From the Research
Management of an extended fetal head during cesarean delivery requires prompt recognition and careful extraction to prevent maternal and fetal injury, with the key approach involving flexing the fetal head vaginally by an assistant or using the reverse breech extraction method, as supported by the most recent and highest quality study 1. The key management for extended fetal head presentation involves careful extraction techniques to minimize complications.
- The reverse breech extraction method, where the surgeon delivers the shoulders and body first, then the head, is a recommended approach, especially when no assistant is available.
- Nitroglycerin (50-100 mcg IV) can be administered to achieve rapid uterine relaxation if needed, as mentioned in previous studies 2, 3.
- Adequate surgical exposure with a generous transverse lower uterine incision is essential, and in cases of severe impaction, a vertical uterine incision may be necessary, as highlighted in the study 4.
- Controlled, gentle movements are crucial to prevent uterine tears, fetal injury, and maternal hemorrhage, and after delivery, careful inspection of the lower uterine segment for extensions or tears is important, as emphasized in the study 5. The most recent and highest quality study 1 provides a systematic review and meta-analysis of techniques for managing impacted fetal head at cesarean birth, but due to the low or very low GRADE certainty of evidence, no firm recommendations can be made about the superiority of any one technique over another.
- However, based on the available evidence and prioritizing morbidity, mortality, and quality of life, the reverse breech extraction method is recommended as the key approach for managing extended fetal head presentation during cesarean delivery. It is essential to note that the current weaknesses in the evidence base mean that high-quality training is needed across the range of techniques, and future studies are urgently required to improve the evidence base, as highlighted in the study 1.