A multiparous woman at 41+2 weeks is in active labor. Station is 0, position is OT (occiput transverse) at full dilation for 2 hours. Fetal head is not rotating. Which of the following is the MOST appropriate first maneuver to attempt before considering operative delivery?

• A Manual rotation of fetal head to OA (occiput anterior) position ✓
• B Immediate application of Kielland's forceps for rotational forceps delivery
• C Maternal position change to hands-and-knees or lateral Sims position to facilitate rotation
• D Fetal scalp blood sampling to assess for acidemia before deciding on intervention

Explanation

When the occiput transverse position persists at full dilation with the head at 0 station, manual rotation (digital or hand rotation) of the fetal head to occiput anterior is the most appropriate first intervention. Manual rotation has success rates of 70–90% and can facilitate spontaneous or instrumental vaginal delivery, avoiding cesarean section. Maternal position change (C) is appropriate earlier in labor (active phase rotation maneuvers) but at full dilation with 2 hours of delay, manual rotation is indicated first. Kielland's rotational forceps (B) carry higher maternal and fetal complication risks and should be performed only by experienced operators after failed manual rotation or when it is contraindicated. FBS (D) is appropriate if CTG is pathological but does not address the mechanical issue.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.