Management of impacted fetal head: systematic review

Why it matters

Impacted fetal head – where the baby’s head becomes lodged deep in the mother’s pelvis – can complicate as many as one in ten unplanned caesarean births (1.5% of all births) in the UK. It’s an obstetric emergency that can cause serious harm to those in labour and their babies. According to NHS Resolution, impacted fetal head has been a contributory factor in nearly 10% of potentially the most expensive maternity claims.

Despite the rising numbers of occurrences and the potentially serious harm to mothers and babies, it’s unclear which techniques are most effective for prevention and management of impacted fetal head. A high-quality overview of what is and isn’t known from current research is critical to inform training and other resources for clinicians to improve practice and reduce risk of impacted fetal head. That’s why we set out to identify and evaluate currently available published studies.

What we found

Our review identified 24 eligible studies that have compared techniques to prevent or manage impacted fetal head at caesarean birth. Evaluations of the studies revealed that nearly all of them had flaws in study design, execution or reporting. This means there’s little certainty in the current research about which techniques are safest and most effective to manage impacted fetal head.

We also discovered that the published studies didn’t report on training status or the competence of the clinicians performing the techniques, even though gaps in training and competence may contribute to poor outcomes. This led to problems when evaluating studies effectively, as it wasn’t clear whether the procedures were carried out appropriately.

The review highlighted a need for a consensus-based, universally accepted definition of impacted fetal head to streamline future research and training. A possible solution for that was found in a recent consultation with maternity professionals as part of the Avoiding Brain Injury in Childbirth programme.   

Based on the current studies, it is not possible to recommend or prioritise the use of one technique. That’s why maternity professionals should be trained in the range of available techniques. This requires implementation of a standardised, high quality training programme for multi-professional teams based on best available evidence. Such training should also address issues concerning communication with those in labour and their birth partners.

Acknowledgements

This work was done by a collaboration between the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives and THIS Institute, as part of the Avoiding Brain Injury in Childbirth programme funded by the Department of Health and Social Care. We also thank the PROMPT Maternity Foundation, Pauline Hewitt, Sophie Carlisle and Fiona Whiter for their support in conducting this work.