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Background and objective: Delivering a malpositioned and malpresenting fetus remains uncertainty, despite advances in obstetric practice. This study aimed to determine the mode of delivery and neonatal outcome in cases of fetal malposition and malpresentation. Methods: A cross-sectional study of women delivering malpositioned and malpresenting fetuses was conducted at Maternity Teaching Hospital, Erbil city, Kurdistan Region, Iraq, from the 1st of June, to the 30th of November, 2018. Three hundred women and their newborns were followed for seven days of life. Results: The total rate of malposition and malpresentation was 4.8%. Most women (87.3%) delivered by cesarean section, 25% of the neonates were admitted to the neonatal intensive care unit, where 69.3% of these infants stayed for seven days. There were three early neonatal deaths (1.0%), all of them were in occipito-posterior, or occipito-transverse position and were delivered abdominally. Among occipito-posterior and occipito-transverse deliveries, 2.2% ended with the death of the fetus (P = 0.360). An Apgar score of 7 was recorded after 5 minutes for 97.7% of the infants. Around 11% of the women had postpartum hemorrhage. Conclusion: Fetal malpresentation and malposition are not uncommon during labor, and most cases are delivered by cesarean section. Neonatal morbidity and mortality are dependent on the type of presentation and the mode of delivery. Keywords: Malposition; Malpresentation; Perinatal outcome; Breech presentation.

Fetal malpositions and cephalic malpresentations are well-recognized causes of failure to progress in labor. They frequently require operative delivery, and are associated with an increased probability of fetal and maternal complications. Traditional obstetrics emphasizes the role of digital examinations, but recent studies demonstrated that this approach is inaccurate and intrapartum ultrasound is far more precise. The objective of this review is to summarize the current body of literature and provide recommendations to identify malpositions and cephalic malpresentations with ultrasound. We propose a systematic approach consisting of a combination of transabdominal and transperineal scans and describe the findings that allow an accurate diagnosis of normal and abnormal position, flexion, and synclitism of the fetal head. The management of malpositions and cephalic malpresentation is currently a matter of debate, and individualized depending on the general clinical picture and expertise of the provider. Intrapartum sonography allows a precise diagnosis and therefore offers the best opportunity to design prospective studies with the aim of establishing evidence-based treatment. The article is accompanied by a video that demonstrates the sonographic technique and findings.

Fetal malpresentation and fetal malposition are frequently interchanged; however, fetal malpresentation refers to a fetus with a fetal part other than the head engaging the maternal pelvis. Fetal malposition in labor includes occiput posterior and occiput transverse positions. Both fetal malposition and malpresentation are associated with significant maternal and neonatal morbidity, which have significant impact on patients and providers. Accurate diagnosis of both conditions is necessary for appropriate management. In this review, terminology, incidence, diagnosis, and management are discussed.

Background. The frequency of persistent occiput posterior (POP) presentations is 10 to 20%.These POP presentations are associated with higher rates of operative delivery and associated maternal and neonatal complications. Actually, there is no standardized management for POP. Numerous observational studies have shown that using systematic manual rotation (MR) versus expectant in case of POP is associated with a decrease in operative delivery rates. However, selection bias and residual confounding cannot be ruled out in this observational setting. Risks associated to MR are thus lower than potential benefit associated to prevention of operative delivery. We therefore propose to conduct a multicenter randomized controlled trial to test the superiority of systematic MR over expectative management to decrease operative delivery rate of POP. Methods. Eligible participants with a suspicion of POP will have a transabdominal ultrasound to confirm position. After confirming a POP, participants with written consent will be randomized into an experimental group (MR) or a control group (sham procedure).Based on a background risk of operative delivery of 40%, then for a reduction to 30% (α = 0.05, 1-ß = 0.90, and a bilateral test) the study requires 326 women per group. The primary outcome will be operative delivery. Secondary outcomes will be in particular maternal and neonatal morbidities. Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. Discussion. Given that the efficacy of MR has not been proven with a high level of evidence, the practice of this technique is not systematically recommended by scholarly societies and is, therefore, rarely performed by obstetric gynecologists. If our hypothesis regarding the superiority of MR is confirmed, our study will help change delivery practices in cases of POP., Introduction. La fréquence des variétés postérieures persistantes (VPP) est de 10 à 20%. Les VPP sont associées à des taux plus élevés de césarienne et d’extractions instrumentales, avec les complications maternelles et néonatales associées. Actuellement, il n’existe pas de prise en charge standardisé des VPP. Plusieurs études observationnelles ont montré que la réalisation en systématique d’une rotation manuelle (RM) versus une attitude expectative en cas de VPP, était associée à une diminution des accouchements opératoires. Cependant, les biais de sélection et de confusion ne peuvent être évités dans ces études. Les risques de la RM sont plus faibles que le bénéfice potentiel à prévenir les accouchements opératoires. Nous proposons de conduire un essai multicentrique contrôlé, dont l’objectif principal est de montrer la supériorité d’une RM en systématique plutôt que l’expectative en cas de VPP pour diminuer les accouchements opératoires. Méthode. Les patientes éligibles avec une suspicion de VPP bénéficieront d’une échographie abdominale pour confirmer la position. Après confirmation de la VPP, les patientes avec un consentement écrit, seront randomisé soit dans le groupe expérimental soit dans le groupe contrôle. Basé sur un risqué d’accouchement opératoire de 40%, et pour obtenir une diminution de 30 % (α = 0.05, 1-ß = 0.90, et un test bilatéral) l’étude requière 326 patientes par groupe. Le critère de jugement principal sera l’accouchement opératoire. Les critères de jugement secondaires porteront notamment sur la morbidité maternelle et néonatale. L’analyse se fera en intention de traiter. Les critères de jugement principal et secondaires seront comparés en utilisant un test de Chi². Discussion. L’efficacité de la RM n’a pas été démontrée avec un haut niveau de preuve, c’est pour cela que la pratique de la RM n’a pas été recommandée par les sociétés savantes. Si notre hypothèse est confirmée, notre étude permettra de changer les pratiques en cas de VPP.

Background Recent research suggests that latent phase of labor may terminate at 6 rather than 4 centimeters of cervical dilation. The objectives of this study were to: (a) characterize duration of the latent phase of labor among term, low‐risk, United States women in spontaneous labor using the women's self‐identified onset; and (b) quantify associations between demographic and maternal/newborn health characteristics and the duration of the latent phase. Methods This prospective study (n = 1281) described the duration of the latent phase of labor in hours, stratified by parity at the mean, median, and 80th, 90th, and 95th percentiles. The duration of the latent phase was compared for each characteristic using t tests or Wilcoxon rank‐sum tests and regression models that controlled for confounders. Results In this sample of predominantly white, healthy women, duration of the latent phase of labor was longer than described in previous studies: The median duration was 9.0 hours and mean duration was 11.8 hours in nulliparous women. The median duration was 6.8 hours and mean duration was 9.3 hours in multiparous women. Among nulliparous women, longer duration was seen in women whose fetus was in a malposition. Among multiparous women, longer durations were noted in women with chorioamnionitis and those who gave birth between 41 and 41 + 6 weeks’ gestation (vs between 40 and 40 + 6 weeks’ gestation). Conclusions The latent phase of labor may be longer than previously estimated. Contemporary estimates of latent phase of labor duration will help women and providers accurately anticipate, prepare, and cope during spontaneous labor.

A 28-year-old term G3P0020 received an epidural with complete pain relief. Approximately 19 hours after the epidural placement, the pain increased. Sensory levels were rechecked and were bilateral and adequate at T8. Further discussion revealed that the pain was unrelated to her contractions; it was in her buttocks and radiating down the leg. The possibility of the fetus being positioned occiput posterior (OP) was discussed. The patient was placed into knee-chest position with instantaneous relief of her pain. This is the only known case report of epidural breakthrough pain due to an OP fetal malposition with successful intra-partum pain management solely by position change.

Fetal occiput posterior position is associated with increased maternal and fetal morbidities. Currently, clinicians have limited evidence-based techniques or tools to remedy fetal occiput posterior position. The traditional Mexican rebozo technique of pelvic massage, sifting, or jiggling offers a potentially valuable tool to help correct fetal malposition. This article reviews the adaptation of 3 rebozo techniques that can be used in labor to encourage optimum fetal positioning; outlines hospital considerations for safety, fetal heart rate monitoring, and universal precautions; and reviews the implementation plan to introduce and sustain use of the rebozo in a large academic medical center.

Fetal malposition, either occiput posterior or transverse (OT), leads to greater risk of cesarean delivery, prolonged labor, and increased perinatal morbidity. Historically, there is a known association between epidural use and malposition that was assumed to be due to the increased discomfort of laboring with a fetus in the occiput posterior position. However, evidence now suggests that the epidural itself may contribute to fetal malposition by impacting the probability of internal rotation. Fetal malposition may be impacted by manual rotation. Manual rotation has been associated with greater rates of delivering in the occiput anterior position and lower rates of cesarean delivery.

This report describes a case of fetal malposition with abrachia in a Yankasa ewe (Ovis aries ), presented on the 24 th

Bu araştırma, fetüsün oksiput posterior pozisyonda olduğu doğumlarda anne pozisyonunun doğum eyleminin ilerleyişine etkisini belirlemek amacıyla yapılmış randomize kontrollü deneysel bir çalışmadır.Araştırma Temmuz 2014-2015 tarihleri arasında İstanbul'da özel bir hastaneye doğum yapmak üzere başvuran fetüsün oksiput posterior pozisyonda olduğu, araştırmaya katılmayı kabul eden toplam 148 gebe ile yürütüldü.Gebeler girişim ve kontrol grubu olmak üzere iki gruba ayrıldı (n=72). Girişim grubuna, oksiputun olduğu yön boyunca yan yatış pozisyonu 20 dk, secde pozisyonu 15 dk, yatak başına doğru eğilerek durma (dinlenme) 10 dk, ardından oksiputun olduğu yön tarafında yan yatış pozisyonu 20 dk verildi. Kontrol grubunda yer alan gebelere ise rutin doğumhanede uygulanan izlem yapıldı.Girişim grubundaki gebelerin servikal dilatasyon 3,87±1,56 cm, servikal efasman %61,71±11,24, hodge düzlemine göre baş seviyesi -2,46±0,92, %67,1'inin (n=51) posh açık bunların %88,2'sinin amniyos sıvısı berrak idi. Kontrol grubundaki gebelerin servikal dilatasyon 2,47±1,64 cm, servikal efasman %52,64±12,33, hodge düzlemine göre baş seviyesi -2,74±0,75, gebelerin %37,5'i (n=27) posh açık olanlarında %92,6'sında amniyon sıvısı berrak idi.Girişim grubunda uygulanan pozisyon sonrası servikal dilatasyon 5,33±1,99 cm, servikal efasman %70,39±13,80, hodge düzlemine göre baş seviyesi -1,63±1,11 ve gebelerin %85,5'inin (n=65) posh açıkdı. Bunların %86,2'si (n=56) amniyos sıvısı berrakdı. Kontrol grubunun 1 saat sonraki vajinal tuşe bulguları ise servikal dilatasyon 3,14±1,79 cm, servikal efasman %56,39±13,46, hodge düzlemine göre baş seviyesi -2,54±0,99 ve gebelerin %62,5'i (n=45) posh açık olanlarında %88,9'nun amniyon sıvısı berrak idi.Pozisyon sonrası girişim grubundaki gebelerin %51,31'i (n=39) OA, %21,05'i (n=16) OT pozisyona dönmüştü. Kontrol grubunda ise bir gebe OA, 10 gebede OT pozisyonda idi.Girişim ve kontrol grubu pozisyon sonrası değerlendirmeler açısından karşılaştırıldığında dilatasyon, efasman, baş seviyesi, baş pozisyonu açısından istatistiksel olarak anlamlı düzeyde farklıydı. Pozisyon verilen girişim grubundaki daha fazla sayıda gebede kontrol grubuna kıyasla baş pozisyonları anteriora dönmüştü ve doğum eylemi daha hızlı ilerlemekteydi. Fetüsün oksiput posterior pozisyonda olduğu doğumlarda, gebeye yukarıda belirtilen pozisyonların uygulanması doğum eyleminin ilerleyişini kolaylaştırmaktadır.Anahtar kelimeler: Doğum pozisyonu, fetal malpozisyon, oksiput posterior duruş. This research is randomized controlled trial that to evaluate the effect of maternal position on labour progression when the fetüs is occiput posterior position in delivery.Research had been carried out with 148 gravidas who had accept to participate the search when they had applied to the private hospital to labor and the fetüs had been on occiput posterior position between July 2014-2015.Gravidas had been seperated into two groups as tentative attempt and control groups (n=72). Tentative attempt group had been requested to be side-lying position as the same direction along occiput during 20 minutes then prostrate position for 15 minutes, lean forward to bedside for 10 minutes (rest position) finally they had been requested to be side-lying position for 20 minutes again. Other gravidas in control group had been liable to routine deliveryroom observation.The cervical dilatation of the gravidas in tentative attempt was 3,87±1,56 cm, cervical effacement was %61,76±11,24, head level due to hodge plane was -2,46±0,92 and %67,1 of gravidas (n=51) posh open and also %88,2 of these gravidas amniotic fluid was clear. The cervical dilatation of the gravidas in control group was 2,47±1,64 cm. cervical effacement was %52,64±12,33, head level due to hodge plane was -2,74±0,75 and %37,5 of gravidas amniotic fluid was clear.After applied positions to gravidas in tentative attempt group was 5,33±1,99 cm, cervical effacement was %70,39±13,80, head level due to hodge plane was -1,63±1,11 and %85,5 of gravidas (n=65) posh open and also %86,2 of these gravidas (n=56) amniotic fluid was clear. One hour later the vaginal touch symptoms of the gravitas in control group, cervical dilatation 3,14±1,79 cm, cervical effacement was %56,39± 13,46, head level due to hodge plane 2,54±0,99 and %62,5 (n=45) of gravidas posh open and also %88,9 of these gravidas amniotic fluid was clear.After applied positions to gravidas in tentative attempt group %51,31 (n=39) gravidas had became OA and %21,05 (n=16) gravidas had became OT. Also only one gravida was OA and 10 gravidas were OT positions in control group.When the appreciations are composed to after changing positions of gravidas in tentative attempt group and gravidas in control group with regard to dilatation, effacement, head level, head position, there ara statistically significiant differences between two groups. There had been more gravidas in tentative group who had became occiput anterior than gravidas in control group and labor had been gone faster than the other control group. If these positions are applied at deliveries in which the fetüs are occiput posterior positions it makes labor easy to go on.Key Words: Delivery positions, fetal malposition, occiput posterior stance. 105

Objetivo: evaluar la efectividad del tratamiento con acupuntura y moxibustión en un entorno hospitalario, en mujeres embarazadas de 33 a 38 semanas de gestación con presentación no cefálica del feto. Método: estudio experimental de intervención, unicéntrico, en un centro hospitalario de tercer nivel, sobre una muestra de 250 mujeres embarazadas de 33 a 38 semanas de gestación con presentación no cefálica fetal. Como variable principal se consideró la versión o no a presentación cefálica posintervención y como variables secundarias las semanas de gestación en el inicio del tratamiento, la paridad, cómo finalizó el parto, el peso del recién nacido al nacer y la edad de la madre. Resultados: la prevalencia posintervención de reversión del feto a una presentación cefálica fue del 53,5% de todas las embarazadas que hicieron tratamiento con acupuntura y moxibustión y se obtuvieron diferencias significativas (p < 0,0001 en el test de la χ2) con un intervalo de confianza del 95%. El 75% finalizo en parto vaginal, mientras que en el grupo que permaneció en presentación no cefálica el 97,9% de los partos finalizó en cesárea. Durante el tratamiento no mostraron efectos adversos y hubo una gran aceptación y adherencia al tratamiento. Conclusiones: el tratamiento con acupuntura y moxibustión resulto ser efectivo y seguro practicado entre las semanas 33 a 38 de gestación en una presentación no cefálica y disminuyó el número de cesáreas. Se considera recomendable la realización de un ensayo clínico aleatorizado que pueda aportar mayor evidencia científica.

The fetal occiput posterior position poses challenges in every aspect of intrapartum care-prevention, diagnosis, correction, supportive care, labor management, and delivery. Maternal and newborn outcomes are often worse and both physical and psychological traumas are more common than with fetal occiput anterior positions. The purpose of this paper is to describe prevailing concepts that guide labor and birth management with an occiput posterior fetus, and summarize evidence to clarify the state of the science. To identify maternal and fetal risk factors associated with persistent occiput posterior position at delivery, and to examine the association of occiput posterior position with subsequent obstetric outcomes.

We report on the sonographic appearance of a new type of fetal head malposition in labor that has not been previously described systematically. In some circumstances, the fetal lie is characterized by a lateral orientation of the head with respect to the trunk and, on suprapubic ultrasound, a transverse section of the fetal chest together with the facial profile can be seen on the same image. These sonographic findings were documented in five cases of first-stage labor arrest. This report illustrates how, in these circumstances, ultrasound might be helpful in clarifying the precise cause of obstructed labor.

La recomendación de la Organización Mundial de la Salud, en relación al porcentaje de partos que deberían tener vía abdominal es 15%, esto dado por condiciones no prevenibles o patologías materno-fetales que contraindican el nacimiento vía vaginal. En Colombia, la Encuesta Demográfica Nacional de 2010, reporta la realización de cesárea en un 34% de los nacimientos. Una de las indicaciones del parto por vía abdominal, es la mala posición fetal, sin embargo, si está circunstancia es diagnosticada antes del término de la gestación, puede ser manejada con técnicas de la Medicina Tradicional China. Se revisaron los textos clásicos y los estudios publicados recientemente, con relación al uso de Medicina Tradicional China en el manejo de la mala posición fetal, encontrándose que existe suficiente información con relación a la seguridad y efectividad del manejo con moxibustión asociada o no a acupuntura en el punto Vejiga 67 (Zhi yin) para mujeres con gestaciones entre 33 y 35 semanas en ausencia de otro factor de riesgo materno o fetal. Abstract. The recommendation of the World Health Organization in relation to the percentage of deliveries that should have abdominally is 15%, given that conditions or unpreventable maternal-fetal pathologies that contraindicate birth vaginally. In Colombia, the National Demographic Survey of 2010, reports the cesarean section at 34% of births. One of the indications abdominally delivery is fetal malposition, however, if this circumstances is diagnosed before the end of pregnancy, can be managed with techniques of Traditional Chinese Medicine. Classical texts and studies recently published were reviewed regarding the use of Traditional Chinese Medicine in the management of fetal malposition, finding that there is sufficient information regarding the safety and effectiveness of management with moxibustión associated or not with acupuncture at point Bladder 67 (Zhi yin) for women with pregnancies between 33 and 35 weeks in the absence of another maternal or fetal fact risk. Maestría

Fetal malposition, specifically occiput posterior and transverse (OP/OT), is associated with higher intra-partum morbidity. We tested the hypothesis that young maternal age and pelvic immaturity are risk factors for fetal malposition.In a cohort study of all nulliparous teen (≤18 years) deliveries over a 4-year period at one institution, fetal head position at time of delivery was collected and correlated with maternal characteristics and outcome data. Using Risser staging observations, pelvic maturity age was set at 16, and accordingly, the women were divided into two groups (younger vs. older teens). Analysis was performed using Fisher's exact, student t test, and logistic regression modeling.Older teen mothers (16-18 years, n = 609) had higher rates of malposition (22 vs. 12 %, p = 0.02) when compared with younger teens (≤15 years, n = 98). Among all women with a malpositioned fetus, older teens had a higher body mass index (BMI: 32.6 ± 6.7 vs. 28.5 ± 3.5, p = 0.04) and subsequent need for cesarean delivery (69 vs. 33 %, p = 0.02) when compared with their younger counterparts. Although younger teens were more successful in having a vaginal delivery (67 %) with an OP/OT position, it was at the expense of a 25 % rate of severe perineal laceration (third/fourth degree).Obesity, and not young maternal age or pelvic immaturity, is associated with fetal malposition. The direct association with increasing pre-pregnancy BMI and the long-term impacts of the high rates of cesarean delivery in this young population underscores the need for more public health focus.

To examine mode of delivery and perinatal outcomes in women with occiput posterior (OP) or transverse (OT) position in the second stage of labour with a trial of manual rotation compared to expectant management.A retrospective cohort study was designed to examine mode of delivery and perinatal morbidity in women who underwent a trial of manual rotation (n = 731) compared to expectant management (n = 2527) during the second stage of labour with the fetus in OP/OT position. Chi-square test was used to compare categorical outcomes and multivariable logistic regression models were used to control for potential confounders.Compared to expectant management, women with manual rotation were less likely to have: caesarean delivery (CD) [adjusted odds ratio (aOR) 0.12; 95% confidence interval (CI) 0.09-0.16], severe perineal laceration [aOR 0.64; (0.47-0.88)], postpartum haemorrhage [aOR 0.75; (0.62-0.98)], and chorioamnionitis [aOR 0.68; (0.50-0.92)]. The number of rotations attempted to avert one CD was 4. In contrast, women who had a trial of rotation had an increased risk of cervical laceration [aOR 2.46; (1.1-5.4)].Compared with expectant management, a trial of manual rotation with persistent fetal OP/OT position is associated with a reduction in CD and adverse maternal outcomes.

Objective To observe the effect of a trial of instrumental delivery in theatre on outcome for mother and baby. Design A prospective observational study. Methods Relevant maternal and neonatal data were collected for all instrumental deliveries of singleton viable pregnancies delivered over a three month period. Population Two hundred and twenty nine consecutive deliveries conducted by ventouse or forceps because of fetal distress or dystocia. Setting The maternity unit of a teaching hospital delivering around 6000 women annually. Main outcome measures The decision-to-delivery intervals (DDI), mode of delivery and neonatal condition at birth. Results Sixty (26%) deliveries were managed as a trial in theatre, 46 (77%) because of prolonged second stage, with malposition being a factor in 39, and 14 (23%) because of fetal distress. The mean ± SD DDI for these 60 deliveries was 59.2 ± 20.4 minutes (median 58 minutes) compared with 21.2 ± 9.0 minutes (median 20 minutes) for 169 delivered in the labour room (P < 0.0001). Of these 169 deliveries, 168 were delivered within 46 minutes and 1 delivered by caesarean section at 60 minutes. Nine women (13%) ultimately delivered by caesarean section, eight following a trial in theatre; in seven, there was malposition. Deliveries following a trial had slightly less favourable cord blood gas results. Conclusions Trial of instrumental delivery takes two to three times longer than delivery in the labour room; fetal malposition was the major indication for the trial of instrumental delivery and reason for failed delivery. Adopting the recent guidelines of the Royal College of Obstetricians and Gynaecologists, at least 107 (47%) should have been managed as a trial in theatre. The added delay in delivery could be damaging to an already hypoxic fetus, and the use of a trial should be individually assessed.

Occiput posterior position is the most common malpresentation in labour, contributes to about 18% of emergency caesarean sections and is associated with a high risk of assisted delivery. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and to the neonate, respectively. There is level 2 evidence that prophylactic manual rotation reduces the caesarean section rate and assisted vaginal delivery. But there has been no adequately powered randomised controlled trial. This is a protocol for a double-blinded, multicentre, randomised controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate. Eligible participants will be (greater than or equal to) 37 weeks’ with a singleton pregnancy and a cephalic presentation in the occiput posterior position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 68%, then for a reduction to 50%, an alpha value of 0.05 and a beta value of 0.2, 254 participants will need to be enrolled. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, and protocol number X110410. Participants with written consent will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery (defined as vacuum, forceps and/or caesarean section deliveries). Secondary outcomes will be caesarean section, significant maternal mortality/morbidity and significant perinatal mortality/morbidity. Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. The results of the trial will be presented at one or more medical conferences. The trial will be submitted to peer review journals for consideration for publication. There will be potential to incorporate the results into professional guidelines for obstetricians and midwives. The Australian New Zealand Clinical Trials Registry ACTRN12612001312831 . Trial registered 12 December 2012.

OBJECTIVE: We sought to determine the factors associated with selection of rotational instrumental vs cesarean delivery to manage persistent fetal malposition, and to assess differences in adverse neonatal and maternal outcomes following delivery by rotational instruments vs cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study over a 5-year period in a tertiary United Kingdom obstetrics center. In all, 868 women with vertex-presenting, single, liveborn infants at term with persistent malposition in the second stage of labor were included. Propensity score stratification was used to control for selection bias: the possibility that obstetricians may systematically select more difficult cases for cesarean delivery. Linear and logistic regression models were used to compare maternal and neonatal outcomes for delivery by rotational forceps or ventouse vs cesarean delivery, adjusting for propensity scores. RESULTS: Increased likelihood of rotational instrumental delivery was associated with lower maternal age (odds ratio [OR], 0.95; P < .01), lower body mass index (OR, 0.94; P < .001), lower birthweight (OR, 0.95; P < .01), no evidence of fetal compromise at the time of delivery (OR, 0.31; P < .001), delivery during the daytime (OR, 1.45; P < .05), and delivery by a more experienced obstetrician (OR, 7.21; P < .001). Following propensity score stratification, there was no difference by delivery method in the rates of delayed neonatal respiration, reported critical incidents, or low fetal arterial pH. Maternal blood loss was higher in the cesarean group (295.8 ± 48 mL, P < .001). CONCLUSION: Rotational instrumental delivery is often regarded as unsafe. However, we find that neonatal outcomes are no worse once selection bias is accounted for, and that the likelihood of severe obstetric hemorrhage is reduced. More widespread training of obstetricians in rotational instrumental delivery should be considered, particularly in light of rising cesarean delivery rates.

Fetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate. Eligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity. Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410). This trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies. This trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752 ) on 4 January 2013.

Kielland's rotational forceps are designed to overcome malposition of the fetal head in the second stage of labor. After a decline in their use because of reported adverse outcomes and fear of litigation, recent evidence suggests that they may be safe and effective in trained hands and significantly more successful at achieving operative vaginal delivery than either rotational ventouse or manual rotation. This is important because of the increased short and long-term morbidity related to cesarean section compared with the reduced morbidity of subsequent pregnancy after operative vaginal delivery. Kielland's forceps are therefore re-emerging as a useful instrument in the armamentarium of modern obstetrics. Limitations to wider use of Kielland's forceps are the lack of training opportunities as well as that contemporary evidence remains underpowered to detect rare adverse outcomes.

We report on the sonographic appearance of a new type of fetal head malposition in labor that has not been previously described systematically. In some circumstances, the fetal lie is characterized by a lateral orientation of the head with respect to the trunk and, on suprapubic ultrasound, a transverse section of the fetal chest together with the facial profile can be seen on the same image. These sonographic findings were documented in five cases of first-stage labor arrest. This report illustrates how, in these circumstances, ultrasound might be helpful in clarifying the precise cause of obstructed labor.

The occiput posterior (OP) is considered to be the most common fetal malposition of a fetus in a cephalic presentation. Delivery of a fetus in an OP position could be either the result of the persistency of this position throughout the entire labor, called persistent occiput posterior position, or it may arise from a malrotation happening during the second stage of labor from an initial non-OP position.

Objectives To evaluate diagnostic methods used to detect occiput posterior and to describe the efficacy of posturing to enhance rotation from occiput posterior to occiput anterior. Data sources Keyword search using PubMed, CINAHL, Cochrane Review, and Dissertation Abstracts International. Study selection Studies published from 1996 to 2006 (except one published in 1983) that focused on the use of ultrasonography versus digital vaginal examination to diagnose fetal position and maternal posturing to enhance rotation from occiput posterior to occiput anterior. Data extraction Eight prospective studies regarding malposition diagnosis were reviewed and analyzed for error rates and predictors affecting ability to detect fetal position; five randomized controlled trials were evaluated for effects of various maternal postures on fetal rotation from occiput posterior to occiput anterior. Data synthesis If fetal malposition is accurately diagnosed in early labor, subsequent nursing management can focus on rotation toward occiput anterior position, leading to a safer delivery for mother and baby. Conclusions Antepartum ultrasonography is more accurate than digital vaginal examination in diagnosing fetal malposition; however, its efficacy needs to be further explored using randomized controlled trials and cost‐benefit analyses before routine use is recommended. Furthermore, Sims' posture on the same side as the fetal spine is recommended during labor to enhance rotation from occiput posterior to occiput anterior.

To compare the immediate maternal and neonatal morbidity in women delivered by forceps or cesarean section after failed ventouse delivery.Case notes of 400 consecutive successful ventouse deliveries compared with 342 failed ventouse deliveries, where delivery was subsequently achieved with either forceps (N = 247) or cesarean section (N = 95), which took place between October 1999 and May 2003, were reviewed.Failed ventouse delivery was associated with an increased chance for fetal malposition (OR 3.7, 95% CI 2.6 - 5.3) and postpartum hemorrhage (OR 3.5, 95% CI 1.8 - 6.8). Compared to forceps after failed ventouse, cesarean section was associated with a higher prevalence of postpartum hemorrhage (OR 7.8, 95% CI 3.6 - 16.9) and fewer third degree perineal tears (p0.05). There were no significant differences between cesarean section and forceps delivery after failed ventouse for neonatal morbidity.Failure of ventouse delivery is 3 - 4 times more likely with a fetal malposition and is associated with an increased risk of postpartum hemorrhage. While cesarean section increases the postpartum hemorrhage rate, forceps delivery is associated with increased likelihood of third degree perineal tears. The neonatal morbidity was comparable regardless of whether forceps or cesarean was used after failed ventouse.