29/10/2024
In June 2023, a key Royal College of Obstetricians & Gynaecologists (RCOG) Scientific Impact Paper (No 73) was published reviewing the current evidence regarding the prediction, prevention and management of Impacted Fetal Head (IFH) at caesarean birth. IFH occurs when the baby’s head becomes lodged deep in the maternal pelvis making it difficult to deliver the baby by caesarean section. Clinicians are faced with a technically challenging emergency, often at the end of a prolonged labour. Recent UK studies suggest that IFH may complicate as many as one in 10 unplanned caesarean births and we see a number of claims arising out of these distressing circumstances, often sadly involving fractures and very serious brain injury. NHS Resolution have undertaken a thematic analysis of cases considered under the Early Notification scheme Learning from avoidable brain injuries at birth - NHS Resolution. One of the six recommendations made is the need to raise awareness of the risks relating to impacted fetal head. 9% of the 96 cases reviewed involved a problem with impacted fetal head and/or difficult delivery of the head at caesarean section. This is noted to be a high incidence of a problem not previously reported by NHS Resolution.
In the event of a claim, it is for the Claimant to prove that alternative management of this difficult situation would have made a difference to the outcome and that the methods used to deliver the baby did not accord with reasonable medical practice. From anecdotal reports, skills have been lost in the UK and there is a variation in preferred techniques. A study carried out in 2021 (Impacted foetal head at caesarean section: a national survey of practice and training - PubMed) reported that there was a lack of IFH training and that training was inconsistent and inadequate.
Options for delivery include:-
- an assistant pushing the head up from the vagina
- delivering the baby feet first, by ‘reverse breech’
- using a balloon device, a ‘fetal pillow’ to elevate the baby’s head (now to be used with caution); and
- giving drugs to relax the uterus.
Innovative devices are also in use, such as the Tydeman Tube, which aim to reduce the risks involved in managing the considerable force required when the fetal head becomes seriously lodged in the maternal pelvis. More data is needed before their effectiveness can be fully evaluated. There are risks to both mother and baby in all cases, with fast decisions to be made with no guaranteed good outcome.
One of the reasons IFH can occur is a loss of perspective on the progress in labour, with the obstetric and midwifery team hopeful that just a little more time pushing will lead to a successful vaginal delivery, with multiple attempts at instrumental delivery often taking place late in a prolonged labour and a lack of holistic overview of the labour process. Manoeuvres used or the force exerted can be deemed inappropriate and dangerous, though some injury may be inevitable if lives are to be to be saved.
It is clear that it would be helpful to provide obstetricians with protocols and a proforma template in the medical records to guide practice in these situations, setting out recommended sequential interventions, much as template records for dealing with shoulder dystocia have proved to be useful for both clinicians and lawyers working to defend claims. Data capture through a standardised medical record format can encourage prompt and appropriate clinical practice and significantly increase the chances of a successful defence. It will also provide better evidence over time to evaluate which techniques are associated with the best outcomes.
The next stage of the NHS programme Avoiding Brain Injuries in Childbirth (ABC) is to be welcomed. This is being trialled in a pilot phase from 7 October 2024 with nine selected NHS maternity units in North West England and South London using the ABC training and resources involving clinical trainers, maternity team staff, with input from women, birthing people and birth partners. Six of the sites are piloting the impacted fetal head during caesarean birth programme which could be rolled out nationally next year if the initiative is successful.
This builds on work carried out by Professor Tim Draycott and the RCOG in conjunction with Mary Dixon-Woods, Director of THIS Institute and The Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge. The framework should help to better manage the risks of dealing with this potentially devastating emergency and reduce the volume of very high value claims that can result from shortcomings in obstetric practice. Further work on developing protocols and guidance will no doubt be important. Lessons learnt from claims can provide a valuable contribution to this process and help to devise evidence based recommendations to guide medical practice.