Original Research

A randomized controlled trial of prophylactic early

manual rotation of the occiput posterior fetus at the
beginning of the second stage vs expectant
management
D1X X
Jeffrey C. Broberg, MD;
D2X X D3X X
Aaron B. Caughey, MD,
D4X X PhD

BACKGROUND: Women whose fetuses are in the occiput posterior
head position at the time of delivery are known to have longer second
stages of labor and more complicated deliveries including more operative
deliveries (cesarean, forceps, or vacuum-assisted delivery) and more third-
and fourth-degree lacerations than those whose fetuses are in the occiput
anterior position.
OBJECTIVE: We hypothesized that rotating the fetus at the start of the
second stage might decrease these complications.
STUDY DESIGN: At Utah Valley Regional Medical Center, we ran-
domized term (37 weeks or beyond), nulliparous patients with epidurals
and a singleton fetus in the occiput posterior position to either
attempted early manual rotation 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)
to show a difference of 36 minutes of pushing time between the
2 groups.
RESULTS: We randomized 65 patients (33 to early manual rotation and
32 to control). When we examined a variety of baseline obstetrical charac-
teristics, we found no statistically different values for the 2 groups. The
early manual rotation group had a shorter median second stage of labor
(65 minutes vs 82 minutes; P=.04).
CONCLUSION: Early manual rotation of the occiput posterior fetus led
to a shorter second stage of labor in this small randomized trial. Future
larger randomized trials are needed to validate these findings.
Key words: arrest of descent, malpresentation

Introduction Residents trained in the use of rota- dystocia or for fetal indications for

O cciput posterior (OP) fetal head

position is a known risk factor for
prolonged first and second stages of
labor and for increased risks of opera-
tive vaginal delivery, severe perineal lac-
erations, and cesarean delivery.1−7
Management of OP fetal head position
in the first stage of labor is generally
accepted to be expectant. However,
management of persistent OP fetal head
position in the second stage is more var-
ied, with options of interventions
including cesarean delivery, operative
vaginal delivery from the OP position
or with the use of rotational forceps to
the more favorable occiput anterior
(OA) position, or manual rotation fol-
lowed by either expectant management
or operative vaginal delivery.
Cite this article as: Broberg JC and Caughey AB A ran-
domized controlled trial of prophylactic early manual rota-
tion of the occiput posterior fetus at the beginning of the
second stage vs expectant management. Am J Obstet
Gynecol MFM 2021;3:100327.
2589-9333/$36.00
© 2021 The Author(s). Published by Elsevier Inc. This is
an open access article under the CC BY-NC-ND license <
tional forceps at the time of graduation
from residency programs are decreasing,
and few are using this in their practice
after graduation.8,9 Thus, for most prac-
ticing obstetrical and gynecology pro-
viders, options for intervention for
persistent OP position are cesarean
delivery, operative vaginal delivery from
the OP position (either vacuum or for-
ceps), or manual rotation to the OA
position. Because of the known increased
maternal and neonatal morbidity from
cesarean and operative vaginal deliveries,
especially from the OP position, and
because of the paucity of practitioners
trained in rotational forceps, attention
has turned toward manual rotation of
the fetal head as an attractive option for
the management of this challenging clin-
ical scenario. Studies looking at rotating
the fetus manually in the second stage of
labor have suggested this to be a safe and
effective method of decreasing the conse-
quences of this malposition.10−15
In general, managing OP position in
the second stage of labor has focused on
expectant management, with interven-
tions being implemented only for
immediate delivery. Partially because of
the principle of “First do no harm,” but
also because the fetus will often sponta-
neously rotate to the OA position, man-
ual rotation of the fetal head is often
performed after arrest of descent or for
fetal indications for delivery.
However, there is evidence that the
success rate of manual rotation
decreases as the fetal head descends into
the maternal pelvis.11 By waiting, the
mother may be at an increased risk of
morbidity from operative delivery
(either cesarean or vaginal). Thus, “pro-
phylactic” early manual rotation (EMR)
of the fetal head has been proposed as a
possible intervention before the diagno-
sis of fetal distress or arrest of descent.11
It is also unclear at what point during
the second stage to attempt rotation. To
date, there are no prospective data to
guide the clinician as to the optimal
time to rotate the baby in the second
stage.
With this background, our objective
was to perform a prospective random-
ized controlled trial of nulliparous
patients at term, whose fetus was in the

March 2021 AJOG MFM 1

Original Research
AJOG MFM at a Glance
Why was this study conducted?
This study aimed to determine whether there was a benefit to manual rotation at
the beginning of maternal pushing efforts as opposed to waiting to rotate if
needed later in the second stage.
Key findings
There was a shorter pushing time if rotation was performed at the start of mater-
nal pushing.
What does this add to what is known?
This study adds information as to the timing of manual rotation.
OP position, comparing EMR of the
fetal head “prophylactically” at the
onset of maternal pushing efforts with a
control group of patients who began
pushing without manual rotation, but
could be rotated if indicated for slow
progress or for fetal indications. We
hypothesized that rotating at the onset
of pushing would decrease maternal
pushing time.
Materials and Methods
Between March of 2010 and June of
2012 at Utah Valley Regional Medical
Center, Intermountain Healthcare,
Provo, Utah, we randomized 65 nullipa-
rous patients with epidurals who were at
between 37 and 42 weeks’ estimated
gestational age and whose singleton
fetus with reassuring fetal heart tracing
was in the OP position to either
attempted EMR or to a control group
who began pushing without manual
rotation. If the fetal position was felt by
digital examination to be OA or trans-
verse, ultrasound was not performed.
Randomization was performed at the
time of consent at the beginning of the
second stage of labor and was done by
drawing a sealed envelope from a box.
Physicians were called to assess the
head position of the fetus once the cer-
vix was completely dilated. If the fetus
was determined by digital exam to be in
the OP position (or right or left OP
positions), a transabdominal ultrasound
was performed to confirm fetal head
position. With confirmation of the OP
position by ultrasound and if the patient
then consented to the study, she was
randomized to either the EMR group or
2 AJOG MFM March 2021
the control group. Patients in the EMR
group then underwent attempted man-
ual rotation as they began pushing.
Patients in the control group began
pushing without attempted rotation.
For both groups, manual rotation
could be performed later in the second
stage if indicated for slow progress or
other usual indications, such as concern
for fetal well-being and need to expedite
delivery. Nurses were asked to call the
physician to assess the patient when
there was lack of descent after 1 hour, at
2 hours of total pushing, or for concerns
for fetal or maternal well-being. Physi-
cians were free to intervene as indicated
by manual rotation, assisted vaginal
delivery with vacuum or forceps
(including rotational forceps), or cesar-
ean delivery. Notably, 7 providers were
involved in the study and performed all
of the rotations. All of the patients were
patients of the rotating providers who
were all physicians of Valley Women’s
Health.
To have adequate power to examine
the length of pushing time in the second
stage, using a large study which docu-
mented pushing times and fetal head
positions,16 we estimated that to find a
36-minute difference, we would need 32
patients in each arm for 80% power
with an alpha of 0.05. We recorded
patient characteristics for both groups
including age, gestational age, height,
weight, weight gain in pregnancy, and
ethnicity. We recorded times of the
stages of labor, method of delivery,
number of episiotomies, type of perineal
lacerations, estimated blood loss, and
fetal position and weight at delivery.
All participating obstetrical providers
were already trained in and were com-
fortable using manual rotation in their
obstetrical practice. Rotations were per-
formed by placing the provider’s hand
in the vagina, grasping the fetal occiput,
and using a gentle motion to manually
rotate the fetal head to the anterior posi-
tion. If the head position was left OP,
then the physician’s right hand was used
for counterclockwise rotation, and if
right OP, the left hand was used for
clockwise rotation. If the physician was
unable to fit the hand in the vagina,
then a digital rotation was attempted by
placing the fingers posterior to the lamb-
doidal sutures and exerting force toward
the direction of expected rotation. The
rotation attempt was deemed successful
if the head changed to an anterior posi-
tion. If the head was either in a posterior
or transverse position after 3 attempts,
the attempt was deemed unsuccessful. A
single provider did all rotations on study
patients. Additional providers were not
consulted if the rotation was unsuccess-
ful. We also recorded whether there
were any complications from the rota-
tion attempts.
The primary outcome was the length
of the second stage of labor. We also
examined multiple secondary outcomes
including rotation success, delivery
position, mode of delivery, and mater-
nal and neonatal complications. Out-
comes were examined with intention-
to-treat analysis. We compared length
of labor outcomes using the Wilcoxon
rank sum. Dichotomous and categorical
outcomes were compared with the chi-
square or Fisher exact tests. Statistical
analysis was performed with Stata v. 11
(StataCorp LLC, College Station, TX),
and the statistical significance threshold
was set at P=.05.
Results
We consented a total of 65 patients who
met the criteria for randomization. All
65 were included and completed the
study. There were 33 in the EMR group
and 32 in the control group.
There was no difference between the 2
groups in terms of baseline patient char-
acteristics including maternal age, gesta-
tional age, maternal weight and maternal
 Original Research

operatively (5 forceps-assisted, 5 vac-

TABLE 1
uum-assisted, and 2 cesarean deliver-
Patient characteristics: early manual rotation vs control
ies), and in the control group, 9 of 32
Characteristic Early manual rotation (n=33) Control (n=32) P valuea (28%) were delivered operatively (6 for-
ceps-assisted, 2 vacuum-assisted, and 1
Maternal age, y 23.9 23.2 .21
cesarean delivery) (Table 2). Operative
Maternal height, in 65.5 65.5 .94 deliveries were performed for nonreas-
Maternal weight at delivery, lb 180.9 181.8 .92 suring fetal status and for arrest of
Maternal BMI at delivery 29.6 29.8 .98 descent in both groups. There was no
difference in those indications between
Weight of newborn, g 3503 3446 .65
the groups (each group had 3 operative
Gestational age at delivery, wk 39.6 39.6 .85 deliveries for nonreassuring fetal
Maternal weight gain in pregnancy, lb 34.3 31.8 .40 status).
Induction of labor 12/33 (36.4%) 10/32 (31.3%) .66 Of the 33 patients in the EMR group,
BMI, body mass index.
23 were rotated successfully on initial
a
Continuous outcomes that were normally distributed were compared with the Student t test. Nonnormally distributed variables
attempt, and 2 could later be successfully
were compared with the Wilcoxon rank sum test. Categorical variables were compared with the Fisher exact test. manually rotated. The other 8 were
Broberg. Prophylactic early manual rotation of the occiput posterior fetus. Am J Obstet Gynecol MFM 2021. unable to be successfully rotated giving a
success rate of 25 of 33 or 76%. The
median pushing time for the patients suc-
cessfully rotated on initial attempt was 44
weight gain, and fetal weight (Table 1). groups. The EMR group had a median minutes. The median pushing time for
Our population was largely white (26 of pushing time of 65 minutes, and the the patients who could not be successfully
33 in the EMR group, 27 of 32 in the con- control group had a median pushing rotated initially was 133 minutes. In the
trol), with each group having 1 patient of time of 82 minutes (Figure 1). There EMR group, 26 of 33 patients were either
Polynesian descent and 3 of Hispanic was no statistical difference between the manually rotated successfully or rotated
descent. The EMR group had 2 of Asian 2 groups in terms of operative vaginal spontaneously (79%).
descent and the control group had 1. or cesarean delivery or for third- and In the control group, 21 of 32 patients
There was 1 patient in the EMR group fourth-degree lacerations. The total rate rotated spontaneously (66%). Of the 11
for whom ethnicity was not recorded. of operative deliveries between the 2 patients in the control group who did
There was a statistical difference in groups was similar. For the EMR group, not rotate spontaneously, 7 could be
the median pushing time between the 2 12 of 33 (36%) were delivered manually rotated successfully. One did
not spontaneously rotate but delivered
spontaneously OP. Therefore, in the con-
trol group of 32 patients, 29 rotated
FIGURE 1
spontaneously, were able to be manually
Kaplan-Meier survival estimates
rotated, or delivered spontaneously OP
(91%) (Figure 2). The median pushing
time for these patients was 77.5 minutes.
The median pushing time for the patients
in the control group who did not rotate
spontaneously was 153 minutes.
We did not identify any complications
related to the rotations. In particular, no
cord prolapses, cervical lacerations, or
injury to the fetus occurred. Notably, 1
newborn was diagnosed as having a
cephalohematoma. This patient was part
of the control group and was never
rotated (spontaneously rotated). We did
not have any Apgar scores of <7 at 5
Kaplan-Meier survival curves comparing the length of the second stage between the 2 groups: EMR minutes in either group. A diagnosis of
vs expectant management (control). The log-rank test for the survival curves had a P value of .02. chorioamnionitis was similar in each
EMR, early manual rotation. group (4 patients in the EMR group and
Broberg. Prophylactic early manual rotation of the occiput posterior fetus. Am J Obstet Gynecol MFM 2021. 6 in the control group).

March 2021 AJOG MFM 3

Original Research

TABLE 2
Early manual rotation vs control
Measured outcomes Early manual rotation (n=33) Control (n=32) P valuea
Median length of pushing time
Overall 65 (19−122) min 82 (69−153) min .04
In those who rotated n=25 (76%); 44 (17−72) min n=21 (66%); 75 (49−98) min .02
In those who did not rotate n=8; 133 (93−180) min n=11; 153 (90−168) min .92
Second stage of <1 h 15/33 (46) 6/32 (19) .033
Second stage of <2 h 24/33 (73) 21/32 (66) .598
CD 2/33 (6.1) 1/32 (3.1) .57
Operative vaginal delivery 10/33 (30.3) 8/32 (25) .78
Third- and fourth-degree lacerations 4/33 (12.1) 2/32 (6.2) .41
Shoulder dystocia 2/33 (6.0) 2/32 (6.2) 1.00
Mean estimated blood loss 303 289 .688
Postpartum hemorrhage 3/33 (9.0) 3/32 (9.3) 1.00
Fetal head position 4/33 (12) 3/32 (9) 1.00
OP at delivery (2 CD, 2 FAVD) (1 SVD, 1 FAVD, 1 CD)
Values are expressed as number (percentage) unless indicated otherwise.
CD, cesarean delivery; FAVD, forceps-assisted vaginal delivery; OP, occiput posterior; SVD, spontaneous vaginal delivery.
a
Continuous outcomes that were normally distributed were compared with the Student t test. Nonnormally distributed variables were compared with the Wilcoxon rank sum test. Categorical variables
were compared with the chi-square or Fisher exact test, depending on the proportion of outcomes.
Broberg. Prophylactic early manual rotation of the occiput posterior fetus. Am J Obstet Gynecol MFM 2021.

Comment
Principal findings
FIGURE 2
We found statistically significant
Schematic of study populations
(P = .04) shorter median pushing times
for nulliparous women whose fetuses
were in the OP position at the onset of
pushing who underwent attempted
manual rotation than the control group
who were allowed to push without
attempted manual rotation until clini-
cally indicated. The median difference
between the 2 groups was 17 minutes,
which is a 20% decrease in pushing
time if the fetus was rotated at the onset
of pushing.

Results
Debates on how best to manage the OP
fetus in the literature can be seen at least
as far back as the 1930s.17−20 Multiple
studies over the last few decades suggest
that manual rotation of the fetal head
Flowchart of randomized patients showing the EMR group and the control group with subsequent for persistent OP position decreases
delivery outcomes (SVD, OVD, and CD). complications related to the malposi-
AVD, assisted vaginal delivery; CD, cesarean delivery; EMR, early manual rotation; OVD, operative vaginal delivery; SVD, spontaneous tion.1−4 It is noteworthy that we found
vaginal delivery. a significant difference in pushing time
Broberg. Prophylactic early manual rotation of the occiput posterior fetus. Am J Obstet Gynecol MFM 2021. with early rotation even though rotation

4 AJOG MFM March 2021


was performed if indicated in the con-
trol group.
Clinical implications
Our study confirms that of others that
suggest a benefit of manual rotation for
OP fetuses in the second stage of labor.
It adds information regarding the tim-
ing of that rotation. Until now, when a
provider has identified a nulliparous
patient with a fetus in the OP position
at the beginning of the second stage of
labor, there has not been a randomized
clinical trial to help guide the decision
as to whether to rotate at that time or to
wait until arrest of descent or for non-
reassuring fetal status that requires
delivery. Our study suggests that rota-
tion at the start of pushing may be war-
ranted, at least in terms of decreasing
pushing time.
Our data tend to confirm that from
previous studies10 that manual rotation
is more likely to be successful when
done prophylactically vs waiting for
arrest of descent to perform the rota-
tion. Rotation done prophylactically
had a success rate of 70% (23 of 33),
and rotations done after arrest of prog-
ress were successful 50% of the time (9
of 18). The reason for the decreased
success rate is unclear. The commonly
cited theory that rotations are more dif-
ficult because the fetal head is “wedged”
in the pelvis may not be the reason for
the decreased success rate. It may well
be because of the fact that by waiting
until arrest, we are selecting a subset of
fetuses who are more difficult to rotate,
those who are easier to manually rotate,
and those who have already spontane-
ously rotated.
There was no difference in our study
in operative delivery rates between the 2
groups. One potential reason for this is
that if the patient is managed without
rotation, many of those fetuses will
eventually rotate on their own (again,
these may be the patients whose fetuses
could be rotated at the start of pushing.)
Alternatively, the fetuses who are not
able to be rotated manually may not
have rotated spontaneously in the con-
trol group and thus remain OP and be
more likely to need an operative
delivery. The EMR may save time but
not decrease operative deliveries.
Strengths and limitations
Our study is a prospective randomized
trial. It adds information not just to the
benefit of rotation but the timing of the
rotation. However, it is a small trial at a
single institution, with a relatively
homogenous patient population man-
aged by a single group of providers. We
recognize that larger studies will need to
be performed to determine whether
generalizing these data to more diverse
populations and settings still shows
benefit.
Although our study was randomized,
it was not blinded. The patient, nurse,
and the physician caring for the patient
were aware of the randomization. This
is a limitation of the study. Blinding
would require additional nursing and
physician staffing and a “sham” rotation
to blind the patient and nurse. We did
not have the resources necessary for
this. A large multicenter trial with
resources sufficient to have nursing per-
sonnel and patients blinded to the
grouping would allow better determina-
tion of any difference between the 2
groups.
We did not have a single clinically
significant complication attributable to
manual rotation in the 44 patients who
underwent attempted manual rotations.
We had 2 small perineal lacerations that
did not require intervention until after
delivery, and we had 2 fetal heart rate
decelerations that resolved spontane-
ously and did not require intervention.
In particular, we did not have any cases
of cord prolapses, fetal heart rate
changes requiring intervention, cervical
lacerations, or fetal injury in our study
patients. This confirms the data referred
to earlier from previous studies suggest-
ing that manual rotation in the second
stage can be done safely.10,11 However,
our study was small and not powered to
assess risks of rare complications.
Larger studies are needed to confirm
our safety data and to allow a more
informed discussion with our patients
as we consider rotations done prophy-
lactically, early in the second stage of
labor.
Original Research
We did not notice a difference in
operative delivery rate (cesarean, vac-
uum, or forceps delivery) between the 2
groups. Because manual rotation was
performed in both groups, it would take
a very large number of patients to deter-
mine whether the longer pushing times
could lead to an increase in these opera-
tive deliveries, presumably because of
maternal exhaustion or nonreassuring
fetal status. Our study suggests that EMR
does not decrease operative deliveries.
The study was powered to detect a
36-minute difference in pushing time
between the 2 groups based on pushing
times estimated from previous studies
documenting fetal position at the onset
of pushing. 16 Our pushing times
(65 and 82 minutes for EMR and con-
trol group) were significantly shorter
than anticipated based on those prior
studies and as such we were able to
detect a statistically significant differ-
ence in pushing time despite only hav-
ing a 17 minute difference in pushing
time between the 2 groups. The reasons
for the shorter pushing time in our
group of patients may be our patient
population being healthy, above average
height (mean, 65.5 inches), and young
(mean, 23 years).
Research implications
A larger, multicenter, blinded random-
ized trial would be needed to help
answer these questions. In 2014, Graham
et al21 conducted a pilot randomized
controlled trial. Those women with a
fetus in the OP position at the beginning
of the second stage were randomized to
either a digital rotation or a sham proce-
dure. They determined that such a study
with patient and nursing staff being
blinded to the intervention was accept-
able to the staff and the patients. This
type of study would help add to and clar-
ify our findings, including whether early
rotation is safe, decreases pushing time,
and affects operative delivery rates.
Conclusions
Manual rotation of the OP presenting
fetus at the onset of the second stage
seems to decrease the time of maternal
pushing. Clinical assessment of the
head position at the onset of the second
March 2021 AJOG MFM 5
Original Research
stage is an important part of providing
optimal care to our patients. Our goal
in performing this study was to help
physicians make evidence-based deci-
sions as they counsel their patients
when confronted with the fetus in the
OP position at the start of the second
stage of labor. Given the likelihood that
manual rotation will become the main
intervention other than cesarean deliv-
ery for the OP positioned fetus, further
research in this area is warranted. Fore-
most in this research should be safety
concerns. A 20% reduction in pushing
time may be attractive to our patients
but not if that places them and their
fetuses at risk. & Vacuum and forceps training in residency:
ACKNOWLEDGMENTS
The authors acknowledge the following physi-
cians, who in addition to the first author man-
aged the deliveries of the study patients,
consented and randomized them, and per-
formed the manual rotations: Scott Rees, DO;
Scott Jacob, MD; Peter Drewes, MD; Jefforey
Thorpe, MD; Kent Gamette, MD; and Brian
Wolsey, MD. Without their assistance and
cooperation, the study could not have been
completed.
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Author and article information
From Valley Women’s Health, Provo, UT (Dr Broberg);
Utah Valley Hospital, Intermountain Healthcare, Provo, UT
(Dr Broberg); Department of Obstetrics and Gynecology,
Oregon Health and Science University, Portland, OR (Dr
Caughey).
Received Jan. 4, 2021; revised Jan. 24, 2021;
accepted Jan. 26, 2021.
The authors report no conflict of interest.
Clinical Trial Registration: ISRCTN23995324: early
manual rotation, March 3, 2016.
Presented at the 36th annual meeting of the Society
for Maternal-Fetal Medicine, Atlanta, GA, February 1−6,
2016, and the 79th annual meeting of the Pacific Coast
Obstetrical and Gynecological Society, Newport Beach,
CA, October 3−7, 2012.
Corresponding author: Jeffrey C. Broberg, MD.
broberg@valleywomenshealth.com