Outcomes of second stage cesarean section following the use of a fetal head elevation device: A systematic review and meta-analysis

Management of impacted fetal head at cesarean birth: A systematic review and meta-analysis

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.

Management of impacted fetal head at cesarean delivery

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.

Management of Impacted Fetal Head at Caesarean Birth: Scientific Impact Paper No. 73

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.

Validation of a novel birth simulator for impacted fetal head at cesarean section: An observational simulation study

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.

Physical exercise and its associated factors among Ethiopian pregnant women: a cross-sectional study based on the theory of planned behavior

Introduction

Women in Ethiopia prefer sedentary behavior and are physically inactive during pregnancy; this increases the risks of pregnancy-related complications. Therefore, this study aimed to assess physical exercise and its associated factors among pregnant women attending Antenatal Care at Debermarkose Referral Hospital, Northwest Ethiopia: using the theory of planned behavior.

Methods

An institution-based cross-sectional study was conducted from 23rd February to 10th June, 2020. A systematic random sampling technique was used to select 333 study participants. Data were collected with face-to-face interviews using a pretested structured questionnaire. Epi-info and STATA version 14.0 were used for data entry and analysis respectively. Multivariable linear regression analysis was done to identify the association between dependent and independent factors, and p < 0.05 was used as a cutoff to determine statistical significance at multivariable logistics regressions.

Result

A total of 333 pregnant women were participated in this study with response rate of 98%. The proportion of variance (R²) in intention accounted for the factors was 0.79. The magnitude of intention to do physical exercise during the current pregnancy was 3.8 ± 2. primary level of education (β = 0.43; 95% CI 0.25, 0.61), 2nd trimester gestational age (β = 0.19; 95% CI 0.04, 0.33), 3rd trimester gestational age (β = 0.17; 95% CI 0.02, 0.32), Attitude (β = 0.34; 95% CI 0.19, 0.49), subjective norm (β = 0.12; 95% CI 0.01, 0.23) and perceived behavioral control (β = 0.45; 95% CI 0.33, 0.57) were significantly associated with pregnant womens’ intention to do physical exercise during pregnancy period.

Conclusion and recommendations

This study provided that the theory of planned behavior could be successfully applied to identify the factors related to the intention to do physical exercise during pregnancy The program designers who work on pregnancy better consider providing Information education and communication to change the attitude, work on influencing significant individuals and barriers and enabling factors.

Duration of the second stage of labour and risk of subsequent spontaneous preterm birth

OBJECTIVES

To determine the risk of spontaneous preterm birth (sPTB) associated with the length of second stage of labour in the first term delivery.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

POPULATION

Women with first two consecutive singleton births and the first birth at term. Those who did not reach the second stage of labour in the first delivery were excluded.

METHODS

Charts from 2007 to 2019 were reviewed.

MAIN OUTCOME MEASURES

Rate of sPTB (<37 weeks of gestation) in the second delivery.

RESULTS

Of 13 958 women who met study inclusion criteria, 1464 (10.5%) parturients had a prolonged second stage (≥180 min) in their first term delivery. The rate of sPTB in the second delivery was similar in those with and without a prolonged second stage in first delivery (2.8% versus 2.8%; adjusted odds ratio [aOR] 1.35, 95% CI 0.96-1.90). After adjustment for mode of delivery, prolonged second stage was also not associated with subsequent sPTB in those who delivered by spontaneous and operative vaginal delivery. Those delivered by second-stage caesarean section in the first delivery had a higher risk of sPTB in the second delivery (25/526, 4.8%; aOR 2.66, 95% CI 1.71-4.12; p < 0.001), with a more pronounced risk in those with second-stage caesarean following a prolonged second stage of labour (15/259, 5.8%; aOR 3.40, 95% CI 1.94-5.94; p < 0.001).

CONCLUSION

Second-stage duration in a first term vaginal delivery is not associated with subsequent sPTB. The risk of sPTB is increased following second-stage caesarean section, particularly if performed after a prolonged second stage.

Current Resources for Evidence-Based Practice, November 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of autonomy and respect in maternity care and commentaries on reviews focused on whether to induce women who present with mild preeclampsia in the late preterm period and the extent to which urinary incontinence symptoms prevent women from participating in exercise. It also includes a brief update about the USPSTF guidelines on screening for gestational diabetes.

Current Resources for Evidence-Based Practice, September 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes an assessment of safety of birth centers in the United States and commentaries on reviews focused on aspirin prophylaxis in pregnancy and the new gestational weight gain evidence summary from the United States Preventive Services Task Force.