Persistent fetal occiput posterior position: obstetric outcomes.
ABSTRACT To evaluate the obstetric outcomes associated with persistent occiput posterior position of the fetal head in term laboring patients.
We performed a cohort study of 6434 consecutive, term, vertex, laboring nulliparous and multiparous patients, comparing those who delivered infants in the occiput posterior position with those who delivered in the occiput anterior position. We examined maternal demographics, labor and delivery characteristics, and maternal and neonatal outcomes.
The prevalence of persistent occiput posterior position at delivery was 5.5% overall, 7.2% in nulliparas, and 4.0% in multiparas (P <.001). Persistent occiput posterior position was associated with shorter maternal stature and prior cesarean delivery. During labor and delivery, the occiput posterior position was associated with prolonged first and second stages of labor, oxytocin augmentation, use of epidural analgesia, chorioamnionitis, assisted vaginal delivery, third and fourth degree perineal lacerations, cesarean delivery, excessive blood loss, and postpartum infection. Newborns had lower 1-minute Apgar scores, but showed no differences in 5-minute Apgar scores, gestational age, or birth weight.
Persistent occiput posterior position is associated with a higher rate of complications during labor and delivery. In our population, the chances that a laboring woman with persistent occiput posterior position will have a spontaneous vaginal delivery are only 26% for nulliparas and 57% for multiparas.
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ABSTRACT: To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia. We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2-year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position. The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P <.001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago. Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.Obstetrics and Gynecology 12/2001; 98(6):1027-31. · 4.80 Impact Factor
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ABSTRACT: To measure the length of active labor (first and second stages) in a low-risk population of non-Hispanic white, Hispanic, and American Indian women, and to identify any differences among these ethnic populations. Descriptive statistics are presented for 1473 low-risk women at term who delivered at the University of New Mexico Hospital. Data examined by ethnicity included demographics, intrapartum care and complications, and duration of the active-phase first stage (4 cm to complete cervical dilatation) and second stage (complete cervical dilatation to delivery) of labor. Compared with Friedman's criteria, 20% of these low-risk women had a prolonged active phase of the first stage, and 4% had a prolonged second stage, without excess maternal or infant morbidity. The mean length of active-phase, first-stage labor was 7.7 hours for nulliparas and 5.7 hours for multiparas (statistical limits 19.4 and 13.7 hours, respectively), with no differences according to ethnic group. The mean length of second stage was 53 minutes for nulliparas and 17 minutes for multiparas (statistical limits 147 and 57 minutes, respectively). American Indian nulliparas had significantly shorter second stages than non-Hispanic white women (P < .05). Active labor in healthy women lasted longer than is widely appreciated. Upward revision of clinical expectations for the length of active labor is warranted.Obstetrics and Gynecology 03/1996; 87(3):355-9. · 4.80 Impact Factor
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ABSTRACT: Objective: To determine if epidural analgesia is associated with differences in rates of severe perineal trauma during vaginal deliveries. Methods: We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using χ2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables. Results: Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3). Conclusion: Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy. Epidural analgesia has become popular in modern obstetric practice because of its excellent labor-pain relief. Investigators extensively have examined consequences of this anesthetic technique on courses of labor and methods of delivery. In a recent review, 102 manuscripts were analyzed on the subject. 1 Despite the interest in its obstetric consequences, there have been few reports that evaluated possible interactions of regional epidural analgesia and perineal trauma. 2-7 Results of those studies have conflicted. It has been suggested that by relaxing the muscles of the pelvic floor, epidural might allow more controlled delivery of the fetal head, reducing obstetric lacerations. 2 However, epidural blockade could interfere with the second stage of labor, leading to increased obstetric intervention and perineal trauma. This study was carried out to determine if epidural analgesia for labor-pain relief is associated with differences in rates of severe perineal trauma (third- and fourth-degree obstetric lacerations) during vaginal deliveries in nulliparas, and evaluate any responsible factors.Obstetrics and Gynecology 07/1999; 94(2):259-262. · 4.80 Impact Factor