Improvement Stories

Identification and
Manual Rotation of the
Occiput Posterior Fetus

Contributors:
Cathy L. Emeis, PhD, CNM
Assistant Professor, Nursing and
Assistant Program Director, Nurse-Midwifery
Oregon Health & Science University
School of Nursing

Sally Hersh, DNP, CNM
Manager, OHSU Nurse-Midwifery Practice

What did you set out to change or improve?
The ability of recognize and potentially correct an occiput posterior fetal position impacting active labor and/or second stage labor.

How did you change it? What new policy, process, or practice did you put in place?
We hosted a nurse-midwifery grand rounds on the topic to increase awareness of the impact of persistent OP position on labor and birth outcomes. This grand rounds contained a practical component on how to manually rotate the fetus as well as the role of ultrasound in helping to diagnose an OP fetus.

Who was involved in making the change and what was each person’s role?
This particular topic was an individual midwife’s passion. She developed a presentation after noticing that many medical students and residents lacked the skill to identify and rotate OP babies. Additionally, two of our attending physicians are published authors on this topic, so there was great interest and support. Our department at Oregon Health & Science University has been active in a multi-faceted approach to reducing the cesarean delivery rate; this maneuver was seen as one method to achieve this goal. This training opportunity has been repeated several times with opportunities for learners to simulate manual rotation on dolls.

How did you determine if the change worked? What data did you collect? How did you define “success”? How did you ensure your change didn’t have any unintended negative consequences?
The OHSU Faculty Nurse-Midwifery service has a robust data collection tool that documents fetal position at birth. However, it does not document manual rotation, so this intervention will be added in the next upgrade. Because of the increased awareness of the outcomes associated with OP position, a recent upgrade to the OHSU EHR (Epic) contains more detail on fetal position during labor and has a box to indicate whether manual rotation was performed. Ongoing data collection and analyses will determine the number of mothers with manual rotation performed in labor. A potential negative consequence for manual rotation is cervical laceration if manual rotation is performed before complete dilation. Cervical laceration is a rare outcome and is already tracked.

Other methods of determining the effects of this change: The OHSU midwives are actively involved in weekly Department OB M&M case presentations. Furthermore, there are ongoing informal discussions about cases in which rotation was used at board rounds (twice daily).Also, the midwives are often consulted by the Family Medicine and OB residents if there is a malposition and give consultative advice on ideas for position changes. In the Epic EHR order set, another provider may order an inpatient CNM consultation (listed along with other options/services for consultation).

What was the biggest barrier to making the change and how did you overcome it?
There have been very few barriers. There has been some theoretical debate regarding whether manual rotation is best performed prior to, or at, complete dilation. There are few data to inform this question and this has been suggested as a research project.

CNMs typically are less likely to use ultrasound in labor to determine fetal position, so more consistent use of verifying fetal position with ultrasound is being encouraged.

If you have data or other evidence that your change was successful, please provide that data.
We acknowledge that it will be difficult to “prove” that manual rotation actually affects true health outcomes, but for women who had manual rotation performed we will be able to document the cesarean delivery or assisted vaginal delivery rate.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
Consider offering training multiple times during the year to provide practice opportunities and address the needs of new learners as they join the institution. Also, consider how you will document and track the processes and outcomes before widespread implementation.