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Peled T, Muraca GM, Ratner M, Sela HY, Kirubarajan A, Weiss A, Grisaru-Granovsky S, Rottenstreich M. Impacted fetal head extraction methods at second stage cesarean and subsequent preterm delivery: A multicenter study. Int J Gynaecol Obstet 2024. [PMID: 38235842 DOI: 10.1002/ijgo.15383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
OBJECTIVE Second-stage cesarean delivery (CD) is associated with subsequent preterm birth (PTB). It has been suggested that an increased risk of PTB after second-stage cesarean delivery could be linked to a higher chance of cervical injury due to the extension of the uterine incision. Previous studies have shown that reverse breech extraction is associated with lower rates of uterine incision extensions compared to the "push" method. We aimed to investigate the association between the method of fetal extraction during second-stage CD and the rate of spontaneous PTB (sPTB), as well as other maternal and neonatal outcomes during the subsequent pregnancy. METHODS This was a multicenter retrospective cohort study. The study population included women in their first subsequent singleton delivery following a second-stage CD between 2004 and 2021. The main exposure of interest was the method of fetal extraction in the index CD ("push" method vs. reverse breech extraction). The primary outcome of this study was sPTB <37 weeks in the subsequent pregnancy. Secondary outcomes were overall PTB, trial of labor, and other adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression modeling. RESULTS During the study period, 2969 index CD during second stage were performed, of those 583 met the inclusion criteria, of whom 234 (40.1%) had fetal extraction using the reverse breech extraction method, while 349 (59.9%) had the "push" method for extraction. In univariate analysis, women in those two groups had statistically similar rates of sPTB (3.7% vs. 3.0%; odds ratio [OR] 1.25, 95% CI: 0.49-3.19) and overall PTB (<37, <34 and <32 weeks), as well as other maternal, neonatal, and trial of labor outcomes. This was confirmed by multivariate analyses with an adjusted OR of 1.27 (95% CI: 0.43-3.71) for sPTB. CONCLUSION Among women with a previous second-stage CD, no significant difference was observed in PTB rates in the subsequent pregnancies following the "push" method compared to the reverse breech extraction method.
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Affiliation(s)
- Tzuria Peled
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Giulia M Muraca
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Miri Ratner
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Abirami Kirubarajan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Ari Weiss
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel
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Cornthwaite K, Bahl R, Winter C, Wright A, Kingdom J, Walker KF, Tydeman G, Briley A, Schmidt-Hansen M, Draycott T. Management of Impacted Fetal Head at Caesarean Birth: Scientific Impact Paper No. 73. BJOG 2023; 130:e40-e64. [PMID: 37303275 DOI: 10.1111/1471-0528.17534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Cornthwaite K, Hewitt P, van der Scheer JW, Brown IAF, Burt J, Dufresne E, Dixon‐Woods M, Draycott T, Bahl R. Definition, management, and training in impacted fetal head at cesarean birth: a national survey of maternity professionals. Acta Obstet Gynecol Scand 2023; 102:1219-1226. [PMID: 37430482 PMCID: PMC10407013 DOI: 10.1111/aogs.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/05/2023] [Accepted: 05/10/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION This study assessed views, understanding and current practices of maternity professionals in relation to impacted fetal head at cesarean birth, with the aim of informing a standardized definition, clinical management approaches and training. MATERIAL AND METHODS We conducted a survey consultation including the range of maternity professionals who attend emergency cesarean births in the UK. Thiscovery, an online research and development platform, was used to ask closed-ended and free-text questions. Simple descriptive analysis was undertaken for closed-ended responses, and content analysis for categorization and counting of free-text responses. Main outcome measures included the count and percentage of participants selecting predefined options on clinical definition, multi-professional team approach, communication, clinical management and training. RESULTS In total, 419 professionals took part, including 144 midwives, 216 obstetricians and 59 other clinicians (eg anesthetists). We found high levels of agreement on the components of an impacted fetal head definition (79% of obstetricians) and the need for use of a multi-professional approach to management (95% of all participants). Over 70% of obstetricians deemed nine techniques acceptable for management of impacted fetal head, but some obstetricians also considered potentially unsafe practices appropriate. Access to professional training in management of impacted fetal head was highly variable, with over 80% of midwives reporting no training in vaginal disimpaction. CONCLUSIONS These findings demonstrate agreement on the components of a standardized definition for impacted fetal head, and a need and appetite for multi-professional training. These findings can inform a program of work to improve care, including use of structured management algorithms and simulation-based multi-professional training.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & GynaecologistsLondonUK
- Translational Health SciencesUniversity of BristolBristolUK
| | | | - Jan W. van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Imogen A. F. Brown
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | | | - Mary Dixon‐Woods
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Tim Draycott
- Royal College of Obstetricians & GynaecologistsLondonUK
- North Bristol NHS TrustBristolUK
| | | | | | - Rachna Bahl
- Royal College of Obstetricians & GynaecologistsLondonUK
- University Hospitals Bristol and WestonBristolUK
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4
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van der Scheer JW, Cornthwaite K, Hewitt P, Bahl R, Randall W, Powell A, Ansari A, Attal B, Willars J, Woodward M, Brown IAF, Olsson A, Richards N, Price E, Giusti A, Leeding J, Hinton L, Burt J, Dixon-Woods M, Maistrello G, Fahy N, Lyons O, Draycott T. Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot. BMJ Open Qual 2023; 12:e002340. [PMID: 37524515 PMCID: PMC10391817 DOI: 10.1136/bmjoq-2023-002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/07/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK. OBJECTIVES To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams. METHODS The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups. RESULTS Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners. CONCLUSIONS The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.
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Affiliation(s)
- Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katie Cornthwaite
- Royal College of Obstetricians and Gynaecologists, London, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | | | - Rachna Bahl
- Royal College of Obstetricians and Gynaecologists, London, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Alison Powell
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bothaina Attal
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet Willars
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Imogen A F Brown
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Annabelle Olsson
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Natalie Richards
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Evleen Price
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alessandra Giusti
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joann Leeding
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | - Oscar Lyons
- RAND Europe, Cambridge, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, UK
- North Bristol NHS Trust, Westbury on Trym, UK
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Ammitzbøll ILA, Andersen BR, Lange KHW, Clausen T, Løkkegaard ECL. Response to the commentary "Anaesthesia for caesarean section and the miscredit of top-up epidurals". Eur J Obstet Gynecol Reprod Biol 2023; 286:147-148. [PMID: 37253648 DOI: 10.1016/j.ejogrb.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023]
Affiliation(s)
- I L A Ammitzbøll
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark.
| | - B R Andersen
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - K H W Lange
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - T Clausen
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - E C L Løkkegaard
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
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Ammitzbøll ILA, Andersen BR, Lange KHW, Clausen T, Løkkegaard ECL. Risk factors for and consequences of difficult fetal extraction in emergency caesarean section. A retrospective registry-based cohort study. Eur J Obstet Gynecol Reprod Biol 2023; 283:74-80. [PMID: 36801595 DOI: 10.1016/j.ejogrb.2023.02.012] [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: 12/08/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
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.
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Affiliation(s)
- I L A Ammitzbøll
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark.
| | - B R Andersen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - K H W Lange
- Department of Clinical Medicine, University of Copenhagen, Denmark; Department of Anesthesiology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - T Clausen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - E C L Løkkegaard
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
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Gq Peak A, Barwise E, Walker KF. Techniques for managing an impacted fetal head at caesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol 2023; 281:12-22. [PMID: 36525940 DOI: 10.1016/j.ejogrb.2022.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Amelia Gq Peak
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Elena Barwise
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Kate F Walker
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
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Wyn Jones N, Mitchell EJ, Wakefield N, Knight M, Dorling J, Thornton JG, Walker KF. Impacted fetal head during second stage Caesarean birth: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2022; 272:77-81. [PMID: 35290876 DOI: 10.1016/j.ejogrb.2022.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence of, and complication rates from, impacted fetal head at full dilatation Caesarean birth in the UK, and record what techniques were used. DESIGN Prospective observational study using the UK Obstetric Surveillance System (UKOSS). SETTING 159 (82%) of the 194 UK hospitals with obstetric units. POPULATION All women who underwent second stage Caesarean birth in the UK between 1st March and 31st August 2019. Further information was collected on cases where a dis-impaction technique was used, or the operating surgeon experienced 'difficulty' in delivering the head. METHODS Prospective observational study. MAIN OUTCOME MEASURES Technique(s) used, maternal and neonatal outcomes. RESULTS 3,518 s stage Caesarean births reported. The surgeon used a dis-impaction technique or reported 'difficulty' in 564 (16%) of these. The most common dis-impaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal "pillow" (n = 176). Thirteen babies (2%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head). CONCLUSIONS Difficulty with delivery of the fetal head and the use of dis-impaction techniques during second stage Caesarean sections are common but there is no consensus as to the best method to achieve delivery and in what order.
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Affiliation(s)
- Nia Wyn Jones
- Clinical Associate Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Eleanor J Mitchell
- Assistant Professor of Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Natalie Wakefield
- Trial Manager, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Marian Knight
- Professor of Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jon Dorling
- Consultant Neonatologist and Professor of Paediatrics, Neonatal Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, UK
| | - Jim G Thornton
- Emeritus Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Kate F Walker
- Clinical Associate Professor of Obstetrics, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK.
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Hanley SJ, Walker KF, Wakefield N, Plachcinski R, Pallotti P, Tempest N, Pillai A, Thornton J, Jones N, Mitchell EJ. Managing an impacted fetal head at caesarean section: a UK survey of healthcare professionals and parents. Eur J Obstet Gynecol Reprod Biol 2022; 271:88-92. [DOI: 10.1016/j.ejogrb.2022.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/24/2022]
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Is duration of passive second stage associated with a risk of hysterotomy extension during cesarean? PLoS One 2021; 16:e0258049. [PMID: 34597319 PMCID: PMC8486087 DOI: 10.1371/journal.pone.0258049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 09/16/2021] [Indexed: 11/20/2022] Open
Abstract
Objective To assess obstetric factors associated with hysterotomy extension among women undergoing a second-stage cesarean. Study design This 5-year retrospective cohort study (2013–2017) included all women with second-stage cesarean deliveries of live-born singleton fetuses in cephalic presentation at term. It took place at a tertiary center that practices delayed pushing. We performed univariable and multivariable logistic regression to assess the maternal, obstetric, and neonatal factors associated with hysterotomy extension mentioned in the surgical report. Operative time, postpartum hemorrhage, and maternal complications were also studied. Results Of the 3350 intrapartum cesareans, 2637 were performed at term for singleton fetuses in cephalic presentation: 747 (28.3%) during the second stage of labor, 83 (11.1%) of which were complicated by a hysterotomy extension. The median duration of the passive phase of the second stage did not differ between women with and without an extension (164 min versus 160 min, P = 0.85). No other second-stage obstetric characteristics, i.e., duration of the active phase, fetal head station, or fetal malposition, were associated with the risk of extension. Factors significantly associated with extension were the surgeon’s experience and forceps use during the cesarean. Women with an extension, compared to women without one, had a longer median operative time (49 min versus 32 min, P<0.001) and higher rates of postpartum hemorrhage and blood transfusion (respectively, 30.1% versus 15.1%, p = 0.002 and 7.2% versus 2.4%, P = 0.03). Conclusion The risk of a hysterotomy extension does not appear to be associated with second-stage obstetric characteristics, including the duration of the passive phase of this stage. In our center, which practices delayed pushing, prolonging this passive phase beyond 2 hours does not increase the risk of hysterotomy extension in second-stage cesareans.
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11
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Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:406-413. [PMID: 33640101 DOI: 10.1016/j.jogc.2021.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review the most effective clinical approaches to disengage an impacted fetal head during cesarean delivery. TARGET POPULATION Women who undergo cesarean delivery of an infant with a deeply impacted head. OPTIONS The "push" technique (from below) or the "pull" technique (reverse breech extraction). OUTCOMES Proper management of this clinical scenario can reduce maternal and perinatal morbidity and mortality. BENEFITS, HARMS, AND COSTS Using an evidence-informed approach when an impacted fetal head is anticipated has the potential to reduce maternal and fetal complications and short- and long-term harm and their associated costs. Research into the value of simulation learning, regular labour assessments, and team preparedness for possible interventions will help inform quality care. EVIDENCE The following search terms were entered into PubMed/Medline, Google Scholar, and Cochrane for the publication period 2012-2019: • 'Guidelines' 'manual' • 'Caesarean Section' • 'full dilation' • 'operative delivery' • 'impacted head' • 'Caesarean' AND 'full dilation' AND 'impacted head' • 'Caesarean' AND 'second stage of labour' OR 'second stage' AND 'impacted head' • 'Caesarean' OR 'operative delivery' AND 'impacted head' A total of 32 articles were retrieved and 24 were deemed appropriate to include as references. Many of these articles represented expert opinion. Randomized controlled trials had small sample sizes and were conducted in settings that limit the generalizability of their findings to the Canadian population.20 INTENDED USERS: Intrapartum health care providers.
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Bloch C, Dore S, Hobson S. Opinion de comité n° 415 : Césarienne au deuxième stade avec enclavement de la tête fœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:414-422. [PMID: 33640102 DOI: 10.1016/j.jogc.2021.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIF Passer en revue les stratégies cliniques les plus efficaces pour désengager une tête fœtale enclavée pendant la césarienne. POPULATION CIBLE Les femmes qui subissent une césarienne lorsque la tête fœtale est fortement enclavée. OPTIONS La technique par poussée (par le bas) ou par traction (grande extraction du siège par voie abdominale). RéSULTATS: La prise en charge adéquate de cette situation clinique peut réduire les risques de morbidité et mortalité maternelle et périnatale. BéNéFICES, RISQUES ET COûTS: Lorsque l'on anticipe un enclavement de la tête fœtale, il est possible de réduire le risque de complications maternelles et fœtales, les atteintes à court et à long terme ainsi que les coûts associés en adoptant une stratégie fondée sur des données probantes. Les recherches sur la valeur de l'apprentissage par simulation, les évaluations régulières pendant le travail et la préparation de l'équipe aux interventions possibles aideront à orienter les soins de qualité. DONNéES PROBANTES: Les termes de recherche suivants ont été utilisés dans les bases de données PubMed-Medline, Google Scholar et Cochrane pour la période de publication de 2012 à 2019 : • "Guidelines" "manual" • "Caesarean Section" • "full dilation" • "operative delivery" • "impacted head" • "Caesarean" AND "full dilation" AND "impacted head" • "Caesarean" AND "second stage of labour" OR "second stage" AND "impacted head" • "Caesarean" OR "operative delivery" AND "impacted head" Au total, 32 articles ont été récupérés et 24 ont été jugés adéquats comme références. Plusieurs de ces articles étaient des opinions d'experts. Les essais cliniques randomisés avaient des échantillons de petite taille et ont été menés dans des contextes qui limitent la généralisabilité de leurs résultats à la population canadienne20. PROFESSIONNELS CIBLES Fournisseurs de soins de santé intrapartum.
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Romano G, Mitchell E, Plachcinski R, Wakefield N, Walker K, Ayers S. The acceptability to women of techniques for managing an impacted fetal head at caesarean section and of randomised trials evaluating those techniques: a qualitative study. BMC Pregnancy Childbirth 2021; 21:103. [PMID: 33530956 PMCID: PMC7852117 DOI: 10.1186/s12884-021-03577-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/20/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND This study aimed to explore women's views on the acceptability of different techniques for managing an impacted fetal head at caesarean; and the feasibility and acceptability of conducting a trial in this area. METHODS Qualitative semi-structured interviews with a systematic sample of women who experienced second stage emergency caesarean section at a tertiary National Health Service (NHS) hospital in England, UK. Thematic analysis was used to extract women's views. RESULTS Women varied in their perceptions of the acceptability of different techniques for managing impacted fetal head. Trust in medical expertise and prioritising the safety of the baby were important contextual factors. Greater consensus was found around informed choice in trials where subthemes considered the timing of invitation, reduced capacity to give consent in emergency situations, and the importance of birth outcomes and having good rapport with healthcare professionals who invite women into trials. Finally, women reflected on the importance of supportive antenatal and postpartum education for impacted fetal head. CONCLUSIONS This research provides information on the acceptability of techniques and any trial to evaluate these techniques. Findings illustrate the importance of context and quality of care to both acceptability and approaching women to take part in a future trial.
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Affiliation(s)
- Gabriella Romano
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Eleanor Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK
| | | | - Natalie Wakefield
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK
| | - Kate Walker
- Nottingham Clinical Trials Unit, University of Nottingham, Building 42 University Park, Nottingham, NG7 2RD, UK.
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, Lenton, University of Nottingham, Nottingham, NG7 2RD, UK.
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
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Wang LH, Seow KM, Chen LR, Chen KH. The Health Impact of Surgical Techniques and Assistive Methods Used in Cesarean Deliveries: A Systemic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6894. [PMID: 32967222 PMCID: PMC7558715 DOI: 10.3390/ijerph17186894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/14/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022]
Abstract
Cesarean delivery is one of the most frequently performed surgeries in women throughout the world. However, the most optimal technique to minimize maternal and fetal morbidities is still being debated due to various clinical situations and surgeons' preferences. The contentious topics are the use of vacuum devices other than traditional fundal pressure to assist in the delivery of the fetal head and the techniques of uterine repair used during cesarean deliveries. There are two well-described techniques for suturing the uterus: The uterus can be repaired either temporarily exteriorized (out of abdominal cavity) or in situ (within the peritoneal cavity). Numerous studies have attempted to compare these two techniques in different aspects, including operative time, blood loss, and maternal and fetal outcomes. This review provides an overview of the assistive method of vacuum devices compared with fundal pressure, and the two surgical techniques for uterine repair following cesarean delivery. This descriptive literature review was performed to address important issues for clinical practitioners. It aims to compare the advantages and disadvantages of the assistive methods and surgical techniques used in cesarean deliveries. All of the articles were retrieved from the databases Medline and PubMed using the search terms cesarean delivery, vacuum, and exteriorization. The searching results revealed that after exclusion, there were 9 and 13 eligible articles for vacuum assisted cesarean delivery and uterine exteriorization, respectively. Although several studies have concluded vacuum assistance for fetal extraction as a simple, effective, and beneficial method during fetal head delivery during cesarean delivery, further research is still required to clarify the safety of vacuum assistance. In general, compared to the use of in situ uterine repairs during cesarean delivery, uterine exteriorization for repairs may have benefits of less blood loss and shorter operative time. However, it may also carry a higher risk of intraoperative complications such as nausea and vomiting, uterine atony, and a longer time to the return of bowel function. Clinicians should consider these factors during shared decision-making with their pregnant patients to determine the most suitable techniques for cesarean deliveries.
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Affiliation(s)
- Li-Hsuan Wang
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
| | - Kok-Min Seow
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111, Taiwan;
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
| | - Li-Ru Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei 10449, Taiwan;
- Department of Mechanical Engineering, National Chiao-Tung University, Hsinchu 30010, Taiwan
| | - Kuo-Hu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei 231, Taiwan;
- School of Medicine, Tzu-Chi University, Hualien 970, Taiwan
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Monod C, Buechel J, Gisin S, Abo El Ela A, Vogt DR, Hoesli I. Simulation of an impacted fetal head extraction during cesarean section: description of the creation and evaluation of a new training program. J Perinat Med 2019; 47:857-866. [PMID: 31494636 DOI: 10.1515/jpm-2019-0216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 08/14/2019] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Cécile Monod
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
| | - Johanna Buechel
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
| | - Stefan Gisin
- Department of Anesthesia, University Hospital Basel and Simulation Center SimBa, Basel, Switzerland
| | - Aisha Abo El Ela
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
| | - Deborah R Vogt
- Clinical Trial Unit, Department Clinical Research, University Hospital Basel and University Basel, Basel, Switzerland
| | - Irene Hoesli
- Department of Gynecology and Obstetrics, University Hospital Basel, Basel, Switzerland
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Giugale LE, Sakamoto S, Yabes J, Dunn SL, Krans EE. Unintended hysterotomy extension during caesarean delivery: risk factors and maternal morbidity. J OBSTET GYNAECOL 2018; 38:1048-1053. [PMID: 29565193 PMCID: PMC6151157 DOI: 10.1080/01443615.2018.1446421] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We conducted an observational retrospective cohort study to evaluate the risk factors and the maternal morbidity associated with unintended extensions of the hysterotomy during caesarean delivery. We evaluated 2707 women who underwent low-transverse caesarean deliveries in 2011 at an academic, tertiary-care hospital. Hysterotomy extensions were identified through operative reports. Of the 2707 caesarean deliveries, 392 (14.5%) had an unintended hysterotomy extension. On the multivariable regression modelling, neonatal weight (OR 1.42; 95%CI 1.17-1.73), the arrest of labour [first-stage arrest (2.42; 1.73-3.38); second-stage arrest (5.54; 3.88-7.90)] and a non-reassuring foetal status (1.65; 1.20-2.25) were significantly associated with hysterotomy extensions. Hysterotomy extensions were significantly associated with an increased morbidity including an estimated blood loss >1200 millilitres (2.06; 1.41-3.02), a decline in postoperative haemoglobin ≥3.7 g/dL (2.07; 1.35-3.17), an evaluation for lower urinary tract injury (5.58; 3.17-9.81), and a longer operative time (8.11; 6.33-9.88). Based on these results, we conclude that unintended hysterotomy extensions significantly increase the maternal morbidity of caesarean deliveries. Impact statement What is already known on this subject? Maternal morbidity associated with caesarean delivery (CD) is significantly greater than that in vaginal delivery. Unintended extensions of the hysterotomy occur in approximately 4-8% of CDs and are more common after a prolonged second stage of labour. The morbidity associated with hysterotomy extensions has been incompletely evaluated. What do the results of this study add? We demonstrate a rate of hysterotomy extension in a general obstetric population of approximately 15%, which is higher than previously reported estimates, and represents a potential doubling of the rate of the unintended hysterotomy extensions in recent years. The most significant risk factor for a hysterotomy extension was a second-stage labour arrest with a fourfold increase in the frequency of extensions. A hysterotomy extension is a significant independent risk factor for an intraoperative haemorrhage, a drop in postoperative haemoglobin, an intraoperative evaluation for lower urinary tract injury, and longer CD operative times. What are the implications of these findings for clinical practice and/or further research? A second-stage arrest is a strong independent risk factor for a hysterotomy extension. Recent re-evaluations of the labour curve that extend the second stage of labour will likely increase the frequency of CDs performed after a prolonged second stage. In these scenarios, obstetricians should be prepared for an unintended hysterotomy extension and for the possibility of a longer procedure with the increased risks of blood loss and the need for evaluation of the lower urinary tract.
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Affiliation(s)
- Lauren E. Giugale
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Sara Sakamoto
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Jonathan Yabes
- Center for Research on Healthcare, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Elizabeth E. Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of UPMC, Pittsburgh, PA, USA
- Magee-Womens Research Institute, Pittsburgh, PA, USA
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Difficult Deliveries in Cesarean Section. J Obstet Gynaecol India 2017; 68:344-348. [PMID: 30224836 DOI: 10.1007/s13224-017-1052-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022] Open
Abstract
Cesarean section rate has been on the rise. It is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, there are situations during C section where delivery of fetus may be difficult. This can cause maternal and fetal complications. To avoid such mishaps, anticipation of potential difficulties and planning in advance can be fruitful. This amounts to mobilization of a good team of anesthetist, assistant and skilled neonatologist. Proper technical skills are needed not only to use the equipment but to deal with such situations for safe delivery of the fetus. The training in technical skills can be imparted through drill protocols under C section skills. This way, one should try and accomplish safe atraumatic fetal delivery.
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Berghella V, Gimovsky AC, Levine LD, Vink J. Cesarean in the second stage: a possible risk factor for subsequent spontaneous preterm birth. Am J Obstet Gynecol 2017. [PMID: 28648691 DOI: 10.1016/j.ajog.2017.04.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
There has been a dramatic rise in the frequency of cesarean sections, surpassing 30% of all deliveries in the US. This upsurge, coupled with a decreasing willingness to allow vaginal birth after cesarean section, has resulted in an expansion of the use of vacuum assistance to safely extract the fetal head. By avoiding the use of a delivering hand or forceps blade, the volume being delivered through the uterine incision can be decreased when the vacuum is used properly. Reducing uterine extensions with their associated complications (eg, excessive blood loss) in difficult cases is also a theoretical advantage of vacuum delivery. Maternal discomfort related to excessive fundal pressure may also be lessened. To minimize the risk of neonatal morbidity, proper cup placement over the “flexion point” remains essential to maintain vacuum integrity and reduce the chance of inadvertent detachment and uterine extensions. Based on the published literature and pragmatic clinical experience, utilization of the vacuum device is a safe and effective technique to assist delivery during cesarean section.
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Affiliation(s)
| | - Jon E Block
- Independent consultant, San Francisco, CA, USA
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Dempsey A, Diamond KA, Bonney EA, Myers JE. Caesarean section: techniques and complications. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.ogrm.2017.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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