Definition, Management, and Training in Impacted Fetal Head at Cesarean Birth: A National Survey of Maternity Professionals

Abstract

ABSTRACT Impacted fetal head (IFH) is a complication that occurs in 10% of cesarean deliveries (CDs). Disimpacting the fetal head can have significant maternal risks, including trauma to the uterus, vagina, cervix, and bladder, postpartum hemorrhage, as well as neonatal risks, including skull fracture, intracranial hemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit, and death. Perinatal head injury due to IFH has resulted in increased litigation, with IFH identified as a contributing factor in nearly 10% of the most expensive maternity claims in the United Kingdom in 2018. International consensus on the most effective and safe management of IFH is lacking. Moreover, recent surveys of maternity professionals in the United Kingdom have reported a scarcity of training, lack of confidence, and underused techniques for IFH. Understanding how maternity professionals view the management of IFH during CD is helpful to improve care, training, and research. The aim of this study was to assess the views, understanding and practices to manage IFH during CD. This was a survey of health care professionals who provide maternity care or work in policy, research, or other areas of maternity care, using a secure online collaborative platform called Thiscovery. Participants included Thiscovery subscribers and members of clinical practice societies, such as the Royal College of Midwives, Royal College of Obstetricians and Gynecologists, and Royal College of Anesthetists. The survey analyzed responses for open-ended questions, with free-text entries, and closed-ended questions. A total of 419 participants were included in the analysis, including 144 midwives, 216 obstetricians, and 59 other maternity professionals. A high level of agreement was found among 79% of obstetricians who preferred a definition of IFH at CD that included “additional maneuvers and/or tocolysis to disimpact and deliver the fetal head.” About a third of free-text responses from 17 respondents noted a need to incorporate the difficulty or inability to get a hand below the fetal head for delivery. Approximately 95% of participants agreed or strongly agreed that management of IFH at CD requires a multiprofessional approach. When asked about communicating an IFH emergency, 55% preferred using the declaration, “This is an impacted fetal head.” Free-text responses from 57 participants emphasized the importance of clear communication and awareness of the emergency across all team members before and during the management of IFH as well as with the woman and birth partner. More than 70% found that a change of operator, manual cephalic extraction, tocolysis, operating changing hand, reserve breech extraction, Fetal Pillow, head-down tilt, and vaginal disimpaction were safe and effective techniques and adjunctive measures for managing IFH at CD. However, free-text responses from 56 participants found mixed views on the use of tocolysis, noting the risk of complications such as postpartum hemorrhage. The use of Fetal Pillow was positively accepted by 71 participants. Comparing obstetricians with midwives, approximately three quarters of obstetricians considered vaginal disimpaction before CD acceptable (72% preincision and 76% postincision). Fewer midwives favored this technique (25% preincision and 52% postincision), with 88% reporting that knowing the position of the fetal head would be helpful to know before undertaking vaginal disimpaction. Training in vaginal disimpaction was considered essential by 85% of midwives and obstetricians. Yet only 81% of midwives and 57% of obstetricians had received such training. The preferred method of training was hands-on training in simulation (91%), followed by animated video illustrating disimpaction techniques (73%) and small-group teaching (55%). Free text responses form 159 participants demonstrated a need and appetite for more training. The most frequent suggestions to improve care for IFH at CD included holding briefings and debriefings before and after the emergency and having robust plans for escalation and calling for help. This study identified high agreement among United Kingdom maternity professionals to define IFH at CD. The study authors suggested a standard definition as “a cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvers and/or tocolysis are required to disimpact and deliver the fetal head.” In addition, using unambiguous language in the emergency, such as declaring “This is an impacted fetal head,” facilitates teamwork and collaboration and improves care.