CD004944 Standard

Cochrane Database of Systematic Reviews
Techniques for assisting difficult delivery at caesarean section

(Review)
Waterfall H, Grivell RM, Dodd JM
Waterfall H, Grivell RM, Dodd JM.

Techniques for assisting difficult delivery at caesarean section.
Cochrane Database of Systematic Reviews 2016, Issue 1. Art. No.: CD004944.
DOI: 10.1002/14651858.CD004944.pub3.
www.cochranelibrary.com
Techniques for assisting difficult delivery at caesarean section (Review)

Copyright 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 29
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Techniques for assisting difficult delivery at caesarean section (Review) i

[Intervention Review]
Techniques for assisting difficult delivery at caesarean section
Heather Waterfall1 , Rosalie M Grivell2 , Jodie M Dodd3
1 Womens and Childrens Division, Lyell McEwin Hospital, Elizabeth, Australia. 2 Discipline of Obstetrics and Gynaecology, Robinson
Research Institute, The University of Adelaide, Womens and Childrens Hospital, Adelaide, Australia. 3 School of Paediatrics and
Reproductive Health, Discipline of Obstetrics and Gynaecology, The University of Adelaide, Womens and Childrens Hospital, Adelaide,
Australia
Contact address: Jodie M Dodd, School of Paediatrics and Reproductive Health, Discipline of Obstetrics and Gynaecology, The
University of Adelaide, Womens and Childrens Hospital, 72 King William Road, Adelaide, South Australia, 5006, Australia.
jodie.dodd@adelaide.edu.au.
Editorial group: Cochrane Pregnancy and Childbirth Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 1, 2016.
Citation: Waterfall H, Grivell RM, Dodd JM. Techniques for assisting difficult delivery at caesarean section. Cochrane Database of
Systematic Reviews 2016, Issue 1. Art. No.: CD004944. DOI: 10.1002/14651858.CD004944.pub3.
ABSTRACT
Background
Caesarean section involves making an incision in the womans abdomen and cutting through the uterine muscle. The baby is then
delivered through that incision. Difficult caesarean birth may result in injury for the infant or complications for the mother. Methods
to assist with delivery include vacuum or forceps extraction or manual delivery utilising fundal pressure. Medication that relaxes the
uterus (tocolytic medication) may facilitate the birth of the baby at caesarean section. Delivery of the impacted head after prolonged
obstructed labour can be associated with significant maternal and neonatal complication; to facilitate delivery of the head the surgeon
may utilise either reverse breech extraction or head pushing.
Objectives
To compare the use of tocolysis (routine or selective use) with no use of tocolysis or placebo and to compare different extraction methods
at the time of caesarean section for outcomes of infant birth trauma, maternal complications (particularly postpartum haemorrhage
requiring blood transfusion), and long-term measures of infant and childhood morbidity.
Search methods
We searched the Cochrane Pregnancy and Childbirth Groups Trials Register (30 September 2015) and reference lists of retrieved
studies.
Selection criteria
All published, unpublished, and ongoing randomised controlled trials comparing the use of tocolytic agents (routine or selective) at
caesarean section versus no use of tocolytic or placebo at caesarean section to facilitate the birth of the baby. Use of instrument versus
manual delivery to facilitate birth of the baby. Reverse breech extraction versus head pushing to facilitate delivery of the deeply impacted
fetal head.
Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
Techniques for assisting difficult delivery at caesarean section (Review) 1
Main results
Seven randomised controlled trials, involving 582 women undergoing caesarean section were included in this review. The risk of bias
of included trials was variable, with some trials not adequately describing allocation or randomisation.
Three comparisons were included.
1. Tocolysis versus no tocolysis
A single randomised trial involving 97 women was identified and included in the review. Birth trauma was not reported. There were
no cases of any maternal side-effect reported in either the nitroglycerin or the placebo group. No other maternal and infant health
outcomes were reported.
2. Reverse breech extraction versus head push for the deeply impacted head at full dilation at caesarean section
Four randomised trials involving 357 women were identified and included in the review. The primary outcome of birth trauma was
reported by three trials and there was no difference between reverse breech extraction and head push for this rare outcome (three studies,
239 women, risk ratio (RR) 1.55, 95% confidence interval (CI) 0.42 to 5.73). Secondary outcomes including endometritis rate (three
studies, 285 women, average RR 0.52, 95% CI 0.26 to 1.05, Tau I = 0.22, I = 56%), extension of uterine incision (four studies, 357
women, average RR 0.23, 95% CI 0.13 to 0.40), mean blood loss (three studies, 298 women, mean difference (MD) -294.92, 95%
CI -493.25 to -96.59; I = 98%) and neonatal intensive care unit (NICU)/special care nursery (SCN) admission (two studies, 226
babies, average RR 0.53, 95% CI 0.23 to 1.22, Tau I = 0.27, I = 74%) were decreased with reverse breech extraction. No differences
were observed between groups for many of the other secondary outcomes reported (blood loss > 500 mL; blood transfusion; wound
infection; mean hospital stay; average Apgar score).
There was significant heterogeneity between the trials for the outcomes mean blood loss, operative time and mean hospital stay, making
comparison difficult. However the operation duration was significantly shorter for reverse breech extraction, which may correspond
with ease of delivery and therefore, the amount of tissue trauma and therefore, significantly less blood loss. Given the heterogeneity,
we cannot define the amount of difference in blood loss, operative time or hospital stay however.
3. Instrument (vacuum or forceps) versus manual extraction at elective caesarean section
Two randomised trials involving 128 women were identified and included in the review. Only one trial reported maternal and infant
health outcomes as prespecified in this review. This trial reported birth trauma as an outcome but there were no instances of birth
trauma in either comparison group. There were no differences found in mean fall in haemoglobin (Hb) between groups (one study, 44
women, MD 0.03, 95% CI -0.53 to 0.59), or in uterine incision extension (one study, 44 women, RR 0.70, 95% CI 0.13 to 3.73).
Authors conclusions
There is currently insufficient information available from randomised trials to support or refute the routine or selective use of tocolytic
agents or instrument to facilitate infant birth at the time of difficult caesarean section. There is limited evidence that reverse breech
extraction may improve maternal and fetal outcomes, though there was no difference in primary outcome of infant birth trauma.
Further randomised controlled trials are needed to answer these questions.
PLAIN LANGUAGE SUMMARY

Techniques for assisting difficult caesarean section
Caesarean section involves making an incision in the womans abdomen and then cutting through the wall of the uterus. The baby is
then born through these incisions. Numerous different ways have been suggested to facilitate the birth of the baby at difficult caesarean
section and reduce the risk of injury to the baby, such as fractures and nerve damage. Some situations increase the likelihood of injury
to mother and baby, especially if the woman has been in labour a long time or the babys head is deep in the mothers pelvis.
This review includes a total of seven studies, involving 582 women and examines which techniques are safest for mother and baby. The
risk of bias in trials was variable, with some trials not adequately describing the methods of randomisation.
At an emergency caesarean after a long labour, there is evidence from the developing world that delivery of the buttocks or feet of the
baby first (reverse breech extraction) is safer than delivery of the head by pushing from the vagina back into the uterus. In four trials
involving 357 women, delivery of the buttocks or feet first was associated with fewer adverse outcomes for the mother, including less
bleeding, infection and a shorter operation duration. There was no significant difference in trauma to the baby but admission to special
care or neonatal intensive care was decreased with delivery of the buttocks or feet first than when the head was pushed up from the
vagina.
At a planned, non-labouring caesarean section there is limited evidence to support techniques (forceps or vacuum extractor on the
babys head) other than the use of the surgeons hands to deliver the head of the baby through the uterine incision. Two trials involving
128 women compared forceps/vacuum with manual delivery without any significance difference in outcomes.
There is also insufficient evidence to support the use of medication to relax the uterus (tocolysis) at the time of a caesarean to assist
with safe delivery of the baby, with only one trial involving 97 women addressing this question.
Description of the intervention

BACKGROUND Different techniques have been described to facilitate the delivery
of the fetal head at the time of caesarean section at term (37 to 41
weeks of pregnancy). The technique depends on the location of the
fetal head. At an elective caesarean, the head is often free floating
and methods to facilitate delivery include manual delivery utilising
Description of the condition fundal pressure (De Costa 2006), vacuum extraction (Solomens
Caesarean section involves making an incision in the womans 1962), and forceps (Acosta-Sison 1938). Fundal pressure involves
abdomen and cutting through the uterine muscle. The baby is the assistant placing one or two hands on the uterine fundus and
then delivered through that incision. There are many situations exerting downwards force while the obstetrician directs the head
where caesarean section is indicated, and the clinical circumstances towards the uterine incision (De Costa 2006). Vacuum extraction
can cause potential difficulty when delivering the baby. was first described using a metal cup (Solomens 1962) and then
In most situations, the baby can be delivered without trauma with a soft cup (Boehm 1985; Pelosi 1984) applied directly to the
through the uterine incision. In other circumstances, particularly fetal head through the uterine incision.
after a woman been in labour for a long period of time, delivery In contrast to the floating head often found at elective caesarean
may be more difficult, complicated by swelling of both maternal procedures, at an emergency caesarean, the fetal head may be
and fetal tissue, and the position of the fetal head deep within deeply impacted in the maternal pelvis, especially when the labour
the maternal pelvis. In this situation, the baby may be difficult to progress has been slow. Disengaging the impacted fetal head may
deliver through the incision, with an increased risk of trauma for result in extension of the uterine incision into the broad ligament,
both the woman and her baby. cervix or vagina, with possible damage to uterine blood vessels
In some situations, the fetal head may not be well engaged within (De Costa 2006). Extraction and delivery of the fetal head in this
the maternal pelvis, and delivery of the baby through the uterine situation can be achieved utilising either an abdominovaginal ap-
incision may be difficult and require manipulation of the baby. proach with head pushing from the vagina (Landesman 1984) or
Difficult caesarean birth may result in injury for the infant (such reverse breech extraction, where the baby is delivered by grasp-
as fractures, peripheral nerve damage, spinal cord injury and sub- ing the feet or buttocks and delivering them through the incision,
dural haematoma), resulting from direct trauma to the baby, or with the head delivered last (Fong 1997). Other techniques de-
secondary to a delay in the timing of birth with subsequent re- scribed include use of a disimpaction system (Papanikolaou 2009)
duction in oxygen delivery. The most common form of injury to or Patwardhan technique, where the infants shoulders are deliv-
the baby at the time of caesarean section is laceration to the skin. ered, then the trunk, breech, limbs then finally the head (Kumar
This is reported to occur in between 0.74% to 3.12% of all cae- Saha 2014; Mukhopadhyay 2005).
sarean births (Dessole 2004; Haas 2002; Smith 1997). Difficult If the fetus cannot be delivered through a standard transverse in-
caesarean birth may also cause trauma to the mother, with injury cision through the lower segment, the uterine incision may need
to the broad ligament, cervix, vagina or disruption of the major to be extended, utilising either a J shape or inverted T shape inci-
uterine blood vessels or the urinary tract. The degree of damage sion that commonly involves the upper segment or main part of
and the amount of blood loss can impact on the duration of in- the uterus (De Costa 2006). Such an incision is associated with
patient stay and maternal recovery. more complications for the woman, especially during a subsequent

pregnancy and delivery (Landon 2004). birth are all important to consider and potentially impacted by
The breech presentation may also pose difficulties for delivery of such interventions.
the baby at caesarean section in both the emergency and elective
settings. Techniques utilised for delivery of a breech presentation
at caesarean section include grasping a foot or both feet to facilitate Why it is important to do this review
delivery of the buttocks (De Costa 2006). The shoulders and head
can then be delivered utilising the same manoeuvres employed Rates of caesarean section are increasing, and techniques used at
for vaginal breech birth, including the Lovsett and Mauriceau- this common operation should be supported by evidence to ensure
Smellie-Veit manoeuvres, or forceps can be applied to the after- rare complications, including birth trauma, are decreased.
coming head. Caesarean section at full dilatation with obstructed labour can be
During difficult delivery of the baby at the time of caesarean sec- difficult, with potential complications for mother and baby. Evi-
tion, the uterus may contract and contribute to mechanical im- dence is needed to guide clinicians as to which technique, reverse
pediments with the delivery. A number of medications have been breech extraction or head push best facilitates delivery with the
used in order to relax the uterus (tocolysis) and facilitate the birth least complications for mother and baby.
of the infant. Tocolytic agents act through a variety of mecha- There are risks associated with the use of medication to relax the
nisms to relax the uterus and prevent uterine contractions and uterus, including excessive bleeding and possible interference with
have been used mainly in treating preterm labour and include be- the blood the baby receives from the placenta at birth. There is
tamimetics (such as salbutamol or terbutaline) (Gyetvai 1999); currently limited evidence available to help with informed deci-
calcium channel blockers (such as nifedipine) (Flenady 2014a); sions around the use of these drugs at difficult caesareans. Until
non-steroidal anti-inflammatory drugs (such as indomethacin) there is evidence that these drugs do more good than harm, they
(Reinebrant 2015); magnesium sulphate (Crowther 2014); nitric should not be used.
oxide donors (Duckitt 2014); and oxytocin receptor antagonists
(Flenady 2014b). These drugs have side-effects for the woman
and, as they are able to cross the placenta, may affect the infant
(Gyetvai 1999; Neilson 2014). Side-effects for the woman include OBJECTIVES
tachycardia (increased heart rate), hypotension (low blood pres-
sure), nausea and vomiting, hyperglycaemia (high blood sugar lev- 1. To compare the use of tocolysis (routine or selective use)
els), and pulmonary oedema (fluid accumulation in the lungs) with no use of tocolysis, or placebo at the time of caesarean
(Crowther 2014; Duckitt 2014; Flenady 2014b; Gyetvai 1999; section when a difficult delivery is encountered or anticipated.
Neilson 2014).
2. To compare head pushing with reverse breech extraction for
While uterine relaxation at caesarean section may be a beneficial
the deeply impacted fetal head after prolonged obstructed labour.
effect as it relaxes the uterus to facilitate birth of the infant, it can
be followed by uterine atony (where the uterus does not contract 3. To compare the use of either forceps, vacuum or manual
after birth) causing subsequent postpartum haemorrhage. delivery with fundal pressure at the time of elective caesarean
birth when the fetal head is difficult to deliver.
All comparisons utilise outcomes of infant birth trauma, mater-
How the intervention might work
nal complications (particularly postpartum haemorrhage requir-
This review compares three interventions for delivery of the fetus at ing blood transfusion), and long-term measures of infant and
caesarean section. Firstly, the use of tocolysis (routine or selective) childhood morbidity.
with no use of tocolysis or placebo at the time of caesarean birth,
secondly, the use of either forceps, vacuum or manual delivery
with fundal pressure at the time of elective caesarean birth and METHODS
finally, the use of head pushing versus reverse breech extraction for
the deeply impacted fetal head at the time of emergency caesarean
section.
These interventions may expedite the delivery of the fetus and may
Criteria for considering studies for this review
reduce the risk of birth trauma. Any benefit of increased ease of in-
fant birth and reduction in birth trauma has to be balanced against
the potential complications for the woman, including postpartum Types of studies
haemorrhage and damage to the urinary tract. All published, unpublished, and ongoing randomised controlled
Outcome measures for infant and childhood, and short-term and trials comparing:
long-term maternal morbidity, for women undergoing caesarean

1. use of any tocolytic (routine or selective) at caesarean 11. Pain scores post operatively (as defined/measured by trial
section with no use of tocolytic or placebo; authors)
2. reverse breech extraction versus head pushing at caesarean 12. Maternal side-effects (not prespecified)
section for the deeply impacted fetal head in obstructed labour;
3. use of an instrument (forceps or vacuum) to assist with
delivering the fetal head at elective caesarean section with no Outcome measures for the infant
instrument. 1. Apgar less than four at five minutes
We excluded quasi-randomised trials (e.g. those randomised by 2. Average Apgar score (not prespecified)
date of birth or hospital number) from the analysis. Studies pre- 3. Cord pH less than 7.10 or low pH/low base excess as
sented in abstract form only will not be included until the full defined by trialists
report becomes available to assess methodological quality and rel- 4. Admission to neonatal special care or intensive care unit
evance to the scope of the review. If identified, cluster-randomised 5. Neonatal death - (defined as death within the first 28 days
trials will be considered for inclusion in future updates. of life)
6. Length of stay in a neonatal special care or intensive care
unit
Types of participants 7. Intraventricular haemorrhage
Women undergoing a caesarean birth with anticipated/possible 8. Periventricular leukomalacia
difficulty in delivering the fetus.
Longer-term outcomes for the infant

Types of interventions 1. Cerebral palsy
1. Use of tocolytic agents (routine or selective) at caesarean 2. Developmental delay in childhood (as defined by trial
section versus no use of tocolytic or placebo at caesarean section. authors)
2. Use of reverse breech extraction versus head push at
caesarean section for obstructed labour.
3. Use of forceps or vacuum at caesarean section versus no use Measures of satisfaction include
of forceps or vacuum at caesarean section. 1. Womens satisfaction
2. Womens preferences for care
Types of outcome measures
Health service use
1. Length of postoperative stay for the woman and infant
Primary outcomes
2. Readmission to hospital of the woman or infant, or both
Infant birth trauma (any of: subdural or intracerebral haemor- Only outcomes with available data appear in the analysis tables.
rhage, spinal cord injury, basal skull fracture, other fracture, pe- Only outcome data that were prestated by the review authors have
ripheral nerve injury). been used.
Secondary outcomes
Search methods for identification of studies
The following methods section of this review is based on a standard
Outcome measures for the woman template used by the Cochrane Pregnancy and Childbirth Group.
1. Extension of uterine incision
2. Blood loss > 500 mL at time of caesarean birth
3. Amount of blood loss at caesarean (mL) Electronic searches
4. Mean fall in haemoglobin (Hb) (not prespecified) We searched the Cochrane Pregnancy and Childbirth Groups
5. Blood transfusion Trials Register by contacting the Trials Search Co-ordinator (30
6. Endometritis/endometrial infection September 2015).
7. Wound infection (as defined by trial authors) For full search methods used to populate the Pregnancy and Child-
8. Ureteral/bladder/cervical injury birth Groups Trials Register including the detailed search strate-
9. Operative time (duration of surgery) gies for CENTRAL, MEDLINE, Embase and CINAHL; the list
10. Mean hospital stay (not prespecified) of handsearched journals and conference proceedings, and the list

of journals reviewed via the current awareness service, please fol- Data extraction and management
low this link to the editorial information about the Cochrane We designed a form to extract data. For eligible studies, two review
Pregnancy and Childbirth Group in The Cochrane Library and se- authors extracted the data using the agreed form. We resolved
lect the Specialized Register section from the options on the discrepancies through discussion or, if required, we consulted a
left side of the screen. third author. We entered data into Review Manager software (
Briefly, the Cochrane Pregnancy and Childbirth Groups Trials RevMan 2014) and checked for accuracy.
Register is maintained by the Trials Search Co-ordinator and con- When information regarding any of the above was unclear, we
tains trials identified from: attempted to contact authors of the original reports to provide
1. monthly searches of the Cochrane Central Register of further details.
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE (Ovid);
3. weekly searches of Embase (Ovid); Assessment of risk of bias in included studies
4. monthly searches of CINAHL (EBSCO); Two review authors independently assessed risk of bias for each
5. handsearches of 30 journals and the proceedings of major study using the criteria outlined in the Cochrane Handbook for
conferences; Systematic Reviews of Interventions (Higgins 2011). We resolved
6. weekly current awareness alerts for a further 44 journals any disagreement by discussion or by involving a third assessor.
plus monthly BioMed Central email alerts.
Search results are screened by two people and the full texts of all
relevant trial reports identified through the searching activities de- (1) Random sequence generation (checking for possible
scribed above are reviewed. Based on the intervention described, selection bias)
each trial report is assigned a number that corresponds to a spe- We described for each included study the method used to generate
cific Pregnancy and Childbirth Group review topic (or topics), the allocation sequence in sufficient detail to allow an assessment
and is then added to the Register. The Trials Search Co-ordina- of whether it should produce comparable groups.
tor searches the Register for each review using this topic number We assessed the method as:
rather than keywords. This results in a more specific search set low risk of bias (any truly random process, e.g. random
which has been fully accounted for in the relevant review sections number table; computer random number generator);
(Included, Excluded, Awaiting Classification or Ongoing). high risk of bias (any non-random process, e.g. odd or even
[For additional searching carried out in a previous version of the date of birth; hospital or clinic record number);
review (Dodd 2006), see Appendix 1.] unclear risk of bias.
(2) Allocation concealment (checking for possible selection

Searching other resources bias)
We searched the reference lists of retrieved studies. We described for each included study the method used to con-
We did not apply any language or date restrictions. ceal allocation to interventions prior to assignment and will assess
whether intervention allocation could have been foreseen in ad-
vance of, or during recruitment, or changed after assignment.
We assessed the methods as:
Data collection and analysis low risk of bias (e.g. telephone or central randomisation;
For the methods used when assessing the trials identified in the consecutively numbered sealed opaque envelopes);
previous version of this review, see Dodd 2006. high risk of bias (open random allocation; unsealed or non-
For this update we used the following methods when assessing the opaque envelopes, alternation; date of birth);
reports identified by the updated search. unclear risk of bias.
The following methods section of this review is based on a standard
template used by the Cochrane Pregnancy and Childbirth Group.
(3.1) Blinding of participants and personnel (checking for
possible performance bias)
We described for each included study the methods used, if any, to
Selection of studies blind study participants and personnel from knowledge of which
Two review authors independently assessed for inclusion all the intervention a participant received. We considered that studies
potential studies we identified as a result of the search strategy. We were at low risk of bias if they were blinded, or if we judged that
resolved any disagreement through discussion or, if required, we the lack of blinding would be unlikely to affect results. We assessed
consulted a third author. blinding separately for different outcomes or classes of outcomes.

We assessed the methods as: (6) Other bias (checking for bias due to problems not
low, high or unclear risk of bias for participants; covered by (1) to (5) above)
low, high or unclear risk of bias for personnel. We described for each included study any important concerns we
had about other possible sources of bias.
We assessed whether each study was free of other problems that
(3.2) Blinding of outcome assessment (checking for possible could put it at risk of bias:
detection bias) low risk of other bias;
We described for each included study the methods used, if any, to high risk of other bias;
blind outcome assessors from knowledge of which intervention a unclear whether there is risk of other bias.
participant received. We assessed blinding separately for different
outcomes or classes of outcomes.
We assessed methods used to blind outcome assessment as: (7) Overall risk of bias
low, high or unclear risk of bias. We made explicit judgements about whether studies were at high
risk of bias, according to the criteria given in the Handbook (
Higgins 2011). With reference to (1) to (6) above, we assessed
(4) Incomplete outcome data (checking for possible attrition the likely magnitude and direction of the bias and whether we
bias due to the amount, nature and handling of incomplete considered it is likely to impact on the findings. We planned
outcome data) to explore the impact of the level of bias through undertaking
We described for each included study, and for each outcome or sensitivity analyses - see Sensitivity analysis.
class of outcomes, the completeness of data including attrition and
exclusions from the analysis. We stated whether attrition and ex-
Measures of treatment effect
clusions were reported and the numbers included in the analysis at
each stage (compared with the total randomised participants), rea-
sons for attrition or exclusion where reported, and whether miss- Dichotomous data
ing data were balanced across groups or were related to outcomes.
For dichotomous data, we presented results as summary risk ratio
Where sufficient information was reported, or could be supplied
with 95% confidence intervals.
by the trial authors, we re-included missing data in the analyses
which we undertook.
We assessed methods as: Continuous data
low risk of bias (e.g. no missing outcome data; missing
For continuous data, we used the mean difference for outcomes
outcome data balanced across groups);
are measured in the same way between trials. We planned to use
high risk of bias (e.g. numbers or reasons for missing data
the standardised mean difference to combine trials that measured
imbalanced across groups; as treated analysis done with
the same outcome, but used different methods.
substantial departure of intervention received from that assigned
at randomisation);
unclear risk of bias. Unit of analysis issues
(5) Selective reporting (checking for reporting bias) Cluster-randomised trials

We described for each included study how we investigated the We did not identify any cluster-randomised trials for inclusion in
possibility of selective outcome reporting bias and what we found. this review. In future updates, we will include cluster-randomised
We assessed the methods as: trials in the analyses along with individually-randomised trials.
low risk of bias (where it is clear that all of the studys We will adjust their sample sizes using the methods described in
prespecified outcomes and all expected outcomes of interest to the Handbook using an estimate of the intracluster correlation co-
the review have been reported); efficient (ICC) derived from the trial (if possible), from a similar
high risk of bias (where not all the studys prespecified trial or from a study of a similar population. If we use ICCs from
outcomes have been reported; one or more reported primary other sources, we will report this and conduct sensitivity analyses
outcomes were not prespecified; outcomes of interest are to investigate the effect of variation in the ICC. If we identify both
reported incompletely and so cannot be used; study fails to cluster-randomised trials and individually-randomised trials, we
include results of a key outcome that would have been expected plan to synthesise the relevant information. We will consider it
to have been reported); reasonable to combine the results from both if there is little het-
unclear risk of bias. erogeneity between the study designs and the interaction between

the effect of intervention and the choice of randomisation unit is an overall summary, if an average treatment effect across trials was
considered to be unlikely. considered clinically meaningful. The random-effects summary
We will also acknowledge heterogeneity in the randomisation unit was treated as the average of the range of possible treatment effects
and perform a subgroup analysis to investigate the effects of the and we discussed the clinical implications of treatment effects dif-
randomisation unit. fering between trials. If the average treatment effect was not clin-
ically meaningful, we did not combine trials.
Where we used random-effects analyses, we presented the results
Cross-over trials as the average treatment effect with 95% confidence intervals, and
Cross-over trials are not considered eligible for inclusion in this the estimates of Tau and I.
review.
Subgroup analysis and investigation of heterogeneity

Dealing with missing data
Subgroup analysis was not carried out due to insufficient data.
For included studies, we noted levels of attrition. We planned to In future updates we plan to carry out the following prespecified
explore the impact of including studies with high levels of missing subgroup analyses:
data in the overall assessment of treatment effect by using sensi- 1. gestational age at caesarean section (less than 34 weeks
tivity analysis. gestation or greater than 34 weeks gestation);
For all outcomes, we planned to carry out analyses, as far as pos- 2. type of uterine incision at caesarean (lower segment
sible, on an intention-to-treat basis, i.e. we planned to attempt to transverse incision (with or without extension of the incision),
include all participants randomised to each group in the analyses, midline uterine incision);
and all participants would be analysed in the group to which they 3. type of tocolytic used;
were allocated, regardless of whether or not they received the al- 4. effect of labour (caesarean section prior to labour versus in
located intervention. The denominator for each outcome in each labour);
trial would be the number randomised minus any participants 5. or multiple versus singleton gestation.
whose outcomes were known to be missing. We will carry out subgroup analyses on the following outcome:
1. infant birth trauma.
We will assess subgroup differences by interaction tests available
Assessment of heterogeneity
within RevMan 2014.
We assessed statistical heterogeneity in each meta-analysis using
the Tau, I and Chi statistics. We regarded heterogeneity as sub-
stantial if an I was greater than 30% and either the Tau was Sensitivity analysis
greater than zero, or there was a low P value (less than 0.10) in the
We planned to carry out sensitivity analyses to explore the effect of
Chi test for heterogeneity.
trial quality assessed by concealment of allocation, high attrition
rates (greater than 20%), or both, with poor-quality studies being
Assessment of reporting biases excluded from the analyses in order to assess whether this made
any difference to the overall result. Sensitivity analysis was not
Had there been 10 or more studies in the meta-analysis, we planned
carried out due to insufficient number of trials being included in
to investigate reporting biases (such as publication bias) using fun-
meta-analyses.
nel plots. We planned to assess funnel plot asymmetry visually, If
asymmetry was suggested by a visual assessment, we planned to
perform exploratory analyses to investigate it.
RESULTS
Data synthesis
We carried out statistical analysis using the Review Manager soft-
ware (RevMan 2014). We used fixed-effect meta-analysis for com-
Description of studies
bining data where it was reasonable to assume that studies were
estimating the same underlying treatment effect: i.e. where trials
were examining the same intervention, and the trials populations
and methods were judged sufficiently similar. If there was clinical Results of the search
heterogeneity sufficient to expect that the underlying treatment ef- The search strategy identified 32 trial reports for consideration in
fects differed between trials, or if substantial statistical heterogene- this review. Seven trials (nine reports) were included and 19 trials
ity was detected, we used random-effects meta-analysis to produce (23 reports) were excluded.

Included studies Excluded studies
Seven randomised controlled trials, involving 582 women under- We excluded 19 trials from the review, with four studies excluded
going caesarean section were included in this review. as abstracts only were available and no further information could
be obtained to allow inclusion (Naghibi 2008; Papanikolaou 2009;
Seal 2013; Wright 1995). Bellad 2013 is excluded at present be-
Tocolysis versus no tocolysis cause it is not yet published and although contact has been made
with the author, data are not yet finalised. Three studies were ex-
The search identified a single randomised controlled trial of 97
cluded as they were retrospective cohort studies (Chopra 2009
women, that was able to be included in the review. This study
Kumar Saha 2014; Levy 2005), and two were excluded as they were
involving a three-way comparison between nitroglycerin (compar-
prospective cohort studies and not randomised (Kadhum 2009;
ing two different doses 0.25 mg and 0.5 mg), and placebo admin-
Mukhopadhyay 2005). The trials Burke 1989, Magann 1993,
istered at the time of caesarean section to facilitate fetal extraction Kaukinen 1978, Kulier 1997 and Visser 1979 were excluded as
(David 1998). Data were analysed as a single-pair comparison; they involved administration of tocolytic agents for intrauterine
nitroglycerin (either 0.25 mg or 0.5 mg) compared with placebo.
fetal resuscitation prior to a caesarean section for fetal distress.
The trial by Hong 1993 was excluded as it involved the use of
tocolytic agents in women with hypertension for the prevention
Reverse breech versus head push for obstructed labour of hypertension in response to laryngeal stimulation at the time of
The search identified four randomised controlled trials including intubation prior to caesarean section. The trial by Eisler 1999 was
357 women. All four trials compared the morbidity and mortal- excluded as it involved continuous tocolytic infusion for two hours
ity associated with the push method and the pull (reverse breech) prior to birth, for the improvement of infant respiratory effort and
method to deliver the impacted head at caesarean section for ob- glucose metabolism. The Buhimschi 2002 trial was excluded as it
structed labour (Bastani 2012; Fasubaa 2002; Frass 2011; Veisi did not involve women who required caesarean section. The trial
2012). by Fothergill 1971 was excluded because it assessed anaesthetic
duration, not tocolysis effect.
For details of the excluded studies, see the table of Characteristics
Elective use of instrument versus fundal pressure of excluded studies.
The search identified a single randomised controlled trial of 44

women that utilised a three-way comparison between vacuum, for-
ceps and manual delivery to deliver the cephalic fetus at caesarean
Risk of bias in included studies
section (Bofill 2000), comparing safety and ease of delivery. Vac- Overall, the methodological quality of the trials was variable
uum and forceps were combined as a single experimental group (see Description of studies and Characteristics of included
(instrumental delivery) for comparison with manual delivery. studies).There was variable reporting of the prespecified outcomes
A further randomised controlled trial was identified that compared of the review, with all seven trials presenting information that
the transplacental microtransfusion from mother to baby with could be incorporated into the meta-analysis (Bastani 2012; Bofill
manual versus instrumental delivery at caesarean section in 84 2000; David 1998; Fasubaa 2002; Frass 2011; Owens 2003; Veisi
women (Owens 2003). 2012).
For details of the included studies, see the table of Characteristics See Figure 1 and Figure 2 for a summary of Risk of bias assess-
of included studies. ments.

Figure 1. Risk of bias graph: review authors judgements about each risk of bias item presented as
percentages across all included studies.

Figure 2. Risk of bias summary: review authors judgements about each risk of bias item for each included
study.

Allocation
Primary outcomes
While all of the studies were stated to be randomised, the method Infant birth trauma was not reported in the David 1998 trial.
of randomisation was adequately described in three trials as involv-
ing either computer-generated randomisation sequences or tables
of random numbers (David 1998; Fasubaa 2002; Owens 2003). Secondary outcomes
The method of allocation concealment was assessed as adequate
There were no differences identified between nitroglycerin and
in two trials, both utilising sequentially numbered, sealed, opaque
placebo for the occurrence of any maternal side-effect (one study;
envelopes (Bofill 2000; Owens 2003), no trials utilised telephone
97 women; risk ratio (RR) not estimable), Analysis 1.1. There
randomisation.
were no other prespecified maternal or infant outcomes reported
Four trials (Bastani 2012; Bofill 2000; Frass 2011; Veisi 2012)
that could be included in this review. The trial reported the ease of
stated they were randomised but did not describe the randomisa-
delivery of the baby at caesarean section, and mean infant Apgar
tion process.
scores, but the method of reporting in the published paper pre-
cluded inclusion in the results of this review.
Blinding
Blinding of outcome assessor was indicated in only three of the Reverse breech versus head push for obstructed
trials (Bastani 2012; David 1998; Fasubaa 2002). labour
Where the comparison was of surgical technique the surgeon could Four studies compared reverse breech extraction with vaginal head
not be blinded, Fasubaa 2002 and Bastani 2012 describe blinding pushing to assist with delivery of the deeply impacted fetal head in
of the anaesthetist assessing operative blood loss. The other studies obstructed labour (Bastani 2012; Fasubaa 2002; Frass 2011; Veisi
do not mention any other forms of blinding. 2012).
For ethical reasons, David 1998 unblinded the anaesthetist admin-
istering tocolysis, however the woman, surgeon and neonatologist
were blinded. Primary outcomes
Of the fetal outcomes assessed, Fasubaa 2002, Bastani 2012 and
Veisi 2012 reported infant birth trauma; with no difference be-
Incomplete outcome data
tween the two interventions (three studies; 239 women; RR 1.55,
There was no loss of data and therefore all studies were assessed as 95% confidence interval (CI) 0.42 to 5.73), Analysis 2.1.
low risk of attrition bias.
Secondary outcomes
Selective reporting Two trials (Fasubaa 2002; Frass 2011) reported admission to
All expected outcomes were reported in the included trials, with neonatal intensive care unit (NICU) or special care nursery
no concerns regarding selective outcome reporting. (SCN), with significantly fewer babies admitted in the reverse
breech extraction group (two studies, 226 babies, average RR 0.53,
95% CI 0.23 to 1.22, Tau 0.27, I 74%), Analysis 2.8. Two trials
Other potential sources of bias (Bastani 2012; Veisi 2012) reported no admission to NICU but
No other potential sources of bias was identified in any of the did not describe admission to SCN. There was no difference in
studies included. the average Apgar score between the groups (three studies, 239
babies, mean difference (MD) 0.36, 95% CI -0.64 to 1.36; Tau =
0.77, I = 98%), Analysis 2.13.
Effects of interventions
For maternal outcomes, all trials reported uterine incision exten-
sion and three trials (Bastani 2012; Fasubaa 2002; Frass 2011)
reported endometritis rates. For the woman, reverse breech was
Tocolysis versus no tocolysis associated with a significantly lower rate of uterine incision exten-
We identified one study involving a three-way comparison be- sion when compared with head push (four studies, 357 women,
tween nitroglycerin (comparing two different doses 0.25 mg and average RR 0.23, 95% CI 0.13 to 0.40; Tau= 0.10, I = 31),
0.5 mg), and placebo administered at the time of caesarean section Analysis 2.2, and reverse breech was also associated with less en-
to facilitate fetal extraction (David 1998). dometritis (three studies, 285 women, average RR 0.52, 95% CI

0.26 to 1.05;Tau = 0.22, I = 56%), Analysis 2.6. Operative It was not possible to conduct the planned subgroup analyses re-
time was described by all authors, with reverse breech associated lated to gestational age at caesarean section (less than 34 weeks
with a significantly shorter duration of operation (four studies, gestation or greater than 34 weeks gestation); type of uterine inci-
357 women, MD -14.99 minutes, 95% CI -27.67 to -2.30; Tau sion at caesarean (lower segment transverse incision (with or with-
= 164.16, I = 99%), Analysis 2.11. Mean blood loss was also out extension of the incision), midline uterine incision); type of
significantly less with reverse breech extraction (three studies, 298 tocolytic used; effect of labour (caesarean section prior to labour
women, MD -294.92 mL, 95% CI -493.25 to -96.59; Tau = versus in labour); or multiple versus singleton gestation.
28196.38, I = 98%), Analysis 2.4.
Reverse breech for obstructed labour was not associated with any
significant reduction in blood loss greater than 500 mL,blood
transfusion, wound infection or mean hospital stay (Analysis DISCUSSION
2.3; Analysis 2.5; Analysis 2.7; Analysis 2.12). No difference was
observed between groups for early neonatal death (one study, 108
women, RR 0.54, 95% CI 0.23 to 1.24), Analysis 2.9. In one trial,
Tocolysis versus no tocolysis
mean fall in haemoglobin (Hb) was reduced in the reverse breech
group (118 women, MD -0.44, 95% CI -0.72 to -0.16), Analysis Tocolytic agents have been used extensively to induce uterine re-
2.10. laxation, and have been used anecdotally at the time of caesarean
The heterogeneity for mean blood loss (Analysis 2.4), operative section, where difficulties with birth of the infant are anticipated
time (Analysis 2.11), mean hospital stay (Analysis 2.12) and av- or encountered. While uterine relaxation at caesarean section may
erage Apgar score (Analysis 2.13) was extreme, the results being be a beneficial effect as it relaxes the uterus to facilitate birth of
very variable and so should be interpreted with caution. the infant, it can also be followed by uterine atony (where the
No study addressed long-term outcomes for the infant or measures uterus does not contract after birth) causing subsequent postpar-
of satisfaction for the woman. No information was given as to tum haemorrhage. Any benefit to facilitate infant birth and re-
cost-analysis differences between the groups. duction in birth trauma has to be balanced against the potential
complications for the woman, including postpartum haemorrhage
secondary to uterine atony.
Elective use of instrument versus fundal pressure at There is currently insufficient information from randomised con-
elective caesarean section trolled trials assessing the role of tocolytic agents in facilitating
Two studies compared instrumental with manual pressure at elec- infant birth at caesarean section and reducing the risk of infant
tive caesarean section (Bofill 2000; Owens 2003). Owens 2003 birth trauma. The occurrence of maternal side-effects and risk of
aimed to compare the amount of placental alkaline phosphatase postpartum blood loss was similarly not reported in the single trial
released into the maternal circulation with the two techniques. identified and included in the review.
Further information is required to address the role of tocolysis
to facilitate infant birth at caesarean section adequately, with at-
Primary outcomes
tention particularly to adequate reporting of maternal and infant
Bofill 2000 reported birth trauma as an outcome but there were health outcomes.
no instances of birth trauma in either comparison group, Analysis
3.1.
Reverse breech versus head push for obstructed
Secondary outcomes labour
No trial reported on any fetal outcomes. Maternal blood loss was Four studies investigated caesarean section for obstructed labour,
assessed in both trials, but different reporting methods mean that comparing reverse breech extraction with vaginal push. Three
results cannot be combined for the meta-analysis. Bofill 2000 de- studies (Bastani 2012; Fasubaa 2002; Veisi 2012) addressed our
scribed mean fall in Hb; there was no difference between groups primary outcome of infant birth trauma, and found no differ-
(one study, 44 women, MD 0.03, 95% CI -0.53 to 0.59) Analy- ence between the techniques. However other outcome assess-
sis 3.3, while Owens 2003 described estimated blood loss, again ments reported by both authors were sufficiently homogeneous to
with no difference between the interventions. Bofill 2000 reported allow analysis, they demonstrated that reverse breech extraction
uterine incision extension with no difference between interven- may be superior for mother and baby. For the mother, the risk
tions, (one study, 44 women, RR 0.70, 95% CI 0.13 to 3.73) of endometritis and uterine incision extension was significantly
Analysis 3.2. decreased with reverse breech extraction. For baby, likelihood of
Neither study described any of the other prespecified outcomes admission to special care nursery (SCN) or neonatal intensive care
for this review. unit (NICU) was significantly less with reverse breech extraction.

Neither study addressed Apgar score less than four at five minutes. trauma and other adverse outcomes at elective caesarean section, a
Fasubaa 2002, Bastani 2012 and Veisi 2012 did report average large number of patients would need to be recruited to adequately
Apgar at five minutes, there was no difference between the com- power such a study.
parison groups. There was no difference in early neonatal death
rate or stillbirth rate.
There was significant heterogeneity between the trials for the out- Summary of main results
comes mean blood loss, operative time and mean hospital stay,
making comparison difficult. However the operation duration was This review aimed to address three clinical situations at difficult
significantly shorter for reverse breech extraction, which may cor- caesarean section: 1) use of tocolysis compared with placebo, 2)
respond with ease of delivery and therefore the amount of tissue reverse breech compared with head push from below for the deeply
trauma and therefore significantly less blood loss. Given the het- impacted fetal head, and 3) use of an instrument compared with
erogeneity we cannot define the amount of difference in blood manual delivery at elective caesarean section.
loss, operative time or hospital stay however. The reason for the ex- 1. One trial addressing the use of tocolysis at caesarean section
treme heterogeneity is not apparent from the text in the published was included for review, unfortunately infant outcomes were not
studies. Possible reasons for difference in operative time may be addressed in the study. There was no significant difference in
related to different surgical technique, difference in duration of maternal side-effects between the tocolysis and placebo group,
stay may be due to different hospital policies or financial restric- and other maternal outcomes were not reported, therefore
tion on length of stay, rather than medical need. limiting analysis.
Two studies (Fasubaa 2002; Frass 2011) were conducted in low- 2. At caesarean section for obstructed labour with a deeply
income settings (Yemen and Nigeria, respectively), and both au- impacted fetal head, reverse breech extraction appears to be
thors commented that obstructed labour is still common in their significantly safer for mother and baby than head push from
country. Two studies were undertaken in Iran (Bastani 2012; Veisi below. Maternal outcomes demonstrating significant
2012), both having less study participant than the former two improvement in the reverse breech extraction group include less
trials. These results therefore may not be applicable to obstetric endometritis, decreased blood loss and decreased rates of wound
units in middle-income or high-income settings. Further research extension. For babies, there was no significant difference in rates
is required to confirm these results in low-income settings, poten- of the primary outcome, birth trauma, but neonatal intensive
tially including patients where a vaginal instrumental delivery was care unit (NICU) and SCN admissions were decreased with
unsuccessfully attempted prior to caesarean section. reverse breech extraction. These results suggest that reverse
Novel methods for fetal disimpaction are reported in the literature breech extraction may be better for both mother and baby than
(Papanikolaou 2009; Seal 2013); these may be associated with less head push from below.
maternal and infant trauma than either vaginal push or reverse 3. Use of an instrument (either forceps or vacuum) at elective
breech extraction. If data are published these may be included in caesarean section compared with manual delivery did not
the next review update. significantly alter maternal or infant outcomes, however there
was only trial suitable for inclusion that addressed these
outcomes.
Elective use of instrument versus fundal
pressure at elective caesarean section
Two studies addressed the use of an instrument (either vacuum
Overall completeness and applicability of
or forceps) at elective caesarean section, though only one author
evidence
(Bofill 2000) conducted their study to investigate the safety and Evidence for all three interventions is limited, mostly due to the
ease of delivery with an instrument compared with fundal pres- small numbers of participants in the included trials. In particular,
sure. Owens 2003 instead investigated the amount of transplacen- tocolysis and instrument for elective caesarean each had only one
tal microtransfusion from mother to infant with fundal pressure trial with data describing relevant outcomes, therefore most of the
compared with an instrument, and thus did not address the pre- results were not statistically significant.
specified outcomes of this review. There was no difference in birth The four trials addressing delivery of the deeply impacted fetal
trauma in the one study that addressed this outcome (Bofill 2000); head in the context of obstructed labour were based in Nigeria,
there was no difference in infant outcomes where described, and Iran and Yemen, therefore due to differences in practice and pop-
no difference in blood loss, uterine incision extension or other ulations, generalisability may be limited.
maternal outcomes.
Further research is required to clarify the safety of using an in-
strument (either forceps or vacuum) instead of fundal pressure at
Quality of the evidence
elective caesarean section. Given the relatively low rate of birth

The risk of bias in trials was variable, with some trials not ade- Studies included were conducted in the low-income settings and
quately describing allocation or randomisation. Blinding of asses- therefore these results may not be applicable to Western practice,
sors was frequently not adequately described. Whilst blinding of however when a deeply impacted head is encountered at caesarean
the surgeon may not be possible when studying different surgical section, reverse breech extraction is a suitable technique to employ
techniques, there was inadequate description of blinding of other by those trained to do so.
assessors including anaesthetists, paediatricians and the woman.
Instrument at elective caesarean section - there is currently insuf-
ficient evidence from randomised trials to support or refute the
routine or selective use of an instrument to deliver the fetal head
Potential biases in the review process at caesarean section.
We attempted to minimise bias in the review process by conducting
a comprehensive search of the literature and ensuring that study Implications for research
assessment, data extraction and data entry was conducted by two Further randomised controlled trials that are adequately powered
review authors. to assess maternal and infant health outcomes are required to an-
swer the question of whether use (selective or routine) of tocolytic
agents or elective use of an instrument to facilitate infant birth at
Agreements and disagreements with other the time of caesarean section is of greater benefit than harm for
studies or reviews both the woman and her infant. As the outcome of fetal injury is
rare, the sample size would need to be large to be able to reliably
One systematic review was found that addressed the issue of re- detect differences related to their use.
verse breech extraction compared with head push at caesarean after
obstructed labour (Berhan 2014). The authors also noted reduc- Further randomised controlled trials are also required to assess
tion in uterine incision extension, blood loss, operation time and whether the conclusions drawn above regarding reverse breech ex-
admission to NICU with pull compared with push techniques. traction are applicable in middle-income and high-income set-
tings.
AUTHORS CONCLUSIONS
ACKNOWLEDGEMENTS
Implications for practice We thank K Reid for her contribution to the development of the
protocol and its review in its original format.
Tocolysis - there is currently insufficient information available
from randomised trials to support or refute the routine or selec- This project was supported by the National Institute for Health
tive use of tocolytic agents to facilitate infant birth at the time of Research, via Cochrane Infrastructure funding to Cochrane Preg-
caesarean section. There is limited information available relating nancy and Childbirth. The views and opinions expressed therein
to the occurrence of maternal side-effects from therapy, including are those of the authors and do not necessarily reflect those of the
morbidity related to postpartum blood loss. Systematic Reviews Programme, NIHR, NHS or the Department
of Health.
Obstructed labour - there is limited evidence from low-income
settings that reverse breech extraction instead of head push has As part of the pre-publication editorial process, this review has
benefits for mother and baby, including decreased operation du- been commented on by three peers (an editor and two referees
ration, blood loss, decreased endometritis and decreased admis- who are external to the editorial team), a member of the Pregnancy
sion to special care nursery (SCN) or neonatal intensive care unit and Childbirth Groups international panel of consumers and the
(NICU). There was no difference in Apgar score or birth trauma. Groups Statistical Adviser.

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Naghibi K. Randomized comparison of glyceryl trinitrate
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and volatile anesthetics to facilitate fetal extraction in
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Doctors. Australasian Medical Publishing, 2006.
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used)}
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Varma R. Reducing complications related to caesarean
cesarean delivery. American Journal Obstetrics and Gynecology
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2004;191(5):16737.
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Gynecology and Obstetrics. 2009:S304. Duckitt 2014
Duckitt K, Thornton S, ODonovan OP, Dowswell T.
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Seal S, Barman SC, Tibriwal R, De A, Kanrar P, Mukherjii Database of Systematic Reviews 2014, Issue 5. [DOI:
J. Reducing complications in a caesarean section at full 10.1002/14651858.CD002860.pub2
dilation using fetal pillow: a prospective randomised trial.
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Flenady V, Wojcieszek AM, Papatsonis DNM, Stock OM,
2013;120(Suppl s1):184.
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Seal S, Mukherji J. A novel technique to reduce the
inhibiting preterm labour and birth. Cochrane Database
complications of the 2nd stage caesarean delivery using
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fetal pillow: A randomised controlled trial. BJOG: an
14651858.CD002255.pub2
international journal of obstetrics and gynaecology 2015;122
(Suppl S1):375. Flenady 2014b
Seal S, Tibriwal R, Kanrar P, De A, Mukherjii J, Barman Flenady V, Reinebrant HE, Liley HG, Tambimuttu
SC. Elevating fetal head prior to performing a caesarean EG, Papatsonis DNM. Oxytocin receptor antagonists
section at full dilation using fetal pillow: A prospective for inhibiting preterm labour. Cochrane Database of
randomised trial. BJOG: an international journal of obstetrics Systematic Reviews 2014, Issue 6. [DOI: 10.1002/
and gynaecology 2015;122(Suppl S1):215. 14651858.CD004452.pub3
Fong 1997 Systematic Reviews 2014, Issue 2. [DOI: 10.1002/
Fong YF, Arulkumaran S. Breech extraction - an alternative 14651858.CD004352.pub3
method of delivering a deeply engaged head at cesarean Pelosi 1984
section. International Journal of Gynecology and Obstetrics Pelosi M, Apuzzio J. Use of the soft silicone obstetric
1997;56:1834. vacuum cup for delivery of the fetal head at caesarean
Gyetvai 1999 section. Journal of Reproductive Medicine 1984;29:28992.
Gyetvai K, Hannah ME, Hodnett ED, Ohlsson A. Reinebrant 2015
Tocolytics for preterm labor: a systematic review. Obstetrics Reinebrant HE, Pileggi-Castro C, Romero CLT, dos Santos
& Gynecology 1999;94:86977. RAN, Kumar S, Souza J, et al. Cyclo-oxygenase (COX)
Haas 2002 inhibitors for treating preterm labour. Cochrane Database
Hass DM, Ayres AW. Laceration injury at cesarean section. of Systematic Reviews 2015, Issue 6. [DOI: 10.1002/
Journal of Maternal-Fetal & Neonatal Medicine 2002;11(3): 14651858.CD001992.pub3
1978. RevMan 2014 [Computer program]
Higgins 2011 The Nordic Cochrane Centre, The Cochrane Collaboration.
Higgins JPT, Green S, editors. Cochrane Handbook for Review Manager (RevMan). Version 5.3. Copenhagen:
Systematic Reviews of Interventions Version 5.1.0 [updated The Nordic Cochrane Centre, The Cochrane Collaboration,
March 2011]. The Cochrane Collaboration, 2011. 2014.
Available from www.cochrane-handbook.org. Smith 1997
Smith JF, Hernandez C, Wax JR. Fetal laceration injury
Landesman 1984 at cesarean delivery. Obstetrics & Gynecology 1997;90(3):
Landesman R, Graber E. Abdominovaginal delivery: 3446.
Modification of the cesarean operation to facilitate delivery
Solomens 1962
of the impacted head. American Journal of Obstetrics and
Solomen, E. Delivery of the head by Malmstrom vacuum
Gynecology 1984;148:70710.
extractor during cesarean section. Obstetrics & Gynecology
Landon 2004 1962;19:201.
Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker
S, Varner MW, et al. Maternal and perinatal outcomes
References to other published versions of this review
associated with a trial of labor after prior cesarean delivery.
Dodd 2006
New England Journal of Medicine 2004;351:25819.
Dodd JM, Reid K. Tocolysis for assisting delivery at
Neilson 2014 caesarean section. Cochrane Database of Systematic Reviews
Neilson J, West HM, Dowswell T. Betamimetics 2006, Issue 4. [DOI: 10.1002/14651858.CD004944.pub2
for inhibiting preterm labour. Cochrane Database of
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Bastani 2012
Methods Randomised, unblinded trial.
Participants Women with prolonged obstructed labour, at full dilatation, arrest of descent greater than
1 hour and station +2, dystocia, vertex presentation. Exclusions: multiple pregnancies,
fetal anomalies, previous caesarean delivery, premature delivery
Interventions The pull method (reverse breech extraction) was compared to the push method (cephalic
delivery with digital pressure via the vagina)
Outcomes Operative blood loss, uterine incision extension toward broad ligament/vagina, blood
transfusion, wound infection, endometritis, bladder injury, ligation of hypogastric ar-
teries and hysterectomy, urethral injury, prolonged hospital stay
Notes
Risk of bias
Bias Authors judgement Support for judgement
Random sequence generation (selection Unclear risk No description of randomisation process given.
bias)
Allocation concealment (selection bias) Unclear risk Not described.
Blinding of participants and personnel Unclear risk Not described.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Low risk Anaesthetist blinded, responsible for assessment of es-
bias) timated blood loss
All outcomes
Incomplete outcome data (attrition bias) Low risk Nil loss apparent.
All outcomes
Selective reporting (reporting bias) Low risk All prespecified outcomes described.
Other bias Low risk Nil other bias apparent.

Bofill 2000
Methods Randomised unblinded trial, randomisation by envelope.
Participants 39 weeks gestation, at least 1 previous caesarean delivery, cephalic presentation without
fetopelvic engagement by vaginal examination, patient willingness to randomise to de-
livery technique
Exclusion criteria: fetal malpresentation (transverse or breech), serious maternal or fetal
disease (maternal or fetal coagulopathy, fetal structural malformation or evidence of
non-reassuring fetal status), a deeply engaged fetal vertex or maternal unwillingness to
undergo randomisation
Interventions Random allocation to instrumental delivery (forceps or vacuum) or manual/fundal pres-

sure delivery
Outcomes Delivery as randomised, time to delivery, uterine incision extension, postoperative Hb,
drop in Hb, pain scores, Apgars, cord artery pH, birthweight
Notes
Risk of bias
Random sequence generation (selection Unclear risk No description of randomisation process.

bias)
Allocation concealment (selection bias) Low risk Series of opaque manilla envelopes.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Unclear risk Not described.

bias)
All outcomes
Incomplete outcome data (attrition bias) Low risk No loss apparent.

All outcomes

David 1998
Methods Randomised, double-blind, placebo-controlled trial; randomisation involved computer-

generated random number sequence
Participants Pregnant women 34-42 weeks gestation with singleton pregnancy and planned caesarean
section.
Exclusion: pregnancy-induced hypertension, pre-eclampsia, heart disease, previous car-
diac surgery, intravenous tocolysis within 48 hours of caesarean section
Interventions Random allocation to 0.25 mg intravenous nitroglycerin, 0.5 mg intravenous nitroglyc-

erin, or intravenous saline (placebo)
Outcomes Estimation of ease of fetal extraction (difficult, normal, easy); degree of uterine relaxation
(none, minimal, strong, very strong); postpartum bleeding (decreased, normal, heavier);
median blood loss; median change in systolic and diastolic blood pressure; median Apgar
score; median cord pH; maternal side-effects (headache, flushing, bradycardia)
Notes
Risk of bias
Random sequence generation (selection Low risk Computer-generated list of random num-
bias) bers.
Allocation concealment (selection bias) Unclear risk Random-number list kept away from clin-
ical care area.
Blinding of participants and personnel Low risk Patients, surgical team and neonatologists
(performance bias) were blinded, the anaesthetist was not
All outcomes
Blinding of outcome assessment (detection Low risk Surgeons were blinded, they performed as-
bias) sessment of primary outcome (ease of fetal
All outcomes extraction)
Incomplete outcome data (attrition bias) Low risk No loss apparent.

All outcomes
Selective reporting (reporting bias) Low risk No selective reporting apparent.

Fasubaa 2002
Methods Randomised unblinded trial, randomisation involved computer-generated random num-

ber sequence
Participants Patients with prolonged obstructed labour. Exclusion criteria: intrauterine fetal death,
congenital fetal anomaly, multiple pregnancy, ruptured uterus, previous caesarean sec-
tion, fetal head more than 2 finger-breadths palpable per abdomen
Outcomes Operation time, operative blood loss, degree of uterine incision extension either towards
the broad ligament or vagina, Apgar scores, fetal outcome, neonatal admission rate, fetal
injury during delivery, wound infection, endometritis, hospital stay and total hospital
bill
Notes
Risk of bias
Random sequence generation (selection Low risk Computer-generated random sampling

bias) method.
Blinding of participants and personnel Unclear risk No blinding described.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Low risk Anaesthetist blinded, responsible for assess-
bias) ment of estimated blood loss and operation
All outcomes duration
All outcomes
Frass 2011
Methods Randomised unblinded trial, no description of the randomisation process was given
Participants Singleton, term, cephalic, obstructed labour, requiring abdominal delivery. Exclusion
criteria: multiple pregnancy, non-cephalic presentation, previous scar, preterm labour

Frass 2011 (Continued)
Outcomes Prespecified outcomes: frequency of uterine incision extension. Reported outcomes:

uterine rupture, blood transfusion, operative time, PPH, endometritis, wound infection,
mean hospital stay, mean fall in Hb, mean blood loss, Apgar score < 7, admission to
nursery, stillbirth
Notes
Risk of bias
Random sequence generation (selection Unclear risk Distribution of women to either group
bias) was made randomly based on 1:1 ratio, no
other description given
Blinding of participants and personnel Unclear risk No blinding described.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Unclear risk No blinding described.

bias)
All outcomes
All outcomes
Owens 2003
Methods Randomised unblinded trial, randomisation involved computer-generated consecutive

numbered envelopes generated in blocks of 50
Participants Pregnant, singleton gestation, caesarean delivery. Exclusion criteria: woman given fundal
pressure in labour prior to caesarean delivery, failed operative vaginal delivery, breech
presentation, known abruptios, placenta praevia, external cephalic version attempt within
last 3 days
Interventions Forceps was compared to manual delivery with fundal pressure

Owens 2003 (Continued)
Outcomes Prespecified - per cent of umbilical cord blood placental alkaline phosphatase between
the groups
Reported outcomes: conduction anaesthesia, low transverse uterine scar used, abdominal
incision to uterine incision (minute), uterine incision to delivery (second), estimated
blood loss, birthweight
Notes
Risk of bias
Random sequence generation (selection Low risk Randomisation using computer-generated

bias) consecutive numbered envelopes generated
in blocks of 50
Allocation concealment (selection bias) Low risk Opaque envelopes opened after consent.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Unclear risk No blinding described.

bias)
All outcomes
All outcomes
Veisi 2012
Methods Randomised unblinded trial, no description of the randomisation process was given
Participants Women with singleton pregnancy at 37-42 weeks, cephalic presentation with obstructed
dystocia - full cervical dilation and fetal head impacted in pelvis leading to caesarean
delivery after failed attempt at operative vaginal delivery. Exclusion criteria - suspected
macrosomia > 4000 g, intrauterine fetal death, multiple pregnancy, previous caesarean
or myomectomy, chorioamnionitis, third trimester haemorrhage

Veisi 2012 (Continued)
Outcomes Operation time, estimated blood loss, incidence of extension of uterine incision, bladder
injury, postpartum fever, postoperative wound complication. Neonatal - 1 and 5 minute
Apgar score, admission to NICU, fetal injury
Notes
Risk of bias
Random sequence generation (selection Unclear risk No description of randomisation process

bias) given.

(performance bias)
All outcomes
Blinding of outcome assessment (detection Unclear risk No description of blinding given.

bias)
All outcomes
All outcomes
Hb: haemoglobin
NICU: neonatal intensive care unit
PPH: postpartum haemorrhage
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Bellad 2013 Study not yet published, contact made with author, awaiting data to be finalised. To be included next review
Buhimschi 2002 Tocolysis used prior to caesarean section for fetal distress
Burke 1989 Tocolysis used for intrauterine resuscitation prior to caesarean section for fetal distress. Trial used quasi-
randomised techniques (alternate month)

(Continued)
Chopra 2009 Retrospective.
Eisler 1999 Continuous tocolytic infusion used 2 hours prior to caesarean section to improve infant respiratory effort
and metabolism
Fothergill 1971 Assessment of anaesthetic duration, not tocolysis effect.
Hong 1993 Tocolytic agent used to prevent hypertension following intubation in hypertensive women
Kadhum 2009 Not randomised.
Kaukinen 1978 Tocolysis used prior to caesarean section for fetal distress
Kulier 1997 Tocolysis used for intrauterine resuscitation prior to caesarean section for fetal distress
Kumar Saha 2014 Retrospective.
Levy 2005 Retrospective.
Magann 1993 Tocolysis used for intrauterine resuscitation prior to caesarean section for fetal distress
Mukhopadhyay 2005 Not randomised.
Naghibi 2008 Tocolysis used appropriately but unable to contact author to obtain full data set
Papanikolaou 2009 Not randomised.
Seal 2013 Email to RG Medical College in India to request data - no response
Visser 1979 Tocolysis used prior to caesarean section for fetal distress
Wright 1995 Technique for facilitating delivery at elective caesarean section described, but unable to contact author to
obtain full data set

DATA AND ANALYSES
Comparison 1. Tocolysis versus placebo
No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size
1 Maternal side-effects (not 1 97 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
prespecified)
Comparison 2. Reverse breech versus head push
No. of No. of
1 Infant birth trauma 3 239 Risk Ratio (M-H, Fixed, 95% CI) 1.55 [0.42, 5.73]
2 Extension of uterine incision 4 357 Risk Ratio (M-H, Random, 95% CI) 0.23 [0.13, 0.40]
3 Blood loss > 500 mL 1 118 Risk Ratio (M-H, Random, 95% CI) 0.5 [0.18, 1.37]
4 Mean blood loss 3 298 Mean Difference (IV, Random, 95% CI) -294.92 [-493.25,
-96.59]
5 Blood transfusion 2 177 Risk Ratio (M-H, Random, 95% CI) 0.57 [0.20, 1.66]
6 Endometritis 3 285 Risk Ratio (M-H, Random, 95% CI) 0.52 [0.26, 1.05]
7 Wound infection 4 357 Risk Ratio (M-H, Fixed, 95% CI) 0.96 [0.58, 1.59]
8 Admission to neonatal special 2 226 Risk Ratio (M-H, Random, 95% CI) 0.53 [0.23, 1.22]
care or intensive care unit
9 Early neonatal death rate 1 108 Risk Ratio (M-H, Random, 95% CI) 0.54 [0.23, 1.24]
10 Mean fall in Hb (not 1 118 Mean Difference (IV, Random, 95% CI) -0.44 [-0.72, -0.16]
prespecified)
11 Operative time (min) 4 357 Mean Difference (IV, Random, 95% CI) -14.99 [-27.67, -2.
30]
12 Mean hospital stay (not 3 285 Mean Difference (IV, Random, 95% CI) -1.13 [-2.75, 0.48]
prespecified)
13 Average Apgar at 5 minutes 3 239 Mean Difference (IV, Random, 95% CI) 0.36 [-0.64, 1.36]
(not prespecified)

Comparison 3. Elective instrument versus fundal pressure
No. of No. of
1 Infant birth trauma 1 44 Risk Ratio (M-H, Fixed, 95% CI) 0.0 [0.0, 0.0]
2 Extension of uterine incision 1 44 Risk Ratio (M-H, Fixed, 95% CI) 0.7 [0.13, 3.73]
3 Mean fall in Hb 1 44 Mean Difference (IV, Fixed, 95% CI) 0.03 [-0.53, 0.59]
WHATS NEW
Date Event Description
30 September 2015 New search has been performed Methods updated. The review now includes seven ran-
domised controlled trials, involving 582 women
30 September 2015 New citation required and conclusions have changed Scope of the review changed to include techniques,
rather than just tocolysis for assisting difficult cae-
sarean section. New comparisons added: assessing
techniques for caesarean at full dilation (four trials
identified and included Bastani 2012; Fasubaa 2002;
Frass 2011; Veisi 2012); and also instrument use at
elective caesarean (two trials identified and included
Bofill 2000; Owens 2003).
As a consequence of the change in scope, the title has
changed from, Tocolysis for assisting delivery at cae-
sarean section to Techniques for assisting difficult de-
livery at caesarean section
HISTORY
Date Event Description
29 May 2012 Amended Search updated. Six trial reports added to Studies awaiting classification (Bofill 2000a; Fasubaa
2002a; Fothergill 1971; Naghibi 2008a; Owens 2003a; Wright 1995a)
20 September 2008 Amended Converted to new review format.

CONTRIBUTIONS OF AUTHORS
At the time of this update, H Waterfall and R Grivell developed the new protocol and review with input from J Dodd. J Dodd is the
guarantor of the review. This 2015 review update was prepared by H Waterfall and R Grivell and J Dodd commented on drafts.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
Discipline of Obstetrics and Gynaecology, The University of Adelaide, Australia.
External sources
Neil Hamilton Fairley Fellowship supported by the NHMRC (ID 399224), Australia.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

As part of the latest update and change in focus of this review, the outcomes and comparisons have been significantly altered from the
previously published version.
Previously the only comparison in the review was tocolysis at caesarean section, the scope of the review has expanded to include other
techniques for difficult caesarean sections. Two additional comparisons have been included; comparing reverse breech extraction with
head push for fully dilated caesarean sections, and the use of an instrument compared with manual delivery at elective caesarean section.
The selection criteria for studies has been expanded to include studies that address the above comparisons.
The prespecifed outcomes have been altered to include an additional assessment of blood loss - mean fall in haemoglobin (Hb), and
also assessment of average Apgar score, maternal side-effects. Length of hospital stay changed to mean hospital stay and stillbirth rate
removed.
As a consequence of the change in scope, the title has changed from, Tocolysis for assisting delivery at caesarean section to Techniques
for assisting difficult delivery at caesarean section.
INDEX TERMS
Medical Subject Headings (MeSH)

Tocolysis;
Birth Injuries [etiology]; Cesarean Section [ methods]; Extraction, Obstetrical [adverse effects; methods]; Randomized
Controlled Trials as Topic; Tocolytic Agents [ administration & dosage]

MeSH check words
Female; Humans; Pregnancy


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Cochrane Database of Systematic Reviews

Techniques for assisting difficult delivery at caesarean section

Waterfall H, Grivell RM, Dodd JM

Waterfall H, Grivell RM, Dodd JM.

Techniques for assisting difficult delivery at caesarean section (Review)

Techniques for assisting difficult delivery at caesarean section (Review) i

Techniques for assisting difficult delivery at caesarean section

Heather Waterfall1 , Rosalie M Grivell2 , Jodie M Dodd3

Editorial group: Cochrane Pregnancy and Childbirth Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Description of the intervention

Techniques for assisting difficult delivery at caesarean section (Review) 3

Techniques for assisting difficult delivery at caesarean section (Review) 4

Longer-term outcomes for the infant

Techniques for assisting difficult delivery at caesarean section (Review) 5

(2) Allocation concealment (checking for possible selection

Techniques for assisting difficult delivery at caesarean section (Review) 6

(5) Selective reporting (checking for reporting bias) Cluster-randomised trials

Techniques for assisting difficult delivery at caesarean section (Review) 7

Subgroup analysis and investigation of heterogeneity

Techniques for assisting difficult delivery at caesarean section (Review) 8

The search identified a single randomised controlled trial of 44

Techniques for assisting difficult delivery at caesarean section (Review) 9

Techniques for assisting difficult delivery at caesarean section (Review) 10

Techniques for assisting difficult delivery at caesarean section (Review) 11

Techniques for assisting difficult delivery at caesarean section (Review) 12

Techniques for assisting difficult delivery at caesarean section (Review) 13

Techniques for assisting difficult delivery at caesarean section (Review) 14

Techniques for assisting difficult delivery at caesarean section (Review) 15

Techniques for assisting difficult delivery at caesarean section (Review) 18

Characteristics of included studies [ordered by study ID]

Methods Randomised, unblinded trial.

Bias Authors judgement Support for judgement

Allocation concealment (selection bias) Unclear risk Not described.

Blinding of participants and personnel Unclear risk Not described.

Other bias Low risk Nil other bias apparent.

Techniques for assisting difficult delivery at caesarean section (Review) 19

Methods Randomised unblinded trial, randomisation by envelope.

Interventions Random allocation to instrumental delivery (forceps or vacuum) or manual/fundal pres-

Bias Authors judgement Support for judgement

Random sequence generation (selection Unclear risk No description of randomisation process.

Blinding of participants and personnel Unclear risk Not described.

Blinding of outcome assessment (detection Unclear risk Not described.

Incomplete outcome data (attrition bias) Low risk No loss apparent.

Other bias Low risk Nil other bias apparent.

Techniques for assisting difficult delivery at caesarean section (Review) 20

Methods Randomised, double-blind, placebo-controlled trial; randomisation involved computer-

Interventions Random allocation to 0.25 mg intravenous nitroglycerin, 0.5 mg intravenous nitroglyc-

Bias Authors judgement Support for judgement

Incomplete outcome data (attrition bias) Low risk No loss apparent.

Selective reporting (reporting bias) Low risk No selective reporting apparent.

Other bias Low risk Nil other bias apparent.

Techniques for assisting difficult delivery at caesarean section (Review) 21

Methods Randomised unblinded trial, randomisation involved computer-generated random num-

Bias Authors judgement Support for judgement

Random sequence generation (selection Low risk Computer-generated random sampling

Allocation concealment (selection bias) Unclear risk Not described.

Blinding of participants and personnel Unclear risk No blinding described.

Other bias Low risk Nil other bias apparent.

Techniques for assisting difficult delivery at caesarean section (Review) 22

Outcomes Prespecified outcomes: frequency of uterine incision extension. Reported outcomes:

Bias Authors judgement Support for judgement

Allocation concealment (selection bias) Unclear risk Not described.