Revisiting the Vaginal Push-Up to Facilitate the Challenging Cesarean Delivery [18Q]

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Cesarean delivery (CD) at advanced dilation, especially full dilation (FD) may be technically more difficult due to a deeply impacted fetal head. Two maneuvers, vaginal push-up and reverse breech extraction, have been employed. A vaginal push-up can be performed with minimal training and may facilitate delivery. Our objective is to assess maternal and fetal outcomes of vaginal push-up versus no maneuver during fully dilated CD.


A 17 month retrospective analysis of full term patients who progressed to active labor and FD and had a non-emergent CD was performed.


309 patients met inclusion criteria, 91 of which were FD. A push-up was used in 62 CDs, 41 at FD. Demographics were similar across groups. Among FD CD, there was non-significant increase in uterine incision extension between push-up vs no push-up (55.9% vs 49.1%, P=.12). EBL (981 vs 911 mL), mean post-operative drop in hematocrit (7.16 vs 6.48), requirement for blood transfusion (8.1% vs 4.5%), and incidence of maternal post-operative fever (4.9% vs 3.7%) were non-significant. Neonatal outcomes were the same. Direct occiput posterior position is significantly associated with need for push-up (59.4% vs 36.4%, P<.001, OR 3.95, 95% CI 2.2–7.2).


The vaginal push-up does not increase maternal or fetal morbidity while facilitating challenging deliveries. Standardization of the technique, including preoperative planning and use of a vaginal betadine preparation may further reduce morbidity and mortality. Further studies and training may result in more widespread use of a push-up as the rates of CD and in particular FD CD increase.

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