From the Guidelines
The vaginal push method in impacted fetal head during cesarean delivery is associated with a significantly higher risk of neonatal birth injury, ranging from 9% to 24%, and should be avoided in favor of alternative techniques like the reverse breech extraction (pull method) to minimize fetal trauma. This method carries a higher risk of fetal trauma compared to alternative techniques, with neonatal injuries commonly seen including skull fractures, intracranial hemorrhage, brachial plexus injuries, and facial bruising or lacerations 1. The higher injury rate occurs because the push method applies direct pressure on the fetal head when it is wedged deeply in the maternal pelvis, potentially causing compression against bony structures.
Some key points to consider when managing impacted fetal head during cesarean delivery include:
- The need for an experienced operator to perform the delivery
- The importance of considering alternative extraction methods, such as the pull method, to reduce the risk of neonatal injury
- The potential complications associated with the push method, including uterine incision extensions, need for blood transfusion, and infections 1
- The importance of efficient and skilled approach to reduce both the duration of the impacted fetal head and the risk of direct trauma
The most recent systematic review published in 2022 included 7 prospective randomized studies and 12 observational studies, with 9 of 11 cohort studies meeting the Critical Appraisal Skills Programme (CASP) criteria and 8 of 10 RCTs fully meeting the CASP criteria, reported that the “pull” method, including reverse breech extraction and the Patwardhan method, may be safer for women than vaginal disimpaction 1. Therefore, the pull method is recommended as a safer alternative to the vaginal push method for managing impacted fetal head during cesarean delivery.
From the Research
Neonatal Birth Injury Associated with Vaginal Push Method
- The rate of neonatal birth injury associated with the vaginal push method in impacted fetal head is not directly stated in the provided studies.
- However, a study published in 2022 2 compared maternal and neonatal outcomes associated with delivery techniques via cesarean section, including the "push" technique, and found that the "pull" technique carries lower risks as compared to the "push" technique.
- Another study published in 2023 3 found that operative vaginal delivery, including vacuum and forceps, was associated with an increased risk of severe neonatal birth injury, but did not specifically address the vaginal push method.
- A systematic review and meta-analysis published in 2024 4 compared techniques to prevent or manage impacted fetal head at cesarean birth, but found that the certainty of evidence was low or very low for all outcomes, and no firm recommendations could be made about the superiority of any one technique.
- Other studies 5, 6 have reported on birth injuries and neurodevelopmental outcomes after instrumental vaginal delivery, but did not specifically address the vaginal push method in impacted fetal head.
- Therefore, there is limited evidence to determine the rate of neonatal birth injury associated with the vaginal push method in impacted fetal head, and further research is needed to address this question.