Delivery of the impacted head of the fetus at caesarean section after prolonged obstructed labour: a randomised comparative study of two methods

Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis

INTRODUCTION

Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation.

MATERIAL AND METHODS

We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction.

RESULTS

We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (e.g., risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction.

CONCLUSIONS

The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.

Management of impacted fetal head at cesarean delivery

Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.

Intrapartum transperineal ultrasound: angle of progression to evaluate and predict the mode of delivery and labor progression

Intrapartum ultrasonography serves as a valuable tool for the objective evaluation of labor progression and effectively identifies underlying factors, such as asynclitism, in cases of abnormal labor progression. Among the various ultrasound measurement techniques, the angle of progression (AOP) demonstrates favorable reproducibility and accuracy in assessing fetal head descent. In the context of abnormal labor, interventions differ across different stages of labor, emphasizing the importance of investigating the utility of AOP according to labor stages in this review article. Pre-labor assessment of AOP can be beneficial in terms of counseling for the timing of induction of labor, while a wider AOP value during the prolonged first stage of labor has demonstrated a positive correlation with successful vaginal delivery and shorter time to delivery. In the second stage of labor, the AOP has exhibited efficacy in predicting the mode of delivery and complicated operative deliveries. Furthermore, it has assisted in predicting the duration of labor, thereby highlighting its potential as a decision-making model for labor progression. However, further research is needed to investigate aspects, such as the determination of cutoff values, of AOP, considering the multifaceted characteristics of labor progression, which are influenced by complex interactions among maternal, fetal, and other contributing factors.

Management of Impacted Fetal Head at Caesarean Birth: Scientific Impact Paper No. 73

Over one-quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the caesarean birth, difficulty in delivery of the baby's head may result - this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stay. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned CBs (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. However, there is currently no consensus for how best to manage these births. This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the National Guideline Alliance.

Risk factors for and consequences of difficult fetal extraction in emergency caesarean section. A retrospective registry-based cohort study

INTRODUCTION

This study aimed to assess risk factors for difficult fetal extraction in emergency caesarean sections, focusing on top-up epidural anesthesia compared to spinal anesthesia. Additionally, this study addressed consequences of difficult fetal extraction on neonatal and maternal morbidity.

MATERIAL AND METHODS

This retrospective registry-based cohort study included 2,332 of 2,892 emergency caesarean sections performed with local anesthesia during 2010-2017. Main outcomes were analyzed by crude and multiple adjusted logistic regression providing odds ratios.

RESULTS

Difficult fetal extraction was found in 14.9% of emergency caesarean sections. Risk-factors for difficult fetal extraction included top-up epidural anesthesia (aOR:1.37[95 %CI 1.04-1.81]), high pre-pregnancy BMI (aOR:1.41[95 %CI 1.05-1.89]), deep fetal descent (ischial spine: aOR:2.53[95 %CI 1.89-3.39], pelvic floor: aOR:3.11[95 %CI 1.32-7.33]), and anterior placental position (aOR:1.37[95 %CI 1.06-1.77]). Difficult fetal extraction was associated with increased risk of low umbilical artery pH 7.00-7.09 (aOR:3.50[95 %CI 1.98-6.15]) pH ≤ 6.99 (aOR:4.20[95 %CI 1.61-10.91]), five-minute Apgar score ≤ 6 (aOR:3.41[95 %CI 1.49-7.83]) and maternal blood loss (501-1,000 ml: aOR:1.65[95 %CI 1.27-2.16], 1,001-1,500 ml: aOR:3.24[95 %CI 2.24-4.67], 1,501-2,000 ml: aOR:3.94[95 %CI 2.24-6.94] and ≥ 2001 ml: aOR:2.76[95 %CI 1.12-6.82]).

CONCLUSION

This study identified four risk factors for difficult fetal extraction in emergency caesarean section: top-up epidural anesthesia, high maternal BMI, deep fetal descent and anterior placental position. Additionally, difficult fetal extraction was associated with poor neonatal and maternal outcomes.

Techniques for managing an impacted fetal head at caesarean section: A systematic review

A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an 'impacted fetal head'. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication.

Obstructed labor and its effect on adverse maternal and fetal outcomes in Ethiopia: A systematic review and meta-analysis

Background

Obstructed labor is one of the five major causes of maternal mortality and morbidity in developing countries. In Ethiopia, it accounts for 19.1% of maternal death. The current review aimed to assess maternal and perinatal outcomes of obstructed labor in Ethiopia.

Methods

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed for this systematic review and meta-analysis. A literature search was made using PubMed/MEDLINE, CINAHL, Summon country-specific search, and Cochrane Libraries’ online databases. Search terms were adverse outcome, obstructed labor, maternal outcome, fetal outcome, and Ethiopia. The Newcastle-Ottawa scale (NOS), based on a star scoring system, was used to assess the quality of the included studies. The meta-analysis was conducted using STATA 16 software. The pooled prevalence of an adverse maternal outcome, fetal outcome, and association between adverse outcome and obstructed labor was calculated using a random-effects model. Egger’s test and funnel plot were used to evaluate publication bias.

Result

Eighty-seven studies were included in this review, with an overall sample size of 104259 women and 4952 newborns. The pooled incidence of maternal death was estimated to be 14.4% [14.14 (6.91–21.37). The pooled prevalence of uterine rupture and maternal near-miss was 41.18% (95% CI: 19.83, 62.54) and 30.5% [30.5 (11.40, 49.59) respectively. Other complications such as postpartum hemorrhage, sepsis, obstetric fistula, hysterectomy, bladder injury, cesarean section, and labor abnormalities were also reported. The pooled prevalence of perinatal death was 26.4% (26.4 (95% CI 15.18, 37.7). In addition, the association of obstructed labor with stillbirth, perinatal asphyxia, and meconium-stained amniotic fluid was also demonstrated.

Conclusions

In Ethiopia, the incidence of perinatal and maternal mortality among pregnant women with obstructed labor was high. The rate of maternal death and maternal near miss reported in this review was higher than incidences reported from high-income and most low and middle-income countries. Uterine rupture, postpartum hemorrhage, sepsis, fistula, hysterectomy, and bladder injury were also commonly reported. To improve the health outcomes of obstructed labor, it is recommended to address the three delay models: enhancing communities’ health-seeking behavior, enhancing transportation for an obstetric emergency with different stakeholders, and strengthening the capacity of health facilities to handle obstetric emergencies.

Maternal and neonatal outcomes associated with delivery techniques for impacted fetal head at cesarean section: a systematic review and meta-analysis

OBJECTIVES

Late first-stage or second-stage cesarean section is commonly associated with fetal head impaction, leading to maternal and neonatal complications. This situation requires safe delivery techniques, but the optimal management remains controversial. The aim of this meta-analysis was to compare maternal and neonatal outcomes associated with delivery techniques via cesarean section.

METHODS

An electronic search of three databases, from inception to June 2021, was conducted. Cohort and randomised comparative studies on maternal and neonatal outcomes associated with techniques to deliver an impacted fetal head during cesarean section were included. The methodological quality of the primary studies was assessed. Review Manager 5.4 was used for statistical analyses.

RESULTS

Nineteen articles, including 2,345 women were analyzed. Three fetal extraction techniques were identified. Meta-analyses showed that the "pull" technique carries lower risks as compared to the "push" technique and the "Patwardhan" technique is safer compared to the "push" or the "push and pull" technique.

CONCLUSIONS

In the absence of robust evidence to support the use of a specific technique, the choice of the obstetrician should be based on best available evidence. Our study suggests that the "pull", as well as the "Patwardhan" technique represent safe options to deliver an impacted fetal head.

Using machine learning to identify quality-of-care predictors for emergency caesarean sections: a retrospective cohort study

OBJECTIVES

Emergency caesarean sections (ECS) are time-sensitive procedures. Multiple factors may affect team efficiency but their relative importance remains unknown. This study aimed to identify the most important predictors contributing to quality of care during ECS in terms of the arrival-to-delivery interval.

DESIGN

A retrospective cohort study. ECS were classified by urgency using emergency categories one/two and three (delivery within 30 and 60 min). In total, 92 predictor variables were included in the analysis and grouped as follows: 'Maternal objective', 'Maternal psychological', 'Fetal factors', 'ECS Indication', 'Emergency category', 'Type of anaesthesia', 'Team member qualifications and experience' and 'Procedural'. Data was analysed with a linear regression model using elastic net regularisation and jackknife technique to improve generalisability. The relative influence of the predictors, percentage significant predictor weight (PSPW) was calculated for each predictor to visualise the main determinants of arrival-to-delivery interval.

SETTING AND PARTICIPANTS

Patient records for mothers undergoing ECS between 2010 and 2017, Nordsjællands Hospital, Capital Region of Denmark.

PRIMARY OUTCOME MEASURES

Arrival-to-delivery interval during ECS.

RESULTS

Data was obtained from 2409 patient records for women undergoing ECS. The group of predictors representing 'Team member qualifications and experience' was the most important predictor of arrival-to-delivery interval in all ECS emergency categories (PSPW 25.9% for ECS category one/two; PSPW 35.5% for ECS category three). In ECS category one/two the 'Indication for ECS' was the second most important predictor group (PSPW 24.9%). In ECS category three, the second most important predictor group was 'Maternal objective predictors' (PSPW 24.2%).

CONCLUSION

This study provides empirical evidence for the importance of team member qualifications and experience relative to other predictors of arrival-to-delivery during ECS. Machine learning provides a promising method for expanding our current knowledge about the relative importance of different factors in predicting outcomes of complex obstetric events.

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

Background

The rate of second stage caesarean section (CS) is rising with associated increases in maternal and neonatal morbidity, which may be related to impaction of the fetal head in the maternal pelvis. In the last 10 years, two devices have been developed to aid disimpaction and reduce these risks: the Fetal Pillow (FP) and the Tydeman Tube (TT). The aim of this study was to determine the distance of upward fetal head elevation achieved on a simulator for second stage CS using these two devices, compared to the established technique of per vaginum digital disimpaction by an assistant.

Methods

We measured elevation of the fetal head achieved with the two devices (TT and FP), compared to digital elevation, on a second stage Caesearean simulator (Desperate Debra ™ set at three levels of severity. Elevation was measured by both a single operator experienced with use of the TT and FP and also multiple assistants with no previous experience of using either device. All measurements were blinded

Results

The trained user achieved greater elevation of the fetal head at both moderate and high levels of severity with the TT (moderate: 30mm vs 12.5mm p<0.001; most severe: 25mm vs 10mm p<0.001) compared to digital elevation. The FP provided comparable elevation to digital at both settings (moderate: 10 vs 12.5mm p=0.149; severe 10 vs 10mm p=0.44).

With untrained users, elevation was also significantly greater with the TT compared to digital elevation (20mm vs 10mm p<0.01). However digital disimpaction was significantly greater than the FP (10mm vs 0mm p<0.0001).

Conclusion

On a simulator, with trained operators, the TT provided greater fetal head elevation than digital elevation and the FP. The FP achieved similar elevation to the digital technique, especially when the user was trained in the procedure.

Factors associated with an increased risk of instrumental vaginal delivery in women with epidural analgesia for labour: A retrospective cohort study

BACKGROUND

Epidural analgesia is the most effective form of labour analgesia, but is associated with an increased risk of instrumental delivery.

OBJECTIVE

To evaluate factors that are associated with an increased risk of instrumental delivery.

DESIGN

Retrospective cohort data study.

SETTING

Singapore's major public maternity institution.

PATIENTS

All obstetric patients who received labour epidural analgesia for vaginal delivery between January 2012 to December 2015.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Our primary outcome was the incidence of instrumental delivery.

RESULTS

Out of 17 227 pregnant women who received labour epidural analgesia, 12% (n = 2069) had instrumental delivery. Independent factors associated with an increased risk of instrumental delivery included maternal factors [nulliparity (adjusted odds ratio (aOR) 2.97, 95% CI 2.61 to 3.39, P < 0.0001] and advanced maternal age (aOR 1.04, 95% CI 1.03 to 1.05, P < 0.0001)). Greater maternal height (aOR 0.18, 95% CI 0.08 to 0.40), P < 0.0001) was associated with a reduced risk of instrumental delivery. Significant labour-related factors increasing the risk of an instrumental delivery were the use of prostin (aOR 1.19, 95% CI 1.07 to 1.32, P = 0.0014), pre-epidural analgesia (aOR 1.16, 95% CI 1.05 to 1.28, P = 0.0040), a longer second stage of labour (aOR 1.23, 95% CI 1.20 to 1.26, P < 0.0001), higher infant birth weight (aOR 1.27, 95% CI 1.12 to 1.43, P = 0.0002) and an epidural performed by a senior anaesthetist (aOR 1.94, 95% CI 1.72 to 2.18, P < 0.0001). Labour epidural-related factors for an increased risk of instrumental delivery were the occurrence of breakthrough pain (aOR 1.55, 95% CI 1.37 to 1.76, P < 0.0001), a more dense motor block (aOR 1.14, 95% CI 1.03 to 1.25, P = 0.0097) and having an epidural infusion stopped at full cervical dilatation (aOR 1.18, 95% CI 1.05 to 1.32, P = 0.0048) [receiver operating characteristic (ROC) = 0.75].

CONCLUSIONS

The multivariate model generated would help identify women at higher risk of instrumental delivery, which can help clinicians to address potentially modifiable factors and improve clinical care.

Impacted fetal head: A retrospective cohort study of emergency caesarean section

OBJECTIVE

To investigate risk factors, management and outcomes of impacted fetal head (IFH) at caesarean section (CS).

STUDY DESIGN

This is a retrospective cohort study of all women with singleton, cephalic pregnancies who had an emergency CS during one-year (2016) at North Bristol NHS Trust, UK (n = 838). The incidence of caesarean section at full dilatation (CSFD) and IFH were calculated using the annual birth rate. To identify risk factors for IFH, maternal, perinatal and intrapartum characteristics were compared according to the presence or absence of IFH, and separately for first- and second-stage CS. Techniques employed to disimpact the fetal head were described. Univariable and multivariable comparisons of maternal and perinatal outcomes were made between cases with and without an IFH. Characteristics and outcomes were compared using modified Poisson regression.

RESULTS

CSFD accounted for 2.1 % of all births. IFH complicated 1.5 % of all births (11.3 % of emergency CS), with 55.8 % occurring prior to full cervical dilatation. Increased rates of IFH at CS were associated with: oxytocin augmentation (RR = 2.47 [1.61-3.80]), full cervical dilatation (RR = 4.24 [2.96-6.07], mid/low station (RR = 4.14 [2.72-6.32]), moulding (RR = 4.39 [2.55-7.54]) and caput (RR = 6.60 [3.09-14.10]). Junior operators documented IFH more than consultants (RR = 9.61 [1.35-68.2]). The strategies recorded for managing IFH included: tocolysis, reverse breech extraction and vaginal push up (33.7 %, 14.7 % and 11.6 % cases respectively) with two or more techniques used in 21.1 % cases. IFH at CS was independently associated with an increased risk of uterine extensions (RR = 3.09 [1.96-4.87]) and a composite adverse perinatal outcome (RR = 1.66 [1.21-2.28]).

CONCLUSIONS

IFH is a common and heterogeneous complication associated with increased complications for both mother and baby, independent of those of CSFD. Obstetricians must remain vigilant to the possibility of IFH at all emergency CS, particularly those at full cervical dilatation or with evidence of obstructed labour. There is an urgent need for a standardised management algorithm and training in evidence-based disimpaction techniques.

Fetal extraction maneuvers during cesarean delivery in the second stage of labor

Objective: To compare maternal and neonatal outcomes following cesarean delivery during second stage of labor, according to the fetal extraction method.Methods: A retrospective cohort study of all women who underwent term cesarean delivery during the second stage of labor at a university-affiliated tertiary medical center (2012-2016). The cohort was divided according to three extraction methods: standard vertex extraction, the push method in which the head extraction is accompanied by pushing through the vagina, and the reverse breech extraction method. Primary outcomes were intraoperative maternal complications, and secondary outcomes were neonatal adverse events.Results: Three hundred and fifty women were included, of whom 206 (59%) underwent standard vertex fetal extraction, 116 (33%) the push method extraction, and 28 (8%) reverse breech extraction. Operation time was significantly shorter in the standard vertex extraction method compared to push and reverse breech extraction methods (33.5 vs. 40.5 and 39.0 min, respectively, p = .013). Uterine laceration and incision extension frequencies were lower in the vertex extraction method as well (24.76 vs. 45.69-46.40% in others, p < .001). Delivery related neonatal injury was significantly more frequent in the reverse breech extraction method (39.29 vs. 12-15% in others, p < .001). In a multivariate analysis reverse breech extraction was associated with higher rates of uterine laceration and incision extension (OR = 2.739 95% confidence interval 1.44-6.56, p = .0237) and delivery related neonatal injury (OR = 2.837, 95% CI: 1.081-7.448, p = .0342).Conclusion: Standard vertex extraction method during second stage of labor cesarean delivery is safer both to the mother and neonate when compared to alternative extraction methods.Abbreviations: NRFHR: non-reassuring fetal heart rate; NICU: neonatal intensive care unit.

Difficult caesarean section: A literature review

BACKGROUND

Caesarean section (CS) is usually perceived as a simple and safe alternative to natural birth, but in some instances can be technically difficult with consequent health hazards for both the mother and the fetus. We have proposed an evidence-based literature review of the most common difficult CS scenarios, with the aim to provide useful information about their management, possible prevention and resolution of complications.

METHODS

We identified articles through a reserch in PubMed, Scopus, Web of Science and Ovid MEDLINE for studies published between 1979 and 2019. We included the best available evidence, such as RCTs, non-randomised controlled clinical trials, case-control studies, cohort studies, and case series. About sixty articles were included in this review, four hundred and thirty-six were excluded after reviewing the title or abstract or because they weren't in English.

FINDINGS

The possible causes of "difficult" caesarean sections were divided into four categories: difficult access to the lower uterine segment; complicated fetal extraction, laceration or organ damage and abnormal placentation.

CONCLUSIONS

Knowing in advance the potential technical difficulties and resulting risks allows the surgeon to plan appropriate strategies.

Simulation of an impacted fetal head extraction during cesarean section: description of the creation and evaluation of a new training program

Background Although cesarean sections at full dilatation are increasing, training in delivering a deeply impacted fetal head is lacking among obstetricians. The purpose of the study was to implement and evaluate a theoretical and simulation-based training program for this obstetrical emergency. Methods We developed a training program consisting of a theoretical introduction presenting a clinical algorithm, developed on the basis of the available literature, followed by a simulation session. We used the Kirkpatrick's framework to evaluate the program. A questionnaire was distributed, directly before, immediately and 6 weeks after the training. Self-perceived competencies were evaluated on a 6-point Likert scale. Pre- and post-test differences in the Likert scale were measured with the Wilcoxon signed rank test. Additionally, the training sessions were video recorded and rated with a checklist in relation to how well the algorithm was followed. Results Eleven residents and eight senior physicians took part to the training. More than 40% of participants experienced a comparable situation after the course during clinical work. Their knowledge and self-perceived competencies improved immediately after the training program and 6 weeks later. Major improvements were seen in the awareness of the algorithm and in the confidence in performing the reverse breech extraction (14.3% of the participants felt confident with the maneuver in the pre-training assessment compared with 66.7% 6 week post-training). Conclusion Our theoretical and simulation-based training program was successful in improving knowledge and confidence of the participants in delivering a deeply impacted fetal head during a cesarean section performed at full dilation.

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

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.

The impacted foetal head at caesarean section: incidence and techniques used in a single UK institution

An impaction of the foetal head at caesarean section is a topical concern in modern obstetric practice. The management options for this problem are well described but the incidence or even definition of impaction, is unknown. The primary aim of this study was to ascertain the incidence of impacted foetal head at CS in labour. This prospective study used data from all women undergoing CS during a 12-month period in a single unit. Following completion of all CS, the surgeon completed a questionnaire covering: cervical dilation at time of CS; if the surgeon felt there was a difficulty in delivering the foetal head as an indicator of impaction, as well as the other techniques utilised. Of 440 EMCS in labour, 18% (n = 81) reported a difficulty delivering the head, which was most common at cervical dilation ≥8 cm (n = 124, 48%). A difficulty with the delivery of the foetal head was associated with 36% increased measured blood loss. Impact statement What is already known on this subject? Impaction of the foetal head at a caesarean section is a recognised complication of CS in late labour but there are no reliable data on the incidence of the problem. It is poorly defined and yet many techniques and devices have been described to overcome this problem, however, optimal management remains uncertain. What do the results of this study add? The primary aim of this study was to determine the incidence of the impacted foetal head during CS in labour as determined by whether the surgeon experienced difficulty with delivery of the head. We report that at least some difficulty in delivering the foetal head at CS is common, and most often encountered when cervical dilation is ≥8 cm. When additional manoeuvres were required, the 'push' technique was exclusively adopted with implications for training. A difficulty in delivering the foetal head was associated with a 36% increase in the measured maternal blood loss. What are the implications of these findings for clinical practice and/or further research? Further multi-centre investigation is required to ascertain incidence of this obstetric problem with predicting factors determined. This work will inform decisions about the optimal management.

Maternal and neonatal outcome of reverse breech extraction of an impacted fetal head during caesarean section in advanced stage of labour: a retrospective cohort study

Background

Caesarean section with extraction of a deeply impacted fetal head is technically challenging and is associated with serious maternal and neonatal complications. The purpose of the study was to identify risks and evaluate selected outcome parameters associated with difficult fetal head extraction during caesarean section in advanced labour comparing two different extraction techniques (head pushing vs. reverse breech).

Methods

This retrospective cohort study was conducted at the Division of Obstetrics in a tertiary care hospital in Zurich, Switzerland. 629 women at term with a singleton pregnancy in cephalic presentation during advanced intrapartum caesarean section from December 2012 until December 2016 were evaluated. Primary outcome was the incidence of uterine incision extensions. Secondary outcomes were other selected maternal and neonatal outcome parameters. Data analysis was performed using SPSS with Mann-Whitney U independent sampling test and two-tailed Fisher’s exact test (p < 0.01).

Results

Difficult fetal head extractions are associated with significantly elevated maternal and neonatal risks. When performed by reverse breech technique, significant lower rates of extensions of the uterine incision, shorter operation times and less operative blood loss were identified compared to the head pushing method. No statistically significant differences for the neonatal outcomes were described so far. However, among the group of difficult fetal delivery with the head pushing method two neonates had perinatal skull fractures, with one of those resulting in neonatal death.

Conclusions

The head pushing method is associated with higher maternal morbidity than the reverse breech method for extraction of a deeply engaged fetus during intrapartum caesarean section in advanced stage of labour.

Comparison of 'push method' with 'Patwardhan's method' on maternal and perinatal outcomes in women undergoing caesarean section in second stage

A deeply impacted foetal head in a second stage caesarean section is associated with an increased risk of maternal and neonatal complications. For the present study, we compared the maternal and neonatal outcomes during the use of the 'Push method' and of 'Patwardhan's method' for a foetal head delivery in a second-stage caesarean section. This was a retrospective observational study involving 298 women who underwent a second stage caesarean section with a foetal head at or below the level of their ischial spines and was conducted in a tertiary teaching hospital in South India. The rates of uterine incision extension and other maternal complications were similar in both methods (24.9% vs. 26.0%, p = .850). The rates of neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. Although the maternal complications were similar, the use of Patwardhan's method resulted in higher rates of neonatal complications compared to the Push method during a second stage caesarean section. Future randomised, controlled studies comparing these two methods are needed to confirm their safety and benefits, prior to its routine use in second stage caesarean sections. Impact statement What is already known on this subject? Use of a second-stage caesarean section increases the risk of maternal and neonatal complications. A deeply engaged foetal head, along with the stretching and thinning of the lower uterine segment predisposes to these complications. The recent literature mainly compares the complication rates of the Push method to a Reverse breech extraction, with only small studies reporting the use of Patwardhan's technique for the delivery of a deeply engaged foetal head. What do the results of this study add? This study suggests that the use of either the Push method or of Patwardhan's method results in similar maternal complications such as extension of a uterine incision or postpartum haemorrhage. But neonatal complications such as neonatal sepsis (2.3% vs. 9.2%) and admission to neonatal intensive care unit (36.7% vs. 60.0%) were higher when Patwardhan's method was used. What are the implications of these findings for clinical practice and/or further research? The extension of uterine incision is similar in both methods; however, the neonatal complications were noted to be higher in those delivered with Patwardhan's technique. A future, randomised controlled trial comparing these two techniques is required to confirm the findings, before either of the methods are used in routine practice.

Assessment of fetal head engagement with transperineal ultrasound: Searching for the cutoff level

PURPOSE

Engagement of the fetal head is a determinant element when deciding on operative vaginal delivery. In routine practice, engagement is a clinical diagnosis based on transvaginal digital examination. Transperineal ultrasound might provide complementary information useful for measuring the fetal head-perineum distance (HPD). The purpose of this work was to determine the cutoff HPD distinguishing engagement from non-engagement.

MATERIALS AND METHODS

This single-center prospective study approved by the institutional review board was conducted between December 25, 2012 and August 31, 2015 in 411 nulliparous women; 20 did not provide informed consent and were excluded; analysis concerned 391 patients. Clinical diagnosis - engagement or non-engagement depending on results of the transvaginal digital examination (Farabeuf's and Demelin's signs) - was compared with the ultrasound HPD measurement.

RESULTS

The clinical diagnosis was non-engagement at complete dilatation in 96 patients (24.6%). The cutoff HPD distinguishing between engagement and non-engagement was 57mm (AUC 83.5% [95%CI 79.3-87.8]), with 75.0% [65.5-82.6] sensitivity, 75.9% [70.7-80.5] specificity, 50.3% [42.2-58.4] positive predictive value, and 90.3% [86.0-93.4] negative predictive value.

CONCLUSIONS

In this series, the HPD cutoff distinguishing between engagement and non-engagement was 57mm. Below this cutoff level, the head should be considered engaged, beyond non-engaged. Nevertheless, the pertinence of this cutoff level is hampered by the imprecision of the gold standard used for the clinical diagnosis (transvaginal digital examination). In case of doubt, we recommend, in addition to considering the obstetrical setting, to combine transperineal ultrasound with transvaginal digital examination to avoid deleterious failure of operative vaginal delivery.

Caesarean delivery-related blood transfusion: correlates in a tertiary hospital in Southwest Nigeria

BACKGROUND

Caesarean delivery carries a risk of major intra-operative blood loss and its performance is often delayed by non-availability of blood and blood products. Unnecessary cross-matching and reservation of blood lead to apparent scarcity in centres with limited supply. This study set out to identify the risk factors for blood transfusion in women who underwent caesarean delivery at a tertiary obstetric unit with a view to ensuring efficient blood utilization.

METHODS

A prospective cohort analysis of 906 women who had caesarean deliveries at the Lagos State University Teaching Hospital, Nigeria between January and December, 2011. A comparison was made between 188 women who underwent blood transfusion and 718 who did not. Data were obtained on a daily basis by investigators from patients, clinical notes and referral letters using structured pre-tested data collecting form. Socio-demographic characteristics; antenatal, perioperative and intraoperative details; blood loss; transfusion; and puerperal observations were recorded. EPI-Info statistical software version 3.5.3 was used for multivariable analysis to determine independent risk factors for blood transfusion.

RESULTS

Of the 2134 deliveries during the study period, 906 (42.5%) had caesarean deliveries and of which 188 (20.8%) were transfused. The modal unit of blood transfused was 3 pints (41.3%). The most common indication for caesarean section was cephalo-pelvic disproportion (25.7%).The independent risk factors for blood transfusion at caesarean section were second stage Caesarean Section (aOR = 76.14, 95% CI = 1.25-4622.06, p = 0.04), placenta previa (aOR = 32.57, 95% CI = 2.22-476.26, p = 0.01), placental abruption (aOR = 25.35, 95% CI = 3.06-211.02, p < 0.001), pre-operative anaemia (aOR = 12.15, 95% = CI 4.02-36.71, p < 0.001), prolonged operation time (aOR = 10.72 95% CI = 1.37-36.02, p < 0.001), co-morbidities like previous uterine scar (aOR = 7.02, 95% CI = 1.37-36.02, p = 0.02) and hypertensive disorders in pregnancy (aOR = 5.19, 95% CI = 1.84-14.68, p < 0.001). Obesity reduced the risk for blood transfusion (aOR = 0.24, 95% CI = 0.09-0.61, p = 0.0024).

CONCLUSION

The overall risk of blood transfusion in cesarean delivery is high. Paturients with the second stage Caesarean section, placenta previa, abruptio placentae and preoperative maternal anaemia have an increased risk of blood transfusion. Hence, adequate peri-operative preparations for blood transfusion are essential in these situations. Optimizing maternal hemoglobin concentration during antenatal period may reduce the incidence of caesarean-associated blood transfusion.

[Caesarean section at full dilatation: What are the risks to fear for the mother and child?]

OBJECTIVES

Caesarean section is associated with increased maternal morbidity compared to a vaginal delivery, especially if it occurs during labour. Little data on caesarean section performed at full dilatation is available.

METHODS

This was a retrospective study done in University Hospital of type 3 over a period of ten years, including future primiparous patients who had a caesarean section performed at full dilatation, compared to a control group of patients whose caesarean section was conducted in first part of the labour. We collected different maternal data per- and postoperative and neonatal.

RESULTS

In total, 824 patients were enrolled including 412 in each group. For caesarean section at full dilatation, foetal extraction required more manoeuvres (RR=3.05; 95% CI: 2.1; 4.39; P<0.001); we noted more extension of hysterotomy (RR=1.79; 95% CI: 1.30; 2.46; P<0.001). Postoperative and neonatal maternal morbidity was not different, except more frequent neonatal trauma for caesarean section at full dilatation.

CONCLUSION

A caesarean section at full dilatation has an excess intraoperative risk and requires great caution. Nevertheless, no significant increase of postoperative and neonatal complications can be proved.

Correlation of intrapartum translabial ultrasound parameters with computed tomographic 3D reconstruction of the female pelvis

AIMS

Intrapartum translabial ultrasound [ITU] can be an objective, reproducible and more reliable method than digital vaginal examination when evaluating fetal head position and station in prolonged second stage of labor. However, two-dimensional (2D) ultrasound is not sufficient to demonstrate the ischial spines and other important "landmarks" of the female pelvis. Therefore, the purpose of this study was to evaluate the distance of the interspinous plane as a parallel line to the infrapubic line in 2D ITU with the help of 3D computed tomography and digital reconstruction.

RESULTS

Mean distance between the infrapubic plane and the tip of the ischiadic spine was 32.35 (±4.46) mm. The mean height was 166 (±7) cm; the mean weight was 67.5 (±18.4) kg. Body height and the measured distance were significantly correlated (P=0.025; correlation coefficient of 0.5), whereas body weight was not (P=0.37; correlation coefficient of -0.214).

CONCLUSIONS

With the present results, clinicians were enabled to transfer the reproducible measurements of the "head station" by ITU to the widespread but observer-depending vaginal examination. Furthermore, ITU can be verified as an objective method in comparison to subjective palpation with the ability to optimize the evaluation of the head station according to bony structures as landmarks in a standardized application.

Techniques for assisting difficult delivery at caesarean section

BACKGROUND

Caesarean section involves making an incision in the woman's abdomen and cutting through the uterine muscle. The baby is then delivered through that incision. Difficult caesarean birth may result in injury for the infant or complications for the mother. Methods to assist with delivery include vacuum or forceps extraction or manual delivery utilising fundal pressure. Medication that relaxes the uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section. Delivery of the impacted head after prolonged obstructed labour can be associated with significant maternal and neonatal complication; to facilitate delivery of the head the surgeon may utilise either reverse breech extraction or head pushing.

OBJECTIVES

To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo and to compare different extraction methods at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage requiring blood transfusion), and long-term measures of infant and childhood morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

All published, unpublished, and ongoing randomised controlled trials comparing the use of tocolytic agents (routine or selective) at caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby. Use of instrument versus manual delivery to facilitate birth of the baby. Reverse breech extraction versus head pushing to facilitate delivery of the deeply impacted fetal head.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Seven randomised controlled trials, involving 582 women undergoing caesarean section were included in this review. The risk of bias of included trials was variable, with some trials not adequately describing allocation or randomisation.Three comparisons were included. 1. Tocolysis versus no tocolysisA single randomised trial involving 97 women was identified and included in the review. Birth trauma was not reported. There were no cases of any maternal side-effect reported in either the nitroglycerin or the placebo group. No other maternal and infant health outcomes were reported. 2. Reverse breech extraction versus head push for the deeply impacted head at full dilation at caesarean section Four randomised trials involving 357 women were identified and included in the review. The primary outcome of birth trauma was reported by three trials and there was no difference between reverse breech extraction and head push for this rare outcome (three studies, 239 women, risk ratio (RR) 1.55, 95% confidence interval (CI) 0.42 to 5.73). Secondary outcomes including endometritis rate (three studies, 285 women, average RR 0.52, 95% CI 0.26 to 1.05, Tau I² = 0.22, I² = 56%), extension of uterine incision (four studies, 357 women, average RR 0.23, 95% CI 0.13 to 0.40), mean blood loss (three studies, 298 women, mean difference (MD) -294.92, 95% CI -493.25 to -96.59; I² = 98%) and neonatal intensive care unit (NICU)/special care nursery (SCN) admission (two studies, 226 babies, average RR 0.53, 95% CI 0.23 to 1.22, Tau I² = 0.27, I² = 74%) were decreased with reverse breech extraction. No differences were observed between groups for many of the other secondary outcomes reported (blood loss > 500 mL; blood transfusion; wound infection; mean hospital stay; average Apgar score).There was significant heterogeneity between the trials for the outcomes mean blood loss, operative time and mean hospital stay, making comparison difficult. However the operation duration was significantly shorter for reverse breech extraction, which may correspond with ease of delivery and therefore, the amount of tissue trauma and therefore, significantly less blood loss. Given the heterogeneity, we cannot define the amount of difference in blood loss, operative time or hospital stay however. 3. Instrument (vacuum or forceps) versus manual extraction at elective caesarean section Two randomised trials involving 128 women were identified and included in the review. Only one trial reported maternal and infant health outcomes as prespecified in this review. This trial reported birth trauma as an outcome but there were no instances of birth trauma in either comparison group. There were no differences found in mean fall in haemoglobin (Hb) between groups (one study, 44 women, MD 0.03, 95% CI -0.53 to 0.59), or in uterine incision extension (one study, 44 women, RR 0.70, 95% CI 0.13 to 3.73).

AUTHORS' CONCLUSIONS

There is currently insufficient information available from randomised trials to support or refute the routine or selective use of tocolytic agents or instrument to facilitate infant birth at the time of difficult caesarean section. There is limited evidence that reverse breech extraction may improve maternal and fetal outcomes, though there was no difference in primary outcome of infant birth trauma. Further randomised controlled trials are needed to answer these questions.

Obstetric complications on deployed operations: a guide for the military surgeon

Modern military general surgeons tend to train and then practice in 'conventional' surgical specialties in their home nation; however, the reality of deployed surgical practice, either in a combat zone or on a humanitarian mission, is that they are likely to have to manage patients with a broad range of ages, conditions and pathologies. Obstetric complications of war injury include injury to the uterus and fetus as well as the mother and both placental abruption and uterine rupture are complications that military surgeons may have little experience of recognising and managing. On humanitarian deployments, fetomaternal complications are a common reason for surgical intervention. We report a recent patient's story to highlight the obstetric training needs of military surgeons.

Blood transfusion and caesarean section in a developing country

Our objective was to review blood transfusion practices during caesarean section in a developing country. An audit of 463 consecutive caesarean sections and blood transfusions over a 3-year period (2000 - 2002) was undertaken. The data were collected from the records department in a pre-designed proforma and analysed, using EPI - info Statistical Software version 6. A total of 117 out of 463 (25.2%) caesarean section cases were transfused. The rate of blood transfusion for the various indications were as follows: malpresentation (excluding breech), four out of six (66.7%); placenta praevia, 28 out of 49 (59.1%); uterine rupture, five out of nine (55.6%); breech delivery, eight out of 25 (32%); obstructed labour, 35 out of 124 (28.2%); precious baby, one out of four (25%); previous caesarean section, 24 out of 141 (17.0%); severe pre-eclampsia, five out of 45 (11.1%); fetal distress, three out of 28 (10.7%); and others, three out of 29 (10.3%). A total of 78 (67.2%) of caesarean section cases were emergency. A blood transfusion rate of 25.2% during caesarean section is high. The indications for the caesarean section, preoperative anaemia and quantity of blood loss during caesarean section were significant risk factor for blood transfusion. Efforts should be made to reduce the blood transfusion without increasing maternal morbidity and mortality. This is very important because of rising HIV infection in developing country and blood-borne disease.

Transperineal ultrasound imaging in prolonged second stage of labor with occipitoanterior presenting fetuses: how well does the 'angle of progression' predict the mode of delivery?

OBJECTIVES

To compare the angle of progression on transperineal ultrasound imaging between different modes of delivery in prolonged second stage of labor with occipitoanterior fetal position.

METHODS

We prospectively evaluated 41 women at term (>or= 37 weeks) with failure to progress in the second stage of labor. Only cases with occipitoanterior fetal position were included in the final analysis. These cases were classified into three groups: Cesarean section for failure to progress, vacuum extraction for failure to progress, and spontaneous delivery following prolonged second stage of labor. Transperineal ultrasound examination was performed just before digital examination and subsequent delivery. The angle between a line placed through the midline of the pubic symphysis and a line running from the inferior apex of the symphysis tangentially to the fetal skull (the so-called 'angle of progression') was measured offline by an observer blinded to the mode of delivery.

RESULTS

There were 26 cases with occipitoanterior fetal position (Cesarean section, n = 5; vacuum extraction, n = 16; spontaneous delivery, n = 5). Logistic regression analysis showed a strong relationship between the angle of progression and the need for Cesarean delivery (R(2) measure of fit = 55%, likelihood ratio chi-square P < 0.0001). When the angle of progression was 120 degrees , the fitted probability of either an easy and successful vacuum extraction or spontaneous vaginal delivery was 90%.

CONCLUSIONS

This is the first report to document a strong relationship between an objective ultrasound marker (angle of progression) and the mode of delivery following prolonged second stage of labor with occipitoanterior fetal position. A predictive model using this parameter would allow better decision making regarding operative delivery for obstructed labor.

Tocolysis for assisting delivery at caesarean section

BACKGROUND

Caesarean section involves making an incision in the woman's abdomen and cutting through the uterine muscle. The baby is then delivered through that incision. Difficult caesarean birth may result in injury for the infant. Medication that relaxes the uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section.

OBJECTIVES

To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage requiring blood transfusion), and long-term measures of infant and childhood morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1) and PubMed (1966 to January 2006).

SELECTION CRITERIA

Use of tocolytic agents (routine or selective) at caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

A single randomised trial involving 97 women was identified and included in the review. Maternal and infant health outcomes were not reported.

AUTHORS' CONCLUSIONS

There is currently insufficient information available from randomised trials to support or refute the routine or selective use of tocolytic agents to facilitate infant birth at the time of caesarean section.

Complications associated with cesarean section in the second stage of labor

OBJECTIVE

To determine maternal and neonatal complications associated with cesarean section done in the second stage of labor.

METHOD

Cohort study comparing cesarean sections done in the second stage of labor (cases) with those done for poor progress in the first stage (controls). Only singleton cephalic live pregnancies at 36 weeks or more, without previous cesarean section, were included.

RESULT

There were 39 cases and 39 controls. Cesarean section in the second stage of labor took significantly longer (median 45 vs. 30 min; P<0.001), and was associated with more frequent postoperative pyrexia (10 vs. 2; P=0.012). There were more neonatal admissions in the case group (17 vs. 3; P<0.001). Hypoxic ischemic encephalopathy was more frequent in infants following second-stage cesarean section (8 vs. 1; P=0.013), as was subaponeurotic hemorrhage (6 vs. 0; P=0.012).

CONCLUSION

Cesarean section in the second stage of labor is associated with significant intraoperative and neonatal morbidity.

Complications associated with caesarean delivery in a setting with high HIV prevalence rates

OBJECTIVE

This study was designed to determine the prevalence of complications associated with abdominal delivery in a setting of high caesarean section (C/S) and HIV rates.

METHOD

A detailed review of the records of 737 C/S performed over a three-month period was conducted in a tertiary teaching hospital in Durban, South Africa.

RESULTS

The overall complication rate was 14.2%. Major complications included endometritis, wound sepsis, post-partum haemorrhage and bladder injury. HIV infection may have a negative impact on morbidity rates. Disimpacting the fetal head vaginally had a significant association with endometritis (p=0.021). The use of a corrugated drain did not prevent wound sepsis (p<0.001).

CONCLUSION

Complications associated with C/S are common is a setting of high C/S rates and HIV infection.

Head pushing versus reverse breech extraction in cases of impacted fetal head during Cesarean section

OBJECTIVE

To compare maternal and neonatal morbidity associated with two methods to extract the impacted fetal head during Cesarean delivery.

STUDY DESIGN

We retrospectively analyzed cases with difficult extraction of the impacted fetal head during Cesarean section. We compared maternal and neonatal outcomes between cases that were delivered by head extraction following pushing through the vagina ('push' method) and those that were delivered by the reverse breech technique ('pull' method).

RESULTS

We reviewed 3105 Cesarean section reports. Difficult extraction necessitating the 'push' or 'pull' methods was noted in 48 (1.5%) instances. Women that were delivered by the 'pull' method had significantly lower rate of postpartum fever (5% versus 46%; odds ratios, 0.06; 95% confidence intervals, 0.007-0.51) and extensions of the uterine incision (15% versus 50%; odds ratio, 0.17; 95% CI, 0.04-0.74) compared to those that were delivered by the 'push' method. Neonatal outcomes were good in all cases.

CONCLUSIONS

In cases with difficult extraction of the impacted fetal head during Cesarean section, 'pull' method may result in lower maternal morbidity compared to the traditional 'push' method.

Maternal and perinatal morbidity of caesarean delivery at full cervical dilatation compared with caesarean delivery in the first stage of labour

To estimate maternal and perinatal morbidity associated with caesarean delivery at full cervical dilatation, a population-based cohort study from 1997 to 2002 was used, which included 1623 nullipara with singleton pregnancies at 37-42 weeks of gestation requiring caesarean delivery in labour. Compared to caesarean delivery at less than full dilatation, women undergoing caesarean delivery at full dilatation were more likely to have complications of intraoperative trauma (RR 2.6, P < 0.001) and infants with perinatal asphyxia (RR 1.5, P < 0.05). There was no difference in maternal or perinatal morbidity when duration of the second stage of labour or when failed assisted vaginal delivery was considered.

Obstructed labor: using better technologies to reduce mortality

OBJECTIVE

To identify, from the best available evidence, underutilized and promising technologies that may reduce maternal mortality from obstructed labor.

METHODS

The author sought systematic reviews of randomized trials, individual randomized trials, and, in the absence of randomized data, non-randomized studies and clinical consensus. Data were presented according to the level of the evidence.

RESULTS

Obstructed labor causes approximately 8% of maternal deaths, and indirectly contributes to a greater percentage. Proven or widely accepted technologies that help reduce mortality from obstructed labor include contraception, external cephalic version, the partogram, augmentation of labor, selective amniotomy, selective episiotomy, vacuum extraction, caesarean section, symphysiotomy, and destructive procedures for non-viable fetuses. Technologies of uncertain usefulness include maternal height and shoe size, vaginal cleansing, upright posture for delivery and vaginal lubrication. Unuseful technologies include pelvimetry, estimating fetal weight, early labor induction, routine amniotomy and augmentation, routine episiotomy, and starvation during labor.

CONCLUSION

Access to well-established technologies, particularly safe caesarean section, can reduce maternal mortality in resource-poor countries.