Tuesday, December 13, 2016

FETAL PILLOW: a novel technique to improve safety of cesarean section at full dilatation.

Fetal Pillow: courtesy safe obstetrics 

courtesy: http://www.safeobstetrics.com/

Obstructed labor with fetal head deeply impacted in the pelvic cavity is a situation dreaded by every obstetrician. The situation cannot be foreseen at the beginning of labor and is usually diagnosed in second stage of labor. Per Zhu BP et al dystocia complicates 20% of all labor with the prevalence being highest in the first birth.[1] It is associated with several complications like increased blood loss, extension of the thinly stretched lower uterine incision, infection and neonatal head trauma.

Numerous methods are used to safely deliver the deeply engaged head. at the time of Caesarean section at full dilation (CSFD). Among the conventional methods ‘the pull technique’ or ‘reverse Breech Extraction or the push technique’ are in common use. Reviews have shown that the pull technique has advantage over push technique regarding neonatal and maternal morbidity.[2]

Another method is ‘Patwardhan Technique’ which is often labeled superior to ‘push’ and ‘pull’ technique due to lesser maternal morbidities. [3] It is especially useful in eliminating the extension of lower uterine incision and allowing these patients future trial of vaginal births. [4] [5]

In recent years, ​Safe Obstetric Systems, UK[6] have launched Fetal Disimpacting System or ‘Fetal Pillow’, used to atraumatically elevate the fetal head out of pelvis at the time of cesarean section. It is in the market for 5 years and is being used I 18 countries across the globe.

As per the Safe Obstetrics System (SOS) Fetal Pillow is a single use silicone balloon filled with saline which inflates only in an upward direction. The surgeon inserts the Fetal Pillow (FP) under the fetal head and inflates it - thus elevating the fetal head and allowing an easier delivery with minimal manipulation. After catheterization of the bladder for CSFD, the folded FP silicone balloon is inserted through the vagina and placed between the fetal head and the pelvic floor. The position of the FP does not change, whether the fetal head is in an occipito-posterior, occipito-transverse position or is deflexed. When the FP is in position, the woman’s legs are placed flat on the operating table and an assistant inflates the balloon whilst the woman is draped. Inflation of the balloon in the pelvic cavity results in a 3-4 cm upward displacement of fetal head. This should facilitate an easier delivery with minimal manipulation. Moreover, the uterine incision can be sited higher on a thicker part of the lower segment. The FP is deflated soon after delivery of the fetal head by opening the two-way tap attached to the distal end of the filling tube. It is removed at the end of the caesarean section by gently pulling at the tubing.[7]

In UK 65 hospitals are using it. The NICE guidelines by UK states that ‘The Committee recognised the potential for insertion of a balloon device to disimpact an engaged fetal head before an emergency caesarean section to become widely used if further evidence shows it to be safe and efficacious. The Committee noted that there is ongoing research evaluating the safety and efficacy of this procedure.’[8]

A Randomized Control Trial published in the December issue of International Journal of Gynecology and Obstetrics has shown that fetal pillow significantly improves the maternal and neonatal safety. [9]

The authors concluded that: “with routine use of the Fetal Pillow, this unpredictable and serious situation can be managed by all grades of staff…. this has benefits for women in this emergency, for doctors who have to manage them, and for hospitals who have to cope with the emergency.”  

The study was carried out in two teaching hospitals in West Bengal and recruited 240 pregnant women who had to have emergency cesarean section at full dilatation of cervix. They were randomly assigned to the two-study arms:  women in one arm received fetal pillow and women in other arm received conventional technique. (non-pillow group)

Fetal Pillow reduced the risk of blood transfusion by 72 per cent, risk of significant uterine extension by 77 per cent with only 5% women using fetal pillow had extension of the uterine incision against 32.5% in conventional methods. 

Neonatal morbidity was also reduced as evident decrease in NICCU admission by 26%. In addition, it reduced the length of hospital stay by one day, and operating time by 20 minutes.

Ramesh Ganapathy, consultant in fetal medicine, and clinical director, Epsom and St Helier Hospital, says: “CSFD is one of the most technically demanding deliveries performed by an obstetrician and is often performed out-of-hours, without immediately available senior support.  Evidence shows that it carries a high risk of complications for both mother and baby.

“There are several different techniques to help deliver the baby. However, there is no single technique that minimises the risks associated with CSFD and improves safety for both mother and baby.

“The Fetal Pillow provides a simple and effective method to deliver the baby safely, reducing the risk of complications, and it also minimises the risks and stress for health care professionals.  From my experience, use of Fetal Pillow has shown a significant trend towards improving confidence in performing this surgery, reduction in maternal morbidity, and a complementary reduction in cost of care by reducing duration of stay, and blood transfusions.”


[1] https://www.ncbi.nlm.nih.gov/pubmed/26868074
[2] http://www.omicsonline.com/open-access/disengagement-of-the-deeply-engaged-fetal-head-during-cesarean-section-conventional-method-versus-reverse-breech-extraction-review-2090-7214-1000239.php?aid=74810
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939599/
[4] Saha PK, Gulati R, Goel P, Tandon R, Huria A. Second Stage Caesarean Section: Evaluation of Patwardhan Technique. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(1):93-95.
[5] Bansiwal R, Anand H, Jindal M. Safety of patwardhan technique in deeply engaged head. Int J Reprod Contracept Obstet Gynecol. 2016; 5(5): 1562-1565.
[6] http://www.safeobstetrics.com/clinical-evidence.html
[7] http://www.safeobstetrics.com/uploads/9/0/4/7/90477263/fetal_pillow_rct_press_release_may_2016_final.pdf
[8] https://www.nice.org.uk/guidance/ipg515/chapter/6-Committee-comments
[9] https://www.ncbi.nlm.nih.gov/pubmed/26868074

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