Dystocia
Conditions
Keywords
Obstructed labor, C section. push method, reverse breech
Brief summary
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.
Detailed description
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. 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 subgaleal hematoma mainly due to manipulations. Currently, the most popular approaches for fetal head delivery are the push and pull methods. 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 more safe, it is more difficult to perform and usually warrants an aggressive uterine incision to deliver the fetus. In 2013, investigators 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. In this study, investigators aim to validate this approach in comparison to the classic push method.
Interventions
PROCEDURECesarean section
Abdominal disimpaction with lower uterine segment support: the edge of the lower uterine segment is grasped by 3-4 modified Allies forceps (with broader jaws) applied 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 delivered. Classic push method: delivering the head with assistance by pushing the fetal head vaginally
Sponsors
Aswan University
Assiut University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Subject)
Eligibility
Sex/Gender
FEMALE
Age
18 Years to 40 Years
Healthy volunteers
No
Inclusion criteria
* Singleton term pregnancy, 37 to 42 weeks of gestation. * Cephalic presentation. * The cervix is fully dilated. * Ruptured membranes. * Adequate uterine contractions. * Impacted fetal head in maternal pelvis
Exclusion criteria
* Intrauterine fetal death * Major fetal anomalies * Non-cephalic presentation * Multiple pregnancy * Preterm caesarean \< 37 weeks * Abnormal placentation.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Extension of uterine incision | During delivery of the fetus | The incidence of extension of uterine incision |
| Length of extension of uterine incision | During delivery of the fetus | If extension of uterine incision happens, the length of extension will be measured |
| Injury of the vagina | During delivery of the fetus | Extension of uterine incision into the vagina |
| Injury of the bladder | During delivery of the fetus | Extension of uterine incision into the bladder |
| Injury of the ureter | During delivery of the fetus | Extension of uterine incision into the ureter |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| APGAR score | At 1 and 5 minutes after delivery of the newborn | — |
| Cesarean section operative time | Time from incision to closure of the skin (within 24 hours of recruitment) | Duration of Cesarean section operation |
| Postoperative infections | 1 week of postpartum | Puerperal sepsis and Cesarean section wound infection |
| Need for neonatal admission to neonatal intensive care unit | Within 24 hours of delivery of the newborn | — |
| Intra-operative blood loss | During Cesarean section only | Amount of blood loss as estimated by suction device from incision to closure of the skin |
| The incidence of postpartum hemorrhage | During the first 24 hours post-operative | Loss of more than 500 ml during the first 24 hours after surgery and the management that will be done |
| Incidence of blood transfusion | During surgery and within the first 24 hours postoperative | The incidence of blood transfusion due to significant blood loss (based on blood loss and clinical judgement hypotension, tachycardia, pallor) |
| Fetal traumatic birth injuries | During Cesarean section (fetal delivery) | Skull fractures, limb fractures, brachial plexus injury, cephalhematoma, and subgaleal hematoma |
Contacts
Primary ContactSherif A. Shazly, MBBCh, MSc
Backup ContactAmr Shehata, MBBCh, MD
Outcome results
None listed