Clinical Rounds: Management of Occiput Posterior Position


  • Jocelyn Hart CNM, MS,

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    • Jocelyn Hart, CNM, MS, is a recent graduate of Columbia University's Midwifery program. She practices at the Morris Heights Women's Health and Birthing Center in the Bronx.

  • Amy Walker CNM, MS

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    • Amy Walker, CNM, MS, practices full scope midwifery at Montachusett Women's Health in Leominster, Massachusetts. Ms. Wallker is recent graduate from the Columbia University Nurse Midwifery Program.

Montachusett Women's Health, 100 Hospital Rd., Suite 1B, Leominster, MA 01453. E-mail:


A 27-year-old, para 1 at 40 1/7 weeks' gestation presented to the labor and delivery unit in labor. Her prenatal course was uncomplicated, and her previous obstetric history included a vaginal delivery of a full-term 7-pound, 9-ounce male infant. She described her first birth as being “straightforward.” It was 10 hours in length, and she received an epidural for analgesia. Upon this admission, she stated that she had been having regular, painful contractions for the past 10 hours. Her cervix was 1 cm dilated, 50% effaced, and the fetus was at −3 station. The membranes were intact. She was experiencing intensely painful contractions every 2 to 3 minutes, and reported severe back pain and exhaustion. Leopold's maneuvers revealed small parts on the left anterior side, and the fetal back was difficult to palpate, consistent with an occiput posterior (OP) position. Per hospital protocol, she was confined to bed rest and placed on continuous fetal and uterine monitoring. Five hours after admission, her membranes ruptured spontaneously with clear fluid. The fetus was then at −2 station, and her cervix had dilated to 4 cm and was 80% effaced. She reported increased pain and requested an epidural, hoping to get some rest. After the epidural was placed, her contractions became irregular (every 3–10 min), and as a result, oxytocin augmentation was started. Approximately 1 hour later, the external uterine monitor began failing to record contractions, and an intrauterine pressure catheter was placed. Ten hours after admission, and 4 hours after oxytocin was started, her cervix had dilated to 7 cm. Despite several epidural boluses, she continued to experience severe back pain, and a belly binder was applied as a relief measure. Throughout her labor, she stayed in bed with position changes that were limited to left lateral and right lateral. Cervical dilatation did not progress beyond 7 cm, and no fetal descent occurred over the next 4 hours, despite progressive oxytocin augmentation and an adequate contraction pattern based on Montevideo units. The midwife collaborated with the attending obstetrician and a cesarean section was recommended for failure to progress. A healthy baby boy who was noted to be in direct OP position was born via cesarean section with Apgar scores of 9/9. He weighed 8 pounds, 10 ounces.