More needs to be done to avoid, and treat, impacted fetal head

The Early Notification Scheme (ENS) is a national programme for the early reporting of babies born with a severe brain injury following delivery. The most recent ENS progress report highlights that difficult delivery of the fetal head/impacted fetal head at caesarean section is an emerging problem in the UK, affecting an astonishing 9% of cases reported to them. I wanted to find out why.

What causes impacted fetal head?

Difficult delivery of the fetal head during a caesarean section may arise when the baby’s head becomes impacted in the maternal pelvis during the course of labour. Strong uterine contractions can lodge the baby’s head firmly in the pelvis, making extraction of the head during a caesarean delivery extremely difficult.

Impacted fetal head appears to be more common when a decision is made to deliver by caesarean section at a later stage of labour. Therefore extraction of the head may be more difficult in situations where there has been a failed attempt to deliver the baby by instrumental delivery or a failed induction of labour.

A difficult extraction of the head during a caesarean section can lead to complications for both the mother and the baby. This may include a mother experiencing severe bleeding or injury to the surrounding tissues. However for a child this may result in brain injury either as a result of a shortage of oxygen during the prolonged delivery or as a result of direct trauma to the head.

Why are cases of impacted fetal head on the rise?

There are a number of theories in circulation, aiming to explain why impacted fetal head is on the rise. They include:

• increasing rates of induction of labour;
• changes in how deliveries are managed;
• an increase in caesarean sections being performed at a late stage of labour, once the mother is more fully dilated; and
• a lack of consistent training and management protocols for impacted fetal head.

A recent study looking at the incidence of impacted fetal head at caesarean section revealed that impacted fetal head is most commonly encountered when cervical dilation was greater than eight centimetres.

A lack of consistent training and management protocols for impacted fetal head could also be an issue. A survey led by the obstetric team at Southmead Hospital in Bristol revealed that although 98% of UK obstetricians had encountered impacted fetal head, but over 10% of them had not received any training on how to address it.

The ENS report recommends that further research is required to understand the cause of impacted fetal head/difficult delivery of the fetal head at caesarean section and to develop standardised management of the situation.

Our experience of impacted fetal head

At RWK Goodman, we support children affected by difficult deliveries. An injury caused by a difficult caesarean section can be extremely varied. From skull fractures to widespread brain damage, we work with families helping them to navigate the legal process of pursuing a claim for compensation.

We (at the time of writing) represent a little girl who was delivered by emergency caesarean section following induction of her mother’s labour. The caesarean section was required because the heart rate monitor was showing that the baby was in distress.

The delivery of the baby’s head was difficult and she was born in poor condition having suffered from a shortage of oxygen and a skull fracture and bleed on the brain. This little girl has done extremely well but requires additional care, therapies and equipment to maximise her quality of life, all of which can be achieved through the compensation that she receives on an ongoing basis.

This case shows that a difficult delivery can have implications for the rest of a child’s life. It is therefore my sincere hope that the recent drive to improve the standards of training and management of impacted fetal head will make deliveries increasingly safer.