1
|
Kotaska A, Krause M, Beaudet L. Fetal Pillow Deflates: Low-Lithotomy Caesarean Delivers. BJOG 2025. [PMID: 40207534 DOI: 10.1111/1471-0528.18168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2025] [Revised: 02/12/2025] [Accepted: 03/28/2025] [Indexed: 04/11/2025]
Affiliation(s)
- Andrew Kotaska
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael Krause
- Department of Obstetrics, University Women's Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Luc Beaudet
- University of British Columbia, Vancouver, British Columbia, Canada
- Cowichan District Hospital, Duncan, British Columbia, Canada
| |
Collapse
|
2
|
Kotaska A, Krause M, Beaudet L. Low-lithotomy cesarean section for the impacted fetal head. Am J Obstet Gynecol 2025; 232:e146-e147. [PMID: 39515447 DOI: 10.1016/j.ajog.2024.10.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Accepted: 10/30/2024] [Indexed: 11/16/2024]
Affiliation(s)
- Andrew Kotaska
- Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Adjunct Professor, School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Michael Krause
- Deputy Clinical Director (Retired), Department of Obstetrics, Clinic Nuremberg South, Nuremberg, Germany
| | - Luc Beaudet
- Clinical Instructor, University of British Columbia, Cowichan District Hospital, Duncan, Canada
| |
Collapse
|
3
|
van der Krogt L, Suff N, Story L, Shennan A. Management of impacted fetal head at caesarean section - Current practice and future development. Eur J Obstet Gynecol Reprod Biol 2025; 307:170-174. [PMID: 39938151 DOI: 10.1016/j.ejogrb.2025.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Accepted: 02/09/2025] [Indexed: 02/14/2025]
Abstract
Worldwide, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full dilatation. In labour and at full dilatation, a caesarean section can be technically challenging and is associated with greater risks. The fetal head is lower and can be wedged within the maternal pelvis making it more difficult to deliver, a situation known as 'impacted fetal head'. This is associated with increased maternal and neonatal morbidity including uterine extensions, haemorrhage, fetal trauma and hypoxic ischaemic encephalopathy. This review explores the scope of the issue including the evidence for prevention and management of impacted fetal head, while highlighting key areas for future research.
Collapse
Affiliation(s)
- Laura van der Krogt
- Division of Women's Health King's College London Women's Health Academic Centre St Thomas' Hospital United Kingdom.
| | - Natalie Suff
- Division of Women's Health King's College London Women's Health Academic Centre St Thomas' Hospital United Kingdom
| | - Lisa Story
- Division of Women's Health King's College London Women's Health Academic Centre St Thomas' Hospital United Kingdom
| | - Andrew Shennan
- Division of Women's Health King's College London Women's Health Academic Centre St Thomas' Hospital United Kingdom
| |
Collapse
|
4
|
Cornthwaite KR, Bahl R, Lattey K, Draycott T. Maternal positioning during cesarean delivery complicated by impacted fetal head. Am J Obstet Gynecol 2025; 232:e148. [PMID: 39521306 DOI: 10.1016/j.ajog.2024.10.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Accepted: 10/29/2024] [Indexed: 11/16/2024]
Affiliation(s)
- Katie R Cornthwaite
- Department of Obstetrics and Gynaecology, University Hospitals Bristol National Health Service (NHS) Trust, St Michael's Hospital, Southwell St, Bristol, BS2 8EG, United Kingdom.
| | - Rachna Bahl
- Department of Obstetrics and Gynaecology, University Hospitals Bristol NHS Trust, Bristol, United Kingdom; Royal College of Obstetricians and Gynaecologists
| | - Katherine Lattey
- Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Bristol, United Kingdom
| | - Tim Draycott
- Department of Obstetrics and Gynaecology, North Bristol NHS Trust, Bristol, United Kingdom; Royal College of Obstetricians and Gynaecologists
| |
Collapse
|
5
|
Grey A, Avenell A, Bolland MJ, Thornton JG. The Fetal Pillow Deflates-Lessons for All. BJOG 2025; 132:429-432. [PMID: 39539078 DOI: 10.1111/1471-0528.18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Revised: 10/24/2024] [Accepted: 11/04/2024] [Indexed: 11/16/2024]
Affiliation(s)
- Andrew Grey
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Alison Avenell
- Health Services Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Mark J Bolland
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Jim G Thornton
- Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| |
Collapse
|
6
|
Ragbourne SC, Charles E, Herincs M, Desai N. Anaesthetic considerations for impacted fetal head at caesarean delivery: a focused review. Int J Obstet Anesth 2025; 61:104268. [PMID: 39342879 DOI: 10.1016/j.ijoa.2024.104268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 09/10/2024] [Accepted: 09/12/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Impacted fetal head occurs when the fetal head is deeply engaged within the maternal pelvis and difficult to deliver during caesarean delivery. In order to deliver the fetal head, additional surgical manoeuvres and/or pharmacological tocolysis are needed. The aim of this focused review is to outline the incidence, risk factors, management and complications of this obstetric emergency from the perspective of the anaesthetist. METHODS Databases were searched for free text headings and subject headings associated with different permutations of terms related to impacted fetal head and caesarean delivery. RESULTS Impacted fetal head has been estimated to occur in 1.5 % of elective caesarean deliveries and 2.9-18.4% of all emergency caesarean deliveries at any cervical dilatation. Risk factors include advanced cervical dilatation, labour augmentation with oxytocin, prolonged second stage of labour, fetal malposition and junior grade of operating obstetrician. If impacted fetal head occurs, the anaesthetist in conjunction with the multidisciplinary team should consider decreasing the height of the operating table, providing a step for the obstetrician to stand on, placing the patient in the head down position, providing pharmacological tocolysis with glyceryl trinitrate (or nitroglycerin), beta-2 adrenoreceptor agonists or volatile anaesthetic agents, and managing complications such as postpartum haemorrhage. CONCLUSION Impacted fetal head is an obstetric emergency that the anaesthetist should be familiar with and has a vital role in managing. We propose an algorithm for management that may serve as a clinical decision aid.
Collapse
Affiliation(s)
- S C Ragbourne
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - E Charles
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - M Herincs
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Honorary Senior Clinical Lecturer, King's College London, London, United Kingdom.
| |
Collapse
|
7
|
Ragbourne SC, Charles E, Herincs M, Elwen F, Desai N. Impacted fetal head at cesarean delivery. J Clin Anesth 2024; 99:111598. [PMID: 39276524 DOI: 10.1016/j.jclinane.2024.111598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 08/08/2024] [Accepted: 09/02/2024] [Indexed: 09/17/2024]
Abstract
PURPOSE Impacted fetal head (IFH) can be defined as the deep engagement of the fetal head in the maternal pelvis at the time of cesarean delivery that leads to its difficult or impossible extraction with standard surgical maneuvers. In this narrative review, we aimed to ascertain its incidence, risk factors, management and complications from the perspective of the anesthesiologist as a multidisciplinary team member. METHODS Databases were searched from inception to 24 January 2023 for keywords and subject headings associated with IFH and cesarean delivery. RESULTS IFH has an incidence of 2.9-71.8 % in emergency cesarean section. Maternal risk factors are advanced cervical dilatation, second stage of labor and oxytocin augmentation. Anesthetic and obstetric risk factors include epidural analgesia and trial of instrumental delivery and junior obstetrician, respectively. Neonatal risk factors are fetal malposition, caput and molding. Current evidence indicates a lack of confidence in the management of IFH across the multidisciplinary team. Simple interventions in IFH include lowering the height or placing the operating table in the Trendelenburg position, providing a step for the obstetrician and administering pharmacological tocolysis. Maternal complications are postpartum hemorrhage and bladder injury while neonatal complications include hypoxic brain injury, skull fracture and death. Surgical complications are reviewed to remind the anesthesiologist to anticipate and prepare for potential problems and manage complications in a timely manner. CONCLUSION The anesthesiologist has a fundamental role in the facilitation of delivery in IFH. We have proposed an evidence based management algorithm which may be referred to in this emergency situation.
Collapse
Affiliation(s)
- Sophie C Ragbourne
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Elinor Charles
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Maria Herincs
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Francesca Elwen
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Honorary Senior Clinical Lecturer, King's College London, London, United Kingdom.
| |
Collapse
|
8
|
Malvasi A, Malgieri LE, Stark M, Tinelli A. Dystocia, Delivery, and Artificial Intelligence in Labor Management: Perspectives and Future Directions. J Clin Med 2024; 13:6410. [PMID: 39518549 PMCID: PMC11546974 DOI: 10.3390/jcm13216410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Revised: 10/07/2024] [Accepted: 10/23/2024] [Indexed: 11/16/2024] Open
Abstract
Labor management remains a critical issue in obstetrics, with dystocic labor presenting significant challenges in both management and outcomes. Recent advancements in intrapartum ultrasound have facilitated substantial progress in monitoring labor progression. This paper explores the integration of artificial intelligence (AI) into obstetric care, focusing on the Artificial Intelligence Dystocia Algorithm (AIDA) for assessing spatial dystocia during labor. The AIDA utilizes intrapartum ultrasonography to measure four geometric parameters: the angle of progression, the degree of asynclitism, the head-symphysis distance, and the midline angle. These measurements are analyzed using machine learning techniques to predict delivery outcomes and stratify risk. The AIDA classification system categorizes labor events into five classes, providing a nuanced assessment of labor progression. This approach offers several potential advantages, including objective assessment of fetal position, earlier detection of malpositions, and improved risk stratification, placing labor events within a broader context of labor dystocia and obstetric care and discussing their potential impact on clinical practice. This paper serves as a more comprehensive overview and discussion of the AIDA approach, its implications, perspectives, and future directions. However, challenges such as the technological requirements, training needs, and integration with clinical workflows are also addressed. This study emphasizes the necessity for additional validation across diverse populations and careful consideration of its ethical implications. The AIDA represents a significant advancement in applying AI to intrapartum care, potentially enhancing clinical decision-making and improving outcomes in cases of suspected dystocia. This paper explicates the key methodological approaches underpinning the AIDA, illustrating the integration of artificial intelligence and clinical expertise. The innovative framework presented offers a paradigm for similar endeavors in other medical specialties, potentially catalyzing advancements in AI-assisted healthcare beyond obstetrics.
Collapse
Affiliation(s)
- Antonio Malvasi
- Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari “Aldo Moro”, Policlinico of Bari, 70124 Bari, Italy;
| | | | - Michael Stark
- The New European Surgical Academy (NESA), 10117 Berlin, Germany;
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital Scorrano, 73020 Lecce, Italy
| |
Collapse
|
9
|
Alves ÁLL, Nozaki AM, da Silva LB. Difficult fetal extraction in cesarean section: Number 8 - 2024. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-FPS08. [PMID: 39381342 PMCID: PMC11460424 DOI: 10.61622/rbgo/2024fps08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2024] Open
Abstract
The main causes of difficult fetal extraction during cesarean section are deeply impacted fetal head and floating presentation of the fetus. Studies of management techniques for difficult fetal extraction during cesarean section and the maternal and neonatal results lack scientific evidence, as these predominantly come from case reports, small case series and expert opinions. The deeply impacted fetal head is usually associated with prolongation of the expulsion period and/or unsuccessful attempts at operative vaginal delivery. The main maternal complications associated with the management of the deeply impacted fetal head are lacerations in the lower uterine segment, hematomas in the uterine ligaments and injuries to the uterine vessels, cervix and/or urinary tract. The main neonatal complications associated with the management of a deeply impacted fetal head are intracranial hemorrhage, fractures of the skull and/or cervical spine, nerve injuries, perinatal asphyxia and even death. Among the maneuvers for delivery of the deeply impacted fetal head, the abdominovaginal delivery (push method) seems to be the most associated with maternal and neonatal complications. In the non-insinuated and floating fetal head, the internal podalic version followed by pelvic extraction differs from the reverse breech extraction (pull method). When the fetal head is high in the pelvis, the fetus is internally ejected before the extraction of its body segments, similar to the internal version performed in the vaginal delivery of the second twin with floating presentation of the fetus.
Collapse
Affiliation(s)
- Álvaro Luiz Lage Alves
- Universidade Federal de Minas Gerais Hospital das Clínicas Belo HorizonteMG Brazil Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Alexandre Massao Nozaki
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas São PauloSP Brazil Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | - Lucas Barbosa da Silva
- Hospital das Clínicas São SebastiãoSP Brazil Hospital das Clínicas, São Sebastião, SP, Brazil
| |
Collapse
|
10
|
Gialdini C, Chamillard M, Diaz V, Pasquale J, Thangaratinam S, Abalos E, Torloni MR, Betran AP. Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. EClinicalMedicine 2024; 72:102632. [PMID: 38812964 PMCID: PMC11134562 DOI: 10.1016/j.eclinm.2024.102632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 03/29/2024] [Accepted: 04/19/2024] [Indexed: 05/31/2024] Open
Abstract
Background Caesarean section (CS) is the most performed major surgery worldwide. Surgical techniques used for CS vary widely and there is no internationally accepted standardization. We conducted an overview of systematic reviews (SR) of randomized controlled trials (RCT) to summarize the evidence on surgical techniques or procedures related to CS. Methods Searches were conducted from database inception to 31 January 2024 in Cochrane Database of Systematic Reviews, PubMed, EMBASE, Lilacs and CINAHL without date or language restrictions. AMSTAR 2 and GRADE were used to assess the methodological quality of the SRs and the certainty of evidence at outcome level, respectively. We classified each procedure-outcome pair into one of eight categories according to effect estimates and certainty of evidence. The overview was registered at PROSPERO (CRD 42023208306). Findings The analysis included 38 SRs (16 Cochrane and 22 non-Cochrane) published between 2004-2024 involving 628 RCT with a total of 190,349 participants. Most reviews were of low or critically low quality (AMSTAR 2). The SRs presented 345 procedure-outcome comparisons (237 procedure versus procedure, 108 procedure versus no treatment/placebo). There was insufficient or inconclusive evidence for 256 comparisons, clear evidence of benefit for 40, possible benefit for 17, no difference of effect for 13, clear evidence of harm for 14, and possible harm for 5. We found no SRs for 7 pre-defined procedures. Skin cleansing with chlorhexidine, Joel-Cohen-based abdominal incision, uterine incision with blunt dissection and cephalad-caudal expansion, cord traction for placental extraction, manual cervical dilatation in pre-labour CS, changing gloves, chromic catgut suture for uterine closure, non-closure of the peritoneum, closure of subcutaneous tissue, and negative pressure wound therapy are procedures associated with benefits for relevant outcomes. Interpretation Current evidence suggests that several CS surgical procedures improve outcomes but also reveals a lack of or inconclusive evidence for many commonly used procedures. There is an urgent need for evidence-based guidelines standardizing techniques for CS, and trials to fill existing knowledge gaps. Funding UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by the World Health Organization (WHO).
Collapse
Affiliation(s)
- Celina Gialdini
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
- Facultat de Ciències de la Salut Blanquerna, Universitat Ramon Llull, Barcelona, Spain
| | | | - Virginia Diaz
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Julia Pasquale
- Centro Rosarino de Estudios Perinatales (CREP), Rosario, Argentina
| | - Shakila Thangaratinam
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Edgardo Abalos
- Centro de Estudios de Estado y Sociedad (CEDES), Buenos Aires, Argentina
| | - Maria Regina Torloni
- Evidence Based Healthcare Post-Graduate Program, Department of Medicine, São Paulo Federal University, São Paulo, Brazil
| | - Ana Pilar Betran
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| |
Collapse
|
11
|
Romero R, Sabo Romero V, Kalache KD, Stone J. Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture. Am J Obstet Gynecol 2024; 230:S653-S661. [PMID: 38462251 DOI: 10.1016/j.ajog.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.
Collapse
Affiliation(s)
- Roberto Romero
- Pregnancy Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Bethesda, MD; Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI; Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI.
| | | | - Karim D Kalache
- Department of Clinical Obstetrics and Gynecology, Weill Cornell Medical College-Qatar Division, Doha, Qatar; Division of Maternal-Fetal Medicine, Women's Services, Sidra Medicine, Doha, Qatar
| | - Joanne Stone
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|