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Persistent Occiput Posterior

Barth, William H. Jr MD

doi: 10.1097/AOG.0000000000000647
Contents: Clinical Expert Series
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Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Its diagnosis by physical examination is challenging but is improved with bedside ultrasonography. Occiput posterior discovered in the active phase or early second stage of labor usually resolves spontaneously. When it does not, prophylactic manual rotation may decrease persistent OP and its associated complications. When delivery is indicated for arrest of descent in the setting of persistent OP, a pragmatic approach is suggested. Suspected fetal macrosomia, a biparietal diameter above the pelvic inlet or a maternal pelvis with android features should prompt cesarean delivery. Nonrotational operative vaginal delivery is appropriate when the maternal pelvis has a narrow anterior segment but ample room posteriorly, like with anthropoid features. When all other conditions are met and the fetal head arrests in an OP position in a patient with gynecoid pelvic features and ample room anteriorly, options include cesarean delivery, nonrotational operative vaginal delivery, and rotational procedures, either manual or with the use of rotational forceps. Recent literature suggests that maternal and fetal outcomes with rotational forceps are better than those reported in older series. Although not without significant challenges, a role remains for teaching and practicing selected rotational forceps operations in contemporary obstetrics.

Not all persistent occiput posteriors are the same; some should be delivered by cesarean, some by nonrotational operative vaginal delivery, and others by rotational procedures.

Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Corresponding author: William H. Barth Jr, MD, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Massachusetts General Hospital, Harvard Medical School, Massachusetts General Hospital/Founders 418, 55 Fruit Street, Boston, MA 02114; e-mail:

Financial Disclosure The author did not report any potential conflicts of interest.

Continuing medical education for this article is available at

© 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.