Management of impacted fetal head at cesarean delivery
American Journal of Obstetrics and Gynecology, 2024
Title: Management of impacted fetal head at cesarean delivery
Authors: Cornthwaite KR, Bahl R, Lattey K, Draycott T
Journal and Year: American Journal of Obstetrics and Gynecology, 2024
This UK expert review examines impacted fetal head at cesarean delivery, a serious and increasingly recognized obstetric emergency associated with uterine incision extensions, hemorrhage, adjacent organ injury, neonatal trauma, hypoxic brain injury, and substantial medicolegal exposure. Using observational studies, randomized trials, and systematic reviews, the authors outline preventive and management strategies, including vaginal disimpaction, reverse breech extraction, Patwardhan method, tocolysis, and fetal head elevation devices. A central conclusion is that no single technique is clearly superior, and that outcomes are driven largely by correct execution, operator training, and team preparedness. Importantly, the paper explicitly describes vaginal disimpaction as requiring semilithotomy to permit adequate vaginal access and whole-hand support of the fetal head, and emphasizes wide international variation in practice and training as a contributor to avoidable harm.
My Commentary
When I practiced in Europe, cesarean deliveries were routinely performed in semilithotomy. This was not an exceptional setup reserved for second-stage cesareans or anticipated complications. It was the default position, chosen to ensure immediate vaginal access should the need arise. When I later practiced in the United States and attempted to introduce semilithotomy as a routine approach, I was criticized, largely on cultural and institutional grounds, not because of evidence demonstrating harm or inferiority. The resistance reflected tradition rather than data.
This paper helps explain why that distinction matters. Impacted fetal head is unpredictable and cannot be reliably anticipated based on labor stage alone. The review cites data showing that a substantial proportion of impacted fetal head cases occur outside the second stage of labor. Yet effective vaginal disimpaction, when required, assumes semilithotomy and unobstructed vaginal access. Repositioning a patient intraoperatively, after the abdomen is open and hemorrhage risk is rising, is neither efficient nor benign. Preparedness matters.
The authors also clarify an important misconception. Poor maternal outcomes associated with the vaginal “push” technique appear to be linked not to the concept of vaginal disimpaction itself, but to incorrect execution. Using two or three fingers rather than a cupped whole hand, applying force in the wrong direction, or failing to achieve fetal head flexion all increase risk. These errors are more likely when access is limited, assistance is improvised, and teams are unfamiliar with the technique. In contrast, when vaginal access is planned and teams are trained, vaginal disimpaction can be performed in a controlled and anatomically sound manner.
Systematic reviews summarized in the paper suggest lower maternal morbidity with “pull” techniques such as reverse breech extraction, but these too require anticipation, space, and operator competence. None of these techniques are plug-and-play solutions. They depend on preparation, rehearsal, and an operating room setup that allows rapid escalation without delay.
If U.S. obstetrics accepts the premise, supported by this paper, that impacted fetal head is an unpredictable emergency with high stakes, then the default supine positioning for cesarean delivery deserves critical re-examination. Normalizing semilithotomy for cesarean delivery in the United States, as is common in much of Europe, should not be framed as importing foreign practice, but as adopting a system-level safety strategy grounded in preparedness, training, and harm reduction.