BACKGROUND AND PURPOSE:

• Bertholdt et al. (AJOG, 2022) assessed the association between spontaneous vaginal delivery and manual rotation during labor for OP or transverse positions

METHODS:

• Systematic review and meta-analysis
• Inclusion criteria
  • RCTs
  • Singleton pregnancies at ≥37 weeks
  • Comparison of manual rotation vs control groups
• Study design
  • Subgroup analyses: Types of position (OP or occiput transverse) | Techniques used (whole-hand or digital rotation) | Parity
  • Study quality was evaluated with the revised Cochrane risk-of-bias tool
  • Random-effects models were used based on heterogeneity | Risks ratios were calculated for dichotomous outcomes
  • GRADE criteria used to determine strength of the evidence
• Primary outcome
  • Rate of spontaneous vaginal delivery
• Secondary outcomes
  • Rate of OP position at delivery | Operative vaginal delivery | Cesarean delivery | PPH | Obstetrical anal sphincter injury | Prolonged second stage of labor | Shoulder dystocia | Neonatal acidosis | Phototherapy

RESULTS:

• 7 studies | 1402 women
  • Manual rotation: 704
  • Control: 698
• Manual rotation was associated with a higher rate of spontaneous vaginal delivery
  • Manual rotation: 64.9%
  • Control: 59.5%
  • RR 1.09 (95% CI, 1.03 to 1.16); P=0.005
• Manual rotation was associated with
  • Spontaneous vaginal delivery only for the OP position
    • RR 1.08 (95% CI, 1.01 to 1.15)
  • Reduction in OP or transverse positions at delivery
    • RR 0.64 (95% CI, 0.71 to 0.98)
  • Episiotomies
    • RR 0.84 (95% CI, 0.71 to 0.98)
• The groups did not differ significantly for
  • Cesarean deliveries
  • Operative vaginal deliveries
  • PPH
  • Obstetrical sphincter anal injury
  • Neonatal outcomes

CONCLUSION:

• Manual rotation of OP position vs expectant management increased the rate of spontaneous vaginal delivery with a reduction in OP position and episiotomy at delivery
• Study may have been underpowered to demonstrate associations with maternal morbidity (e.g., PPH or sphincter injury)
• Limitations include confounding factors such as labor management and potential interventions used during deliveries
• The authors state

The benefit-risk balance seemed to favor manual rotation, given its very low rate of complications compared with the benefits of avoiding operative delivery, known not only to be frequently associated with complications but also to affect the woman’s birth experience negatively

We believe that the results of this meta-analysis provided GRADE 2 evidence regarding the impact of manual rotation on spontaneous vaginal delivery 

Learn More – Primary Sources:

Manual rotation of occiput posterior or transverse positions: a systematic review and meta-analysis of randomized controlled trials

Related ObG Topics:

Operative Vaginal Birth: Indications and Clinical Considerations

PROPOP RCT Results: Does Trial of Prophylactic Manual Rotation Reduce Operative Deliveries?

Forceps/Vacuum Delivery vs Cesarean Section and Adverse Maternal and Perinatal Outcomes

Are Number of Pop-Offs, Forcep Pulls or Longer Operative Vaginal Delivery Times Associated with Adverse Neonatal Outcomes?