1. Fetal Malposition
Refers to positions other than an occipitoanterior position.
Malpositions include occipitoposterior and occipitotransverse positions of fetal head in relation to maternal pelvis.
It is usually seen in multipara or those with lax abdominal wall. Fetal malpositions are assessed during labor.

2. Left Occipitoanterior Rotation
(A) A fetus in cephalic presentation, LOA position. View is from outlet. The fetus rotates 90 degrees from this position. (B) Descent and flexion (C) Internal rotation complete. (D) Extension; the face and chin are born

3. Types of Fetal Malposition
Occipitoposterior Position
Arrested labor may occur when the head does not rotate and/or descend. Delivery may be complicated by perineal tears or extension of an episiotomy.
Occipitotransverse Position  
It is the incomplete rotation of OP to OA results in the fetal head being in a horizontal or transverse position (OT).

4. Left Occipitoposterior Rotation
(A) Fetus in cephalic presentation LOP position. View is from outlet. The fetus rotates 135 degrees from this position. (B) Descent and flewion. (C) In ternal rotation beginning. Because of the posterior position, the head will rotate in a longer arc than if it were in an anterior position. (D) Internal rotation complete. (E) Extension; the face and the chin are born. (F) External rotation; the fetus rotates to place the shoulder in an anteroposterior position

5. Maternal risks: Maternal symptoms: prolonged labor
potential for operative delivery
extension of episiotomy,
3rd or 4th degree laceration of the perineum.
Maternal symptoms:
Intense back pain in labor
Dysfunctional labor pattern
prolonged active phase
secondary arrest of dilatation
arrest of descent
Diagnosis: Abdominal examination – the lower part of the abdomen is flattened, fetal limbs are palpable anteriorly and the fetal flank. Vaginal examination – the posterior fontanelle is toward the sacrum and the anterior fontanelle may be easily felt if the head is deflexed Ultrasound

6. Nursing MGT
Encourage the mother to lie on her side from the fetal back, which may help with rotation.
Pelvic – rocking may Knee – chest position
help with rotation may facilitate rotation.
Apply sacral counter – pressure with heel of hand to relieve back pain.
Continue support and encouragement:
Keep client and family informed progress.
Praise client’s efforts to maintain control.

7. Management
If there are signs of obstruction or the fetal heart rate is abnormal at any stage, deliver by caesarean section.
If the membranes are intact, rupture the membranes with an amniotic hook or a Kocher clamp.
If the cervix is not fully dilated and there are no signs of obstruction, augment labor with oxytocin.
If the cervix is fully dilated but there is no descent in the expulsive phase, assess for signs of obstruction.

8. Management If the cervix is fully dilated and if:
the leading bony edge of the head is above -2 station, perform caesarean section;
the leading bony edge of the head is between 0 station and -2 station, Delivery by Vacuum Extraction and Symphysiotomy
If the operator is not proficient in symphysiotomy, perform caesarean section;
If the bony edge of the fetal head is at 0 station, deliver by vacuum extraction or forceps.

9. Management SYMPHYSIOTOMY
A surgical procedure in which the cartilage of the symphysis pubis is divided to widen the pelvis allowing childbirth when there is a mechanical problem.
Currently the procedure is rarely performed in developed countries, but is still routine in developing countries where cesarean section is not always an option.

10. Management
Forceps - provides traction or a means of rotating the fetal head.
Risks: fetal ecchymosis or edema of the face, transient facial paralysis, maternal lacerations, or episiotomy extensions.
Vacuum extraction - Provides traction to shorten the second stage of labor.
Risks: newborn cephalhematoma, retinal hemorrhage and intracranial hemorrhage.

11. Nursing Diagnoses: Impaired gas exchange Pain
Encourage the mother to lie on her side from the fetal back, which may help with rotation.
Knee – chest position may facilitate rotation.
Pelvic – rocking may help with rotation.
Monitor FHB appropriately
Be prepared for childbirth emergencies such as cesarean section, forceps-assisted delivery, and neonatal-resuscitation.
Pain
Encourage relaxation with contractions.
Apply sacral counter – pressure with heel of hand to relieve back pain.
Provide comfortable environment.
Teach breathing exercises for use during early labor until client receives pharmacologic relief.
Monitor physical response for example, palpitations/rapid pulse

12. Nursing Diagnoses: Fatigue Anxiety
Assess psychological and physical factors that may affect reports of fatigue level
Monitor physical response for example, palpitations/rapid pulse
Monitor fetal heart beat and contractions continuously.
Refraining from intervening with client during contraction.
Anxiety
Keep client and family informed progress.
Provide support during labor through personal touch and contact. These methods convey concern.
Continue support and encouragement.
Make the client feel she is somewhat in control of her situation.
Provide client and family teaching.
Identify client’s perception of the threat presented by the situation.