Occiput posterior and transverse positions are frequent during labor, accounting for approximately 20% of all positions at the onset of labor and 5% at delivery.1,2 These fetal head malpositions have been found to be risk factors for cesarean deliveries, instrumental interventions, longer second stages of labor, and third- and fourth-degree perineal lacerations.3,4 Over the past two decades, cesarean rates have been rising unabated in France as in other industrialized countries.5,6 Different practices aimed at diminishing these rates have been studied, including active management of labor, which some authors have found to be helpful, although its effectiveness in reducing the number of cesarean deliveries during labor is controversial.7,8 Manual rotation is also an option used by some physicians to reduce the risk of cesarean delivery and avoid vaginal deliveries in posterior positions. Its complications appear relatively rare.9 However, data on this technique are sparse.10 Only a recent observational study reports that successful manual rotation is associated with a high vaginal delivery rate. Schaffer et al11 found maternal factors, such as parity and age, to be associated with successful rotation. They analyzed only two obstetric factors: induction of labor and use of epidural. Neither was associated with the success of the maneuver. Our hypothesis was that some obstetric conditions at the time of the attempted rotation, such as cervical dilatation, station of the fetal head, and indication for rotation, should be predictors of its success or failure.
In our maternity ward, manual rotation is practiced routinely. We analyzed the risk factors of failure of manual rotations in fetuses in occiput posterior or transverse positions during labor, and we studied neonatal and obstetric outcomes according to the failure or success of the rotation.
MATERIALS AND METHODS
This is a retrospective case-control study performed in a level 3 maternity unit delivering approximately 3,500 infants a year, where manual rotation is routinely practiced by midwives and physicians. The Committee for the Protection of Person Ile-De-France III has examined this work and found it conforms to the ethical standards and to the scientific requirements applicable to biomedical research. Cesarean deliveries accounted for 23.6% of our deliveries in 2003 and 25.4% in 2004. Data are collected prospectively every day in a computerized database. Each delivery chart is reviewed daily by the medical staff. This allows us to study both the patients who had a manual rotation and the success of the rotation.
A partograph, which records cervical dilatation, presentation, and station and position of the fetal head, is completed prospectively during labor. Digital cervical examination is performed hourly. Midwives are asked to identify the head position from 4 cm dilatation.
The technique used for manual rotation is largely based on that described by Tarnier and Chantreuil12 and is performed only when dilatation reaches 7 cm. The patient, bladder emptied, is placed in a dorsal recumbent (flat) position. When the uterus is relaxed, the operator gently places two fingers or, if possible, the entire hand (right hand for left occiput posterior [OP] and transverse [OT] positions and left hand for the right OP and OT positions) behind the fetal ear (right for left positions and left for right positions).13 During the uterine contraction, while the patient is pushing, the operator uses the pressure of the fingers to rotate the anterior fetal head, moving the occiput relative toward the anterior pelvic girdle. Fetal heart rate (FHR) is monitored continuously throughout these procedures. In case of failure, the maneuver can be performed again if the FHR is reassuring. The main indications for manual rotation are lack of progress in dilatation for at least 1 hour or nonengagement. Sometimes, at the end of the first stage, in case of FHR abnormalities, manual rotation is performed to accelerate the end of labor to make vaginal delivery possible. Moreover, the rotation may also be performed prophylactically to reduce the duration of labor or, if the fetal head is engaged in posterior position, to avoid perineal consequences of a delivery in posterior positions.
Between January 1, 2003, and December 31, 2004, in our maternity ward, 4,927 patients delivered (at 37 weeks or more) live singletons in cephalic presentation at term after attempted vaginal delivery. Manual rotation was performed at least once for 796 of them (16.2%). According to our database, manual rotation failed for 85 (10.7%). We used computerized randomization (without matching) to select one control with a successful rotation during the same period for each case with a failed rotation. One author (P.S.) reviewed the partograph and paper file for all 170 selected cases to verify the accuracy of all data included in the analysis. We then excluded eight files that had been wrongly coded (four failures and four successes) and in which there had not been any rotation performed. Moreover, 15 paper files unfortunately could not be found in the hospital archives (nine failures and six successes); these 15 cases were not included in the analysis. Finally, four files initially coded as failures in the database had also been wrongly coded and were reclassified as successes. Thus, we were able to analyze 147 files: 68 failed (cases) and 79 successful manual rotations (controls) (Fig. 1).
Maternal and neonatal factors were parity, age, geographic origin, body mass index at the last consultation, uterine scar, rupture of membranes, induction of labor, gestational age, birth weight, and head circumference. Obstetric factors at attempted manual rotation were indication for rotation (prophylactic, failure to progress, or FHR abnormalities), station of fetal head, and cervical dilatation. We considered that the fetal head was not engaged when it was above station 0, ie, above the level of the ischial spines. Cervical dilatation was categorized as “before full dilatation” and “at full dilatation.” Finally, time of day of the attempted manual rotation was also noted (day or night, the latter defined as 10 pm to 7 am).
Obstetric and neonatal outcomes were recorded: mode of delivery, 5-minute Apgar scores, and umbilical artery pH. Fetal heart rate recordings of all patients were reviewed for this study. We looked for complications that might be due to the rotation: cord prolapse, cervical laceration, or FHR abnormalities. Fetal heart rate abnormalities occurring during the procedure or within 20 minutes after the rotation were classified as mild, moderate, or severe according to the International Federation of Gynecology and Obstetrics (FIGO) classification.14
Manual rotation was considered a failure if, after the last attempt, the fetus remained in an occiput posterior or transverse position. We studied the maternal and neonatal risk factors for failure of manual rotation for each woman (n=147) with a bivariable analysis.
In some cases, rotation may have been attempted several times for the same patient, with different obstetric conditions at each separate attempt, sometimes by different practitioners. For this reason, we also studied the risk of failure according to attempt. For each attempt (n=242), when the fetus remained in an OP or OT position at the end of the attempt, it was considered a failure. To study the obstetric factors for failure of an attempted rotation, we first conducted a bivariable analysis that estimated for each obstetric factor the crude odds ratio associated with failure of that attempt. We then conducted a multivariable analysis using a logistic model and the Huber-White variance estimators to take the intragroup correlation into account (Robust Cluster command of Stata 8.0 software [Stata Corporation, College Station, TX]). Because some women had several attempts, this type of model allowed us to take into account the nonindependence of the attempted rotations for the same patient and accordingly to estimate confidence intervals more precisely. The crude and adjusted odds ratios for the risk factors for failed manual rotation, as well as the 95% confidence intervals, were estimated with the maximum likelihood method. Finally, obstetric and neonatal outcomes were analyzed according to success or failure of the manual rotation. The groups were compared for maternal and neonatal factors and obstetric outcomes with the χ2 test or Fisher exact test when the expected frequency was small (number less than 5).
During the study period, manual rotations were performed in 796 women. The procedure failed in 77 (9.7%) patients. We were able to analyze 147 files: 68 failed and 79 successful manual rotations. Of the 147 patients, 84 (57.1%) had one attempted rotation, 41 (27.9%) had two attempts, 15 (10.2%) had three attempts, four patients (2.7%) had four attempts, and three patients (2.0%) had five attempts, for a total of 242 attempts. Of the 79 successes, 55 (69.6%) occurred on the first attempt. None of the fourth or fifth attempts succeeded (Table 1).
The rate of epidural analgesia during labor was 98.0% (n=144). Of the maternal and neonatal factors studied, only nulliparity and maternal age greater than 35 years were risk factors for failure of the manual rotation (Table 2).
In the bivariable analysis of the obstetric factors at the moment of attempted rotation, nonengagement, absence of full dilatation, indication of failure to progress, and time of day were significantly more frequent in the group with failed rotations than in the success group. Use of oxytocin at the time of the attempted rotation was not associated with a higher risk of failure (crude odds ratio [OR] 1.5, 95% confidence interval [CI] 0.9–2.6). After multivariable analysis, attempted rotation before full dilatation tripled the risk of failure in comparison with a rotation at full dilatation (adjusted OR 3.4, 95% CI 1.3–8.6); rotation for failure to progress also increased the risk of failure compared with prophylactic rotation (adjusted OR 3.3, 95% CI 1.2–8.5) (Table 3). Among 242 attempts of manual rotation, the fetal head was in OT positions in 70 cases (28.9%) and in OP positions in 172 (71.1%). Manual rotation did not succeed more often from OT than from OP positions.
Failures of manual rotation were associated with a higher cesarean rate than successes (58.8% versus 3.8%; P<.001). All seven women with four or five attempts of manual rotation had operative deliveries (one forceps and six cesarean deliveries). The percentages of Apgar scores less than 7 at 5 minutes were similar in the failure and success group. Significantly more infants had an umbilical artery pH less than 7.20 in both groups (42.4% for failures and 25.6% for successes, P=.03). There was no difference between failures and successes for higher levels of acidemia (pH less than 7.10) (Table 4).
Of the 68 women with failed rotations whom we studied, 40 (58.8%) had cesarean deliveries, and all vaginal deliveries were occiput posterior (n=28). No vaginal delivery with a posterior vertex position occurred in the group with successful rotations.
Cervical lacerations complicated manual rotation in two patients with successful maneuvers, but none in the failure group. Surgical repair was simple in both cases. We noted no other complications, including cord prolapse. There were no fourth-degree perineal lacerations in either group; there were two third-degree lacerations in the failure group and one in the success group. The episiotomy rate was 44.2% (n=65). In 71.5% of cases of attempted rotation (n=173), no FHR abnormality occurred, in 18.6% (n=45) there were mild or moderate FHR abnormalities, and in 9.9% (n=24) severe FHR abnormalities. Forty-one women had FHR abnormalities during at least one attempted manual rotation. We found no association between FHR abnormalities after manual rotation and cesarean delivery (Table 5).
Manual rotation may be an effective technique for reducing the cesarean rate in patients with a fetus in occiput posterior or transverse position during labor. In our study the cesarean rate was significantly lower after successful than after failed rotation. As previously reported in the literature, rotation failed more frequently in nulliparas and women older than 35 years.11 Moreover, we showed that attempted rotation before full dilatation and rotation for failure to progress were risk factors for failure of manual rotation. Some women had more than one attempted rotation, but none of the fourth or fifth attempts succeeded.
During the study period, manual rotation failed in 9.7% of all attempts in our institution. This percentage of failure was close to that found in an earlier (1995) study in our department.9 This low failure rate is probably related to the efficacy of this technique when used routinely.
Random selection within the group with successful rotations ensured that our control group was representative. Selecting only one control for each case may have led to a lack of power in our study. With a larger population, more significant associations might have been observed between failure and factors such as station of fetal head. Moreover, other maternal and obstetric factors, for which data were unfortunately not collected, could be potential confounders. For example, we did not collect data about maternal pain and efficacy of epidural analgesia; a painful rotation could be a risk factor for failure.
It is possible that in some cases the diagnosis of position before and after the manual rotation was erroneous. Some physicians recommend using ultrasonography to determine the head position, but we do not use it routinely.15,16 Nonetheless, three points suggest that our results are robust and underline the relevance of the clinical diagnosis. First, the definition of anterior and posterior positions is simpler in our study than in others: we classified positions only as anterior or as transverse and posterior, ie, two categories, whereas other studies used more categories (up to eight).15,16 Second, midwives and obstetricians are asked to assess position early and regularly—every hour from a dilatation of 4 cm. Compliance with this practice is verified daily at staff meetings for all deliveries. Finally, of the vaginal deliveries, all the women with failed manual rotations delivered in occiput posterior positions, and all the women with successful rotation delivered in occiput anterior positions.
Nulliparity and age greater than 35 years have recently been described as factors associated with an increased risk for failure of manual rotation.11 It is possible that the narrowness of the birth canal in nulliparas explains this increased failure rate. However, the study of Shaffer et al11 did not analyze obstetric risk factors at the time of rotation. In our study, rotations performed because of failure to progress were more often a source for failure of manual rotation than those performed prophylactically. This result is consistent with that reported by Haddad et al9 in 1995, where the success rate was 97% for prophylactic rotations and 28% for those indicated for lack of progress in dilatation. Some might argue that prophylactic manual rotation is unjustified when spontaneous rotation is still possible, especially because the rotation might induce FHR abnormalities. Nonetheless, waiting until failure to progress occurs exposes the fetus to a higher risk of failed rotation. Moreover, cesarean deliveries indicated for FHR abnormalities induced by a prophylactic manual rotation are rare. In our study, 64 prophylactic manual rotations were attempted; in only one case was the rotation associated with FHR abnormalities for which the patient had a cesarean delivery.
Manual rotations at night failed twice as often as those performed during the day. Other studies show that physicians’ performance decreases at night. For example, the risk of dural breach during the placement of peridural analgesia is correlated with night hours.17 The epidural rate in our maternity ward is high. This may explain some malpositions during labor, especially if the epidural is placed early when fetal station is still high.18,19 On the other hand, by decreasing maternal pain, epidural analgesia could facilitate manual rotation of the fetal head. Unfortunately, since only three patients did not have epidural analgesia, we cannot confirm this hypothesis.
Manual rotation may allow a reduction of the vaginal delivery rate in the occiput posterior position, a source of third- and fourth-degree perineal lacerations.3 Moreover, the cesarean delivery rate for occiput posterior and transverse positions during labor is higher than for anterior positions. Porreco et al20 recently showed that nonreassuring FHR patterns predict cesarean delivery for dystocia among nulliparous patients with normally oxygenated fetuses. In that study, there were significantly more persistent posterior positions among the cesarean deliveries performed for dystocia than among the vaginal births. They suggest that clinicians should intervene earlier when labor is not progressing. Thus, manual rotation may help to reduce the risk of cesarean delivery. Published series indicate that approximately 10% of all vaginal deliveries are from the OP position.1,2 In our maternity ward, where manual rotation is routinely performed in the case of occiput posterior or transverse positions during labor, fewer than 1% of term vaginal deliveries involve occiput posterior positions. We conducted a 3-month prospective study of 365 patients in labor with singleton cephalic term fetuses; only three patients (0.8%) delivered in posterior position.19 Different practices aimed at reducing cesarean delivery rates have been evaluated, such as active management of labor.7 Few studies, however, have assessed manual rotation.10,11 No study has proved it to be effective in comparison with other techniques, such as postural variations or expectant management. Studies comparing manual rotation with these alternatives might make it possible to analyze its impact on cesarean delivery rates and on perineal laceration rates and to show its safety.
In conclusion, manual rotation may be an effective technique for reducing the cesarean delivery rate in patients with an occiput posterior or transverse position during labor. Knowledge of its risk factors may allow physicians to better select the patients for manual rotation and thus increase its success rate. They should bear in mind that the risk of failure is higher when manual rotation is attempted before full dilatation or indicated for failure to progress.
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