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. 2024 Mar;230(3 Suppl):S980–S987. doi: 10.1016/j.ajog.2022.10.037

Management of impacted fetal head at cesarean delivery

Katie R Cornthwaite a,∗, Rachna Bahl b, Katherine Lattey c, Tim Draycott d
PMCID: PMC11000504  PMID: 38462267

Abstract

Globally, more than 1 in 5 women give birth by cesarean delivery, and at least 5% of these births are at full cervical dilatation. In these circumstances, and when labor has been prolonged in the first stage of labor, the fetal head can become low and wedged deep in the woman’s pelvis, making it difficult to deliver the baby. This emergency is known as impacted fetal head. These are technically challenging births associated with serious risks to both the woman and the baby. The difficulty in disimpacting the fetal head increases maternal risks of hemorrhage and injury to adjacent organs and may have long-term consequences for future pregnancies. In addition, there can be associated neonatal consequences, such as skull fractures, brain hemorrhage, hypoxic brain injury, and, rarely, perinatal death. Globally, maternity staff are increasingly encountering this emergency, with studies in the United Kingdom suggesting that impacted fetal head may complicate as many as 1 in 10 emergency cesarean deliveries. Moreover, there has been a sharp increase in reports of perinatal brain injuries associated with impaction of the fetal head at cesarean delivery. When an impacted fetal head occurs, the maternity team can employ a range of approaches to help deliver the fetal head, including an assistant (another obstetrician or midwife) pushing the head up from the vagina, delivering the baby feet first (reverse breech extraction), administering tocolysis to relax the uterus, and using a balloon cephalic elevation device (Fetal Pillow) to elevate the baby’s head. However, there is currently no consensus on how best to manage these births, resulting in a lack of confidence among maternity staff, variable practice, and potentially avoidable harm in some circumstances. This article examined the evidence for the prevention and management of this critical obstetrical emergency and outlined recommendations for best practices and training.

Key words: cesarean delivery, Fetal Pillow, impacted fetal head, multiprofessional, simulation training

Introduction

Impacted fetal head at cesarean delivery (CD) represents a major clinical concern in current obstetrical care. This unpredictable, high-risk obstetrical emergency is being increasingly reported by maternity care professionals internationally.1,2 Addressing the challenges of impacted fetal head at CD has become more urgent with increasing reports of associated perinatal brain injury, coronial inquiries, and increased litigation.3, 4, 5, 6 However, impacted fetal head remains an unclear and poorly understood condition. This article quantified the extent of the problem, reviewed the current evidence regarding the possible prevention and management, and outlined the latest innovations and recommendations for training.

Definition

There is no clear, consensus definition for impacted fetal head in the published literature. However, most obstetricians responding to a national survey on impacted fetal head at CD would use “the need for additional maneuvers” as a diagnostic criterion.7 Therefore, impacted fetal head can be described as “a cesarean birth where the obstetrician is unable to deliver the fetal head with their usual delivering hand, and additional maneuvers and/or tocolysis are required to disimpact and deliver the head.”

Incidence

There are limited international data estimating the incidence of impacted fetal head, at least partly related to issues with definition.8 However, recent studies in the United Kingdom estimate that impacted fetal head may complicate as many as 1 in 10 emergency CDs (1.5% of all births)2,9 and 16.0% of second-stage CDs.1 The apparent rise in cases of impacted fetal head may, in part, be explained by an increasing rate of CD10,11 and a rise in CD at full dilatation (CDFD).12,13 Worldwide, it is estimated that 21% of women give birth via CD, with rates closer to 30% in more developed countries.11 At least 5% of these CDs occur at full cervical dilatation.2,12, 13, 14

Reduced skill and confidence in the use of rotational and midcavity forceps births and a resulting decline in assisted vaginal birth (AVB) have been proposed as contributory factors.15, 16, 17 Increased use of regional analgesia and rising rates of maternal obesity have also been implicated.18 However, impacted fetal head is a heterogeneous condition, and increased rates of second-stage CD alone do not fully account for the rise in cases and associated injuries.2,6

Complications

Impaction of the fetal head can result in a lack of space between the fetal head and maternal pubic symphysis, making it difficult for the obstetrician to get below the fetal head to disimpact it.4,19 Such difficulties, combined with a stretched and edematous lower segment, increase the risk of unintentional extension of the uterine incision, hemorrhage, bladder and ureteric injuries, and long-term consequences for women in future pregnancies.18,20,21 Attempting to deliver the fetal head during a uterine contraction can further exacerbate problems elevating the head to the uterine incision.22

Problems delivering the head can delay the birth of an already compromised fetus and contribute to hypoxic-ischemic encephalopathy.20,23 Excessive force during attempts to disimpact the fetal head may also cause birth trauma, such as skull fractures and subgaleal and intracranial hemorrhage, resulting in severe neonatal morbidity and, rarely, perinatal death.3,4,20,23 There has been an associated sharp increase in litigation internationally, and in the United Kingdom, impacted fetal head was identified as a contributory factor in nearly 10% of the most expensive National Health Service maternity claims.4, 5, 6,24

Risk factors

Most studies characterizing the risk factors for impacted fetal head have used second-stage CD as a surrogate, making it difficult to separate the risks related to impacted fetal head from the general risks of CDFD.2 Full cervical dilatation is a significant risk factor: impacted fetal head is estimated to complicate approximately 1 in 3 second-stage CDs, and this risk is doubled where AVB has been unsuccessfully attempted.2 However, impacted fetal head is not confined to second-stage CD.9,25 A recent retrospective cohort study of nearly 900 emergency CDs identified that more than 50% of cases of impacted fetal head complicated CD in the first stage of labor.2

Impacted fetal head seems to be more likely if the fetal station is low, if labor has been augmented with oxytocin, and/or if features of obstructed labor, such as caput and molding, are present.2 Fetal malposition and cephalopelvic disproportion may also increase the risk of impaction.25 However, it is not possible to reliably predict impacted fetal head. Therefore, obstetricians should be prepared to encounter impacted fetal head at any emergency CD and be particularly vigilant in these circumstances.

Techniques for prevention of impacted fetal head

Manual vaginal disimpaction before incision

There is anecdotal evidence that many obstetricians advocate performing manual vaginal disimpaction (“push” technique) to elevate the fetal head after a failed AVB and before commencing CD (Table). However, there is currently no evidence to support or oppose this approach.

Table.

Techniques for the prevention and management of impacted fetal head at CD

Techniques for prevention (before starting CD)
Manual vaginal disimpaction (vaginal push method) Introducing a hand into the vagina to move the fetal head up into the abdomen before making a uterine incision to reduce the likelihood of an impacted fetal head
Fetal Pillow Using an inflatable device in the vagina to move the fetal head up into the abdomen before making a uterine incision to reduce the likelihood of an impacted fetal head
Techniques for management (when impacted fetal head encountered during CD)
Uterine relaxation Administering medicine (tocolysis) to relax the uterus and facilitate advanced disimpaction techniques
Abdominal cephalic disimpaction Using the dominant or nondominant hand to flex and lift the fetal head upward into the maternal abdomen to deliver the head
Manual vaginal disimpaction (vaginal push method) Introducing a hand into the vagina to move the head up into the abdomen when encountering an impacted fetal head at CD
Reverse breech extraction A hand is introduced in the upper aspect of the uterus, the baby’s feet are grasped, and the baby is delivered feet first (breech). Once the baby’s shoulders are delivered, the head is lifted out of the pelvis
Patwardhan method A modification of the reverse breech extraction, whereby the arms are delivered first
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CD, cesarean delivery.

Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

Fetal Pillow

There is growing interest in the use of the Fetal Pillow (CooperSurgical, Trumbull, CT) (Figure 1, Table).7 This device is a soft silicone balloon that is inserted vaginally before commencing a CD with a deeply engaged head, low fetal station, or after a failed AVB. The device is intended to elevate the fetal head and make the delivery less traumatic and quicker.26

Figure 1.

Figure 1

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Fetal Pillow

Image reproduced courtesy of CooperSurgical, Inc.

Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

There remains limited, high-quality data about the efficacy of the Fetal Pillow, and evidence of improvement in outcomes is conflicting. Studies investigating Fetal Pillow have compared the device with a range of alternative interventions, including no Fetal Pillow,26, 27, 28, 29 noninflated Fetal Pillow,30 the vaginal “push” method,31 and the Patwardhan method.32

Several of these studies demonstrated that the Fetal Pillow may improve subjective “ease of delivery” and reduce the incision-to-delivery interval.26,29,30 Of note, 2 randomized controlled trials (RCTs) and 2 observational cohort studies have reported that the use of the Fetal Pillow may be associated with reduced rates of unintentional uterine incision extensions.26,29,3130 These findings are supported by a recently published Italian meta-analysis comparing the outcomes after the use of the Fetal Pillow (incision-to-delivery interval: mean difference, −52.26 seconds; 95% confidence interval [CI], −55.2 to −34.94 seconds; P<.001; uterine incision extension: odds ratio [OR], 0.50; 95% CI, 0.3–0.9; P=.02).33

However, recent, larger observational studies have failed to demonstrate any significant improvement in maternal outcomes associated with Fetal Pillow use.27,28 In addition, there is contradictory evidence regarding the effect of the Fetal Pillow on operative blood loss: some studies suggest an increased risk of postpartum hemorrhage,27,28 whereas other studies suggest the reverse.29,31,33

There is similarly no clear neonatal benefit, and data are conflicting. A recent meta-analysis demonstrated better umbilical arterial pH in infants with the use of the Fetal Pillow than that of vaginal push-up.33 Another study comparing the Fetal Pillow with the Patwardhan method reported a reduced risk of admission to the neonatal intensive care unit (NICU) with Fetal Pillow use.32

However, there are several limitations to studies evaluating the Fetal Pillow. Studies are not adequately powered to assess the effect of the device on neonatal outcomes. Only 1 study factored in the time taken to insert the device,30 and no published study reported the decision-to-delivery interval. Furthermore, studies comparing outcomes in CDFD between those using the Fetal Pillow and those using alternative disimpaction methods are likely to overestimate the benefits, as not all CDFD are complicated by impacted fetal head.7 Those requiring advanced disimpaction techniques, such as vaginal push-up or reverse breech extraction, are likely to be more difficult and at greater risk of complications. Moreover, no study reported any training or details of how disimpaction techniques are performed in comparator groups.

The Fetal Pillow is not a panacea. Its role in preventing impacted fetal head in first-stage CD, which forms most impacted fetal head cases, has not been assessed, and other disimpaction techniques may still be required to deliver the head after the device is used.34 Finally, there are no published data about cost-effectiveness. Adequately powered RCTs, reporting cost-effectiveness, are required before its use can be recommended.35

Management strategies (Table)

When an impacted fetal head is encountered, the obstetrician should first identify the space to introduce their hand below the fetal head to flex and elevate it to the incision (abdominal cephalic disimpaction) (Table). This approach is likely to be effective in most cases.2 However, there is currently no available evidence detailing how this basic maneuver should be performed, even though problems executing it may increase the risk of injury: investigations of perinatal deaths involving an impacted fetal head have identified repeated attempts by obstetricians to insert their hand anteriorly between the fetal head and maternal pubic symphysis as a common feature.4

If the obstetrician is unable to disimpact the head using simple, manual maneuvers, other strategies can be employed, including tocolysis,36 vaginal disimpaction (“push” method),37 reverse breech extraction,22,38,39 and the Patwardhan method.40,41

Tocolysis

A reflex contraction may occur when the operator introduces their hand into the uterus, hindering disimpaction of the fetal head.8,22 A brief pause at this stage can allow time for the uterus to relax spontaneously.8 Moreover, some obstetricians advocate using a tocolytic agent to facilitate uterine relaxation (Table).8,18 However, there is insufficient robust evidence to support any benefit or harm from tocolysis.36,42 Clinicians should balance any potential advantages of tocolysis with the possible additional risks of atonic postpartum hemorrhage. Accordingly, if tocolysis is used, we would advocate the administration of a tocolytic agent with a short half-life, such as sublingual nitroglycerin (glyceryl trinitrate) (1–2 sprays; 400–800 μg).

Vaginal disimpaction

Landesman and Graber37 first reported the technique of abdominovaginal delivery, now widely known as the vaginal “push” method, in the American Journal of Obstetrics & Gynecology in 1984 (Table). To date, this method is widely used to support the delivery of an impacted fetal head at CD.43,44 The technique is described as an assistant using a cupped hand and fingers to gently elevate the fetal head, with the woman’s legs repositioned in semilithotomy to ensure adequate vaginal access (Figure 2).18,37 Flexion of the fetal head is key to successful vaginal disimpaction.45 If pressure is applied incorrectly, the fetal head may become more deflexed, compounding impaction behind the pubic symphysis and hindering delivery further.45

Figure 2.

Figure 2

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Vaginal disimpaction

An assistant introduces their whole hand into the vagina to cup the baby’s head with the woman’s legs supported in semilithotomy. Image reproduced with permission from the Avoiding Brain Injuries in Childbirth collaboration.

Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

However, the execution of this technique is highly variable in clinical practice, with many accoucheurs attempting to elevate the fetal head by applying pressure with only 2 or 3 fingers.44 This approach is less likely to be effective and may also increase the risk of fetal injury. Some reports have suggested an association between the vaginal “push” technique and perinatal skull fracture.5,41,45,46 It is axiomatic that pushing up on the fetal head with 1 or 2 fingers might potentially increase the risk of fetal trauma, although digital pressure on the vertex is unlikely to directly cause parietal fractures.47

Reverse breech extraction

Reverse breech extraction, also known as the “pull” technique, involves the operator grasping one or both feet and then pulling the legs to deliver the buttocks, abdomen, and head, similar to an assisted vaginal breech delivery (Figure 3, Table).38,39 Breech extraction is employed worldwide but more widely reported in low-resource settings where obstructed labor may be more common.48, 49, 50, 51, 52, 53, 54 As with vaginal disimpaction, this method requires an efficient and skilled approach to reduce both the duration of the impacted fetal head and the risk of direct trauma; however, many obstetricians lack the training and confidence to perform it.7,55 Moreover, concerns have been raised that errors performing reverse breech extraction may increase the risk of femoral and humeral fractures.41,56

Figure 3.

Figure 3

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Reverse breech extraction

The operator grasps one or both feet A, applies traction toward the woman’s feet to deliver the legs and abdomen B, rotates the body in the midline to deliver each arm in turn C, and applies traction toward the woman’s head to deliver the baby’s head D. Image reproduced with permission from the Avoiding Brain Injuries in Childbirth collaboration.

Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

Patwardhan method

The Patwardhan method is a modification of the reverse breech extraction, whereby the arms are delivered first (Figure 4, Table).40,57 This technique is widely used in India, where it was developed by Dr Patwardhan in 1957.22,57 The Patwardhan method requires specialist training and is rarely practiced in many other parts of the world where obstetricians may be less familiar with how to perform it.44 The traditional method is described for babies in occipitoanterior positions, where the feet may be difficult to reach. The uterine incision is made at the level of the shoulders, and each arm is delivered in turn with gentle traction on the shoulders.22,58 After delivery of both arms, the operator holds the baby’s back by hooking their fingers through both axillae, applying gentle traction while the assistant applies fundal pressure to flex the baby’s abdomen and deliver the breech.40,41 After delivery of the breech, the head is gently lifted out of the pelvis as with a reverse breech extraction.22

Figure 4.

Figure 4

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Patwardhan method

Image reproduced with permission from the Avoiding Brain Injuries in Childbirth collaboration.

Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

Extension of uterine incision

If there is insufficient access for the operator to deliver the breech or suggestion of unintentional uterine extensions while performing a reverse breech extraction, the operator can perform either an inverted “T” or “J” incision to improve access.25,59 Moreover, the operator may need to extend the uterine incision if a Bandl’s ring is encountered.

Comparison of techniques for management

There is a dearth of high-quality research evidence comparing disimpaction techniques and a consequent lack of consensus regarding which is the safest and/or the most effective. Over the last decade, 3 systematic reviews and meta-analyses have compared maternal and neonatal outcomes according to the type of disimpaction technique.19,42,60 The most recent systematic review published in 2022 included 7 prospective randomized studies and 12 observational studies, with 9 of 11 cohort studies meeting the Critical Appraisal Skills Programme (CASP) criteria and 8 of 10 RCTs fully meeting the CASP criteria.60

These systematic reviews reported that the “pull” method, including reverse breech extraction and the Patwardhan method, may be safer for women than vaginal disimpaction.19,38,42,60 The analysis of pooled data demonstrated that the “push” method may be associated with an increased risk of uterine incision extensions (OR, 3.44; 95% CI, 2.62–4.52; P≤.0001), need for blood transfusion (OR, 2.42; 95% CI, 1.07–5.48; P=.03), and infections (OR, 4.25; 95% CI, 1.65–10.96; P=.003).19,42,60 These complications likely result from simultaneous maneuvers employed abdominally to disimpact the fetal head from the pelvis. Inadvertent application of pressure on the uterine lower segment or uterine angles during abdominal cephalic disimpaction can result in the tearing of the angles and/or extensions toward the broad ligament, cervix, and vagina. Lateral extensions risk injury to the uterine arteries and venous plexuses, whereas cervical arteries and vaginal venous plexuses may become damaged by inferior vertical extensions. This can lead to excessive bleeding, increased risk of infection, and prolonged operative time for repair.

Trauma to the uterine lower segment may be further compounded by attempts to elevate the fetal head upward, without first disimpacting the fetal head from the pelvis in a caudal-cranial direction. Moreover, disimpaction may be more difficult if the “push” method is performed incorrectly and ineffectually. As highlighted, misplaced application of pressure during vaginal disimpaction may lead to inadequate flexion or unintended hyperextension of the fetal head and render the maneuver ineffective or even counterproductive.

More recent evidence suggests that reverse breech extraction may also be associated with better neonatal outcomes, including improved Apgar scores and reduced NICU admissions.60 Researchers have hypothesized that this may be because reverse breech extraction avoids additional traumatic compression of the fetal head associated with manual cephalic disimpaction from the pelvis.49 However, there are no available data to suggest a difference in risk of fetal injury between the “push” method and reverse breech extraction.19,42,60 Evidence of a difference in neonatal outcomes between the Patwardhan method and the vaginal push method is also equivocal.19,60

Although findings from systematic reviews align, the evidence base for the effectiveness of different methods is limited and includes low-quality studies. Moreover, the lack of a standardized definition for impacted fetal head at CD results in an inherent risk of bias in studies comparing techniques. Moreover, it poses problems when comparing interventions as part of the meta-analyses as the inclusion criteria are often poorly defined or differ markedly among studies.60 Furthermore, there is significant heterogeneity among study interventions, reported outcomes, and analyses. Most studies fail to report specific details of how disimpaction techniques are performed or any training or competence assessment of clinicians performing them. Most improvements in outcomes are related to a reduction in the extension of uterine incision when delivering the fetal head. However, it is unclear whether disimpaction procedures were performed correctly and whether potential errors in the execution of a technique might have contributed to poor outcomes. Therefore, it is difficult to assess the effectiveness of any technique as it may depend on competence in undertaking it.

In addition, most studies were carried out in low-resource settings, where difficulties with obstructed labor may be more common, maternity practices may differ, and obstetricians may be more familiar with “pull” techniques, such as the Patwardhan method and reverse breech extraction. Therefore, findings may not be generalizable to other maternity settings where exponents of these techniques are limited and training may differ. Moreover, most studies have small sample sizes, and even when pooled, there are insufficient data to detect differences in rarer neonatal outcomes. The safety and efficacy of techniques for managing impacted fetal head at CD performed in the first stage of labor also remain unclear, as most studies include only women undergoing second-stage CD.

Therefore, many clinical scenarios are left unaddressed by the existing literature, and to date, it is not possible to derive firm conclusions regarding the superiority of 1 technique vs another. Well-designed RCTs, in which the inclusion criteria are clearly defined and clinicians are appropriately trained, are urgently required to further investigate the management of impacted fetal head at CD.

Novel devices under investigation

Several other strategies have been described to manage impacted fetal head at CD, including the Tydeman Tube,61 C-Snorkel,62 and fetal head elevating devices.63 However, there is currently insufficient data to recommend their use.

Tydeman Tube

The Tydeman Tube is a single-use, hollow silicon tube with a rounded cup inserted vaginally to elevate the fetal head. It is designed to maximize the degree of disimpaction while minimizing applied pressure across a larger surface area.61,64 The results from simulation testing are promising, but further research in a clinical setting is required to investigate its efficacy and safety before use.61

C-Snorkel

The C-Snorkel is a disposable tube with ventilation ports, intended to release the vacuum between the fetal head and vaginal wall. There are very little data on its use,62,65 and recent reports suggest it may have been withdrawn from the market.62,64,65

Fetal head elevators

Specifically designed obstetrical spoons, which look similar to a single blade of an obstetrical forceps, have been described to deliver an impacted fetal head.63 These include the Coyne spoon, Sellheim spoon, and Murless head extractor, originally developed in the 1950s. However, there is an absence of data demonstrating safety, very little evidence for their use in modern obstetrical practice, and a risk of inappropriate use resulting in maternal visceral injury.63

Nonrecommended techniques

Although it is not currently possible to make firm recommendations regarding the use of 1 technique vs another, a single forceps blade or ventouse, employed abdominally to assist delivery of an impacted fetal head should be avoided. Neither is supported by evidence, and both are inconsistent with the mechanics of disimpacting a head deep in the pelvis. The use of a single forceps as a lever to disimpact the head is considered dangerous.3 Moreover, the use of a vacuum at CD has the potential to cause significant fetal injury, such as intracranial and subgaleal hemorrhage.66,67

Training

A paucity of evidence-based guidelines8,18 and lack of multiprofessional training44 have resulted in a wide variation in practice9,43 and avoidably harmful care in some circumstances.3, 4, 5, 6 It is essential that clinicians are familiar with disimpaction techniques to reduce the potentially devastating complications associated with impacted fetal head. However, techniques are difficult to learn experientially, impacted fetal head is unpredictable, and an experienced consultant obstetrician may not be easily available.

A recent survey of obstetrical trainees and senior labor ward leads in the United Kingdom reported that training for impacted fetal head at CD was inconsistent and inadequate.7 Over half of obstetrical trainees in the United Kingdom would not feel confident performing reverse breech extraction, and fewer than 1 in 10 are familiar with the Patwardhan technique.7 This likely reflects inadequate training as relatively few obstetricians have received practical training (either in real life or in simulation) in disimpaction techniques.7 In the United Kingdom, midwives are often asked to push up vaginally if an impacted fetal head at CD is encountered. However, few have received training in how to do so, and most would insert 2 fingers, as with vaginal examination, to apply pressure to the fetal head.44

High-fidelity simulation and implementation of standardized care pathways are likely to represent the safest and most effective form of training, as with shoulder dystocia.68 Simulation should be multiprofessional and use a validated, high-fidelity birth simulator that realistically simulates impacted fetal head and facilitates rehearsal of all disimpaction techniques.69, 70, 71 There is no single panacea for the management of impacted fetal head, and in difficult cases, multiple and escalating strategies may be required to resolve the impaction.7 Therefore, maternity staff should be trained in a range of strategies so that they have a “toolbox” of techniques to turn to. Training should equip staff with the necessary technical skills to perform these disimpaction techniques and highlight important nontechnical skills, including communication and situation awareness.

Training should be accompanied by management algorithms with a sequential, structured, and flexible approach. Observation of simulated CD and interviews with maternity staff as part of the DiSIMpact study revealed several expert practices and common mistakes, informing lessons for training in the management of impacted fetal head at CD (awaiting publication). In the absence of robust evidence confirming the superiority of 1 technique vs another, we recommend that either vaginal disimpaction or reverse breech extraction is attempted first depending on the clinical circumstances and operator experience. Moreover, algorithms should incorporate key nontechnical skills regarding anticipation and preparation, declaring the emergency and calling for help, and the need to pause both for situation awareness and uterine relaxation.

As part of the PRactical Obstetric Multi-Professional Training Maternity Foundation and the Department of Health–funded Avoiding Brain Injury in Childbirth collaboration, we have developed consensus-driven, evidence-based management algorithms, innovative educational tools, and multiprofessional training to support maternity staff managing this emergency. Training includes hands-on workshops focusing on technical skills and real-time simulations for the whole maternity theater team and an animated video and augmented reality to enhance visualization and illustrate the finer details of how to perform disimpaction techniques. We hope that the implementation of these tools will lead to improved outcomes for both mothers and babies with an impacted fetal head at CD.

Glossary.

AVB, assisted vaginal birth

CASP, Critical Appraisal Skills Programme

CI, confidence interval

CD, cesarean delivery

CDFD, cesarean delivery at full dilatation

NICU, neonatal intensive care unit

OR, odds ratio

RCT, randomized controlled trial

Acknowledgments

The authors would like to acknowledge Pauline Hewitt, lead midwife in the impacted fetal head at cesarean delivery, as part of the Avoiding Brain Injuries in Childbirth collaboration and Cathy Winter, lead midwife at the Practical Obstetric Multi-Professional Training Maternity Foundation.

Footnotes

The authors report no conflict of interest. K.R.C., R.B., and T.D. are funded as part of the Department of Health and Social Care Avoiding Brain Injuries in Childbirth collaboration. K.R.C. and T.D. collaborated with Limbs & Things, Bristol, United Kingdom, as unpaid advisors to develop the novel birth simulator for impacted fetal head at cesarean delivery (Enhanced Caesarean Section Module).

Supplementary Data

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Management of impacted fetal head at cesarean delivery.

<VIDSE>Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

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References

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Management of impacted fetal head at cesarean delivery.

<VIDSE>Cornthwaite. Impacted fetal head at cesarean delivery. Am J Obstet Gynecol 2024.

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