When the fetal occiput fails to spontaneously rotate anteriorly, a persistent occiput posterior presentation results in a more prolonged and painful labor. Manual, vacuum, or forceps rotation is usually necessary but increases the likelihood of maternal and fetal injuries. Regional anesthesia can be used to provide perineal analgesia and pelvic relaxation, allowing manual or forceps rotation followed by forceps delivery. Ref: Butterwoh IV J.F., Mackey D.C., Wasnick J.D. (2013). Chapter 41. Obstetric Anesthesia. In J.F. Butterwoh IV, D.C. Mackey, J.D. Wasnick (Eds), Morgan & Mikhail's Clinical Anesthesiology, 5e.