Traumatic injury from impacted fetal head (IFH) during caesarean birth in the second stage of labour

Impacted fetal head (IFH) is a complication of childbirth in which the unborn baby’s head (or fetal head) becomes wedged or impacted within the mother’s pelvis.

Traumatic birth injuries from impacted fetal head (IFH) during caesarean births in the second stage of labour have risen dramatically in recent years. UK research studies suggest that IFH occurs in around 10% of all unplanned or emergency caesarean births. One in 50 (2%) of babies who are affected by IFH suffer death or other forms of serious harm, including traumatic brain injury at birth.

What is the second stage of labour?

The second stage of labour starts when the mother’s cervix has opened to 10cm and is fully dilated. In a vaginal delivery, this is the stage where the mother pushes the baby out. The second stage of labour ends when the baby is born.

What are the risks of injury from IFH during caesarean birth in the second stage of labour? 

Around a quarter of all babies in the UK are born by caesarean section. One in 20 (5%) of all caesarean births take place after the mother’s cervix is fully dilated in the second (pushing) stage of labour. These are often emergency caesarean sections after prolonged labour.

Emergency caesarean section in the second stage of labour has a greater risk of complications for both mother and baby than caesarean births which are elective (planned) or which take place earlier in labour.

Delivery by caesarean section after the cervix is fully dilated is more difficult, even for experienced obstetricians, as the unborn baby’s head has descended further into the mother’s pelvis where it becomes impacted (wedged) or deeply engaged. 

Complications can arise from the manipulations that are needed during caesarean section to free the baby’s head from its wedged position within the pelvis. There is little room for the obstetric surgeon to place their hand between the pelvis and the fragile fetal head, and this becomes even more difficult when there is moulding (movement of the skull bones) of the baby’s head, which often takes place in labour. The surgeon must act quickly to deliver the baby to avoid risk of serious injury to the baby’s brain, but must also take care to avoid injury to the mother’s uterus which will be stretched and thinned from prolonged labour, making it prone to tearing. The risk of injury to the mother’s uterus is even greater where second stage caesarean section follows an unsuccessful attempt at (vaginal) instrumental delivery. 

What injuries commonly lead to impacted fetal head (IFH) traumatic birth injury claims?

Negligently managed second stage caesarean births with an impacted fetal head (IFH) can cause serious traumatic birth injury to both mother and baby.

IFH birth injuries to the baby include:

• skull fracture;
• intracranial haemorrhage (bleeding inside the skull or the brain);
• nerve damage;
• hypoxic brain injury (HIE);
• death.

Maternal injuries include:

• uterine tears;
• damage to the uterine artery;
• haemorrhage (bleeding);
• bladder and bowel injuries;
• difficulties with future pregnancies.

There is no national guidance on best practice or safe techniques for management of an impacted fetal head (IFH) at caesarean section, but the Royal College of Obstetricians and Gynaecologists (RCOG) and the NHS’ Avoiding Brain Injury in Childbirth (ABC) programme are currently working to improve awareness and maternity teams’ training in relation to the management of this increasingly common obstetric emergency.

How does the fetal head become impacted in labour?

During labour, the unborn baby’s head descends into the mother’s pelvis to position the baby for delivery through the birth canal. This is a natural process, aided by the mother’s contractions, but if the baby is incorrectly positioned their head can become impacted causing obstruction of the vaginal delivery. Maternal obesity and the size of the baby’s head are also thought to increase the risk of impaction of the fetal head (IFH).

Prolonged labour (particularly in the second stage) also increases the risk of IFH but, in general, guidelines for the management of labour recommend that if there is lack of progress in the first stage (before the cervix has fully opened), the uterine stimulant, Syntocinon, should be used to try to stimulate uterine contractions and speed up labour before a caesarean section is considered. In the meantime, as the labour progresses to second stage, the baby’s head can become more deeply impacted.

In the second stage, assisted vaginal delivery may be attempted with forceps or Ventouse suction which, if unsuccessful, further delays the delivery and increases the risks of injury during second stage caesarean section to both mother and baby.

How does injury occur during caesarean delivery of a baby with impacted fetal head (IFH)?

As with any difficult procedure, the risk of failure and harm is increased where the clinician attempting the procedure is inexperienced. A national survey found that over 60% of training grade (below consultant) obstetricians had received no training, whether in live situations or by simulation, for handling the birth of a baby complicated by impacted fetal head. Many junior obstetricians have to deal with this emergency situation for the first time without prior training, often at night when there is no immediate access to help from a senior, more experienced colleague. 

Maternity teams use different methods to deliver a baby’s head that is found to be impacted during a caesarean birth. The choice of technique can increase the risk of injury but there is a lack of consensus or standard guidance about the best way to manage these births. Various procedures have been developed to achieve delivery of a baby where labour is obstructed by an impacted fetal head, including: using an inflatable balloon device to elevate the baby's head; giving the mother medication to relax the uterus; reverse breech extraction, in which the baby is delivered during a caesarean birth by a ‘pull’ procedure similar to a vaginal breech delivery; and more common but controversial ‘push’ techniques.

Push’ techniques involve the operating surgeon attempting to put their hand between the baby’s head and the mother’s pelvis to disengage the head whilst an assisting doctor or midwife pushes the head upwards via the vagina. This puts pressure on the baby’s skull, and can cause skull fractures, brain injury or result in the baby’s death. Where this has caused serious traumatic injury, the mother or baby may have grounds for a negligence claim.

In second stage caesarean births involving IFH, as with all obstetric emergencies, simulation exercises, staff training, early recognition of risk and early action in labour, and multi-disciplinary teamwork under the leadership of a senior obstetrician are essential for the safety of mother and baby.

Read more about our recent liability settlement for a child with severe, traumatic brain injury caused by negligent management of impacted fetal head during the child’s birth.

Read more about IFH traumatic birth injury claims.

If your child has cerebral palsy or neurological disability as a result of medical negligence, or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.