From the Guidelines
Manual vaginal replacement elevation of an impacted fetal head during cesarean delivery carries significant risks of fetal injury, including skull fractures, intracranial hemorrhage, and cervical spine injuries, and should be performed with caution and careful consideration of alternative approaches. The primary risks associated with this procedure occur due to excessive pressure applied to the fetal head during manipulation, especially when the head is deeply wedged in the maternal pelvis 1. The risk increases with the degree of impaction, prolonged second stage of labor, and when excessive force is applied during the maneuver. To minimize these risks, gentle upward pressure should be applied with the flat of the hand rather than fingertips, and the pressure should be distributed evenly across the fetal skull.
Some of the key considerations and techniques to prevent or manage an impacted fetal head include:
- Manual vaginal disimpaction (vaginal push method), which involves introducing a hand into the vagina to move the fetal head up into the abdomen before making a uterine incision 1
- Use of specialized devices like the Fetal Pillow, an inflatable device used in the vagina to move the fetal head up into the abdomen before making a uterine incision 1
- The Patwardhan method, a modification of the reverse breech extraction, which requires specialist training and is widely used in some regions but less familiar in others 1
- Reverse breech extraction (head-last delivery), which may distribute forces more evenly across the fetal body rather than concentrating them on the head, and is considered in cases of severe impaction 1
It is crucial to approach each case with careful consideration of the most appropriate technique to minimize the risk of fetal injury, taking into account the degree of impaction, the skill level of the practitioner, and the availability of specialized devices or assistance. The execution of these techniques is highly variable in clinical practice, and incorrect application of pressure can increase the risk of fetal injury, making it essential to prioritize gentle and skilled manipulation 1.
From the Research
Risk of Fetal Injury with Manual Vaginal Replacement Elevation of Impacted Fetal Head
- The risk of fetal injury with manual vaginal replacement elevation of impacted fetal head is a concern in obstetric care 2.
- A prospective observational study found that 13 babies (2%) died or sustained severe injury out of 3518 second-stage Caesarean births reported, with 564 (16%) of these requiring a dis-impaction technique or experiencing 'difficulty' in delivering the head 2.
- The study also found that manual elevation of the head by an assistant through the vagina was one of the most common dis-impaction techniques used, with 235 cases reported 2.
- However, the evidence base for the safety and efficacy of different techniques for managing impacted fetal head is limited, with low or very low certainty of evidence for most outcomes 3.
- Another study found that the use of instruments, such as forceps or vacuum, at the time of elective repeat cesarean delivery, appears to be safe and effective, but did not specifically address manual vaginal replacement elevation of impacted fetal head 4.
Comparison of Techniques
- A systematic review and meta-analysis compared different techniques for preventing or managing impacted fetal head at cesarean birth, including vaginal disimpaction, reverse breech extraction, the Patwardhan method, and the Fetal Pillow 3.
- The review found that the certainty of evidence was low or very low for all outcomes, and that pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques 3.
- However, some maternal outcomes suggested differences between techniques, such as a higher risk of uterine incision extension with vaginal disimpaction compared to reverse breech extraction 3.