Malposition of Vertex

What is malposition of vertex?

A baby is in a vertex position when the baby's head is positioned to come out first, before the rest of the body, at birth. During normal labor the baby's head rotates so that the baby's face is toward the mother's back. When this rotation does not occur it is referred to as malposition. It may lead to difficult labor.

How does it occur?

Malposition occurs in about 1 of every 20 cases where the baby is in the head-first position for birth.

Sometimes the baby's head faces the front of the mother's pelvis instead of turning toward the mother's back. This position is called persistent occiput posterior. The baby would then be delivered with the head facing the ceiling, which is often a more difficult way to deliver. This position occurs more often in women who are having their first baby and women who have a narrow midpelvis.

Sometimes the baby's head stays in a sideways position, with the baby facing either the right or left of the mother's pelvis. This position is called persistent occiput transverse. It usually occurs because the uterine contractions are not strong enough to help the baby turn his or her head to the proper position, or because the mother has a flattened pelvis.

What are the symptoms?

The symptoms of malposition of vertex may include:

• a lot of back pain
• longer, more tiring labor.

How is it treated?

Women who have had a baby already will usually be able to deliver the baby, but it may be a more difficult delivery. First-time mothers may need more help from the healthcare provider.

If you are fully dilated (the cervix is open all the way) and having good contractions, but the baby's head is in the occiput posterior position, your healthcare provider may do the following:

• Positioning: You may be asked to lie on your side or with your knees against your chest.
• Manual rotation: When the baby's head can be seen through the opening of the vagina, your provider may try to turn the baby's head with his or her hands.
• Forceps rotation: If manual rotation doesn't work, your provider may use forceps to turn the baby's head. Forceps are large steel instruments like tongs that fit alongside the baby's head. Your provider gently turns the forceps and the baby's head. When the head is turned, the baby can be delivered in the normal way.
• Forceps delivery: The baby can be delivered with its head in the occiput posterior position using forceps. You will be given some type of anesthesia for pain relief. Your provider will place forceps alongside the baby's head. Your provider will make a cut in the opening of the vagina to make it bigger (episiotomy) and then gently pull the baby's head down. The cut will be stitched after the baby and placenta are delivered.
• Vacuum rotation and delivery: Your provider will place a plastic or metal cup called a vacuum extractor on the baby's head and apply suction. Your provider will pull gently on the baby's head during a contraction while you are pushing. Your provider may turn the baby's head either before or during delivery.
• Cesarean section (C-section): Your provider may decide to deliver the baby with surgery if:
  • Your provider decides a forceps or vacuum delivery would be too dangerous for the baby.
  • A forceps or vacuum delivery is tried and does not work.
  • Your provider decides the baby is too big to fit through the pelvis.

The following may be done to help with delivery if the baby's head is in the occiput transverse position:

• A drug called oxytocin may be given to you intravenously (IV) to make your contractions stronger and help the baby's head come down the birth canal and turn. This may be enough for delivery of the baby.
• Your provider may try a manual rotation of the baby's head.
• Your provider may use forceps or a vacuum extractor to turn the baby's head and deliver the baby.
• If your provider expects difficulties with the delivery, a cesarean section may be done.

How long will the effects last?

If the baby's head can be turned to a better position, it will probably stay in the new position through the delivery. If the problems with the baby's head position cannot be corrected right away, a cesarean section (C-section) may be necessary to prevent permanent injury. If the baby's head stays in a bad position, the longer delivery is delayed, the greater the risk of permanent brain injury or death for the baby.

How can I take care of myself?

• Remain calm and follow the directions of your healthcare provider.
• It may help to use the breathing and relaxation techniques you learned and practiced in prenatal classes.
• If you are concerned about this or any other problem that might occur during delivery, discuss your concerns and questions with your provider ahead of time. This will help you deal with a normal or problem delivery in the safest and calmest way possible.

What can be done to help prevent malposition of vertex?

There is no general way to prevent malposition of vertex. However, regular prenatal visits will help your provider detect problems ahead of time. Ask your provider about ways you can help reduce the risk of problems during delivery.