Caesarean birth injury rates have risen for mums and babies but training and a new device could change that

Newswise — Approximately 34% of Australian women undergo a cesarean delivery, and a notable portion of these occur during advanced stages of labor when the baby's head is deeply engaged in the mother's pelvis, leading to potential complications in childbirth and endangering the health of both the mother and the baby.

Roughly 10% of emergency cesarean births (CB) involve a condition known as impacted fetal head (IFH), where the baby's head becomes wedged, posing challenges for doctors to maneuver their hand beneath the head for delivery, resulting in prolonged delivery durations.

New data indicates that although most infants born after experiencing impacted fetal head (IFH) only sustain minor harm, a distressing 2% of these babies face severe injuries or even death, with long-lasting implications. According to the NHS Resolution report in the UK, a notable 9% of preventable brain injuries during birth are attributed to impacted fetal head (IFH).

Adverse effects for the mother encompass heightened blood loss, an elevated likelihood of infection, damage to the bladder and urinary tract, the need for uterine tear repair that can lead to complications in future pregnancies, and in severe cases, the possibility of a hysterectomy. Conversely, complications for the baby involve head and facial lacerations, bruising, skull fractures, and hemorrhages. Additionally, there have been documented incidents of eye injuries.

The Royal College of Obstetricians & Gynaecologists in the UK, along with Professor Annette Briley from Flinders University, published a Scientific Impact Paper in BJOG: an International Journal of Obstetrics & Gynaecology, highlighting a noteworthy surge in cases of impacted fetal head (IFH) injuries in recent times. The study reveals that maternity staff employ diverse strategies, lacking a unanimous agreement on the definition or standardized training for managing IFH and facilitating delivery during cesarean births (CB).

Various approaches are utilized to manage this obstetric emergency. These include having an assistant apply pressure to push the baby's head upwards during birth, opting for a feet-first delivery, employing an inflatable balloon device known as the Fetal Pillow, specifically designed to elevate the baby's head, and administering medication to relax the mother's womb, facilitating the delivery process.

However, this scientific impact paper reviewed the available evidence, concluding there is currently no consensus on the best approach for these risky cases.

Numerous maneuvers and certain devices have been introduced to assist in the delivery of babies in such situations. However, thus far, there is a lack of consensus regarding the most effective approach for the well-being of both mothers and babies, as well as the specific training required for healthcare staff handling this emergency scenario.

In the majority of cases, an assistant is typically requested to provide upward pressure from below during delivery. However, certain evidence indicates that reverse breech extraction may be linked to improved outcomes. Unfortunately, a UK-wide survey revealed that over half of obstetric registrars lacked confidence in performing reverse breech extraction, and less than 10% were familiar with the Patwardhan technique.

Dr. Annette Briley, a research co-author and midwife at Flinders University, explains that the objective of the scientific impact paper was to thoroughly examine the existing evidence concerning various maneuvers and devices employed in the management of impacted fetal head (IFH). The paper's findings were integrated with those of a systematic review conducted by the National Guideline Alliance (UK).

The researchers say key steps need to be taken to improve standards:

• High-quality adequately powered RCTs comparing techniques to manage and prevent IFH are required. (Those currently available have significant weaknesses.)
•   A universally accepted definition of IFH would facilitate future research and education.
•   Women and their partners need to inform research around the language and management of IFH.
•   The development and implementation of an evidence-based multi-professional educational package would lead to consistent management of this obstetric emergency.
•    More research is required around the efficacy and cost-effectiveness of the Fetal Pillow

Dr. Briley emphasizes that the data unequivocally demonstrates a notable increase in late labor cesarean sections and the accompanying occurrences of IFH-related injuries in recent times. This highlights the need for additional education and training to establish a standardized approach in managing this obstetric emergency.

"Our review of the current evidence pertaining to the identification, prevention, and management of impacted fetal head (IFH) during childbirth has allowed us to offer guidance and recommendations that aim to enhance outcomes for both mothers and babies in cases of this potentially serious complication. It is crucial for clinicians to rely on the most reliable evidence when providing care for women and babies, including the utilization of optimal techniques to mitigate the potentially devastating complications associated with IFH."

Dr. Briley is involved in a research team that is currently working on the development and evaluation of the Tydeman tube. This innovative solution involves a single-use, hollow silicone tube that is inserted to elevate the baby's head during childbirth. The tube is designed to minimize the applied pressure on the head and reduce any suction effect once access has been established. The aim of this development is to provide a more effective and safer method for managing impacted fetal head (IFH) during delivery.

Due to the limited clinical utilization of the Tydeman Tube, additional research in a clinical setting is necessary to evaluate its effectiveness and safety. This research should involve a comparison with appropriately trained and executed manual disimpaction techniques. Further investigation is required before the Tydeman Tube can be considered for widespread use in managing impacted fetal head (IFH) during childbirth.