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Delivery of an Impacted Fetal Head During Cesarean: A Literature Review and Proposed Management Algorithm

Manning, Jennifer B. MD*; Tolcher, Mary Catherine MD, MS; Chandraharan, Edwin MBBS, MS; Rose, Carl H. MD§

Obstetrical & Gynecological Survey: November 2015 - Volume 70 - Issue 11 - p 719–724
doi: 10.1097/OGX.0000000000000248

Effective and expedient management of an impacted fetal head (IFH) at cesarean delivery is essential to avoid maternal and neonatal morbidity. The incidence of an IFH at the time of cesarean may increase because of changing practice guidelines regarding the acceptable duration of the second stage of labor. Based on limited available evidence comparing the “push,” “pull,” and other methods for delivery of the IFH, we suggest the primary disengagement technique be selected based on surgeon experience and propose a management algorithm “ALERT” for clinical application.

Target Audience Obstetricians and gynecologists, family physicians

Learning Objectives After completing this activity, the learner will be better able to identify risk factors for an impacted fetal head during cesarean delivery, list potential complications associated with an impacted fetal head, describe the “push” and “pull” methods of delivery of an impacted fetal head, and understand the concepts in the ALERT algorithm.

*Resident, United Family Medicine, Allina Health, St Paul, MN; and †Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; ‡Clinical Director of Women’s Services, Department of Obstetrics and Gynaecology, St George’s Healthcare NHS Trust, London, UK; and §Associate Professor of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN

All authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.

Correspondence requests to: Mary Catherine Tolcher, MD, MS, 200 First St SW, Mayo Clinic, Rochester, MN 55905. E-mail:

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