CAESAREAN SECTION

AT FULL DILATATION
A/Prof John Svigos
Discipline of Obstetrics and
Gynaecology
University of Adelaide
 DISIMPACTION
EXTENT OF THE PROBLEM
A deeply impacted fetal head at the time of
caesarean section is estimated to occur in 1.5%
of all caesarean sections and up to 25% of
emergency caesarean sections (Levy et al 2005;
Singh et al 2008).
Risk factors include fetal malposition, prolonged
second stage, failed trial of operative vaginal
delivery.
 DISIMPACTION
The proportion of Second Stage caesarean sections is
projected to increase for several reasons –
• Decreased use of rotational and mid-cavity forceps
• Shift towards vacuum assisted vaginal delivery which is
more likely to fail in the above circumstances
• Increased regional anaesthesia which can prolong the
second stage
• In trying to prevent a primary caesarean section longer
second stages of up to 3 hours in nullips and for multips, 2
hours of pushing without epidural anaesthesia and longer
with an in situ epidural.
• The increasing prevalence of maternal obesity and fetal
macrosomia may also contribute to an impacted fetal head
 DISIMPACTION
Several factors contribute to the mechanism of dystocia in the delivery of the
fetus with an impacted head –
. The lower uterine segment is often distended potentially risking the
complications of an inferior or lateral extension into the vagina or broad
ligament despite a higher than normal lower uterine segment incision with
resultant maternal haemorrhage, endometrial infection, low neonatal Apgar
scores, ICU admission, fetal long bone and skull fracture or fetal laceration.
Only the fetal shoulder may be visible once the uterine cavity is entered or
the fetal head may be significantly deflexed and/or moulded.
. The surgeon’s ability to minimizing the delivering cephalic diameter by
intentional flexion may be limited by splinting of the fetal spine within a
contracted uterus.
. Faced with this the obstetrician must rapidly elect an efficient and effective
delivery technique
 DISIMPACTION
DISENGAGEMENT TECHNIQUES
1. THE “PUSH” METHOD
This is the most favoured method in USA and UK
After lowering the table and using Trendelenberg
position, the woman is placed in the modified lithotomy
position with knees flexed and thighs abducted.
The IGGA inserts a hand into the vagina and gently
replaces the fetal head superiorly into the pelvis with
cupped fingers as the surgeon applies traction to the fetal
shoulders or attempts to flex the head into the uterine
wound.
DISIMPACTION
 DISIMPACTION
2. THE PULL METHOD (REVERSE BREECH EXTRACTION)
Has been studied more extensively in developing
countries where obstructed labour may be more
common.
The obstetrician reaches towards the upper uterine
segment and grasps one or both feet and with a
combination of internal podalic version and footling
breech keeping the back uppermost , the breech and
then the shoulders and finally the head is delivered
through the uterine wound which may need to have a J or
T extension.
DISIMPACTION
 DISIMPACTION
3. OTHER METHODS
3.1 Bimanual Push Method performed by the obstetrician rather
than with the aid of a IGGA
3.2 Patwardhan Method of shoulder traction with manipulation of the
fetal shoulders through the uterine wound followed by delivery of the
head trunk and feet.
3.3 Fetal Pillow Method is gaining popularity with the largest study in
Australia conducted at the Mater Mother’s Hospital in Brisbane.
It consists of a vaginally placed balloon, rather like inserting a posterior
cup of a ventouse, with the mother in a similar lithotomy position as
the Push Method.
The balloon is filled with saline prior to the caesarean section and this
may achieve an elevation of the fetal head of up to 3 cm.
The balloon is deflated with delivery of the head by withdrawing the
saline and the balloon is removed at the conclusion of the operation.
DISIMPACTION
DISIMPACTION
 DISIMPACTION
A Systematic review of the Push and Pull Methods by Berhan and
Berhan 2014 included 11 studies of 1028 women from 7 Middle
Eastern, African and South East Asian countries
The Push Method was associated with a nearly 8 fold increased risk of
uterine wound extensions, haemorrhage, transfusion, and an increase
in operating time compared to
The Pull Method was shown to have a greater chance of long bone
fractures.
Pooled data revealed no significant difference in maternal and fetal
infection and 5 min Apgar scores
The Fetal Pillow Method while rapidly gaining popularity with its
uniform success and relative lack of maternal and fetal injury has the
limitation that the numbers assessed are relatively small and it is not
clear when it should be utilized as it may be unnecessary in some
cases if universally applied which will increase the cost ($500 per unit).
 DISIMPACTION
Thus existing data do not clearly favour a singular delivery
technique and hence it is left to the discretion and
experience of the obstetrician.
(Confirmed by Cochrane review 2016 by Waterfall, Dodd
and Grivell)
Nevertheless there needs to be:
Situational awareness, clear communication, rapid and
decisive operative manouvres, effective multi-disciplinary
team work.
To improve maternal and neonatal safety and promote an
element of standardization we suggest the ALERT
Algorithm (Manning et al 2015)
 DISIMPACTION
ALERT

“A” – alert the multi-disciplinary team early if an

impacted head is suspected.
In cases of prolonged second stage particularly if
attempts at operative vaginal delivery with traction
have been unsuccessfully made.
With the latter a Fetal Pillow could be considered
Preparation should be made for additional
assistants and anaesthesiology personnel with
uterine relaxants available.
 DISIMPACTION
ALERT
“ L “ – lower the operating table to facilitate
manouvres, consider Trendelenberg position
and depending on the obstetrician’s choice of
dealing with a possible fetal head impaction,
place legs in the modified lithotomy position so
that the Fetal Pillow or the Push method can be
employed.
 DISIMPACTION
ALERT
“ E “ – extend the skin, fascial or uterine
incisions (usually perform more superiorly than
usual) if needed after initial assessment
(particularly if the shoulder/s present at the
uterine incision (‘shoulder sign’)
 DISIMPACTION
ALERT
“ R “ - relax uterus with relaxant agents or incise
Bandl ring if present.

“ T “ – techniques for delivery –

Pillow
Push
Pull
 DISIMPACTION
A COMMON SCENARIO: FETAL HEAD IMPACTION NOT
SUSPECTED
If normal attempt at dis-impaction of the fetal head is NOT
SUCCESSFUL then can -
. Lower table and use non dominant hand to try to flex the
fetal head and at the same time consider Trendelenberg
position and a uterine relaxant
IF NOT SUCCESSFUL can
.. place legs in the modified lithotomy position and utilize an
IGGA to assist with the PUSH METHOD
or
.. attempt PULL METHOD – may need to extend uterine
incision ( J or T) and/or abdominal incision
 DISIMPACTION
POST DELIVERY
Strict attention to potential maternal morbidity
as a result of the attempts to deliver and, as
always, careful surgical attention and medical
management.
Accurate documentation
Patient Debrief
Staff Debrief
 DISIMPACTION
SUMMARY
A – alert staff
L – lower the table and position the legs
E – extend incisions
R – relax the uterus
T – techniques for delivery

Pillow
Push
Pull