Reverse Breech Extraction Versus Dis-Impaction of the Head During Cesarean Section for Obstructed Labor
Journal of Gynecology and Womens Health
Abstarct Obstructed labor is most frequently due to mechanical causes: a mismatch between fetal size and the mother's pelvis (feto-pelvic disproportion) or, more precisely, the size of the fetal presenting part and the mother's pelvis. Malposition of the fetal head as in occipito-posterior and deep transverse arrest positions may also cause obstruction. Malpresentations, in particular a brow presentation or a shoulder presentation in a transverse or oblique lie, are further causes of
... auses of obstruction. In rare cases, pathological enlargement of fetal head (as in hydrocephalus), locked twins or pelvic tumors can cause obstruction. Failure of the cervix to dilate during labor despite adequate uterine contractions is rarely secondary to cervical scarring causing stenosis Two distinct techniques have been suggested to overcome the difficulty of delivering the fetus and reduce maternal and fetal risks during CS for obstruction late in second stage of labor OF breech presentation : the 'standard approach' of pushing the fetal head up through the vagina or the 'reverse breech extraction approach 'The objective of this study was to assess the effectiveness and safety of the reverse breech extraction, and compare it with the standard approach of pushing up through the vagina, in delivering the deeply impacted fetal head during emergency CS for prolonged obstruction in advanced second stage of labor. This study shows that the reverse breech extraction technique for delivery of a deeply impacted fetal head in second-stage caesarean section carries a significantly lower risk of extension of the uterine incision compared with the push method. It is also associated with a lower risk of infection a lower operative time, and less operative blood loss; however, there is no difference in blood transfusion rate and neonatal outcome. Limited evidence from three small observational studies suggests that the reverse breech extraction method is associated with a lower risk of uterine extension and a lower risk of blood transfusion, with no difference in neonatal outcome. There is an urgent need to develop trainees' skills on the use of several of these methods to deliver the impacted fetal head, and thus reduce complications associated with full-dilation caesarean section.