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| Fetal Pillow: courtesy safe obstetrics |
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| 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.”
RCOG WORLD CONGRESS FETAL PILLOW SYMPOSIUM.
[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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