Manual rotation of the fetal head for women with fetal malpresentation (occipital posterior (OP) or occipital transverse (OT)) is commonly performed to increase the chances of normal vaginal delivery and is perceived to be safe. Prophylactic manual rotation has the potential to prevent operative delivery and caesarean section, and reduce obstetric and neonatal complications. This review updates a previous 2014 Cochrane review. 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. We searched CENTRAL, MEDLINE, three other databases and three trial registries in March 2024. We reviewed the reference lists of retrieved studies. Randomised controlled trials (RCTs), 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 were eligible. Participants included women at term or preterm, ( 80%) had epidural analgesia. Four RCTs enrolled women in the OP position, one RCT enrolled women in the OT position, and one RCT enrolled women in both the OP and OT positions. All confirmed fetal position using ultrasound. Findings from six RCTs involving 1002 participants suggest that manual rotation, compared to no manual rotation, may result in little to no difference in the rates of operative delivery (RR 0.92, 95% CI 0.81 to 1.04; low-certainty evidence); caesarean section (RR 1.09, 95% CI 0.76 to 1.56; low-certainty evidence); instrumental delivery (RR 0.88, 95% CI 0.75 to 1.03; low-certainty evidence); third- or fourth-degree perineal trauma (RR 0.91, 95% CI 0.55 to 1.49; low-certainty evidence); and postpartum haemorrhage of 500 mL or more (RR 0.94, 95% CI 0.71 to 1.25; low-certainty evidence). There was no maternal or perinatal mortality. A single subgroup analysis for caesarean delivery comparing nulliparous versus multiparous deliveries found evidence of an interaction. Neither subgroup showed evidence of a difference in caesarean delivery. No other subgroup analyses showed evidence of an interaction, including comparisons of occiput posterior versus occiput transverse position; nulliparous versus multiparous deliveries; and digital (fingers) versus whole-hand rotation. Due to the risk of bias (lack of blinding) and imprecision in three studies, we downgraded the certainty of evidence to low. One additional study is ongoing but may be underpowered to detect important differences. 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. This Cochrane review had no dedicated funding. 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.
Phipps et al. (Fri,) studied this question.
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