Impacted foetal head at caesarean section: a national survey of practice and training

Abstract

This is a national survey of UK obstetric trainees and consultant labour ward leads designed to investigate the current practice and training for an impacted foetal head (IFH) at Caesarean Section (CS). An anonymous, on-line survey was disseminated to trainees via Postgraduate Schools and RCOG trainee representatives, and to labour ward leads via their national network. Three hundred and forty-five obstetric trainees and consultants responded. The results show that IFH is variably defined and encountered by most UK obstetricians (98% had encountered IFH and 76% had experienced it before full cervical dilatation). There is significant variation in management strategies, although most respondents would use a vaginal push up to assist delivery prior to reverse breech extraction. Responses revealed a paucity of training and lack of confidence in disimpaction techniques: over one in ten respondents had not received any training for IFH and less than half had received instruction in reverse breech extraction.

Impact statement

• What is already known on the subject? IFH is an increasingly recognised, technically challenging complication of intrapartum CS. A recent report suggested that birth injuries associated with IFH are now as common as with shoulder dystocia. However, there is no consensus nor guidelines regarding the best practice for management or training.

• What do the results of this study add? This study demonstrates that IFH is poorly defined and commonly encountered by UK obstetricians. It highlights that IFH is not restricted to CS at full dilatation and reveals the ubiquity of the vaginal push method in UK practice. We found evidence that UK obstetricians are using techniques which have not been investigated and are not recommended for managing an IFH. Moreover, this survey is an eye-opener as to the paucity of training, highlighting that UK obstetric trainees are not adequately prepared to manage this emergency.

• What are the implications of these findings for clinical practice and/or further research? There is a pressing need to standardise the definition, guidance and training for IFH at CS. Further research should clarify the appropriate techniques for IFH and establish consensus for the best practice. An evidence-based simulation training package, which allows clinicians to learn and practice recognised disimpaction techniques is urgently required.

Keywords:

• Impacted foetal head
• caesarean section
• training

Acknowledgements

The authors would like to thank all the survey respondents who took the time to thoughtfully respond to the survey questions.

Author contributions

KC and TD conceived the idea. KC designed the study, conducted the data collection, analysis and wrote the manuscript, supervised by EL, TD and RB. EL, RB, CW, TD and JK edited and approved the manuscript.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

KC is the recipient of a David Telling Charitable Fellowship, Health Education England South West Simulation Network Fellowship and Limbs and Things Fellowship. Additional funding was provided by the Springboard North Bristol NHS Trust Charitable Fund. The funding sources have no direct role in the study design; collection, analysis or interpretation of the data; writing of the report or decision to submit.