- Slide your fingers between the head and the lower part of the incision
- Keep your hand stiff so it forms a “slide” for the baby’s head while the assistant pushes on the uterine fundus
- Don’t fight the contraction, direct the head through the incision during relaxation phase
- Assistant may push up from below to dis-impact head wedged deep in the pelvis
- Use a vacuum or forceps for high, floating head, delivery aided by fundal pressure and uterine contraction
The fingers are inserted obliquely into the incision allowing the head to slide over the public bone. You may need to use your fingers to rotate the head into a transverse position. Fundal pressure is applied by the operator or assistant.
This diagram demonstrates the correct hand position. Avoid the temptation to pivot on the public bone as this motion tends to tear the uterine incision and cause it to extend into lateral blood vessels.
Delivery of the Head – Floating
- One option is to drain liquor slowly with a small amniotic sac incision and feel the head descend before extending the incision
- Another is using forceps (one or two blades) or vacuum to assist with extraction
- Occasionally internal podalic version can be done to extract baby as a footling breech
Sometimes the head is high and floating. Again, patience is a virtue. Cradle the baby’s cheek in your palm, rotate to transverse and apply Simpson’s or Wrigley’s forceps. A vacuum extractor also works well here. The head is delivered with the next contraction assisted by fundal pressure.
A – the first cesarean forceps blade is placed
B – slight upward and oblique traction is used to lift the head through the incision while the assistant applies fundal pressure.
If the patient has not been in labour or if the amniotic sac is intact, the head may be high and floating. If the head does not settle in the pelvis and deliver into the uterine incision, forceps or vacuum may be applied to the affect delivery. The assistant applies pressure to the uterine fundus to deliver the baby as the operator guides the head through the incision.
Delivery of the Head – Deeply Impacted
- Anticipate with prolonged labour or failed instrumental delivery
- Prepare for possible vaginal disengagement (discuss with assistant access, technique (3-4 fingers/hand, maintaining flexion) consider modified lithotomy for access
- Consider higher uterine incision
- Reverse breech extraction (grasp both feet(pull) and apply traction parallel to axis of body to avoid hyperextension
- If posterior fetal back deliver one arm then same side leg then other leg followed by other arm and finally the head, if anterior deliver both arms , trunk then both legs,baby’s body turned caudal then head scooped out
- Others: Fetal pillow, consider inverted t incision
In prolonged labour or after failed instrumental delivery, the head may be wedged deep in the pelvis. Uterine incision should be done at a slightly higher level. It is important not to fight the uterine contractions when attempting to slide your fingers beneath the vertex. Wait for the relaxation phase before advancing your hand. The head may need to be disimpacted by an assistant pushing up from the vagina.