3 Prophylactic Manual Rotation of Persistent Occiput Posterior to decrease operative Delivery: a Multicentric Randomized Trial

Abstract

Persistent occiput posterior (POP) positions are the commonest malpresentations of the fetal head during labor and are associated with prolonged second stage of labor, cesarean, instrumental deliveries, obstetrical anal sphincter injuries, postpartum hemorrhage and chorioamnionitis. Manual rotation is one of several strategies described to deal with POP. The literature suggests that manual rotation of POP could decrease operative deliveries but no randomized study has confirmed these findings. The aim of this study was to determine if the trial of prophylactic manual rotation during the early second stage of labor is associated with a decrease risk of operative deliveries (instrumental and/or cesarean deliveries). This study was a prospective, randomized, controlled trial conducted in four French hospitals. Women with singleton term pregnancy and POP position confirmed by ultrasound at early second stage of labor and with epidural analgesia were eligible and randomized (1:1) to either receive the trial of prophylactic manual rotation of POP position (intervention group) or no trial of prophylactic manual rotation (standard group). The primary outcome was operative deliveries (instrumental and/or cesarean deliveries). From December 2015 to December 2019, 257 women were randomized: 126 assigned to the intervention group and 131 to the standard group. The groups did not differ in baseline characteristics. Operative delivery was significantly less frequent in the intervention (I) group compared to the standard (S) group (29.4 vs. 41.2%, p=.047, Differentiel (I-S) [95% confidence interval, CI] = -11.8 [-15.7;-7.9]; relative risk [95% CI] = 0.71 [0.51-1.00]). Women in the intervention group were more likely to have a significant shorter second stage of labor and have a neonate with a significant higher Apgar score at 5 minutes. The were no differences in other secondary outcomes. Trial of prophylactic manual rotation of persistent POP positions during the early second stage of labor is associated with a decrease risk of operative delivery.