DOI: 10.1111/1471-0528.

13593 Systematic review

www.bjog.org

Comparison of techniques used to deliver a

deeply impacted fetal head at full dilation: a
systematic review and meta-analysis
YB Jeve,a OB Navti,a JC Konjea,b,c
a
Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, UK b Reproductive Sciences Section, Department of
Cancer Studies and Molecular Medicine, Leicester Royal Infirmary, University of Leicester, Leicester, UK c Center of Excellence in
Reproductive Sciences, Department of Obstetrics and Gynecology, Sidra Medical and Research Center, Doha, Qatar
Correspondence: Dr YB Jeve, Department of Obstetrics and Gynaecology, University Hospitals of Leicester, Leicester, LE25 WW, UK.
Email drybjeve@gmail.com

Accepted 4 July 2015. Published Online 24 August 2015.

Background Second-stage caesarean section with a deeply studies included variables on the participants, comparisons used,
impacted fetal head is associated with maternal and neonatal and feto-maternal outcomes. Meta-analysis was performed using
complications. REVIEW MANAGER 5.3.

Objectives Systematic review and meta-analysis to identify,
appraise and synthesise existing evidence that evaluated various
techniques of delivering a baby with a deeply impacted head at
full-dilation caesarean section. The primary outcome was uterine
extension and secondary outcomes were other maternal and
neonatal morbidities.
Search strategy Online searches of MEDLINE (1946–
January 2015), EMBASE (1950–January 2015), Web of Sciences
(1950–2015), and the Cochrane Library databases were performed
using a set of relevant keywords.
Selection criteria All studies that compared the outcome of
various techniques of delivering the baby’s head at full-dilation
caesarean section.
Data collection and analysis Methodological quality was assessed
using the Newcastle–Ottawa scale. Data collected from each of the
Main results In total, 12 studies were included. Six studies
(n = 455) examined primary outcomes. Meta-analysis showed that
the risks of uterine incision extension, infection, mean blood loss,
and operative time were significantly higher with the push technique
compared with the reverse breech extraction. The evidence to
support the Patwardhan method and fetal pillow was inadequate.
Authors’ conclusions Evidence gathered from observational
studies suggests that reverse breech extraction is associated with
significantly lower maternal risks compared with the push
method.
Keywords Impacted fetal head, push method, reverse breech
extraction, second-stage caesarean section.
Tweetable abstract Meta-analysis suggests reverse breech
extraction during caesarean section to deliver impacted fetus is
safer.

Please cite this paper as: Jeve YB, Navti OB, Konje JC. Comparison of techniques used to deliver a deeply impacted fetal head at full dilation: a systematic
review and meta-analysis. BJOG 2016;123:337–345.

complications.4 Maternal complications of second-stage

Introduction
Caesarean section rates have continued to rise in England
and Wales, with average rates of 26.2% in 2013–14.1
There is an accompanying rise in the overall caesarean
section rate at full dilatation.2 Caesarean sections at full
dilation are associated with higher rates of maternal and
neonatal complications.3 Delivery of the impacted fetal
head in the second stage is technically challenging, and it
is a major factor contributing to the associated increased
caesarean sections include major haemorrhage, longer hos-
pital stay, greater risk of bladder trauma, and extension
tears of the uterine angle leading to broad ligament hae-
matoma.5 Fetal complications include hypoxia, resulting
from difficulty in delivering the fetal head, and direct
trauma. The risks of postpartum maternal complications
directly correlate with the duration of the second stage of
labour and the mode of delivery.6 Where there is failed
instrumental delivery, or sequential use of vacuum and

ª 2015 Royal College of Obstetricians and Gynaecologists 337

 Jeve et al.
forceps, there is a significantly increased risk of both
neonatal and maternal injury.7
The risk of unintentional extension of uterine incisions
is significantly greater in caesarean sections performed in
the second stage compared with those performed in the
first stage.8 In light of these recognised risks, various
measures have been suggested to reduce their occurrence.
These include increased consultant presence at the time
of surgery and continuing training of junior obstetric staff
to ensure safe intrapartum care,2,9 with the focus on
teaching techniques to deliver the impacted fetal head. A
deeply impacted fetal head leads to a lack of space
between the bony pelvis, pelvic muscles, and the fetal
head, making it difficult for the surgeon to insert a
hand to dislodge it from the pelvis. Various techniques
to overcome this difficulty are described in the litera-
ture.10–12 The superiority of one technique over another
is contentious.11,13,14
This systematic review and meta-analysis was designed to
identify, appraise, and synthesise existing evidence that
evaluated various techniques designed to deliver a deeply
impacted fetal head at full-dilation caesarean section.
Methods
A literature search was performed using Ovid MEDLINE
(1946–January 2015), EMBASE (1950–January 2015), Ovid
OLDMEDLINE, Pre-MEDLINE, In-Process, and other
non-indexed citation databases, consisting of In-Process
and PubMed (not MEDLINE) records from NLM, HaPI
(1985–January 2015), Google scholar, Web of Sciences
(1950–2015), and the Cochrane Library. The searches also
included conference proceedings citation indexes. There
were no language restrictions applied. A combination of
Medical Subject Headings and words were used to generate
a subset of: citations for caesarean section* (‘caesarean’,
‘caesarian’, and ‘cesarian and section*’); citations including
fully and dilation (‘second*’ and ‘stage*’, and ‘full dilation’
and ‘caesarean*’); citations including failed instrumental
delivery (‘failed*’ and ‘instrumental*’ and ‘delivery*’,
‘failed*’ and ‘forceps*’, ‘failed vacuum*’, and ‘impacted*’
and ‘fetal*’ and ‘head*’); and citations including various
techniques of delivery of impacted head (‘reverse breech’
and ‘extraction*’, ‘push method*’, ‘pull method’, ‘Patward-
han method*’, ‘Fetal Disimpacting System’, and ‘fetal pil-
low’). These subsets were combined using ‘AND’ or ‘OR’
as appropriate to generate sets of results addressing the
research question. Duplicates were removed. The reference
list of all published articles including review articles was
examined to check for missed citations. No author was
contacted. This review was registered with the PROSPERO
database (CRD42015022069).
338
Study eligibility criteria and data extraction
We included all cohort studies, case–control studies, and ran-
domised comparative studies that compared various tech-
niques used to deliver the baby’s head at full-dilation
caesarean section. The included studies described and com-
pared techniques to deliver singleton term babies with a deeply
engaged head at full-dilation caesarean section. We excluded
case reports and studies without a control group. The studies
analysing techniques used for first-stage caesarean section
were also excluded. Two authors (YJ and ON) independently
performed the study selection and data extraction; all articles
including abstracts from the electronic searches were assessed,
and citations that met the initial predefined selection criteria
were obtained. All titles were screened and relevant abstracts
were obtained. The full text of selected abstracts were
reviewed. The study quality assessment and final inclusion–ex-
clusion decisions were made after an examination of the arti-
cles in full. After independent assessment of the articles, any
disagreement between the two reviewers was resolved by con-
sensus and by input from the most senior author (JK).
The selected studies were assessed for their methodological
quality using the Newcastle–Ottawa scale. The New-castle-
Ottawa scale assesses the quality of non-randomised studies
focusing on design, content, and ease of use. It helps to the
task of incorporating the quality assessment in the interpre-
tation of meta-analytic results. We have used this scale to
assess potential biases at selection, comparability, exposure,
and outcome stages. The ‘risk for bias assessment tool’ rec-
ommended by the Cochrane Collaboration was used to pro-
duce graphs for any bias.15 For each study, information was
obtained on the participants, comparison used (one tech-
nique verses another), and fetomaternal outcomes.
Outcome measures
The primary outcome measure was uterine incision exten-
sion. Secondary outcome measures were operative time,
mean blood loss, blood transfusion rate, infection rate,
mean Apgar score at 5 minutes, and birth trauma. Uterine
extensions included angle extensions on lower segments
and into the broad ligaments. The mean blood loss was as
reported by the authors. Infections included wound and
maternal sepsis in the postoperative period.
Search results
The studies were selected and reported according to the
preferred reporting items for systematic reviews and meta-
analysis (PRISMA) guidelines.16 Of the 440 citations identi-
fied, 21 were selected for detailed evaluation and 12 were
finally included in the meta-analysis (Figure 1).
Various techniques used in the studies included are
described below. The techniques are also demonstrated in
Figure 2.
ª 2015 Royal College of Obstetricians and Gynaecologists
 Delivery of fetal head at full-dilation caesarean section

Identification
Records identified through Additional records identified
database searching through other sources
(n = 566) (n = 4)

Records after duplicates removed

(n = 440)
Screening

Records screened
(n = 444) Records excluded
Titles screened- 444 (n = 385)
Abstracts reviewed -35

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons (n = 9)

(n = 21) Pelosi et al 1984, Fong et
al 1997, Shalzy et al 2013,
Asicioglu et al 2014: no
comparison group
Studies included in between techniques
qualitative synthesis Ziyauddin et al 2013: It
(n = 12) include first stage
Caesarean Section
Included

Sethuram et al 2010:
Explains lacuna in training
Studies included in Landesman et al 1984,
quantitative synthesis Blickstein et al 2004,
(meta-analysis) Singh et al 2008:
(n = 12) Narrative review

Figure 1. PRISMA flow diagram.

Reverse breech extraction, also known as the pull technique
In this method the fetus in cephalic presentation is first
extracted by the breech.11,12 In the reverse breech extraction
method, after opening the uterus, the surgeon introduces a
hand through the uterine incision towards the upper seg-
ment, grasps both feet, and gently pulls the fetus up to
extract it.10 In most of the circumstances, the fetal feet can
be easily reached through a transverse uterine incision;
therefore, an inverted T- or J-shaped incision is not a pre-
requisite of this method.17 The J–shaped incision is typi-
cally an upward extension of the lower segment incision at
one of the lateral ends, whereas an inverted T is an exten-
sion in the middle of the lower segment incision.18,19 It is
used in extreme difficulties of delivery of baby. Avoidance
of hyper-extension of fetal neck and avoidance of forceful
pull on neck whilst dis-impacting fetal head are key steps
to avoid fetal injuries.
The push technique
Pushing from below is technically the same as the tradi-
tional cephalad delivery in a routine caesarean section, but
it is assisted from below by another person. The head
extraction follows pushing through the vagina, and is hence
referred to as the push method.11 Landesman et al.20
described abdominovaginal delivery using a modified litho-
tomy position, with the legs abducted in either the ‘Whit-
more’ or the ‘frog’ position, and with the wedged vertex
gently lifted with a cupped hand through the uterine inci-
sion. It is a modification of the push technique.
The Patwardhan method (shoulders first method)
This technique was first described by Dr. Patwardhan.21 In
cases of occipito-transverse or occipito-anterior positions
with the head deeply impacted in the pelvis, an incision is
made in the lower uterine segment, at the level of the ante-
rior shoulder, which is then delivered out. With gentle
traction on this shoulder, the posterior shoulder is also
delivered. Next, the surgeon hooks the fingers through both
the axillae and with gentle traction, aided by fundal pres-
sure applied by an assistant, the body of the fetus is
brought out of the uterus. The baby’s head, which is the
only part still inside the uterus, is then gently lifted out of
the pelvis. When the back is posterior (occipito-posterior
position) the hand is introduced into the uterus after
delivering the anterior shoulder and a foot is grasped. By
traction on this foot coupled with fundal pressure the

ª 2015 Royal College of Obstetricians and Gynaecologists 339

 Jeve et al.

Different Techniques

Reverse breech extraction technique *

Push technique *

Patwardhan method **

Figure 2. Different techniques. *Used with permission: Barbieri RL. Difficult fetal extraction at cesarean delivery: What should you do? OBG Manag.
2012;24(1):8–10, 12. **Used with permission: Purandare CN, Patel MA, Balsarkar G. Indian contribution to Obstetrics and Gynecology. Journal of
Obstetrics and Gynecology of India. 2012;62(4):384–5.

breech is delivered followed by the trunk. The head is then
delivered by traction on the legs.4,13,22
The Fetal Disimpacting System and ‘fetal pillow’
The Fetal Disimpacting System is manufactured by Safe
Obstetric Systems UK Ltd (Essex, UK). It has of a foldable
base plate that is 11 cm long and 4.5 cm wide, with a
balloon attached to it. It is inserted vaginally below the
fetal head at the time of inserting a Foley catheter. An
assistant uses up to 180 ml of saline solution to inflate the
balloon using a syringe. The inflation is maintained only
for a short time just before making the uterine incision.
The base plate straightens and opens to become flat against
the pelvic floor during the inflation process. The balloon
inflates and gently elevates the fetal head 3–4 cm from its
original position, making it easier to deliver. As soon as

340 ª 2015 Royal College of Obstetricians and Gynaecologists


delivery is achieved, the balloon is deflated and the device
is then gently pulled out using the attached tubing or by
hooking a finger into the base plate.23
Statistical analysis
Study characteristics and outcome data were collected.
Meta-analysis was performed using REVIEW MANAGER 5.3.24 A
fixed-effects model (using the Mantel–Haenszel method)
was used. A random-effects model was used when the I2
statistic showed a heterogeneity of >50%. The effect esti-
mate was expressed as an odds ratio (OR) with 95% confi-
dence interval (CI). It was represented graphically by forest
plots. Clinical heterogeneity was assessed by the study char-
acteristics, study quality, and outcome measures. Statistical
heterogeneity was examined using the chi squared test;
P < 0.05 was suggestive of heterogeneity. Publication bias
was assessed visually using a funnel plot and by formal
testing for primary outcome.
Results
The process of the literature searches and selection of studies
for the quantitative meta-analysis is shown in Figure 1. A
PRISMA checklist and flow diagram was used. A total of 21
full texts were reviewed and 12 studies were included in this
systematic review. Articles were excluded (n = 9) for various
reasons, such as absence of comparison group,3,25–27 inclu-
sion of first-stage caesarean section,28 review articles,17,20,23
and an article describing training issues.29
Most of the studies were observational studies. We found
three prospective randomised comparative studies.10,30,31
Study characteristics are explained in Table S1. No signifi-
cant differences between women included in both groups,
except the technique used to deliver their babies, were
found. All of these studies are from the less resourced
countries. Primary outcome measures were as shown in
Figure 3 and secondary outcome measures were as shown
in Figure 4 and S1. The risk of bias is shown in Figure S2.
Publication bias for the outcome of uterine extension for
the five included studies showed a symmetrical funnel plot
(Figure S2).
Meta-analysis
Primary outcome measures
The random-effects forest plot for all six studies (n = 455)
showed a significantly increased risk of extension of the
uterine incision using the push technique [n/N = 121/231
push technique group (52%) versus n/N = 35/224 (15%)
reverse breech extraction group; OR 5.92, 95% CI 3.21–
10.91, P < 0.00001, I2 = 40%; Figure 3].10,11,30–33 A total of
three studies compared the Patwardhan method with the
push or pull technique.4,22,34 The meta-analysis showed a
ª 2015 Royal College of Obstetricians and Gynaecologists
Delivery of fetal head at full-dilation caesarean section
significantly lower risk of extension of the uterine incision
with the Patwardhan method compared with the push or
reverse breech extraction (OR 30.95, 95% CI 5.95–160.86,
P < 0.0001, I2 = 0%; Figure 3). A wide confidence interval
denotes a less precise effect. Only one study compared the
Fetal Disimpacting System or fetal pillow with the push
technique (n = 174), and this showed a reduced risk of
uterine incision extension (P = 0.03);35 however, the data
in this study were compared with an unmatched historical
control group.
Secondary outcome measures
The operative time was reported in four studies (n = 357);
there was a significant difference in the total operative time
between techniques.10,30–32 The reverse breech technique
was quicker than the push method: the mean difference
was 14.99 minutes (95% CI 2.30–27.67 minutes; Figure 4).
The mean blood loss as reported in four studies (n = 348)
was significantly lower with the reverse breech extraction
technique than with the push method (mean loss difference
203.39 ml, 95% CI 10.32–396.45 ml, P = 0.04;
Figure 4).10,18,31,32
The fixed-effects forest plot for five studies (n = 457)
showed no significant difference in blood transfusion rates
(OR 1.67, 95% CI 0.84–3.32, P = 0.14, I2 = 37%;
Figure 4).11,12,30,32,33 A meta-analysis of two studies
(n = 179) showed that the blood transfusion rate was sig-
nificantly lower with the Patwardhan method than with the
push or pull method (OR 5.00, 95% CI 2.06–12.16,
P = 0.0004; Figure S1).4,34
A total of seven studies (n = 637) compared infection
rates and the fixed-effects forest plot showed a significantly
lower risk of postoperative infection with the reverse breech
extraction technique (OR 1.77, 95% CI 1.09–2.86,
P = 0.02, I2 = 45%; Figure 4).10–12,30–33
Neonatal outcomes reported were mean Apgar scores at
5 minutes and birth trauma. A meta-analysis of four stud-
ies (n = 289) showed no significant difference in Apgar
scores at 5 minutes between the two groups (P = 0.77;
Figure S1),10,18,30,31 and there was no difference in birth
trauma (n = 362) among the two groups (OR 0.47,
95% CI 0.14–1.64, P = 0.24, I2 = 0%; Figure S1).10,12,31
Discussion
Main findings
Landesman et al.20 suggested that with the rising incidence
of caesarean section deliveries and the associated reduction
in rotational and mid-forceps deliveries, techniques to dis-
engage an impacted fetal head might have an increasingly
important role in the obstetricians armamentarium.
Second-stage caesarean sections with deeply impacted heads
are associated with an increased risk of uterine trauma,
341
 Jeve et al.

Push Method Reverse Breech Extraction Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H; Random, 95% CI M-H, Random, 95% CI
Bastani et al 18 30 9 29 18.4% 3.33 [1.14, 9.75]
Fasubaa et al 25 54 8 54 21.6% 4.96 [1.97, 12.46]
Frass et al 24 59 3 59 14.9% 12.80 [3.59, 45.69]
Kadhum et al 14 25 6 25 15.9% 4.03 [1.20, 13.53]
Levy et al 16 28 6 20 15.8% 3.11 [0.92, 10.48]
Veisi et al 24 35 3 37 13.4% 24.73 [6.22, 98.23]

Total (95% CI) 231 224 100.0% 5.92 [3.21, 10.91]

Total events 121 35
Heterogeneity: Tau2 = 0.23; Chi2 = 8.29, df = 5 (P = 0.14): I2 = 40%
Test for overall effect; Z = 5.70 (P < 0.00001) 0.01 0.1 1 0 100
Favours Push Method Favours Reverse Breech

Push/Pull Patwardhan Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Khosla et al 12 50 0 50 32.5% 32.79 [1.88,571.25]
Mukhopadhyay et al 14 50 0 50 30.8% 40.12 [2.32, 694.45]
Saha et al 10 44 0 35 36.7% 21.61 [1.22.383.20]

Total (95% CI) 144 135 100.0% 30.95[5.95, 160.86]

Total events 36 0
Heterogeneity: Chi2 = 0.09, df = 2 (P = 0.95); I2 = 0%
Test for overall effect; Z = 4.08 (P < 0.0001) 0.001 0.1 1 10 100
Favours Push/Pull Favours Patwardhan
Figure 3. Primary outcome – uterine incision extension.

infection, and blood loss.10 Prolonged second stage of
labour results in the stretching and thinning of the lower
uterine segment and a resulting fetal head impaction. This
predisposes women to an increased risk of cervical lacera-
tions and extension of uterine incisions during the delivery
of the fetal head.36 These extensions occur in the lower or
upper uterine segments, the cervix, and into the board liga-
ments. These then increase the risk of bleeding, infections,
and prolong the operative time for repairing them.36 Exten-
sions of the uterine incisions have long-term implications
on the woman’s obstetric future. If the incision extends lat-
erally, there is a high risk of it transecting the uterine arter-
ies or extending to the broad ligament, where the uterine
venous plexuses can be damaged, with resultant profuse
bleeding. Similarly, downward vertical extension of the
uterine incision may cause injury to the cervical arteries or
the vaginal venous plexuses.37
Difficult delivery of the baby increases the risk of neona-
tal morbidity and mortality. Various techniques are
described in the literature to reduce these risks. The push
method and the reverse breech extraction methods are the
most commonly described techniques.11,12,32,37 A limited
number of studies described the Patwardhan tech-
nique.4,22,34 Although the Patwardhan method appears to
result in reduced maternal risks, the evidence in support of
this comes from very small studies and this method is tech-
nically more demanding.
A few observational studies have demonstrated the safety
of the reverse breech technique with associated reduced
maternal complications.11,12 Fasubaa performed a ran-
domised comparative study of the reverse breech extraction
and push methods, and concluded that the reverse breech
extraction method is safer and faster than the ‘push’
method.31 The conclusions from our meta-analysis were
similar. The push method is associated with an increased
fetal morbidity, as suggested by Fasubaa;31 however, our
meta-analysis did not show a statistical difference with
respect to this. Outcomes like Apgar score, neonatal admis-
sion, and early neonatal death rates were lower with the
reverse breech extraction than with the push method. This
may result from the fact that the fetus is subjected to less
assault in the pull method than in the push method. It has
been suggested that head compression commonly occurs
with the push method during disimpaction, accounting for
the relatively lower Apgar scores.31 The reverse breech
extraction is associated with a higher rate of neonatal
trauma, but the results are not statistically significant.
Overall, fetal injuries were minor in all cases, except one
case of a fractured humerus, which occurred with the pull
method. A more gentle approach and careful handling of
the fetus is suggested in order to reduce this complication.
Other approaches that have been used to help delivery of
the impacted head include the use of uterine relaxants.
Ritodrine, Terbutaline, and Nitroglycerin are safe uterine
relaxants that have been used for caesarean delivery.38 A
systematic review, however, suggests that Nitroglycerin was
not superior to placebo for uterine relaxation for fetal extrac-
tion at caesarean section.39 A recent innovation for

342 ª 2015 Royal College of Obstetricians and Gynaecologists

 Delivery of fetal head at full-dilation caesarean section

Operative Time-
Push Method Reverse Breech extraction Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Bastani et al 75.6 12.2 30 75.5 10.8 29 24.2 % 0.10 [–5.77,5.97]
Fasubaa et al 88.5 4.5 54 55.6 5.5 54 25.4 % 32.90 [31.00, 34.80]
Frass et al 67.2 4.7 59 52.9 5.1 59 25.4 % 14.30 [12.53, 16.07]
Veisi et al 45.29 8.74 35 33.38 6.77 37 25.0 % 11.91 [8.28, 15.54]

Total (95% CI) 178 179 100.0% 14.99 [2.30, 27.67]

Heterogeneity: Tau2 = 164.16; Chi2 = 279.18, df = 3 (P < 0.00001): I2 = 99%
Test for overall effect; Z = 2.32 (P < 0.02) –100 –50 0 50 100
Favours Push Method Favours Reverse Breech
Blood Loss-
Push Method Reverse Breech extraction Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Fasubaa et al 1,256.5 54.3 54 898.4 35.2 54 81.7 % 358.10 [340.84, 375.36]
Frass et al 1.231 471 59 787 519 59 0.8 % 444.00 [265.17, 622.83]
Schwake et al 595 172 21 673 196 29 2.3 % –78.00 [–180.47, 24.47]
Veisi et al 57.1 101 35 457 68 37 15.2 % 114.00 [74.00, 154.00]

Total (95% CI) 169 179 100.0% 311.51 [295.90, 327.11]

Heterogeneity: Chi2 = 179.28, df = 3 (P = 0.00001): I2 = 98%
Test for overall effect; Z = 39.13 (P < 0.00001) –1000 –500 0 500 1000
Favours Push Method Favours Reverse Breech
Blood Transfusion-
Push Method Reverse Breech Extraction Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Bastani et al 3 30 1 29 6.9 % 3.11 [0.30, 31.79]
Chopra et al 5 136 4 46 43.7 % 0.40 [0.10, 1.56]
Frass et al 6 59 4 59 27.3 % 1.56 [0.42, 5.83]
Kadhum et al 10 25 4 25 18.2% 3.50 [0.92, 13.31]
Levy et al 3 28 0 20 3.9% 5.63 [0.27, 115.28]

Total (95% CI) 278 179 100.0% 1.67 [0.84, 3.32]

Total events 27 13
Heterogeneity: Chi2 = 6.32, df = 4 (P = 0.18): I2 = 37%
Test for overall effect; Z = 1.46 (P < 0.14) 0.01 0.1 1 10 100
Favours Push Method Favours Reverse Breech
Post partum-Maternal Infection-
Push Method Reverse Breech Extraction Odds Ratio Odds Ratio
Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
Bastani et al 4 30 1 29 3.4 % 4.31 [0.45, 41.09]
Chopra et al 18 136 3 46 14.9 % 2.19 [0.61, 7.79]
Fasubaa et al 15 54 18 54 49.7 % 0.77 [0.34, 1.75]
Frass et al 4 59 3 59 10.7 % 1.36 [0.29, 6.35]
Kadhum et al 5 25 2 25 6.1% 2.88 [0.50, 16.48]
Levy et al 15 28 1 20 2.1% 21.92 [2.57, 187.02]
Veisi et al 4 35 4 37 13.2% 1.06 [0.24, 4.63]

Total (95% CI) 367 270 100.0% 1.77 [1.09, 2.86]

Total events 65 32
Heterogeneity: Chi2 = 10.82; df = 6, (P = 0.09): I2 = 45%
Test for overall effect; Z = 2.33 (P = 0.02) 0.01 0.1 1 10 100
Favours Push Method Favours Reverse breech

Figure 4. Secondary outcomes.

disimpacting the fetal head – the fetal pillow – is said to reduce
maternal risks.23 One comparative study showed a reduction
in the risk of extensions with the fetal pillow. In this study the
fetal pillow was compared with historical controls where the
push or pull method was used.35 Current limited evidence
does not indicate a major advantage of this method over
others, but more studies are required for this conclusion.
Strengths
This is the first comprehensive systematic review and meta-
analysis of various techniques to deliver the impacted fetal
head at second-stage caesarean section. Bastani et al.30
combined first- and second-stage caesarean sections. Our
meta-analysis is not only restricted to second-stage cae-
sarean section but also includes new studies.4,35 We
included previously described as well as newer techniques,
which makes this the most comprehensive review.
Limitations
There are a few inherent limitations to this meta-analysis.
It is impossible to objectively define a truly impacted fetal
head. Therefore, inclusion into any of the studies would
largely have been dependent on the author’s description.
Furthermore, comparison between two techniques is sub-
ject to confounding factors like the experience, skills, and
knowledge of the operators. Secondary outcomes such as

ª 2015 Royal College of Obstetricians and Gynaecologists 343

 Jeve et al.
neonatal death and ischaemic encephalopathy are rare
events, and many studies lack the power to detect a true
difference in these outcomes with different techniques of
managing the impacted head at second-stage caesarean sec-
tion. Most of the studies included here were observational,
and hence there is a need to exercise caution when inter-
preting the results.
Interpretation
The question as to which of the methods for delivering the
impacted head at full-dilation caesarean section is the safest,
and whether there is a role for the sequential use of these
techniques, remains unanswered. The suggested approach is
to use the push method first and then the reverse breech
extraction if it is difficult to deliver the head. It is, however,
unknown if these manoeuvres will have an additional bene-
ficial or an additive detrimental effect.17 Limited evidence
suggests that the reverse breech extraction is associated with
significantly fewer maternal complications, but the chal-
lenge is a lacuna (or gap) in training, as more than half of
trainees are not confident in reverse breech extraction.40
Trainees do not feel confident using techniques like reverse
breech extraction because of a lack of experience. The fact
is that in the UK’s National Health Service it might be diffi-
cult to have round-the-clock supervision by an experienced
obstetrician. Therefore, the training of junior doctors in
these techniques must be a priority. It is important to
develop essential skills among trainees to use different
methods to deliver the impacted fetal head. Like any surgi-
cal technique, appropriate case selection, use of robust sur-
gical techniques, operator’s skills, and experience are keys
for success. Although most of the evidence on these tech-
niques is derived from studies conducted in low-resource
settings, undoubtedly influenced by delays in performing
caesarean section, the techniques are just as applicable in
the more resourced countries, where second caesarean sec-
tion rates are also rising. Perhaps it is time to consider
well-designed, adequately powered, multicentre, prospective
randomised studies in the more resourced countries to pro-
vide more robust evidence on the safety of these
approaches, and the benefits of being able to offer them on
delivery suites. Such an approach may indeed be the first
step to assessing the evidence needed to recommend a par-
ticular method for delivering the impacted fetal head during
second-stage caesarean sections.
Conclusion
This meta-analysis shows 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 compared with the
push method. It is also associated with a lower risk of infec-
344
tion, a lower operative time, and less operative blood loss;
however, there is no difference in blood transfusion rate
and neonatal outcome. Limited evidence from three small
observational studies suggests that the Patwardhan method
is associated with a lower risk of uterine extension and a
lower risk of blood transfusion, with no difference in
neonatal outcome. Newer techniques such as the fetal pillow
require further supportive evidence before being recom-
mended for routine use. There is an urgent need to develop
trainees’ skills on the use of several of these methods to
deliver the impacted fetal head, and thus reduce complica-
tions associated with full-dilation caesarean section.
Contribution to authorship
YJ performed the literature search, review of the papers,
data extraction, meta-analysis, and prepared the article.
OBN reviewed papers as a second reviewer, helped in data
extraction, and contributed to the article. JCK contributed
to research design, overall quality assessment, and prepara-
tion of final article.
Details of ethics approval
Not required.
Funding
None.
Disclosure of interests
Full disclosure of interests available to view online as sup-
porting information.
Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Figure S1. Secondary outcomes.
Figure S2. Risk of bias.
Table S1. Characteristics of studies that compared the
different techniques used to deliver the impacted fetal head
at caesarean delivery. &
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