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Cornthwaite K, van der Scheer JW, Kelly S, Schmidt-Hansen M, Burt J, Dixon-Woods M, Draycott T, Bahl R. Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1702-1713. [PMID: 38787368 DOI: 10.1111/aogs.14873] [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: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
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 (eg 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.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
| | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Sarah Kelly
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | | | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Tim Draycott
- Royal College of Obstetricians & Gynaecologists, London, UK
- North Bristol NHS Trust, Bristol, UK
| | - Rachna Bahl
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
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Cornthwaite KR, Bahl R, Lattey K, Draycott T. Management of impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024; 230:S980-S987. [PMID: 38462267 PMCID: PMC11000504 DOI: 10.1016/j.ajog.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/05/2022] [Accepted: 10/09/2022] [Indexed: 03/12/2024]
Abstract
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.
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Affiliation(s)
- Katie R Cornthwaite
- University of Bristol and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom.
| | - Rachna Bahl
- University Hospitals Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
| | | | - Tim Draycott
- North Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
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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: 7] [Impact Index Per Article: 7.0] [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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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. 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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Cornthwaite K, Draycott T, Winter C, Lenguerrand E, Hewitt P, Bahl R. Validation of a novel birth simulator for impacted fetal head at cesarean section: An observational simulation study. Acta Obstet Gynecol Scand 2022; 102:43-50. [PMID: 36349412 PMCID: PMC9780722 DOI: 10.1111/aogs.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/08/2022] [Accepted: 07/16/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Impacted fetal head (IFH) is a challenging complication of cesarean section (CS) associated with significant morbidity. Training opportunities for IFH have been reported as inconsistent and inadequate. This study assessed the validity of a novel birth simulator for IFH at cesarean section. MATERIAL AND METHODS Obstetricians and midwives collaborated with model-making company, Limbs & Things (UK), to modify the original PROMPT Flex® simulator and develop a new "Enhanced CS Module" for IFH at cesarean section. Changes included addition of a retractable uterus and restricted pelvic inlet, and the fetal mannequin was modified to allow accurate limb articulation and flexion at the waist. Obstetricians and midwives from three maternity units in Southwest England were individually recorded, each undertaking three simulated scenarios of IFH at cesarean section. Obstetricians were asked to deliver the fetal head and midwives, to perform a vaginal push-up. Participants completed a questionnaire on realism (face validity) and usefulness for training (content validity) with five-point Likert scale responses. Construct validity was assessed by testing an a priori hypothesis that "experts" (consultant obstetricians with >7 years' experience) would be more likely to achieve delivery than "novices" (registrars with <7 years' experience). Performance variables were compared between groups using Chi-square and Mann-Whitney U-tests. RESULTS In all, 105 simulated scenarios were undertaken by 35 obstetricians and midwives. A range of techniques were employed to deliver the IFH including change of hand, vaginal disimpaction and reverse breech extraction. Overall, 86% (30/35) described the model as fairly (4)/very realistic (5) (median = 4, interquartile range [IQR] = 4-5). The model was considered fairly (4)/very useful (5) for training by 97% (34/35; median = 5; IQR = 5-5). Experts delivered the fetal head in all simulations (36/36) and novices delivered the head in 76.9% (30/39) (p = 0.002). Experts delivered the fetal head 58% quicker than novices (median = 66.8 s, IQR = 53-86 vs median = 104 s, IQR = 67.7-137). CONCLUSIONS This novel birth trainer realistically simulates IFH at cesarean section and allows rehearsal of all disimpaction techniques. It was reported to be very useful for training and distinguishes between novice and expert obstetricians. Techniques for IFH are difficult to learn experientially. Simulation is likely to provide an effective and safe form of training.
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Affiliation(s)
- Katie Cornthwaite
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK,Translational Health SciencesUniversity of BristolBristolUK
| | - Tim Draycott
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK
| | - Cathy Winter
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK
| | | | - Pauline Hewitt
- Women's Heatlh DepartmentGloucestershire Royal Hospitals NHS Foundation TrustGloucesterUK
| | - Rachna Bahl
- Women's Health DepartmentUniversity Hospital Bristol Foundation NHS TrustBristolUK
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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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Zhan J, Xing A, Tan X. Complete cervical inversion and nearly inappropriate stitching with cesarean section during the second stage of labor: a case report. J Int Med Res 2021; 49:300060521999522. [PMID: 33730903 PMCID: PMC8165849 DOI: 10.1177/0300060521999522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Cesarean section is a common obstetric operation and an important method for saving the
lives of mothers and their neonates in dangerous situations. Nevertheless, cesarean
section has a higher risk and might have more complications compared with natural
delivery. A reasonable choice of delivery method is important for maternal and neonatal
health. The incidence of complications after cesarean section for mothers and neonates
during the second stage of labor significantly increases compared with planned cesarean
section. During the second stage of labor, the fetal head is deep in the pelvic cavity. If
a cesarean section is performed at this stage, it is prone to causing complications,
including difficult delivery of the fetal head, delayed uterine incision, and massive
hemorrhage, which seriously threaten the health of the mother and her neonate. For the
first time, we report a case of cesarean section after complete opening of the uterine
orifice, which led to almost mistakenly suturing the cervix to the uterus. This report
will hopefully help surgeons anticipate such incidents during cesarean section in the
future.
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Affiliation(s)
- Jun Zhan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Aiyun Xing
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Xi Tan
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
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11
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Cornthwaite K, Draycott T, Bahl R, Hotton E, Winter C, Lenguerrand E. Impacted fetal head: A retrospective cohort study of emergency caesarean section. Eur J Obstet Gynecol Reprod Biol 2021; 261:85-91. [PMID: 33901776 DOI: 10.1016/j.ejogrb.2021.04.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/13/2021] [Accepted: 04/17/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Katie Cornthwaite
- Women's Health Department, North Bristol NHS Trust, UK; Translational Health Sciences, University of Bristol, UK.
| | - Tim Draycott
- Women's Health Department, North Bristol NHS Trust, UK
| | - Rachna Bahl
- Women's Health Department, University Hospital Bristol Foundation NHS Trust, UK
| | - Emily Hotton
- Women's Health Department, North Bristol NHS Trust, UK; Translational Health Sciences, University of Bristol, UK
| | - Cathy Winter
- Women's Health Department, North Bristol NHS Trust, UK
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Carbone L, Saccone G, Conforti A, Maruotti GM, Berghella V. Cesarean delivery: an evidence-based review of the technique. Minerva Obstet Gynecol 2021; 73:57-66. [PMID: 33314903 DOI: 10.23736/s2724-606x.20.04681-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The cesarean section is utilized to deliver babies since the late 19th century. Nowadays, the frequency of cesarean section is increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyze different technical aspects of this surgery. The aim of our review was to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and postoperative prophylaxis.
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Affiliation(s)
- Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy -
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Alessandro Conforti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Giuseppe M Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, Federico II University, Naples, Italy
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA
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13
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Krispin E, Fischer O, Kneller M, Arbib N, Salman L, Wiznitzer A, Hadar E. Fetal extraction maneuvers during cesarean delivery in the second stage of labor. J Matern Fetal Neonatal Med 2020; 35:2070-2076. [PMID: 32546078 DOI: 10.1080/14767058.2020.1777273] [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: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Eyal Krispin
- Rabin Medical Center, Helen Schneider Hospital for Women, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Fischer
- Rabin Medical Center, Helen Schneider Hospital for Women, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Kneller
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nissim Arbib
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lina Salman
- Rabin Medical Center, Helen Schneider Hospital for Women, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Wiznitzer
- Rabin Medical Center, Helen Schneider Hospital for Women, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- Rabin Medical Center, Helen Schneider Hospital for Women, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Ezra O, Lahav‐Ezra H, Meyer R, Cahan T, Ilan H, Mazaki‐Tovi S, Sivan E, Barzilay E, Haas J. Cephalic extraction versus breech extraction in second‐stage caesarean section: a retrospective study. BJOG 2020; 127:1568-1574. [DOI: 10.1111/1471-0528.16314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Affiliation(s)
- O Ezra
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - H Lahav‐Ezra
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - R Meyer
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - T Cahan
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - H Ilan
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - S Mazaki‐Tovi
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - E Sivan
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
| | - E Barzilay
- Department of Obstetrics and Gynecology Samson Assuta Ashdod University Hospital Ashdod Israel
- Faculty of Health Sciences Ben‐Gurion University of the Negev Beer‐Sheva Israel
| | - J Haas
- Department of Obstetrics and Gynecology Sheba Medical Center Tel‐Hashomer Israel
- Sackler School of Medicine Tel‐Aviv University Tel Aviv Israel
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15
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Gil M, Chill HH, Kogan L, Porat S, Levitt L, Eliasi E, Dior U. Preferred way of delivery of the impacted fetal head in cesarean sections during second stage of labor. J Obstet Gynaecol Res 2019; 45:2386-2393. [PMID: 31502321 DOI: 10.1111/jog.14115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 08/25/2019] [Indexed: 11/30/2022]
Abstract
AIM To compare maternal and neonatal outcomes between the 'head first' and 'legs first' delivery methods during a second stage cesarean section. METHODS We conducted a retrospective study between January 2009 and May 2015 at a large public university tertiary referral center. Included were all women who underwent cesarean delivery with a fully dilated cervix and a fetal head at the level of the ischial spines or below. The study population was divided into two groups according to way of fetal delivery: The 'legs first' (reverse breech) method and the 'head first' method. Demographics and maternal and fetal outcomes were retrieved for both groups. RESULTS During the study period 447 women underwent a cesarean section while their cervix was fully dilated. Of them, 321 met the inclusion criteria: One hundred and twenty-one (38%) were delivered using the 'legs first' method and 200 (62%) were delivered using the 'head first' method. Indication for surgery and fetal head station was similar for both groups. While no difference in overall intraoperative uterine incision extension rate was observed, a higher rate of uterine incision extension was demonstrated in the 'head first' group in cases in which the second stage was longer than 180 min (33 vs 8 cases, P = 0.02). No differences in maternal postoperative complication rates and neonatal outcomes were observed. CONCLUSION Fetal extraction via the 'legs first' method during prolonged second stage of labor may lower maternal morbidity. Method of delivery does not seem to have an effect on neonatal outcomes.
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Affiliation(s)
- Moran Gil
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Henry H Chill
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Liron Kogan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Shay Porat
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Lorinne Levitt
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Elior Eliasi
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uri Dior
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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16
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Lenz F, Kimmich N, Zimmermann R, Kreft M. 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. BMC Pregnancy Childbirth 2019; 19:98. [PMID: 30917799 PMCID: PMC6437943 DOI: 10.1186/s12884-019-2253-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 03/19/2019] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Franziska Lenz
- Department of Obstetrics and Gynaecology, Kantonsspital Baden AG, Baden, Switzerland
| | - Nina Kimmich
- Division of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Roland Zimmermann
- Division of Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - Martina Kreft
- Division of Obstetrics, University Hospital Zurich, Zurich, Switzerland
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17
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A case-control study about foetal trauma during caesarean delivery. J Gynecol Obstet Hum Reprod 2018; 47:325-329. [PMID: 29793034 DOI: 10.1016/j.jogoh.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/05/2018] [Accepted: 05/17/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The caesarean section rate is gradually increasing in most countries. The frequency of occurrence of foetal injury per birth is estimated to 1%. The majority of these injuries presents a low functional impact, but remains responsible for a significant neonatal morbidity. Even though the foetal risk factors are well documented in cases of vaginal birth, they have not been accurately identified for caesarean section. The aim of this study is to identify the risk factors for neonatal fracture during caesarean section. METHODS We conducted a retrospective case-control study comparing complicated caesarean sections foetal fracture with uncomplicated caesarean sections in a tertiary teaching hospital. We collected all the caesarean sections carried out between 1st January 2003 and 1st September 2015 and selected those the medical files of which presented a foetal fracture diagnosis. RESULTS We identified 10 fractures during the study period, including four skull fractures, three long bone fractures, three clavicle fractures. In all these cases there were no complications with a median perspective of six years (median=6, IQR=4). The push method, which is performed during a caesarean section at the second stage of labour, is identified as a risk factor for foetal trauma in our study (OR: 20.2 [2.8-116.85], p<0.01). A significant correlation was found between transverse lie and foetal trauma (OR: 16.67, CI [1.39; 123.18], p=0.0137). CONCLUSION Foetal trauma during caesarean delivery is a rare event for which the prognosis is most often favourable. Data in the literature on the subject are minimal. This study highlighted transverse lie and the push method as risks factors for foetal fractures during caesarean sections. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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18
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Bruey N, Beucher G, Pestour D, Creveuil C, Dreyfus M. [Caesarean section at full dilatation: What are the risks to fear for the mother and child?]. ACTA ACUST UNITED AC 2017; 45:137-145. [PMID: 28682755 DOI: 10.1016/j.gofs.2017.01.004] [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: 08/01/2016] [Accepted: 01/03/2017] [Indexed: 12/21/2022]
Abstract
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.
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Affiliation(s)
- N Bruey
- Service et département de gynécologie-obstétrique et médecine de la reproduction, pôle femme-enfant, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Centre hospitalier Avranches-Granville, 59, rue de la Liberté, 50300 Avranches, France.
| | - G Beucher
- Service et département de gynécologie-obstétrique et médecine de la reproduction, pôle femme-enfant, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France
| | - D Pestour
- Service de gynécologie obstétrique, CHU d'Angers, 4, rue Larrey, 49100 Angers, France
| | - C Creveuil
- Université de Caen Basse Normandie, esplanade de la paix, 14032 Caen cedex 5, France; Unité de biostatistique et de recherche clinique, hôpital Clémenceau, CHU de Caen, boulevard Clémenceau, 14033 Caen cedex 9, France
| | - M Dreyfus
- Service et département de gynécologie-obstétrique et médecine de la reproduction, pôle femme-enfant, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex 9, France; Université de Caen Basse Normandie, esplanade de la paix, 14032 Caen cedex 5, France
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19
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Nooh AM, Abdeldayem HM, Ben-Affan O. Reverse breech extraction versus the standard approach of pushing the impacted fetal head up through the vagina in caesarean section for obstructed labour: A randomised controlled trial. J OBSTET GYNAECOL 2017; 37:459-463. [DOI: 10.1080/01443615.2016.1256958] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Ahmed Mohamed Nooh
- Obstetrics and Gynaecology Department, Zagazig University Students’ Hospital, Zagazig, Egypt
| | | | - Othman Ben-Affan
- Obstetrics and Gynaecology Department, Al-Ahrar District General Hospital, Zagazig, Egypt
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20
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Menticoglou S. Delivering the Impacted Head at Caesarean Section. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:234. [PMID: 27106192 DOI: 10.1016/j.jogc.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 01/27/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Savas Menticoglou
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Health Sciences Centre, Winnipeg MB
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21
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Abstract
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.
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Affiliation(s)
- Heather Waterfall
- Lyell McEwin HospitalWomen's and Children's DivisionHaydown RoadElizabethSAAustralia
| | - Rosalie M Grivell
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and Gynaecology, Robinson Research Institute72 King William RoadAdelaideSouth AustraliaAustraliaSA 5006
| | - Jodie M Dodd
- The University of Adelaide, Women's and Children's HospitalSchool of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSouth AustraliaAustralia5006
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23
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Jeve YB, Navti OB, Konje JC. Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta-analysis. BJOG 2015; 123:337-45. [DOI: 10.1111/1471-0528.13593] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2015] [Indexed: 11/28/2022]
Affiliation(s)
- YB Jeve
- Department of Obstetrics and Gynaecology; University Hospitals of Leicester; Leicester UK
| | - OB Navti
- Department of Obstetrics and Gynaecology; University Hospitals of Leicester; Leicester UK
| | - JC Konje
- Department of Obstetrics and Gynaecology; University Hospitals of Leicester; Leicester UK
- Reproductive Sciences Section; Department of Cancer Studies and Molecular Medicine; Leicester Royal Infirmary; University of Leicester; Leicester UK
- Center of Excellence in Reproductive Sciences; Department of Obstetrics and Gynecology; Sidra Medical and Research Center; Doha Qatar
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Abstract
Persistent occiput posterior (OP) is associated with increased rates of maternal and newborn morbidity. Its diagnosis by physical examination is challenging but is improved with bedside ultrasonography. Occiput posterior discovered in the active phase or early second stage of labor usually resolves spontaneously. When it does not, prophylactic manual rotation may decrease persistent OP and its associated complications. When delivery is indicated for arrest of descent in the setting of persistent OP, a pragmatic approach is suggested. Suspected fetal macrosomia, a biparietal diameter above the pelvic inlet or a maternal pelvis with android features should prompt cesarean delivery. Nonrotational operative vaginal delivery is appropriate when the maternal pelvis has a narrow anterior segment but ample room posteriorly, like with anthropoid features. When all other conditions are met and the fetal head arrests in an OP position in a patient with gynecoid pelvic features and ample room anteriorly, options include cesarean delivery, nonrotational operative vaginal delivery, and rotational procedures, either manual or with the use of rotational forceps. Recent literature suggests that maternal and fetal outcomes with rotational forceps are better than those reported in older series. Although not without significant challenges, a role remains for teaching and practicing selected rotational forceps operations in contemporary obstetrics.
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Berhan Y, Berhan A. A meta-analysis of selected maternal and fetal factors for perinatal mortality. Ethiop J Health Sci 2014; 24 Suppl:55-68. [PMID: 25489183 PMCID: PMC4249209 DOI: 10.4314/ejhs.v24i0.6s] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In several developing countries, achieving Millennium Development Goal 4 is still off track. Multiple maternal and fetal risk factors were inconsistently attributed to the high perinatal mortality in developing countries. However, there was no meta-analysis that assessed the pooled effect of these factors on perinatal mortality. The purpose of this meta-analysis was to identify maternal and fetal factors predicting perinatal mortality. METHODS In this meta-analysis, we included 23 studies that assessed perinatal mortality in relation to antenatal care, parity, mode of delivery, gestational age, birth weight and sex of the fetus. A computer based search of articles was conducted mainly in the databases of PUBMED, MEDLINE, HINARI, AJOL, Google Scholar and Cochrane Library. The overall odds ratios (OR) were determined by the random-effect model. Heterogeneity testing and sensitivity analysis were also conducted. RESULTS The pooled analysis showed a strong association of perinatal mortality with lack of antenatal care (OR=3.2), prematurity (OR=7.9), low birth weight (OR=9.6), and marginal association with primigravidity (OR=1.5) and male sex (OR=1.2). The regression analysis also showed down-going trend lines of stillbirth and neonatal mortality rates in relation to the proportion of antenatal care. The metaanalysis showed that there was no association between mode of delivery and perinatal mortality. CONCLUSION The present meta-analysis indicated a significant reduction in perinatal mortality among women who attended antenatal care, gave birth to term and normal birth weight baby. However, the association of perinatal mortality with parity, mode of delivery and fetal sex needs further investigation.
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Affiliation(s)
- Yifru Berhan
- Hawassa University, College of Medicine and Health Sciences, Department of Gynecology-Obstetrics
| | - Asres Berhan
- Hawassa University, College of Medicine and Health Sciences, Department of Pharmacology
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