Continuous persistent occiput transverse position during labor - associations of different midwifery interventions...

Persistent occiput transverse (OT) position during active labor can impede effective fetal descent and rotation, increasing the likelihood of labor dystocia and operative birth. Evidence comparing intrapartum management strategies often focuses on delivery mode, while cervical dilation rate - an important process metric guiding escalation - is less frequently evaluated. To compare different intrapartum management strategies for persistent OT in active labor with respect to cervical dilation rate and birth outcomes. We conducted a retrospective cohort study of term (≥37 + 0 weeks), singleton, cephalic pregnancies with persistent OT delivering between January 2023 and January 2025. Participants were classified by the primary strategy initiated after confirmation of persistent OT (index time): supportive care/positioning (n = 210), augmentation without rotation (n = 164), manual rotation attempt (n = 148), and planned rotational operative vaginal delivery (rOVD; n = 90). The primary outcome was cervical dilation rate (cm/h) from index to full dilation. Secondary outcomes included time to full dilation, mode of delivery, maternal morbidity (postpartum hemorrhage, obstetric anal sphincter injury [OASIS]), and neonatal outcomes. Multivariable regression models were applied, with supportive care as the reference; inverse probability of treatment weighting (IPTW) was prespecified as a sensitivity analysis. Mean dilation rate was highest in the manual rotation group (1.57 ± 0.39 cm/h) compared with supportive care (1.11 ± 0.31 cm/h; P < .001), with the shortest median time to full dilation (2.51 hours). In adjusted analyses, manual rotation was associated with a faster dilation rate (adjusted β + 0.423 cm/h, 95% CI: 0.358-0.488; P < .001) and lower odds of cesarean delivery (adjusted OR 0.51, 95% CI: 0.32-0.80; P = .004). OASIS was more frequent in the rOVD group (5.6%; P = .024). In this study, manual rotation was associated with the greatest improvement in cervical dilation rate and a favorable pattern of delivery outcomes. rOVD may facilitate delivery later in labor but may carry increased perineal morbidity. Prospective studies with standardized assessment and timing are warranted.