Key messages
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When a woman is in labour and the cervix is fully dilated, but the baby's head is facing the wrong direction (towards the mother's front or side), it is currently unclear whether turning the baby's head by hand (manual rotation) so that it faces towards the mother's back (the usual position) helps reduce the need for caesarean, vacuum or forceps birth.
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More well-designed studies are needed to better understand whether manual rotation is effective and safe.
What is manual rotation?
Manual rotation is a procedure where a doctor or midwife uses their hand or fingers to gently turn the baby's head into the usual position (facing towards the mother's back) during labour, usually once the woman's cervix is fully dilated.
Why is this important for women in labour whose babies face the wrong way?
When a baby's head is not in the ideal position during labour – facing the mother’s front (occiput posterior, OP) or side (occiput transverse, OT), instead of the usual position facing the mother’s back (occiput anterior, OA) – it can increase the risk of labour not progressing well, complications such as maternal bleeding, severe trauma to the pelvic floor, and the need for a vacuum, forceps, or caesarean birth. Turning the baby’s head to the OA position may help avoid these interventions.
What did we want to find out?
We wanted to find out if manual rotation is better than doing nothing (or usual care) at preventing operative births (vacuum, forceps or caesarean births) in women whose babies are facing the wrong position during labour.
We were interested in the effect of manual rotation on other outcomes, including: maternal and perinatal deaths, serious tears to the perineum during birth (third- or fourth-degree) and serious bleeding after birth (blood loss of 500 mL or more).
What did we do?
We searched for studies that looked at whether manual rotation caused benefits or harms for women and their babies when compared to a sham (pretend) procedure or usual care. We compared and summarised the results and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found six studies that included 1002 pregnant women and their babies. The studies were all conducted in high-income countries. The women all had term (at least 37 weeks or more) pregnancies, the cervix was fully dilated, and the majority had received epidural pain relief.
Main results
Compared with no manual rotation, manual rotation may result in little or no difference in the overall rate of operative delivery. There were no maternal or perinatal deaths in either group.
Manual rotation may not reduce the chance of caesarean section or instrumental (forceps or vacuum) births. Also, there was little to no difference in the number of women experiencing complications, including third- or fourth-degree perineal tears, or serious bleeding after birth.
One more study is ongoing (enrolling 46 women). However, much larger studies will be needed to detect meaningful differences. Future studies are also needed in low- and middle-income countries.
What are the limitations of the evidence?
We have limited confidence in the evidence, mostly due to concerns about study design (specifically, in three of the six studies, women knew which treatment they were receiving), and because the overall number of women included in the studies was small.
How up to date is this evidence?
The evidence is current to March 2024.
Baca abstrak penuh
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.
Matlamat
To assess the effect of prophylactic manual rotation compared to no manual rotation for women with malposition in labour on mode of delivery, and maternal and neonatal outcomes.
Kaedah Pencarian
We searched CENTRAL, MEDLINE, three other databases and three trial registries in March 2024. We reviewed the reference lists of retrieved studies.
Kriteria Pemilihan
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.
Pengumpulan Data dan Analisis
Two review authors independently assessed study eligibility and quality, and extracted data.
Keputusan Utama
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.
Kesimpulan Pengarang
Currently, we are uncertain whether prophylactic manual rotation early in the second stage of labour prevents operative delivery for women with fetal malpresentation. Further appropriately designed trials are required to determine the efficacy of manual rotation in both low-middle income and high-income settings.
Funding
This Cochrane review had no dedicated funding.
Registration
The protocol for this Cochrane review is available at: https//doi.org/10.1002/14651858.CD009298.
The previous version of this Cochrane review is available at: https://doi.org/10.1002/14651858.CD009298.pub2.
