Reducing caesarean birth risks: research

Researchers from Flinders University and the Royal College of Obstetricians and Gynaecologists in the UK have investigated the effectiveness of a range of manoeuvres and devices currently used to reduce the risk of impacted foetal head (IFH) in emergency caesarean births (CB).

Their scientific impact paper has been published in BJOG: An International Journal of Obstetrics & Gynaecology.

Over 34% of women in Australia have a caesarean birth, with a significant proportion of these happening in late labour when the foetal head is deep in the mother’s pelvis and can become impacted, making delivery of the baby challenging and posing serious risks to both mother and baby.

It’s estimated the baby’s head is wedged, known as impacted foetal head, in about 10% of all emergency caesarean births. This makes it difficult for the doctor to get their hand below the baby’s head to deliver it, which leads to longer delivery times.

Recent statistics show that while the majority of babies born following IFH sustain minor damage, 2% of these infants die or suffer serious injuries with lifelong consequences. The NHS Resolution report in the UK states that 9% of avoidable brain injuries at birth are caused by IFH.

Complications for the mother include increased blood loss, an increased risk of infection, bladder and urinary tract damage, uterine tears that require repair and may cause issues in subsequent pregnancies, or even a hysterectomy. Complications for the baby include lacerations and bruising to the head and face, skull fractures, haemorrhages and eye injuries.

The researchers found that there has been a significant rise in cases of IFH injuries in recent years, with maternity staff implementing various approaches to managing this obstetric emergency. These include having an assistant push the baby’s head up during birth; delivering the baby feet first; using an inflatable balloon device (Fetal Pillow) designed to elevate the baby’s head; and administering medication to relax the mother’s womb.

On reviewing the available evidence, the scientific impact paper concluded there was currently no consensus on the best approach for these risky cases.

The researchers made the following recommendations to improve standards:

• High-quality adequately powered randomised controlled trials (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.
   

“We’ve reviewed the existing evidence on strategies to identify, prevent and manage the IFH during caesarean births to provide guidance and recommendations that improve outcomes for mothers and babies when this potentially serious complication occurs,” said research co-author and midwife at Flinders University Dr Annette Briley.

“It’s essential that clinicians use the best evidence to inform care for women and babies, including the optimal techniques to reduce the potentially devastating complications associated with IFH.”

Briley is also part of a research team developing and evaluating the Tydeman Tube, a single-use, hollow silicone tube inserted to elevate the baby’s head. It is designed to minimise applied pressure to the head and reduce any suction effect once access has been achieved.

“A minimal number of Tydeman Tubes have been used clinically; further research in a clinical setting, compared with appropriately trained and executed manual disimpaction, is required to investigate its efficacy and safety before use,” Briley said.

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