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

Give terbutaline and proceed slowly

I administer 0.25 mg of terbutaline just before beginning a cesarean delivery. I then stand on a step adjacent to the operating table. After making the uterine incision, I slowly introduce my right hand, following the fetal occiput, and slowly lift the occiput out of the pelvis.

I have used this technique for many years, and it has never failed to relieve impaction.

Bruce A. Darrow, MD
Poteau, Okla

Breech extraction might extend a transverse incision

I never tried to convert to a breech extraction in cases of fetal impaction, but I would think that doing so would tend to extend a transverse incision.

In my practice, my technique for managing difficult fetal extraction during cesarean delivery was to place the fingers of my right hand around the fetal neck, with two fingers on either side. I would then exert upward traction as I slipped the fingers of my left hand around the head. My left hand is small enough that I was never unable to perform this technique.

I performed about 2,000 cesarean deliveries in my career, and the average operating time was 20 to 25 minutes. I had occasional extensions of the incision but rarely an infection.

Norman Lindley, MD
Alamogordo, NM

A vote to abandon the “labor down” approach

In many cases of fetal impaction, I try to push the fetal head up prior to my incision (after adequate epidural anesthesia and when the patient is not contracting). I recommend that we take our time and avoid rushing or panicking when trying to deliver the fetal head. I also curve the uterine incision upward, away from the broad ligament.

I suggest that we abandon the practice of “laboring down.” It seems that, whenever it is practiced, we are faced with these difficult fetal extractions.

Louis Kokkinakos, MD
Columbia, Md

A few caveats for the push technique

We have used the push technique for cases of difficult fetal extraction, with the following caveats:

• First, with full knowledge of the status of the membranes and cervical dilation, as well as fetal station and attitude and position of the vertex, we position the patient in a way that facilitates the actions of a third trained assistant
• We ensure that the deeply engaged vertex does not interfere with the Foley bladder drain
• We wait to act until the surgeon has a clear view of the lower segment, which is expected to be significantly thinned out if labor has been prolonged
• We utilize a cupped hand, as described by Dr. Barbieri, and avoid pushing straight up
• Before the primary surgeon performs a transverse hysterotomy, we utilize reverse asynclitism (going up rather than coming down as a normal cardinal movement of labor) as the fetal head is moved upward, and we have the primary surgeon “squeeze up the shoulder,” which is usually presenting in the lower segment
• Once the surgeon makes the hysterotomy, he (or she) utilizes the pronating hand, depending on which side of the table he is standing, to reach in and extract the disengaged head.

I’ve found that these last two maneuvers reduce the risk of hyperextending the uterine incision and causing a tear.

For a number of years, we have performed these steps when managing all patients who have either:

• a body mass index (BMI) >50
• a neglected labor with a vertex at or below 0 station, with or without significant parietal disalignment (caput), no further progress of dilation despite an adequate labor pattern, and a Category II fetal heart-rate pattern.

We have had no uterine, bladder, maternal, or neonatal complications.

Federico G. Mariona, MD
Dearborn, Mich

Dr. Barbieri responds Readers offer a wealth of valuable suggestions

I am deeply indebted to the obstetricians who took the time to share their excellent advice on how to deliver an impacted fetus. There is a wealth of clinical knowledge in the OBG Management community, and sharing it in this forum is sure to advance the quality of our obstetric care. I am proud to be a colleague of the readers of OBG Management.

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