How I prevailed over a case of difficult fetal extraction … and more

The importance of a straight wrist

My usual technique is to slip at least three fingers—index, middle, and fourth—below the head to break the suction and flex the head. I keep my wrist rigidly straight and lift the head without flexing my wrist. When my strength is inadequate to elevate the head, I ask the scrub tech or assistant to help by pulling my forearm toward the patient’s head. I imagine that, by not bending my wrist, I am less likely to do damage to the lower segment.

Nancy Reynolds, MD
Fort Bragg, Calif

A two-handed approach to an impacted vertex

One technique to deliver a vertex deeply impacted in the pelvis is to gently slide the pelvic hand under the lower uterine segment as far as possible, eventually curling the fingertips over or against the molded head. Avoid the instinct to lift the wrist to gain leverage, because that is the action that can split the attenuated lower segment, cervix, and vagina, and even injure the bladder. Instead, place the free hand over the back of the wrist of the pelvic hand, and use both hands to apply slow, persistent pressure that is directed cephalad and against the sacral promontory. Eventually, there will be a sound of suction, and the vertex will deliver.

Through 30 years of practice, I have encountered a few small lower-segment tears but never an injury to fetus, bladder, or vagina.

Peter Geittmann, MD
Arlington Heights, III

A left-handed technique can ease the vertex free

I’m a right-handed surgeon, and I stand on the patient’s right side to perform cesarean delivery. I typically use my right hand to deliver the infant’s head, but I shift gears when I encounter an impacted vertex. First, I request a stool so that I can stand about 8 inches higher, and I lean over the patient. I then place my right hand on the infant’s anterior shoulder (and posterior shoulder, if available). With gentle but steady pressure in the cephalic direction, I push the infant up into the fundus. Slowly but surely the infant will move a couple of centimeters—just enough to slide my left hand between the pubic bone and vertex. I cup the vertex.

By using my left hand to grasp the vertex, I can easily reach deeper into the pelvis than is possible with my right hand. Once I have my left hand around the vertex, I grab my left wrist with my right hand and lift cephalad until the vertex is easily delivered anteriorly.

Another advantage of this technique is that I don’t flex the left wrist. Overall, I find that this approach allows a successful delivery with minimal trauma to both infant and uterus.

Robert Anding, MD
Houston, Tex

Difficult fetal extraction requires patience

I’d like to offer three additional points concerning difficult cesarean delivery:

• Patience is critical. Pushing the head out of the pelvis sometimes takes 3 to 5 minutes. The uterus will contract when it is stretched acutely; you need to give it time to relax again before you can push the head high enough to facilitate the extraction. Once the hand is inserted into the lower uterine segment, a pause of 1 or 2 minutes will give the uterus time to relax. I tell the two people performing this maneuver that their hands should touch.
• I tell the surgeon to “cut high up.” The lower uterine segment is often retracted superiorly, and if you do not adjust your site of incision, you end up making a high vaginal incision.
• Beware Bandl’s contraction ring! In obstructed labors, this ring sometimes forms around the fetal neck. When it does, no amount of pulling will deliver the head. If it is recognized ahead of time, uterine relaxation with acute tocolysis will sometimes help; otherwise, an incision may be necessary.

Thomas J. Benedetti, MD, MHA
Seattle, Wash

Uterine relaxation is a must for difficult extraction

Because almost every maneuver to get the baby out will be so much easier with some uterine relaxation, I recommend giving the patient a couple of whiffs of halothane, or nitroglycerine, or another relaxing agent. It is much easier to do an extraction (any kind) when you are not fighting a uterine contraction. This is true for breech extraction at vaginal delivery, as well as management of a second twin. A rock hard, contracting uterus exposes the fetus to trauma when these maneuvers are attempted. I learned this the hard way a million years ago as a first-year resident trying to extract a second twin vaginally without a relaxing agent. An epidural really is not going to relax the uterus.

Robert Frischer, MD
Wichita Falls, Tex