Committee Opinion No. 415: Impacted Fetal Head, Second-Stage Cesarean Delivery

OBJECTIVE: To review the most effective clinical approaches to disengage an impacted fetal head during cesarean delivery. TARGET POPULATION: Women who undergo cesarean delivery of an infant with a deeply impacted head. OPTIONS: The "push" technique (from below) or the "pull" technique (reverse breech extraction). OUTCOMES: Proper management of this clinical scenario can reduce maternal and perinatal morbidity and mortality. BENEFITS, HARMS, AND COSTS: Using an evidence-informed approach when an impacted fetal head is anticipated has the potential to reduce maternal and fetal complications and short- and long-term harm and their associated costs. Research into the value of simulation learning, regular labour assessments, and team preparedness for possible interventions will help inform quality care. EVIDENCE: The following search terms were entered into PubMed/Medline, Google Scholar, and Cochrane for the publication period 2012-2019: • 'Guidelines' 'manual' • 'Caesarean Section' • 'full dilation' • 'operative delivery' • 'impacted head' • 'Caesarean' AND 'full dilation' AND 'impacted head' • 'Caesarean' AND 'second stage of labour' OR 'second stage' AND 'impacted head' • 'Caesarean' OR 'operative delivery' AND 'impacted head' A total of 32 articles were retrieved and 24 were deemed appropriate to include as references. Many of these articles represented expert opinion. Randomized controlled trials had small sample sizes and were conducted in settings that limit the generalizability of their findings to the Canadian population.²⁰ INTENDED USERS: Intrapartum health care providers.