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

This Scientific Impact Paper reviews the current evidence on the prediction, prevention and management of impacted fetal head at caesarean birth.

Plain-language summary

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.

Update June 2023:

On 15 June 2023, the International Journal of Gynecology & Obstetrics retracted the following article: Seal SL, Dey A, Barman SC, Kamilya G, Mukherji J, Onwude JL. Randomized controlled trial of elevation of the fetal head with a fetal pillow during cesarean delivery at full cervical dilatation. Int J Gynecol Obstet 2016;133:178–182.

The retraction cites concerns regarding discrepancies between the retrospective trial registration and the published article. In light of this, updated meta-analysis of studies relating to Fetal Pillow excluding this paper is currently being undertaken by the developers.

Consequently, the College advises caution when reviewing the data regarding the benefits of Fetal Pillow in relation to both maternal and neonatal outcomes.

The observations regarding Fetal Pillow in Scientific Impact Paper No. 73 Management of Impacted Fetal Head at Caesarean Birth will be revised in line with the results of the updated systematic review and meta-analysis. The revised SIP and updated systematic review will be published in due course. All other recommendations about practice are unchanged by this retraction.

COVID disclaimer: This Scientific Impact Paper was developed prior to the emergence of the COVID-19 coronavirus.

Version history: This is the first edition of this paper.

Please note that the Scientific Advisory Committee regularly assesses the need to update.

Further information on this review is available on request.

Developer declaration of interests: Available upon request.

Published: 12 June 2023