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Just Accepted by The Journal of Maternal-Fetal & Neonatal Medicine

Occiput posterior position diagnosis: vaginal examination or


intrapartum sonography? A clinical review.
Antonio Malvasi, Andrea Tinelli MD, Antonio Barbera, Torbjrn Moe
Eggeb, Ospan A Mynbaev, Mario Bochicchio, Elena Pacella, Gian Carlo
Di Renzo.
doi: 10.3109/14767058.2013.825598

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Abstract
The occiput posterior position is one of the most frequent malposition
during labor. During the first stage of labor the fetal head may stay in the
occiput posterior position in 30% of the cases, but of these only 5-7%
remains as such at time of delivery. The diagnosis of occiput posterior
position in the second stage of labor is made difficult by the presence of
the caput succedaneum or scalp hair, both of which may give some
problem in the identification of fetal head sutures and fontanels and their
location in relationship to maternal pelvic landmarks. The capability of
diagnosing a fetus in occiput posterior position by digital examination has
been extremely inaccurate, whereas an ultrasound approach,
transabdominal, transperineal and transvaginal, has clearly shown its superior diagnostic accuracy. This is
true not only for diagnosis of malpositions, detected in both first and second stage of labor, but also in cases of
marked asynclitism.

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OCCIPUT POSTERIOR POSITION DIAGNOSIS: VAGINAL EXAMINATION OR


INTRAPARTUM SONOGRAPHY? A CLINICAL REVIEW.
Abstract
The occiput posterior position is one of the most frequent malposition during labor. During the
first stage of labor the fetal head may stay in the occiput posterior position in 30% of the cases,

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but of these only 5-7% remains as such at time of delivery. The diagnosis of occiput posterior
position in the second stage of labor is made difficult by the presence of the caput succedaneum
or scalp hair, both of which may give some problem in the identification of fetal head sutures and
fontanels and their location in relationship to maternal pelvic landmarks. The capability of
diagnosing a fetus in occiput posterior position by digital examination has been extremely
inaccurate, whereas an ultrasound approach, transabdominal, transperineal and transvaginal, has
clearly shown its superior diagnostic accuracy. This is true not only for diagnosis of
malpositions, detected in both first and second stage of labor, but also in cases of marked
asynclitism.

OCCIPUT POSTERIOR POSITION DIAGNOSIS: VAGINAL EXAMINATION OR


INTRAPARTUM SONOGRAPHY?
Introduction
Historically, X-Ray studies have demonstrated that the fetal head late in the third trimester is
typically positioned with its antero-posterior diameter parallel to the transverse diameter of

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maternal pelvic inlet, usually rotating to an occiput anterior or occiput posterior position as
labour progresses [1]. Bamberg et al recently used an open real-time magnetic resonance
imaging (MRI) scanner to describe the relationship between the fetal head and the pelvis as the
fetus travels through the birth canal [2]. The MRI visualization of a normal occiput anterior late
second-stage of labour showed that extension of the fetal head started when the occiput came
into close contact with the inferior margin of the symphysis pubis. From that point, extension
continued with a simultaneous fetal head gliding downward. At that point, the birth canal curved
upward to form a 90 angle, and the fetal head was delivered by extension and rotation around
the symphysis pubis [3].
On the contrary, the occiput posterior (OP) position occurs in 15-25% of patients before labour at
term [4].
Ultrasound diagnosed OP position during labour can predict OP position at birth [4] and Simkin
concluded in a review that the use of ultrasound examination to identify fetal position is a
method that is far superior to other methods [5].
However, most OP presentations rotate during labor, so that the incidence of OP at vaginal birth
is approximately 5-7% [6], and the expulsive effort associated with each uterine contraction will
push the fetal head against the perineum to a much greater degree than when anterior [7] (figure
1). Therefore, ultrasound diagnosed OP before or in the early stages of labour is not helpful in
predicting mode of delivery [8].
Persistence of the OP position is associated with higher rate of interventions and with maternal
and neonatal complications [9] and the knowledge of the exact position of the fetal head is of
paramount importance prior to any operative vaginal delivery, for both the safe positioning of the
instrument that may be used (i.e. forceps vs vacuum) and for its successful outcome [10]. The
aim of this review is to compare the accuracy of the diagnosis of OP position performed by
digital examination and by ultrasound approach.

Methods
We focused our attention on the diagnosis of the OP position by reviewing the scientific
production on the distinct role of digital examination and ultrasound in the accuracy of a correct
diagnosis. A literature search was performed using PubMed from 2000 to 2012; the following

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search terms were used for the scope of this review: occiput position, occiput posterior position,
malposition, malrotation, fetal head position, fetal occiput position, ultrasound (US), intrapartum
sonography, second stage of labour, caesarean section, epidural analgesia. Peer-reviewed articles
regarding occiput position were included sorted by relevance. Additional articles were identified
from the references of retrieved papers. We excluded articles that did not include the use of
ultrasound in the diagnosis of OP position.

Evidences
Recent evidences suggest that intrapartum sonographic assessment of fetal head position is
possible, by both transabdominal (figure 2) and transperineal approach [7] (figure 3), and is even
more precise than digital vaginal examination.
Barbera et at [11] were the first to follow by ultrasound the position of fetal occiput throughout
the entire length in 37 labouring patients. Transabdominal ultrasound was used in the first stage
and transperineal [11,12,13] approach was used during the second stage of labour. All the 17
foetuses that started in OP position (29% on the left side and 71% on the right), engaged in the
inlet of the pelvis in occiput anterior position and where delivered as such (figure 4). In these
cases the occiput rotated under the symphysis at the beginning of the second stage, and not
within the birth canal.
Sherer et al [14] evaluated the fetal head position during the active phase of the first stage of
labor in 102 pregnant at term in normal singleton cephalic-presenting fetuses, by comparing
transabdominal US and digital examination findings. All participants had ruptured membranes,
cervical dilation 4 cm and fetal head at clinical station -2 or lower compared to the ischial
spines. In only 24% of patients digital vaginal examinations were consistent with ultrasound

assessment and logistic regression revealed that cervical effacement and clinical station
significantly affected the accuracy of digital vaginal examination. Parity, gestational age,
combined spinal epidural anesthesia, cervical dilation, birth weight and examiner experience did
not affect significantly the accuracy of the examination. On the contrary, this increased to 47%
when fetal head position assessed by digital vaginal examination was recorded as correct if
reported within 45o range of the ultrasound assessment. The same authors studied the fetal

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head position also during the second stage of labor in 112 patients [15]. An absolute error of
digital vaginal examination was recorded in 65% of patients. Parity, pelvic station, combined
spinal epidural anesthesia, length of first or second stages of labor, use of oxytocin
augmentation, gestational age, mode of delivery, birth weight, and examiner experience did not
significantly affect the accuracy to the examination. Stratification, when the digital vaginal
examination was recorded as correct if occurring within 45o of the ultrasound assessment,
reduced the error of the digital vaginal examinations to 39%. Independent variables did not affect
examination accuracy in this assessment modality.
Dupuis et al [16] compared the digital vaginal examination and transabdominal ultrasonographic
assessment of the fetal head position during the second stage of labor in 110 patients carrying a
singleton fetus in a cephalic presentation. In 70% of cases, both clinical and ultrasound
examinations indicated the same position of the fetal head. Agreement between the two methods
reached 80% when allowing a difference of up to 45o in the head rotation. Caput succedaneum
tended to diminish the accuracy of clinical examination. In 20% of the cases ultrasonographic
and clinical results were significantly different (i.e., >45o). This rate reached 50% for occiput
posterior and transverse locations. The authors noted that the type of fetal head position
significantly affected the comparison and occiput posterior and transverse head locations were
associated with a significantly higher rate of clinical error.
Another study [17] compared the accuracy of the time-honored digital vaginal examination vs
transabdominal and transvaginal US scan for the determination of fetal head position in labor, as
a prerequisite for safe instrumental deliveries. Sixty laboring women in the second stage of labor
with a deeply engaged fetal head were included in the study. Fetal head position could be
determined in all cases by transvaginal US, but not in 7 cases and 9 cases by digital vaginal
examination and transabdominal US, respectively. A discrepancy of 60o or more between the

digital vaginal examination and transabdominal or transvaginal US was found in 13/60 cases
(21.7%) and 14/60 cases (23.3%), respectively. A 90o discrepancy was found in 9/60 cases
(15%) and 12/60 cases (20%), respectively. In 5 cases, the digital examination erroneously
perceived an occiput posterior position as occiput anterior. No significant differences in fetal
head position were detected between transabdominal and transvaginal US, when the examination
was technically feasible. The authors concluded that transvaginal sonography was the most

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successful and accurate method for determination of fetal head position in the second stage of
labor, and required the least time for performance.
In 1989 Rayburn et al [18] evaluated 86 pregnants exhibiting an arrest of cervical dilatation (>7
cm). Clinicians observed that, although occiput transverse positions were diagnosed accurately
by digital transvaginal examination, the distinction between persistent OP or anterior position
was often inexact by palpation alone.
Gargberg et al [6], sonographically assessed 408 women during the entire labor. Of note, 57% of
the women were in spontaneous labor and 43% had been induced. The authors noted that most
(68%) persistent occiput posterior positions were the result of a malrotation during labor, and
only 32% of persistent cases were already as such at the onset of labor.
Akmal et al [19] investigated if occiput posterior delivery is the consequence of persistence of an
initial occiput posterior position or a malrotation from an initial occiput anterior or transverse
position. They did so by a cross-sectional study involving transabdominal sonography to
determine fetal occipital position in 918 singleton pregnancies with cephalic presentation in
active labor at 37-42 weeks of gestation. They found that the occiput was posterior in 33.0%
(149/452), 33.9% (101/298) and 19.0% (32/168) of fetuses at the respective cervical dilatations
of 3-5, 6-9 and 10 cm and this position persisted at delivery in 21.5% (32/149), 31.7% (32/101)
and 43.8% (14/32) of cases. In 70% (32/46), 91% (32/35) and 100% (14/14) of occiput posterior
deliveries there was persistence of this position at 3-5, 6-9 and 10 cm of cervical dilation. They
concluded that the majority of occiput posterior positions during labor rotate to the anterior
position even at 10 cm of cervical dilatation.

In contrast to the findings of Gardberg et al, the vast majority of occiput posterior positions at
delivery were a consequence of persistence of this position during labor rather than malrotation
from an initial occiput anterior or transverse position.
Lieberman et al [20] studied 1562 nulliparous women during labor (698 in spontaneous labor and
864 undergoing inductions) with serial sonographic assessments of fetal head position. They

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noted that changes in fetal head position are common during labor, with 36% of women having
an occiput posterior fetus on at least one sonographic assessment. Of fetuses that were occiput
posterior-positioned late in labor, only 20.7% were occiput posterior at delivery. Therefore,
nearly 80% of fetuses in an occiput posterior position very late in labor rotated to a different
position before delivery. Conversely, even fetuses in an anterior occiput position late in labor had
a small (5.4%) risk of becoming occiput posterior by the time of delivery. Most fetuses in the
occiput transverse fetal position, even late in labor, rotated to a different position, with only 8.3%
remaining occiput transverse at delivery. Furthermore, of the 190 women who delivered an
occiput posterior fetus, 52% (n=99) were never occiput posterior on ultrasound examination, and
of the 1246 women who delivered an occiput anterior fetus, 33% (n=413) had an occiput
posterior fetus detected by sonography at some time during labor.
Sherer et al [15] in the first stage of labor reported 17.6% of left OP, 5.9% of OP and 14.7% of
right OP, while in the second stage of labor [14] reported 11.6% of left OP, 4.5% of OP and
16.1% of right OP.
Souka et al [21] performed a longitudinal study on 148 women in active labor, using US
examinations in the first and second stages of labor to determine the fetal head position and to
compare it to digital examination. Furthermore they assessed by US the rotation of the fetal head
in normal and obstructed labor. They found that the assessment of the fetal head position by
digital examination was not possible in 60.7% of cases in the first stage and in 30.8% during the
second stage of labor. Difficulty in assessing the position was more likely if the occiput was
posterior in comparison to anterior and on the maternal right side in comparison to the left. In the
second stage, it was three times more likely for the assessment not to be possible digitally if the
occiput was posterior. In the cases when assessment by vaginal examination was possible, the
correlation with US was average in the first stage and good in the second stage. Overall fetal
head position assessment by digital examination was accurate in 31.28% of the cases in the first

stage and 65.7% of the cases in the second stage of labor. Rotation of the fetal head was highly
unlikely when labor begun in the occipital anterior position. Persistent occipital posterior
position developed through failure to rotate from an initial occipital posterior or transverse
position. Duration of the first stage of labor was independently related to parity and position of
the fetal spine at presentation, and duration of the second stage of labor was independently
related to parity, birth weight, position of the fetal head at the beginning of the second stage,

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rotation and position of the head at delivery.


Kreiser et al [22] investigated the role of US vs digital examination for the determination of fetal
occiput position during the second stage of labor of 44 parturients by a prospective cohort study.
The error rate in detecting fetal occiput position was significantly lower using the ultrasound
technique (6.8%) compared to vaginal examination (29.6%). Parity, maternal body mass index or
fetal weight had no influence on the error rate.
Chou et al [23] investigated whether ultrasonography was more accurate than vaginal
examination in the determination of fetal occiput position in 88 patients in the second stage of
labor: vaginal examination determined fetal occiput position correctly in 71.6% of the time,
whereas ultrasound examination determined fetal occiput position correctly in 92.0% of the time.
Akmal et al [24] reported about the determination of fetal head position in 64 singleton
pregnancies undergoing instrumental delivery. Fetal position was assessed by vaginal digital
examination performed by the attending obstetrician and by transabdominal ultrasound
performed by a trained sonographer who was not aware of the clinical findings. Digital
examination failed to define the correct fetal head position in 17 (26.6%) cases. In 12 of 17
(70.6%) errors the difference was 90 and in five (29.4%) the difference was between 45 and
90. The accuracy of vaginal digital examination was 83% for occiput-anterior and 54% for
occiput-lateral + occiput-posterior positions. Akmal et al [25] further investigated the value of
ultrasonographically determined occiput position in the early stages of the active phase of labor,
in addition to traditional maternal, fetal and labor-related characteristics, in the prediction of the
likelihood of caesarean section. In 601 singletons pregnant, delivery occurred vaginally in 514
(86%) cases and by caesarean section in 87 (14%). The fetal occiput position was posterior in
209 (35%) cases and in this group the incidence of caesarean section was 19% (40 cases),
compared with 11% (47 of 392) in the non-occiput posterior group. The authors concluded that

the risk of caesarean section can be estimated during the early stage of active labor by the
sonographically determined occiput position, in addition to traditional maternal, fetal and laborrelated characteristics.
Peregrine et al [9] assessed fetal head position, both clinically and sonographically, before
induction of labor, and at time of delivery. Furthermore they investigated whether the occiput

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posterior (OP) position was associated with adverse delivery outcome. Ninety-seven (36%) of
270 women with full outcome data had an OP position on ultrasonography before induction of
labor. Of these 97 women, eight (8%) were OP at delivery. Sixty-eight percent of the 25 OP
positions at delivery occurred due to a malrotation from a non-OP position during labor.
Blasi et al [26] performed a preliminary investigation on 100 patients in singleton pregnancy,
assessing the predictive values of the position of the fetal spine and of the occiput during the first
and second stages of labor recorded by intrapartum ultrasound for persistent occiput posterior
(OP) position. Eighty four pregnancies were evaluated in the second stage of labor, with 74 of
these also followed from the first stage. Fifty-one percent of fetuses were found to be in an OP
position during the first stage of labor, but the majority of these rotated to an anterior position
before delivery. There were six cases of OP position at delivery, and all of these were among the
23 fetuses that were found to be in an OP position by ultrasound evaluation during the second
stage of labor. All six were also found to have a posterior spine position during the second stage
of labor, with this finding observed in only one fetus with occiput anterior position at delivery.
Sabsamruei et al [27] evaluated the value of intrapartum ultrasonographically determined occiput
position and risk of cesarean section in 330 singleton term pregnant women with fetuses in
cephalic presentation who were in early active phase of labor. The incidence of occiput posterior
was 29.7% and they concluded that fetal occiput posterior presentation determined in early stage
of active labor by ultrasonography was a significant independent risk of cesarean section, even if
the occiput posterior position is associated frequently to asynclitism [28].
When asynclitism complicates the PO position, not both by only one orbit can be visualized.
This is called the squint sign [29]. If the occiput is in contact with left sacroiliac joint (left
occiput position), the visualization of only the right orbit toward the upper portion of the left
inferior ramous of the pubis is called anterior asynclitism (figure 5) and the visualization of the

left orbit will give us diagnosis of posterior asynclitism. The mirroring position, with the occiput
in contact with the right sacroiliac joint (right occiput position), may reveal an anterior or
posterior asynclitism, depending respectively if the anterior orbit is the left (figure 6) and the
posterior orbit is the right.
Moreover, authors investigated [30] the incidence of occiput posterior position in labor with and

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without combined spinal epidural analgesia (CSE) by low dose of sufentanyl and ropivacaine.
One hundred and thirty two women were subdivided in two groups: patients without analgesia
and patients with CSE analgesia. In the second stage, a total of 79 fetuses were noted in
persistent occiput posterior position (POPP) and 36 were translated from anterior to posterior
position (TAPP) fetuses. Specifically, in the first group there were 17 TAPP, whereas in the CSE
analgesia group there were 19 in TAPP, without significant differences. The number of
asynclitism was higher in the POPP group (84%) respect to the TAPP group (75%), and so was
the rate of caesarean section (67% versus 52.7%).
Eggeb et al [4] evaluated two separate outcomes: one, the proportion of fetal head rotation
from occiput posterior to occiput anterior during labor after term prelabor rupture of membranes;
two, if OP positions before labor were associated with a longer duration of labor and higher risk
of

operative

deliveries.

Before

the

start

of labor,

40

(26%)

fetuses

were

in occiput posterior position, and 34 (85%) of them rotated to occiput anterior during labor. Ten
(6.6%) fetuses were delivered in OP, and six of them were in OP before the start of labor. They
concluded

that

transabdominal

ultrasound

examination

can

determine

the

fetal

head position before the start of labor, but the position of the head did not predict the course
of labor, probably because the fetal head may rotate during labor even after PROM.
Torkildsen et al. [31] investigated position in 105 primiparous women with prolonged first stage
of labor and concluded that most fetuses (73%) rotated spontaneously from OP to OA even in
this subgroup of women with labor dystocia.

Discussion and conclusion

Diagnosis of fetal occiput position is of extreme importance in todays obstetric practice since a
substantial increase in maternal and neonatal morbidity has been associated with it. Maternal
complications are: length of labor >12 hours, chorioamnionitis, oxytocin augmentation, 3 rd/4th
degree tear, operative vaginal delivery, Cesarean Section, excessive blood loss, post partum
infection. Neonatal complication are: higher rate of 5-minues Apgar <7, umbilical artery pH <7,
base excess <-12, meconium stained amniotic fluid, meconium aspiration syndrome, birth

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trauma, admission to intensive care nursery, higher mean duration of stay in hospital. In front of
all these complication it appears clear that the attending practitioner needs to be able to obtain a
correct diagnosis, to have an appropriate management in labor and a safe approach in case of
operative vaginal delivery or Cesarean Section.
The current literature [32,33] has clearly demonstrated that the accuracy of ultrasound in labor is
far superior to digital vaginal examination that continues to be very subjective and prone to
errors.
The ultrasound performed during labor, transabdominal, transvaginal or transperineal allows a
more accurate diagnosis of fetal head rotation from occiput posterior to occiput-anterior position
and of persistent occiput posterior position. It is important to underlie that the presence of OP
position in the first stage of labor is not synonymous of a persistency in this position. The
majority of these will rotate anteriorly, ending in an occiput anterior delivery. But it is imperative
to make sure that this rotation happened and ultrasound assessment is way superior, objective
and reproducible. Furthermore, in case of asynclitism complicating the picture, the ultrasound
use further improves the diagnosis. In conclusion we may say that it is time to reduce the
diagnostic errors that the digital vaginal examination may generate and rely of the diagnostic
power that ultrasound assessment may provide. The clinician has now a powerful tool able to
help reduce the morbidities that both mother and fetus may face when a persistent occiput
position will occur.

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Legends
Figure 1.
Graphic representation of progression of the occiput posterior position in the birth canal during
the second stage (panel a) and the peculiar expulsion of fetal head at the perineum (panel b),
(Barbera et al. [7] with permission).

Figure 2.

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Identification of occiput posterior position by transabdominal ultrasound. The probe is placed on


moms abdomen on a transverse view (panel a). Specific fetal anatomic structures are visualized.
In this case fetal orbits and nasal bridge are clealy visualized at 12:00 oclock, just underneath
the exploring probe, with the occiput consequently in a posterior position (panel b), (Barbera et
al. [7] with permission).

Figure 3.
Identification of maternal and fetal landmark by transperineal ultrasound. The probe is
positioned on moms perineum on a sagittal view showing the long axis of the symphysis pubic
and the fetal head contour. The angle between the long axis of the symphysis and the line
connecting its lower pole tangential to the fetal contour is created [21]. Panel a, b, and c show
different angle of progression at different station in the birth canal. Molding and asynclitism in
this occiput posterior position can easily be recognized (Barbera et al. [7] with permission).

Figure 4.
Fetal head position during the entire labor. Diagnosis made by transabdominal ultrasound during the first
stage, by transperineal ultrasound during the second stage, by clinical assessment at time of delivery. L=
left; R= right. (Barbera et al. [11], with permission).

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Figure 5.
Fetal cephalic presentation in left occiput posterior, with anterior asyncitism and only the anterior orbit
visualized by ultrasound, squint sign (panel a: graphic representation; panel b: transbdominal
ultrasound used up to the beginning of the second stage of labor (Barbera et al. [29], with permission).

Figure 6.
Fetal cephalic presentation in right occiput posterior, with anterior asyncitism and only the anterior orbit
visualized by ultrasound, squint sign (panel a: graphic representation; panel b: transbdominal
ultrasound used up to the beginning of the second stage of labor (Barbera et al. [29], with permission).

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