OBJECTIVES: Accurate determination of fetal head position is essential for managing labor, particularly in cases of slow progress or before operative vaginal interventions. Several studies have shown that ultrasound examinations are more accurate than clinical examinations, but few ultrasound studies are done in sub-Saharan Africa. Clinical vaginal assessment of fetal position remains the standard in most African settings, but its accuracy is limited by examiner skills and labor conditions. This study aimed to compare clinical and ultrasound assessments of fetal position during active labor, to identify factors contributing to clinical misdiagnosis, and to evaluate the impact of misdiagnosis on delivery mode. METHODOLOGY: An observational cohort study was conducted at Kilimanjaro Christian Medical Centre in Moshi, Tanzania, from 19 RESULTS: The final study population comprised 215 women, 204 were examined in the active first labor stage and 210 in the second stage. Fetal position could not be determined clinically in 40/204 (19.6%) women in the active first stage, but ultrasound successfully determined position in all cases. The overall agreement rate in the active first stage was 101/164 (61.6%), with 60/76 (78.9%) agreement in OA position and 41/88 (46.6%) agreement in non-OA positions. Agreement in classifying position into four categories (OA, LOT, OP, and ROT) was moderate (Cohen's kappa, CONCLUSIONS: Clinical and ultrasound assessments showed moderate agreement. Caput succedaneum and molding influenced clinical misdiagnosis, and misdiagnosed positions were associated with higher CS rates.