Delivery of the Aftercoming Head

The fetal head may be extracted with forceps or by one of the following maneuvers.
Mauriceau Maneuver
The index and middle finger of one hand are applied over the maxilla, to flex the head, while
the fetal body rests on the palm of the hand and forearm (Fig. 24-14). The forearm is
straddled by the fetal legs. Two fingers of the other hand then are hooked over the fetal neck,
and grasping the shoulders, downward traction is applied until the suboccipital region appears
under the symphysis. Gentle suprapubic pressure simultaneously applied by an assistant helps
keep the head flexed. The body then is elevated toward the maternal abdomen, and the
mouth, nose, brow, and eventually the occiput emerge successively over the perineum. With
this maneuver, the operator uses both hands simultaneously and in tandem to exert
continuous downward gentle traction simultaneously on the fetal neck and on the
maxilla. At the same time, appropriate suprapubic pressure applied by an assistant is helpful
in delivery of the head (see Fig. 24-14).

A. Delivery of the aftercoming head using the Mauriceau maneuver. Note that
as the fetal head is being delivered, flexion of the head is maintained by
suprapubic pressure provided by an assistant. B. Pressure on the maxilla
is applied simultaneously by the operator as upward and outward traction
is exerted.

B. Modified Prague Maneuver

C. Rarely, the back of the fetus fails to rotate to the anterior. When this occurs, rotation

of the back to the anterior may be achieved by using stronger traction on the fetal legs
or bony pelvis. If the back still remains oriented posteriorly, extraction may be
accomplished using the Mauriceau maneuver and delivering the fetus back down. If
this is impossible, the fetus still may be delivered using the modified Prague
maneuver, which, as practiced today, consists of two fingers of one hand grasping the
shoulders of the back-down fetus from below while the other hand draws the feet up
over the maternal abdomen (Fig. 24-15).

Delivery of the aftercoming head using the modified Prague maneuver

necessitated by failure of the fetal trunk to rotate anteriorly

Forceps to Aftercoming Head

Specialized forceps can be used to deliver the aftercoming head. Piper forceps, shown in
Figure 24-16, or divergent Laufe forceps may be applied electively or when the Mauriceau
maneuver cannot be accomplished easily. The blades of the forceps should not be applied to
the aftercoming head until it has been brought into the pelvis by gentle traction, combined
with suprapubic pressure, and is engaged. Suspension of the body of the fetus in a towel
effectively holds the fetus and helps keep the arms out of the way.

Piper forceps for delivery of the aftercoming head. A. The fetal body is held
elevated using a warm towel and the left blade of forceps applied to the
aftercoming head. B. The right blade is applied with the body still elevated. C.
Forceps delivery of aftercoming head. Note the direction of movement shown by
the arrow.

Entrapment of the Aftercoming Head

Occasionallyespecially with a small preterm fetusthe incompletely dilated cervix will
constrict around the neck and impede delivery of the aftercoming head. At this point, it must
be assumed that there is significant and even total cord compression, and thus time is of the
essence. With gentle traction on the fetal body, the cervix, at times, may be manually slipped
over the occiput. If this is not successful, then Dhrssen incisions as shown in Figure 24-17
may be necessary. Other alternatives include intravenous nitroglycerintypically 100

gto provide cervical relaxation for relief of head entrapment (Dufour and
colleagues, 1997; Wessen and associates, 1995). There is, however, no compelling evidence
of its efficacy for this purpose. General anesthesia is another option.

Dhrssen incision being cut at 2 o'clock, which is followed by a second incision at

10 o'clock. Infrequently, an additional incision is required at 6 o'clock. The
incisions are so placed as to minimize bleeding from the laterally located cervical
branches of the uterine cavity. After delivery, the incisions are repaired as
described in Chapter 35, Management

As a last resort, replacement of the fetus higher into the vagina and uterus, followed by
cesarean delivery, can be used to rescue an entrapped breech fetus that cannot be delivered
vaginally. Steyn and Pieper (1994) described use of the Zavanelli maneuvercesarean
delivery after replacement of the fetus back into the uterusto deliver a healthy 2590-g

newborn with head entrapment. Sandberg (1999) reviewed 11 breech deliveries in which this
maneuver was used.
In some countries, symphysiotomy is used to widen the anterior pelvis. Sunday-Adeoye and
colleagues (2004) reported that at the Mater Misericordiae Hospital, in Nigeria, 3.7 percent of
27,477 deliveries from 1982 to 1989 were accomplished with symphysiotomy! In his review,
Menticoglou (1990) reported that its use has been associated with good infant outcomes in 80
percent of reported cases. Lack of operator training and the potential to cause serious
maternal injury explain its rare use in this country (Goodwin and colleagues, 1997).

William Obstetric