Definition, management, and training in impacted fetal head at caesarean birth: a national survey of maternity professionals  

Contributors

• Katie Cornthwaite
• Pauline Hewitt
• Jan W. van der Scheer
• Imogen A.F. Brown
• Jenni Burt
• Eliane Dufresne
• Mary Dixon-Woods
• Tim Draycott
• Rachna Bahl

Why it matters

Impacted fetal head is an obstetric emergency where a baby’s head becomes lodged deep in the mother’s pelvis. It can complicate as many as 10% of unplanned caesarean births in the UK (1.5% of all births). It may cause damage  – sometimes serious – to the person in labour and to the baby.  For babies, bad outcomes of impacted fetal head include skull fracture, intracranial haemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit, and even death. The NHS Resolution Early Notification Scheme has identified it as a contributory factor in nearly 10% of potentially the most expensive maternity claims of 2018.

Despite the significance of the problem, consensus on the safest and most effective ways to deal with impacted fetal head has been lacking. There is a need to engage with professionals to inform the development of standardised definitions, clinical management approach, and training.

Our approach

We carried out a survey of UK maternity professionals to assess their views, understanding, and current practices in relation to impacted fetal head at caesarean birth. Inviting qualified healthcare professionals, such as obstetricians, midwives, and anaesthetists, the survey was undertaken as part of the Avoiding Brain Injury in Childbirth (ABC) programme commissioned by the UK’s Department of Health and Social Care.

What we found

A total of 419 participants from around the UK completed the survey.

Participants’ views highlighted how important it is to use safe, effective techniques for managing impacted fetal head. They were also clear that good “non-technical” skills such as team communication were essential.

An important achievement of the survey was that it showed broad agreement on what constitutes an impacted fetal head at caesarean birth, and good support for this standardised definition:

“A caesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional manoeuvres and/or tocolysis (medication to suppress contractions) are required to disimpact and deliver the fetal head.”

Having a single, standardised definition will be very helpful for practice and for training, as it will mean everyone is working with shared understanding.

Participants in the survey also strongly supported consistent use of shared language between team members when talking about impacted fetal head. In an emergency situation, clearly and calmly saying something like, “This is an impacted fetal head” was a preferred choice, instead of phrases such as “The head is wedged” or “The head is stuck”, which could risk alarming those in labour and their birth partners.

Availability of training and expertise was variable. More than 80% of midwives reported a lack of training in some areas, and some obstetricians and midwives favoured unsafe practices. Most participants agreed with the need to standardise approaches to managing the emergency that would involve the entire multi-professional team needed for the emergency. Survey participants were keen to have for high quality training, suggesting that it would help to improve care and increase professional confidence.

This survey provides a basis for the first consensus-based, standardised definition for this important obstetric emergency. It provides insights into the importance of non-technical skills, shows a need and appetite for standardised training for multi-professional teams, and can be used to inform a programme of work to improve care.

With thanks to the authorship group members:

Akbar Ansari, Andy Paterson, André Sartori, Bethan Everson, Chloe Hughes, Caroline Walker, Emily Hotton, Giulia Maistrello, Jordan Moxey, Lisa Hinton, Louise Dewick, Luke Steer, Ruth Cousens, Sarah Blackwell, Wendy Randall.