Is epidural analgesia a risk factor for occiput posterior or

transverse positions during labour?

Camille Le Ray, Marion Carayol, Se´bastien Jaquemin,

Alexandre Mignon, Dominique Cabrol, Franc¸ois Goffinet

*

Department of Obstetrics and Gynecology, Maternity Port-Royal, Cochin-Saint Vincent-de-Paul Hospital,

AP-HP University Paris V, 123 Bd de Port-Royal, 75014 Paris, France

Received 21 July 2004; received in revised form 29 December 2004; accepted 18 February 2005

Abstract

Objective: The aim of this study was to assess whether the station of the fetal head at epidural placement is associated with the risk of
malposition during labour.
Study design: Retrospective study (covering a 3-month period) of patients in labour with singleton cephalic term fetuses and epidural
placement before 5 cm of dilatation. We studied the following risk factors for malposition: station and cervical dilatation at epidural
placement, induction of labour, parity and macrosomia. Malposition, defined as all occiput posterior and occiput transverse positions, was
assessed at 5 cm of dilatation because of our policy of systematic manual rotation for malpositions.
Results: The study included 398 patients, 200 of whom had malpositions diagnosed at 5 cm of dilatation. In both the univariate and
multivariate analyses, station at epidural placement was the only risk factor significantly associated with this malposition (adjusted OR: 2.49,
95% CI 1.47–4.24). None of the other factors studied was significantly associated with malposition: nulliparity (OR 1.45, 95% CI 0.96–2.20),
macrosomia (OR 0.75, 95% CI 0.37–1.50), induction of labour (OR 0.84, 95% CI 0.49–1.45), or dilatation less than 3 cm at epidural
administration (OR 1.16, 95% CI 0.59–2.30). Only three infants of the 365 delivered vaginally (0.8%) were born in occiput posterior
positions.
Conclusion: Epidural placement when the fetal head is still ‘‘high’’ is associated with an increased rate of occiput posterior and transverse
malpositions during labour.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Epidural analgesia; Occiput posterior position; Labour

1. Introduction

The birth of infants whose presentation is cephalic but

whose position is some variation of occiput posterior is
associated with more operative vaginal deliveries and more
third and fourth degree perineal tears

[1,2]

. Many authors

have therefore sought to identify the risk factors for posterior
positions

[3–9]

.

Because of the importance attributed today to pain relief,

studies comparing patients ‘‘with’’ or ‘‘without’’ analgesia
are especially difficult to perform and ethically question-

able. In recent decades, France has witnessed extensive
development of pain management for women in labour. In
1998, 70.8% of obstetric patients received epidural analgesia

[10]

. This may have harmful effects on labour and delivery;

in particular, some authors reported an increased rate of
caesarean and assisted vaginal deliveries

[11–13]

, although a

recent review of the literature reported that the overall
results of the studies on this topic do not support this
association

[14]

.

Better use of this treatment (doses, products used,

moment of administration, etc.) may help reduce these
adverse effects. Epidural placement before engagement has
been shown to increase the rate of fetal head malposition

[7,14]

. One hypothesis is that in the cases of a malposition at

www.elsevier.com/locate/ejogrb

European Journal of Obstetrics & Gynecology and

Reproductive Biology 123 (2005) 22–26

* Corresponding author. Tel.: [phone]; fax: [phone].

E-mail address: [e-mail] (F. Goffinet).

0301-2115/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejogrb.2005.02.009

a high station, placement of an epidural reduces the
possibility that the fetal head will rotate during labour. The
mechanisms may be either insufficient uterine activity or
relaxation of the pelvic muscles.

Epidurals are nonetheless most often placed at the

beginning of labour and thus only rarely after engagement.
We sought to test the hypothesis of a relation between the
station of the fetal head at epidural placement and the risk of
fetal head malposition in the second stage of labour in a
study adapted to current obstetric practices.

2. Materials and methods

This retrospective study took place from 1 February

through 30 April 2003 in a tertiary-care maternity ward that
delivers 3500 infants per year. The unit has at least two
anesthetists present at all times, exclusively for maternity
patients; this enables rapid epidural placement when patients
so request (in the absence of contraindications) or for
medical indications.

Of the 773 deliveries during the 3 months of the study

period, we included 398 patients who met the following
criteria (

Fig. 1

): in labour with singleton cephalic term

(>37 weeks) fetuses, received epidural analgesia during
labour but before 5 cm of dilatation and had position
assessed at 5 cm. Conversely, the exclusion criteria were
any one of: caesarean before labour or before 5 cm
dilatation;

multiple

pregnancy;

breech

presentation;

in utero death; preterm delivery; either no epidural or
its placement after 5 cm, and position not diagnosed at
5 cm.

During the 3-month study period, one investigator

(Camille Le Ray) collected data at the daily staff meeting.
This information from the patients’ records and partographs,
which the midwives completed during labour, enabled us to
test our underlying hypothesis.

We considered as malposition all the varieties of posterior

and transverse positions. Position was assessed by the
midwife or obstetrician after a digital cervical examination
conducted systematically every hour from 3 cm of dilata-
tion. The principal endpoint was fetal head malposition at
5 cm, because we attempt manual rotation starting at 7–8 cm
when an occiput posterior position stops or slows labour and
systematically at full dilatation. Defining position at full
dilatation or delivery would not therefore have enabled us to
assess the true malposition rate. The technique used for
manual rotation is based on that described by Tarnier: with
fetal head fixed or engaged, patient in dorsal recumbent (flat)
position, bladder empty, the operator places two fingers
behind the fetus’s anterior ear and rotates the head as the
mother is pushing and through a uterine contraction

[15]

.

We studied the other variables that have been associated

with malposition in the literature: parity, induction of labour,
station of fetal head and cervical dilatation at epidural
placement, macrosomia (birth weight

4000 g)

[4–7,9,16]

.

Station of the fetal head (the presenting part for all

included cases) at epidural placement was noted on the
partograph and in the records, classified as follows:

5 (just

coming into the pelvis),

4 (head floating),

3 (head

floating, starting to dip),

2 (head dipping),

1 (head

dipped, almost engaged), 0 (engaged, at level of ischial
spines), +1 (engaged), + 2 (engaged). We considered stations

5 and

4 as high and the others as low.

C. Le Ray et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 123 (2005) 22–26

23

Fig. 1. Inclusion and exclusion criteria.

Epidural placement took place at the patient’s request

when no standard contraindications were present. With the
patient in a sitting or lateral decubitus position, the epidural
space was identified with an 18G Tuohy needle, a catheter
was inserted 3–4 cm, and then a test dose of 60 mg of
lidocaine was administered. After verifying the absence of
intrathecal or vascular administration, we administered
fractionated boluses of 5 ml bupivacaine 0.125% and 5–
10 mcg of sufentanil to obtain satisfactory analgesia within
15 min, with sensitivity at the T10 level (15–20 ml
depending on the patient’s height). The epidural analgesia
was then maintained with continuous electric pump
administration of bupivacaine 0.1% combined with sufen-
tanil 0.4 mcg/ml at the rate required for 8–14 ml/h.
Additional boluses of bupivacaine were administered if
needed, and the catheter was replaced if analgesia failed.

The Chi-2 test was used to compare the groups and the

Anova test (or Fisher’s exact test) to compare the
quantitative variables. A multivariate logistic regression
analysis studied the factors associated with malposition at
5 cm (Statview 5.0 software). In the logistic model, we
calculated the odds ratios and their 95% confidence intervals
for all the factors studied, regardless of their p value in the
univariate analysis.

3. Results

In all, 546 women with singleton pregnancies gave birth

during the study period to live term fetuses in cephalic
presentations; 501 (91.8%) had epidural analgesia. Among
them, 74 patients (14.8%) had the epidural placed only after
they had reached 5 cm or more dilatation; in this group 30
(40.5%) had a normal anterior position at 5 cm, and 28
(37.8%) a malposition; this information was missing for 16
patients (21.6%). Position was not assessed for 29 (6.8%) of
those who had epidural analgesia before 5 cm (cf.

Fig. 1

).

The study finally included 398 patients with epidural

placement before 5 cm and position assessed at 5 cm. This
study population is described in

Table 1

, as are the labour

conditions (station and cervical dilatation) at epidural
placement. Because we intentionally chose to exclude those
patients for whom presentation was not assessed at 5 cm,
there are no missing data.

Of the factors studied, only high fetal head at epidural

placement was significantly more frequent among those with

malposition at 5 cm than among those with occiput anterior
positions (

Table 2

) (26.5 versus 13.6%, p = 0.001). After

logistic regression and inclusion of all the factors studied in
the model, only high station at epidural administration
remained independently associated with malposition at 5 cm
(

Table 3

) (adjusted OR 2.49, 95% CI [1.47–4.24]).

Of the 200 infants in malpositions at 5 cm, 102 (51%)

turned spontaneously between 5 cm and full dilatation, 15
(7.5%) women had caesareans before any rotation could be
attempted, and rotation was attempted for 83 women
(41.5%). In the latter group, seven finally had caesarean
deliveries: three for non-engagement at full dilatation, two
for arrest at 8 and 9 cm, and two for FHR anomalies; manual
rotation failed for four of them.

Only three babies of the 365 delivered vaginally (0.8%)

were born in an occiput posterior position. The epidural had
been placed with the fetal head ‘‘high’’ for only one of them.
Malposition was noted for all three at 5 cm. Two cases
involved failed manual rotation at full dilatation: severe
FHR anomalies resulted in emergency forceps deliveries. In
one case, rotation was not attempted. The patient, having her
fifth baby, gave birth rapidly with only brief expulsive
efforts.

C. Le Ray et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 123 (2005) 22–26

24

Table 1
Population characteristics

Characteristics studied

n = 398 (%)

Mean

 S.D.

Age (years)

31.2

 5.4

No previous deliveries

235 (59.0)

Term (weeks)

39.5

 1.2

Labour induced

85 (21.4)

Malposition at 5 cm dilatation

200 (50.3)

Cervical dilatation at epidural placement (cm)

2

71 (17.8)

3

230 (57.8)

4

97 (24.4)

Station of fetal head at epidural placement

5

12 (3.0)

4

68 (17.1)

3

157 (39.4)

2

156 (39.2)

1

3 (0.7)

0

2 (0.5)

+1

0 (0)

Birth weight (g)

3390

 447

S.D., standard deviation.

Table 2
Univariate analysis of factors associated with malposition at 5 cm

Malposition at 5 cm N = 200, n (%)

Anterior position at 5 cm N = 198, n (%)

p

‘‘High’’ station at EA (n = 80)

53 (26.5)

27 (13.6)

0.001

Nulliparity (n = 235)

126 (63.0)

109 (55.0)

0.11

Macrosomia (n = 38)

17 (8.5)

21 (10.6)

0.47

Induction (n = 85)

40 (20.0)

45 (22.7)

0.51

Dilatation < 3 cm at EA (n = 71)

37 (18.5)

34 (17.2)

0.93

EA, epidural analgesia.

4. Comment

This study shows that placement of epidural analgesia

when the station of the fetal head is still ‘‘high’’ is associated
with an increase in the number of occiput posterior or
transverse positions at 5 cm of dilatation, independently of
the other factors studied.

Robinson et al. showed a relation between station at

epidural placement and the malposition rate, but they
considered station high if engagement had not occurred

[7]

.

In our practice, more than 90% of the patients received
epidural analgesia from the onset of labour, before
engagement. Epidural placement after engagement was
extremely rare: there were none in this series, and only two
patients (0.5%) were at a station as low as fixed at epidural
placement. We needed to conduct a study adapted to our
practice procedures to examine the relation between station
at epidural placement and malposition rate.

Because the same investigator did not assess station for

all patients, a classification bias is possible. Nonetheless,
others have reported interobserver agreement about station,
assessed with digital cervical examination during labour, at
around 90%

[17]

.

The decision to assess position at 5 cm of dilatation was

based on our policy of attempted manual rotation, system-
atically at full dilatation as well as in cases of arrest of
progress due to malposition, starting at 7–8 cm dilatation.
Assessing position at full dilatation would therefore have
been useless. This policy resulted in a low rate of deliveries
with malposition, 0.8% compared with approximately 5% in
most of the series reported

[1,6,8]

. It is nonetheless probable

that most of the posterior presentations at birth were
posterior during labour, including at 5 cm of dilatation; in
our series, the three posterior presentations at birth were
already posterior at 5 cm of dilatation.

Our policy of manual rotation resulted in a very small

number of deliveries in occiput posterior position. This
practice nonetheless has disadvantages: in an earlier series
of 368 cases of manual rotation, we reported one cord
prolapse, 40 cases of FHR anomalies (onset or aggravation),
resulting in 19 caesareans, and 10 cervicovaginal tears

[15]

.

If position was not certain at 5 cm, it was not reported on

the partograph. This category included 29 patients (6.8%) of
the 427 who had received epidural analgesia before 5 cm. It is
unlikely that this exclusion biased the interpretation of our
results because there were only a few of these women (n = 29)

and none had a child born in an occiput posterior position.
Moreover, the distribution of station at epidural placement for
these 29 women was similar to that for the 398 women for
whom position was known at 5 cm: 23 (79.3%) low (station

3 or more) and 6 (20.7%) high (station

4 or

5).

Some specialists recommend using ultrasound to

determine position

[18–21]

. We think our data on positions

are reliable, however, for two reasons. First, we did not
distinguish between the right and left occiput posterior and
transverse (

908) positions in the malposition group or

between the right and left occiput anterior positions (

908)

in the anterior group, while the studies cited consider the
position diagnosis erroneous if the error exceeds 458.
Second, in our practice, midwives and obstetricians are
trained and encouraged (daily at staff meetings) to diagnose
position early and systematically every hour after 3 cm. The
pertinence of this clinical diagnosis seems reinforced by the
fact that all of the posterior positions at delivery had been
identified at 5 cm of dilatation.

In both the univariate and multivariate analyses, the only

factor significantly associated with fetal head malposition
during labour was epidural placement at a high station.
Other risk factors for occiput posterior positions have been
reported, studied most often in univariate analyses

[3–6]

.

Only Sizer et al. conducted a logistic regression, but it did
not take into account either the obstetrical characteristics at
epidural placement (station of fetal head and cervical
dilatation) or parity. In both our study and the literature,
nulliparity is a risk factor for malposition, on the borderline
of significance

[5]

. The combination of macrosomia and

induction of labour with occiput posterior presentation is
found inconsistently in the literature

[4–7]

. Finally, in

accordance with previous findings, cervical dilatation at
epidural placement was not a risk factor for malposition in
our study

[7,9]

.

Our study was retrospective, and the association between

analgesia placement at a ‘‘high’’ fetal station and malposi-
tion at 5 cm cannot therefore be considered causal.
Moreover, it is probable that the malpositions at 5 cm were
already mostly posterior or transverse at the ‘‘high’’ stations
of early labour. Similarly, the possible association of
dystocic presentation or labour with greater pain and thus
earlier recourse to analgesia could have induced an
indication bias. This bias is probably an important limitation
of our and similar studies.

We cannot know if waiting for the head to descend to

place the epidural would help to reduce the malposition rate
in later labour. Accordingly, a policy of waiting to place the
epidural might be useful. Only a prospective study could
determine this: it would need to compare two groups of
women with high stations requesting epidurals, one
receiving immediate epidural placement and a one with
placement delayed until further descent. Since current trends
lean rather towards emphasizing pain relief during labour
and delivery, such a randomized study may be difficult to
conduct.

C. Le Ray et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 123 (2005) 22–26

25

Table 3
Logistic regression for prediction of malposition at 5 cm of dilatation

Variable

OR

95% CI

‘‘High’’ station at epidural placement

2.49

1.47–4.24

Nulliparity

1.45

0.96–2.20

Macrosomia

0.75

0.37–1.50

Induction

0.84

0.49–1.45

Dilatation < 3 cm at epidural placement

1.16

0.59–2.30

OR, odds ratio; 95% CI, 95% confidence interval.

While epidurals are not contraindicated when station is

high, it may nonetheless be better for some women whose
pain is bearable to await a lower station before analgesia.
This approach might also diminish the number of manual
rotations to be performed.

5. Conclusion

This study shows that the placement of epidural analgesia

when cephalic presentation is still ‘‘high’’ is associated with
a higher percentage of occiput posterior and transverse
positions during labour, independently of other risk factors
studied. A different study is nonetheless necessary to show
that delaying epidural placement in these women would
reduce the risk of malposition. These data show that
assessment of epidural practices remains important.

Epidural anesthesia incontestably improves the safety

and comfort of women in labour. The issues raised in this
study do not involve reducing access to epidurals for the
women who want them but rather optimizing their use to
minimize any adverse effects on the course of labour.

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