Management of delivery when malposition of the fetal head complicates the second stage of labour

Key content Second stage caesarean section (CS) is associated with greater maternal and neonatal morbidity and second stage CS rates are rising. Malposition of the fetal head is the most common indication for CS in the second stage of labour. Rotational vaginal deliveries are high risk obstetric procedures requiring advanced operator expertise and are associated with increased rates of failure. Currently, there are no UK guidelines for performing, training and documentation of rotational vaginal deliveries. The Royal College of Obstetricians and Gynaecologists' training matrix advises trainees to be competent at rotational ventouse before commencing specialist training year 6 and does not mention any other methods of rotational vaginal delivery. Learning objectives To learn how to manage fetal malposition in the second stage of labour. To identify appropriate maternal and fetal factors for trials of rotational instrumental vaginal delivery. To understand the requirement for national guidelines for documentation and training. Ethical issues Is exclusion of Kielland forceps and manual rotation in the current training matrix deskilling the future workforce? Is 24-hour consultant presence on the labour ward a practical solution to promote training and increase success rates in rotational vaginal deliveries? Can the use of training mannequins replace or reduce the length of appropriately supervised hands-on practice?