Prophylactic manual rotation of the fetal head (manual rotation alone) to reduce operative delivery and complications for mother and babies.

Rationale: 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.

Objectives: 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.

Search methods: We searched CENTRAL, MEDLINE, three other databases and three trial registries in March 2024. We reviewed the reference lists of retrieved studies.

Eligibility criteria: 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, (< 37 weeks' gestation) planning a vaginal birth with a cephalic singleton fetal malposition in labour. We defined prophylactic manual rotation as rotation performed without immediate instrumental vaginal delivery. We excluded non-randomised studies, and studies comparing manual rotation as part of a multi-component intervention without the ability to isolate the effect.

Outcomes: Critical outcomes were operative delivery (forceps or vacuum delivery or caesarean section), maternal and perinatal mortality, caesarean section, instrumental delivery (forceps or vacuum delivery), third- or fourth-degree perineal trauma and postpartum haemorrhage of 500 mL or more.

Risk of bias: Two review authors independently assessed RCTs for inclusion and extracted data. Two review authors independently evaluated the risk of bias using the Cochrane risk of bias (RoB 1, version 5.2) tool.

Synthesis methods: We analysed dichotomous data using a random effects model and presented the results as summary risk ratios (RRs) with 95% confidence intervals (CIs). We also assessed the certainty of the evidence using the GRADE approach.

Included studies: The review included six RCTs in Australia, France and the USA, recruiting a total of 1002 participants. We judged the overall risk of bias to be low for three RCTs (444 participants). We assessed the other three RCTs (558 participants) to have a high risk of performance and detection bias as they did not blind the control group. All RCTs included pregnant women in labour ≥ 37 weeks gestation with a singleton pregnancy at full cervical dilatation. A single study enrolled only nulliparous women. The majority of women (> 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.

Synthesis of results: 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.

Authors' conclusions: 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.