ROBERT L. BARBIERI, MD
(EDITORIAL; MARCH 2019)
A classic approach for managing fetal malposition
For those of us who trained and practiced obstetrics in the days of the 6% primary cesarean delivery (CD) rate, we never considered the management of the persistent occiput posterior (OP) position to be particularly difficult. I outline below a method that requires no unusual level of skill or dexterity.
- The cervix must be fully dilated.
- Dense regional anesthesia must be achieved.
- The vertex must have reached +1 station.
- The position must be clearly established, and this does not require anything other than the ability to palpate an ear, as it can be pointed only in one direction. If you feel ultrasonography is needed, be my guest.
- Use an obstetric lubricant to reduce resistance and minimize lacerations.
- While a trial of manual rotation is reasonable, it commonly will not succeed and requires that an operator’s hand be inserted rather than a slender and less traumatic device (forceps).
- Next, palpate the sagittal suture to determine whether the position is straight OP versus left OP or right OP. This should not be difficult unless the poor woman has gone through 2 or 3 hours of unproductive pushing, thereby creating caput.
- After proper forceps application is confirmed, gently apply upward pressure. This will make rotation easier.
- Dr. Irving’s recommendations notwithstanding, the forceps handles are not carried in a wide sweep. One should use Kielland’s forceps, which do not have a pelvic curve and were invented for this precise indication. The forceps are simply rotated.
- Try to avoid delivery as an OP, as this pulls a much larger diameter deflexed head through the pelvis and usually results in significant lacerations.
- Episiotomy is not always required if rotation has succeeded.
- Once descent to the outlet has been achieved, it is probably best to switch to a forceps with a pelvic curve to achieve easier extension.
- This should complete the delivery, but as a general rule, if more than minimal resistance is met in any of the above steps, abandon the procedure and move to CD.
- This process should result in at least a 70% success rate.
As is most likely understood by the current generation of obstetricians who appear to be satisfied with a 30% to 40% primary CD rate, the above reflects the views of a long-retired ObGyn (whose CD rate never exceeded 10%) and may be inappropriate for those who are not adequately trained in or comfortable with vaginal obstetrics.
David M. Priver, MD
San Diego, California
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