Prophylactic manual rotation for fetal malposition to reduce operative delivery and reduce complications for mothers and babies


Most babies are in a position where the baby is looking backwards (an anterior position for the back of the head) before and during delivery. When the baby is looking forwards (in the posterior position) or sideways (the transverse position), the baby's head has a wider profile in the birth canal so descent may be more difficult. The posterior and transverse positions are associated with longer labour, more painful labour, the need for epidural pain relief, higher rates of vaginal tears that sometimes includes the anus and rectum, bleeding after birth and infection in the uterus after the birth. It is also more common for the woman to have a forceps, vacuum or caesarean birth, in some instances in the late first or early second stage of labour, and usually when the mother's cervix is fully dilated.

Manual rotation may be performed to turn the baby's head to the anterior position. Manual rotation entails the use of the accoucheur's hand or fingers to rotate the baby's head. It may take two or three contractions to be performed and the position is commonly held for two contractions.

Study characteristics

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and other databases for clinical trials comparing manual rotation with expectant management (waiting), speeding up of labour or operation. The women were at term (at least 37 weeks of pregnancy). The results are current to October 2014.

Key results

We found only one small pilot trial involving 30 women that assessed the feasibility of manual rotation versus routine care (no manual rotation). The study reported no clear difference for the review's primary outcomes of operative delivery (vacuum-assisted delivery or forceps delivery (or both), or caesarean section) and no mother or baby deaths. In terms of adverse events, there were no reported cases of umbilical cord prolapse or cervical laceration and a single case of a non-reassuring or pathological cardiotocograph during the procedure.

Further research is needed to assess the effect of manual rotation in second stage of labour to reduce operative delivery rates.

Quality of the evidence

We considered the study at low risk of bias but it did not have sufficient participants to detect important clinical benefits or harms of manual rotation to correct the baby's position in second stage of labour.

Authors' conclusions: 

Currently, there is insufficient evidence to determine the efficacy of prophylactic manual rotation early in the second stage of labour for prevention of operative delivery. One additional study is ongoing. Further appropriately designed trials are required to determine the efficacy of manual rotation.

Read the full abstract...

Manual rotation is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Manual rotation has the potential to prevent operative delivery and caesarean section, and reduce obstetric and neonatal complications.


To assess the effect of prophylactic manual rotation for women with malposition in labour on mode of delivery, and maternal and neonatal outcomes.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (31 October 2014), the Australian and New Zealand Clinical Trials Registry (ANZCTR),, Current Controlled Trials and the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 23 February 2014), previous reviews and, references of retrieved studies.

Selection criteria: 

Randomised, quasi-randomised or cluster-randomised clinical trials comparing prophylactic manual rotation in labour for fetal malposition versus expectant management, augmentation of labour or operative delivery. We defined prophylactic manual rotation as rotation performed without immediate assisted delivery.

Data collection and analysis: 

Two review authors independently assessed study eligibility and quality, and extracted data.

Main results: 

We included only one small pilot study (involving 30 women). The study, which we considered to be at low risk of bias, was conducted in a tertiary referral hospital in Australia, and involved women with cephalic, singleton pregnancies. The primary outcome was operative delivery (instrumental delivery or caesarean section).

In the manual rotation group, 13/15 women went on to have an instrumental delivery or caesarean section, whereas in the control group, 12/15 women had an operative delivery. The estimated risk ratio was 1.08 (95% confidence interval 0.79 to 1.49). There were no maternal or fetal mortalities in either group

There were no clear differences for any of the secondary maternal or neonatal outcomes reported (e.g. perineal trauma, analgesia use duration of labour).

In terms of adverse events, there were no reported cases of umbilical cord prolapse or cervical laceration and a single case of a non-reassuring or pathological cardiotocograph during the procedure.