Manual rotation of occiput posterior during labor increases the rate of spontaneous vaginal delivery

Reference

Bertholdt C, Morel O, Zuily S, Ambroise-Grandjean G. Manual rotation of occiput posterior or transverse positions: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2022;226(6):781-793.

Synopsis

These French authors conducted a meta-analysis of 7 randomized controlled trials (N = 1402 participants) of manual rotation during labor of ultrasound-confirmed fetal occiput posterior or occiput transverse. They included studies of women in labor with singleton pregnancy of at least 37 weeks' gestation. They excluded studies without a control group. None of the studies masked participants or birth attendants, but outcome assessors were masked in all but one study. Complementary interventions, such as maternal positioning, were allowed in both groups. Two methods of manual rotation were allowed. Whole-hand rotation was defined as placement of the operator’s whole hand into the maternal vagina behind the fetal ear to both flex and rotate the fetal head. Digital rotation was defined as use of 1 or 2 of the operator’s fingers placed on either side of the fetal sagittal suture to correct fetal head deflection and guide rotation during contractions. The authors of this meta-analysis assessed the risk of bias of the included studies as low and without publication bias. There was considerable crossover in the control groups, reaching 34% of control patients receiving a manual rotation intervention in one of the studies. Manual rotation was significantly associated with a modest increase in spontaneous vaginal delivery with moderate certainly (65% vs 60%; relative risk [RR] 1.09; 95% CI 1.03 - 1.16; P = .005). The association for digital rotation, separate from whole-hand rotation, was not statistically significant though the sample size was relatively small. A small decrease in the use of episiotomy was also seen in the manual rotation groups (RR 0.84; 0.71 - 0.98). Cesarean deliveries did not differ between groups. The corresponding decrease in operative vaginal delivery didn’t reach statistical significance (RR 0.87; 0.75 - 1.01). The authors assessed maternal anal sphincter injury, postpartum hemorrhage, and several neonatal outcomes, none of which reached statistical significance.