From the Guidelines
The optimal maternal positioning for the push method in cases of impacted fetal head is the modified lithotomy position with the mother's hips flexed and abducted, as it allows for efficient disimpaction and minimizes the risk of trauma to both mother and baby. This position enables an assistant to place a hand vaginally to help dislodge the impacted head by applying upward pressure while the surgeon simultaneously applies gentle traction from above 1. Alternative positions, such as steep Trendelenburg (30-45 degrees) or the "all-fours" position, may also be considered, although the latter is rarely practical during cesarean delivery.
Key considerations for the push method include:
- Ensuring adequate uterine relaxation with medications like nitroglycerin (50-100 mcg IV bolus) or terbutaline (0.25 mg IV) to reduce uterine tone 1
- Performing the push method with gentle, steady pressure rather than forceful maneuvers to avoid fetal injury
- Maintaining communication between the vaginal assistant and the surgeon for coordinated efforts
Recent studies have highlighted the importance of careful technique and positioning to minimize complications, including uterine incision extensions, need for blood transfusion, and infections 1. The modified lithotomy position is preferred, as it allows for efficient disimpaction and minimizes the risk of trauma to both mother and baby. While other positions, such as those suggested in guidelines for urgent obstetric situations, may be considered, the modified lithotomy position is the most appropriate choice for the push method in cases of impacted fetal head 1.
From the Research
Optimal Maternal Positioning for the Push Method
The optimal maternal positioning for the push method in cases of impacted fetal head is not explicitly stated in the provided studies. However, some studies suggest that certain positions and techniques can be used to facilitate delivery:
- Decreasing the height of the operating table and providing a step for the obstetrician to stand on may be helpful 2
- Placing the patient in the head down position may also be beneficial 2
- The use of a Fetal Pillow, a simple inflatable device, can help push the fetal head upwards and reduce complications 3
Comparison of Delivery Methods
Several studies compare the push method with other delivery methods, including Patwardhan's method and the reverse breech technique:
- A study found that the push method and Patwardhan's method resulted in similar maternal complications, but the push method had lower rates of neonatal complications 4
- Another study suggested that the reverse breech technique may be safer and faster than the push method 5
- A literature review proposed a management algorithm "ALERT" for clinical application, which suggests selecting the primary disengagement technique based on surgeon experience 6
Management of Impacted Fetal Head
The management of impacted fetal head is a critical aspect of obstetric care:
- A focused review outlined the incidence, risk factors, management, and complications of impacted fetal head at caesarean delivery, and proposed an algorithm for management 2
- The review suggested that the anaesthetist, in conjunction with the multidisciplinary team, should consider various strategies to manage impacted fetal head, including pharmacological tocolysis and surgical manoeuvres 2