Manual rotation of occiput posterior or transverse positions: a systematic review and meta-analysis of randomized controlled trials

• Published in: American journal of obstetrics and gynecology 2022-06, Vol.226 (6), p.781-793
• Main Authors: Bertholdt, Charline, Morel, Olivier, Zuily, Stéphane, Ambroise-Grandjean, Gaëlle
• Format: Article
• Language: English
• Subjects: cesarean delivery; Cesarean Section; Delivery, Obstetric - methods; digital rotation; Female; Humans; Infant, Newborn; instrumental rotation; Labor Presentation; management of labor; manual rotation; obstetrical anal sphincter injury; occiput posterior; occiput transverse; operative delivery; Parity; Pregnancy; Randomized Controlled Trials as Topic; second stage of labor; spontaneous vaginal delivery
• ISSN: 0002-9378; 1097-6868
• DOI: 10.1016/j.ajog.2021.11.033

The primary objective of this systematic review was to assess the association between spontaneous vaginal delivery and manual rotation during labor for occiput posterior or transverse positions. Our secondary objective was to assess maternal and neonatal outcomes. An electronic search of PubMed, EMBASE, ClinicalTrials.gov, and the Cochrane Register of Controlled Trials covered the period from January 2000 to September 2021, without language restrictions. The eligibility criteria included all randomized trials with singleton pregnancies at ≥37 weeks of gestation comparing the manual rotation groups with the control groups. The primary outcome was the rate of spontaneous vaginal delivery. Additional secondary outcomes were rate of occiput posterior position at delivery, operative vaginal delivery, cesarean delivery, postpartum hemorrhage, obstetrical anal sphincter injury, prolonged second stage of labor, shoulder dystocia, neonatal acidosis, and phototherapy. Subgroup analyses were performed according to types of position (occiput posterior or occiput transverse), techniques used (whole-hand or digital rotation), and parity (nulliparous or parous). The quality of each study was evaluated with the revised Cochrane risk-of-bias tool for randomized trials, known as RoB 2. The meta-analysis used random-effects models depending on their heterogeneity, and risks ratios were calculated for dichotomous outcomes. Here, 7 of 384 studies met the inclusion criteria and were selected. They included 1402 women: 704 in the manual rotation groups and 698 in the control groups. Manual rotation was associated with a higher rate of spontaneous vaginal delivery: 64.9% vs 59.5% (risk ratio, 1.09; 95% confidence interval, 1.03–1.16; P=.005; 95% prediction interval, 0.90–1.32). This association was no longer significant after stratification by parity or technique used. Manual rotation was associated with spontaneous vaginal delivery only for the occiput posterior position (risk ratio, 1.08; 95% confidence interval, 1.01–1.15). Furthermore, it was associated with a reduction in occiput posterior or transverse positions at delivery (risk ratio, 0.64; 95% confidence interval, 0.48–0.87) and episiotomies (risk ratio, 0.84; 95% confidence interval, 0.71–0.98). The groups did not differ significantly for cesarean deliveries, operative vaginal deliveries, or neonatal outcomes. Manual rotation increased the rate of spontaneous vaginal delivery.