Subject: Posterior Protocol

POLICY:         A fetus that presents at any point in the course of labor in the Occiput Posterior position may cause a long, dysfunctional labor.  There may be an increase in the incidence of transfer to the hospital for obstetrical intervention due to the sequelae of the OP position.

                      The incidence of OP at labor onset is 15%-32%, with mixed parities.  At delivery, the incidence of OP is 5.5% overall; 7% in primiparas, 4% in multiparous women.  The incidence of OP is increased if the woman has an epidural, to approximately 13%. 

                     Actions to rotate an OP fetus to OA antepartum may not prevent OP in labor.  A fetus that is OA in labor may not remain that way, in fact 68% of OP fetuses in labor where OA at labor onset.  Most fetuses will  rotate and the incidence of persistent OP at birth is 5%.      

(Penny Simpkin, “The OP Fetus: How Little We Know”)

GUIDELINES: 1. Concerns With OP Position

·         Longer labor

·         Maternal fatigue, discouragement

·         Increased need for emotional support

·         Increased incidence of transfer to hospital for obstetrical intervention

·         Increased need for medical intervention

·         Increased risk of surgical delivery

·         Possible traumatic delivery for mother/baby, increased stress and trauma in the pp

2.  Possible Identifying Characteristics of OP Fetus

Common indicators for identification of the OP baby are not reliable! The only reliable indicator of fetal position if OP is suspected in labor may be diagnosis by ultrasound.

·         “Dip” in abdomen, a “plateau” appearance

·         Back pain a chief complaint, not just during a contraction, but persistent back pain (may be present only 28% of the time!)

·         Delayedprogress, dysfunctional labor pattern

·         Difficulty auscultating fetal heart tones, location of fetal heart tones off to the side of maternal abdomen

·         Digital exam may not be reliable in determining OP position

3.  Considerations Before Labor Starts to Rotate OP Baby

·         OP exercises, see

·         Refer for chiropractic care, acupuncture, physical therapy as indicated

PROCEDURE: 1.  Positions and Movements to Rotate OP Fetus in Labor (Refer to

·         Hands and Knees position

·         Open Knee Chest Position, attempt to maintain position for 30-45 mins

·         Standing Lunge position

·         Rebozo

·         The Rollover

·         The Pelvic Release

·         Side Lying

·         Dangle (partner supported or hanging)

·         Exaggerated Sims position

·         McRobert’s position (in second stage)

·         Rope pull

·         Birth ball, rotating hips

2.  Comfort Measures for OP Position

·         Hot/cold pack to lower back

·         Counter pressure on back

·         Hip squeeze

·         Consider sterile water injections

·         Emotional support

·         Use of water tub

·         Shower, position changes in shower or tub

·         Consider giving mother homeopathic Kali Carb. 200c or 30c to encourage rotation of OP fetus

·         Use of all above mentioned position changes

3. Other Considerations

·         Persistent acynclitism/ OT position

·         Inadequate contraction pattern

·         Emotional dysfunction

4. Diagnosis of OP in Labor

·         Attempt to determine via digital examination by location of fetal sutures

·         Determine position by ultrasound examination