What is the management of pathological fetal attitude (Position)?

From the Guidelines

The management of pathological fetal attitude, particularly in cases of impacted fetal head at cesarean delivery, should prioritize techniques that minimize risks to both the mother and the baby, with uterine relaxation and abdominal cephalic disimpaction being key strategies. When encountering an impacted fetal head during cesarean delivery, the approach to management is critical for preventing complications. According to the most recent and highest quality study 1, techniques for managing an impacted fetal head include uterine relaxation, abdominal cephalic disimpaction, manual vaginal disimpaction, reverse breech extraction, and the Patwardhan method.

Key Considerations

• Uterine relaxation through the administration of tocolysis can facilitate advanced disimpaction techniques, reducing the risk of complications during delivery 1.
• Abdominal cephalic disimpaction, which involves flexing and lifting the fetal head upward into the maternal abdomen, is a recommended approach for delivering the head in cases of impaction 1.
• Other methods, such as manual vaginal disimpaction, reverse breech extraction, and the Patwardhan method, may also be considered based on the specific circumstances of the delivery 1.

Clinical Approach

The clinical approach to managing pathological fetal attitude should be guided by the principles of minimizing morbidity, mortality, and improving quality of life for both the mother and the baby. This involves careful assessment of the fetal position and attitude, and the selection of the most appropriate management strategy based on the specific presentation and the availability of resources. As highlighted in a recent study 1, the management of impacted fetal head at cesarean delivery is a critical area of concern, with significant risks to both the mother and the baby if not managed properly.

Recommendations

• Uterine relaxation and abdominal cephalic disimpaction should be considered as first-line strategies for managing impacted fetal head at cesarean delivery, given their potential to reduce complications and improve outcomes 1.
• The selection of the most appropriate management strategy should be based on a careful assessment of the fetal position and attitude, as well as the specific circumstances of the delivery.
• Maternal and fetal well-being should be closely monitored throughout the management process, with adjustments made as necessary to minimize risks and optimize outcomes.

From the Research

Management of Pathological Fetal Attitude (Position)

• The management of breech presentation, a type of pathological fetal attitude, is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV) 2.
• ECV may reduce the number of breech presentations and caesarean sections, but there have also been reports of complications with the procedure 2.
• The use of intrapartum ultrasound has been found to be more reliable than digital examination in assessing malpresentation and malposition, and can help in improving management decision making 3, 4.
• Intrapartum sonography can be used to assess fetal position and presentation, as well as fetal attitude, to predict and aid in decision making regarding delivery 3, 4.
• Fetal malpresentation, malposition, and asynclitism are among the most common determinants of a protracted active phase of labor, arrest of dilatation during the first stage, and arrest of descent in the second stage, and can be diagnosed using intrapartum sonography 4.
• The sonographic assessment of the head position in labor is simple to perform, whereas the assessment of malpresentation and asynclitism warrants a higher level of expertise 4.
• ECV attempt is associated with a decreasing rate of breech presentation at birth, and potentially with a lower rate of cesarean section, without an increase of severe maternal and perinatal morbidity 5.
• Parenteral tocolysis, for ECV attempt at term, is associated with a higher success rate, higher rate of achieved cephalic presentation in labor, and a lower cesarean section rate 5.

Diagnosis and Assessment

• Intrapartum ultrasound can be used to diagnose and assess cephalic malpositions and malpresentations, and can help in improving management decision making 3.
• The sonographic evaluation of the fetal head position and attitude during labor can be used to diagnose and assess malpresentation, malposition, and asynclitism 4.
• The use of intrapartum sonography can confirm the digital findings of asynclitism, and can be used to quantify the degree of flexion in fetuses in non-occiput-posterior or occiput-posterior position 4.

Clinical Practice

• ECV attempt should be performed with immediate access to an operating room for emergency cesarean 5.
• The ECV attempt before 37 weeks, compared to ECV attempt after 37 weeks, increases the rate of cephalic presentation at birth, but with a small increase risk of moderate prematurity 5.
• ECV attempt should be performed from 36 weeks of gestation 5.
• Parenteral tocolysis should be used for ECV attempt at term to increase its success rate 5.
• Cardiotocography should be performed prior and during 30 minutes after the ECV procedure 5.