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Healthcare | Legal

Improving clinical and legal outcomes for impacted foetal head at caesarean section

8 Feb 2023, by Amy Sarcevic

Impacted foetal head (IFH) at caesarean section is the third most litigated infant brain injury in the United Kingdom, and an emerging medico legal issue in Australia, where a number of high-profile cases have been reported to coroners over the last decade.

Overall, IFH complicates around 10 percent of intrapartum caesarean sections (CS), but the condition is more heterogeneous than previously thought, affecting 16-31 percent of second stage caesareans. Around half of IFH cases are encountered before full cervical dilatation.

The condition is associated with maternal and foetal complications, including PPH and direct cranial trauma. Some of these incidents result in infant brain injury – one of the costliest types of legal claim.

With caesarean births on the rise, the problem is growing, prompting concern from practitioners around the world.

Professor Tim Draycott, former Vice President of the Royal College of Obstetricians and Gynaecologists (RCOG) and senior obstetric advisor to the UK NHS Resolution, says, despite its seriousness, the clinical standards and legal precedence for impacted foetal head are unclear.

Ahead of the Medico Legal Congress he argues that a better understanding of causation, along with mandatory clinical training, could improve outcomes for this common heterogeneous emergency.

“Unfortunately, the risk of impacted foetal head cannot be eliminated, but one of the best things we can do is diagnose it efficiently and manage it effectively,” said Prof Draycott.

“There are a number of highly technical skills that can improve the safety of foetal head disimpactment – and there are ways of communicating during the emergency that reduce the impact on families – but these skills not routinely taught. In fact, there is a vacuum of guidance and training in this area that needs to be filled.”

The UK’s Department of Health is currently funding the production of training materials for impacted foetal head as part of its Avoiding Brain Injuries in Childbirth (ABC) program.

Canada, too, is updating its guidelines with the imminent release of a Scientific Impact Paper.

Prof Draycott – who was formerly in charge of guidelines at the RCOG – believes these materials will make a meaningful impact; in the same way similar initiatives for shoulder dystocia already have.

“Publications from the USA, Finland, Spain, and the UK have all highlighted the effectiveness of specialised shoulder dystocia training in the prevention of neonatal injury. Given the vacuum of training and guidance that currently exists for the management of impacted foetal head I am confident similar initiatives in this area will give similar results,” he said.

Reflecting on recent case law and emerging overseas guidelines, Prof Draycott will present at the Medico Legal Congress, where he will share more thoughts on how the clinical standards and legal precedent for impacted foetal head could be improved.

“If we combine legal precedent with accurate clinical information, we can achieve the best outcomes for both the health service and families,” he concluded.

The 32nd annual Congress will be held 14-15 March 2023 at the PARKROYAL Darling Harbour Sydney.

Learn more and register your place here.

About Professor Tim Draycott

Professor Tim Draycott is a Consultant Obstetrician at North Bristol NHS Trust from where he co-leads the international PROMPT training programme. He recently completed a term as Vice Presidents at the RCOG where he was responsible for clinical quality.

Prof Draycott also serves as a Senior Maternity Advisor to NHS Resolution and formerly National Director for The Tommy’s Centre for Maternity Improvement, jointly formed by the RCOG and the Royal College of Midwives (RCM). He is the clinical obstetric lead for the Department of Health Avoiding Brain Injuries in Childbirth (ABC) programme.

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