Manual Rotation of Fetuses in Posterior or Transverse Position Might Reduce Operative Delivery Rates

August 12, 2013

By Will Boggs, MD

NEW YORK (Reuters Health) Aug 12 - Manual rotation of fetuses in occiput posterior (OP) or occiput transverse (OT) position is associated with reduced operative delivery rates, researchers from France report.

Lead author Dr. Camille Le Ray from University Paris-Descartes in Paris told Reuters Health this technique has become standard care in some maternity wards, including theirs.

"Obstetricians and midwives should therefore be trained to perform this maneuver," Dr. Le Ray said in an email.

Of the 20% of fetuses in OP position during labor, only 5% remain occiput posterior at delivery. Different techniques have been proposed to rotate these fetuses from OP to occiput anterior in an effort to reduce labor time and the risk of operative deliveries.

Dr. Le Ray and colleagues compared the mode of delivery of women with fetuses in posterior position at full dilatation in two level III university hospitals, one with a policy favoring modifications of maternal position and the other favoring manual rotation.

Manual rotation was attempted in 0.9% of cases at hospital 1 and 78.9% of cases at hospital 2, whereas maternal posture changes were used in 57.6% of cases at hospital 1 and 21.8% or cases at hospital 2.

Manual rotation was successful in rotating the fetus's head to an occiput anterior position in 155 of 172 cases at hospital 2 (90.1%), according to the September Obstetrics & Gynecology report.

Operative delivery rates were significantly higher at hospital 1 than at hospital 2 (38.7% vs. 23.2%, p<0.01), mainly because of significantly higher rates of instrumental deliveries at hospital 1 than at hospital 2 (28.8% vs. 15.0%, p<0.01).

Neonatal outcomes did not differ between the two hospitals.

In multivariable analyses that adjusted for potential confounders, the risk of operative delivery was 55% lower when manual rotation was attempted (regardless of hospital), whereas changing maternal posture was not associated with a significant change in the risk of operative delivery.

Although there is no published randomized trial comparing the effect of manual rotation and expectant management on mode of delivery in women with fetuses in OP or OT position, Dr. Le Ray said a controlled randomized trial is in progress in Australia.

"Manual rotation is taught in labor wards during ObGyn residency or during their practical training for midwifery students," Dr. Le Ray said. "Ideally, manual rotation should be attempted at the beginning of the second stage (i.e., after the diagnosis of full dilatation)."

Dr. Hideki Sakamoto, who was not involved in the study, told Reuters Health by email that manual rotation should be the standard of care for these fetuses, "as the technique is lot easier and safer than vacuum or forceps, needless to say than a c section."

"First, have an adequate epidural or spinal anesthesia. Try rotation during pushing," Dr. Sakamoto, from Aiku Maternal and Child Health Center in Tokyo, Japan, suggested.

SOURCE: http://bit.ly/1eE41P3

Obstet Gynecol 2013;122:634-640.

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