anterior
lip becomes edematous
•Poor uterine contractions
•Misdirection of the driving force

22. MISDIRECTIONOFDRIVINGFORCEINOP

23. MANAGEMENT
I stage
Epidural / Sedation
Adequate hydration
Partogram
Assess progress of labour
Repeated bladder distention -Suspect OP.
If labour is prolonged -Reassess

24. MANAGEMENTOF2NDSTAGE
Majority ( 80 to 85 %) undergo long anterior
rotation and normal delivery as Occipitoanterior

25. LONG ANTERIOR
ROTATION

26. SHORTPOSTERIORROTATION
•Face to pubis delivery
-Liberal episiotomy as the larger
occipito-frontal diameter emerges
•If delay assist with forceps or vacuum
•Direction of traction :Outward then
upward followed by downward traction

27. SHORTPOSTERIOR
ROTATION

28. FACETOPUBISDELIVERYWITHOCCIPITOFRONTAL
DIAMETEREMERGINGOUTOFTHEINTROITUS

29. HOWWILLYOUDEFINEDEEPTRANSVERSEARREST?
1.Full cervical dilatation
2.Sagittal suture in the transverse diameter of
maternal pelvis
3.In the cavity (0 station)
4.Good uterine contractions
5.No progress in labour
for 2 hrs in a primi
1 hr in a multi

30. IF DTA REASSESSTHEFOLLOWING
•Station & position of head
•Presence of caput & degree of moulding
•Reassessment of the mid pelvis esp sacral
curve, side walls & space below the arrest
for rotation of head
•Size of the fetus
•Adequacy of uterine contractions

31. MANAGEMENT
• Contractions inadequate -Oxytocin
• Adequate pelvis, average size baby with good
contractions
Vacuum extraction
Rarely Manual rotation or Kielland’s forceps
or forceps rotation can be tried
----

32. MANUAL ROTATION

33. LSCS ISPREFERREDIF
•Mid cavity or outlet contraction is suspected
•Soft tissue odema or poor space below the
arrest for rotation
•EFW is > 3.5 kg
•Large caput & pathologic moulding is present
•In spite of good uterine contractions the
head is jammed in the pelvis for a long time

34. COMPLICATIONS
Maternal
•Prolonged labour
•PROM
•Pueperal Sepsis
•PPH
•↑ed operative deliveries &Perineal injuries
Fetal
Asphyxia and injuries

35. NAMETHEFOLLOWING?
•Denominator
•Position
•Attitude
•Engaging diameter

36. SUMMARY
OP is a malposition of occiput
Leads to prolonged labour
Mechanisms are long anterior ,short
anterior, short posterior and non–rotations.
Labor-Await rotation If pronged assisted by
vaccum or rarely manual or forceps rotation
Arrest of labour or inadequate pelvis –LSCS