definition of occiput presentation

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Fetal Positions for Labor and Birth

Knowing your baby's position can you help ease pain and speed up labor

In the last weeks of pregnancy , determining your baby's position can help you manage pain and discomfort. Knowing your baby's position during early labor can help you adjust your own position during labor and possibly even speed up the process.

Right or Left Occiput Anterior

Illustration by JR Bee, Verywell 

Looking at where the baby's head is in the birth canal helps determine the fetal position.The front of a baby's head is referred to as the anterior portion and the back is the posterior portion. There are two different positions called occiput anterior (OA) positions that may occur.

The left occiput anterior (LOA) position is the most common in labor. In this position, the baby's head is slightly off-center in the pelvis with the back of the head toward the mother's left thigh.

The right occiput anterior (ROA) presentation is also common in labor. In this position, the back of the baby is slightly off-center in the pelvis with the back of the head toward the mother's right thigh.

In general, OA positions do not lead to problems or additional pain during labor or birth.  

Right or Left Occiput Transverse

Illustration by JR Bee, Verywell  

When facing out toward the mother's right thigh, the baby is said to be left occiput transverse (LOT). This position is halfway between a posterior and anterior position. If the baby was previously in a posterior position (in either direction), the LOT position indicates positive movement toward an anterior position.

When the baby is facing outward toward the mother's left thigh, the baby is said to be right occiput transverse (ROT). Like the previous presentation, ROT is halfway between a posterior and anterior position. If the baby was previously in a posterior position, ROT is a sign the baby is making a positive move toward an anterior position.

When a baby is in the left occiput transverse position (LOT) or right occiput transverse (ROT) position during labor, it may lead to more pain and a slower progression.

Tips to Reduce Discomfort

There are several labor positions a mother can try to alleviate pain and encourage the baby to continue rotating toward an anterior position, including:

• Pelvic tilts
• Standing and swaying

A doula , labor nurse, midwife , or doctor may have other suggestions for positions.

Right or Left Occiput Posterior

When facing forward, the baby is in the occiput posterior position. If the baby is facing forward and slightly to the left (looking toward the mother's right thigh) it is in the left occiput posterior (LOP) position. This presentation can lead to more back pain (sometimes referred to as " back labor ") and slow progression of labor.

In the right occiput posterior position (ROP), the baby is facing forward and slightly to the right (looking toward the mother's left thigh). This presentation may slow labor and cause more pain.

To help prevent or decrease pain during labor and encourage the baby to move into a better position for delivery, mothers can try a variety of positions, including:

• Hands and knees
• Pelvic rocking

Mothers may try other comfort measures, including:

• Bathtub or shower (water)
• Counter pressure
• Movement (swaying, dancing, sitting on a birth ball )
• Rice socks (heat packs)

How a Doctor Determines Baby's Position

Leopold's maneuvers are a series of hands-on examinations your doctor or midwife will use to help determine your baby's position. During the third trimester , the assessment will be done at most of your prenatal visits.   Knowing the baby's position before labor begins can help you prepare for labor and delivery.

Once labor begins, a nurse, doctor, or midwife will be able to get a more accurate sense of your baby's position by performing a vaginal exam. When your cervix is dilated enough, the practitioner will insert their fingers into the vagina and feel for the suture lines of the baby's skull as it moves down in the birth canal.   It's important to ensure the baby is head down and moving in the right direction.

Labor and delivery may be more complicated if the baby is not in a head-down position, such as in the case of a breech presentation.

How You Can Determine Baby's Position

While exams by health practitioners are an important part of your care, from the prenatal period through labor and delivery, often the best person to assess a baby's position in the pelvis is you. Mothers should pay close attention to how the baby moves and where different movements are felt.

A technique called belly mapping can help mothers ask questions of themselves to assess their baby's movement and get a sense of the position they are in as labor approaches.

For example, the position of your baby's legs can be determined by asking questions about the location and strength of the kicking you feel. The spots where you feel the strongest kicks are most likely where your baby's feet are.

Other landmarks you can feel for include a large, flat plane, which is most likely your baby's back. Sometimes you can feel the baby arching his or her back.

At the top or bottom of the flat plane, you may feel either a hard, round shape (most likely your baby's head) or a soft curve (most likely to be your baby's bottom).

Guittier M, Othenin-Girard V, de Gasquet B, Irion O, Boulvain M. Maternal positioning to correct occiput posterior fetal position during the first stage of labour: a randomised controlled trial .  BJOG: An International Journal of Obstetrics & Gynaecology . 2016;123(13):2199-2207. doi:10.1111/1471-0528.13855

Gizzo S, Di Gangi S, Noventa M, Bacile V, Zambon A, Nardelli G. Women’s Choice of Positions during Labour: Return to the Past or a Modern Way to Give Birth? A Cohort Study in Italy .  Biomed Res Int . 2014;2014:1-7. doi:10.1155/2014/638093

Ahmad A, Webb S, Early B, Sitch A, Khan K, MacArthur C. Association between fetal position at onset of labor and mode of delivery: a prospective cohort study .  Ultrasound in Obstetrics & Gynecology . 2014;43(2):176-182. doi:10.1002/uog.13189

Nishikawa M, Sakakibara H. Effect of nursing intervention program using abdominal palpation of Leopold’s maneuvers on maternal-fetal attachment .  Reprod Health . 2013;10(1). doi:10.1186/1742-4755-10-12

Choi S, Park Y, Lee D, Ko H, Park I, Shin J. Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes .  The Journal of Maternal-Fetal & Neonatal Medicine . 2016;29(24):3988-3992. doi:10.3109/14767058.2016.1152250

Bamberg C, Deprest J, Sindhwani N et al. Evaluating fetal head dimension changes during labor using open magnetic resonance imaging .  J Perinat Med . 2017;45(3). doi:10.1515/jpm-2016-0005

Gabbe S, Niebyl J, Simpson J et al.  Obstetrics . Philadelphia, Pa.: Elsevier; 2012.

By Robin Elise Weiss, PhD, MPH Robin Elise Weiss, PhD, MPH is a professor, author, childbirth and postpartum educator, certified doula, and lactation counselor.

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

Was this article helpful?

What to know if your baby is breech

What's a sunny-side up baby?

What happens to your baby right after birth

How your twins’ fetal positions affect labor and delivery

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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INTRODUCTION

● (See "Occiput transverse position" .)

● (See "Compound fetal presentation" .)

● (See "Face and brow presentations in labor" .)

● (See "Overview of breech presentation" and "Delivery of the singleton fetus in breech presentation" .)

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Chapter 10:  Normal Mechanisms of Labor

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Left occiput anterior: loa.

• BIRTH OF THE PLACENTA
• CLINICAL COURSE OF LABOR: LOA
• RIGHT OCCIPUT ANTERIOR: ROA
• Full Chapter
• Supplementary Content

LOA is a common longitudinal cephalic presentation ( Fig. 10-1 ). Two-thirds of occiput anterior positions are in the LOA position. The attitude is flexion, the presenting part is the posterior part of the vertex and the posterior fontanelle, and the denominator is the occiput (O).

FIGURE 10-1.

Left occiput anterior.

Diagnosis of Position: LOA

Abdominal examination.

The lie is longitudinal. The long axis of the fetus is parallel to the long axis of the mother

The head is at or in the pelvis

The back is on the left and anterior and is palpated easily except in obese women

The small parts are on the right and are not felt clearly

The breech is in the fundus of the uterus

The cephalic prominence (in this case the forehead) is on the right. When the attitude is flexion, the cephalic prominence and the back are on opposite sides. The reverse is true in attitudes of extension

Fetal Heart

The fetal heart is heard loudest in the left lower quadrant of the mother's abdomen. In attitudes of flexion, the fetal heart rate is transmitted through the baby's back. The point of maximum intensity varies with the degree of rotation. As the child's back approaches the midline of the maternal abdomen, so does the point where the fetal heart is heard most strongly. Therefore, in a left anterior position, it is heard below the umbilicus and somewhere to the left of the midline, depending on the exact situation of the back.

Vaginal Examination

The station of the head is noted—whether it is above, at, or below the ischial spines

If the cervix is dilated, the suture lines and the fontanelles of the baby's head can be felt. In the LOA position, the sagittal suture is in the right oblique diameter of the pelvis

The small posterior fontanelle is anterior and to the mother's left

The bregma is posterior and to the right

Since the head is probably flexed, the occiput is a littler lower than the brow

Normal Mechanism of Labor: LOA

The mechanism of labor as we know it today was described first by William Smellie during the 18th century. It is the way the baby adapts itself to and passes through the maternal pelvis. There are six movements, with considerable overlapping:

Internal rotation

Restitution

External rotation

The following description is for left anterior positions of the occiput.

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Medical Information

Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

• Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
• Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
• Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

• Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
• Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
• Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
• Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

• Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
• Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
• Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
• Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

• Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
• Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

Hashtags: #Delivery #FacePresentation #BrowPresentation #Childbirth #ObstetricDelivery

On the Article

Krish Tangella MD, MBA

Alexander Enabnit

Alexandra Warren

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Abnormal Fetal lie, Malpresentation and Malposition

Original Author(s): Anna Mcclune Last updated: 1st December 2018 Revisions: 12

• 1 Definitions
• 2 Risk Factors
• 3.2 Presentation
• 3.3 Position
• 4 Investigations
• 5.1 Abnormal Fetal Lie
• 5.2 Malpresentation
• 5.3 Malposition

The lie, presentation and position of a fetus are important during labour and delivery.

In this article, we will look at the risk factors, examination and management of abnormal fetal lie, malpresentation and malposition.

Definitions

• Longitudinal, transverse or oblique
• Cephalic vertex presentation is the most common and is considered the safest
• Other presentations include breech, shoulder, face and brow
• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) – this is ideal for birth
• Other positions include occipito-posterior and occipito-transverse.

Note: Breech presentation is the most common malpresentation, and is covered in detail here .

Fig 1 – The two most common fetal presentations: cephalic and breech.

Risk Factors

The risk factors for abnormal fetal lie, malpresentation and malposition include:

• Multiple pregnancy
• Uterine abnormalities (e.g fibroids, partial septate uterus)
• Fetal abnormalities
• Placenta praevia
• Primiparity

Identifying Fetal Lie, Presentation and Position

The fetal lie and presentation can usually be identified via abdominal examination. The fetal position is ascertained by vaginal examination.

For more information on the obstetric examination, see here .

• Face the patient’s head
• Place your hands on either side of the uterus and gently apply pressure; one side will feel fuller and firmer – this is the back, and fetal limbs may feel ‘knobbly’ on the opposite side

Presentation

• Palpate the lower uterus (above the symphysis pubis) with the fingers of both hands; the head feels hard and round (cephalic) and the bottom feels soft and triangular (breech)
• You may be able to gently push the fetal head from side to side

The fetal lie and presentation may not be possible to identify if the mother has a high BMI, if she has not emptied her bladder, if the fetus is small or if there is polyhydramnios .

During labour, vaginal examination is used to assess the position of the fetal head (in a cephalic vertex presentation). The landmarks of the fetal head, including the anterior and posterior fontanelles, indicate the position.

Fig 2 – Assessing fetal lie and presentation.

Investigations

Any suspected abnormal fetal lie or malpresentation should be confirmed by an ultrasound scan . This could also demonstrate predisposing uterine or fetal abnormalities.

Abnormal Fetal Lie

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted – ideally between 36 and 38 weeks gestation.

ECV is the manipulation of the fetus to a cephalic presentation through the maternal abdomen.

It has an approximate success rate of 50% in primiparous women and 60% in multiparous women. Only 8% of breech presentations will spontaneously revert to cephalic in primiparous women over 36 weeks gestation.

Complications of ECV are rare but include fetal distress , premature rupture of membranes, antepartum haemorrhage (APH) and placental abruption. The risk of an emergency caesarean section (C-section) within 24 hours is around 1 in 200.

ECV is contraindicated in women with a recent APH, ruptured membranes, uterine abnormalities or a previous C-section .

Fig 3 – External cephalic version.

Malpresentation

The management of malpresentation is dependent on the presentation.

• Breech – attempt ECV before labour, vaginal breech delivery or C-section
• Brow – a C-section is necessary
• If the chin is anterior (mento-anterior) a normal labour is possible; however, it is likely to be prolonged and there is an increased risk of a C-section being required
• If the chin is posterior (mento-posterior) then a C-section is necessary
• Shoulder – a C-section is necessary

Malposition

90% of malpositions spontaneously rotate to occipito-anterior as labour progresses. If the fetal head does not rotate, rotation and operative vaginal delivery can be attempted. Alternatively a C-section can be performed.

• Usually the fetal head engages in the occipito-anterior position (the fetal occiput facing anteriorly) - this is ideal for birth

If the fetal lie is abnormal, an external cephalic version (ECV) can be attempted - ideally between 36 and 38 weeks gestation.

• Breech - attempt ECV before labour, vaginal breech delivery or C-section

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Why would posterior position matter in labor?  The head is angled so that it measures larger. The top of the head molds less than the crown.

Baby’s spine is extended, not curled, so the crown of the head is not leading the way. Baby can’t help as much during the birth process to the same degree as the curled up baby.

Some posteriors are easy, while others are long and painful, and there are several ways to tell how your labor will be beforehand. After this, you may want to visit What to do when….in Labor .

Belly Mapping ® Method tips:  The Right side of the abdomen is almost always firmer, but the direct OP baby may not favor one side or the other. Baby’s limbs are felt in front, on both sides of the center line. A knee may slide past under the navel. 

The OP position (occiput posterior fetal position) is when the back of the baby’s head is against the mother’s back. Here are drawings of an anterior and posterior presentation.

• When is Breech an Issue?
• Belly Mapping® Breech
• Flip a Breech
• When Baby Flips Head Down
• Breech & Bicornuate Uterus
• Breech for Providers
• What if My Breech Baby Doesn't Turn?
• Belly Mapping ®️ Method
• After Baby Turns
• Head Down is Not Enough
• Sideways/Transverse
• Asynclitism
• Oblique Lie
• Left Occiput Transverse
• Right Occiput Anterior
• Right Occiput Posterior
• Right Occiput Transverse
• Face Presentation
• Left Occiput Anterior
• OP Truths & Myths
• Anterior Placenta
• Body Balancing

Look at the above drawing. The posterior baby’s back is often extended straight or arched along the mother’s spine. Having the baby’s back extended often pushes the baby’s chin up.

Attention: Having the chin up is what makes the posterior baby’s head seem larger than the same baby when it’s in the anterior position.

Because the top of the head enters (or tries to enter) the pelvis first, baby seems much bigger by the mother’s measurements. A posterior head circumference measures larger than the anterior head circumference.

A large baby is not the same issue, however. The challenge with a posterior labor is that the top of the head, not the crown of the head leads the way.

A baby with their spine straight has less ability to wiggle and so the person giving birth has to do the work of two. This can be long and challenging or fast and furious. Also, there are a few posterior labors that are not perceived different than a labor with a baby curled on the left.

Why? Anatomy makes the difference. Learn to work with birth anatomy to reduce the challenge of posterior labor by preparing with our Three Balances SM and more.

What to do?

• Three Balances SM
• Dip the Hip
• Psoas Release
• Almost everything on this website except Breech Tilt

In Labor, do the above and add,

• Abdominal Lift and Tuck
• Other positions to Open the Brim
• Open the Outlet during pushing

There are four posterior positions

The direct OP is the classic posterior position with the baby facing straight forward.   Right Occiput Transverse   (ROT) is a common starting position in which the baby has a bit more likelihood of rotating to the posterior during labor than to the anterior.   Right Occiput Posterior   usually involves a straight back with a lifted chin (in the first-time mother). Left Occiput Posterior places the baby’s back opposite the maternal liver and may let the baby flex (curl) his or her back and therefore tuck the chin for a better birth. These are generalities, of course. See a bit more about posterior positions in   Belly Mapping ® on this website. Want to map your baby’s position? Learn how with the   Belly Mapping ® Workbook .

Pregnancy may or may not show symptoms.   Just because a woman’s back doesn’t hurt in pregnancy doesn’t mean the baby is not posterior. Just because a woman is quite comfortable in pregnancy doesn’t mean the baby is not posterior. A woman can’t always feel the baby’s limbs moving in front to tell if the baby is facing the front.

The four posterior fetal positions

Four starting positions often lead to (or remain as) direct   OP   in active labor.   Right Occiput Transverse   (ROT),   Right Occiput Posterior   (ROP), and Left Occiput Posterior (LOP) join direct OP in adding labor time. The LOP baby has less distance to travel to get into an LOT position.

As labor begins, the high-riding, unengaged Right Occiput Transverse baby slowly rotates to   ROA , working past the sacral promontory at the base of the spine before swinging around to LOT to engage in the pelvis. Most babies go on to OA at the pelvic floor or further down on the perineal floor.

If a baby engages as a ROT, they may go to OP or ROA by the time they descend to the midpelvis. The OP baby may stay OP. For some, once the head is lower than the bones and the head is visible at the perineum, the baby rotates and helpers may see the baby’s head turn then! These babies finish in the ROA or OA positions.

Feeling both hands in front, in two separate but low places on the abdomen, indicates a posterior fetal position. This baby is Left Occiput Posterior.

Studies estimate 15-30% of babies are OP in labor. Jean Sutton in   Optimal Fetal Positioning   states that 50% of babies trend toward posterior in early labor upon admission to the hospital. Strong latent labor swings about a third of these to LOT before dilation begins (in “pre-labor” or “false labor”).

Recent research shows about 50% of babies are in a posterior position when active labor begins, but of these, 3/4 of them rotate to anterior (or facing a hip in an occiput transverse, head down position.

Jean Sutton’s observations, reported in her 1996 book, indicates that some babies starting in a posterior position will rotate before arriving to the hospital. Ellice Lieberman observed most posteriors will rotate out of posterior into either anterior or to facing a hip throughout labor. Only 5-8% of all babies emerge directly OP (13% with an epidural in Lieberman’s study). At least 12% of all   cesareans   are for OP babies that are stuck due to the larger diameter of the OP head in comparison to the OA head. It’s more common for ROT, ROP, and OP babies to rotate during labor and to emerge facing back (OA). Some babies become stuck halfway through a long-arc rotation and some will need a cesarean anyway.

The three anterior starting positions for labor

Why not ROA? ROA babies may have their chins up and this deflexed position may lengthen the course of labor. Less than 4% of starting positions are ROA, according to a Birmingham study. This might not be ideal for first babies, but is not a posterior position either.  

The spectrum of ease across posterior labors

Purchase Parent Class

Baby’s posterior position may matter in labor

With a posterior presentation, labor may or may not be significantly affected. There is a spectrum of possibilities with a posterior baby. Some women will not know they had a posterior baby because no one mentions it. Either the providers didn’t know, or didn’t notice. If labor moved along, they may not have looked at fetal position clues since there was no reason to figure out why labor wasn’t progressing. If a woman didn’t have back labor (more pain in her back than in her abdomen), the provider may not have been “clued into” baby’s position.

Some posterior babies are born in less than 8 hours and position did not slow down labor. Some posterior babies are born in less than 24 hours and position did not slow down labor enough to be out of the norm. Some posterior babies are born in less than 36-48 hours without the need for interventions.

Some posterior labors are manageable when women are mobile, supported, and eat and drink freely, as needed. Some posterior labor needs extra support that a well-trained and experienced doula may provide, but that typically a mate or loved one would not have the skills or stamina to keep up with. Some posterior labors progress only with the help of a highly-trained pregnancy bodyworker or deep spiritual, or otherwise a non-conventional model of care. Or, they seem only able to finish with medical intervention.

Some posterior labors are served by an epidural, meaning the pelvic floor relaxes enough for the baby to rotate and come out. Some epidurals, on the other hand, make it so that a woman can not finish the birth vaginally.

NOTE:   Parents should know — some birth researchers, like Pediatrician John Kennell, are seriously asking whether a mother’s epidural turns off her body’s release of pain-relieving hormones which a baby relies on during childbirth. Some babies can’t turn and can’t be born vaginally and must be born by   cesarean. This is a spectrum of possibilities. I’ve seen every one of the above possibilities several times and can add the wonderful experience of seeing a woman laughing pleasurably and squatting while her posterior baby slid out on to her bedroom floor.

Possible posterior effects, some women will have one or two and some will have many of these:

The forehead that overlaps the pubic bone after labor starts must turn and drop into the pelvis to allow the birth to happen naturally. A cesarean finish of the labor is possible. Look at Abdominal Lift and Tuck in Techniques to guide you to solutions for easier engagement and progress.

• Longer pregnancy (some research shows this and some doesn’t)
• The amniotic sac breaking (water breaks, membranes open, rupture of membranes) before labor (1 in 5 OP labors)
• Not starting in time before induction   is scheduled
• Labor is longer and stronger and less rhythmic than expected
• Start and stop   labor pattern
• The baby may not engage, even during the pushing stage
• Longer early labor
• Longer active labor
• Back labor (in some cases)
• Pitocin may be used when labor stalls (but a snoring good rest followed by oatmeal may restore a contraction pattern, too)
• Longer pushing stage
• Maybe a woman has all three phases of labor lengthened by the OP labor or one or two of the three phases listed
• Sometimes the baby’s head gets stuck turned halfway to anterior – in the transverse diameter. This may be called a transverse arrest (not a   transverse lie ).
• More likely to tear
• More likely to need a vacuum (ventouse) or forceps
• More likely to need a   cesarean

These effects are in comparison to a baby in the   left occiput anterior   or   left occiput transverse   fetal position at the start of labor.

Who might have a hard time with a posterior baby?

This family just had a fast posterior birth of their second child! Ease in labor includes other factors beyond baby position.

• A first-time mom
• A first-time mom whose   baby hasn’t dropped into the pelvis by 38 weeks gestation   (two weeks before the due date)
• A woman with an   android pelvis   (“runs like a boy,” often long and lanky, low pubis with narrow pubic arch and/or sitz bones close together, closer than or equal to the width of a fist)
• A woman whose baby, in the third trimester, doesn’t seem to change position at all, over the weeks. He or she kicks in the womb and stretches, but whose trunk is stationary for weeks. This mother’s broad ligament may be so tight that she may be uncomfortable when baby moves.
• A woman who has an epidural early in labor (data supports this), before the baby has a chance to rotate and come down.
• A woman who labors lying in bed
• Low-thyroid, low-energy woman who has gone overdue (this is my observation)
• A woman who lacks support by a calm and assured woman who is calming and reassuring to the birthing mother (a doula)
• A woman put on the clock
• A woman who refuses all help when the labor exceeds her ability to physically sustain her self (spilling ketones, dehydration, unable to eat or rest in a labor over X amount of hours which might be 24 for some or 48 for others)
• A woman whose birth team can’t match an appropriate technique to the needs of the baby for flexion, rotation, and/or descent from the level of the pelvis where the baby is currently at when stuck

Who is likely to have an easy time with a posterior baby?

• A second-time mom who’s given birth readily before (and pushing went well)
• A posterior baby with a tucked chin on his or her mama’s left side with   a round pelvic brim
• An average-sized or smaller baby
• Someone whose posterior baby changes from right to left after doing inversions and other   balancing work , though the baby is still posterior
• A woman with a baby in the Left Occiput Posterior, especially if the baby’s chin is tucked or flexed
• A woman who gets bodywork, myofascial release, etc.
• A woman whose posterior baby engages, and does not have an   android (triangular) pelvis or a small outlet
• And of all of these, what is necessary is a pelvis big enough to accommodate the baby’s extra head size
• A woman who uses active birthing techniques — vertical positions, moves spontaneously and instinctively or with specific techniques from Spinning Babies ® , and other good advice
• A woman in a balanced nervous state, not so alert and “pumped up,” on guard, etc.

Any woman may also have an easier time than public opinion might indicate, too, just because she isn’t on this list. Equally, just because she is on the “hard” list doesn’t mean she will have a hard time for sure. These are general observations. They are neither condemnations nor promises. Overall, some posterior babies will need help getting born, while some posterior babies are born easily (easy being a relative term).

Let’s not be ideological about posterior labors.

While most posterior babies do eventually rotate, that can still mean there is quite a long wait – and a lot of physical labor during that wait. Sometimes it means the doula, midwife, nurse, or doctor is asking the mother to do a variety of position changes, techniques, and even medical interventions to help finish the labor. Patience works for many, but for some a   cesarean   is really the only way to be born. Read   What To Do When…in Labor .

What causes a baby to be posterior?

There is a rising incidence of posterior babies at the time of birth. We know now that epidural anesthesia increases the rate of posterior position at the time of birth from about 4% (for women who don’t choose an epidural in a university birth setting) up to about 13% (Lieberman, 2005). Low thyroid function is associated with fetal malposition such as posterior or breech. (See   Research & References .)

Most babies who are posterior early in labor will rotate to anterior once labor gets going. Some babies rotate late in labor, even just before emerging. Studies such as Lieberman’s show that at any given phase of labor, another 20% of posterior babies will rotate so that only a small number are still posterior as the head emerges.

My observations are that the majority of babies are posterior before labor. The high numbers of posterior babies at the end of pregnancy and in the early phase of labor is a change from what was seen in studies over ten years old. Perhaps this is from our cultural habits of sitting at desks, sitting in bucket seats (cars), and leaning back on the couch (slouching). Soft tissues such as the psoas muscle pair or the broad ligament also seem to be tight more often from these postures, from athletics (quick stops, jolts, and falls), from accidents, and from emotional or sexual assault.

Being a nurse or bodyworker who turns to care for people in a bed or on a table will also twist the lower uterine segment (along with some of the previously mentioned causes). This makes the baby have to compensate in a womb that is no longer symmetrical. Less often, the growing baby settles face-forward over a smaller pelvis, or a triangular-shaped pelvis (android). At the end of pregnancy, the baby’s forehead has settled onto a narrower than usual pubic bone, and if tight round ligaments hold the forehead there, the baby may have a tough time rotating. These are the moms and babies that I’m most concerned with in my work at Spinning Babies®. A baby that was   breech   beyond week 30 – 34 of pregnancy will flip head down in the posterior position. A woman with a history of breech or posterior babies is more likely to have a breech or posterior baby in the next pregnancy. However, she may not have an as long labor.

The best way to tell if your baby is OP or not, usually, is if you feel little wiggles in the abdomen right above your pubic bone. These are the fingers. They’d feel like little fingers wiggling, not like a big thunk or grinding from the head, though you might feel that, too. The little fingers will be playing by the mouth. This is the easiest indication of OP. The wiggles will be centered in the middle of your lower abdomen, close to the pubic bone. If you feel wiggles far to the right, near your hip, and kicks above on the right, but not near the center and none on the left, then those signal an   OA   or   LOT   baby (who will rotate to the OA easily in an active birth). After this, you might go to   What to do when…in Labor.

Check out our current references in the   Research & References   section.

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Understanding Right Occiput Anterior – ROA fetal position + FAQs

Medically Reviewed by: Dr. Veena Shinde (M.D, D.G.O,  PG – Assisted Reproductive Technology (ART) from Warick, UK) Mumbai, India

• >> Post Created: January 30, 2022
• >> Last Updated: April 24, 2024

Table of Contents - Right Occiput Anterior Position

Medical terms for a baby’s position when entering the mother’s pelvic region just before labor can be daunting. However, it isn’t as intimidating as it may seem; some basic knowledge on the subject can help you in understanding your pregnancy and labor better.

When we talk about baby positions, anterior and posterior are the basic. In both these positions, the baby’s head could be down, towards the cervix or feet could be down (breech baby).

In medical terms, the back of a baby’s head is called the ‘ occiput .’ In this article we have tried to put forth all you need to know about Right Occiput Anterior position (ROA position), risks associated and some of the most common FAQs mothers  who have been told that they have and ROA position in labor have.

What is Right Occiput Anterior position?

Going by the explanation given above, in the ROA fetal position, the baby enters the mother’s pelvic region from the right (R), in the anterior (A) position (facing the mother’s spine).

It might be easier to understand the exact ROA fetal position using the picture of a woman’s pelvic area.

What is Right Occiput Anterior Presentation?

‘Presentation’ in terms of pregnancy is used to describe the baby’s first body part that enters the mother’s pelvic region just before labor.

So there is a difference between ‘presentation’ and ‘position’; presentation primarily gives an understanding if the baby is head-down or breech, while position is in connection with the mother’s body (left, right, anterior, posterior).

Now in Right occiput anterior/ ROA position , presentation will be the top of the baby’s head (also called vertex) , with the baby’s occiput or back towards the mother’s belly.

Movements and kicks in Right Occiput Anterior position (ROA fetal Position)

In Right Occiput Anterior , as the baby’s back and shoulders are on the mother’s right side, the limbs are obviously on the left side, and therefore, any movements are felt by the mother on the left side of the belly.

Baby’s kicks would obviously be felt on the upper left side of the belly in the ROA position.

What are the variables with ROA fetal position that affect labor?

There are certain factors that can affect labor in the ROA fetal position.

• Baby’s chin being towards or away from its chest
• First-time childbirth
• Balance and tone of the soft tissues involved in childbirth (uterus, ligaments, fascia)
• Pelvic shape and size
• Pelvic alignment
• Placenta position

If in ROA position, for any reason, if the head is not getting positioned right, like instead having chin first, then you need to first understand that by easy methods you can slowly try and move your baby in proper head down position through:

• Regular walks – here natural laws of gravity along with movements help in naturally positioning your baby in the right position – head first just before birth
• You could take help of a pregnancy belt as well – in confidence with your doctor or midwife
• A few jiggly movements of hips, buttocks and thighs also helps in loosening the muscles giving space for your baby to move and change the position.

Left Occiput Anterior (LOA position) Vs. Right occiput anterior (ROA position)

The baby’s position while entering the mother’s pelvic region decides how the labor and delivery of the baby will happen.

An Occiput anterior position ( Left occiput Anterior/ LOA position or ROA position), wherein the baby’s face is towards the mother’s spine and back is toward the mother’s belly is the ideal position for birth.

On the other hand, posterior position ( LOP position or ROP position), where the baby’s back is with the mother’s back, could cause a comparatively more painful labor and  likelihood of a C-section for the baby’s birth goes up.

Continue reading below ↓

Read this next

Vertex Presentation: How does it affect your labor & delivery?

Everything you need to know about Placenta Position & Placenta Health – with FAQs

The Ultimate List of Baby Must Haves

Is right occiput anterior fetal position normal.

The Right Occiput Anterior (ROA) position is one of the common baby positions before labor.

Yes, it is one of the normal positions from the various other baby positions, like various breech positions, oblique positions and so on.

Is ROA position bad as compared to the LOA position?

No, ROA is as good as LOA position for the baby before labor.

It is believed that LOA position is better because in most women the left side of the pelvis is slightly larger, giving more space to the baby to grow. However, ROA is also normal and a good baby position.

How to know if the baby is in the anterior position?

If your baby is in the anterior (A) position, it means its back is toward your belly, giving it a characteristic round shape seen in pregnancies.

On the other hand, if the baby is in the posterior (P) position, with its back toward the mother’s back and limbs toward the belly, it will give the belly a bumpier look and a hollow space might be visible around the navel.

How to ensure the baby in the right position during birth?

Having the baby in the best possible position before labor begins or even during labor will not only affect the baby’s delivery, but also ease the labor and birth experience for the mother. With the baby being in the best possible position, it can sometimes cut down the chances of a C-section and make the whole process comparatively less painful.

Your doctor will guide you through the process to get your baby in the best possible position for birth.

Medical professionals say how they have witnessed that when the baby is in the optimal position, both the mother’s and baby’s bodies work together towards delivery in the best way.

Key takeaway

The most important takeaway from this article is that the Right Occiput Anterior / ROA baby position is normal, safe, and one of the optimal baby positions before labor.

Of course, as always, we recommend you to talk to your doctor in case of any doubts or concerns. They will also guide you on how to get your baby to the best possible position for labor and delivery.

Happy Pregnancy!

Khushboo Kirale

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Persistent Occiput Posterior position - OUTcomes following manual rotation (POP-OUT): study protocol for a randomised controlled trial

Hala phipps.

RPA Women & Babies, Royal Prince Alfred Hospital, Sydney, NSW Australia

Discipline of Obstetrics, Gynaecology and Neonatology, University of Sydney, Sydney, NSW Australia

Jon A Hyett

Sabrina kuah.

Women’s and Children’s Hospital, Adelaide, SA Australia

John Pardey

Nepean Hospital, Penrith, NSW Australia

Joanne Ludlow

Andrew bisits.

Royal Hospital for Women, Sydney, NSW Australia

Felicity Park

The John Hunter Hospital, Newcastle, NSW Australia

David Kowalski

Canterbury Hospital, Sydney, NSW Australia

Bradley de Vries

Occiput posterior position is the most common malpresentation in labour, contributes to about 18% of emergency caesarean sections and is associated with a high risk of assisted delivery. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and to the neonate, respectively.

There is level 2 evidence that prophylactic manual rotation reduces the caesarean section rate and assisted vaginal delivery. But there has been no adequately powered randomised controlled trial. This is a protocol for a double-blinded, multicentre, randomised controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.

Methods/Design

Eligible participants will be (greater than or equal to) 37 weeks’ with a singleton pregnancy and a cephalic presentation in the occiput posterior position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 68%, then for a reduction to 50%, an alpha value of 0.05 and a beta value of 0.2, 254 participants will need to be enrolled.

This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, and protocol number X110410.

Participants with written consent will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery (defined as vacuum, forceps and/or caesarean section deliveries). Secondary outcomes will be caesarean section, significant maternal mortality/morbidity and significant perinatal mortality/morbidity.

Analysis will be by intention-to-treat. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders.

The results of the trial will be presented at one or more medical conferences. The trial will be submitted to peer review journals for consideration for publication. There will be potential to incorporate the results into professional guidelines for obstetricians and midwives.

Trial registration

The Australian New Zealand Clinical Trials Registry ACTRN12612001312831 . Trial registered 12 December 2012.

Persistent occiput posterior (OP) position is associated with 18% of intrapartum caesarean sections and a high risk of assisted vaginal delivery [ 1 - 3 ]. Caesarean section is now a major contributing factor to maternal mortality and morbidity following childbirth in developed countries [ 4 , 5 ]. Obstetric intervention by forceps and ventouse delivery is associated with complications to the maternal genital tract and neonate, respectively [ 6 - 8 ].

Manual rotation from the OP to the occiput anterior (OA) position is a safe, relatively simple and easy to perform procedure that could reduce the operative delivery rate (defined as vacuum delivery, forceps delivery and/or caesarean section) and therefore increase the chances of a normal vaginal birth [ 9 ]. It is performed by only a minority of obstetricians and midwives in Australia and New Zealand, yet is considered to be acceptable by the vast majority [ 10 , 11 ]. However, obstetricians and midwives would perform a manual rotation if there was evidence that it reduced the risk of operative delivery to 50% or less [ 10 , 11 ] suggesting that demonstration of efficacy will translate into clinical practice.

Preliminary studies of efficacy are promising, but there has been no adequately powered randomized controlled trial (RCT) [ 12 , 13 ]. It has been recommended that RCTs be conducted to explore the efficacy of manual rotation in the management of OP labours [ 14 ].

Epidemiology

The prevalence of the OP position is 15 to 32% at the onset of labour [ 15 - 18 ], 10 to 20% early in the second stage of labour and 5 to 8% at delivery [ 2 , 17 , 19 , 20 ]. The operative delivery rate varies from 54% to 82% when the OP position is present at delivery, compared with 6% to 22% when the fetus is in the more common OA position [ 3 , 16 , 19 , 20 ]. When the OP position is present at the beginning of the second stage of labour, the operative delivery rate was about 70% in two higher risk cohorts [ 2 , 3 ].

Thus, of all women who plan to have a normal vaginal birth, 10 to 20% will have a fetus in the OP position early in the second stage of labour. These women will be eligible to have a manual rotation to modify their background risk of up to 70% of obstetric intervention with forceps, vacuum or caesarean section.

Complications of the occiput posterior position

The OP position is associated with more frequent induction and augmentation of labour and prolonged first and second stage of [ 3 , 17 , 18 , 21 ], chorioamnionitis, post-partum haemorrhage, third and fourth degree perineal tears, wound infection and endometritis [ 22 , 23 ]. Associated adverse neonatal outcomes include birth trauma, low 5-minute Apgar score, and admission to the neonatal intensive care unit [ 24 ].

The intervention in current practice

Manual rotation is a well-accepted component of obstetric practice, particularly in the context of rotating the fetus to the OA position immediately prior to the application of non-rotational forceps such as Neville-Barnes [ 25 ]. However, it is also used commonly in a prophylactic setting (without assisted delivery) to reduce the complications associated with OP delivery [ 12 , 13 ]. In a survey of obstetricians in Australia and New Zealand, 70% believed it was acceptable in a prophylactic setting; but only 38% had performed a manual rotation in the last year, and most of these had only performed one or two [ 10 ]. Both obstetricians and midwives reported they would perform a manual rotation if there was evidence that it would reduce the chances of operative delivery from 68% to 50% or less [ 10 , 11 ]. Thus demonstration of efficacy would provide substantial scope for the intervention to be introduced into widespread practice.

The efficacy of the intervention

Preliminary cohort studies report that manual rotation is associated with a reduction in caesarean section and adverse maternal outcomes:

• In a retrospective cohort study, Schaffer et al. (2006) (n = 731) reported that the caesarean section rate was lower in women who had a successful manual rotation compared to when the fetus was unable to be rotated (2% versus 34%) [ 26 ]. However, there was no control group of women for whom a manual rotation was not performed and it is not possible to know if this was due to the procedure itself or to underlying confounders such as a smaller fetus.
• In a prospective cohort study with historical controls (n = 61), the local labour ward policy was changed from not performing prophylactic manual rotation to routinely performing the procedure for OP position about ‘half way’ into the second stage of labour [ 12 ]. The operative delivery rate for fetuses in the OP position fell from 73% prior to the change in policy to 23% after the policy was implemented, but this study design is subject to a significant risk of bias.
• Schaffer et al . (2011) re-reported their 2006 data with a control group identified retrospectively from a database and found a 9% risk of caesarean section when manual rotation was performed compared with a 41% risk when it was not [ 13 ]. However, the authors had information on the fetal position at the time of birth but not earlier in the second stage of labour when the procedure was performed. Thus OP fetuses that were destined to rotate naturally to the OA position would have been included in the intervention group, but not the control group, which would result in an overestimation of the caesarean section rate in the control group and of the efficacy of manual rotation.

Thus preliminary studies suggest that manual rotation reduces the risk of operative delivery but are susceptible to significant bias. An RCT would best provide unbiased answers regarding the effects of manual rotation of the fetal occiput on maternal and perinatal outcomes.

The safety of the intervention

Manual rotation has long been considered to be safe [ 9 ]. One retrospective cohort study reported lower rates of complications when it was performed for OP position compared to when it was not (Table  1 ) [ 13 ]:

Complications of manual rotation versus expectant management (Shaffer 2011) [ 13 ]

Thus, third and fourth degree tears, chorioamnionitis, post-partum haemorrhage, endometritis and 5-minute Apgars less than 7 all improved when prophylactic manual rotation was performed. but cervical laceration was increased.

In the POP-OUT trial manual rotation will be performed at full dilatation, which theoretically will minimize the risk of cervical laceration.

There is also a single case report of an umbilical cord prolapse associated with a manual rotation [ 27 ]. In this report, an emergency caesarean section was performed and the baby was born alive and presumably well. Other risk factors such as amniotomy, application of a fetal scalp electrode and external cephalic version were more frequently associated with umbilical cord prolapse [ 27 ].

The timing of the intervention

Manual rotation from the OP position may be performed at full cervical dilatation or late in the first stage of labour. In a French case control study (n = 147) in a labour ward where prophylactic manual rotation was performed routinely, two risk factors for inability to rotate the fetus were identified: [ 1 ] attempted rotation before full dilatation and [ 2 ] failure to progress in labour [ 28 ]. Thus. we consider that it would be reasonable to attempt prophylactic manual rotation after full dilatation is achieved, but relatively early in the second stage of labour, before the fetal head becomes impacted in the maternal pelvis.

Rationale for operative delivery as the primary outcome

Operative delivery was selected as the primary outcome for the POP-OUT Trial because it is clearly associated with important short- and long-term outcomes for the woman and her baby [ 6 - 8 , 29 - 32 ]. Other important obstetric parameters will be measured, but reported as secondary outcomes. Reducing the rate of operative delivery for OP position is perceived to be very important by obstetricians and midwives [ 10 , 11 ]. In high income countries, emergency caesarean section is associated with significant maternal morbidity and a fivefold increase in maternal mortality [ 33 ].

Explanation for choice of comparator

A sham procedure was chosen as a comparator to minimize the risk of performance bias. There would be substantial scope for management to differ according to treatment allocation if it was known. For example, a women could be encouraged to push more strongly if her midwife was aware that a manual rotation had been performed.

The aim of the study is to determine the efficacy of elective manual rotation in the management of OP position in the second stage of labour.

Among women who are at least 37 weeks gestation and whose baby is in the OP position early in the second stage of labour, manual rotation compared with a ‘sham’ rotation will result in a reduction in operative delivery.

Primary objectives

The primary objectives are to determine the differences between intervention and control groups in the operative delivery rate (defined as vacuum, forceps and/or caesarean section deliveries).

Secondary objectives

The secondary objectives are to determine the differences between intervention and control groups in caesarean section, in the combined measure of serious maternal morbidity and mortality within six weeks of birth, and in the combined measure of serious perinatal/neonatal morbidity and mortality within six weeks of birth.

Trial design

The POP-OUT trial is designed as a superiority, double-blinded, multicentre, randomised controlled clinical trial with two parallel groups and a primary endpoint of operative delivery. Randomization will be performed as block randomization with a 1:1 allocation.

Study settings

Hospitals in Australia that have 2,000 or more deliveries per year include the following:

• Canterbury Hospital, NSW
• The John Hunter Hospital, NSW
• The Nepean Hospital, NSW
• The Royal Hospital for women, Randwick, NSW
• The Royal Prince Alfred Hospital, NSW
• The Women and Children’s Hospital, SA

We do not intend to recruit in any other centres. A list of participating centres may be found at www.popout.me/participating-hospitals .

Eligibility criteria

Inclusion criteria.

Inclusion criteria include the following:

• age ≥ 18 years
• singleton pregnancy
• ≥37 weeks of gestation
• planned vaginal birth
• cephalic presentation
• full cervical dilatation
• occiput posterior position confirmed by ultrasound where the occiput is <45° from the midline

Exclusion criteria

Most exclusion criteria were selected on the basis of predisposition to requiring an operative delivery and are as follow:

• clinical suspicion of cephalopelvic disproportion
• previous caesarean section
• brow or face presentation
• ‘Pathologic’ CTG according to RCOG classification plus either baseline >160 beats per minute or reduced variability
• fetal scalp pH <7.25 or lactate >4
• known or suspected chorioamnionitis
• intrapartum haemorrhage >50 mL
• temperature ≥38.0°C in labour
• pre-existing maternal diabetes
• suspected fetal bleeding disorder (theoretical risks associated with procedures involving manipulation of fetal position)
• known major anatomical fetal abnormality (could influence safety or efficacy of manual rotation).

Eligibility criteria for study centres

Ability to provide a 24-hour on-call service with experienced operators to perform the intervention.

Individuals who will perform the intervention

Only obstetricians or midwives who are experienced in performing a manual rotation and have performed at least 20 procedures will participate in the study. All operators will complete a questionnaire outlining their technique and experience.

Intervention: manual rotation

Intervention description.

Manual rotation is performed at full dilatation if the fetal position is OP. The technique employed will be at the discretion of the operator performing the procedure.

With the membranes ruptured, a vaginal examination is performed and the woman is asked to bear down. Constant pressure is exerted with the index finger against the lambdoid suture to rotate fetal head. This may take 2 to 3 contractions and the position is commonly held for two contractions while the woman bears down to reduce the risk of reverting back to the OP position.

Alternatively, the examiner places two fingers behind the fetal ear or the entire hand behind the occiput and applies constant flexion and rotation to the fetal head.

For purposes of the POP-OUT Trial, the procedure will be described as a ‘manual rotation (digital)’ if only the fingers are used and as a ‘manual rotation (whole hand)’ if the whole hand is used.

Comparator: sham procedure

Comparator description.

Women randomized to the ‘sham rotation’ will have the same apparent vaginal examination as the intervention but no rotational force will be applied. The woman is asked to bear down. The accoucheur places fingers in the vagina over 5 contractions as if s/he were performing a manual rotation.

The intervention will begin once full dilatation has been diagnosed and the woman has the first urge to push or after one hour, whichever occurs first.

Criteria for discontinuing or modifying the intervention

The intervention or sham will be discontinued if there is a clinical necessity or at the request of the participant. This could occur if there is evidence of fetal compromise necessitating emergent delivery or if the participant is in significant discomfort.

Each operator will complete a data collection form at the time of the procedure or sham, which will describe in detail what was done. Adherence with treatment allocation will be monitored by comparing these datasheets with the computer randomisation records.

All interventions and usual care provided by doctors and midwives looking after the participant will be allowed. However, if the doctor is intending to perform an operative delivery or a manual rotation, the woman will not be randomised. Data will be collected about use and timing of any manual rotations performed by the participant’s carers.

Primary outcome

The primary outcome will be operative delivery (vacuum, forceps and/or caesarean section).

Secondary outcomes

Secondary outcomes will include the following:

• Caesarean section (reported as proportion of participants who had a caesarean section) and
• Serious maternal morbidity or mortality (combined outcome), which includes the following: post-partum haemorrhage requiring blood transfusion, third or fourth degree perineal trauma; dilatation and curettage for bleeding or retained placental tissue; cervical laceration; vertical uterine incision; vulvar or perineal haematoma; pneumonia; venous thromboembolism requiring anticoagulation; wound infection requiring hospital stay more than 7 days; readmission to hospital for obstetric-related causes; wound dehiscence; maternal fever of at least 38.5°C on two occasions at least 24 hours apart not including the first 24 hours; bladder, ureter or bowel injury requiring repair; genital-tract fistula; bowel obstruction; or admission to intensive care unit. This will be reported as a proportion of participants with serious morbidity or mortality.
• Serious perinatal/neonatal morbidity or mortality within 6 weeks of birth (combined outcome), which will include the following: shoulder dystocia requiring manouvres other than McRoberts/suprapubic pressure or resulting in neonatal injury, 5-minute Apgars < 4; arterial cord pH <7.0 or lactate >10 or base excess < −15; seizures < 24 hours of age, intubation/ventilation >24 hours, tube feeding >4 days, admission to neonatal intensive care >4 days, neonatal jaundice requiring phototherapy, neonatal fracture, intraventricular/intracranial haemorrhage, subgaleal haemorrhage, neonatal blood transfusion, hypoxic ischaemic encephalopathy, or neuropraxia. This will be reported as a proportion of participants with serious morbidity or mortality.

Other outcomes

Other outcomes will be assessed during delivery admission and at t 6-weeks, 6-months, and 1-year postpartum.

The following outcomes will be assessed during delivery admission:

• length of second stage (median)
• time from intervention or sham until delivery (median)
• estimated blood loss at delivery (median: visual estimation by midwife or doctor)
• any perineal/vaginal trauma requiring suturing (proportion)
• length of hospital stay (median)

The following outcomes will be assessed at 6 weeks:

• still breast feeding (proportion)
• satisfaction with birth (VAS scale) (median)
• saw a health professional for depression since delivery (proportion)
• health-related quality of life (SF-12) (median)

The following outcomes will be assessed at 6 months:

The following outcomes will be assessed at one year:

• pelvic floor function (bowel, urinary, prolapse, and sexual function domains - using the Australian pelvic floor function questionnaire [ 34 ] (medians)

Sample size

The sample size (254) was calculated on the basis of the primary outcome. The power calculation was based on our prospective cohort study of 160 women that was completed in May 2009 [ 3 ] and showed an operative delivery rate of 68% in the OP group, and from our survey of obstetricians conducted in 2010, who indicated they would perform a manual rotation for OP position if it reduced the rate of operative delivery from 68% to 50% [ 10 ]. To detect a reduction in the rate of operative delivery from 68% in the control group to 50% in the intervention group, a sample size of 127 women in each group (total = 254) will be required to have 80% power of finding a result. Alpha = 0.05 (2-tailed), Beta = 0.20 (Epi-Info version 3.3.2).

Randomization/allocation concealment

Randomization will be stratified by parity, hospital site and epidural due to the potentially strong association between operative delivery (the primary outcome) and each of these factors. Randomization will be centrally controlled using computerized sequence generation, which can be accessed 24 hours per day using a toll-free telephone line.

In order to reduce the risk of randomising an ineligible participant, randomisation will occur immediately before the intervention or sham procedure is to be performed. An example of a participant becoming ineligible would be if the fetus rotated from the occiput posterior to occiput transverse position. Each investigator will complete a data collection form at the time the manual rotation or sham procedure is performed outlining the treatment allocation, clinical findings, and whether or not the fetus was successfully rotated.

The following groups will be masked:

• The participants
• The clinicians caring for the participant (including doctors and midwives)
• The data collectors
• The statisticians who will perform the analysis

Unblinding will occur if the clinician requests it on the basis of clinical need or if the participant insists.

Data collection, management and analysis

Study conduct.

Consent will occur at three possible time points Figure  1 :

• Antenatally
• In the latent phase of labour
• In the active phase of the first stage of labour, with an effective epidural anaesthesia

An overview of the conduct of the POP-OUT Trial.

An ultrasound will be performed at full dilatation by the clinician caring for the woman and the findings will be recorded on a data sheet immediately afterwards.

An hour after full dilatation or at the first urge to push, a study investigator (with no clinical responsibility for the woman in the trial) will confirm the OP position by a second (pre-procedure) bedside ultrasound. If the fetal position is still OP and the woman still wishes to participate, then the study investigator will randomise the woman to either manual or sham rotation. The treatment allocation will be recorded on a randomisation sheet that the investigator will keep on their person and not show to any of the participant’s carers.

After the manual rotation or sham has been performed the ultrasound will be repeated, ensuring that the woman and her carers do not see the screen. The investigator will leave and the woman will have her usual care from this point onwards. The investigator will record the findings of the vaginal examination he/she performed before the procedure, details of the procedure and post-procedure ultrasound findings on the same data sheet as the pre-procedure ultrasound. The study investigator will also keep this data sheet on their person and not show it to any of the participants’ carers.

Participants will be provided with written information via information pamphlets, posters and the trial website. Informed consent will be obtained by research midwives or midwives/medical staff involved in potential participants’ care (Figure  1 , Table  2 ). A detailed information sheet will be provided to all participants. Participants will be informed of the potential risks of manual rotation, including umbilical cord prolapse, given the opportunity to ask questions and informed that they have the right to change their mind at any time.

The POP-OUT study time-line for the schedule of enrolment, allocation and follow-up

Mode of delivery will be ascertained from the medical records.

Labour and delivery outcomes, perineal trauma, blood loss, duration of hospitalisation, short-term neonatal outcomes, and admission to the neonatal intensive care unit, maternal or neonatal readmission to the same institution, and other components of the combined secondary outcomes will be ascertained by a study investigator not involved in clinical care, using the medical records recorded contemporaneously by the clinician and by contacting the participants’ clinician for further information if required. Maternal depression, health related quality of life (SF-12), birth satisfaction (VAS), maternal or neonatal readmission to another institution, ongoing breast feeding, pelvic floor symptoms and components of the combined secondary outcomes will be collected by structured maternal questionnaires at 6 weeks, 6 months and 12 months post-delivery as outlined in section 15. Questionnaires will be completed by mail-out, online via the trial website and by telephone depending on the participants’ preferences (Figure  1 , Table  2 ). Data collectors will be unaware of the treatment allocation at all times.

As the primary outcome is mode of delivery and randomisation occurs during the second stage of labour, we expect 100% ascertainment for the primary outcome.

Study investigators will perform site visits about four times per year to promote recruitment, provide education for clinical staff and site investigators and to audit centre medical records to verify the accuracy of the data collected by the sites.

Each participants will receive a phone call at each time point by research staff not involved in her care to ask her preference for follow-up. Unless she declines further participation, each participant will receive a reminder phone call and will be offered completion of the questionnaire by telephone if they feel they cannot complete it by mail or online.

Data management

Data collected will be entered into a registered electronic database by research staff blinded to treatment allocation and who are not involved in the clinical care of the participants. Hardcopies of participants’ data will be stored in a locked office. The electronic database will include the study identification number but no directly identifying data such as medical record number, date of birth or personal address. The de-identified database will be backed up on a server at Royal Prince Alfred Hospital. Data linking identifying details to the study number will be kept at a separate location in a locked filing cabinet. At the end of the study, data will be kept in a locked filing cabinet, and de-identified electronic data will be kept on a portable medium such as a USB drive in a separate secure location at Royal Prince Alfred Hospital.

All electronic data will be checked for accuracy by a second member of the research team and any apparent data entry errors will be discussed by the primary investigators and investigated/corrected as required.

Analysis will be by intention-to-treat (according to treatment allocation), including withdrawals and losses to follow-up. Losses to follow-up for the primary outcome are not expected because randomisation will occur at full dilatation and the primary outcome is the mode of delivery.

The results will be reported according to CONSORT guidelines.

Demographics and other potential confounders will be compared by treatment allocation in a univariate analysis. Categorical outcome measures will be compared by proportions (chi-squared test), means for normally distributed data ( t -test), or rank order for non-normally distributed data (Mann–Whitney- U test).

A logistic regression analysis of treatment allocation and other variables on the primary outcome measure, operative delivery, will be performed. The following variables will be considered for the logistic regression model: maternal body mass index, maternal age, maternal height, maternal ethnicity, gestation, induction of labour, gestational diabetes, neonatal gender, and RCOG CTG classification in the second stage of labour. Parity, study site and the presence of epidural for intrapartum analgesia at the time of randomisation will not be included because randomisation is stratified for these variables. Only variables where P <0.25 in the univariate regression will be included in the multivariate model. Continuous variables that do not show a linear association with the logit function will be divided into quartiles and treated as categorical. Interaction terms will be considered for treatment allocation versus each of the other variables and where clinically appropriate between non-treatment variables. P <0.01 will be considered evidence of interaction. Terms will be excluded from the model in a stepwise backward manner until all remaining terms are both statistically significant ( P <0.05) and clinically significant (that is, removal of the term results in a clinically significant change in the estimate of the odds ratio of treatment allocation for the primary outcome). The analysis will be performed using SAS 9.2 (or a more recent version of SAS).

Subgroup analyses will be performed according to the technique of manual rotation employed (manual/whole hand versus digital/fingers) and according to operator ability (data will be divided into two approximately equal groups according to the success rate of the operator who performed the manual rotation).

Data safety monitoring committee

Draft terms of reference for a data and safety monitoring committee provide for potential cessation of the trial if significant safety concerns are raised. The data and safety monitoring committee will consist of three people who are not involved in the study and do not have a working relationship with the primary investigators. Adverse events will be reported to the committee.

Interim analysis and stopping rules

There will be no interim analysis. The Data Safety Monitoring Committee may advise that the trial be stopped if significant concerns about the safety of manual rotation are found.

Any serious complications will be referred to the Data Monitoring Committee.

There will be no external auditing of the trial.

Research ethics approval

This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, Protocol number X110410.

This trial addresses an important clinical question concerning a commonly used procedure that has the potential to reduce operative delivery and its associated complications. Due to the nature of the intervention, a number of issues are worthy of discussion.

First, empirical evidence suggests that blinding reduces bias in randomised controlled trials. However, blinding may be difficult in the case of procedural interventions. In this trial, we intend to assess the efficacy of blinding by asking the woman’s carer to guess the treatment allocation after manual rotation or sham rotation has occurred. The purpose of this is to allow the reader to assess the risk of bias associated with knowledge of treatment allocation.

Second, the efficacy of procedural interventions may depend on the experience and training of individual operators. The ‘success’ of manual rotation of individual operators will be assessed by recording the ultrasound determined fetal position after the manual rotation or sham procedure has been performed. We will report on any major differences between the success rates of individual practitioners.

Third, due to the ethics of consent in labour, consent will be obtained when it is unknown if the fetus will be in the occiput posterior position in the second stage of labour, which is an eligibility criterion. Thus, it is likely that only a minority of consented participants will be randomised, which will result in a large workload per randomisation (the pilot study was used as a reference).

Finally, women who progress rapidly in labour may give birth before they can be randomised and women with regional analgesia will have more opportunity to be consented. This could result in the study population having a higher background risk of the primary outcome than non-consented women who meet our eligibility criteria, which could impact the generalisability of our findings.

Protocol amendments

If modification to the study protocol is considered necessary, then permission will be sought from the ethics committee and the changes will be described in the final report.

Confidentiality

All the information collected from the study will be treated confidentially, and only the researchers will have access to it. Hard copies of data collection forms will be stored in a locked office. The electronic database will be de-identified and stored at a different location to codes linking identifying data to study identification numbers. The electronic database will be on Microsoft Access, password-protected, and only accessible by research staff.

Roles and responsibilities

Trial management committee.

The committee consists of Hala Phipps, Jon Hyett and Bradley de Vries, who are responsible for the following:

• Study planning
• Organisation of Steering Committee meetings
• Randomisation
• Reporting of any serious adverse events to the Data Monitoring Committee
• Budget administration and organising contracts with individual centres
• Providing advice for site investigators
• Auditing and visiting sites
• Data verification
• Following up of study participants

Site investigators

In each participating centre, a lead investigator (obstetrician) will be responsible for identification, recruitment data collection and completion of relevant trial forms, along with adherence with study protocol. Each lead investigator will be a steering committee member.

Steering committee

The Steering Committee will be chaired by Brad de Vries, and all lead investigators will be steering committee members and are responsible for the following:

• Recruitment of pregnant women on the study and liaising with principal investigators HP, JH and BD.
• Reviewing progress of study and facilitating the smooth running of the trial.
• Reporting the results of the trial.

Data manager

The data manager will be responsible for maintenance of the trial IT system, data entry and data verification.

Trial status

Start date: 16 April 2012.

Number currently recruited: 160.

Acknowledgements

This study is funded by a research grant from the NHMRC (National Health and Medical Research Council (project grant ID 1029664)). Additional support has been provided by the Royal Australian and New Zealand College of Obstetrics and Gynaecology Research Foundation, Luke Proposch Perinatal Research Scholarship, 2012.

Abbreviations

Competing interests

The authors state explicitly that there are no conflicts of interest

1. Dr Hala Phipps is financially supported by a research grant for the POP-OUT Trial from the NHMRC (National Health and Medical Research Council (project grant ID 1029664)). She is also supported by a Luke Proposch Perinatal Research Scholarship from the Royal Australian and New Zealand College of Obstetrics and Gynaecology Research Foundation

Dr Hala Phipps, Dr Brad de Vries and Professor Jon Hyett are co-authors on a Cochrane systematic review assessing the efficacy of prophylactic manual rotation for reducing operative delivery, which is likely to include the results of this trial when they become available.

Authors’ contributions

HP is the primary investigator and assisted in the trial design, applications for funding, overall co-ordination of the trial, data management and drafting the first version of the report. JH assisted in trial supervision, trial design, applications for funding, contribution to ongoing conduct of the trial and contribution to writing the report. SK, JP, JL, AB assisted in applications for funding, site co-ordination, performing the intervention, contribution to ongoing conduct of the trial and contribution to writing the report. DK and FP assisted in site co-ordination, performing the intervention, contribution to ongoing conduct of the trial and contribution to writing the report. BdV is responsible for the trial concept and supervision, trial design, applications for funding, overall co-ordination of the trial, performing the intervention, data management and assisting in drafting the first version of the report. All authors read and approved the final manuscript.

Contributor Information

Hala Phipps, Email: [email protected] .

Jon A Hyett, Email: [email protected] .

Sabrina Kuah, Email: [email protected] .

John Pardey, Email: ua.moc.yedrap@nhoj .

Joanne Ludlow, Email: [email protected] .

Andrew Bisits, Email: [email protected] .

Felicity Park, Email: ua.ude.dysu.dem@ticilef .

David Kowalski, Email: ua.moc.tensutpo@ikslawokd .

Bradley de Vries, Email: [email protected] .