Preferred way of delivery of the impacted fetal head in cesarean sections during second stage of labor

Abstract

Aim: To compare maternal and neonatal outcomes between the 'head first' and 'legs first' delivery methods during a second stage cesarean section. Methods: We conducted a retrospective study between January 2009 and May 2015 at a large public university tertiary referral center. Included were all women who underwent cesarean delivery with a fully dilated cervix and a fetal head at the level of the ischial spines or below. The study population was divided into two groups according to way of fetal delivery: The 'legs first' (reverse breech) method and the 'head first' method. Demographics and maternal and fetal outcomes were retrieved for both groups. Results: During the study period 447 women underwent a cesarean section while their cervix was fully dilated. Of them, 321 met the inclusion criteria: One hundred and twenty-one (38%) were delivered using the 'legs first' method and 200 (62%) were delivered using the 'head first' method. Indication for surgery and fetal head station was similar for both groups. While no difference in overall intraoperative uterine incision extension rate was observed, a higher rate of uterine incision extension was demonstrated in the 'head first' group in cases in which the second stage was longer than 180 min (33 vs 8 cases, P = 0.02). No differences in maternal postoperative complication rates and neonatal outcomes were observed. Conclusion: Fetal extraction via the 'legs first' method during prolonged second stage of labor may lower maternal morbidity. Method of delivery does not seem to have an effect on neonatal outcomes.

Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study

“…The different extraction methods have been thoroughly described in other sources. 14 In brief, in the reverse breech extraction method the surgeon reaches towards the upper uterine segment, grasps one or both fetal legs, and applies gentle traction until the legs become visible at the uterine incision. Subsequently, the fetal legs are delicately pulled to reveal the shoulders, followed by the delivery of the fetal arms.…”

“…Comparisons of these methods have shown favorable outcomes with the reverse breech extraction method, resulting in fewer immediate maternal complications, such as uterine incision extensions and maternal blood loss. [14][15][16][17][18][19][20] The biological mechanism underlying the increased risk of PTB among patients with a previous second-stage CD is still not elucidated. However, it is hypothesized that hysterotomy extensions near or within the internal cervical os during the second stage CD could cause cervical trauma, impairing the ability of the cervix to maintain a subsequent pregnancy to term.…”

“…Two main methods for fetal extraction in cases of an impacted fetal head are the “push” method (flexing and pushing the fetal head upwards, in some cases, with vaginal assistance of another person) and the reverse breech extraction method (the operator reaches through the uterine incision and delivers the baby feet‐first with gentle traction). Comparisons of these methods have shown favorable outcomes with the reverse breech extraction method, resulting in fewer immediate maternal complications, such as uterine incision extensions and maternal blood loss 14–20 …”

A comparison of technicques to disimpact the fetal head on a second stage caesearean simulator

“…In order to facilitate elevation and disimpaction of the fetal head during a full dilatation CS, a number of techniques have been proposed. In current obstetric practive in the UK the digital ‘push-up’ method is most commonly used, but the reverse breech ‘pull’ method is also described [ 9 , 10 ]. Alternative methods using vaginal devices have been introduced, aiming to reduce the trauma associated with these techniques.…”