الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
The majority of pregnant women as well as obstetricians aim for normal vaginal birth.
Dystocia, which complicates up to 20% of all vaginal deliveries, is often diagnosed in the second stage of labor, when the fetal head is engaged in the pelvis, and vaginal delivery is replaced by cesarean.
However, caesarean delivery cannot provide assurance against maternal and neonatal morbidity when there is difficulty in disengaging a deeply impacted fetal head, a situation that may result in serious maternal and neonatal morbidity.
Difficult caesarean birth may result in injury for the infant or complications for the mother.
Multiple factors can contribute to impaction of the fetal head, including reluctance to intervene during a prolonged second stage, use of epidural anesthesia, trial of instrumental delivery, and fetal head malposition.
Whatever be the cause, extracting a deeply impacted head is a real challenge and associated with several complications (trauma to the fetus, increased risk of infection, uterine incision extension, and excess blood loss).
According to WHO, it is estimated that worldwide, more than 500,000 women die of complications of pregnancy and childbirth every year.
Approximately, another 7 million who survive childbirth suffer serious health problems and a further 50 million suffer adverse health consequences and an overwhelming majority occurs in developing countries.
Adverse outcomes in low risk pregnancies occur in 8.6% of vaginal deliveries and 9.2% of caesarean section deliveries.
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 as in such situations, the lower uterine segment may be over-distended and indistinguishable from the vagina. Therefore, the uterine incision may inadvertently be placed too low, or in the vagina.
Also, it may be difficult for the operating surgeon to maneuver his hand below the deeply engaged fetal head, which may be further compounded by the presence of molding and edema on the fetal head (caput succedaneum).
This prospective controlled study was conducted at labor ward of department of obstetrics and gynecology at Ain Shams University Maternity Hospital and Minya University from September 2021 until March 2023 to compare between the two techniques. A total of 70 pregnant women were enrolled and divided into two equal groups.
Regarding basic demographic characteristics, statistical analysis of current study reported that there was no difference between both groups regarding maternal age, parity and gestational age.
Regarding maternal complications, statistical analysis of current study reported that the push technique caused uterine incision extension more than the reverse breech technique but with no statistically significant difference. Also, it caused blood transfusion more than the reverse breech technique with no statistically significant association. No difference was reported between both groups as regard operative time. However, blood loss was statistically significant higher among cases of push technique compared with reverse breech extraction group.
Regarding fetal complications, statistical analysis of current study reported that there were no differences between both groups regarding fetal injury, birth weight and Apgar score 1 and 2.
The strength points of our study that it was the first study in Ain Shams University Hospitals to compare between the two techniques used to deliver a deeply impacted fetal head at full cervical dilation which are push technique and pull or reverse breech extraction technique regarding maternal and fetal outcomes. Every effort was made to ascertain that all follow-up data were documented, and only complete information was included in data analysis. All clinical assessment and evaluation of study outcomes were done by the same team.
The limitations of the study are worthy of mention, this study was a hospital-based study, hence there was a limited number of cases with relatively smaller sample size relative to study outcomes, not being a multicentric study and this represents a significant risk of publication bias and did not represent a particular community. Also, widespread of Covid-19 pandemic at the starting duration of current study interfered with enrollment and accessibility of patients.
In conclusion, in women with advanced labor, reverse breech extraction technique is better to be utilized for delivery of deeply impacted fetal head during cesarean section as it is associated with less extension of uterine incision and need for blood transfusion. Both technique of delivery had no effect on fetal health.