Manual Rotation of the
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
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
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.