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    Interventional procedure overview of balloon disimpaction of the baby's head at emergency caesarean during the second stage of labour

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    Indications and current treatment

    A caesarean during the second stage of labour is associated with an increased risk of adverse perinatal outcomes compared with an elective caesarean or a caesarean during the first stage of labour. Delivery of the baby can be more difficult if the head is impacted deep within the pelvis, further increasing the risks to the woman, trans man or non-binary person giving birth, and to the baby. The definition of an impacted baby's head is subjective. But a UK survey published in 2023 proposed the definition: 'A cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvres and/or tocolysis are required to disimpact and deliver the fetal head' (Cornthwaite 2023).

    Difficulties in disimpacting a deeply engaged baby's head can delay the birth of a baby that is already at risk. For the woman, trans man or non-binary person giving birth, there is increased risk of complications such as:

    • extension of the uterine incision

    • haemorrhage

    • infection

    • bladder injury.

    For the baby, complications include:

    • umbilical artery acidosis

    • skull or limb fracture

    • hypoxic ischaemic encephalopathy

    • brachial plexus injury.

    Two main approaches are commonly used to disimpact an engaged baby's head. One involves the surgeon or an assistant placing fingers of a cupped hand through the vagina and pushing the baby's head back up the pelvis. This can be associated with vaginal tissue trauma. The other approach (reverse breech extraction) involves the surgeon delivering the baby's feet first through the uterine incision, and then delivering the head. The Patwardhan technique and the modified Patwardhan technique are modifications of the reverse breech extraction method. They involve delivering a shoulder or both shoulders of the baby first, followed by the body and, lastly, the head.