Disengagement of the deeply engaged fetal head during cesarean section in advanced labor: Conventional method versus reverse breech extraction

Abstract

Maternal and fetal morbidity of two different methods of delivering the baby during cesarean section performed in advanced labor when the fetal head is deeply engaged was assessed retrospectively, i.e. delivering as 'cephalic' with or without assistance to push up the fetal head from the vagina (head first or push method) and 'reverse breech extraction' (feet first or pull method). Records of 182 women with a single fetus in cephalic presentation, who had undergone cesarean section at cervical dilatation at > or =7 cm, with the vertex at or below zero station, were reviewed. Extension of the uterine incision occurred in significantly more women during 'cephalic' delivery as compared to 'reverse breech extraction' (22.8% versus 2.2%; p=0.001). Use of 'reverse breech extraction' is an attractive and safe alternative to the standard methods for intra-operative disengagement of a deeply impacted fetal head in order to reduce maternal and fetal morbidity.

Disengagement of the Deeply Engaged Fetal Head during Cesarean Section Conventional Method versus Reverse Breech Extraction- Review of Literature

“…This may result in extension of incision laterally or downwards and may involve uterine vessels, the ureter or trauma to fetal head [30].…”

“…In the reverse breech extraction the fetus in cephalic presentation is extracted through the uterine incision by the podalic pole [29,30]. In this method, after opening the uterus, the surgeon introduces a hand through the uterine incision towards the upper segment, grasps both feet, and gently pulls the fetus up to extract it through the uterine incision [25].…”

“…Results from retrospective [29,30] and some prospective [2] studies show that maternal and fetal outcomes in cases involving the pull method are better than those in cases involving the push method . All operations were performed by the same obstetric chief resident under the direct supervision of one of the co-authors.…”

“…The operation time was longer with the push method than with the pull method (overall standard mean differences (SMD)] 2.7; 95% CI, 0.57-4.82) [2,[25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41]. The duration of the hospital stay was also significantly longer in the push group [2]; however, the overall SMD showed no association with either technique [2,29,41].…”

“…Although different techniques are described in the literature [25,29,30] The superiority of one technique over another is yet to be proven [29,31,32] (Table 1). …”