Delivery of the deeply engaged head: a lacuna in training

Abstract

The percentage of second stage caesarean sections is on the rise. The delivery of a deeply engaged head in the second stage by caesarean section is an experience feared by most junior registrars. Among the different delivery techniques described, the pull technique has been proven to have a lesser morbidity than the push technique. However, trainees do not receive any structured training in either of these methods. We undertook a survey among 150 UK trainees in SPROGS 2008 in order to understand their experience in dealing with a deeply engaged head in second stage by CS, to ascertain whether trainees feel that they need training to deal with the situation and to discover the means by which this training can be delivered. The questionnaire return rate was 94%. More than 80% agreed that they had faced difficulties in the past while trying to deliver a deeply engaged head. Only 20% used the recommended semi-lithotomy position during caesarean section for an impacted head. Among the trainees who had received only UK training, only 42% were confident of doing a pull method if the need arose. More than 80% of the trainees agreed that supervised sessions to teach alternative techniques for delivery, such as the reverse breech/pull method would be useful and that it would improve their confidence when doing a trial of vaginal delivery. The RCOG agreed that there is little formal training in delivery of a deeply engaged head and is considering recommending trainees complete 2 OSATS (Objective Structured Assessment Tools) in this area. It has also asked the authors to form a skills and drills protocol, which the authors have done and submitted to the RCOG.

Authors' reply re: Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta‐analysis

“…Although evidence supports reverse breech extraction technique, there is a huge gap in training. 3 Our meta-analysis of included studies shows beneficial effects of reverse breech extraction. Therefore we uphold our original conclusion that the reverse breech extraction technique for delivery of a deeply impacted fetal head in second-stage caesarean section carries a significantly lower risk of extension of the uterine incision, lower risk of infection, is quicker, and is associated with less operative blood loss as compared with the push method.…”

“…2 Limited evidence suggests that the reverse breech extraction is associated with significantly fewer maternal complications, but the challenge is a lacuna (or gap) in training, as more than half of trainees are not confident in reverse breech extraction.' 3 We discussed the view expressed by Blickstein to use the push method first and then the reverse breech extraction but it is not known whether that will be beneficial or detrimental. Although evidence supports reverse breech extraction technique, there is a huge gap in training.…”

“…[2][3][4] Although magnesium sulphate is a lifesaving drug for the treatment of eclampsia it is potentially toxic, occasionally leading to fatality. Unfortunately, the minimum therapeutic serum level of magnesium is never explored rigorously as it is often performed in microbiological studies.…”

“…Currently, in many low-resource countries with lower average maternal weight, low-dose magnesium sulphate regimens (a total dose of 20.5-22.5 g in the first 24 hours) have been tried, with low case fatality and fewer recurrences of seizures. [2][3][4] The mean total dose of magnesium sulphate administered per patient was significantly less compared with the Pritchard regimen (40.0 versus 23.9 g; P < 0.001).…”

“…3 The data are therefore the best available evidence for the Epi Re: Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic review and meta-analysis…”