I would like to compliment Dr. Andrew Chao on his excellent article, “Safe delivery of the fetal head during cesarean section” [January]. Dr. Chao addresses a seldom-discussed topic—delivering the fetal head from a low pelvic station—that presents a clinical dilemma to every practicing Ob/Gyn.
In my years of practice, I have found the straightwrist elevation of the fetal vertex to be the most important aspect of this difficult delivery. As Dr. Chao points out, levering the vertex from the pelvis often causes extensions down to the bladder or cervix. My technique for handling this problem is to have the operating physician always use the hand closest to the patient’s head when elevating an engaged fetal vertex. This across-the-body reach automatically results in the straightline traction needed to elevate the head. This position makes it virtually impossible to lever the lower uterine segment unless the operator turns his body and leans over.
—DAVID J. EVANS, MD, FACOG
SIDNEY, OHIO
Dr. Chao responds:
Thanks to Dr. Evans for his novel suggestion. His technique uses the operator’s non-dominant hand and arm, advanced into position by—I presume—rotation of the trunk. If the fingers meet resistance during insertion, clinicians may consider bracing the outside of the elbow with the opposite hand to give the maneuver additional rigidity and strength.