An in depth look at the challenges presented by Caesarean Section and Impacted Fetal Head

Incidents of babies suffering brain injuries associated with impacted fetal head (IFH) at caesarean section have been rising in recent years with a corresponding increase in claims for medical negligence. Despite this there is no consensus among the medical community about how to manage these births.

According to a recent paper called ‘Management of Impacted Fetal Head at Cesearean Birth (Scientific Impact Paper73)', this has resulted in a lack of confidence among maternity staff, as well as variations in practice between different hospitals and, in some instances, avoidable harm. Here I look in more detail at IFH.

Numbers of affected births

More than one quarter of women in the UK give birth by caesarean section. Many caesareans are planned but some are required as an emergency where a birth has not progressed as expected. Scientific impact paper 73 sets out that more than one in 20 caesareans take place towards the end of labour when a woman’s cervix is fully dilated. In these circumstances, and where labour has been prolonged, the baby’s head can become lodged in the mother’s pelvis and require disimpacting. This can create considerable difficulty with delivery and is a medical emergency. However, there is no clear definition for IFH which means that its recognition and documentation can differ from hospital to hospital.

Complications

The complications for the mother that can ensue include tears to the uterus and serious bleeding. For the baby, there is an increased risk of damage to the head and face, decreased oxygen to the brain and nerve injuries. IFH can also lead to death.

The latest UK studies suggest that IFH may complicate as many as one in ten unplanned caesareans - 1.5 percent of all births. Two in 100 babies affected by IFH die or are seriously injured and there has been a marked increase in brain injuries.

What is causing the increase?

It is thought this could be partly due to a rise in the number of caesarean sections. It is also suggested that increased use of anaesthesia and rising rates of maternal obesity may be exacerbating the problem. IFH does not only occur in late labour, it can also happen in the first stage. Nonetheless, it is more likely to be encountered in cases of prolonged labour.

No guidelines or training?

As matters stand, according to the Royal College of Midwives (RCM), there is no evidence-based training around these incidents and no guidelines as to how to manage such technically challenging births. However, the Royal College of Obstetricians and Gynaecologists (RCOG) as well as the RCM want to build a consensus for best practice. Prototype tools to support management and training have been developed which they hope will help prevent injuries in childbirth.

Scientific paper 73 provides a review of the current evidence regarding prevention and management of IFH and sets out different possible techniques and approaches to help deliver a baby’s head. Techniques discussed include manual disimpaction (the push technique), use of a fetal pillow to elevate the head, and reverse breech extraction.

As well as discussing various disimpaction techniques, the paper sets out the importance of a multidisciplinary approach and the necessity of being prepared to encounter difficulties at all unplanned caesarean births. The maternity team should be alerted before the operation if there is any suspicion of IFH and a senior obstetrician informed. Further details are given surrounding the roles that those in theatre should take and the preparatory steps that should be addressed including the height of the operating table.

Problems with documentation

The paper also reveals that techniques for disimpaction are often poorly documented. More generally, I often come across issues with documentation when dealing with claims for clinical negligence.

Differences in approach?

Surprisingly, the paper highlights emerging evidence that less experienced obstetricians are more likely to diagnose an IFA and employ more advanced manoeuvres to disimpact the fetal head. Further research is needed in this area but this trend could reflect differences in practice between generations of practitioners.

Going forward

Scientific impact paper 73 and the guidance for practitioners therein is a very welcome step forward. However, evidently more is needed to create a universally accepted definition of the condition, to provide clear national guidelines and to develop a standardised multi professional training programme.

Medical Negligence Claims

At Kingsley Napley we specialise in birth injury claims and have very significant experience in this area, obtaining regular multi million pound awards for injured children. We are aware of the complexities surrounding IFH.

When bringing a claim, it must be shown that the treatment provided was below a reasonable standard and this is usually judged by whether or not a reasonable body of medical practitioners in that field (i.e. obstetricians or midwives) would have acted in a similar way. It then has to be shown that, as a result of any failings in treatment, an injury was suffered.

As a medical negligence lawyer, I welcome guidelines which help to bring more clarity as to whether the standard of care in a particular case is reasonable. Where there is no consensus on correct practice, there are obvious challenges.

FURTHER INFORMATION

If you want to speak to one of our specialist solicitors, please do not hesitate to contact us, we offer a free initial consultation and can visit you at home or in hospital.

You may be interested in the information on our birth injury and Early Notification Scheme pages.

About the author

Aideen McGarry is a Senior Associate in the Clinical Negligence and Personal Injury Department. Aideen has experience working on high-value clinical negligence and personal injury claims.