Does it matter which way a baby comes out of the birth canal, or which way it’s facing during a C-section? For people in labor, not necessarily, as many different head positions result in healthy, safe deliveries, although labor times are often longer for people who don’t deliver “the normal way.” It does matter to your obstetrician, however, because the head position tells them how the labor is progressing and will affect any surgical delivery plans they may have. Dr. Fox tells us all about birth positions, face-up deliveries, and what’s important about the angle and orientation of babies as they’re being born.
“Occiput Posterior (OP) – A Sunny Side Up Birth”
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Dr. Fox: Hey. Welcome to the “Healthful Woman” podcast, the fastest-growing podcast in women’s health. Today’s Monday, June 27th, 2022. For today’s podcast, I am flying solo, pitching a complete game, the one-man band, whatever metaphor you prefer. Either way, you all get the pleasure or displeasure of hearing only my voice for the entire podcast. So, buckle in.
The topic of today’s podcast, occiput posterior (OP), a sunny side up birth was suggested by one of our wonderful listeners, Alexis Cohen. Alexis emailed us, and I quote, “We listened to your podcast on inductions, so we knew pretty much what to expect. So, thank you. My baby ended up being face-up, which I was surprised they didn’t know from before. Bender successfully turned her as she was coming out, but as the mother, I was very afraid. I have so many questions now, why is it so scary to be face up? When’s the latest the baby would turn? How come we didn’t know? What are the chances for C-section for face up? Would love if we even got a podcast on this. Thank you.”
Well, thank you, Alexis, for the email and for the great questions and the podcast suggestion. This one’s for you. All right. Enjoy today’s podcast. See you next week. We’ll be having a podcast on Monday, July 4th, which is going to be an amazing day for many reasons. Tune in next week to hear why. How about that for a teaser? Thanks for listening. Have a great week.
Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics on women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman”, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Hey, everyone. So, I’m doing this podcast solo today. I feel a little bit like Tom Hanks in “Cast Away” without Wilson the volleyball. But we’re gonna be talking about occiput posterior position which we call OP for occiput posterior, some people call it a sunny-side-up delivery, or face-up delivery. And essentially, I just wanted to talk about sort of what it is, how we get to that, sort of, what is the typical positions the baby’s head takes in labor, why it matters, why you might care about it, and what we do about it?
This is something that I think there’s a lot of confusion about for people who are gonna, you know, have babies or they’re pregnant and they’re asking, where is the head and what’s the position? And somebody told me, is it facing this way? Is it facing that way? And it’s important. So we’re gonna go over all that. Hopefully, this will be comprehensive. Obviously, if after this, you still have questions, feel free to email them to us and I will try to either get back to you by email or potentially add an addendum to a podcast in like a Q&A session. Okay. So essentially, as I was saying, an occiput posterior (OP) is when the baby is born, and when the head comes out, the face of the baby is facing towards the ceiling or towards the sky rather than towards the floor.
Now, as a background for this, there is a sort of typical way a baby’s head navigates the pelvis as it goes into it and ultimately out during birth. And sort of our world, we call that the cardinal movements of labor. Now, not every baby follows in exactly the same way, but this is sort of the typical way. And what essentially has to happen is the baby’s head, if you think about it, right? If you look at sort of your head from the ceiling down, it’s not a circle, it’s actually an oval. And so from the front of your head, like your forehead to the back of the head is sort of the wider part of the oval and from your ear to ear is sort of the more narrow part. Now, everyone’s head is shaped differently and some are a little bit more circular and a little more oval, but they’re almost always an oval.
So if you think of the baby’s head as an oval, the long part of the head, right, so front to back, is harder to fit through something, obviously, than the narrow part. So, when the baby’s head is trying to enter the pelvis, it’s sort of think of it as diving down into the mother’s pelvis. And the mother’s pelvis, the first thing it’s gonna see is also an oval, but it’s shaped from the mother’s left to right, right? So her sort of pelvic bones are shaped, what we call the inlet where the baby’s head goes into the pelvis is an oval that’s, you know, wider left to right than it is front to back. So when the baby enters the pelvis, typically, its head is aligned facing her left or facing her right so the oval of the head sort of fits nicely into the oval of the pelvis side-to-side.
But what’s interesting is as the baby goes down and then eventually out the, what we call outlet as the baby leaves the pelvis is actually an oval from up to down. So the baby’s head typically enters the pelvis with the longer part, front to back part of the baby’s head, side to side in the mother’s belly from her left to right, it has to exit essentially 90 degrees, up-down or down-up. And so it rotates, we call that internal rotation. Usually during labor, as the head is going down into the pelvis, sort of like a screw going into the wall, as it goes down, it also rotates. And what happens most of the time when the baby’s head rotates is that it rotates in a way that the chin goes towards the floor and the back of the head goes towards the ceiling.
So it’s sort of facing down to the floor. And that’s what typically happens. And when a woman is in labor and we’re examining how far dilated the cervix is, we can also feel where is the head in that sort of process of rotating, right? So we feel for a lot of things, we check how far dilated the cervix is and how consistent it is. So we’ll frequently say something like the cervix is 4 centimeters dilated and 80% effaced. But we also say something else, how high up is the head? We say something like minus three, minus two, minus one. That sort of indicates minus three is higher, minus one, two, three is lower.
And then we also indicate, what’s the position of the head? And we use these terms like LOP, or ROP, or OT. And it’s essentially, we think of sort of the head with the back of the head, we call the occiput, the O, as like 12 o’clock. And sort of, as that, we can feel it. It’ll sort of start out if it’s the back of the head towards either her right or her left. So we’ll say like three o’clock or nine o’clock and then it’s gonna rotate hopefully from three o’clock to 12 o’clock. So if the back of the head is at 12 o’clock, the front of the head is facing six o’clock or the floor. And we describe that over the course of labor.
Now, why do we care? So, number one, it helps us assess the progress of labor. So, as we feel the head descending and we also feel the head rotating, we know that the head is sort of navigating the pelvis in a sort of healthy and normal way and we anticipate the labor’s gonna continue that way and it’s gonna continue to do so. It also, we need to know sort of where’s the head and the position of the head if we plan on doing any form of an operative delivery like forceps or vacuum. And, you know, several weeks ago, we had a podcast, me and Melka talked about operative delivery.
But one of the absolute things you need to know if you’re gonna do an operative delivery is what’s the position of the head because the instruments sort of fit on the head in a certain way. So you have to know exactly how the head is positioned if you’re gonna put these instruments on. And also when she starts pushing to deliver, it’s easier from certain positions of the baby’s head than others. Namely, if the baby’s facing the floor, what we call OA, which is occiput anterior. So just to break that down again, occiput is the back of the head. So, if the back of the head is anterior, which means up, that means the front of the head or the face is down. And so that’s sort of the typical position.
But if we’ve noticed that it’s the opposite OP or occiput posterior, that means the occiput, the back of the head, fetal head is posterior or towards the floor or six o’clock, that means that the baby’s facing up towards 12 o’clock or towards the sky. And it’s more difficult to deliver from this position really just based on the geometry, the shape of the pelvis and how the head, you know, can only flex a certain amount because the chin will hit the chest. And so, geometrically, when the baby is facing down towards the floor, it’s a little bit of an easier fit or an easier navigation through the pelvis to exit versus if the baby’s head is facing towards the ceiling or occiput posterior.
So that’s sort of why it matters, right? It matters to us because we need to see if the labor’s progressing properly. If we have to do some form of an operative delivery, we need to know the position of the head. But also, it helps us sort of understand and manage expectations for how long we think she’s gonna push or how hard it’s gonna be to push based on whether it’s in the sort of “better position,” facing the floor, versus the “worse position,” the occiput posterior or OP, facing the ceiling.
And essentially, since the head rotates during labor, if you assess the position of the head either before labor or early in labor, very frequently, it’s gonna be occiput posterior sort of facing the ceiling. But we don’t worry about that too much because, again, the head is supposed to rotate during the course of labor as it descends. At the time of birth, it really only happens about 5% of the time. Meaning most births, 95% of births when the baby’s head comes out, it’s gonna come out facing the floor and about 5% of the time it’s gonna come out facing the ceiling or sunny-side up.
Now, some people will report that when they’re laboring and the baby’s facing up, they feel something called back labor where when they have their contractions, instead of feeling them more in their front and their belly, they feel them more sort of in their back. And that definitely could be true just because if the baby’s facing the ceiling frequently, the baby’s spine is also sort of down and maybe more towards her back. And that can happen, but it’s not necessarily predictable. Meaning people with back labor can have a baby that’s facing the “better way” and people without back labor can have it the wrong way. But it’s sort of something that sometimes we see together, but not always. In that 5% of deliveries when the baby’s facing occiput posterior or the baby’s facing the ceiling, you know, it seems to happen more commonly in certain women rather than others.
It’s more common in your first birth. It’s more common as women get older, as women weigh more. It’s more common with bigger babies and sort of later gestational ages. And it actually seems to be a little bit more common if you have an epidural. It’s not exactly clear why that is. There’s some debate, some people believe that it’s actually not that the epidural causes the baby’s head to face in that position, but rather, since the baby’s head is facing in that position, women are more likely to ask for an epidural because they’re in more pain.
Actually, newer studies seem to say that’s incorrect that if they look at women who ask for epidurals and they look at percentages, it seems to be actually that the epidural somehow does increase the chance of the baby being OP, and possibly it’s because it sort of relaxes the pelvic muscles and potentially that tightness of the pelvic muscles is part of the reason the baby’s head sort of like twists in normally into the pelvis, does that rotation. Again, it’s not entirely clear, but that’s a theory. So it’s a little bit more common with an epidural, but still so instead of maybe 5% of the time, maybe it’s 10% of the time. So most people, even with an epidural, the baby will face “the normal way,” but it may be slightly higher.
And the reason we care, number one, as we said before, it takes longer to deliver. It’s harder to push, longer time of pushing, more force is needed, more time is needed to sort of navigate that head when it’s facing up to get out of the pelvis. So that’s one reason it matters. A second reason is since it’s harder, it also increases the chance of requiring either an operative vaginal delivery or even a cesarean delivery. So we know that if we see a baby that’s in the occiput posterior position when mom is pushing, not early, but sort of when it’s navigated through the pelvis and it’s remaining that way, there is statistically a higher chance of a C-section being required and a higher chance of needing a forceps or vacuum delivery.
In addition, if the baby successfully delivers vaginally, there is a higher chance of the mother having a large tear and a higher blood loss. Again, since sort of… It’s almost as if the head is bigger if it’s coming out OP rather than coming out facing the floor. It’s not actually bigger, but since it comes out in a different way, that sort of the diameter of the head that’s sort of coming through the pelvis is different, it’s the equivalent of having a bigger head for the baby, which would, again, be harder to deliver and potentially cause more tearing and blood loss for the mother. There are some risks to the baby, but it’s not a direct risk to the baby. Like it doesn’t injure the baby’s head or face or anything like that. Most of the consequences to the baby seem to be related just to the fact of a longer labor, right?
When women have longer labors, there’s a higher chance of a baby, let’s say, go to the NICU, or needing some resuscitation, or having a fever, or something like that. So again, it’s not specifically dangerous for the baby to be in that position, but if that leads to a much longer labor or harder pushing, it could lead potentially to something to the baby. So that’s sort of the issue. And the question is what can we do about it? Now, before labor, there’s really nothing to do about it, right? So if we see someone in the office and we say, “Oh, the baby’s facing up or the baby’s, you know, facing to the side,” it’s not a problem. That’s actually normal. That’s very common. And since she’s not in labor, we would not expect the head to be sort of rotating into the pelvis the way it would in labor.
And so, typically, before labor, the head faces, as we said, side to side, to the left or to the right. And sometimes it faces, you know, up or down, but it really doesn’t make a difference at all. In labor, it’s something that we note, but it really doesn’t mean much because, again, the head’s gonna rotate almost all the time. So, in early labor, you might find the head sort of as more posterior, like, you know, 20% or 30% of the time, but again, since at birth it’s only 5%, that means the vast majority are just gonna sort of rotate on their own in the correct way.
So, we don’t really make a big deal about it during the labor if it’s more posterior, but we do track, is it rotating or is it not rotating? One of the nice things I like to know if the baby’s head is posterior is where is the baby’s back? Is it more to the mother’s right or more to the mother’s left? And the reason is based on where it is, we sort of know which direction the head is expected to rotate. So, if the baby’s during labor sort of straight up and down where the back of the head is at 12 o’clock, the front of the head is at 6 o’clock and it’s gonna rotate and it could either go clockwise or counterclockwise. And based on where the baby’s back is, that’s gonna sort of indicate which weight’s gonna go. And so, I’ll try to get a sense of where the back is either by feeling it, and sometimes I’ll even use ultrasound to find out where it is just so I can understand and predict which way it’s going to turn.
Now, there are some, you can, you know, some doctors talk about this, some midwives talk about this. You can Google this for sure. There’s a lot of talk about, maybe we can change the mother’s position in labors, you know, put one leg up above one leg down, have her go on all fours, have her go on her side, sort of to change the pressure on the pelvis, or gravity, or whatever it is to sort of manipulate the head that way to rotate, to sort of encourage it to rotate during labor from OP to OA. And it’s hard to know if that actually works or not. Maybe it does, maybe it doesn’t. But most of the studies that have been done in this where they sort of like take a lot of women who’s the baby’s like this. And half of them, they change their position, and half of them, they don’t. It has not seemed to pan out to be that helpful.
Now, of course, the studies may be incorrect or they could not be using the right positions or it could be more nuanced. Some women need some position, others need another. So, I’m not saying it doesn’t work, but we’ve never really been able to find something that reliably is gonna work to turn the head into the proper position, more so, than just waiting and doing nothing. So, it’s not harmful to move around positions in labor, you know, with an epidural, without an epidural, but it’s unclear if that’s really gonna work.
Now, once someone is fully dilated and starting to push and the head is still posterior, there’s really a few options of what we can do. The first option is what I would call expected management, which is basically, she’s pushing, and we sort of see what happens with the head. And often as she’s pushing, the head is gonna rotate on its own. And this is particularly true for someone who it’s not their first baby. Very, very commonly if I’m delivering someone, it’s their second, their third, their fourth baby, you know, the back of the head is either at 6 o’clock, or 7 o’clock, or 8 o’clock. It’s sort of mostly posterior.
Once she starts pushing, that baby just sort of comes down and rotates at the same time. And frequently, if I’ll have like a student with me, I’ll have them watch the head. And you can really see it turn like a dial. It’s unbelievable. And within a few pushes, the head rotates and comes right out. So that’s definitely an option. It’s certainly an option for someone who’s had several babies. But even someone on their first baby, when they’re pushing, you can sort of sense, when they’re pushing, not only is the head descending, but is it also rotating? And if it is, then probably between the contraction forces and her forces of pushing, the baby’s sort of descending into the pelvis and rotating in the expected manner and there’s nothing you need to do.
Now, there is a procedure that we call manual rotation which is essentially where the obstetrician, the midwife, is sort of guiding the head to rotate from below. There’s different ways to do it. Essentially, I mean, literally, it’s like taking the head and we’re rotating it. And the key for us is to know exactly, you know, where to put our fingers and how to rotate it and how maybe to flex the head and sort of when to do it. There’s skill involved in doing it, but it’s not a particularly complicated procedure. It’s safe for the baby. It’s safe for the mother. It’s effective. And it can definitely reduce the time needed to push. And, in fact, it can lower the risk of a C-section.
And I think that this is one of the reasons that I really like to know where the spine is, the baby’s spine, so I sort of know which way I’m trying to rotate the head. And if I’m not sure where the spine is, I’ll usually check by ultrasound because that way I know whether I’m trying to rotate the head clockwise or counterclockwise. And this is a maneuver that’s pretty effective. There’s a lot of studies on this. And again, it’s safe for the baby. It’ ‘s safe for the mother. It doesn’t always work. Sometimes that head is just sort of lodged in facing sunny-side up, and that’s okay, and then she keeps pushing. And the mother can deliver the baby facing sunny-side up. But again, in that time, it usually takes a little bit longer, maybe slightly more difficult. So, I typically try to rotate the head if it’s not rotating on its own.
There is a way to rotate the head with forceps, it’s called an operative rotation where basically we put on a special kind of forceps and use that to rotate the head. That’s something that was done a lot in the past. The people who possess the skill to do that safely, there’s fewer and fewer them. So, if you have someone taking care of you who is very skilled to doing this, it is a safe thing to do, but a lot of people are not trained to do that. I trained in it a little bit, so I don’t often do it or I don’t usually do it, but it is something that is a possibility, to really put on forceps solely to rotate the head.
Now, when we put on forceps, sometimes we do rotate the head to a certain degree but rotating at 180 degrees is something that’s specifically done as its own sort of standalone procedure. And just to give an example of why this is all useful, recently, I took over care for a patient in labor. So, I sort of took over care right at the end of her labor. And the doctor who had been taking care of her beforehand had been tracking the position and told me, said, “Hey, you know, Natie, this head is OP.” Basically, directly OP that the, you know, again, what I knew what he meant was that the back of the head, it was at six o’clock, baby’s facing straight up to the sky. So when I went to examine her, and I confirmed that, in fact, the baby’s head was directly OP, at the time I examined her, she was fully dilated and ready to start pushing.
So, one of the first things I did is I went and I got an ultrasound because I hadn’t been following her on pregnancy, on labor and I just wanted to check the rest of the position. And I sort of confirmed that the baby’s spine was on the mother’s right side, which since I’m facing her would be my left side, mother’s right side. And when she started pushing, she was doing very, very well. She was pushing great, but the head wasn’t really rotating and it wasn’t descending so well. And the heart rate was dropping a little bit, which is normal with pushing, but nothing too concerning. So since it wasn’t rotating on its own, I, you know, spoke to her about it. And I was gonna attempt the manual rotation, which was very easy to do. I was able to rotate the head where the back of the head was at 6 o’clock and then I was able to rotate it clockwise to 7 o’clock, 8 o’clock, 9 o’clock, 10 o’clock, between 10 o’clock and 11 o’clock.
So now the baby’s, the back of the head was at like 10 o’clock or 11 o’clock and the front of the head was facing down. And then I had her continue pushing. And the pushing was then much more effective. The head was coming down really nicely and she probably would’ve delivered on her own within, let’s say 15, 20 minutes, but the heart rate started to drop in a more concerning fashion. And so I spoke to her and, you know, we decided to do an operative delivery and I put on forceps and the baby was born one, two, three, very, very uncomplicated, straightforward forceps delivery.
Now, had I not put on the forceps, right? She probably would’ve delivered within, you know, 10 or 15 minutes. But again, I think delivering the baby quicker was safer for the baby because of the heart rate dropping. Now, had I not been told by the OB who was taking care of her before that the baby was OP, I would maybe not have known that. Sometimes it’s difficult to know the position of the baby. So that was really helpful to me. And because I was able to rotate the head, number one, the head was able to descend low enough that I could safely put on forceps. And number two, it got into a position that made the forceps a lot easier.
And I suspect that had I not been able to rotate the head or had I not rotated the head, I didn’t try, that the head would’ve been too high and as she was pushing and the heart rate would’ve dropped, it may have ultimately led to a C-section. So this is sort of like, to me, a really good example of number one, why, you know, this is a healthy mother, healthy baby, everything’s perfectly fine, but just sort of geometrically since the baby was facing up, it was gonna be a harder time to push.
And for her, since with pushing the heart rate was dropping in a way that was getting more and more concerning, it could have been one of those cases where the OP position led to a C-section. But since, you know, the doctor clued me in on it and I was able to rotate the head sort of pretty easily and then do the forceps, everything was able to be done safely and she had a vaginal delivery and everything went well.
So I tried to give my solo review of OP. And again, just as a review, OP’s not a problem per se, right? It happens about 5% of the time. Usually, when the baby’s head starts out facing either to the side or up, it’s going to rotate during labor or when she’s pushing into facing down, which is easier. But in the cases where it doesn’t and it ends up again, some of the time she’ll just push and deliver and everything’s gonna be fine. Some of the time she’s gonna push, the head’s gonna rotate, then she’ll deliver and it’ll be fine. And if those aren’t happening, there’s sometimes an option for us to manually rotate the baby’s head so that the baby can face down.
All right, everyone. I hope that was helpful. I hope that was a good explanation of OP. I hope that hearing my voice alone for this whole podcast wasn’t too distressing for you. We’ll see you back next week with some more interesting stuff on “Healthful Woman”. Thanks a lot.
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