A Randomized Controlled Trial of Prophylactic Early Manual Rotation of the Occiput Posterior Fetus at the Beginning of the Second Stage vs. Expectant Management.

Abstract Objectives Women whose fetuses are in the occiput posterior (OP) head position at the time of delivery are known to have longer second stages of labor, as well as more complicated deliveries including more operative deliveries (cesarean section, forceps or vacuum assisted) and more third and fourth degree lacerations when compared to those whose fetuses are in the occiput anterior position.  We hypothesized that rotating the ss Study Design At Utah Valley Regional Medical Center, we randomized term (37 weeks or beyond), nulliparous patients with epidurals and a singleton fetus in the OP position, to either attempted early manual rotation (EMR) to occiput anterior, or to a control group managed expectantly. The control group could later be rotated if indicated by the clinical setting. The primary outcome was the length of the second stage of labor. Dichotomous outcomes were compared utilizing the chi-square test and continuous outcomes were compared utilizing the Student t-test or Wilcoxon rank Sum test.  The sample size estimate was for 64 patients to be randomized (32 in each group) in order to show a difference of 36 minutes of pushing time between the two groups. Results We randomized 65 patients (33 to EMR and 32 to control). When we examined a variety of baseline obstetric characteristics, we found no statistically different values for the two groups. The EMR group had a shorter median second stage of labor (65 minutes vs. 82 minutes, p=0.04). Conclusion Early manual rotation of the OP fetus led to a shorter second stage of labor in this small randomized trial. Future larger randomized trials are needed to validate these findings.