MALPOSITION

“ Malposition refers to any

position of the vertex other than the
flexed occipito-anterior one.”

OCCIPITO POSTERIOR POSITION

“In a vertex presentation where
the occiput is placed posteriorly over
the sacroiliac joint, sacrum called
occipito-posterior postion.”
• Occiput placed over:- Right sacroiliac
joint called RIGHT OCCIPITO
POSTERIOR

• Occiput placed over:- Left sacroiliac

joint called LEFT OCCIPITO
POSTERIOR

• Traditionally called 3rd and 4rh position

of the vertex.
• Occiput placed over:- sacrum called
DIRECT OCCIPITO POSTERIOR

• All the three positions are Primary

(before the onset of labour ) or
Secondary ( developing after labour
starts )
• In majority of cases (90 %), ANTERIOR
ROTATION of occiput occurs and
follows the course like that of an
occipito anterior position and it is
favorable position

• But as the posterior position

occasionaly gives rise to dytocia, it is
described along with malpositions
 INCIDENCE
• At onset of labour:- About 10 %

• Expected to be more during late

pregnancy and less during late second
stage of labour

• Right occipito posterior is 5 times more

common than the left occipito posterior
• Dextro-rotation of the uterus and the
presence of sigmoid colon on the left,
disfavor Left Occipito Posterior
Position

• (Dextro-rotation is movement/rotation
to the right/ clockwise, opp. is
laevorotation)
 CAUSES
 Shape of the pelvic inlet

 Fetal factors

 Uterine factor
 Shape of the pelvic inlet

More than 50 % cases are associated

with the ANTHROPOID OR ANDROID
PELVIC

The wide occiput can comfortably be

placed in the wider posterior segment
of the pelvis
 FETAL FACTORS

Marked deflexion of the fetal head

Cuases of deflexion:-
1. High pelvic inclination (gedree
of slopping)
2. Anterior attachment of placenta
3. Primary bradycephaly
• High pelvic inclination
– Inclination of brim is high and the
upper sacrum is relatively vertical
and convex

– Occiput will be placed to posterior

surface
• Anterior attachment of placenta

– Well flexed attitude but convexity of

maternal and fetal spine is opposite,
which leads to deflexion of fetal head
and thus the occiput with occupy the
posterior part
• Primary bradycephaly (flatened
area at back of the skull)

– Diminishes the effective movement

of flexion
 Uterine factor

Abnormal uterine contraction which

may be cause or effect, lead to
persistent deflexion and occipito
posterior postion
 DIAGNOSIS
 ABDOMINAL EXAMINATION

On inspection abdomen looks flat

below the level of umbelicus
 UMBILICAL GRIP

Fetal limbs are more easily palpable near

the midline on either side
The fetal back is felt far away from the
midline on the flank and often difficult to
outline clearly.
The anterior shoulder lies far away from
the midline
 PELVIC GRIP
Head is not engaged
Sinciput not felt as in well flexed occipito
posterior

 AUSCULTATION
Intensity of fetal heart sound felt on the
flank and often difficult to locate
 VAGINAL EXAMINATION

Elongated bag of membranes which is

likely to rupture during examination
Sagital suture occupies any obligue
diameters of the pelvis
Posterior fontanelle felt near the sacroiliac
joint
Anterior fontanelle felt more easily
because of deflexion of the head, lower
than posterior fontanelle
 MECHANISM OF LABOUR
• IN FAVOURABLE:
– Flexion
– Internal rotation of the head (head 3/8 ant.,
shoulder 2/8): occupy RIGHT oblidue
diameter in ROP and LEFT obligue
diameter in LOP
– Further descent : as occipito anterior p.
– Restitution
– External rotation
– Birth of the shoulders and trunk
• IN UNFAVOURABLE:
– Incomplete forward rotation: deep
transverese arrest
– Non rotation
– Malrotation
• Mechanism of “face to pubis” delivery
– Further descent occurs until the root of the
nose
– Flexion occurs
– Restitution
– External rotation
– Persistant occipito-posterior
 MANAGEMENT
• Early diagnosis
• Watchfull expectancy for decent and
anterior rotation
• Early cesarean section: Anticipating
prolonged labour, no progress of
labour, Persistant of deflexion and non-
rotation, Arrest labour, incoordinated
uterine contraction, fetal distress
MANAGEMENT OF ARREST OPP
1. Arrest in transverse / obligue occipito
posterior position:-
– Ventouse
– Alternative methods like mannual rotation
and extraction, cesarean section and
craniotomy
2. Occipitosacral arrest:-
– Forceps application followed by etraction
as face-to-pubis
– Liberal mediolateral episiotomy should be
 DEEP TRANSVERSE ARREST
• The head is deep in to the cavity,
sagital suture is placed in the
transverse bispinous diameter and
there is no progress in descent of the
head even after 0.5 to 1 hour following
full dilatation of the cervix
 CUASES
• Pelvic structure
• Deflexion of the head
• Weak uterine contraction
• Laxity of pelvic floor muscles
 DIAGNOSIS
• Head is engaged
• Sagital suture lies in transverse
bispinous diameter
• Anterior fontanelle is palpable
• Faulty pelvic architecture
 MANAGEMENT
• If Vaginal delivery not safe: Cesarean
section
• If Vaginal delivery safe: ventouse,
mannual rotation, forcep rotation
 MANNUAL ROTATION OF OPP
• The mannual rotation can be
accomplished with whole hand method
or with half hand method.

Steps:-
Put the patient under general anesthesia
Provide lithotomy position
Maintain full surgical asepsis
Catheterizaion should be done
Identify direction of occiput by PV Exa.
• WHOLE HAND METHOD:-

Step I: Gripping of the head

Step II: Rotation of the Head
Step III: Application of forceps
Step I: Gripping of the head

In ROP or ROT the Left hand and in LOP or

LOT the Right hand is usually used.

The correctsponding hand is introduced

into the vagina in cone shapped manner
after seperating the labia by two fingers of
other hand.
In Occipito transverse position, the four
fingers are pushed in the sacral hollow to
be placed over the posterior parital bone
and the thumb is placed over the anterior
parital bone.

In oblique posterior position, four fingers

of patially supinated hand are placed over
the occiput and the thumb is placed over
the sinciput.
Step II: Rotation of the head

Slight disimpaction may be needed for

good grip.

By the movement of pronation of the hand,

the head is rotated to bring the occiput
anterior along the shortest route.

Simultaneouslty, the back of the fetus is

rotated by the external hand from the flank
to the midline.
This is an essential prerequisite, for
anterior rotation of head.

A little over rotation is desirable

anticipating slight recurrence of
malposition before the application of
forceps.
 In the Alternative
method, the four
fingers of the
pronated right hand
are placed over the
sinciput and the
thumb over the
occiput in ROP. The
head is rotated in the
supination movement
of the hand.
Step III: Application of the forceps

 Following Rotation, when the right hand is

placed over the left side of the pelvis, left
blade of the forcep is introduced.

When the left hand is used, it is placed on

the right side of the pelvis after rotation, as
such the right blade is to be introduced
first and the left blade is then to be
introduced underneath the right blade.
While introducing the blades, it is
preferable that an assistant fixes the head
by suprapubic pressure in a manner of
first pelvic grip.

As it is a mid forceps application, axis

traction device should be used.
DIFFICULTIES:-

Failure to grip the head adequetly due to

lack of space
Failure to dislodge the head from the
impacted position
Inadequate anesthesia
Wrong case selection
DANGERS-

Accidental slipping of the head above the

pelvic brim and prolapse of the cord

 It is better to be perform cesarean section

in such a situation.
• Half HAND METHOD:-

Steps:
The rotation is done only by using the
right hand.
The four fingers are introduced into the
vagina and tangential pressure is applied
on the head at the level of diameter of
engagement.
The pressure is applied on the side and
the parietal eminence of the head.

In ROP or ROTpositions, the fingers are

placed anterior to the head and the
pressure is applied by the ulnar border of
the hand.

In LOP or LOT positions, the fingers are

placed posteriorly and the pressure is
applied by the radial border of the hand.
The force is applied intermittently till the
occiput is placed behind the symphysis
pubis.