Letters to the Editor: Managing impacted fetal head at cesarean

“STOP USING INSTRUMENTS TO ASSIST WITH DELIVERY OF THE HEAD AT CESAREAN; START DISENGAGING THE HEAD PRIOR TO SURGERY”

ERROL R. NORWITZ, MD, PHD, MBA (AUGUST 2016)

Patient positioning helps in managing impacted fetal head

As a general practice ObGyn, I have seen an increasing incidence of difficult cesareans as a result of prolonged second stage of labor. Dr. Norwitz cites this increase in his article. I have found that trying to elevate the fetal head prior to the start of surgery has been remarkably ineffective. In my practice, I place all my patients with second-stage arrest in low lithotomy stirrups (“blue fins”); this allows the nurses easier access to the vagina to elevate the head at surgery while I am reaching down from above. Usually, this facilitates delivery. It also allows better assessment of blood loss through the vagina as the cesarean progresses, and it makes placement of a Bakri balloon easier if necessary. If stirrups are not available, the patient can be placed in frog leg positioning so that my assistant can reach down and elevate the head if necessary. I find that in a patient with a very small pelvis, it is hard to get my hand down to the baby’s head. I have not yet done a breech extraction, but I know it is possible. I would probably try nitroglycerin first.

I think that difficult cesarean delivery is much more common than difficult shoulder dystocia, and we should develop standard procedures for addressing the issue and use simulation models to practice. In my time-out prior to surgery, I discuss my concerns so that everyone is ready for it, including the anesthesiologist/CRNA, and we have nitroglycerin available to relax the uterus if necessary. I hope that the American College of Obstetricians and Gynecologists (ACOG) will develop a committee opinion about this very important issue.

Marguerite P. Cohen, MD
Portland, Oregon

Assistant is key in disengaging fetal head

Disengaging the head by an assistant during a cesarean delivery is probably the most successful and useful method for managing an impacted fetal head at cesarean. The disengagement of the head prior to cesarean is practiced routinely in Europe, where forceps delivery is frequently performed. However, the disengagement should be done in the operating room (OR) just prior to or during the cesarean. To perform this in the delivery room, as suggested in Dr. Norwitz’s article, risks the associated fetal bradycardia due to head compression that might compromise an already compromised fetus. In addition, there is a risk of cord prolapse or release of excessive amniotic fluid resulting in cord compression. Also, in many hospitals in the United States, there is some delay to perform the cesarean because the OR is on a different floor from the labor and delivery room and the OR staff come from home.

Vacuum extraction can be safely used for the extraction of the head if it is not possible to deliver it manually. However, the head should be manually disimpacted and rotated to occiput anterior prior to application of the vacuum. But the presence of caput might pose some difficulty with proper application and traction.

It is important to remember that the risk factors for an impacted fetal head are also risk factors for postoperative infection. Therefore, vaginal preparation with antiseptic solution should be considered prior to cesarean delivery for all patients in labor. ¹

Raymond Michael, MD
Marshall, Minnesota

Reference

1. Haas DM, Morgan Al Darei S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2010;3:CD007892.