6/10/2016 Disclosures • I have nothing to disclose Persistent Occiput Posterior (OP): Is Manual Rotation the Answer? Brian L. Shaffer, MD Maternal Fetal Medicine Doernbecher Fetal Therapy June 10, 2016 Clinical scenario – you get a page…. Objectives: Persistent OP: Manual Rotation? • Background 39 yo G1 at 40 3/7 weeks – Incidence & Etiology - Pushing for 3 ½ hours, fatigued – Associated Maternal & Neonatal morbidity - Category II tracing • Diagnosis of Persistent OP - Minimal-moderate variability, intermittent late • Management decelerations – Pre-labor & Stage I - EFW 3800g….. – Stage II • Prophylactic, After a pre-defined time period, “Late” • Manual Rotation: Technique • Clinical scenarios 1
6/10/2016 Clinical scenario – you get a page…. Background: Persistent OP • Fetal occiput in the posterior quadrants until delivery 39 yo G1 at 40 3/7 weeks – SVD or Indicated (AOD, etc.) - Pushing for 3 ½ hours, fatigued – Most common fetal malposition - Category II tracing - Minimal-moderate variability, intermittent late decelerations - EFW 3800g - …and “I think she is OP” Can you come and assess her? Background: Persistent OP Background: Etiology • Parity – nulliparous; Age >35; BMI >30; >41 weeks • Onset of Labor – 25% of fetuses in OP (~1/2 OT) • Anterior placenta; Fetal macrosomia (>4000g) – 80-90% rotate to OA prior to delivery • Labor augmentation • OP and Stage II • Prior OP birth – If OP at onset of stage 2 – rotation to OA? - 50-80% – If OA at onset of stage 2 - rotation to OP? ~5% • Shape of pelvis - occiput attracted to area of most room – At birth: 5-12% OP • Right OP (60%), Left (30%), Direct (10%) 2
6/10/2016 Background: Etiology Background: Etiology - Epidural • Parity – nulliparous; Age >35; BMI >30; >41 weeks • Epidural � More relaxed levator complex • Anterior placenta; Fetal macrosomia (>4000g) – Inhibits rotation of OP to OA – more persistent OP • Labor augmentation – Retrospective cohort studies* (OR: 2.2-3.25) • Prior OP birth – But Nulliparous women have more OP! – “Back labor” – no difference in rate of epidural @ • Shape of pelvis - occiput attracted to area of most room – Anthropoid • Randomized controlled trials^ • More common - African American – Epidural vs. No analgesia/other methods – RR 1.4 (0.98-1.99) • Epidural *Sizer AR Obstet Gynecol 2000; Cheng YW J Mat Fet Neo Med 2006. @ Lieberman E Obstet Gynecol 2005, ^Anim-Somuah M Cochrane 2011 Persistent OP – Maternal Outcomes/Morbidity Persistent OP – Maternal Outcomes/Morbidity Subocciptobregmatic: 9.5cm Occiptofrontal: 11.5cm Subocciptobregmatic: 9.5cm Occiptomental: 13.5cm Occiptofrontal: 11.5cm Occiptomental: 13.5cm Barth WH, Obstet Gynecol 2015 Barth WH, Obstet Gynecol 2015 3
6/10/2016 Persistent OP – Maternal Outcomes Persistent OP – Neonatal Outcomes* • Labor dystocia Outcome OR (95% CI) – Longer stage I, more likely – prolonged stage I Apgar <7 @ 5min 1.5 (1.2-1.9) • Augmentation – oxytocin, amniotomy CUA acidemia 2.0 (1.5-2.7) – Longer stage 2 – PEOPLE* – Add 45 minutes Meconium 1.3 (1.2-1.4) • Operative vaginal birth - ~2 fold increase Birth Trauma 1.8 (1.2-2.6) – Failed operative vaginal delivery NICU admission 1.6 (1.3-1.9) – 3 rd & 4 th degree lacerations Neonatal morbidity 1.4 (1.2-1.6) • VAVD and persistent OP: ~33% • FAVD and persistent OP: 50-70% Shoulder dystocia 0.5 (0.3-0.97) • Cesarean – strongest association in late stage II Brachial Plexus Injury 10.4 (3.0-35.9) � Bleeding, extension, injury *Cheng YW Obstet Gynecol 2006; Cheng YW Am J Obstet Gynecol 2006 *Senecal J Obstet Gynecol 2005 Diagnosis - OP Diagnosis - OP • Ultrasound • Digital examination – Axial view – orbits, post fossa, falx – May be challenging – caput, molding – Axial/Sagittal view – Location of fetal spine – Differ by >45°? -- 30-80%* – All vs. selective/uncertain examination *Barth WH Obstet Gynecol 2015 *Barth WH Obstet Gynecol 2015 4
6/10/2016 Diagnosis - OP Diagnosis - OP • Ultrasound • Ultrasound – Axial view – orbits, post fossa, falx – Axial view – orbits, post fossa, falx – Axial/Sagittal view – Location of fetal spine – Axial/Sagittal view – Location of fetal spine – All vs. selective/uncertain examination – All versus selective/uncertain examination *Barth WH Obstet Gynecol 2015 *Barth WH Obstet Gynecol 2015 Management – Persistent OP Management - Pre-labor/Antepartum period • Can we prevent Persistent OP? What to do…? • Can exercises facilitate anterior rotation of the occiput? Dictated by when you are aware of OP – Hands/Knees thought to promote rotation to OA^ • Pre-labor/Antepartum – Multicenter, randomized, n= >2500* – 36-37 weeks • Active Labor – Stage I – Daily Walk vs. Hands/Knees/Pelvic rocking 10 min 2/day • Stage II • Await spontaneous labor – Onset of stage II – “Prophylactic” – Persistent OP: ~8% in both groups – After some Pre-defined period of time ~ 1h – No difference in CD – Lack of Progress/Arrest • No evidence of benefit – No large RCTs to guide management ^Kariminia A BMJ 2004 5
6/10/2016 Management - Active labor, Stage I Management – Stage 2 • Most OP fetuses spontaneously rotate to OA OPTIONS: • RCTs* - Maternal repositioning did not: 1) Prophylactic manual rotation – Increase OA at time of delivery – Decrease operative vaginal delivery rates 2) Rotation after some defined period of time - 1h nullip • Late stage I – manual rotation 3) Rotation for Arrest of Descent – Less success^ 4) Expectant management – Increased risk for cord prolapse & cervical laceration • No intervention has proven successful *Stremler R. Birth 2005; Desbriere R. Am J Ob Gyn 2013; ^Le Ray C. Obstet Gynecol 2007 Management – Stage 2: Examination Persistent OP and fetal station • Station - May be difficult to assess • Leopold – Abdominal palpation of BPD – BPD above spines? – High station despite visible scalp • Leopold for BPD • Pelvis: Is the pelvis adequate – Arch, Spines, AP? – Treat Android, Anthropoid and Gynecoid differently – Do the fetus and pelvis match?, EFW? • Progress? – Onset of stage II – Manual rotation success indirectly related to time in OP *Barth WH Obstet Gynecol 2015 – Limit unnecessary procedures – Frequent assessments of descent 6
6/10/2016 Management – Stage 2: Examination Management – Stage 2: Examination • Station - May be difficult to assess • Other clinical factors – BPD above spines? – Urge to push • Leopold for BPD – Anesthesia • Pelvis: Is the pelvis adequate – Arch, Spines, AP? – Chorioamnionitis – Treat Android, Anthropoid and Gynecoid differently – Do the fetus and pelvis match?, EFW? • What is the timeline for this birth? • Progress? – Onset of stage II – Rotation success indirectly related to time in OP – Limit unnecessary procedures Management – Stage 2 Management – Expectant management OPTIONS: • Labor progressing, FHR category I 1) Prophylactic rotation (manual or forceps) – Occiput posterior at onset of stage II • 50-80% spontaneously rotate to OA 2) Rotation after some defined period of time - 1h nullip – Manual rotation is not risk free 3) Rotation for Arrest of Descent • Uncommon but important related morbidity 4) Expectant management • Cervical laceration (~2%), NRFHT (1%), discomfort – Frequent assessment of descent/progress – May continue to progress and undergo SVD • What is the pelvis type? 7
6/10/2016 Management - Onset of stage 2 Management – Prophylactic rotation OPTIONS: • RCT: Term, Nulliparous, Epidural, OP, n=64* – Onset of stage II: 1) Prophylactic rotation (manual) • Manual rotation vs. Expectant management 2) Rotation after some defined period of time - 1h nullip – Early manual rotation 3) Rotation for Arrest of Descent • Successful rotation: 83% vs. 20% (p=0.001) 4) Expectant management • Shorter stage II: 65 vs. 82 minutes (p=0.04) • No difference: – 3 rd /4 th degree lacerations, – Cesarean – Operative vaginal birth – No evidence of harm *Broberg Am J Ob Gyn 2016 S63. Management – Stage 2 Management – Stage 2 Rotation after some period of time OPTIONS: 1) Prophylactic rotation (manual or forceps) • Prospective, n=61 – 2 nd stage, sono confirmed persistent OP 2) Rotation after some defined period of time - 1h nullip – Randomized by time period 3) Rotation for Arrest of Descent/NRFHT – Expectant vs. Manual rotation 4) Expectant management – Nulliparas – at 60 minutes (90 min if epidural) – Multiparas – at 30 minutes (60 min if epidural) * Reichman Eur J Obstet Gynecol 2006 8
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