DELIVERING THE MALROTATED HEAD

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

OCCIPITO POSTERIOR POSITION

MALROTATED HEAD??

OCCIPITO POSTERIOR

INCIDENCE OF ALL VERTEX

DEFINITION
IN A VERTEX PRESENTATION IF

OCCIPUT
OR

IS PLACED

POSTERIORLY OVER EITHER

SACRO-ILIAC JOINT

DIRECTLY OVER THE SACRUM

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

As a consequence, the foetal head is deflexed and larger diameters of the foetal skull

OCCIPITOPOSTERIOR

RIGHT OCCIPITOPOSTERIOR
Occiput faces Right sacroiliac joint

ROP

RIGHT OCCIPITOTRANVERSE
Anterior fontanelle on left side Saggital suture lies in transverse diameter of inlet

ROT

LEFT OCCIPITOPOSTERIOR
Occiput faces left sacroiliac joint

LOP

LEFT OCCIPITOTRANVERSE
Anterior fontanelle on right side Saggital suture is in 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.

KNOW THY OP

Antenatal diagnosis

Listen to the mother

The mother may complain of backache She may feel that her babys bottom is very high up against her ribs.
She may report feeling movements

There is a saucer-shaped depression at or just or below the umbilicus. This depression is created by the dipbetween the head and the head & the lower limbs of the fetus.
Suprapubic flattening outline created by the high, The

On inspection

unengaged head can look like a full bladder

While the breech is easily palpated at the fundus, the back is difficult to palpate as it is well out to the maternal side, sometimes almost adjacent to the maternal spine

On palpation
.

Limbs can be felt on both sides of the midline.

On palpation.
.

The head is usually high, a posterior position being the 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

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
Early

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

Membranes may rupture during examination

On many occasions after the first stage of labour has 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

Diagnosis of Occipito-posterior Positions in Late Labour

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 probably an occipito-posterior one.

USG can be very informative

THE POP MOM

PREVIOUS LSCS

PRIMI

SHORT STATURE

THE POP BABY

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

Pendulous abdomen

Anthropoid brim DIRECT OP Android brim Tranverse dia being near sacrum - BPD fits it Flat sacrum - Deflexed head OP Anterior placenta encourages foetus to flex around it

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

ASSENGER OWER ELVIS SYCHE

engagement

LABOUR

descent flexion internal rotation extension external rotation expulsion

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.

Descent & Flexion

WHATS 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

WHATS 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 th of a circle. rotation is by 2/8

INTERNAL ROTATION

DESCENT

FLEXION

INTERNAL
ROTATION ROTATION

INTERNAL ROTATION

BUT IN OCCIPITO POSTERIOR .

FLEXION

is incomplete due

to 1) anterior placentation convexities of maternal & foetal spine appose foetal spine straightens & head deflexes 2) High pelvic inclination

& IN OCCIPITO POSTERIOR .

INTERNAL ROTATION
may 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 ROTATION i in occipitoposterior

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

& THEN IN FAVOURABLE OCCIPITO POSTERIOR

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

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

unfavourable

favourable

FAVOURABLE OUTCOME
PREREQUISITES
VERAGE SIZED BABY GGRESSIVE CONTRACTIONS DEQUATE PELVIS

GYNECOID PELVIS is a favourable pelvis

A GYNECOID a wide fore

narrower hind

has & a

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

ANDROID PELVIS
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

ANTHROPOID PELVIS
Anthropoid Pelvis Pelvic brim is an anteroposterior ellipse Gynecoid pelvis turned 90 degrees Narrow ischial spines Much more common in black women Favours Direct OP/OA

UNFAVOURABLE FACTORS
eficient contractions elayed engagement eflection persists escent arrest

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

favourable

unfavourable

UNFAVOURABLE?? COURSE OF LABOUR WHEN THE HEAD IS MALROTATED

 Occiput rotates only of a circle saggital suture lies in bispinous diameter DEEP TRANVERSE ARREST

INTERNAL ROTATION MAY NOT OCCUR .

th 1/8

INTERNAL ROTATION MAY NOT OCCUR .

Occiput & sinciput reach pelvic floor together & neither moves NON ROTATION

Sinciput reaches pelvic floor first sinciput rotates anteriorly by 1/8th circle Occiput lies in sacral hollow POP or PERSISTENT OCCIPITO POSTERIOR POSITION

INTERNAL ROTATION MAY NOT OCCUR .

PERSISTENT OCCIPITO POSTERIOR d i t i o n Definition It is the con

that results in skull presentation from the r o t a t i o n o f t h e occiput

backward towards the sacrum . T h i s o c c u r s o n l y

when the head enters the pelvis with the occiput more

POP GARDBERG et al CONTROVERSY!! Study of

1/3rd cases only occiput was posterior at start of labour 2/3rd 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

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

GARDBERG STUDY

 68% POPs were initially Occipito

Anterior Malrotation Persistent Occipito Posterior 32% were Occipito Posterior at outset 87.5 Operative intervention 87% OPs rotated OA POPs more in those initially OPs

RESULTS !!

 POPs had less posterior placenta POPs had more operative 1Babywt interventions 2 LSCS High maternal BMI Forceps
Low 1min APGAR 3 Post placenta

RESULTS .

Intrapartum sonography useful in investigating the development of the persistent occipito Gardberg et al 1998 USG easy method to assess foetal head position before labour. Peregrine et al 2007

POP

posterior position.

USG can be very informative

 MALPOSITION & MALROTATION ROP, LOP POP failure of spontaneous rotation to anterior or transverse position prior to vaginal delivery occiput rotates backwards towards sacrum malrotation

PASSENGER

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 & Desopo 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

DEEP TRANSVERSE ARREST

Fate of OCCIPITOPOSTERIOR LABOUR OP

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

Unfavourable (10%)

Favourable (90%)
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 Non-rotation Oblique posterior arrest Occiput rotate posteriorly by 1/8th POPP/ occipitosacral position Arrest

Deep transverse arrest

Face to pubis delivery

HOW TO MANAGE AN OP ?

ECOGNITION OTATION ELIEF from OP...

HAND KNEE POSITION IN LABOUR

Maternal 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 OP OP POSITION AT BIRTH. RANDOMISED CONTROLLED TRIAL TRIAL WITH 2547 WOMEN. KARIMINIA ET AL 2003. NO PROVEN BENEFIT.

COCHRANE DATABASE

FIRST STAGE OF LABOUR

xclude contracted pelvis xclude cord presentation xpect & augment a slow labour , give oxytocin pidural/ painkillers for backache

caregiver support reduces rate of LSCS

PREVENT RUPTURE OF MEMBRANES

AVOID

EPIDURAL IN operative vaginal OP more delivery with epidural Pain relief decreases risk of 2 degree vaginal tear
nd

increases 2 nd stage delay decreases blood loss > 500ml increases vaginal delivery if p u s h i n g i s d e l a ye d till 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
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

POPP
POPP Arrest

Spontaneous face to pubis delivery Dead baby

Adequate pelvis

Inadequate pelvis

Head above the ischial spine / big baby

Head below the spines Forceps with deep episiotomy

C/S

Craniotomy

C/S (best)

Manual rotation + forceps

FACE TO PUBIS DELIVERY

l

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

POP DELIVERY
l

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

P O P D E L I V E R Y

Step 1

Step 2

P O P D E L I V E R Y

Step 3 Step 4 Steps 1 - 4

FORCEPS FOR DIRECT OP POSITION

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.

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

ACOG 2003

Management of DTA
DTA or oblique posterior arrest
Assisted delivery

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

Inadequate pelvis

Dead baby

C/S

Craniotomy

DEEP TRANSVERSE ARREST

1) Manual rotation followed by vaginal delivery/forceps 2) Vacuum extraction-Ventouse 3) 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 SPONTAN. VAGINAL. B OCCIPITO ANTERIOR LSCS VENTOUSE MANUAL ROTATION CONTROL

77% 93%

26% 15%

NIL 23%

23% 50%
REICHMAN ET AL 2008

DIGITAL ROTATION
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.

MANUAL ROTATION + FORCEPS

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.

 Indications

MANUAL ROTATION

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

VENTOUSE
Proper 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.

ITS ALWAYS MORE POSTERIOR THAN YOU THINK!!!

A poem by Aldo Vacca

Vacuum extraction may drive some to distraction While others may find comfort in a drink Though 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' profusion Made of plastic, rubber, steel or alloyed zinc But design, not the make-up is the feature that will make cups Move a little more posterior than you think

Need and good intention are the mother of invention New cups appear as quick as you can blink When the head is mal-rotated, the flexion point is situated A good deal more posterior than you think

To find the point that's flexing should never be perplexing It's on the vertex, in the midline not the brink Three centimeters or an inch plus, from the landmark well used by us And often more POSTERIOR than you think

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

Kielland'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 DTA

Kielland's Forceps:

FORCEPS IN DTA

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

KIELLAND FORCEPS

KIELLAND
Christian Caspar Gabriel Kielland
1871-1941

KIELLANDS 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.

KIELLANDS FORCEPS
The Claw Lock allows the blades to slide on each other and correct or encourage synclitism of the fetal head as required.

y.

HAZARD
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

Bartons 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 OP Scanzoni 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

THANK YOU