We appreciate the interest by Le Ray and colleagues in our article. We agree that cesarean delivery during the second stage of labor owing to fetal malposition should be avoided if possible. However, we disagree that the "high" complication rates associated with Kielland's rotational forceps delivery mean that they no longer have a place in delivering fetuses with persistent malposition during the second stage of labor. We demonstrated there was no difference in rates of neonatal encephalopathy or neonatal unit admission after Kielland's rotational forceps delivery (0.7%; 3.3%) compared with nonrotational forceps (0.2%, P=.38; 6.1%, P=.25), ventouse (0.6%, 3.8%; both P>.99), and vaginal delivery (0.1%, P=A5; 3.7%, ￡>.99). Although, in experienced hands, manual rotation is reported to have a low failure rate of 10%,2 other studies report failure rates of up to 25%.3 In those cases in which manual rotation fails, delivery is usually by cesarean, which we showed had higher rates of postpartum hemorrhage and neonatal unit admission.
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