(612) Cost-effectiveness of manual rotation in the setting of persistent occiput posterior position

Thursday, January 30, 2025

4:00 PM – 6:00 PM

Submitting Author and Presenting Author(s)

Riane Bradbury-Huang, N/A (she/her/hers)

Undergraduate Student
Barnard College of Columbia University
Portland, Oregon, United States

Coauthor(s)

Aaron B. Caughey, MD, PhD

Professor and Chair
Oregon Health & Science University
Portland, Oregon, United States

Objective: Persistent occiput posterior position during the second stage of labor occurs in approximately 5% of annual pregnancies. This fetal position is associated with longer labors, higher cesarean rates, and increased perinatal complications. Manual rotation of the fetal occiput can resolve the malposition in a subset of pregnancies. We examined the outcomes and costs of manual rotation versus expectant management in the setting of persistent occiput posterior position in the second stage of labor.

Study Design: We developed a decision-analytic model using TreeAge to compare outcomes between manual rotation versus expectant management for a theoretical cohort of 70,400 individuals, the annual number of nulliparous patients with persistent fetal OP position. Outcomes included cesarean delivery, post-op infection, instrumental delivery, severe perineal laceration, postpartum hemorrhage, and maternal death in addition to costs and quality-adjusted life years (QALYs). The willingness-to-pay (WTP) threshold was set at $100,000/QALY. We conducted literature searches to find inputs for the model, and conducted sensitivity analyses to discover and vary the drivers of the model in order to study its strengths.

Results: Within the theoretical cohort of 70,400 pregnancies, manual rotation prevented 24,119 cesarean sections, 1,206 post-op infections, 7,040 instances of postpartum hemorrhage, and 3 maternal deaths. However, it also resulted in an increased 10,353 instrumental deliveries and 4,796 severe perineal lacerations due to the reduction of cesareans. The manual rotation strategy was dominant to expectant management, resulting in more QALYs for lower costs. Sensitivity analyses demonstrated that manual rotation remained cost-effective until the cost of vaginal delivery was above $23,037.

Conclusion: We found manual rotation led to better outcomes and lower costs for nulliparous patients with persistent fetal OP position compared to expectant management. Further study of the impact of manual rotation and how it can be more widely trained and adopted is important for future research.