KEY POINTS
- Position yourself so your upper trunk, arm, and hand move as a unit to elevate the head.
- Elevate the head to the level of the uterine incision, rather than bringing the incision down to the head.
- Rotate the occiput anteriorly to present the shortest fetal head diameters to the incision.
- Reduce the lower lip of the uterine incision beneath the fetal head, as you would reduce a posterior cervical lip at a vaginal delivery.
Although it’s a skill vital for cesarean birth, manual delivery of the fetal head from a low pelvic station is given only cursory coverage in standard obstetrics texts and reviews.1-4 To learn successful methods, therefore, physicians are forced to rely on observation, anecdotal experience, and—least desirably—trial and error.
Possibly the most frequently employed maneuver in this scenario is to have an assistant elevate the head with his or her hand.1,3,4 However, this technique may not provide sufficient elevation. Furthermore, subsequent manipulation by the clinician may extend the uterine incision and risk injury to the uterine vessels and bladder. It is an untested assumption that such extensions increase the risk of uterine rupture during subsequent trials of labor.
With the goals of minimizing delay, head compression, and strain on the uterine incision, I developed the elevate, rotate, and reduce (ERR) technique for expeditious delivery of the head from a deep pelvic station.
Approaching the head
Begin the procedure by identifying the fetal position; if it is occiput posterior, you may wish to have a disposable vacuum extractor available. Then stand so that your dominant hand is closest to the patient’s pelvis.
When making the abdominal incision, consider fetal size and maternal body habitus. Be sure all layers of the incision are long enough to permit manipulation and delivery—don’t let surgical pride force you to struggle with an inadequate Pfannenstiel incision. Be prepared to identify and extend any layer of the incision that gives considerable resistance at the time of delivery.
Before proceeding to the uterine incision, make sure there is adequate rectus separation. Check the clearance by separating the right and left bodies of the rectus muscle with manual traction. If more room is needed, create a “partial Maylard incision” by cutting bilateral transverse incisions with Mayo scissors across the medial third of each body. This gives the fetus more room while avoiding damage to the inferior epigastric vessels.
The uterine incision should be as wide as the mean fetal head diameter—usually the same 10 cm that we expect of the fully dilated cervix at term. In patients with an undeveloped lower uterine segment, varices, adhesions, or leiomyomata, there may be insufficient width for a low-transverse incision. In these cases you may need to convert to a U, J, or vertical incision.
Take advantage of a well-developed lower uterine segment and avoid tight U- or V-shaped transverse incisions. Identify the uterine vessels with adequate retraction, and incise laterally right up to them. An alternate technique would be to extend the initial incision by pulling apart the ends with your index fingers, laterally and cephalad (towards the mother’s axillae). Blunt dissection may cause less bleeding from the uterine vessels.5
The ERR technique
“Don’t break the wrist” is a classic admonition, familiar to generations of obstetricians. It warns against a practice that begins by reaching for the head with extended wrist, not elevating the head enough, and delivering the head from whatever position it presents in. The head is delivered with firm wrist flexion (breaking, cocking, or levering the wrist) and anterior traction. This puts caudal leverage upon the lower edge of the uterine incision, which may cause an extension down to the bladder or into the cervix. The ERR technique corrects these errors and minimizes strain on the incision.
Elevate. The first goal of ERR is to elevate the fetal vertex to the lower edge of the uterine incision. Bringing the incision down to the presenting part may strain it. Start by holding the fingers of your dominant hand together, with the thumb tucked against the lateral base Safe delivery of the fetal head during cesarean section of the index finger and the fingers extended straight.
Next, insert your fingertips into the uterine incision and advance them around the fetal head—but not while standing erect with your wrist extended. Such a posture would cause 2 problems: First, you would have insufficient leverage and strength to advance your fingers deep into the pelvis. Second, the angle of your wrist would be obstructed by the uterine incision, the lower edge of the abdominal incision, and the pubis.