Manual Rotation in Occiput Posterior or Transverse Positions — Risk Factors and Consequences on the Cesarean Delivery Rate
Manual Rotation in Occiput Posterior or Transverse Positions—Risk Factors and Consequences on the Cesarean Delivery Rate
Abstract & Commentary
By John C. Hobbins, MD, Professor and Chief of Obstetrics, University of Colorado Health Sciences Center, Denver, is Associate Editor for OB/GYN Clinical Alert.
Dr. Hobbins reports no financial relationship to this field of study.
Synopsis: This paper resurrects a technique that has gotten little recent attention—second stage manual rotation for fetuses in the occiput posterior or transverse positions.
Source: Le Ray C, et al. Manual rotation in occiput posterior or transverse positions. Obstet Gynecol. 2007;110(4):873-879.
The author reviewed a year's worth of data from a busy hospital in France where manual rotation was liberally used. The procedure, which will be described below, was used in 796 patients, in whom 85 (9.7%) failed. In 17 patients in the "failure" group the charts were uninterpretable, leaving data from the remaining 68 to be compared against data from 79 randomly chosen charts from the "success" group (controls).
The results were very enlightening. The operators were no more successful when fetuses were in the occiput transverse (OT) positions than in the occiput posterior (OP) positions. Of the 79 successes 70% occurred with one attempt. When 4 or 5 attempts were utilized none succeeded. If the rotation was attempted before full dilatation (in 20% of cases), there was a 3-fold greater chance of failure than if it was attempted at full dilatation.
Most importantly, Cesarean delivery occurred in 58.8% of the "failed" group vs 3.8% in the "successful" group. Epidural had little effect on the study results since 98% of the patients had them. There were no differences in Apgar scores and maternal morbidity between groups. All of the "failures" who delivered vaginally remained in a posterior position and the all of the "successes" stayed in an anterior position.
Commentary
Although there is a potential for bias in the study dealing with variability in operator skills and appropriateness of controls, one cannot help but be impressed with how much the Cesarean section rate was diminished in those having successful rotations. Certainly, the indigenous Cesarean section rate in patients with persistent posterior positions is very high, and there is evidence of higher rates of pelvic floor damage in patients delivering vaginally with fetuses in this position. Therefore, it would seem to make sense in those progressing sluggishly in the second stage to give it a try.
The technique described in the paper is as follows: With the patient on her back, if the head is in an LOP or LOT position, the right hand is gently inserted (or if not, two fingers) behind the ear between contractions. Then, during a contraction with the patient pushing, an attempt is made to rotate the head counterclockwise. If the fetus is in an ROP or ROT position, the left hand is used and the head is rotated in a clockwise direction. Obviously, if the maneuver causes a worrisome change in the fetal heart rate, one desists. The author seemed to be occasionally successful on the second and third attempts, but not with more attempts.
Many certified nurse midwives have advocated having patients with "posterior" labor in the hands and knees position, which still could lend itself to a rotation attempt, especially if the fetus is in a ROP position and the operator is very right-handed.
The author reviewed a year's worth of data from a busy hospital in France where manual rotation was liberally used. The procedure, which will be described below, was used in 796 patients, in whom 85 (9.7%) failed.Subscribe Now for Access
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