CHAPTER II

LITERATURE REVIEW

2.1 Definition and Cause of Fetal Head Impacted

The fetal head impacted is Impaction where the fetal head fails to descend in
the maternal pelvis. On this case obstetric complication that requires cesarean
delivery with skillful handling in an organized manner to avoid serious maternal and
neonatal sequel. Multiple factors can contribute to impaction of the fetal head,
including reluctance to intervene during a prolonged second stage include head
malposition, use of epidural anesthesia, and trial of instrumental delivery. 9

A prolonged second stage phase may result from oversedation or from

entering labor early with a thickened or uneffaced cervix. It may be misdiagnosed in
the face of frequent prodromal contractions. Protraction of active labor is more easily
diagnosed and is dependent upon the 3 P' s. The first P, the passenger, may produce
abnormal labor because of the infant's size (eg, macrosomia) or from malpresentation.
The second P, the pelvis, can cause abnormal labor because its contours may be too
small or narrow to allow passage of the infant. Both the passenger and pelvis cause
abnormal labor by a mechanical obstruction, referred to as mechanical dystocia. With
the third P, the power component, the frequency of uterine contraction may be
adequate, but the intensity may be inadequate. Disruption of communication between
adjacent segments of the uterus may also exist, resulting from surgical scarring,
fibroids, or other conduction disruption. Whatever the cause, the contraction pattern
fails to result in cervical effacement and dilation. This is called functional dystocia.
Uterine contractile force can be quantified by the use of an intra-uterine pressure
catheter. Use of this device allows for direct measurement and calculation of uterine
contractility per each contraction and is reported in Montevideo units (MVUs). For

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uterine contractile force to be considered adequate, the force produced must exceed
200 MVUs during a 10-minute contraction period. Arrest disorders cannot be
properly diagnosed until the patient is in the active phase and had no cervical change
for 2 or more hours with the contraction pattern exceeding 200 MVUs. Uterine
contractions must be considered adequate to correctly diagnose arrest of
dilation.9,10,11,12

Epidural analgesia for labor and delivery was introduced in 1938, but began
gaining popularity in the 1970s, such that approximately 61% of women delivered in
the United States receive such analgesia. This concomitant increase has prompted
some to question whether the rise in cesarean birth rates has been influenced by the
increased use of epidural analgesia during childbirth. This concern is buttressed by
the fact that the leading indication for primary cesarean is dystocia, diagnosed when
labor is ineffective, and that epidural analgesia reportedly prolongs labor, specifically
the second stage. Importantly, frequent interventions such as the use of epidural
analgesia have been reported to alter normal labor, further complicating its meaning.
On the other hand dystocia, difficult labor, is characterized by abnormally slow labor
progress and arises from four distinct abnormalities such a expulsive forces,
presentation, position, or fetal development, maternal bony pelvis, and soft tissues of
the reproductive tract that form an obstacle in fetal descent. The abnormalities can be
mechanistically simplified into three categories to include prolongation, protraction,
and arrest disorders. Thats why epidural anesthesia considered for nulliparous
because study found that nulliparous women progress from 4 to 6 cm cervical dilation
much slower than previously thought and that can cause the fetal head impacted.11,12,13

2.2 Management of Fetal Head Impacted

Management of impacted fetal head during second stage cesarean requires
careful and gentle attention to various surgical steps for delivery of a fetus without
adverse maternal and neonatal outcomes, mostly by an experienced surgeon. Actually,
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that are so many method to deliver the fetus with head impacted such a push method,
pull method, pathwardhan method, simple device ( Fetal disimpacting System) and
C- snorkel. But, All these techniques rely on extensive experience that is often not
immediately available on the labour ward. Caesarean sections are usually performed
by doctors in training who are unlikely to be experienced enough to deviate from the
normal techniques of performing a caesarean section and they are so many
complications.

For example is generally the obstetrics are have two approaches are
commonly used to disimpact an engaged fetal head. One involves the surgeon or
midwife placing a hand through the vagina and pushing the babys head back up the
pelvis. This is often associated with vaginal tissue trauma. The other approach
(reverse breech extraction) involves the surgeon delivering the babys feet through the
uterine incision, and then delivering the Head .This method is associated with fetal
hip injury, shoulder injury and facial or neck trauma, and is avoided whenever
possible. Difficulties in disimpacting an engaged fetal head can often delay the
delivery of an already compromised fetus and result in all the above complications .
There is a risk of the complications described above and also risks of obstetric
haemorrhage, in jury to uterine vessels and trauma to the urinary tract. But, using the
fetal disimpacting system had no found any trauma in mother and the fetus. So, in
this study we will describe about using disimpacting fetal system to reduce morbidity
and mortality in impacted fetal head.

2.3 Definiton of Fetal Disimpacting System

The Fetal Disimpacting System consists of a silicone balloon that can be

inserted through the vagina to rest under the fetal head. It can then be inflated with
saline in an attempt to elevate the fetal head. The Foetal Disimpacting System is
manufactured by Safe Obstetric Systems UK Ltd (Essex, UK). It consists of a base
plate 11 cm long and 4.5 cm wide, foldable along the midline of the short axis
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towards the superior surface, to which a balloon is attached. The balloon is attached
through a connector to a tube 80 cm in length that is, in turn, attached to a 60 ml
syringe through a two-way connector.

2.4 Procedure

Insertion of a balloon device to disimpact an engaged fetal head aims to

elevate the fetalhead, without trauma, immediately before an emergencycaesarean
section, usuallyat full dilatation. A disposable soft silicone balloon device is inserted
vaginally, using a lubricant. It is pushed posteriorly towards the coccyx and placed
between the pelvic floor and the feta head, usually at full dilatation of the cervix.
The balloon surface is in contact with the fetal head while the base plate of the
device rests on the anococcygeal ligament, preventing any downward movement
during inflation. This is similar to the placement of a ventouse cup. Once the device is
in position, the mothers legs are placed flat on the operating table, and the balloon is
inflated using sterile saline via a tube connected to a two-way tap. The balloon is
designed to inflateonlyin an upward direction. The engaged fetal head is elevated out
of the pelvis by a few centimetres. The intention is to allow the surgeon to site the
uterine incision slightly higher up on the lower segment of the uterus, on a wider and
thicker part of the segment, so avoiding trauma to the utero-vesical reflection and
making the delivery easier with less manipulation. Immediately after delivery the
balloon is deflated by opening the two-way tap, and the device is removed from the
vagina by traction.
Following the procedure, the vagina is inspected for trauma. The time taken
for this manoeuvre is around 30 seconds. An assistant uses between 100120 ml of
saline to inflate theballoon using a syringe. The inflation is maintainedonly for a short
time just before making the uterineincision. 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 23 cm from its position, making it easier to
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deliver. As soon as delivery is achieved, the balloon is deflated and can be removed:
the device can be gently pulled out using the attached tubing or by hooking a finger
into the base plate.

Figure 2.1 Fetal Disimpacting System.

Study in india with 174 respondens ( 50 using balloon device vs 124 control) about
that efficacy with rapid review of evidence identified 1 non-randomised comparative
study that compared women who had a balloon device inserted to disimpact engaged
fetal head before a caesarean section (n=50) against unmatched historical controls
(n=124): women who had a second stage caesarean section.

Reported that no maternal deaths were reported in women in the balloon

device group where as maternal deaths were reported in 2% (2/124) of women in the
control group. The mean time between uterine incision and delivery was 2.79 0.4
minutes in the balloon device group and 8.43 1.7 minutes in the control group. The
mean time taken to complete caesarean sections was 31.84.6 minutes in the balloon
device group and 52.110.7 minutes in the control group Extensions of uterine
incisions that resulted in increased operating times or blood loss or extensions that
involved 1 or more uterine arteries, the cervix, vagina or other organs,were reported
in 4% (2/50) of women in the balloon device group and 15% (19/124) in the control
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group. Blood loss of more than 1 liter was reported in 2% (1/50) of women in the
balloon device group and 8% (10/127) of women in the control group Blood
transfusions were needed for 2% (1/50) of women in the balloon device group and
5% (6/127) of women in the control group (p=0.36).Admission to an intensive care
was required for no women in the balloon device group and 4.0% (5/124) of women
in the control group

There were no neonatal deaths in the balloon device group and 2 neonatal
deaths (2%, 2/124) in the control group Apgar scores of less than 3 at 5 minutes were
reported in 4% (2/50) of babies in the balloon device group and 3% (4/124) of babies
in the control group Admission to an intensive care unit for more than 24 hours was
required for 6% (3/50) of babies in the balloon device group and 10% (12/124) of
babies in the control group. Seizure was reported in 2% (1/50) of babies in the
balloon device group and 2% (3/124) of babies in the control group. No further
details were provided. Intubation was not needed in any babies in the balloon device
group whereas it was needed in 4% (5/124) of babies in the control group. Neonatal
injury was not reported in anybabies inthe balloon device group whereas it was
reported in 5% (6/124) of babiesinthe control groupNo further detailswere provided.
Infection was not reported in any babies from the balloon device group whereas it
was reported in 6% (7/124) of babies fromthe control group. Timing of infection was
not reported.
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