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Cornthwaite K, van der Scheer JW, Kelly S, Schmidt-Hansen M, Burt J, Dixon-Woods M, Draycott T, Bahl R. Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024; 103:1702-1713. [PMID: 38787368 PMCID: PMC11324922 DOI: 10.1111/aogs.14873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/27/2024] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation. MATERIAL AND METHODS We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non-randomized comparative studies (n ≥ 30 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS-I, and certainty of evidence using GRADE. We synthesized data using meta-analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction. RESULTS We identified 24 eligible studies (11 randomized and 13 non-randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and/or the Fetal Pillow®. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (eg risk ratio of 3.41 [95% CI: 2.50-4.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction. CONCLUSIONS The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
| | - Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Sarah Kelly
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | | | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Cambridge, UK
| | - Tim Draycott
- Royal College of Obstetricians & Gynaecologists, London, UK
- North Bristol NHS Trust, Bristol, UK
| | - Rachna Bahl
- Royal College of Obstetricians & Gynaecologists, London, UK
- University Hospitals Bristol and Weston, Bristol, UK
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Sadler LC, Thompson JMD, Alsweiler JM, McKinlay CJD, Cronin R, Browne E, Baillie-Bellew T, Harvey AD, Hill MG. Maternal and neonatal morbidity associated with Fetal Pillow® use at full dilatation caesarean: A retrospective cohort. BJOG 2024; 131:1240-1248. [PMID: 38287196 DOI: 10.1111/1471-0528.17772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
OBJECTIVE To investigate associations of the Fetal Pillow® with maternal and neonatal morbidity. DESIGN Retrospective cohort. SETTING Two tertiary maternity units, New Zealand. POPULATION OR SAMPLE Full dilatation singleton, term, cephalic caesarean section, with three comparisons: at Unit A (1) before versus after introduction of the Fetal Pillow® (1 Jaunary 2016-31 October 2021); (2) with versus without the Fetal Pillow® after introduction (27 July 2017-31 October 2021); and (3) between Unit A and Unit B during the same time period (1 January 2019-31 October 2021). The Fetal Pillow® is unavailable at Unit B. METHODS Cases were ascertained and clinical data were extracted from electronic clinical databases and records. Outcome data were adjusted and presented as adjusted odds ratios (aOR) with 95% CI. MAIN OUTCOME MEASURES Primary outcome "any" uterine incision extension; secondary outcomes included major extension (into adjacent structures), and a composite neonatal outcome. RESULTS In all, 1703 caesareans were included; 375 with the device and 1328 without. Uterine incision extension rates were: at Unit A before versus after introduction: 26.8% versus 24.8% (aOR 0.88, 95% CI 0.65-1.19); at Unit A with the Fetal Pillow® versus without: 26.1% versus 23.8% (aOR 1.14, 95% CI 0.83-1.57); and at Unit A versus Unit B: 24.2% versus 29.2% (aOR 0.73, 95% CI 0.54-0.99). No differences were found in major extensions, or neonatal composite outcome. CONCLUSIONS Despite the relatively large size of this study, it could not rule out either a positive or a negative association between use of the Fetal Pillow® and uterine extensions, major uterine incision extensions, and neonatal morbidity. Randomised controlled trial evidence is required to assess efficacy.
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Affiliation(s)
- Lynn C Sadler
- Women's Health, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - John M D Thompson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
| | - Jane M Alsweiler
- Department of Paediatrics, University of Auckland, Te Whatu Ora, Auckland, New Zealand
| | - Christopher J D McKinlay
- Department of Paediatrics, University of Auckland, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Robin Cronin
- Department of Women's Health, Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | | | | | - Amanda D Harvey
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Meghan G Hill
- Women's Health, Te Whatu Ora Te Toka Tumai, Auckland, New Zealand
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Sadler L, Cronin R, Browne E, Harvey A, Hill MG. Obstetrician views on Fetal Pillow® device use and research in Aotearoa New Zealand: A cross-sectional survey. Aust N Z J Obstet Gynaecol 2024. [PMID: 38634663 DOI: 10.1111/ajo.13824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/03/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND There is anecdotal evidence of Fetal Pillow® use, but no formal local information on clinician practices and perspectives. AIMS To assess obstetrician use of the Fetal Pillow®, knowledge of relevant research, and interest in a proposed randomised controlled trial in Aotearoa New Zealand. MATERIALS AND METHODS Anonymous cross-sectional survey of practising obstetricians and obstetric trainees in Aotearoa New Zealand distributed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RESULTS Of 136 respondents (69% specialists and 31% trainees), 130 had heard of the Fetal Pillow® device, and 108 had used it at least once (43% more than ten times). The device was available in 17/21 units represented. The 108 users of the device reported this was most commonly on collegial advice (63%) or after personal experience of a difficult delivery (33%) and most (80%) believed it reduced maternal morbidity. Only around one-third of the 130 respondents who had heard of the device agreed there was adequate research demonstrating its efficacy for maternal (36%) and neonatal (30%) morbidity. The majority reported they would change practice in response to a randomised trial, although they were more likely to start use (81% of current non-users) than stop (53% of users). Most (70%) respondents agreed they would encourage patients to participate in a randomised trial. CONCLUSIONS The Fetal Pillow® is available in most maternity units in Aotearoa New Zealand. The majority of obstetric clinicians believe it reduces maternal morbidity, while acknowledging the lack of scientific evidence. Most would support a randomised trial.
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Affiliation(s)
- Lynn Sadler
- Women's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Robin Cronin
- Te Whatu Ora Counties Manukau, Auckland, New Zealand
| | - Erena Browne
- Women's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Amanda Harvey
- Women's Health, Te Whatu Ora Auckland, Auckland, New Zealand
| | - Meghan G Hill
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
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Baycroft A, Conti D, Sultan P. Essential notes: impacted fetal head. BJA Educ 2024; 24:81-83. [PMID: 38375491 PMCID: PMC10874754 DOI: 10.1016/j.bjae.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/21/2024] Open
Affiliation(s)
| | - Daniel Conti
- University of California Davis, Sacramento, CA, USA
| | - Pervez Sultan
- Stanford University School of Medicine, Stanford, CA, USA
- University College London, London, UK
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Bahl R, Hotton E, Crofts J, Draycott T. Assisted vaginal birth in 21st century: current practice and new innovations. Am J Obstet Gynecol 2024; 230:S917-S931. [PMID: 38462263 DOI: 10.1016/j.ajog.2022.12.305] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 03/12/2024]
Abstract
Assisted vaginal birth rates are falling globally with rising cesarean delivery rates. Cesarean delivery is not without consequence, particularly when carried out in the second stage of labor. Cesarean delivery in the second stage is not entirely protective against pelvic floor morbidity and can lead to serious complications in a subsequent pregnancy. It should be acknowledged that the likelihood of morbidity for mother and baby associated with cesarean delivery increases with advancing labor and is greater than spontaneous vaginal birth, irrespective of the method of operative birth in the second stage of labor. In this article, we argue that assisted vaginal birth is a skilled and safe option that should always be considered and be available as an option for women who need assistance in the second stage of labor. Selecting the most appropriate mode of birth at full dilatation requires accurate clinical assessment, supported decision-making, and personalized care with consideration for the woman's preferences. Achieving vaginal birth with the primary instrument is more likely with forceps than with vacuum extraction (risk ratio, 0.58; 95% confidence interval, 0.39-0.88). Midcavity forceps are associated with a greater incidence of obstetric anal sphincter injury (odds ratio, 1.83; 95% confidence interval, 1.32-2.55) but no difference in neonatal Apgar score or umbilical artery pH. The risk for adverse outcomes is minimized when the procedure is conducted by a skilled accoucheur who selects the most appropriate instrument likely to achieve vaginal birth with the primary instrument. Anticipation of potential complications and dynamic decision-making are just as important as the technique for safe instrument use. Good communication with the woman and the birthing partner is vital and there are various recommendations on how to achieve this. There have been recent developments (such as OdonAssist) in device innovation, training, and strategies for implementation at a scale that can provide opportunities for both improved outcomes and reinvigoration of an essential skill that can save mothers' and babies' lives across the world.
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Affiliation(s)
- Rachna Bahl
- Department of Obstetrics and Gynaecology, University Hospitals Bristol National Health Service Trust, Bristol, United Kingdom; Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
| | | | - Joanna Crofts
- Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, United Kingdom; Department of Obstetrics and Gynaecology, North Bristol National Health Service Trust, Bristol, United Kingdom
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Cornthwaite KR, Bahl R, Lattey K, Draycott T. Management of impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024; 230:S980-S987. [PMID: 38462267 PMCID: PMC11000504 DOI: 10.1016/j.ajog.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/05/2022] [Accepted: 10/09/2022] [Indexed: 03/12/2024]
Abstract
Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman's pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby's head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.
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Affiliation(s)
- Katie R Cornthwaite
- University of Bristol and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom.
| | - Rachna Bahl
- University Hospitals Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
| | | | - Tim Draycott
- North Bristol NHS Trust and Royal College of Obstetricians and Gynaecologists, Bristol, United Kingdom
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Briley AL, Silverio SA, Shennan AH, Tydeman G. Experiences of Impacted Foetal Head: Findings from a Pragmatic Focus Group Study of Mothers and Midwives. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7009. [PMID: 37947566 PMCID: PMC10647298 DOI: 10.3390/ijerph20217009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/29/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION We aimed to explore the lived experiences of caesarean birth complicated by impaction of the foetal head, for mothers and midwives. METHODS A pragmatic, qualitative, focus group study of mixed-participants was conducted, face-to-face. They were postpartum women (n = 4), midwives (n = 4), and a postpartum midwife (n = 1) who had experience of either providing care for impacted foetal head, and/or had experienced it during their own labour, in Fife, United Kingdom. Data were transcribed and were analysed using template analysis. RESULTS Three main themes emerged through analysis: (i) current knowledge of impacted foetal head; (ii) current management of impacted foetal head; and (iii) experiences and outcomes of impacted foetal head. Each theme was made up of various initial codes when data were analysed inductively. Finally, each theme could be overlaid onto the three core principles of the Tydeman Tube: (1) to improve outcomes for mother and baby in the second stage of labour; (2) to reduce the risk of trauma to mother and baby in complicated births; and (3) to increase respectful care for women in labour; thus allowing for a neat analytic template. CONCLUSION A lack of consensus regarding definition, management, and training were highlighted by the midwives. Women anticipated caesarean birth in late labour as straightforward and were therefore unaware of this potential complication. Women and midwives would welcome any new device to facilitate delivery of the impacted foetal head (IFH) as long as it is fully evaluated prior to widespread introduction. Women were not averse to being part of this evaluation process.
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Affiliation(s)
- Annette L. Briley
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA 5042, Australia;
| | - Sergio A. Silverio
- Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London SE1 1UL, UK;
- School of Psychology, Faculty of Health, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Andrew H. Shennan
- Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London SE1 1UL, UK;
| | - Graham Tydeman
- Maternity Services, Victoria Hospital, NHS Fife, Kirkcaldy KY2 5AH, UK;
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Cornthwaite K, Bahl R, Winter C, Wright A, Kingdom J, Walker KF, Tydeman G, Briley A, Schmidt-Hansen M, Draycott T. Management of Impacted Fetal Head at Caesarean Birth: Scientific Impact Paper No. 73. BJOG 2023; 130:e40-e64. [PMID: 37303275 DOI: 10.1111/1471-0528.17534] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Over one-quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the caesarean birth, difficulty in delivery of the baby's head may result - this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stay. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned CBs (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. However, there is currently no consensus for how best to manage these births. This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the National Guideline Alliance.
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Cornthwaite K, Hewitt P, van der Scheer JW, Brown IAF, Burt J, Dufresne E, Dixon‐Woods M, Draycott T, Bahl R. Definition, management, and training in impacted fetal head at cesarean birth: a national survey of maternity professionals. Acta Obstet Gynecol Scand 2023; 102:1219-1226. [PMID: 37430482 PMCID: PMC10407013 DOI: 10.1111/aogs.14600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/05/2023] [Accepted: 05/10/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION This study assessed views, understanding and current practices of maternity professionals in relation to impacted fetal head at cesarean birth, with the aim of informing a standardized definition, clinical management approaches and training. MATERIAL AND METHODS We conducted a survey consultation including the range of maternity professionals who attend emergency cesarean births in the UK. Thiscovery, an online research and development platform, was used to ask closed-ended and free-text questions. Simple descriptive analysis was undertaken for closed-ended responses, and content analysis for categorization and counting of free-text responses. Main outcome measures included the count and percentage of participants selecting predefined options on clinical definition, multi-professional team approach, communication, clinical management and training. RESULTS In total, 419 professionals took part, including 144 midwives, 216 obstetricians and 59 other clinicians (eg anesthetists). We found high levels of agreement on the components of an impacted fetal head definition (79% of obstetricians) and the need for use of a multi-professional approach to management (95% of all participants). Over 70% of obstetricians deemed nine techniques acceptable for management of impacted fetal head, but some obstetricians also considered potentially unsafe practices appropriate. Access to professional training in management of impacted fetal head was highly variable, with over 80% of midwives reporting no training in vaginal disimpaction. CONCLUSIONS These findings demonstrate agreement on the components of a standardized definition for impacted fetal head, and a need and appetite for multi-professional training. These findings can inform a program of work to improve care, including use of structured management algorithms and simulation-based multi-professional training.
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Affiliation(s)
- Katie Cornthwaite
- Royal College of Obstetricians & GynaecologistsLondonUK
- Translational Health SciencesUniversity of BristolBristolUK
| | | | - Jan W. van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Imogen A. F. Brown
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | | | - Mary Dixon‐Woods
- THIS Institute (The Healthcare Improvement Studies Institute), School of Clinical MedicineUniversity of CambridgeCambridgeUK
| | - Tim Draycott
- Royal College of Obstetricians & GynaecologistsLondonUK
- North Bristol NHS TrustBristolUK
| | | | | | - Rachna Bahl
- Royal College of Obstetricians & GynaecologistsLondonUK
- University Hospitals Bristol and WestonBristolUK
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van der Scheer JW, Cornthwaite K, Hewitt P, Bahl R, Randall W, Powell A, Ansari A, Attal B, Willars J, Woodward M, Brown IAF, Olsson A, Richards N, Price E, Giusti A, Leeding J, Hinton L, Burt J, Dixon-Woods M, Maistrello G, Fahy N, Lyons O, Draycott T. Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot. BMJ Open Qual 2023; 12:e002340. [PMID: 37524515 PMCID: PMC10391817 DOI: 10.1136/bmjoq-2023-002340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/07/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK. OBJECTIVES To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams. METHODS The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups. RESULTS Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%-92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%-100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners. CONCLUSIONS The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.
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Affiliation(s)
- Jan W van der Scheer
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Katie Cornthwaite
- Royal College of Obstetricians and Gynaecologists, London, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | | | - Rachna Bahl
- Royal College of Obstetricians and Gynaecologists, London, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Alison Powell
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Akbar Ansari
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bothaina Attal
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Janet Willars
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matthew Woodward
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Imogen A F Brown
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Annabelle Olsson
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Natalie Richards
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Evleen Price
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Alessandra Giusti
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Joann Leeding
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | | | - Oscar Lyons
- RAND Europe, Cambridge, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim Draycott
- Royal College of Obstetricians and Gynaecologists, London, UK
- North Bristol NHS Trust, Westbury on Trym, UK
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Ammitzbøll ILA, Andersen BR, Lange KHW, Clausen T, Løkkegaard ECL. Response to the commentary "Anaesthesia for caesarean section and the miscredit of top-up epidurals". Eur J Obstet Gynecol Reprod Biol 2023; 286:147-148. [PMID: 37253648 DOI: 10.1016/j.ejogrb.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023]
Affiliation(s)
- I L A Ammitzbøll
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark.
| | - B R Andersen
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - K H W Lange
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - T Clausen
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
| | - E C L Løkkegaard
- Department of Obstetrics and Gynecology, North Zealand Hospital, Denmark; Department of Anesthesiology, Copenhagen University Hospital, North Zealand, Denmark; Department of Clinical Medicine, Health and Medical Sciences, University of Copenhagen, Denmark
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12
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Lear CA, Westgate JA, Bennet L, Ugwumadu A, Stone PR, Tournier A, Gunn AJ. Fetal defenses against intrapartum head compression-implications for intrapartum decelerations and hypoxic-ischemic injury. Am J Obstet Gynecol 2023; 228:S1117-S1128. [PMID: 34801443 DOI: 10.1016/j.ajog.2021.11.1352] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/05/2021] [Accepted: 11/14/2021] [Indexed: 01/27/2023]
Abstract
Uterine contractions during labor and engagement of the fetus in the birth canal can compress the fetal head. Its impact on the fetus is unclear and still controversial. In this integrative physiological review, we highlight evidence that decelerations are uncommonly associated with fetal head compression. Next, the fetus has an impressive ability to adapt to increased intracranial pressure through activation of the intracranial baroreflex, such that fetal cerebral perfusion is well-maintained during labor, except in the setting of prolonged systemic hypoxemia leading to secondary cardiovascular compromise. Thus, when it occurs, fetal head compression is not necessarily benign but does not seem to be a common contributor to intrapartum decelerations. Finally, the intracranial baroreflex and the peripheral chemoreflex (the response to acute hypoxemia) have overlapping efferent effects. We propose the hypothesis that these reflexes may work synergistically to promote fetal adaptation to labor.
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Affiliation(s)
- Christopher A Lear
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Jenny A Westgate
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand; Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Austin Ugwumadu
- Department of Obstetrics and Gynaecology, St. George's University of London, London, United Kingdom
| | - Peter R Stone
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Alexane Tournier
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Fetal Physiology and Neuroscience Group, Department of Physiology, The University of Auckland, Auckland, New Zealand; Department of Paediatrics, Starship Children's Hospital, Auckland, New Zealand.
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13
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Ammitzbøll ILA, Andersen BR, Lange KHW, Clausen T, Løkkegaard ECL. Risk factors for and consequences of difficult fetal extraction in emergency caesarean section. A retrospective registry-based cohort study. Eur J Obstet Gynecol Reprod Biol 2023; 283:74-80. [PMID: 36801595 DOI: 10.1016/j.ejogrb.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/17/2023]
Abstract
INTRODUCTION This study aimed to assess risk factors for difficult fetal extraction in emergency caesarean sections, focusing on top-up epidural anesthesia compared to spinal anesthesia. Additionally, this study addressed consequences of difficult fetal extraction on neonatal and maternal morbidity. MATERIAL AND METHODS This retrospective registry-based cohort study included 2,332 of 2,892 emergency caesarean sections performed with local anesthesia during 2010-2017. Main outcomes were analyzed by crude and multiple adjusted logistic regression providing odds ratios. RESULTS Difficult fetal extraction was found in 14.9% of emergency caesarean sections. Risk-factors for difficult fetal extraction included top-up epidural anesthesia (aOR:1.37[95 %CI 1.04-1.81]), high pre-pregnancy BMI (aOR:1.41[95 %CI 1.05-1.89]), deep fetal descent (ischial spine: aOR:2.53[95 %CI 1.89-3.39], pelvic floor: aOR:3.11[95 %CI 1.32-7.33]), and anterior placental position (aOR:1.37[95 %CI 1.06-1.77]). Difficult fetal extraction was associated with increased risk of low umbilical artery pH 7.00-7.09 (aOR:3.50[95 %CI 1.98-6.15]) pH ≤ 6.99 (aOR:4.20[95 %CI 1.61-10.91]), five-minute Apgar score ≤ 6 (aOR:3.41[95 %CI 1.49-7.83]) and maternal blood loss (501-1,000 ml: aOR:1.65[95 %CI 1.27-2.16], 1,001-1,500 ml: aOR:3.24[95 %CI 2.24-4.67], 1,501-2,000 ml: aOR:3.94[95 %CI 2.24-6.94] and ≥ 2001 ml: aOR:2.76[95 %CI 1.12-6.82]). CONCLUSION This study identified four risk factors for difficult fetal extraction in emergency caesarean section: top-up epidural anesthesia, high maternal BMI, deep fetal descent and anterior placental position. Additionally, difficult fetal extraction was associated with poor neonatal and maternal outcomes.
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Affiliation(s)
- I L A Ammitzbøll
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark.
| | - B R Andersen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - K H W Lange
- Department of Clinical Medicine, University of Copenhagen, Denmark; Department of Anesthesiology, Nordsjællands Hospital, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - T Clausen
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
| | - E C L Løkkegaard
- Department of Obstetrics and Gynecology, Nordsjællands Hospital, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark; Nordsjællands Hospital, 3400 Hillerød, Denmark
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14
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Walker KF, Mitchell EJ, Ayers S, Jones NW, Ogollah R, Wakefield N, Dorling J, Pallotti P, Pillai A, Tempest N, Plachcinski R, Bradshaw L, Knight M, Thornton JG. Feasibility of a RCT of techniques for managing an impacted fetal head during emergency caesarean section: the MIDAS scoping study. Health Technol Assess 2023; 27:1-87. [PMID: 37022927 DOI: 10.3310/kuyp6832] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Background Second-stage caesarean sections, of which there are around 34,000 per year in the UK, have greater maternal and perinatal morbidity than those in the first stage. The fetal head is often deeply impacted in the maternal pelvis, and extraction can be difficult. Numerous techniques are reported, but the superiority of one over another is contentious and there is no national guidance. Objective To determine the feasibility of a randomised trial of different techniques for managing an impacted fetal head during emergency caesarean. Design A scoping study with five work packages: (1) national surveys to determine current practice and acceptability of research in this area, and a qualitative study to determine acceptability to women who have experienced a second-stage caesarean; (2) a national prospective observational study to determine incidence and rate of complications; (3) a Delphi survey and consensus meeting on choice of techniques and outcomes for a trial; (4) the design of a trial; and (5) a national survey and qualitative study to determine acceptability of the proposed trial. Setting Secondary care. Participants Health-care professionals, pregnant women, women who have had a second-stage caesarean, and parents. Results Most (244/279, 87%) health-care professionals believe that a trial in this area would help guide their practice, and 90% (252/279) would be willing to participate in such a trial. Thirty-eight per cent (98/259) of parents reported that they would take part. Women varied in which technique they thought was most acceptable. Our observational study found that impacted head is common (occurring in 16% of second-stage caesareans) and leads to both maternal (41%) and neonatal (3.5%) complications. It is most often treated by an assistant pushing the head up vaginally. We designed a randomised clinical trial comparing the fetal pillow with the vaginal push technique. The vast majority of health-care professionals, 83% of midwives and 88% of obstetricians, would be willing to participate in the trial proposed, and 37% of parents reported that they would take part. Our qualitative study found that most participants thought the trial would be feasible and acceptable. Limitations Our survey is subject to the limitation that, although responses refer to contemporaneous real cases, they are self-reported by the surgeon and collected after the event. Willingness to participate in a hypothetical trial may not translate into recruitment to a real trial. Conclusions We proposed a trial to compare a new device, the fetal pillow, with a long-established procedure, the vaginal push technique. Such a trial would be widely supported by health-care professionals. We recommend that it be powered to test an effect on important short term maternal and baby outcomes which would require 754 participants per group. Despite the well-known difference between intent and action, this would be feasible within the UK. Future work We recommend a randomised controlled trial of two techniques for managing an impacted fetal head with an in-built internal pilot phase and alongside economic and qualitative substudies. Study registration This study is registered as Research Registry 4942. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kate F Walker
- Lifespan and Population Health Academic Unit, University of Nottingham, Nottingham, UK
| | - Eleanor J Mitchell
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Susan Ayers
- Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London
| | - Nia W Jones
- Lifespan and Population Health Academic Unit, University of Nottingham, Nottingham, UK
| | - Reuben Ogollah
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Natalie Wakefield
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Jon Dorling
- Neonatal Unit, Southampton General Hospital, University Hospital Southampton NHS Trust, Southampton, UK
| | - Phoebe Pallotti
- Department of Midwifery, University of Nottingham, Nottingham, UK
| | - Arani Pillai
- Department of Anaesthetics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nicola Tempest
- Department of Women's and Children's Health, Liverpool Women's NHS Foundation Trust, Liverpool, UK
| | | | - Lucy Bradshaw
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Jim G Thornton
- Lifespan and Population Health Academic Unit, University of Nottingham, Nottingham, UK
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15
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Gq Peak A, Barwise E, Walker KF. Techniques for managing an impacted fetal head at caesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol 2023; 281:12-22. [PMID: 36525940 DOI: 10.1016/j.ejogrb.2022.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 12/02/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
A complication arising at caesarean birth when the baby's head is deeply engaged in the pelvis and may be difficult to deliver, is known as an 'impacted fetal head'. This obstetric emergency occurs in 16% of second stage caesarean sections. Multiple techniques are described in the literature to manage the complication but there is no consensus regarding which technique results in the best maternal and neonatal outcomes. The objective of this review is to determine which technique for managing impacted fetal head at caesarean section has the best maternal and neonatal outcomes. A literature search of three electronic databases was conducted in November 2021. Studies directly comparing two methods for the management of impacted fetal head at caesarean section in the second stage were included. Systematic reviews, meta-analyses, case-control studies, and studies not fitting the search criteria were excluded. Data was extracted in Covidence and meta-analysis of the six most commonly reported outcomes was conducted using RevMan 5.4. In total, 16 studies (3344women) were included. 13 studies (2506women) compared the push method with reverse breech extraction. meta-analysis showed that risk of extension of the uterine incision, blood transfusion, bladder injury, postpartum haemorrhage, NICU admission and Apgar score <7 at 5 min were significantly higher with the push method compared with reverse breech extraction. Three studies (838women) compared the push method with Patwardhan's technique. meta-analysis of studies comparing the push method with Patwardhan's technique found no significant differences between the two groups in any of the six maternal or neonatal outcomes. Evidence derived from small, inadequately powered studies suggests reverse breech extraction is associated with better outcomes than the push method. The method which produces the best outcomes is still unknown as not all methods have been tested. Further high quality, adequately powered RCTs are warranted for definitive conclusions to be drawn and to ameliorate the paucity of evidence on how best to manage this complication.
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Affiliation(s)
- Amelia Gq Peak
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Elena Barwise
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
| | - Kate F Walker
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham, United Kingdom.
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16
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Chooi KY, Deussen AR, Louise J, Cash S, Dodd JM. Maternal and neonatal outcomes following the introduction of the Fetal Pillow at a tertiary maternity hospital: A retrospective cohort study. Aust N Z J Obstet Gynaecol 2022. [DOI: 10.1111/ajo.13635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Kathrina Y.L. Chooi
- Department of Obstetrics and Gynaecology, Women's and Babies' Division Women's and Children's Hospital Adelaide South Australia Australia
| | - Andrea R. Deussen
- Women's and Children's Health and The Robinson Research Institute The University of Adelaide Adelaide South Australia Australia
| | - Jennie Louise
- Women's and Children's Health and The Robinson Research Institute The University of Adelaide Adelaide South Australia Australia
| | - Sarah Cash
- Department of Obstetrics and Gynaecology, Women's and Babies' Division Women's and Children's Hospital Adelaide South Australia Australia
| | - Jodie M. Dodd
- Department of Obstetrics and Gynaecology, Women's and Babies' Division Women's and Children's Hospital Adelaide South Australia Australia
- Women's and Children's Health and The Robinson Research Institute The University of Adelaide Adelaide South Australia Australia
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17
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Cornthwaite K, Draycott T, Winter C, Lenguerrand E, Hewitt P, Bahl R. Validation of a novel birth simulator for impacted fetal head at cesarean section: An observational simulation study. Acta Obstet Gynecol Scand 2022; 102:43-50. [PMID: 36349412 PMCID: PMC9780722 DOI: 10.1111/aogs.14432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 07/08/2022] [Accepted: 07/16/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Impacted fetal head (IFH) is a challenging complication of cesarean section (CS) associated with significant morbidity. Training opportunities for IFH have been reported as inconsistent and inadequate. This study assessed the validity of a novel birth simulator for IFH at cesarean section. MATERIAL AND METHODS Obstetricians and midwives collaborated with model-making company, Limbs & Things (UK), to modify the original PROMPT Flex® simulator and develop a new "Enhanced CS Module" for IFH at cesarean section. Changes included addition of a retractable uterus and restricted pelvic inlet, and the fetal mannequin was modified to allow accurate limb articulation and flexion at the waist. Obstetricians and midwives from three maternity units in Southwest England were individually recorded, each undertaking three simulated scenarios of IFH at cesarean section. Obstetricians were asked to deliver the fetal head and midwives, to perform a vaginal push-up. Participants completed a questionnaire on realism (face validity) and usefulness for training (content validity) with five-point Likert scale responses. Construct validity was assessed by testing an a priori hypothesis that "experts" (consultant obstetricians with >7 years' experience) would be more likely to achieve delivery than "novices" (registrars with <7 years' experience). Performance variables were compared between groups using Chi-square and Mann-Whitney U-tests. RESULTS In all, 105 simulated scenarios were undertaken by 35 obstetricians and midwives. A range of techniques were employed to deliver the IFH including change of hand, vaginal disimpaction and reverse breech extraction. Overall, 86% (30/35) described the model as fairly (4)/very realistic (5) (median = 4, interquartile range [IQR] = 4-5). The model was considered fairly (4)/very useful (5) for training by 97% (34/35; median = 5; IQR = 5-5). Experts delivered the fetal head in all simulations (36/36) and novices delivered the head in 76.9% (30/39) (p = 0.002). Experts delivered the fetal head 58% quicker than novices (median = 66.8 s, IQR = 53-86 vs median = 104 s, IQR = 67.7-137). CONCLUSIONS This novel birth trainer realistically simulates IFH at cesarean section and allows rehearsal of all disimpaction techniques. It was reported to be very useful for training and distinguishes between novice and expert obstetricians. Techniques for IFH are difficult to learn experientially. Simulation is likely to provide an effective and safe form of training.
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Affiliation(s)
- Katie Cornthwaite
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK,Translational Health SciencesUniversity of BristolBristolUK
| | - Tim Draycott
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK
| | - Cathy Winter
- Women's Health DepartmentNorth Bristol NHS TrustBristolUK
| | | | - Pauline Hewitt
- Women's Heatlh DepartmentGloucestershire Royal Hospitals NHS Foundation TrustGloucesterUK
| | - Rachna Bahl
- Women's Health DepartmentUniversity Hospital Bristol Foundation NHS TrustBristolUK
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18
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Wyn Jones N, Mitchell EJ, Wakefield N, Knight M, Dorling J, Thornton JG, Walker KF. Impacted fetal head during second stage Caesarean birth: A prospective observational study. Eur J Obstet Gynecol Reprod Biol 2022; 272:77-81. [PMID: 35290876 DOI: 10.1016/j.ejogrb.2022.03.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine the incidence of, and complication rates from, impacted fetal head at full dilatation Caesarean birth in the UK, and record what techniques were used. DESIGN Prospective observational study using the UK Obstetric Surveillance System (UKOSS). SETTING 159 (82%) of the 194 UK hospitals with obstetric units. POPULATION All women who underwent second stage Caesarean birth in the UK between 1st March and 31st August 2019. Further information was collected on cases where a dis-impaction technique was used, or the operating surgeon experienced 'difficulty' in delivering the head. METHODS Prospective observational study. MAIN OUTCOME MEASURES Technique(s) used, maternal and neonatal outcomes. RESULTS 3,518 s stage Caesarean births reported. The surgeon used a dis-impaction technique or reported 'difficulty' in 564 (16%) of these. The most common dis-impaction techniques used were manual elevation of the head by an assistant through the vagina (n = 235) and a fetal "pillow" (n = 176). Thirteen babies (2%) died or sustained severe injury. Four babies died (two directly attributable to the impacted fetal head). CONCLUSIONS Difficulty with delivery of the fetal head and the use of dis-impaction techniques during second stage Caesarean sections are common but there is no consensus as to the best method to achieve delivery and in what order.
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Affiliation(s)
- Nia Wyn Jones
- Clinical Associate Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Eleanor J Mitchell
- Assistant Professor of Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Natalie Wakefield
- Trial Manager, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | - Marian Knight
- Professor of Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, UK
| | - Jon Dorling
- Consultant Neonatologist and Professor of Paediatrics, Neonatal Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, UK
| | - Jim G Thornton
- Emeritus Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK
| | - Kate F Walker
- Clinical Associate Professor of Obstetrics, Department of Obstetrics and Gynaecology, Division of Population and Lifespan Sciences, University of Nottingham, UK.
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