title: Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation.
abstract: BACKGROUND
  To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry's spatulas (TS), in the setting of failed manual rotation (MR).
  
  
  METHODS
  We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015. The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions.
  
  
  RESULTS
  Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p < 0.002). Both groups were similar regarding most fetal outcomes and no birth trauma occurred in our study population. In a multivariable logistic regression analysis, OP operative delivery was a significant risk factor of severe perineal lacerations (OR = 9.5; 95% CI: 2.05-44.05).
  
  
  CONCLUSIONS
  Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.
authors.forename: Paul
authors.initials: P
authors.lastname: Guerby
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.
authors.forename: Mickael
authors.initials: M
authors.lastname: Allouche
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.
authors.forename: Caroline
authors.initials: C
authors.lastname: Simon-Toulza
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.|b UMR 1027 INSERM, University Paul Sabatier Toulouse III , Toulouse , France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Vayssiere
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.|b UMR 1027 INSERM, University Paul Sabatier Toulouse III , Toulouse , France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Parant
authors.affiliation: a Gynecology and Obstetrics Department , Paule de Viguier Hospital , CHU Toulouse , France.
authors.forename: Fabien
authors.initials: F
authors.lastname: Vidal
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007746:Labor Presentation; D007744:Obstetric Labor Complications / Q000517:prevention & control*; D010502:Perineum / Q000293:injuries; D011247:Pregnancy; D011446:Prospective Studies; D012307:Risk Factors; D014710:Version, Fetal / Q000295:instrumentation / Q000379:methods*; D055815:Young Adult
keywords: Rotational vaginal birth; manual rotation; severe perineal tears