Occiput transverse position
- Aaron B Caughey, MD, PhD
Aaron B Caughey, MD, PhD
- Professor and Chair
- Department of Obstetrics & Gynecology
- Associate Dean for Women's Health Research & Policy
- Oregon Health & Science University
This topic will discuss the diagnosis, clinical course, and management of occiput transverse (OT) position. OT position is unrelated to transverse lie, in which the long axis of the fetal body is perpendicular to that of the mother. (See "Transverse fetal lie".)
OCCIPUT TRANSVERSE POSITION
Digital examination — The diagnosis of OT is generally based on findings from the transvaginal digital examination. The fetal sagittal suture and fontanelles (figure 1) are palpable in the transverse diameter of the pelvis. The fetal ears can be palpated superiorly under the symphysis and inferiorly above the sacrum/coccyx. If the occiput (posterior fontanelle) is on the mother's left side, the position is LOT; if the occiput (posterior fontanelle) is on the mother’s right side, the position is ROT (figure 2).
Ultrasound examination — While digital vaginal examination of fetal position has been the accepted standard for diagnosis, there is evidence to suggest that ultrasound assessment of fetal position can be more consistent . Either transabdominal, transvaginal, or transperineal  ultrasound can be employed, though at least one group reported greater success using a transvaginal approach . If ultrasound is used to determine fetal positon, the obstetric provider should receive specialized training for the procedure and undergo supervision by a more experienced diagnostician until he/she develops proficiency.
The key diagnostic feature for identification of OT position is the location of the fetal orbits. Both orbits are posterior when the fetus is occiput anterior (OA) and both are anterior when the fetus is occiput posterior (OP), whereas in OT position, one orbit is anterior and the other is posterior. If both orbits are on the maternal left, then the fetal position is ROT. If both orbits are on the maternal right, then the position is LOT.
Differential diagnosis — Anterior or posterior asynclitism, defined as rotation of the sagittal suture away from or toward the pubic symphysis, respectively, may result in misdiagnosis of OT as either occiput anterior or occiput posterior. Palpation of the fetal ears superiorly and inferiorly can help distinguish OT position from asynclitism. If the diagnosis is uncertain after careful physical assessment, ultrasound examination can be used to clarify the fetal position [4,5].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:
- Dupuis O, Ruimark S, Corinne D, et al. Fetal head position during the second stage of labor: comparison of digital vaginal examination and transabdominal ultrasonographic examination. Eur J Obstet Gynecol Reprod Biol 2005; 123:193.
- Ghi T, Bellussi F, Eggebø T, et al. Sonographic assessment of fetal occiput position during the second stage of labor: how reliable is the transperineal approach? J Matern Fetal Neonatal Med 2015; 28:1985.
- Zahalka N, Sadan O, Malinger G, et al. Comparison of transvaginal sonography with digital examination and transabdominal sonography for the determination of fetal head position in the second stage of labor. Am J Obstet Gynecol 2005; 193:381.
- 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.
- Eggebø TM, Hassan WA, Salvesen KÅ, et al. Prediction of delivery mode by ultrasound-assessed fetal position in nulliparous women with prolonged first stage of labor. Ultrasound Obstet Gynecol 2015; 46:606.
- 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.
- 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.
- 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.
- Danforth DN. Transverse arrest. Clin Obstet Gynecol 1965; 8:854.
- American College of Obstetricians and Gynecologists (College), Society for Maternal-Fetal Medicine, Caughey AB, et al. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol 2014; 210:179.
- Shaffer BL, Cheng YW, Vargas JE, Caughey AB. Manual rotation to reduce caesarean delivery in persistent occiput posterior or transverse position. J Matern Fetal Neonatal Med 2011; 24:65.
- 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.
- 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.
- Hamilton BE, Martin JA, Osterman MJ, et al. Births: Final Data for 2014. Natl Vital Stat Rep 2015; 64:1.
- O'Mahony F, Hofmeyr GJ, Menon V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev 2010; :CD005455.
- Vacca A. Operative vaginal delivery: clinical appraisal of a new vacuum extraction device. Aust N Z J Obstet Gynaecol 2001; 41:156.
- Bird GC. The use of the vacuum extractor. Clin Obstet Gynaecol 1982; 9:641.
- Bird GC. The importance of flexion in vacuum extractor delivery. Br J Obstet Gynaecol 1976; 83:194.
- Vacca A. Vacuum-assisted delivery. Best Pract Res Clin Obstet Gynaecol 2002; 16:17.
- OCCIPUT TRANSVERSE POSITION
- - Digital examination
- - Ultrasound examination
- Differential diagnosis
- Clinical course
- PERSISTENT OCCIPUT TRANSVERSE
- Clinical course
- - Treat hypocontractile uterine activity
- - Manage progressive descent expectantly
- - Interventions for arrest
- Choice of approach
- Manual rotation
- Forceps rotation
- Vacuum extraction
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS