Fetal Positions – Passenger (Nursing)

00:00 So now, let's look at this graphic and let's think about all of those components. What part of the baby is coming through the pelvis first? It's the head. And the head in this position looks like it's flexed and if you're having trouble being able to determine that, look at the other view. So if we look from the lithotomy view, you can't see the face so that means the head is flexed. So we're going to use the occiput as our landmark. Okay? Where is the occiput facing? It's actually facing the anterior portion of the pelvis. I know we talked about right and left, but right now Clitus is not facing right or left. Clitus is facing straight anterior so we don't need to determine right or left right now. So the occiput is in the anterior position.

00:47 So the way we would report this is we would say "This fetus is in the OA position." And actually, this is the best position for delivery. So do you see this, occiput anterior? Now, let's see what happens as the baby begins to rotate. So you'll recall from our previous lecture, we talked about how the baby doesn't just sort of fall out. The baby has to turn, rotate sort of like a corkscrew. So in this position, you see the baby has turned. We still have the occiput as the landmark that we're going to use, but this time it's facing the maternal right side of the pelvis. So this position is right occiput and is it on the anterior or posterior portion of the pelvis? It's on the anterior side. So the way we would report this is right occiput anterior.

01:45 Let's turn Clitus just a little bit more. Now, the position is transverse so if you look at the view on the opposite side, you'll see that the sagittal suture is dividing the pelvis. Now we have right occiput transverse then we have right occiput posterior. Now, the baby is in a straight OP position so the exact opposite of occiput anterior. Now just a side note, we'll talk about this a little bit more when we think about comfort in labor. I want you to think about where the fetal spine is in relationship to the maternal spine. Are you getting the picture? What you hopefully are thinking about and feeling is now we have a situation where there is bone-on-bone. So think about how uncomfortable this might be for a laboring pregnant patient to have the fetal spine rubbing up against the coccyx. So, this position is particularly painful in labor and sometimes when patients complain about a lot of pain we have an idea that perhaps the fetus is in this position. It's a little bit harder to deliver the fetus and it's important that we're able to recognize that. So this is occiput posterior. Now we're going to move to the left side of the pelvis and we have left occiput posterior, left occiput transverse, and finally left occiput anterior. So we've made a full circle around the pelvis with the occiput as the landmark. Now I will show you what that looks like. Clitus is back so now I want to show you with the pelvis. Hopefully this will make it a little bit easier. So in the occiput anterior position, then the occiput which is this part of Clituses head is facing the anterior portion of the pelvis then we can rotate, ROA, ROT, OP. Remember we talked about bone-on-bone? That's what it looks like. Painful, painful, painful. Then, we move over to the left side of the pelvis LOP, LOT, LOA, and all the way back to OA. And remember that OA is the best position for delivering vaginally. Now we're going to go through the exact same thing, but we're going to use a different landmark. So this time the middle initial is not going to be an O. It's going to be an M because we have a face presentation. Poor flexion, remember? This is a fully extended face and that's what we see. So in this graphic, what you see is the mentum is on the anterior portion of the pelvis. So let's do our 360 with the mentum. So, mentum anterior, right mentum anterior. Now I want you to really think about this landmark because if I use the occiput, then I would get this wrong because in this picture, the occiput is actually on the opposite side of the pelvis. So we have to know that the mentum is our landmark. So the mentum is right anterior. Now, we have a right mentum transverse. Then we have a right mentum posterior. We have mentum posterior, we have left mentum posterior, we have left mentum transverse, and we have left mentum anterior. So same 360, different landmark.

05:26 Where is the chin? So make sure that you know with an occiput we see the top of the head and all the fontanelles and with the mentum we're going to see the face. Now, I'm going to demonstrate that with my pelvis. Well, I have Clitus I want to show you one more thing and this has implications for delivery. So, understanding that during the delivery process, the head or whatever is presenting has to traverse the coccyx, it sort of makes a J on the way out. So I want you to think about that in reference to the chin. Now, in this position when I deliver the baby's head, the head will scoop up under just like this. That's great. Now what would happen if I turn the chin this way? Hmm. I'm going to show you this on the graphic, and I think this will help. Okay, here's the graphic. This is the mentum anterior position.

06:27 Again, think about the trajectory of the pelvis in the mentum anterior then the head can actually adjust and to be delivered safely through the vagina. In the mentum posterior position, however, this is not possible. So if we find that the fetus is in the mentum posterior position, then we recommend a Caesarean delivery for the safety of the baby. So, our mnemonic is MA CAN BUT PA CAN'T. Alright, last one. This time our landmark is the sacrum. So this is for a fetus in the breech position. The sacrum is going to be the bony part that we can feel with the digital exam so we're going to go back through our 360, but this time using the sacrum as a landmark. So here we go. Sacrum anterior, the sacrum is facing the very front of the pelvis. As we turn, right sacrum anterior, right sacrum transverse, right sacrum posterior. So you can see we're moving towards the back side or the posterior side of the pelvis. We have sacrum posterior, left sacrum posterior, left sacrum transverse, left sacrum anterior. So that's what it looks like. I'm going to show you one more time with my pelvis and I think you're going to have it. Okay, we've gone from a cephalic presentation to a breech.

08:03 The sacrum is our landmark. Here we go. Sacrum on the anterior side of the pelvis. Right sacrum anterior, right sacrum transverse, sacrum posterior, left sacrum posterior, left sacrum transverse, left sacrum anterior, and back to sacrum anterior. You did it. We got through it. Just remember, go back and practice a few times. Sometimes when you actually have the elements in your hand, it makes sense. The other thing I want to caution you about for testing purposes is make sure you look at both views. We've been talking mostly about Clitus in this position, but make sure you look at the graphic on the other side and you can use the landmarks in the scalp to determine the position of the fetus. Okay?