Ultrasound Obstet Gynecol 2014; 43: 176182

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.13189

Association between fetal position at onset of labor

and mode of delivery: a prospective cohort study
A. AHMAD*, S. S. WEBB*, B. EARLY*, A. SITCH, K. KHAN and C. MACARTHUR
*Birmingham Womens NHS Foundation Trust, Birmingham, UK; Public Health, Epidemiology & Biostatistics, University of Birmingham,
Edgbaston, UK; Womens Health and Clinical Epidemiology, Barts and The London School of Medicine & Dentistry, London, UK

K E Y W O R D S: birth outcome; fetal occiput position; left occipito-anterior; LOA; mode of delivery; occiput position

ABSTRACT

INTRODUCTION

Objectives To determine the association between fetal

position at onset of labor and mode of delivery,
specifically left occipito-anterior (LOA) fetal position and
spontaneous vaginal delivery (SVD).

It is a common midwifery and obstetric belief that the

progression of labor is underpinned by fetal position, i.e.
the relation of the fetal presenting part to the mothers
pelvis, during labor. Fetal malposition is associated
with increased morbidity for both the mother and
neonate1 8 . Malposition poses a particularly high risk
in first labors5,7,9 11 . At onset of labor, the left occipitoanterior (LOA) fetal position has often been considered
as optimum when compared with other positions for
achieving a spontaneous vaginal delivery (SVD)12 15 .
Optimal fetal positioning through maternal posturing to
encourage the fetus to adopt an LOA position is practiced
by many worldwide, and is promoted through textbooks,
the Internet and midwifery teaching16 21 . A systematic
review performed by the first author looked at the effect
of fetal position at the onset of labor and scrutinized all
potentially relevant studies22 . The review found that the
theory that the LOA fetal position at onset of labor is
optimal for achieving SVD had never been empirically
tested7,22 24 . Of the two relevant studies identified by the
systematic review, one reported an association between
posterior positions and Cesarean section, while another
found no association between mode of delivery and
position, but observed that it was possible for fetuses
initially in an anterior position to rotate to posterior and
vice versa23,24 . Both investigations were flawed, as they
did not assess the full range of positions possible at onset
of labor and had insufficient statistical power.
The relationship between fetal position at onset of
labor and mode of delivery remains poorly explored and
documented22 . Faber25 suggests that issues associated
with fetal position at onset of labor are difficult to
establish, since no data exist on the subject. As robust
evidence on optimum fetal position is fundamental to
practice, we set out to determine if there is a link between
fetal position at onset of labor and birth outcome for the
mother and neonate.

Methods All nulliparous women who were booked at the

Birmingham Womens NHS Foundation Trust over an 18month period from April 2007 to September 2008 with a
singleton live fetus without structural anomalies at term
gestation were invited to take part in the study. Women
recruited to the study underwent a transabdominal
ultrasound scan to determine fetal occiput position at
the onset of labor. They were then followed up until birth
to determine outcome. The primary outcome measure
was mode of delivery, categorized into SVD, instrumental
delivery and Cesarean section.
Results Of 1647 eligible women, 1250 had valid scans
at onset of labor; 155 of the 1250 (12.4%) had fetuses
in the LOA position. Analysis showed no evidence of
difference in odds ratio (OR) of SVD for fetuses in the
LOA position compared with all other positions (OR
0.864 (95% CI, 0.6171.209); P = 0.394). No difference
remained with adjustment for confounding effects of
variables known to influence mode of delivery (OR 0.837
(95% CI, 0.5511.272); P = 0.405). No other occipital
position showed significant association with SVD. There
was no evidence of the LOA position being associated
with Cesarean section, ventouse or forceps delivery.
Conclusion There is no evidence of an association
between the fetal LOA position at onset of labor and
SVD. This finding challenges the conventional theory that
LOA is the optimum fetal position at onset of labor, and
suggests that antenatal practices encouraging adoption
of the LOA position through maternal posturing are
unnecessary. Copyright 2013 ISUOG. Published by
John Wiley & Sons Ltd.

Correspondence to: Dr A. Ahmad, Birmingham Womens NHS Foundation Trust, Birmingham, B15 2TG, UK (e-mail: draishahahmad@gmail.com)
Accepted: 1 August 2013

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

ORIGINAL PAPER

Association between fetal position and mode of delivery

177

METHODS
A protocol for a prospective cohort study was developed
and ethical approval obtained from the South Birmingham Research Ethics Committee. Local research and
development approval was granted by the Birmingham
Womens NHS Foundation Trust (BWH), where recruitment took place over an 18-month period from April
2007 to September 2008. The recruitment program took
a multi-strategy approach, aiming to invite to the study all
nulliparous women meeting the specified eligibility criteria, due to give birth at the BWH during the study period.
The primary recruiters were the community midwives, as
every pregnant woman attending the BWH is allocated a
community midwife. Each woman has set appointments
with her midwife, thus ensuring several opportunities to
be invited to join the study. Women giving their consent
to be enrolled were identified by the study marking on
their maternity records. Others were recruited on site by
hospital midwives, antenatal educators and research midwives. The study thus ensured that a robust recruitment
program was implemented.
Eligibility criteria were a live, singleton fetus with no
known structural abnormalities at 37 weeks gestation
in cephalic presentation. The labor could be spontaneous
or induced and, at the time of final recruitment to
the cohort, women had to be in early labor (cervical
dilatation 4 cm). Initial recruitment to the study targeted
women from 28 weeks gestation but women who had
a non-cephalic fetal presentation, those with labor
commencing before 37 weeks, those booked for elective
Cesarean section or those admitted in established labor
(cervical dilatation > 4 cm), became ineligible.

Determination of fetal position

Transabdominal ultrasound examination is the gold standard for determining fetal head/occiput position26 32 . We
performed transabdominal, suprapubic ultrasonography
using intracranial structures, in particular the paired thalami, as markers to identify fetal occiput position29,30,32 .
Staff performing the scans received training in the technique, and quality assurance involved validation of all
ultrasound images confirming the position-defining structures. Validation was undertaken by an independent clerk,
who compared all the images with the structures marked
by the scanning midwife on the data collection sheet to
ensure conformity with the study protocols.
Once the women had received an initial ultrasound
scan, they were reviewed 12 h later, and if they had not
entered established labor the scan was repeated. This
procedure was continued until each study participant had
entered established labor, ensuring that the fetal position
was determined within the period of early labor before
the start of active labor.
Fetal occiput position was categorized into one of the
following eight groups: left occipito-anterior (LOA), right
occipito-anterior (ROA), direct occipito-anterior (DOA),
left occipito-lateral (LOL), right occipito-lateral (ROL),

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

DOA
ROA

LOA
45
LOL

ROL

LOP

ROP
DOP

Figure 1 Classification of fetal occiput position within the pelvic

cavity. As there are eight fetal positions and the mid-point for each
position is known within the cavity, an equal 45 proportion was
allocated to each fetal position. DOA, direct occipito-anterior;
DOP, direct occipito-posterior; LOA, left occipito-anterior; LOL,
left occipito-lateral; LOP, left occipito-posterior; ROA, right
occipito-anterior; ROL, right occipito-lateral; ROP, right
occipito-posterior.

left occipito-posterior (LOP), right occipito-posterior

(ROP) and direct occipito-posterior (DOP) (Figure 1).

Ascertainment of outcomes
The primary outcome measure was mode of delivery,
categorized into SVD, ventouse delivery, forceps delivery
and Cesarean section, the main analyses being based
on SVD vs non-SVD categorization. Secondary outcome
measures were labor augmentation, use of pain relief,
neonatal Apgar scores at 1 and 5 min, duration of first and
second stages of labor and duration of rupture of membranes. Outcome data were ascertained at birth. Baseline
characteristics were also recorded for each participant.
Staff providing care and those recording outcomes were
blinded to the data on scanning for fetal position.

Sample size and statistical analysis

Fifty-seven percent of all deliveries at the BWH between
April 2006 and March 2007 were SVD33 . If one assumes
that each position is equally likely, 12.5% of women
would be expected to present in the LOA position. To
detect an absolute difference of 15% (55% to 70%)
between SVD occurrence in the group presenting in
non-LOA positions and the group presenting in the LOA
position, with a significance level of 5% and power of
90%, a total sample size of 1056 (924 in the non-LOA
group and 132 in the LOA group) would be needed.
The study recruited 1250 women, thus fulfilling the
requirements of this criterion.
The characteristics of the study participants were
tabulated. The proportion of deliveries that were SVD
was calculated for fetuses presenting in LOA and nonLOA positions and a two-sample test of proportions
was carried out. The relationships between all fetal
positions and the four modes of delivery (SVD, ventouse,
forceps and Cesarean section) were investigated using

Ultrasound Obstet Gynecol 2014; 43: 176182.

Ahmad et al.

178

exploratory data analysis. Fetal position by onset of

labor (spontaneous or induced) was also investigated.
Logistic regression models were tested with each mode of
delivery as the outcome, firstly to see whether there were
any differences between the LOA position and all other
positions combined, and secondly to compare all positions
individually with the LOA position. The regression models
were adjusted to allow for the confounding effects of age,
induction of labor, use of epidural, duration of labor
and birth weight, variables known to influence mode of
delivery10,34 39 . Logistic regression and linear regression
models were used in the analysis of secondary outcomes
(augmentation of labor, duration of active first and second
Table 1 Characteristics of study group of 1250 women with
singleton term pregnancy without structural anomalies
Characteristic

n (%)

Gravidity/parity
1/0
2/0
3/0
4/0
Age
20 years
2125 years
2630 years
3135 years
> 35 years
Ethnicity
White British
South Asian: Pakistani
South Asian: Indian
South Asian: Bangladeshi
Black: African
Black: Caribbean
Chinese
Mixed
Other/not stated
Onset of labor
Spontaneous
Induced

967 (77.4)
215 (17.2)
47 (3.8)
21 (1.7)
232 (18.6)
391 (31.3)
344 (27.5)
206 (16.5)
77 (6.2)
712 (56.9)
186 (13.0)
79 (6.3)
22 (1.8)
37 (3.0)
26 (2.1)
28 (2.2)
42 (3.3)
118 (9.4)
757 (60.6)
493 (39.4)

stages, duration of rupture of membranes, neonatal Apgar

scores at 1 and 5 min and use of pain relief).

RESULTS
During the study period, of the total of 2838 births to nulliparous women, 1191 were ineligible (owing to elective
Cesarean section, congenital fetal abnormality, arrival at
hospital after onset of labor or because an ultrasound
scan could not be performed). Of the remaining 1647
women recruited and scanned, 349 were later lost, mainly
because a subsequent scan was not carried out within 12 h
of the participants entering established labor; a further
48 had non-valid scans with fetal position technically
unobtainable. Thus the final study group comprised 1250
women with valid scans obtained at onset of labor, in
whom onset of the active stage followed within 12 h.
Characteristics of the study group are shown in Table 1.
The study provided data on the prevalence of all fetal
occiput positions at the onset of labor, for all labors and
for spontaneous and induced labors separately (Table 2).
The individual positions were grouped into anterior
(LOA/ROA/DOA), lateral (LOL/ROL) and posterior
(LOP/ROP/DOP). Of these grouped fetal positions,
the anterior group at the onset of labor was least
common, with a frequency of 23.8%. The frequency
of the posterior group was 29.7% and the lateral fetal
positions were most common, with a frequency of
46.6%. The most common single fetal position was
the LOL (27.4%) and the least common was the ROA
(3.8%), while the prevalence of the LOA position was
12.4%. The prevalence of the OA positions was similar
for induced (23.7%) and spontaneous labors (23.8%).
The OL positions occurred more often in induced labors
(51.1%) than in spontaneous labors (43.6%), and the OP
positions occurred less often in induced labors (25.2%)
than in spontaneous labors (32.6%).
Table 2 shows mode of delivery categorized by occiput
position. Of the fetuses in the LOA position at onset

Table 2 Fetal occiput positions according to type of onset of labor and mode of delivery in a cohort of 1250 pregnant women
Fetal
Onset of labor
occiput
position Spontaneous
Induced
LOA
ROA
DOA
LOL
ROL
LOP
ROP
DOP
All OA
All OL
All OP
All

84 (11.1)
29 (3.8)
67 (8.9)
195 (25.8)
135 (17.8)
111 (14.7)
102 (13.5)
34 (4.5)
180 (23.8)
330 (43.6)
247 (32.6)
757 (100.0)

Mode of delivery
All

SVD

Ventouse

Forceps

Cesarean

All

71 (14.4)
155 (12.4)
77/155 (49.7)
25/155 (16.1)
25/155 (16.1)
28/155 (18.1) 155 (100.0)
18 (3.7)
47 (3.8)
26/47 (55.3)
6/47 (12.8)
7/47 (14.9)
8/47 (17.0)
47 (100.0)
28 (5.7)
95 (7.6)
56/95 (58.9)
16/95 (16.8)
7/95 (7.4)
16/95 (16.8)
95 (100.0)
148 (30.0)
343 (27.4)
179/343 (52.2)
50/343 (14.6)
45/343 (13.1)
69/343 (20.1) 343 (100.0)
104 (21.1)
239 (19.1)
127/239 (53.1)
37/239 (15.5)
18/239 (7.5)
57/239 (23.8) 239 (100.0)
56 (11.4)
167 (13.4)
95/167 (56.9)
18/167 (10.8)
24/167 (14.4)
30/167 (18.0) 167 (100.0)
47 (9.5)
149 (11.9)
75/149 (50.3)
19/149 (12.8)
20/149 (13.4)
35/149 (23.5) 149 (100.0)
21 (4.3)
55 (4.4)
26/55 (47.3)
9/55 (16.4)
8/55 (14.5)
12/55 (21.8)
55 (100.0)
117 (23.7)
297 (23.8)
159/297 (53.5)
47/297 (15.8)
39/297 (13.1)
52/297 (17.5) 297 (100.0)
252 (51.1)
582 (46.6)
306/582 (52.6)
87/582 (14.9)
63/582 (10.8) 126/582 (21.6) 582 (100.0)
124 (25.2)
371 (29.7)
196/371 (52.8)
46/371 (12.4)
52/371 (14.0)
77/371 (20.8) 371 (100.0)
493 (100.0) 1250 (100.0) 661/1250 (52.9) 180/1250 (14.4) 154/1250 (12.3) 255/1250 (20.4) 1250 (100.0)

Data presented as n (%). DOA, direct occipito-anterior; DOP, direct occipito-posterior; LOA, left occipito-anterior; LOL, left
occipito-lateral; LOP, left occipito-posterior; OA, occipito-anterior; OL, occipito-lateral; OP, occipito-posterior; ROA, right
occipito-anterior; ROL, right occipito-lateral; ROP, right occipito-posterior; SVD, spontaneous vaginal delivery.

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound Obstet Gynecol 2014; 43: 176182.

Association between fetal position and mode of delivery

of labor, the proportion achieving an SVD was 49.7%
(77/155), and for the fetuses not in the LOA position the
proportion was 53.3% (584/1095). A two-sample test of
proportions showed no evidence of a difference in the
proportion of fetuses achieving SVD in the LOA and
non-LOA positions (difference 0.037; P = 0.393).
Logistic regression models showed no evidence to
suggest that the odds of SVD were different for fetuses
in the LOA position when compared with all other
positions (odds ratio (OR) 0.864 (95% CI, 0.6171.209;
P = 0.394); adjusted models showed no evidence of
a difference also (OR 0.837 (95% CI, 0.5511.272;
P = 0.405). No other occipital position had a significant
association with SVD (Table 3).
Logistic regression models looking at the association
between fetal position and the other modes of delivery
(Cesarean section, ventouse and forceps delivery) showed
only two significant associations. The results of modeling
suggested that fetuses in the DOA and ROL positions were
less likely to have forceps delivery than were fetuses in
the LOA position (OR 0.414 (95% CI, 0.1710.998);
P = 0.049 and OR 0.424 (95% CI, 0.2230.806);
P = 0.009, respectively).
No significant associations were found between any of
the secondary outcomes and LOA fetal position (Table 4).

DISCUSSION
This study demonstrates that none of the eight fetal positions identified at the point of labor onset is associated
with mode of delivery or birth outcome, a result that may
be considered unexpected. The most likely reason for this
is that so far all reported studies on posterior fetal position
and associated morbidity have assessed fetal position
during the active first or second stage of labor, therefore
investigating the persistent occiput posterior position
comparative to grouped anterior and/or lateral positions.
The present study, however, measured position at onset
of labor before the start of active labor. The seemingly
dissimilar results are therefore not contradictory findings
but are new findings not previously reported. Such
findings question antenatal and early labor practices that
are used to promote anterior fetal rotation.
This study has demonstrated, for the first time, the
prevalence of fetal positions at onset of labor, showing
that the anterior occiput positions were the least common.
The posterior positions occurred in 29.7% of the women,
which is two to three times greater than the figures
previously reported for OP presentation at the onset of
labor5,8,24,25,40,41 . The most commonly occurring fetal
position group was the lateral one, which, considering
the mechanism of labor, is not surprising. However,
despite the lateral positions being most common, they still
accounted for fewer than 50% of presenting positions.
The secondary outcome measures of pain relief,
duration of labor, augmentation of labor and Apgar
scores, did not reveal any association with fetal position.
Strengths of the study include the use of a prospective
design, which allowed the relationship between fetal

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

179

position and outcome of labor to be explored in a

standardized manner, reducing the risk of bias. To
appropriately carry out the study, a precise definition
of early labor was used that ensured objectivity and
uniformity of the point at which ultrasound testing
was performed42 . The study protocol and its execution
identified and captured scan data in the period during
which measurement of fetal position was most relevant
to the study outcome. Blinding of both the attending
clinicians and the participants to the scan findings
removed potential bias.
The study was conducted at a single center and may,
therefore, draw associative criticism. The center at which
the study was conducted, however, is one of the largest
womens hospitals in England. The trust has a midwifeled birth center and a consultant-led delivery suite, and
the study included women who were admitted to both
units. The trust is a tertiary referral unit and a center
of excellence, and the guidelines and hospital policies
are underpinned by research and by the UK National
Institute for Health and Clinical Excellence guidelines,
which would suggest that trust practices reflect the general
care pathways seen in other maternity units. Additionally
the inclusion of birth-center participants, as well as those
in the delivery suite, meant that the philosophy and
practices of such centers were reflected within the study
cohort.
This study recruited only nulliparous women with a
singleton fetus in cephalic presentation in order that
engagement of the head should have taken place; however,
this does mean that the results cannot be generalized to
the whole population of laboring women.
The power of the study was estimated a priori to test
reliably our primary hypothesis (that of an association
between LOA fetal position at onset of labor and SVD),
minimizing the risk of a type-II error. We used modeling
techniques to adjust for the possible confounding effects
of several variables when testing the association between
fetal occiput position and SVD. All four variables used for
adjustment, i.e. maternal age, use of epidural analgesia,
duration of labor and birth weight, confirmed known
trends using the study data, yet after adjustment there
was still a lack of any association between fetal position
at onset of labor and SVD. We are therefore confident
that our finding that there is no association between
LOA fetal position at onset of labor and SVD is valid
and, therefore, that current beliefs about an optimal fetal
position need reconsideration.
Our study findings led to several interesting observations. The posterior occiput positions occurred at a
much higher frequency than that previously reported
at onset of labor5,8,24,25,40,41 . The lateral positions were
most prevalent, but the specific rates were again different
from results reported in the literature. We believe that
our findings are more robust as a consequence of the
validity of the ultrasound test used in the study. What
remains intriguing is that textbooks suggest that occiput
engagement takes place in the lateral position2,3,43,44 . We
observed that 29.7% of pregnancies were posterior and

Ultrasound Obstet Gynecol 2014; 43: 176182.

Ahmad et al.

180

Table 3 Logistic regression modeling of delivery mode according to fetal occiput position in a cohort of 1250 pregnant women
Unadjusted analysis
Fetal position
SVD
LOA
ROA
DOA
LOL
ROL
LOP
ROP
DOP
Ventouse
LOA
ROA
DOA
LOL
ROL
LOP
ROP
DOP
Forceps
LOA
ROA
DOA
LOL
ROL
LOP
ROP
DOP
Cesarean section
LOA
ROA
DOA
LOL
ROL
LOP
ROP
DOP

Adjusted analysis*

Odds ratio (95% CI)

Odds ratio (95% CI)

0.864 (0.6171.209)
1.254 (0.6512.416)
1.455 (0.8682.437)
1.105 (0.7561.616)
1.149 (0.7661.721)
1.337 (0.8612.074)
1.027 (0.6551.610)
0.908 (0.4911.681)

0.394
0.498
0.155
0.604
0.502
0.195
0.909
0.759

0.837 (0.5511.272)
1.417 (0.6313.179)
1.836 (0.9523.543)
1.060 (0.6621.699)
1.206 (0.7222.014)
1.473 (0.8442.571)
0.980 (0.5591.718)
0.972 (0.4542.081)

0.405
0.398
0.070
0.807
0.475
0.173
0.944
0.942

1.166 (0.7361.848)
0.761 (0.2921.983)
1.053 (0.5302.093)
0.887 (0.5261.497)
0.952 (0.5481.656)
0.628 (0.3281.203)
0.760 (0.3991.447)
1.017 (0.4422.340)

0.513
0.576
0.883
0.654
0.863
0.161
0.404
0.968

1.116 (0.6941.795)
0.744 (0.2791.985)
1.001 (0.4902.044)
0.895 (0.5211.535)
1.086 (0.6131.925)
0.671 (0.3441.308)
0.814 (0.4181.586)
1.014 (0.4292.398)

0.652
0.555
0.999
0.686
0.777
0.241
0.546
0.975

1.440 (0.9042.294)
0.910 (0.3662.261)
0.414 (0.1710.998)
0.785 (0.4621.335)
0.424 (0.2230.806)
0.873 (0.4751.604)
0.806 (0.4271.524)
0.885 (0.3732.098)

0.125
0.839
0.049
0.372
0.009
0.661
0.507
0.782

1.290 (0.7672.170)
0.865 (0.3162.368)
0.337 (0.1300.873)
0.925 (0.5131.670)
0.509 (0.2521.028)
0.950 (0.4801.883)
1.053 (0.5192.136)
0.823 (0.3132.166)

0.338
0.778
0.025
0.796
0.060
0.883
0.887
0.693

0.843 (0.5461.302)
0.930 (0.3922.207)
0.919 (0.4681.805)
1.142 (0.7021.859)
1.421 (0.8572.356)
0.993 (0.5621.754)
1.393 (0.7972.432)
1.266 (0.5922.705)

0.441
0.870
0.805
0.593
0.174
0.981
0.244
0.543

0.592 (0.2181.607)
1.219 (0.2127.015)
1.121 (0.2445.148)
1.838 (0.6175.477)
1.944 (0.6166.138)
0.869 (0.2153.506)
2.573 (0.8139.194)
1.906 (0.4019.060)

0.304
0.825
0.883
0.274
0.257
0.843
0.104
0.418

Reference is LOA position unless otherwise indicated. *Adjustment for confounders: age, induction of labor, use of epidural, duration of
labor and neonatal birth weight. Reference is non-LOA position. DOA, direct occipito-anterior; DOP, direct occipito-posterior; LOA, left
occipito-anterior; LOL, left occipito-lateral; LOP, left occipito-posterior; ROA, right occipito-anterior; ROL, right occipito-lateral; ROP,
right occipito-posterior; SVD, spontaneous vaginal delivery.

Table 4 Logistic regression modeling of secondary outcomes according to left occipito-anterior (LOA) fetal position in a cohort of 1250
pregnant women
Unadjusted analysis
Outcome
Augmentation (odds ratio)
Pain (odds ratio)
Apgar score at 1 min (odds ratio)
Apgar score at 5 min (odds ratio)
Duration of first stage of labor (min) (difference)
Duration of second stage of labor (min) (difference)
Duration of membrane rupture (min) (difference)

Adjusted analysis*

Estimate (95% CI)

Estimate (95% CI)

0.831 (0.586 to 1.176)

0.770 (0.520 to 1.139)
1.182 (0.692 to 2.016)
2.431 (0.321 to 18.395)
4.208 (83.780 to 92.196)
7.727 (16.859 to 1.404)
1.302 (222.686 to 220.083)

0.296
0.190
0.541
0.395
0.925
0.097
0.991

0.781 (0.511 to 1.195)

0.720 (0.452 to 1.147)
1.274 (0.691 to 2.350)
1.918 (0.248 to 14.850)
13.681 (69.153 to 96.517)
8.089 (16.763 to 0.586)
22.681 (238.104 to 192.742)

0.255
0.167
0.438
0.533
0.746
0.068
0.836

Data are odds ratio or difference when fetal position is LOA with reference position being non-LOA. *Adjustment for confounders: age,
induction of labor, epidural use, duration of labor (for augmentation, pain and Apgar scores only) and neonatal birth weight. Odds of no
augmentation. Odds of no pain relief (with entonox only). Odds of Apgar score 8.

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound Obstet Gynecol 2014; 43: 176182.

Association between fetal position and mode of delivery

entered established labor within 12 h, which suggests that
engagement can be achieved in positions other than the
lateral occiput one.
We found no association between the LOA fetal
position at onset of labor and mode of delivery.
Furthermore, the LOA position was not associated with a
reduction in, or need for, pain relief, duration of labor or
use of intervention.
Interestingly, the study did not show any association of
fetal position at onset of labor with increased operative
delivery, oxytocin augmentation, duration of labor and
low Apgar scores1,4,6,8 , which are usually associated
with the OP position. However, previous studies were
undertaken with fetal position assessed during the active
first or second stage of labor.
In conclusion, this prospective study aimed to see if
there is a link between fetal occiput position at onset
of labor and its association with birth outcome for
the mother and her newborn; we found that the LOA
position, generally thought to be optimal at onset of
labor for achieving SVD, is not associated with improved
outcomes or increased likelihood of SVD. There is a need
to reconsider, and probably discard, the theory of an
optimum fetal position in light of the current study.

181

10.

11.

12.
13.
14.

15.

16.
17.
18.

19.

ACKNOWLEDGMENTS
20.

The research was funded by the Royal College of

Midwives, Birmingham Womens NHS Foundation Trust,
West Midlands NWAHP and Mothercare.

21.

22.

REFERENCES
1. Cheng YW, Shaffer BL, Caughey AB. The association between
persistent occiput posterior position and neonatal outcomes.
Obstet Gynecol 2006; 107: 837844.
2. Normal labour and delivery. In Williams Obstetrics (22nd edn),
Cunningham FG, Leveno KJ, Bloom S, Hauth JC, Gilstrap LC
3rd , Wenstrom KD (eds). McGraw-Hill Medical: London, UK,
2008.
3. McCormick C. The first stage of labour: physiology and early
care. In Myles Textbook for Midwives (15th edn), Fraser DM,
Cooper MA (eds). Churchill Livingstone: London, UK, 2008;
433457.
4. Benavides L, Wu J, Hundley AF, Ivester TS, Visco AG. The
impact of occiput posterior fetal head position on the risk of
anal sphincter injury in forceps-assisted vaginal deliveries. Am
J Obstet Gynecol 2005; 192: 17021706.
5. Fitzpatrick M, McQuillan K, OHerlihy C. Influence of
persistent occiput posterior position on delivery outcome.
Obstet Gynecol 2001; 98: 10271031.
6. Pearl ML, Roberts JM, Laros RR, Hurd W. Vaginal delivery
from the persistent occiput posterior position. Influence on
maternal and neonatal morbidity. J Reprod Med 1993; 38:
955961.
7. Ponkey SE, Cohen AP, Heffner LJ, Lieberman E. Persistent fetal
occiput posterior position: obstetric outcomes. Obstet Gynecol
2003; 101: 915920.
8. Sizer A, Nirmal D. Occipitoposterior position: associated
factors and obstetric outcome in nulliparas. Obstet Gynecol
2000; 96: 749752.
9. Parente MP, Jorge RM, Mascarenhas T, Fernandes AA, Martins
JA. The influence of an occipito-posterior malposition on

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

23.

24.

25.
26.

27.

28.

29.

30.

the biomechanical behavior of the pelvic floor. Eur J Obstet

Gynecol Reprod Biol 2009; 144 (Suppl): S166S169.
Sharma V, Colleran G, Dineen B, Hession MB, Avalos G,
Morrison JJ. Factors influencing delivery mode for nulliparous
women with a singleton pregnancy and cephalic presentation
during a 17-year period. Eur J Obstet Gynecol Reprod Biol
2009; 147: 173177.
Le Ray C, Carayol M, Jaquemin S, Mignon A, Cabrol D,
Goffinet F. Is epidural analgesia a risk factor for occiput
posterior or transverse positions during labour? Eur J Obstet
Gynecol Reprod Biol 2005; 123: 2226.
Holman L. Optimal fetal positioning: making a great turn
around. Midwifery Today Int Midwife 2001; 57: 41, 60.
Nolan M. Jean Sutton and optimal fetal positioning. Mod
Midwife 1997; 7: 1517.
Sutton J, Scott P. Optimal fetal positioning. A midwifery
approach to increasing the number of normal births. MIDIRS
Midwifery Digest 1994; 4: 283286.
Sutton J, Scott P. Understanding and Teaching Optimal Foetal
Positioning (2nd edn). Birth Concepts: Tauranga, New Zealand,
1996.
Donna S. Birth: Countdown to Optimal (1st edn). Fresh Heart
Publishing: London, UK, 2008.
Johnson R, Taylor W. Skills for Midwifery Practice. Churchill
Livingstone: Edinburgh, UK, 2010.
Yates S. Pregnancy and Childbirth. A holistic approach to
massage and body work. Churchill Livingstone: London, UK,
2010.
Schmid V, Downe S. Midwifery skills for normalising unusual
labours. In Essential Midwifery Practice Intrapartum Care.
Walsh D, Downe S (eds). Wiley-Blackwell: Chichester, UK,
2010; 159191.
Davis E. Heart and Hands: A Midwifes Guide to Pregnancy
and Birth. Celestial Arts: London, UK, 2004.
NCT. NCT The UKs largest charity for parents. Available at: http://www.nct.org.uk/birth/helping-your-baby-goodposition-birth. [Accessed 19 April 2010].
Ahmad A. The Association Between Fetal Position at the Onset
of Labour and Birth Outcomes. The University of Birmingham:
Birmingham, UK, 2012.
Akmal S, Kametas N, Tsoi E, Howard R, Nicolaides KH.
Ultrasonographic occiput position in early labour in the
prediction of caesarean section. BJOG 2004; 111: 532536.

Gardberg M, Laakkonen E, Salevaara

M. Intrapartum
sonography and persistent occiput posterior position: a study
of 408 deliveries. Obstet Gynecol 1998; 91: 746749.
Faber P. The persistent OP. Can maternal position rotate the
baby? Pract Midwife 1998; 1: 1619.
Sherer D, Miodovnik M, Bradley K, Langer O. Intrapartum
fetal head position II: comparison between transvaginal digital
examination and transabdominal ultrasound assessment during
the second stage of labor. Ultrasound Obstet Gynecol 2002;
19: 264268.
Akmal S, Kametas N, Tsoi E, Hargreaves C, Nicolaides
KH. Comparison of transvaginal digital examination with
intrapartum sonography to determine fetal head position before
instrumental delivery. Ultrasound Obstet Gynecol 2003; 21:
437440.
Blasi I, DAmico R, Fenu V, Volpe A, Fuchs I, Henrich W,
Mazza V. Sonographic assessment of fetal spine and head
position during the first and second stages of labor for the
diagnosis of persistent occiput posterior position: a pilot study.
Ultrasound Obstet Gynecol 2010; 35: 210215.
Chou MR, Kreiser D, Taslimi M, Druzin M, El-Sayed Y.
Vaginal versus ultrasound examination of the fetal occiput
position during the second stage of labor. Am J Obstet Gynecol
2004; 191: 521524.
Sherer D, Abulafia O. Intrapartum assessment of fetal head
engagement: comparison between transvaginal digital and
transabdominal ultrasound determinations. Ultrasound Obstet
Gynecol 2003; 21: 430436.

Ultrasound Obstet Gynecol 2014; 43: 176182.

Ahmad et al.

182
31. Sherer DM, Miodovnik M, Bradley K, Langer O. Intrapartum
fetal head position 1: comparison between transvaginal digital
examination and transabdominal ultrasound assessment during
the active stage of labor. Ultrasound Obstet Gynecol 2002; 19:
258263.
32. Souka A, Haritos K, Basayiannis N, Noikokyri N, Antsaklis
A. Intrapartum ultrasound for the examination of the fetal
head position in normal and obstructed labor. J Matern Fetal
Neonatal Med 2003; 13: 5963.
33. Birmingham Womens Hospital. Obstetrics Annual Report,
April 2006March 2007. Birmingham Womens Hospital:
Birmingham, UK, 2007.
34. Anim-Somuah M, Smyth R, Howell C. Epidural versus nonepidural or no analgesia in labour. The Cochrane Database of
Systematic Reviews. CD000331.2010.
35. Kirchengast S. Maternal age and pregnancy outcome an
anthropological approach. Anthropol Anz 2007; 65:
181191.
36. Abu-Heija A, Zayed F. Primary and repeat caesarean sections:
comparison of indications. J Obstet Gynaecol 1998; 18:
432434.
37. Leong EW, Sivanesaratnam V, Oh LL, Chan YK. Epidural
analgesia in primigravidae in spontaneous labour at term:

Copyright 2013 ISUOG. Published by John Wiley & Sons Ltd.

38.
39.

40.

41.

42.

43.

44.

a prospective study. J Obstet Gynaecol Res 2000; 26:

271275.
El-Hamamy E, Arulkumaran S. Poor progress of labour. Obstet
Gynaecol Reprod Med 2005; 15: 18.
Mocanu EV, Greene RA, Byrne BM, Turner MJ. Obstetric and
neonatal outcome of babies weighing more than 4.5 kg: an
analysis by parity. Eur J Obstet Gynecol Reprod Biol 2000; 92:
229233.
Gardberg M, Tuppurainen M. Anterior placental location
predisposes for occiput posterior presentation near term. Acta
Obstet Gynecol Scand 1994; 73: 151152.
Neri A, Kaplan B, Rabinerson D, Sulkes J, Ovadia J. The
management of persistent occipito-posterior position. Clin Exp
Obstet Gynecol 1995; 22: 126131.
National Institute for Health and Clinical Excellence. Intrapartum Care. Care of healthy women and their babies during
childbirth. NICE Clinical Guideline 55. National Institute for
Health and Clinical Excellence: London, UK, 2007.
Dietze M. A re-evaluation of the mechanism of labour for
contemporary midwifery practice. Midwifery Matters 2001;
88: 38.
Selman T, Johnston T. Mechanisms and management of normal
labour. Obstet Gynaecol Reprod Med 2010; 20: 201206

Ultrasound Obstet Gynecol 2014; 43: 176182.