Objective <p>To investigate the efficacy and safety of applying the ultrasound-guided bone fulcrum lever rotation method during manual rotation of the fetal head in cases of labor dystocia due to fetal head malposition.</p> Methods <p>This retrospective study analyzed 109 parturients with persistent occiput posterior (POP) or occiput transverse (OT) positions in the second stage of labor, who delivered at a tertiary hospital in Jiangsu Province, China, between January 2024 and September 2025. Participants were divided into an experimental group (ultrasound-guided bone fulcrum lever rotation, <i>n</i> = 54) and a control group (conventional manual rotation, <i>n</i> = 55). Comparisons were made regarding the fetal head rotation success rate, the mode of delivery, and the neonatal outcomes.</p> Results <p>The success rate of fetal head rotation was significantly higher in the experimental group compared to the control group (88.89% vs. 67.27%, <i>P</i> = 0.006). The rotation procedure time was shorter in the experimental group (<i>P</i> = 0.019), and the rate of spontaneous vaginal delivery was significantly higher (94.44% vs. 76.36%, <i>P</i> = 0.008). There were no significant differences in neonatal outcome indicators between the two groups.</p> Conclusion <p>In this study, intrapartum ultrasound localization was combined with manual rotation manipulation for the management of cephalic dystocia. The results indicated that this combined intervention yielded better clinical efficacy than conventional manual rotation alone, and thus it holds high clinical application value.</p>