From the Guidelines
The use of the "pull" method, such as reverse breech extraction, is recommended over the "push" method for managing an impacted fetal head during vaginal delivery, as it may be associated with a lower risk of uterine incision extensions, need for blood transfusion, and infections 1. When managing an impacted fetal head during vaginal delivery, the priority is to minimize trauma while safely delivering the baby. The recommended approach includes several steps:
- First, adequate anesthesia should be ensured for the mother.
- Then, the obstetrician should attempt manual disimpaction by inserting a hand between the vaginal wall and fetal head to gently elevate and dislodge it, using techniques such as the Patwardhan method or reverse breech extraction, which have been shown to be effective in reducing the risk of fetal injury and improving neonatal outcomes 1.
- If this fails, an episiotomy may be necessary to create more space.
- In some cases, instrumental delivery with vacuum or forceps may be required, though these carry their own risks. Throughout the process, excessive force should be avoided as it can lead to injuries such as cephalohematoma, subgaleal hemorrhage, skull fractures, or brachial plexus injuries. After delivery, the newborn should be thoroughly examined for any signs of trauma, including bruising, asymmetrical movement, or abnormal neurological signs. The mother should also be monitored for potential complications like vaginal tears or postpartum hemorrhage. This approach balances the need for successful delivery with minimizing trauma to both mother and baby, as the impacted fetal head represents a challenging obstetrical emergency requiring careful management. It is essential to note that the evidence base for the effectiveness of different methods is limited, and most studies fail to report specific details of how disimpaction techniques are performed or any training or competence assessment of clinicians performing them 1. Therefore, it is crucial to prioritize the most recent and highest-quality study, which recommends the use of the "pull" method over the "push" method 1.
From the Research
Birth Injury after Impacted Fetal Head using Vaginal Push
- The use of vaginal push in cases of impacted fetal head during cesarean section has been associated with a higher risk of birth injury, including head trauma and skull fractures 2, 3.
- A systematic review of 16 studies found that the push method was associated with a higher risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission, and Apgar score <7 at 5 minutes compared to reverse breech extraction 2.
- Another study found that the push method was associated with a higher rate of postpartum fever and extensions of the uterine incision compared to the reverse breech technique 3.
- Instrumental vaginal delivery, which involves the use of vacuum extractors or obstetric forceps, has also been associated with a substantial risk of head injury, including hemorrhage, fractures, and brain damage 4.
- The significance of incomplete skull fracture in birth injury has been highlighted, with the suggestion that many skull fractures in newborns may present as incomplete fractures, which can be difficult to diagnose using plain X-ray studies 5.
Comparison of Techniques
- A systematic review and meta-analysis of 24 studies found that the current evidence base is weak, with low or very low certainty of evidence for all outcomes, making it difficult to recommend one technique over another for managing impacted fetal head at cesarean birth 6.
- The review found that some maternal outcomes suggested differences between techniques, but these were based on unreliable pooled estimates and were often at risk of bias 6.
- The study highlights the need for high-quality training and future studies to improve the evidence base, using a standard definition of impacted fetal head and agreed maternal and neonatal outcome sets 6.