Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Occiput posterior position

Cynthia Holcroft Argani, MD
Andrew J Satin, MD, FACOG
Section Editor
Vincenzo Berghella, MD
Deputy Editor
Vanessa A Barss, MD, FACOG


Occiput posterior (OP) position (figure 1) is the most common fetal malposition. It is important because it is associated with labor abnormalities that may lead to adverse maternal and neonatal consequences.


The prevalence of OP position depends on when the diagnosis is made. Before labor, 15 to 20 percent of term fetuses in cephalic presentation are OP, but only 5 percent are OP at vaginal delivery because most OP fetuses spontaneously rotate to an anterior position during labor [1-5]. In some cases, the OP position at delivery results from malrotation from an occiput anterior (OA) or occiput transverse (OT) position [2]; however, this is unlikely once the second stage has begun [6].


Reported risk factors for OP position at delivery include [6-14]:


Maternal age greater than 35 years

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Aug 30, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Gardberg M, Laakkonen E, Sälevaara M. Intrapartum sonography and persistent occiput posterior position: a study of 408 deliveries. Obstet Gynecol 1998; 91:746.
  2. Peregrine E, O'Brien P, Jauniaux E. Impact on delivery outcome of ultrasonographic fetal head position prior to induction of labor. Obstet Gynecol 2007; 109:618.
  3. Vitner D, Paltieli Y, Haberman S, et al. Prospective multicenter study of ultrasound-based measurements of fetal head station and position throughout labor. Ultrasound Obstet Gynecol 2015; 46:611.
  4. Akmal S, Tsoi E, Howard R, et al. Investigation of occiput posterior delivery by intrapartum sonography. Ultrasound Obstet Gynecol 2004; 24:425.
  5. Souka AP, Haritos T, Basayiannis K, et al. Intrapartum ultrasound for the examination of the fetal head position in normal and obstructed labor. J Matern Fetal Neonatal Med 2003; 13:59.
  6. Lieberman E, Davidson K, Lee-Parritz A, Shearer E. Changes in fetal position during labor and their association with epidural analgesia. Obstet Gynecol 2005; 105:974.
  7. Ponkey SE, Cohen AP, Heffner LJ, Lieberman E. Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol 2003; 101:915.
  8. Cheng YW, Shaffer BL, Caughey AB. Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med 2006; 19:563.
  9. Le Ray C, Carayol M, Jaquemin S, et al. Is epidural analgesia a risk factor for occiput posterior or transverse positions during labour? Eur J Obstet Gynecol Reprod Biol 2005; 123:22.
  10. Floberg J, Belfrage P, Ohlsén H. Influence of the pelvic outlet capacity on fetal head presentation at delivery. Acta Obstet Gynecol Scand 1987; 66:127.
  11. Senécal J, Xiong X, Fraser WD, Pushing Early Or Pushing Late with Epidural study group. Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol 2005; 105:763.
  12. Sizer AR, Nirmal DM. Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstet Gynecol 2000; 96:749.
  13. Gardberg M, Stenwall O, Laakkonen E. Recurrent persistent occipito-posterior position in subsequent deliveries. BJOG 2004; 111:170.
  14. Ghi T, Youssef A, Martelli F, et al. Narrow subpubic arch angle is associated with higher risk of persistent occiput posterior position at delivery. Ultrasound Obstet Gynecol 2016; 48:511.
  15. Fitzpatrick M, McQuillan K, O'Herlihy C. Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol 2001; 98:1027.
  16. Yancey MK, Zhang J, Schweitzer DL, et al. Epidural analgesia and fetal head malposition at vaginal delivery. Obstet Gynecol 2001; 97:608.
  17. Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2011; :CD000331.
  18. Wheeler TL 2nd, Richter HE. Delivery method, anal sphincter tears and fecal incontinence: new information on a persistent problem. Curr Opin Obstet Gynecol 2007; 19:474.
  19. Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol 2007; 196:344.e1.
  20. Fitzgerald MP, Weber AM, Howden N, et al. Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol 2007; 109:29.
  21. Wu JM, Williams KS, Hundley AF, et al. Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries. Am J Obstet Gynecol 2005; 193:525.
  22. Ben-Haroush A, Melamed N, Kaplan B, Yogev Y. Predictors of failed operative vaginal delivery: a single-center experience. Am J Obstet Gynecol 2007; 197:308.e1.
  23. Mazouni C, Porcu G, Bretelle F, et al. Risk factors for forceps delivery in nulliparous patients. Acta Obstet Gynecol Scand 2006; 85:298.
  24. Cheng YW, Shaffer BL, Caughey AB. The association between persistent occiput posterior position and neonatal outcomes. Obstet Gynecol 2006; 107:837.
  25. Cheng YW, Norwitz ER, Caughey AB. The relationship of fetal position and ethnicity with shoulder dystocia and birth injury. Am J Obstet Gynecol 2006; 195:856.
  26. Akmal S, Kametas N, Tsoi E, et al. Comparison of transvaginal digital examination with intrapartum sonography to determine fetal head position before instrumental delivery. Ultrasound Obstet Gynecol 2003; 21:437.
  27. Chou MR, Kreiser D, Taslimi MM, et al. Vaginal versus ultrasound examination of fetal occiput position during the second stage of labor. Am J Obstet Gynecol 2004; 191:521.
  28. Malvasi A, Tinelli A, Barbera A, et al. Occiput posterior position diagnosis: vaginal examination or intrapartum sonography? A clinical review. J Matern Fetal Neonatal Med 2014; 27:520.
  29. Sherer DM, Miodovnik M, Bradley KS, Langer O. Intrapartum fetal head position II: Comparison between transvaginal digital examination and transabdominal ultrasound assessment during the second stage of labor. Ultrasound Obstet Gynecol 2002; 19:264.
  30. Kariminia A, Chamberlain ME, Keogh J, Shea A. Randomised controlled trial of effect of hands and knees posturing on incidence of occiput posterior position at birth. BMJ 2004; 328:490.
  31. Le Ray C, Lepleux F, De La Calle A, et al. Lateral asymmetric decubitus position for the rotation of occipito-posterior positions: multicenter randomized controlled trial EVADELA. Am J Obstet Gynecol 2016; 215:511.e1.
  32. Verhoeven CJ, Rückert ME, Opmeer BC, et al. Ultrasonographic fetal head position to predict mode of delivery: a systematic review and bivariate meta-analysis. Ultrasound Obstet Gynecol 2012; 40:9.
  33. Stremler R, Hodnett E, Petryshen P, et al. Randomized controlled trial of hands-and-knees positioning for occipitoposterior position in labor. Birth 2005; 32:243.
  34. Desbriere R, Blanc J, Le Dû R, et al. Is maternal posturing during labor efficient in preventing persistent occiput posterior position? A randomized controlled trial. Am J Obstet Gynecol 2013; 208:60.e1.
  35. Le Ray C, Serres P, Schmitz T, et al. Manual rotation in occiput posterior or transverse positions: risk factors and consequences on the cesarean delivery rate. Obstet Gynecol 2007; 110:873.
  36. Haddad B, Abirached F, Calvez G, Cabrol D. [Manual rotation of vertex presentations in posterior occipital-iliac or transverse position. Technique and value]. J Gynecol Obstet Biol Reprod (Paris) 1995; 24:181.
  37. Barth WH. Persistent occiput posterior. Obstet Gynecol 2015; 125:695.
  38. Reichman O, Gdansky E, Latinsky B, et al. Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. Eur J Obstet Gynecol Reprod Biol 2008; 136:25.
  39. Shaffer BL, Cheng YW, Vargas JE, et al. Manual rotation of the fetal occiput: predictors of success and delivery. Am J Obstet Gynecol 2006; 194:e7.
  40. Cargill YM, MacKinnon CJ, Arsenault MY, et al. Guidelines for operative vaginal birth. J Obstet Gynaecol Can 2004; 26:747.
  41. Dennen, PC. Dennen's forceps deliveries, 3rd ed, FA Davis Company, Philadelphia 1989.
  42. Tarnier, S, Chantreiul, G, Lauwergus, H. Traité de l'art des accouchements (Tome 2), Paris 1982.
  43. Masturzo B, Farina A, Attamante L, et al. Sonographic evaluation of the fetal spine position and success rate of manual rotation of the fetus in occiput posterior position: A randomized controlled trial. J Clin Ultrasound 2017; 45:472.
  44. Damron DP, Capeless EL. Operative vaginal delivery: a comparison of forceps and vacuum for success rate and risk of rectal sphincter injury. Am J Obstet Gynecol 2004; 191:907.
  45. Stock SJ, Josephs K, Farquharson S, et al. Maternal and neonatal outcomes of successful Kielland's rotational forceps delivery. Obstet Gynecol 2013; 121:1032.
  46. Vidal F, Simon C, Cristini C, et al. Instrumental rotation for persistent fetal occiput posterior position: a way to decrease maternal and neonatal injury? PLoS One 2013; 8:e78124.