Definition, management, and training in impacted fetal head at cesarean birth: a national survey of maternity professionals

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.


| INTRODUC TI ON
Maternity professionals increasingly encounter impacted fetal head (IFH) at emergency cesarean births. Recent UK studies estimate that IFH may complicate 10% of cesarean births, or 1.5% of all births. 1,2 IFH is technically challenging and is associated with significant risks to mother and baby. 1,3,4 Difficulty in disimpacting the fetal head can result in trauma to the uterus and bladder, postpartum hemorrhage and longer hospital stay. 1,3,4 Babies are at increased risk of complications including skull fracture, intracranial hemorrhage, head and face trauma, low oxygen levels, admission to the neonatal intensive care unit and even death. 1,[3][4][5] Reports of perinatal brain injury associated with IFH have risen, resulting in coronial enquiries, and increased litigation nationally and internationally. [5][6][7][8][9] The NHS Resolution Early Notification Scheme identified IFH as a contributory factor in nearly 10% of potentially the most expensive UK maternity claims in 2018, making it twice as common as claims relating to cases of shoulder dystocia. 9 A range of techniques can be employed to manage IFH, 3,[10][11][12][13][14][15] but there is no international consensus, beyond national committee opinions, 16 on which are safest and most effective. Recent surveys of maternity professionals in the UK indicate a paucity of training, lack of confidence and under-use of techniques that may be needed. 17,18 A standardized definition of IFH and an agreed approach to anticipation, communication and step-wise management of IFH at cesarean birth have been lacking. 9,18 These gaps have likely contributed to variable practice and potentially harmful care in some circumstances. 18 An exploration of the views of maternity professionals is an essential first step to improving care, training and research. We therefore undertook a survey of UK maternity professionals to assess their views, understanding and current practices in relation to IFH at cesarean birth, with the aim of informing the development of a standardized definition, clinical management approach and training.

| MATERIAL AND ME THODS
The survey was undertaken using Thiscovery (https://www.thisc overy.org/about), a secure online collaboration platform. It was targeted at qualified healthcare professionals currently providing care, or working in policy, research or other contexts relevant to maternity in the UK.
Participants were recruited from: Thiscovery subscribers who had previously signed up and consented to take part in activities relevant to maternity care; those who responded to targeted in-  18 We undertook simple descriptive analysis of questions with closed-ended responses. Count and percentages were calculated using R statistical software and Microsoft Excel for the total group and for professional subgroups (midwives, trainee/registrar/specialty obstetricians, consultant obstetricians).
Analysis of free-text entries was based on qualitative content analysis, with a focus on manifest content of categories. [19][20][21][22] First, clinicians (KC, PH, TD, RB) and analysts (JWvdS, IAFB, MDW) generated six categories based on the topics and questions of the survey.
Secondly, an analyst (IAFB) coded all free-text entries to one of the six categories, verified by another analyst (JWvdS). If a participant's free-text entry included more than one suggestion or comment, the entry was split, and coded as two or more separate responses.
Thirdly, a clinician (PH) and two analysts (IAFB and JWvdS) generated subcategories "bottom-up" (ie data-driven) based on participant responses. The last step was an analyst (IAFB) counting the number of responses and the number of participants providing those responses, within categories and subcategories. Another analyst (JWvdS) verified these counts. Analyses were restricted to data of K E Y W O R D S brain injury, cesarean birth, disimpaction, fetal pillow®, impacted fetal head, maternity, online, survey, training, vaginal push-up

Key message
This survey offers the foundation for the first consensusbased, standardized definition for impacted fetal head at cesarean birth. It provides insights into the usefulness of non-technical skills for managing impacted fetal head, demonstrates appetite for training across the multiprofessional team, and can inform a program of work to improve care.
participants who completed all closed-ended questions (completecase analysis excluding incomplete data of 38 participants).

| Ethics statement
The study received ethical approval on October 25, 2021 from the University of Cambridge Psychology Research Ethics Committee (PRE.2021.089). All participants provided online consent before starting the survey.

| RE SULTS
A total of 419 participants consented to take part and completed all closed-ended questions, including 144 midwives, 216 obstetricians and 59 other clinicians (Table 1), with participation spanning all regions of the UK (Table S1).

| Definition
When asked to select one or more components for a clinical definition, 79% (n = 171) of obstetricians preferred a definition including "additional maneuvres and/or tocolysis to disimpact and deliver the fetal head" ( Table 2). About a third also preferred specifically referring to the delivering hand (ie difficulty or inability to get the usual delivering hand or either hand below the fetal head), with one-quarter also preferring reference to "deeply engaged in the pelvis". The 17 free-text responses on this topic provided insight into why only about a third of participants selected a definition of IFH that incorporates the difficulty or inability of getting a hand below the fetal head to deliver it.
"I have found that in a recent case of impacted fetal head that I managed, I could get my hand below the head but it was wedged such that it could not be flexed or elevated." [Trainee/registrar/specialty obstetrician] One participant explained why 'deeply engaged in the pelvis' might not be appropriate for a definition of IFH, since "some deeply engaged heads can be easily lifted from the pelvis". [Consultant obstetrician].

| Multi-professional approach
Virtually all participants (95%, n = 398) agreed or strongly agreed that management of IFH at cesarean birth requires a multi-professional approach. Over 80% of participants indicated that midwives, trainee obstetricians, anesthetists, neonatologists, operating department practitioners and/or theater nurses would typically be present in theater for an emergency cesarean birth (Table S2). Only 38% (n = 157) indicated that consultant obstetricians would typically be present.

| Communication
To communicate an IFH emergency with other team members, over half of participants preferred using the declaration "This is an impacted fetal head", whereas few or no participants preferred "The head is stuck" or "wedged" (Table 3)

| Anticipation and management
Midwives and obstetricians largely agreed on level of suspicion of encountering IFH at cesarean birth in four given scenarios (Table 4).
Midwives and obstetricians were least certain whether they should suspect IFH at cesarean birth with lack of progress in labor at 5 cm even with signs of obstruction in the form of significant caput and molding.
Over 70% of obstetricians indicated they found the following techniques and adjunctive measures acceptable (ie appropriate, safe and effective) for managing IFH prior to or at cesarean birth: change of operator, manual cephalic extraction (ie abdominal cephalic TA B L E 1 Professional roles of survey participants (N = 419).

Phrase to communicate IFH to team n (%)
"This is an impacted fetal head" 232 (55) "I am having difficulty delivering the head" 103 (25) "This is a deeply engaged fetal head" 44 (11) "I am unable to deliver the head" 28 (7) "The head is stuck" 5 (1) "The head is wedged" 0 (0) None, there is no need to declare this emergency 0 (0) IFH at cesarean birth is a challenging, high-risk obstetric emergency with a relatively high incidence, 1,2,23 yet it has escaped consensual definition to date. Our survey has identified agreement on relevant defining components, based on selection of one or more previously identified definitional components, 18 supplemented by free-text responses. This leads us to suggest a standard pragmatic definition for potential use in practice, training, audit and research: A cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvres and/or tocolysis are required to disimpact and deliver the fetal head.
We also found appetite for consistent use of language during clinical scenarios involving IFH. This approach is supported by evidence from other obstetric emergencies, such as shoulder dystocia, showing that clearly and calmly declaring the emergency using unambiguous terminology facilitates teamworking, communication and management. 24 Our survey suggests a preference for the declaration "This is an impacted fetal head". Very few or no participants chose more vernacular phrases ("The head is wedged", "The head is stuck"), perhaps because these might be more alarming for the person in labor. Free-text responses also emphasized the need to consider communication with the woman and birth partner as part of the IFH management approach.
Also important is awareness of the likelihood of IFH and the circumstances under which it can occur. 9 Most midwives and obstetricians correctly classified scenarios with increased risk (unsuccessful assisted vaginal birth and deep transverse arrest) but there appeared to be less awareness that IFH is not confined to cesarean birth at full cervical dilation. 1,2 Given emerging evidence that IFH may be as common in cesarean birth performed prior to full cervical dilation, 1,2 maternity professionals should be prepared to encounter an IFH at all emergency cesarean births, and be trained accordingly.
The right skills and interventions are needed to manage this emergency, 18  inal disimpaction indicate it is imperative that a whole hand is used to cup the baby's head in order to flex and elevate it, while avoiding focal pressure points on the fetal skull. 8,10,11,28 This is easier to perform if it is possible to provide adequate vaginal access through flexion and abduction of both of the woman's legs. 10,11,28 Safe and effective vaginal disimpaction depends on skill, knowledge and manual dexterity, but does not appear to be consistently or routinely taught, 18  Other strengths of the study include a multi-disciplinary approach used in devising the survey, the inclusive methods used for conducting the study, and independent analysis of the data by health services analysts to minimize clinical bias.
The sample represents a relatively small proportion of the population of maternity professionals in the UK. Notwithstanding, the wide participation of various professionals across the UK and alignment of our findings with previous reports offers confidence that similar results would be found in a larger sample. 17,18,24 Our use of complete-case analysis may have introduced some biased estimates if there were differential responses to particular questionnaire items. 43 Finally, the sample size precluded statistical comparison of subgroups, limiting interpretation of differences between professional groups.

| CON CLUS ION
There is high agreement among UK maternity professionals on com-