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Delivery of impacted fetal head during second stage Cesarean section: Push method versus abdominal disimpaction with lower uterine segment support: A randomized clinical trial protocol

(Push with Lower Uterine Segment Support: PLUS trial)

Introduction:

Obstructed labor refers to failure of labor progress in spite of good uterine contractions and is attributed to mismatch between the size of the presenting part of the fetus and the mother’s pelvis. Approximately 8% of maternal deaths worldwide are attributed to obstructed labor and subsequent puerperal infection, uterine rupture, and postpartum hemorrhage (1, 2).

In these situations, Cesarean section could minimize maternal and neonatal morbidity. However, Cesarean section is challenging when the head is deeply impacted and is associated with high risk of maternal injuries and perinatal injuries. The most common complication is extension of uterine incision which could involve the vagina, bladder, ureters and broad ligament. Neonates are also at risk of skull fractures, cephalhematoma, and subgleal hematoma mainly due to manipulations. Currently, the most popular approaches for fetal head delivery are the push and pull methods (2, 3).

Although push method seems to be more convenient and does not necessitate extensive experience, it is more significantly associated with extension than the pull method. Although pull method seems to be safer, it is more difficult to perform and usually warrants an aggressive uterine incision to deliver the fetus (4). In 2013, we published a case series on abdominal disimpaction with lower uterine segment support which basically allows obstetricians to deliver the fetal head through a transverse uterine incision with minimal risk of extensions and neonatal complications (5).

Aim of the study:

 

The study aims to compare maternal and early neonatal outcomes of abdominal disimpaction with lower uterine segment support in comparison to the classic “push” method for delivery of impacted fetal head during Cesarean section for obstructed labor.

  • Primary Outcome: The primary outcome is the incidence, direction and length of uterine incision extensions, and the incidence of injury nearby organs (vagina, bladder, ureters, broad ligament).​

 

  • Secondary Outcomes:

  1. Operative time

  2. Intra-operative blood loss

  3. The incidence of postpartum hemorrhage, and management performed.

  4. Incidence of blood transfusion

  5. The incidence of fetal traumatic birth injuries

  6. Neonatal APGAR score at 1 and 5 minutes.

  7. Need for neonatal admission to NICU

  8. Incidence of maternal postoperative infections (puerperal sepsis and CS wound infections) and neonatal sepsis.

 

​​Study intervention:

 

Participants will be randomly assigned to one of two groups:

Group I: Classic push method will be performed to disimpact fetal head at the time of Cesarean section.

In the push method, after opening into the uterus, the patient's knees were flexed and her legs abducted. An assistant then introduced their hand into the patient's vagina and exerted pressure to dislodge the fetal head and elevate it toward the surgeon's hand. The surgeon then delivered the fetus via routine cesarean section (8).  

Group II: Abdominal disimpaction with lower uterine segment support will be performed during CS.

Abdominal disimpaction with lower uterine segment support is conducted by incising the uterus transversely at or slightly below the retraction ring. The incision is extended carefully in both directions just like in traditional cesarean section, then the edge of the lower uterine segment is grasped by LUS forceps (modified Allies forceps designed for this study); the most lateral forceps on each side is applied at the incision angles and then each one is applied 3-4 mm apart from the other along the lower edge of the incision until it is completely supported. These forceps are handled by the assistant, and gentle traction is applied upward, perpendicular to the uterine surface and away from the fetal head without excessive force. Accordingly, the hand of the surgeon could be inserted into the uterine cavity, and adequate space for manipulations is available without applying pressure on the lower segment. The fetal head is eventually grasped and drawn by the surgeon’s single dominant hand until it becomes opposite to the scar. The grasping forceps are then released by the assistant and the head is then simply delivered (5).​​

References

  1. Manning JB, Tolcher MC, Chandraharan E, Rose CH. Delivery of an Impacted Fetal Head During Cesarean: A Literature Review and Proposed Management Algorithm. Obstetrical & Gynecological Survey. 2015 Nov 1;70(11):719-24.

  2. Dolea C, AbouZahr C. Global burden of obstructed labour in the year 2000. World Health Organization (WHO), Geneva, Switzerland. 2003 Jul;1:17.

  3. Jeve YB, Navti OB, Konje JC. Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta-analysis. BJOG: An International Journal of Obstetrics & Gynaecology. 2016 Feb 1;123(3):337-45.

  4. Menticoglou S. Delivering the Impacted Head at Caesarean Section. Journal of Obstetrics and Gynaecology Canada. 2016 Mar 1;38(3):234.

  5. Shazly SA, Elsayed AH, Badran SM. Abdel Badee AY, Ali MK. Abdominal disimpaction with lower uterine segment support as a novel technique to minimize fetal and maternal morbidities during cesarean section for obstructed labor: a case series. Am J Perinatol 2013;30:695–8.

  6. Dolea C, AbouZahr C. Global burden of obstructed labour in the year 2000. World Health Organization (WHO), Geneva, Switzerland. 2003 Jul;1:17.

  7. World Health Organization. Maternal Mortality. World Health Day —Safe Motherhood. Geneva, Switzerland: WHO; 1998(2):1–3

  8. R. Landesman, E.A. Graber Abdominovaginal delivery: modification of the cesarean section operation to facilitate delivery of the impacted head Am J Obstet Gynecol, 148 (6) (1984), pp. 707–710

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Study coordinators:

  • Ahmed Yassein

  • Gena Elassall 

  • Ahmed Salah

Dr. Amr Shehata