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Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Delivery, Face Presentation, and Brow Presentation: Understanding Fetal Positions and Birth Scenarios

Introduction:.

During childbirth, the position of the baby plays a significant role in the delivery process. While the most common fetal presentation is the head-down position (vertex presentation), variations can occur, such as face presentation and brow presentation. This comprehensive article aims to provide a thorough understanding of delivery, face presentation, and brow presentation, including their definitions, causes, complications, and management approaches.

Delivery Process:

  • Normal Vertex Presentation: In a typical delivery, the baby is positioned head-down, with the back of the head (occiput) leading the way through the birth canal.
  • Engagement and Descent: Prior to delivery, the baby's head engages in the pelvis and gradually descends, preparing for birth.
  • Cardinal Movements: The baby undergoes a series of cardinal movements, including flexion, internal rotation, extension, external rotation, and restitution, which facilitate the passage through the birth canal.

Face Presentation:

  • Definition: Face presentation occurs when the baby's face is positioned to lead the way through the birth canal instead of the vertex (head).
  • Causes: Face presentation can occur due to factors such as abnormal fetal positioning, multiple pregnancies, uterine abnormalities, or maternal pelvic anatomy.
  • Complications: Face presentation is associated with an increased risk of prolonged labor, difficulties in delivery, increased fetal malposition, birth injuries, and the need for instrumental delivery.
  • Management: The management of face presentation depends on several factors, including the progression of labor, the size of the baby, and the expertise of the healthcare provider. Options may include closely monitoring the progress of labor, attempting a vaginal delivery with careful maneuvers, or considering a cesarean section if complications arise.

Brow Presentation:

  • Definition: Brow presentation occurs when the baby's head is partially extended, causing the brow (forehead) to lead the way through the birth canal.
  • Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension.
  • Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the potential need for instrumental delivery or cesarean section.
  • Management: The management of brow presentation depends on various factors, such as cervical dilation, progress of labor, fetal size, and the presence of complications. Close monitoring, expert assessment, and a multidisciplinary approach may be necessary to determine the safest delivery method, which can include vaginal delivery with careful maneuvers, instrumental assistance, or cesarean section if warranted.

Delivery Techniques and Intervention:

  • Obstetric Maneuvers: In certain situations, skilled healthcare providers may use obstetric maneuvers, such as manual rotation or the use of forceps or vacuum extraction, to facilitate delivery, reposition the baby, or prevent complications.
  • Cesarean Section: In cases where vaginal delivery is not possible or poses risks to the mother or baby, a cesarean section may be performed to ensure a safe delivery.

Conclusion:

Delivery, face presentation, and brow presentation are important aspects of childbirth that require careful management and consideration. Understanding the definitions, causes, complications, and appropriate management approaches associated with these fetal positions can help healthcare providers ensure safe and successful deliveries. Individualized care, close monitoring, and multidisciplinary collaboration are crucial in optimizing maternal and fetal outcomes during these unique delivery scenarios.

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Krish Tangella MD, MBA

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Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

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Labor is the process that leads to childbirth. It begins with the onset of regular uterine contractions and ends with delivery of the newborn and expulsion of the placenta. Pregnancy and birth are physiological processes. Thus, labor and delivery should be considered normal for most women.

Fetal position within the birth canal is critical to labor progress and to the delivery route. It should be determined in early labor, and sonography can be implemented for unclear cases. Important relationships include fetal lie, presentation, attitude, and position.

Of these, fetal lie describes the relationship of the fetal long axis to that of the mother. In more than 99 percent of labors at term, the fetal lie is longitudinal . A transverse lie is less frequent. Occasionally, the fetal and maternal axes may cross at a 45-degree angle to form an oblique lie . This is unstable and becomes longitudinal or transverse during labor.

Fetal Presentation

The presenting part is the portion of the fetal body either within or in closest proximity to the birth canal. It usually can be felt through the cervix on vaginal examination. In longitudinal lies, the presenting part is either the fetal head or the breech, creating cephalic and breech presentations, respectively. When the fetus lies with the long axis transversely, the shoulder is considered the presenting part.

Cephalic presentations are subclassified according to the relationship between the head and body of the fetus ( Fig. 22-1 ). Ordinarily, the head is flexed sharply so that the chin contacts the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation . Much less often, the fetal neck may be sharply extended so that the occiput and back come into contact, and the face is foremost in the birth canal— face presentation . The fetal head may assume a position between these extremes. When the neck is only partly flexed, the anterior (large) fontanel may present— sinciput presentation . When the neck is only partially extended, the brow may emerge— brow presentation . These latter two are usually transient. As labor progresses, sinciput and brow presentations almost always convert into occiput or face presentations by neck flexion or extension, respectively. If not, dystocia can develop ( Chap. 23 , p. 441).

FIGURE 22-1

Longitudinal lie, cephalic presentation. Differences in attitude of the fetal body in (A) occiput, (B) sinciput, (C) brow, and (D) face presentations. Note changes in fetal attitude as the fetal head becomes less flexed.

Four diagrams depict various presentations in longitudinal lie with cephalic presentation.

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Obstetric and Newborn Care I

Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

Figure 10-1. Typical types of presentations.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

Figure 10-2. Types of attitudes. A--Complete flexion. B-- Moderate flexion. C--Poor flexion. D--Hyperextension

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

Figure 10-3. Measurement of station.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

ROP (Right Occiput Posterior)

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

Figure 10-4. Breech positions.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

Figure 10-5. Examples of fetal vertex presentations in relation to quadrant of maternal pelvis.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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the presentation of the fetal head is referred to as

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Breech - series—Normal position of the baby

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Breech - series

The term "fetal presentation" refers to the part of your baby's body that is closest to the birth canal. In most full-term pregnancies, the baby is positioned head down, or cephalic, in the uterus.

Review Date 11/21/2022

Updated by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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  • Childbirth Problems

the presentation of the fetal head is referred to as

Fetal Presentation, Position, and Lie (Including Breech Presentation)

  • Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

the presentation of the fetal head is referred to as

Position and Presentation of the Fetus

Variations in fetal position and presentation.

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Labor and Birth

Labor and Birth Just the facts In this chapter, you’ll learn: types of fetal presentations and positions ways in which labor can be stimulated signs and symptoms of labor stages and cardinal movements of labor nursing responsibilities during labor and birth, including ways to provide comfort and support. A look at labor and birth Labor and birth is physically and emotionally straining for a woman. As the patient’s body undergoes physical changes to help the fetus pass through the cervix, she may also feel discomfort, pain, panic, irritability, and loss of control. To ensure the safest outcome for the mother and child, you must fully understand the stages of labor as well as the factors affecting its length and difficulty. With an understanding of the labor and birth process, you’ll be better able to provide supportive measures that promote relaxation and help increase the patient’s sense of control. Fetal presentation Fetal presentation is the relationship of the fetus to the cervix. It can be assessed through vaginal examination, abdominal inspection and palpation, sonography, or auscultation of fetal heart tones. By knowing the fetal presentation, you can anticipate which part of the fetus will first pass through the cervix during delivery. How long and how hard Fetal presentation can affect the length and difficulty of labor as well as how the fetus is delivered. For example, if the fetus is in a breech presentation (the fetus’s soft buttocks are presenting first), the force exerted against the cervix by uterine contractions is less than it would be if the fetus’s firm head presented first. The decreased force against the cervix decreases the effectiveness of the uterine contractions that help open the cervix and push the fetus through the birth canal. Presenting difficulties Sometimes, the fetus’s presenting part is too large to pass through the mother’s pelvis or the fetus is in a position that’s undeliverable. In such cases, cesarean birth may be necessary. In addition to the usual risks associated with surgery, an abnormal fetal presentation increases the risk of complications for the mother and fetus. Factors determining fetal presentation The primary factors that determine fetal presentation during birth are fetal attitude, lie, and position. Fetal attitude Fetal attitude (degree of flexion) is the relationship of the fetal body parts to one another. It indicates whether the presenting parts of the fetus are in flexion (complete or moderate) or extension (partial or full). What’s in an attitude? Complete flexion Moderate flexion Partial extension Full extension In complete flexion, the head of the fetus is tucked down onto the chest, with the chin touching the sternum. Moderate flexion (aka military position or sinciput), the head of the fetus is slightly flexed but held straighter than in complete flexion. The chin doesn’t touch the chest. In partial extension, the head of the fetus is extended, with the head pushed slightly backward so that the brow becomes the first part of the fetus to pass through the pelvis during birth. In complete extension, the head and neck of the fetus are hyperextended and the occiput touches the fetus’s upper back. The back is usually arched, which increases the degree of hyperextension. This position is commonly called the fetal position. Many fetuses assume this attitude early in labor but convert to complete flexion as labor progresses. This is an uncommon fetal position and a vaginal birth is unlikely. Commonly, this skull diameter is too large to pass through the pelvis. The occiput is the presenting part. The top of the head is the presenting part. The brow or forehead is the presenting part. The mentum (chin) is the presenting part. Fetal lie The relationship of the fetal spine to the maternal spine is referred to as fetal lie. Fetal lie can be described as longitudinal, transverse, or oblique. Fetal position Fetal position is the relationship of the presenting part of the fetus to a specific quadrant of the mother’s pelvis. It’s important to define fetal position because it influences the progression of labor and whether surgical intervention is needed. Spelling it out Fetal position is defined using three letters. The first letter designates whether the presenting part is facing the woman’s right (R) or left (L) side. The second letter or letters refer to the presenting part of the fetus: the occiput (O), mentum (M), sacrum (Sa), or scapula or acromion process (A). The third letter designates whether the presenting part is pointing to the anterior (A), posterior (P), or transverse (T) section of the mother’s pelvis. The most common fetal positions are left occiput anterior (LOA) and right occiput anterior (ROA). (See Fetal position abbreviations , page 298 .) Duration determinant Commonly, the duration of labor and birth is shortest when the fetus is in the LOA or ROA position. When the fetal position is posterior, such as left occiput posterior (LOP), labor tends to be longer and more painful for the woman because the fetal head puts pressure on her sacral nerves. (See Determining fetal position .) Which way do I Lie? Longitudinal Transverse Oblique The fetal spine is parallel to the maternal spine. The fetal spine is at a 90-degree angle to the maternal spine. The fetal spine is at a 45-degree angle to the maternal spine. Approximately 99% of all fetuses are in this position. The presenting part can be either vertex or breech. Occurs in less than 1% of all deliveries and is considered abnormal. The presenting part can be a shoulder, an iliac crest, a hand, or an elbow. Also considered abnormal and is rare. The presenting part can also be a shoulder, an iliac crest, a hand, or an elbow. Fetal position abbreviations Here’s a list of presentations that are used when documenting vertex presentations. Although it is possible to apply the same abbreviation system to breech (sacrum), face (mentum) and shoulder (acromion process) presentation, it is rarely done due to those presentations precipitating a cesarean section delivery. Vertex presentations (occiput) LOA, left occipitoanterior ROA, right occipitoanterior LOP, left occipitoposterior ROP, right occipitoposterior LOT, left occipitotransverse ROT, right occipitotransverse Types of fetal presentation Fetal presentation refers to the part of the fetus that presents into the birth canal first. It’s determined by fetal attitude, lie, and position. Fetal presentation should be determined in the early stages of labor in case an abnormal presentation endangers the mother and the fetus. (See Classifying fetal presentation , pages 300 and 301.) The four main types of fetal presentation are: cephalic breech shoulder compound. Cephalic presentation When the fetus is in cephalic presentation, the head is the first part to contact the cervix and expel from the uterus during delivery. About 95% of all fetuses are in cephalic presentation at birth. The four types of cephalic presentation are vertex, brow, face, and mentum (chin). Determining fetal position Fetal position is determined by the relationship of a specific presenting part (occiput, sacrum, mentum [chin], or sinciput [deflected vertex]) to the four quadrants (anterior, posterior, right, or left) of the maternal pelvis. For example, a fetus whose occiput (O) is the presenting part and who’s located in the right (R) and anterior (A) quadrant of the maternal pelvis is identified as ROA. These illustrations show the possible positions of a fetus in vertex presentation. Vertex In the vertex cephalic presentation, the most common presentation overall, the fetus is in a longitudinal lie with an attitude of complete flexion. The parietal bones (between the two fontanels) are the presenting part of the fetus. This presentation is considered optimal for fetal descent through the pelvis. Classifying fetal presentation Fetal presentation may be broadly classified as cephalic, shoulder, compound, or breech. Almost all births are cephalic presentations. Breech births are the second most common type. Cephalic In the cephalic, or head-down, presentation, the position of the fetus may be further classified by the presenting skull landmark, such as vertex, brow, sinciput, or mentum (chin). Shoulder Although a fetus may adopt one of several shoulder presentations, examination can’t differentiate among them; thus, all transverse lies are considered shoulder presentations. Compound In compound presentation, an extremity prolapses alongside the major presenting part so that two presenting parts appear in the pelvis at the same time. Breech In the breech, or head-up, presentation, the position of the fetus may be further classified as frank, where the hips are flexed and knees remain straight; complete, where the knees and hips are flexed; kneeling, where the knees are flexed and the hips remain extended; and incomplete, where one or both hips remain extended and one or both feet or knees lie below the breech; or footling, where one or both feet extend below the breech. Brow In brow presentation, the fetus’s brow or forehead is the presenting part. The fetus is in a longitudinal lie and exhibits an attitude of partial flexion. Although this isn’t the optimal presentation for a fetus, few suffer serious complications from the delivery. In fact, many brow presentations convert to vertex presentations during descent through the pelvis. Face The face type of cephalic presentation is unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie and exhibits an attitude of complete extension. Because the face is the presenting part of the fetal head, severe edema and facial distortion may occur from the pressure of uterine contractions during labor. Faced with potential complications If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor may be prolonged and ineffective in some instances, and vaginal birth may not be possible because the presenting part has a larger diameter than the pelvic outlet. Attempts to manually convert the face presentation to a more favorable position are rarely successful and are associated with high perinatal mortality and maternal morbidity. Mentum The mentum, or chin, type of cephalic presentation is also unfavorable for the mother and the fetus. In this presentation, the fetus is in a longitudinal lie with an attitude of complete extension. The presenting part of the fetus is the chin, which may lead to severe edema and facial distortion from the pressure of the uterine contractions during labor. The widest diameter of the fetal head is presenting through the pelvis because of the extreme extension of the head. If labor is allowed to progress, careful monitoring of both the fetus and the mother is necessary to reduce the risk of compromise. Labor is usually prolonged and ineffective. Vaginal delivery is usually impossible because the fetus can’t pass through the ischial spines. Breech presentation Although 25% of all fetuses are in breech presentation at week 30 of gestation, most turn spontaneously at 32 to 34 weeks’ gestation. However, breech presentation occurs at term in about 3% of births. Labor is usually prolonged with breech presentation because of ineffective cervical dilation caused by decreased pressure on the cervix and delayed descent of the fetus. It gets complicated In addition to prolonging labor, the breech presentation increases the risk of complications. In the fetus, cord prolapse; anoxia; intracranial hemorrhage caused by rapid molding of the head; neck trauma; and shoulder, arm, hip, and leg dislocations or fractures may occur. Complications that may occur in the mother include perineal tears and cervical lacerations during delivery and infection from premature rupture of the membranes. How will I know? A breech presentation can be identified by abdominal and cervical examination. The signs of breech presentation include: fetal head is felt at the uterine fundus during an abdominal examination fetal heart tones are heard above the umbilicus soft buttocks or feet are palpated during a cervical examination. Once, twice, three types more The three types of breech presentation are complete, frank, and incomplete. Complete breech In a complete breech presentation, the fetus’s buttocks and the feet are the presenting parts. The fetus is in a longitudinal lie and is in complete flexion. The fetus is sitting crossed-legged and both legs are drawn up (hips flexed) with the anterior of the thighs pressed tightly against the abdomen; the lower legs are crossed with the calves pressed against the posterior of the thighs; and the feet are tightly flexed against the outer aspect of the posterior thighs. Although considered an abnormal fetal presentation, complete breech is the least difficult of the breech presentations. Frank breech In a frank breech presentation, the fetus’s buttocks are the presenting part. The fetus is in a longitudinal lie and is in moderate flexion. Both legs are drawn up (hips flexed) with the anterior of the thighs pressed against the body; the knees are fully extended and resting on the upper body with the lower legs stretched upward; the arms may be flexed over or under the legs; and the feet are resting against the head. The attitude is moderate. Incomplete breech In an incomplete breech presentation, also called a footling breech, one or both of the knees or legs are the presenting parts. If one leg is extended, it’s called a single-footling breech (the other leg may be flexed in the normal attitude); if both legs are extended, it’s called a double-footling breech. The fetus is in a longitudinal lie. At least one of the thighs and one of the lower legs are extended with little or no hip flexion. Perhaps expect prolapse A footling breech is the most difficult of the breech deliveries. Cord prolapse is common in a footling breech because of the space created by the extended leg. A cesarean birth may be necessary to reduce the risk of fetal or maternal mortality. Shoulder presentation Although common in multiple pregnancies, the shoulder presentation of the fetus is an abnormal presentation that occurs in less than 1% of deliveries. In this presentation, the shoulder, iliac crest, hand, or elbow is the presenting part. The fetus is in a transverse lie, and the attitude may range from complete flexion to complete extension. Lacking space and support In the multiparous woman, shoulder presentation may be caused by the relaxation of the abdominal walls. If the abdominal walls are relaxed, the unsupported uterus falls forward, causing the fetus to turn horizontally. Other causes of shoulder presentation may include pelvic contraction (the vertical space in the pelvis is smaller than the horizontal space) or placenta previa (the low-lying placenta decreases the vertical space in the uterus). Early identification and intervention are critical when the fetus is in a shoulder presentation. Abdominal and cervical examination and sonography are used to confirm whether the mother’s abdomen has an abnormal or distorted shape. Attempts to turn the fetus may be unsuccessful unless the fetus is small or preterm. A cesarean delivery may be necessary to reduce the risk of fetal or maternal death. Compound presentation In a compound presentation, an extremity presents with another major presenting part, usually the head. In this type of presentation, the extremity prolapses alongside the major presenting part so that they present simultaneously. Engagement Engagement occurs when the presenting part of the fetus passes into the pelvis to the point where, in cephalic presentation, the biparietal diameter of the fetal head is at the level of the midpelvis (or at the level of the ischial spines). Vaginal and cervical examinations are used to assess the degree of engagement before and during labor. A good sign Because the ischial spines are usually the narrowest area of the female pelvis, an engagement indicates that the pelvic inlet is large enough for the fetus to pass through (because the widest part of the fetus has already passed through the narrowest part of the pelvis). Floating away In the primipara, nonengagement of the presenting part at the onset of labor may indicate a complication, such as cephalopelvic disproportion, abnormal presentation or position, or an abnormality of the fetal head. The nonengaged presenting part is described as floating. In the multipara, nonengagement is common at the onset of labor; however, the presenting part quickly becomes engaged as labor progresses. Station Station is the relationship of the presenting part of the fetus to the mother’s ischial spines. If the fetus is at station 0, the fetus is considered to be at the level of the ischial spines. The fetus is considered engaged when it reaches station 0. Grand central stations Fetal station is measured in centimeters. The measurement is called minus when it’s above the level of the ischial spines and plus when it’s below that level. Station measurements range from — 1 to — 3 cm (minus station) and + 1 to + 4 cm (plus station). A crowning achievement When the station is measured at + 4 cm, the presenting part of the fetus is at the perineum—commonly known as crowning. (See Assessing fetal engagement and station , page 306 .) Advice from the experts Assessing fetal engagement and station During a cervical examination, you’ll assess the extent of the fetal presenting part into the pelvis. This is referred to as fetal engagement. After you have determined fetal engagement, palpate the presenting part and grade the fetal station (where the presenting part lies in relation to the ischial spines of the maternal pelvis). If the presenting part isn’t fully engaged into the pelvis, you won’t be able to assess station. Station grades range from —3 (3 cm above the maternal ischial spines) to +4 (4 cm below the maternal ischial spines, causing the perineum to bulge). A zero grade indicates that the presenting part lies level with the ischial spines. A look at labor stimulation For some patients, it’s necessary to stimulate labor. The stimulation of labor may involve induction (artificially starting labor) or augmentation (assisting a labor that started spontaneously). Although induction and augmentation involve the same methods and risks, they’re performed for different reasons. Many high-risk pregnancies must be induced because the safety of the mother or fetus is in jeopardy. Medical problems that justify induction of labor include preeclampsia, eclampsia, severe hypertension, diabetes, Rh sensitization, prolonged rupture of the membranes (over 24 hours), and a postmature fetus (a fetus that’s 42 weeks’ gestation or older). Augmentation of labor may be necessary if the contractions are too weak or infrequent to be effective. Conditions for labor stimulation Before stimulating labor, the fetus must be: in longitudinal lie (the long axis of the fetus is parallel to the long axis of the mother) at least 39 weeks’ gestation or have fetal lung maturity established The ripe type In addition to the above fetal criteria, the mother must have a ripe cervix before labor is induced. A ripe cervix is soft and supple to the touch rather than firm. Softening of the cervix allows for cervical effacement, dilation, and effective coordination of contractions. Using Bishop score, you can determine whether a cervix is ripe enough for induction. (See Bishop score , page 308 .) When it isn’t so great to stimulate Stimulation of labor should be done with caution in women age 35 and older and in those with grand parity or uterine scars. Labor should not be stimulated if, but not limited to: transverse fetal position umbilical cord prolapse active genital herpes infections women who have had previous myomectomy (fibroid removal) from the inside of the uterus stimulation of the uterus increases the risk of such complications as placenta previa, abruptio placentae, uterine rupture, and decreased fetal blood supply caused by the increased intensity or duration of contractions. Methods of labor stimulation If labor is to be induced or augmented, one method or a combination of methods may be used. Methods of labor stimulation include breast stimulation, amniotomy, oxytocin administration, and ripening agent application. Breast stimulation In breast stimulation, the nipples are massaged to induce labor. Stimulation results in the release of oxytocin, which causes contractions that sometimes result in labor. The patient or her partner can help with breast stimulation by: applying a water-soluble lubricant to the nipple area (to prevent irritation) gently rolling the nipple through the patient’s clothing. Too much, too soon? One drawback of breast stimulation is that the amount of oxytocin being released by the woman’s body can’t be controlled. In some cases (rarely), too much oxytocin leads to excessive uterine stimulation (tachysystole or tetanic contractions), which impairs fetal or placental blood flow, causing fetal distress. Bishop score Bishop score is a tool that you can use to assess whether a woman is ready for labor. A score ranging from 0 to 3 is given for each of five factors: cervical dilation, length (effacement), consistency, position, and station. If the woman’s score exceeds 8, the cervix is considered suitable for induction. Factor Score Cervical dilation • Cervix dilated <1 cm 0 • Cervix dilated 1 to 2 cm 1 • Cervix dilated 2 to 4 cm 2 • Cervix dilated >4 cm 3 Cervical length (effacement) • Cervical length >4 cm (0% effaced) 0 • Cervical length 2 to 4 cm (0% to 50% effaced) 1 • Cervical length 1 to 2 cm (50% to 75% effaced) 2 • Cervical length <1 cm (>75% effaced) 3 Cervical consistency • Firm cervical consistency 0 • Average cervical consistency 1 • Soft cervical consistency 2 Cervical position • Posterior cervical position 0 • Middle or anterior cervical position 1 Zero station notation (presenting part level) • Presenting part at ischial spines —3 cm 0 • Presenting part at ischial spines —1 cm 1 • Presenting part at ischial spines +1 cm 2 • Presenting part at ischial spines +2 cm 3 Modifiers Add 1 point to score for: Preeclampsia Each prior vaginal delivery Subtract 1 point from score for: Postdates pregnancy Nulliparity Premature or prolonged rupture of membranes Adapted with permission from Bishop, E. H. (1964). Pelvic scoring for elective induction. Obstetrics and Gynecology, 24, 266-268. Amniotomy Amniotomy (artificial rupturing of the membranes) is performed to augment or induce labor when the membranes haven’t ruptured spontaneously. This procedure allows the fetal head to contact the cervix more directly, thus increasing the efficiency of contractions. Amniotomy is virtually painless for both the mother and the fetus because the membranes don’t have nerve endings. System requirements To perform amniotomy, the fetus must be in the vertex presentation with the cervix dilated to at least 2 cm; additionally, the head should be well applied to the cervix to help prevent umbilical cord prolapse. Nurse need to be aware of the potential for umbilical cord prolapse during an amniotomy if the head is not fully engaged into the pelvis at zero station. Let it flow, let it flow, let it flow During amniotomy, the woman is placed in a dorsal recumbent position. An amniohook (a long, thin instrument similar to a crochet hook) is inserted into the vagina to puncture the membranes. If puncture is properly performed, amniotic fluid gushes out. Advice from the experts Complications of amniotomy Umbilical cord prolapse—a life-threatening complication of amniotomy—is an emergency that requires immediate cesarean birth to prevent fetal death. It occurs when amniotic fluid, gushing from the ruptured sac, sweeps the cord down through the cervix. Prolapse risk is higher if the fetal head isn’t engaged in the pelvis before rupture occurs. Cord prolapse can lead to cord compression as the fetal presenting part presses the cord against the pelvic brim. Immediate action must be taken to relieve the pressure and prevent fetal anoxia and fetal distress. Here are some options: Insert a gloved hand into the vagina and gently push the fetal presenting part away from the cord. Place the woman in Trendelenburg position to tilt the presenting part backward into the pelvis and relieve pressure on the cord. Administer oxygen to the mother by face mask to improve oxygen flow to the fetus. If the cord has prolapsed to the point that it’s visible outside the vagina, don’t attempt to push the cord back in. This can add to the compression and may cause kinking. Cover the exposed portion with a compress soaked with sterile saline solution to prevent drying, which could result in atrophy of the umbilical vessels. Persevere if it isn’t clear Normal amniotic fluid is clear. Bloody or meconium-stained amniotic fluid is considered abnormal and requires careful, continuous monitoring of the mother and fetus. Bloody amniotic fluid may indicate a bleeding problem. Meconium-stained amniotic fluid may indicate fetal distress. If the fluid is meconium-stained, note whether the staining is thin, moderate, thick, or particulate. Take a whiff Amniotic fluid has a scent described as either a sweet smell or odorless. A foul smell indicated the presence of an infection and the patient needs further evaluation. Prolapse potential Amniotomy increases the risk to the fetus because there’s a possibility that a portion of the umbilical cord will prolapse with the amniotic fluid. Fetal heart rate (FHR) should be monitored during and after the procedure to make sure that umbilical cord prolapse didn’t occur. (See Complications of amniotomy , page 309 .) Oxytocin administration Synthetic oxytocin (Pitocin) is used to induce or augment labor. It may be used in patients with gestational hypertension, prolonged gestation, maternal diabetes, Rh sensitization, premature or prolonged rupture of membranes, and incomplete or inevitable abortion. Oxytocin is also used to evaluate for fetal distress after 31 weeks’ gestation and to control bleeding and enhance uterine contractions after the placenta is delivered. Oxytocin is always administered I.V. with an infusion pump. Throughout administration, FHR and uterine contractions should be assessed, monitored, and documented according to National Institutes of Child Health and Human Development (NICHD) criteria. First things first Prior to the start of an infusion you should have at least a 15-minute strip of both FHR and uterine activity to establish a reassuring FHR. There also should be a Bishop score documented as a measure of ensuring the cervix is ripe for labor. Additionally, a set of maternal vital signs should also be obtained. Nursing interventions Here’s how to administer oxytocin: Start a primary I.V. line. Insert the tubing of the administration set through the infusion pump, and set the drip rate to administer the oxytocin at a starting infusion rate of 0.5 to 2 mU/minute. The maximum dosage of oxytocin is 20 mU/minute. Typically, oxytocin is diluted 10 units in 500 ml or 20 units in 1,000 ml of an isotonic solution; lactated Ringer is the most common. This dilution results in a dosage of 2 mU/minute for every 3 ml/hour of I.V. fluid infused. An alternative dosing is 30 units diluted in 500 ml and the dosage becomes 1 mU/minute for every 1 ml/hour of I.V. fluid infused. Piggyback ride The oxytocin solution is then piggybacked to the primary I.V. line, through the lowest possible access point on the I.V. tubing. If a problem occurs, such as a nonreassuring FHR pattern or uterine tachysystole, stop the piggyback infusion immediately and resume the primary line. Immediate action Because oxytocin begins acting immediately, be prepared to start monitoring uterine contractions. Increase the oxytocin dosage as ordered—but never increase the dose more than 1 to 2 mU/minute every 15 to 60 minutes. Typically, the dosage continues at a rate that maintains a regular pattern (uterine contractions occur every 2 to 3 minutes lasting less than 2 minutes duration). If more is in store Before each increase, be sure to assess contractions, maternal vital signs, fetal heart rhythm, and FHR. If you’re using an external fetal monitor, the uterine activity strip or grid should show contractions occurring every 2 to 3 minutes. The contractions should last for about 60 seconds and be followed by uterine relaxation. If you’re using an internal uterine pressure catheter (IUPC), look for an optimal baseline value ranging from 5 to 15 mm Hg. Your goal is to verify uterine relaxation between contractions. Assist with comfort measures, such as repositioning the patient on her other side, as needed. Following through Continue assessing maternal and fetal responses to the oxytocin. Maternal assessment should include blood pressure, pulse, and a pain assessment Review the infusion rate to prevent uterine tachysystole. To manage tachysystole, discontinue the infusion and administer oxygen. (See Complications of oxytocin administration , page 312 .) To reduce uterine irritability, try to increase uterine blood flow. Do this by changing the patient’s position and increasing the infusion rate of the primary I.V. line. After tachysystole resolves, resume the oxytocin infusion per your facility’s policy. Advice from the experts Complications of oxytocin administration Oxytocin can cause uterine tachysystole. This, in turn, may progress to tetanic contractions, which last longer than 2 minutes. Signs of tachysystole include contractions that are less than 2 minutes apart and last 90 seconds or longer, uterine pressure that doesn’t return to baseline between contractions, and intrauterine pressure that rises over 75 mm Hg. What else to watch for Other potential complications include fetal distress, abruptio placentae, uterine rupture, and water intoxication. Water intoxication, which can cause maternal seizures or coma, can result because the antidiuretic effect of oxytocin causes decreased urine flow. Stop signs Watch for the following signs of oxytocin administration complications. If any indication of any potential complications exists, stop the oxytocin administration, administer oxygen via face mask, and notify the doctor immediately. Fetal distress Signs of fetal distress include: late decelerations bradycardia. Abruptio placentae Signs of abruptio placentae include: sharp, stabbing uterine pain pain over and above the uterine contraction pain heavy bleeding hard, boardlike uterus. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Uterine rupture Signs of uterine rupture include: sudden, severe pain during a uterine contractions tearing sensation absent fetal heart sounds. Also watch for signs of shock, including rapid, weak pulse; falling blood pressure; cold and clammy skin; and dilation of the nostrils. Water intoxication Signs and symptoms of water intoxication include: headache and vomiting (usually seen first) hypertension peripheral edema shallow or labored breathing dyspnea tachypnea lethargy confusion change in level of consciousness. Ripening agent application If a woman’s cervix isn’t soft and supple, a ripening agent may be applied to it to stimulate labor. Drugs containing prostaglandin E 2 —such as dinoprostone (Cervidil, Prepidil, Prostin E2)—are commonly used to ripen the cervix. These drugs initiate the breakdown of the collagen that keeps the cervix tightly closed. The ripening agent can be: applied to the interior surface of the cervix with a catheter or suppository applied to a diaphragm that’s then placed against the cervix inserted vaginally. Additional doses may be applied every 3 to 6 hours; however, two or three doses are usually enough to cause ripening. The woman should remain flat after application to prevent leakage of the medication. Success half the time The success of this labor stimulation method varies with the agent used. After just a single application of a ripening agent, about 50% of women go into labor spontaneously and deliver within 24 hours. Those women who don’t go into labor require a different method of labor stimulation. Prostaglandin should be removed before amniotomy. Use this drug with caution in women with asthma, glaucoma, and renal or cardiac disease. Not to be ignored Prior to application of the ripening agent, a 15-minute strip of FHR and uterine activity should be completed as a baseline. Although the ripening agent is applied, carefully monitor the patient’s uterine activity. If uterine tachysystole occurs or if labor begins, the prostaglandin agent should be removed. The patient should also be monitored for adverse effects of prostaglandin application, including headache, vomiting, fever, diarrhea, and hypertension. FHR and uterine activity should be monitored continuously between 30 minutes and 2 hours after vaginal insertion, dependent upon the agent used. Onset of labor True labor begins when the woman has bloody show, her membranes rupture, and she has painful contractions of the uterus that cause effacement and dilation of the cervix. The actual mechanism that triggers this process is unknown. Before the onset of true labor, preliminary signs appear that indicate the beginning of the birthing process. Although not considered to be a true stage of labor, these signs signify that true labor isn’t far away. Preliminary signs and symptoms of labor Preliminary signs and symptoms of labor include lightening, increased level of activity, Braxton Hicks contractions, and ripening of the cervix. Subjective signs, such as restlessness, anxiety, and sleeplessness, may also occur. (See Labor: True or false?) Lightening Lightening is the descent of the fetal head into the pelvis. The uterus lowers and moves into a more anterior position, and the contour of the abdomen changes. In primiparas, these changes commonly occur about 2 weeks before birth. In multiparas, these changes can occur on the day labor begins or after labor starts. More pressure here, less pressure there Lightening increases pressure on the bladder, which may cause urinary frequency. In addition, leg pain may occur if the shifting of the fetus and uterus increases pressure on the sciatic nerve. The mother may also notice an increase in vaginal discharge because of the pressure of the fetus on the cervix. However, breathing becomes easier for the woman after lightening because pressure on the diaphragm is decreased. Advice from the experts Labor: True or false? Use this chart to help differentiate between the signs and symptoms of true labor and those of false labor. Signs and symptoms True labor False labor Cervical changes Cervix softens and dilates No cervical dilation or effacement Level of discomfort Intense Mild Location of contractions Start in the back and spread to the abdomen Abdomen or groin Uterine consistency when palpated Hard as a board; can’t be indented Easily indented with a finger Regularity of contractions Regular with increasing frequency and duration Irregular; no discernible pattern; tends to decrease in intensity and frequency with activity Frequency and duration of contractions affected by position or activity No Yes Ruptured membranes Possible No Increased level of activity After having endured increased fatigue for most of the third trimester, it’s common for a woman to experience a sudden increase in energy before true labor starts. This phenomenon is sometimes referred to as “nesting” because, in many cases, the woman directs this energy toward last-minute activities, such as organizing the baby’s room, cleaning and straightening her home, and preparing other children in the household for the new arrival. A built-in energy source The woman’s increase in activity may be caused by a decrease in placental progesterone production (which may also be partly responsible for the onset of labor) that results in an increase in the release of epinephrine. This epinephrine increase gives the woman extra energy for labor. Braxton Hicks contractions Braxton Hicks contractions are mild contractions of the uterus that occur throughout pregnancy. They may become extremely strong a few days to a month before labor begins, which may cause some women, especially a primipara, to misinterpret them as true labor. Several characteristics, however, distinguish Braxton Hicks contractions from labor contractions. Patternless Braxton Hicks contractions are irregular. There’s no pattern to the length of time between them and they vary widely in their strength. They gradually increase in frequency and intensity throughout the pregnancy, but they maintain an irregular pattern. In addition, Braxton Hicks contractions can be diminished by increasing activity or by eating, drinking, or changing position. Labor contractions can’t be diminished by these activities. Painless Braxton Hicks contractions are commonly painless—especially early in pregnancy. Many women feel only a tightening of the abdomen in the first or second trimester. If the woman does feel pain from these contractions, it’s felt only in the abdomen and the groin—usually not in the back. This is a major difference from the contractions of labor. No softening or stretching Probably, the most important differentiation between Braxton Hicks contractions and true labor contractions is that Braxton Hicks contractions don’t cause progressive effacement or dilation of the cervix. The uterus can still be indented with a finger during a contraction, which indicates that the contractions aren’t efficient enough for effacement or dilation to occur. Ripening of the cervix Ripening of the cervix refers to the process in which the cervix softens to prepare for dilation and effacement. It’s thought to be the result of hormone-mediated biochemical events that initiate breakdown of the collagen in the cervix, thus causing it to soften and become flexible. As the cervix ripens, it also changes position by tipping forward in the vagina. Ripening of the cervix doesn’t produce outwardly observable signs or symptoms. The ripeness of the cervix is determined during a pelvic examination, usually in the last weeks of the third trimester. Signs of true labor Signs of true labor include uterine contractions, bloody show, and spontaneous rupture of membranes. Uterine contractions The involuntary uterine contractions of true labor help effacement and dilation of the uterus and push the fetus through the birth canal. Although uterine contractions are irregular when they begin, as labor progresses they become regular with a predictable pattern. Early contractions occur anywhere from 5 to 30 minutes apart and last about 30 to 45 seconds. The interval between the contractions allows blood flow to resume to the placenta, which supplies oxygen to the fetus and removes waste products. As labor progresses, the contractions increase in frequency, duration, and intensity. During the transition phase of the first stage of labor—when contractions reach their maximum intensity, frequency, and duration— they each last 60 to 90 seconds and recur every 2 to 3 minutes.

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Training for managing impacted fetal head at caesarean birth: multimethod evaluation of a pilot

Jan w van der scheer.

1 THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK

Katie Cornthwaite

2 Royal College of Obstetricians and Gynaecologists, London, UK

3 Translational Health Sciences, University of Bristol, Bristol, UK

Pauline Hewitt

4 Royal College of Midwives, London, UK

Rachna Bahl

5 University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK

Wendy Randall

Alison powell, akbar ansari, bothaina attal, janet willars, matthew woodward, imogen a f brown, annabelle olsson, natalie richards, evleen price, alessandra giusti, joann leeding, lisa hinton, mary dixon-woods, giulia maistrello.

6 RAND Europe, Cambridge, UK

Oscar Lyons

7 Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

Tim Draycott

8 North Bristol NHS Trust, Westbury on Trym, UK

Associated Data

bmjoq-2023-002340supp002.pdf

bmjoq-2023-002340supp003.pdf

bmjoq-2023-002340supp001.pdf

Data are available upon reasonable request. The data that support the findings of this evaluation are available on request from the corresponding author. Access to fully anonymised data may be granted to bona fide researchers under a data sharing agreement. The data are not publicly available due to privacy or ethical restrictions.

Implementation of national multiprofessional training for managing the obstetric emergency of impacted fetal head (IFH) at caesarean birth has potential to improve quality and safety in maternity care, but is currently lacking in the UK.

To evaluate a training package for managing IFH at caesarean birth with multiprofessional maternity teams.

The training included an evidence-based lecture supported by an animated video showing management of IFH, followed by hands-on workshops and real-time simulations with use of a birth simulation trainer, augmented reality and management algorithms. Guided by the Kirkpatrick framework, we conducted a multimethod evaluation of the training with multiprofessional maternity teams. Participants rated post-training statements about relevance and helpfulness of the training and pre-training and post-training confidence in their knowledge and skills relating to IFH (7-point Likert scales, strongly disagree to strongly agree). An ethnographer recorded sociotechnical observations during the training. Participants provided feedback in post-training focus groups.

Participants (N=57) included 21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals from five maternity units. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH. Confidence in technical and non-technical skills relating to managing IFH was variable before the training (5%–92% agreement with the pre-training statements), but improved in nearly all participants after the training (71%–100% agreement with the post-training statements). Participants and ethnographers reported that the training helped to: (i) better understand the complexity of IFH, (ii) recognise the need for multiprofessional training and management and (iii) optimise communication with those in labour and their birth partners.

Conclusions

The evaluated training package can improve self-reported knowledge, skills and confidence of multiprofessional teams involved in management of IFH at caesarean birth. A larger-scale evaluation is required to validate these findings and establish how best to scale and implement the training.

WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Impacted fetal head (IFH) is a technically challenging obstetric emergency that may complicate up to 10% of caesarean births in the UK and is associated with potentially devastating complications for mother and baby.
  • Recent surveys of UK maternity professionals indicate a lack of confidence and underuse of appropriate techniques for managing IFH, in part because of paucity of high-quality training.

WHAT THIS STUDY ADDS

  • Multiprofessional training including lecture-based, visual and simulation methods can improve self-reported technical and non-technical knowledge and skills of maternity professionals for anticipating, identifying and managing an IFH.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • The training package is ready for use across the UK following validation in a larger, representative sample of UK maternity units, including establishing how best to scale and implement the training at a local and regional level.
  • Systematic monitoring will be needed to determine long-term effectiveness of implementation of the training.

Introduction

Impacted fetal head (IFH) is a technically challenging obstetric emergency increasingly encountered during unplanned caesarean births. 1–3 Complicating up to 10% of caesarean births in the UK (1.5% of all births), 4–6 it is associated with significant risks to mother and baby, including postpartum haemorrhage, trauma to uterus and bladder, hypoxic ischaemic brain injury and skull fractures. 1 2 4 6 Reports of perinatal brain injury linked to IFH have risen in recent years, along with coronial inquiries and increased litigation nationally and internationally. 6–10 In recent surveys, UK maternity professionals reported lack of confidence, knowledge and skills relating to anticipating, identifying and managing an IFH, possibly owing to paucity of and limited access to high-quality training. 11–14 As a result, practice in relation to IFH management is variable, 12 15 likely contributing to adverse outcomes. 6

Although the need for IFH training was identified over 10 years ago, 16 the UK currently lacks nationally standardised, multiprofessional training aimed at improving the technical skills ( table 1 ) 1 17–22 and non-technical skills (eg, teamwork, communication) 23–26 required for managing IFH. In management of other obstetric emergencies, implementation of high-quality training that includes simulation-based practice has been associated with significant improvement in clinical outcomes. 27 Simulation-based practice is likely to be particularly important for IFH training, 28 29 since efforts to ensure workplace learning during clinical care are challenged by various factors. These factors include the unpredictability of IFH, variable availability of experienced obstetricians to supervise trainees and difficulties in demonstrating the techniques executed below the level of incision where they cannot be seen. 4 12 15

The range of techniques that may be employed to prevent and manage impacted fetal head (IFH) at caesarean birth 1 17–22

Despite the need for practice of techniques to prevent or manage IFH ( table 1 ), 22 training tested so far has not included birth simulators that enable realistic rehearsal of techniques such as vaginal disimpaction and reverse breech extraction. 30–33 Current training is also limited by a tendency to focus exclusively on obstetricians. 30–33 This neglects the key role of midwives in performing vaginal disimpaction 15 and misses opportunities to foster multiprofessional teamwork, communication with those in labour and their birth partners, and other non-technical skills for managing obstetric emergencies. 23–26

In this article, we report an evaluation of a multiprofessional training package for managing IFH at caesarean birth as part of the Avoiding Brain Injury in Childbirth (ABC) programme, which was commissioned by the UK’s Department of Health and Social Care in 2021.

Training package

We developed a training package, informed by national surveys on IFH practice and training, 12 14 development and validation of a novel birth simulator, 15 and systematic review and appraisal of literature on IFH management. 22 34 Development included codesign, 35–37 with maternity professionals and service users, of an evidence-based lecture, hands-on workshops and simulated scenarios. These were supported by IFH management algorithms developed based on user testing and qualitative research with maternity professionals. 22 34 Patient and public involvement (PPI) informed principles for communication with women and birth partners during obstetric emergencies, which were applied throughout the training, including in the algorithms. Online supplemental material 1 provides a summary of key learning points for participants and the communication principles. Table 2 provides an overview of the training.

Overview of the training for anticipating, identifying and managing impacted fetal head (IFH)

Supplementary data

Training was designed for delivery in a single session lasting up to 3 hours. The session started with a lecture presenting evidence on anticipating, identifying and managing an IFH ( table 2 ). The lecture introduced the communication principles ( online supplemental material 1 ), including examples of ‘conversation starters’ for healthcare professionals communicating during obstetric emergencies (eg, “Impacted fetal head means that the baby’s head is wedged low in your pelvis. We have a plan to manage this and some colleagues will arrive to assist with the birth.”) An animated video visualised anatomical considerations for IFH and illustrated how to perform manoeuvres to deliver an IFH at caesarean birth ( figure 1 and table 2 ). In the pilot testing (see below), the lecture and video were only available to participants during the session.

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Animation video (screenshot, top image), birth simulation trainer with practice of vaginal disimpaction (photo, middle image) and augmented reality tool (photo, bottom image) as used during the training.

Next, the participating teams took part in three subsequent workshops ( table 2 ). During the workshops, participants obtained hands-on training of all disimpaction techniques using the management algorithms, augmented reality tool and validated birth simulation trainer ( figure 1 ). 15 34

Finally, the teams participated in a real-time standardised, simulated scenario of IFH during caesarean birth ( online supplemental material 1 ). This enabled further practice of technical skills for IFH management techniques ( tables 1 and 2 ) and non-technical skills such as multiprofessional teamwork, team communication and application of the principles for communicating with women and birth partners ( table 2 and online supplemental material 1 ). The simulations included a ‘pregnant’ actor and birth partner (see PPI section below), who received a standardised briefing before the simulation ( online supplemental material 1 ). The training finished with a clinical debrief, consistent with recommended simulation practice. 28

Patient and public involvement (PPI)

PPI was focused on communication with women and birth partners during obstetric emergencies. Five service users who had a range of maternity experiences and experience of advocating for improvement and inclusion of under-represented voices, provided PPI input to the overall ABC programme. This group helped shape the training package during fortnightly meetings. Additional input was gained from a group of 15 women with experience of obstetric emergency, who met twice online in facilitated focus groups to discuss communication during obstetric emergencies, with focus on IFH. We also invited representatives of Maternity Voices Partnerships (MVP) 38 to attend the training as an observer or simulation actor and to provide feedback in the post-training focus groups (see below). All MVP representatives provided written consent to take part in the quality improvement activity. 39 The PPI contributors were invited to join the ABC Contributor Group for academic outputs and were paid in accordance with National Institute for Health and Care Research guidance on involvement. 40

Multimethod evaluation

The training was piloted with multiprofessional teams in sessions facilitated by ABC clinicians (KC, PH, RB, WR). We conducted a multimethod evaluation of the training, guided by the Kirkpatrick framework. 41–43 The evaluation focused on the first two Kirkpatrick levels: (1) participants’ reactions to and opinions about the training and (2) the extent to which participants acquired new knowledge, skills, attitudes, confidence and commitment based on their participation in the training. 42 Similar methodology has been used to evaluate training for other obstetric emergencies. 44–46 The evaluation was a quality improvement activity, 39 47 including observations, focus group discussions and questionnaires.

Settings and participants

The training involved the range of healthcare professionals who are likely to be present in the operating theatre at the time of caesarean births in UK maternity units (eg, midwives, obstetricians, anaesthetists, maternity support workers, theatre staff). Due to ongoing pressures caused by the COVID-19 pandemic, the five participating units were selected primarily on their availability and ability to facilitate simulation sessions. They did represent diversity of maternity settings. Local training leads in each unit invited relevant team members. Interested and available team members provided written consent to take part and agreed to recording of the quality improvement activity. 39 Participants were offered a £50 thank you voucher and invited to join the ABC Contributor Group for academic outputs.

Observations

A trained ethnographer with experience in studying maternity care observed the training sessions, using a fieldnote form to characterise relevant aspects of the observed sociotechnical system, focusing on non-technical skills ( online supplemental material 2 ). This included observations on teamwork during IFH management, professional roles and boundaries, communication among team members, communication of team members with the ‘pregnant’ actor and birth partner, as well as the atmosphere during the sessions. The ethnographer augmented their handwritten fieldnotes following the session and dictated them for audio transcription.

Focus groups

Immediately after the training, the ethnographer facilitated an audio-recorded focus group discussion (approximately 30 min) based on a semistructured topic guide ( online supplemental material 2 ). Discussion focused on: (i) what participants perceived as the most and least helpful parts of the training, (ii) how teamwork might change as a result of the training and (iii) potential impact of the training on communication with women and birth partners during IFH emergencies. Service user representatives who observed or acted during the training participated in the discussions (see PPI section above). Audio recordings were transcribed verbatim.

Questionnaires

Online questionnaires ( online supplemental material 2 ) were administered immediately before the training and immediately after the focus group discussions. Participants completed the questionnaires using a Qualtrics weblink accessed through their mobile devices. Before and after training, participants rated statements about confidence in knowledge and technical/non-technical skills addressed in the training ( figure 2 and online supplemental table S1 ). Ratings were given along 7-point Likert scales, ranging from strongly agree to strongly disagree. The post-training questionnaire additionally asked participants to rate statements (along 7-point Likert scales) on how helpful or useful the training was to their clinical practice and improving outcomes following IFH ( table 3 and online supplemental table S2 ). It also asked about the extent to which they would recommend the training to a colleague (Net Promoter Score, scale of 1–10). 48

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Percentage of participants, before and after training, who strongly agreed or agreed with statements on confidence in knowledge and technical/non-technical skills relating to anticipating, identifying and managing impacted fetal head (IFH) at caesarean birth. Online supplemental table S2 provides a detailed breakdown of the data.

Number and percentage of participants agreeing with post-training questionnaire statements on relevance and helpfulness of the training for anticipating, identifying and managing impacted fetal head (IFH)

Online supplemental table S1 provides a detailed breakdown of the data.

Data analysis

We analysed the questionnaire data using descriptive statistics, only including data of participants who completed the pretraining and post-training questionnaires (complete-case analysis excluding incomplete data of five participants). For the Net Promoter Score, we calculated the ratio of promoters (score of 9 or 10) to detractors (score of 0–6). 48 For the questions on confidence in knowledge and skills, we determined the mean of difference in scores before and after training (post−pre mean). The small sample size precluded any statistical comparisons.

We analysed the transcribed observation notes and focus group discussions to generate initial common themes with a focus on: (i) participants’ reactions to and opinions about the training and (ii) the extent to which participants perceived that they had acquired new knowledge or skills. 41–43 Building on these initial themes, we then undertook further analysis 49 to generate further insight into how the training had been received and potential areas for improvement. Themes identified overlapped with three main questionnaire topics (ie, understanding of IFH, multiprofessional teamwork, communication). These three topics guided the final synthesis of the observation and focus group data, which was refined in discussion with the wider multidisciplinary evaluation team.

Pilot testing and evaluation of the training took place with 57 multiprofessional team members from five different units (21 midwives, 25 obstetricians, 7 anaesthetists and 4 other professionals). The five units included tertiary and district general hospitals from different UK regions (East England, South East England, West England), ranging from 3000 to 8000 births per year, all with obstetric-led and alongside midwifery-led settings. Participants from two units took part in pilot testing in their own clinical settings, while the other three units were facilitated at a specialist venue with a clinical simulation space. Four MVP representatives observed and/or acted during one or more training sessions.

Responses to the questionnaires suggested very positive participant reactions to the training. Over 95% of participants agreed that the training was relevant and helpful for their clinical practice and improving outcomes following IFH ( table 3 and online supplemental table S2 ). We found very high levels of participant agreement that learning was aided by the simulations (100%, n=57), management algorithms (96%, n=55) and animated video (96%, n=55) ( table 3 and online supplemental table S2 ). The Net Promoter Score was very high (88%), with 50 participants giving a rating of 9–10 and others giving a rating of 7–8 (n=6) or 5 (n=1).

The questionnaires also suggested that participants acquired new knowledge and technical/non-technical skills. Self-reported confidence in knowledge and skills relating to managing IFH at caesarean birth was variable before the training, but improved in nearly all participants after the training ( figure 2 and online supplemental table S2 ). The largest increases in confidence (post−pre mean) were observed in the technical skill of performing vaginal disimpaction (+1.76), the non-technical skills of teamwork (+2.51), communication among team members (+1.77) and communicating with those in labour and their birth partners (+1.61) ( online supplemental table S2 ).

Observations and focus groups

The observation and focus group data allowed insight into the role of the training in better understanding how to manage IFH in clinical practice.

Better understanding

The focus groups highlighted that participants felt the training addressed an important gap for some. For others, the training formalised and extended knowledge and technical skills that had been gathered experientially.

I’ve been a midwife for over 20 years and I cannot believe I have not been taught how to disimpact a fetal head when it is so important. (Midwife) It’s just things that you have learned over time, over experiences and everything. But you now have the format and a clear picture in your head. (Obstetrician)

Midwifery participants explained that the training helped to better understand the severity and complexity of IFH and how the theory and practice introduced in the training increased confidence in technical skills such as performing vaginal disimpaction. Obstetricians also noted how the training had enhanced their technical knowledge and skills.

The situation and the practice that we did was really good, it kind of complemented what I already knew and kind of polished me a bit. (Obstetrician)

The animated video, birth simulator and augmented reality tool helped uncover details of an emergency that in daily practice remains largely ‘hidden’. Participants discussed the importance of both obstetric and non-obstetric team members (eg, midwives, anaesthetists, other theatre staff) seeing the specifics of IFH and its management in a manner not possible in practice.

They [an obstetrician] also made the point [during a workshop] that it was really important to have appropriate training and to be competent in this procedure and that it was quite a difficult thing to learn because it was so hidden. Therefore, they said that the video […] had been very helpful in helping to show what was going on inside. (Ethnography notes) […] it’s a lot about the visualisation of what’s actually happening with impacted fetal head because a lot of the MDT team, […] theatre team and anaesthetists don’t really know what’s going on with that hand and that head and that. Showing that visually really helped. (Obstetrician)

Multiprofessional teamwork

The training appeared to improve non-technical skills around teamwork, in part by enhancing the understanding of the different roles and contributions of team members. This included further appreciation of all team members of what obstetricians need to do during an IFH emergency and their challenge of finding the right technique for the specifics of the presenting clinical situation.

[Practising together] gave a wider appreciation to the difficulties faced by the obstetricians, that it is not just an obstetrician problem and that everybody else in the room can help. (Ethnography notes) You’ve just got a better understanding of what the obstetrician’s going through, it’s not, oh come on, deliver this baby. You're actually like, they’re trying. But they’re trying to find the right technique in…to delivery. (Midwife)

Similarly, an ethnographer noted “[it] was a bit of a revelation to a few” that when the obstetrician paused to allow the uterus to relax after a contraction induced by the obstetrician’s hand being placed inside the uterus, this was a deliberate pause and not a moment of indecision. Such ‘revelations’ were facilitated by working in smaller groups and sequential workshops to allow various team members to experience techniques hands-on.

The anaesthetist was overheard saying […] he had been oblivious to what that [vaginal disimpaction] meant, he thought that it was just a push and that there was no skill to it. Felt he had had his eyes opened to the complexity of the procedures that were involved in disimpacting a fetal head. (Ethnography notes) […] there is real value for midwifery there to understand […] getting hands on in the sim, to actually understand what that obstetrician is going through. Trying to get that hand under that fetal head was really powerful for me. (Midwife)

Training led to better understanding of each other’s roles and improved awareness that managing IFH crosses traditional professional boundaries and requires inclusion of all multiprofessional members to maximise learning across the theatre team.

[considering] past history of maternity and theatre teams having issues […], a lot of the guys think that as soon as you hit those doors into theatre that’s their area. (Theatre practitioner) And it’s a shame, because if we were trained together then we would break down some of those barriers, wouldn’t we? (Midwife) Exactly. (Theatre practitioner) They [maternity support workers] are actually really fundamental to this because they will literally be picking stuff up, putting the calls out, you know. (Midwife)

The management algorithms were seen as helpful in enabling teams to create a shared mental model of management steps and in facilitating consultant obstetricians in rapidly gaining an overview of the obstetric emergency if they enter the theatre at a later stage.

That is the benefit of the multidisciplinary training, knowing that you’re working your way through an algorithm […] If this doesn’t work, we do this […] that we all understand and that we’re all trained to do the same. (Obstetrician) […] so often we as consultants get called not from the beginning. So, what’s really helpful to know is what’s already been tried […] you know where you are in the algorithm and you know what they’ve tried. (Obstetrician)

Communication

Training in non-technical skills around team communication helped participants realise how important verbalisations in theatre were, such as stating the clinical situation is an IFH emergency and what clinical action is being undertaken. Participants also positively reflected on the training’s emphasis on high quality communication with those in labour and birth partners in all aspects of the training.

…whenever we do skills training or [name of training], it’s always mentioned but it’s almost, sort of, mentioned as a throwaway comment, you know, oh and of course you were…debrief your woman or…it’s almost, like, tagged on at the end. So it’s the first time I’ve really experienced where it [communication] had a real showcase. (Midwife)

Participants found the conversation starters from the lecture a particularly useful resource in supporting better communication with the women and birth partners during the emergency.

It’s given me quite a lot to take away to the other emergencies that we manage, PPHs [post-partum haemorrhages] where the caesarean takes a long time or shoulders [dystocia] is a good example where you might need to, sort of, communicate. Yeah, I agree, the conversation starter sentences are really good. (Obstetrician)

MVP representatives highlighted during the focus groups the importance of communication with the woman about the possibility of vaginal disimpaction, obtaining informed consent for vaginal disimpaction, and the potential negative effects of silences during critical moments (eg, feeling stressed about whether a silence indicates clinicians’ anxiety and/or a negative outcome). They recommended involving service users in the further design and evaluation of the training. During the focus groups, participants and MVP representatives reflected on the importance of finding the right balance of communicating with the person in labour and their partner, while remaining focused on the technical manoeuvres required to safely deliver the baby. Participants and MVP representatives generally agreed that the training could further emphasise that one professional (eg, the anaesthetist) should be designated to communicate with the woman and birth partner during the emergency. Two obstetricians felt that the priority should be given to clinical manoeuvres while expressing that an explanation would follow as soon as the acute emergency was more under control.

In this evaluation of a training package for managing IFH at caesarean birth involving 57 multiprofessional team members from five UK maternity units, the vast majority of participants considered the training relevant and helpful for their clinical practice and improving outcomes following IFH. Participants reported substantial improvements in confidence in knowledge and skills for the technical and non-technical aspects of anticipating, identifying and managing an IFH. Supported by a range of resources and learning methods, the training appeared to enhance three key areas of understanding and practice. First, participants better understood the complexity of IFH by observing and experiencing the otherwise ‘hidden’ aspects of IFH and its management techniques. Second, training as a multiprofessional team improved non-technical skills, including better awareness that managing IFH requires a co-ordinated team effort including the obstetrician, midwife, anaesthetist and other team members. Third, participants furthered their understanding of optimal communication during the emergency, including the benefits of standardised communication among team members and the value of bespoke communication with women and birth partners.

Our findings of improved confidence in technical skills indicate that the training familiarises maternity professionals with IFH techniques in simulation. This could help address inexperience and feelings of uncertainty reported by UK maternity professionals when needing to use a variety of techniques to prevent or manage IFH. 12 14 Indeed, midwifery participants in particular expressed surprise and dissatisfaction about lack of previous training in this area, as also found in previous surveys. 12 13 The training substantially increased participants’ confidence in the technique of vaginal disimpaction (‘push-up’), potentially reducing the risk of neonatal injury attributed to incorrect execution of this technique. 9 50 The training is also the first to provide realistic hands-on practice and improve confidence of obstetricians in reverse breech extraction, a technique likely underused in UK practice due to inexperience. 12 This was enabled by the use of a novel validated birth simulation trainer, which provides more opportunities for practising caesarean birth techniques than other available birth trainers. 12 15 34 Although further evaluation is required, improved confidence of maternity professionals in their technical IFH skills could help reduce current variation in practice 12 15 and risks to mother and baby associated with IFH. 1 2 4 6

The improved confidence in team management for IFH found in this evaluation is consistent with previous findings of the benefits of multiprofessional simulation training for obstetric emergencies. 27 51–54 IFH technical training that focuses on obstetricians alone 30–33 is unlikely to deliver the improvement needed in required non-technical skills associated with multiprofessional training. Required non-technical skills include those relating to anticipation and preparation, situation awareness, communication and shared understanding, teamwork and behaviour, as well as decision-making. 23–26 55 Obstetrician-only training also overlooks the potentially beneficial effects of multiprofessional simulation practice on a collaborative culture and psychological safety. 28 56 57

Participants found the IFH management algorithms helpful for creating shared mental models for the team when dealing with the emergency. Again, this finding aligns with practice in other areas of obstetrics. 58–60 Examples include shoulder dystocia and assisted vaginal birth, where structured task lists or algorithms have also successfully been used to transfer knowledge across a maternity team, both in real life and simulation. 58–60 The management algorithms were grounded in evidence from a systematic review, PPI feedback and clinical user testing, 22 34 in contrast to previously proposed algorithms. 32 61 62

The improved confidence in team communication for IFH was likely related to the training’s emphasis on standardised use of language. This finding is similar to evidence on other obstetric emergencies that for example shows that clearly and calmly declaring the emergency using unambiguous terminology facilitates teamworking, communication and management. 23 26 63 An important element of the training was its emphasis on communicating with service users during emergency healthcare provision. 64–68 Participants valued this element of the training, such as the opportunity to practise using the communication principles and conversation starters that had been codesigned with the PPI group. Any future development or piloting of the training should continue with input from service users, 69–71 as emphasised by MVP representatives during the focus group discussions.

Strengths and limitations

This is the first evaluation of multiprofessional training for managing IFH at caesarean birth using lecture-based, visual and simulation methods to maximise learning of maternity professionals and teams. It is distinct from previous work on IFH training that focused on obstetricians alone or was limited by the surgical techniques taught. 30–33 A further strength of the evaluation is the inclusion of various types and sizes of hospitals, maternity professionals with different levels of experience and input from maternity service users. Other strengths include use of a structured framework (Kirkpatrick) to inform the multimethod evaluation and the multidisciplinary data collection and analysis.

This evaluation does have some limitations. Ongoing pressures caused by the COVID-19 pandemic required the use of convenience sampling of units and piloting of the training with a relatively small participant sample. This might limit representativeness of our results for the wider population of maternity units and professionals in the UK. Another limitation is the use of complete-case analysis for the questionnaires, which may have introduced some biased estimates if there were differential responses to particular questionnaire items. 72 Although it was not possible to quantify whether any social desirability bias may have affected scores, the observations and focus groups showed no indication of this. Finally, the scope of this evaluation did not stretch to evaluating evidence for changes in clinical outcomes, though it is promising that over 95% of participants agreed that the training would help improve outcomes following IFH.

Multiprofessional training for IFH at caesarean birth, using high-quality training methods including simulation, has very promising potential to improve maternity professionals’ knowledge and skills for managing IFH. Validation of our findings is needed in a larger, representative sample of UK maternity units, including establishing how best to scale and implement the training at a local and regional level. This should be followed by national dissemination and implementation of the training and evaluation of its impact using a core outcome set or routine data collection of IFH-specific clinical outcomes.

Acknowledgments

The authors thank all maternity service users for their time and insights through the patient and public involvement workshops and the facilitators at the maternity units for their support and help. For recruitment and communications support, the authors thank the Avoiding Brain Injury in Childbirth (ABC) communications team with members from the Royal College of Midwives (RCM), Royal College of Obstetricians and Gynaecologists and The Healthcare Improvement Studies Institute (THIS Institute). The authors are grateful for the many and varied contributions from colleagues across the ABC programme team and external to the team, including the visual designers (Dan Gould Design, Soapbox) and video agency (Hobson Curtis).

Twitter: @janvdscheer, @MaryDixonWoods, @oscarlyonsnz, @THIS_Institute @MidwivesRCM @RCObsGyn

Collaborators: ABC Contributor Group members: Alexandra Emms, Bethan Everson, Christopher W. Sadler, Clare F. Redfearn, Daniel Wolstenholme, Eftychia Sousi, Emma Crookes, Fida M Ali, Helen Gardner, Kerry A. Noble, Laura Cowell, Louise Lea, Muhammad Nauman Mehr, Nicky Lyon, Philippa Storer, Rhiannon S. Wong, Samiramis Saba, Sandra Igwe, Susanna Stanford and Zenab Barry.

Contributors: All authors read and approved the final manuscript. Their specific contributions, following Contributor Roles Taxonomy, are as follows: JWvdS contributed to conceptualisation, formal analysis, methodology, project administration, writing—original draft preparation and writing—review and editing. KC contributed to conceptualisation, funding acquisition, investigation, methodology, project administration, resources and writing—review and editing. PH and WR contributed to investigation, project administration, resources and writing—review and editing. RB contributed to conceptualisation, funding acquisition, project administration, supervision, resources, writing—original draft preparation and writing—review and editing. AP contributed to formal analysis, investigation, project administration and writing—review and editing. AA, IAFB and AO contributed to formal analysis, project administration and writing—review and editing. BA, NR, EP and AG contributed to formal analysis and writing—review and editing. JW contributed to investigation and writing—review and editing. MW contributed to resources and writing—review and editing. JL contributed to investigation, project administration and writing—review and editing. LH contributed to conceptualisation, investigation and project administration. JB contributed to funding acquisition, writing—original draft preparation and writing—review and editing. MD-W and TD contributed to conceptualisation, funding acquisition, methodology, supervision and writing—review and editing. GM contributed to formal analysis, visualisation and writing—review and editing. NF and OL contributed to methodology and writing—review and editing. JWvdS acts as the guarantor of the work.

Funding: The Avoiding Brain Injury in Childbirth programme (Department of Health and Social Care, UK) supported this work. THIS Institute is funded by the Health Foundation, Grant/Award Number: RHZF/001 - RG88620. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. Mary Dixon-Woods is a National Institute for Health and Care Research (NIHR) Senior Investigator (NF-SI-0617-10026).

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Please see the Methods section for further details.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study involves human participants but the UK’s Health Research Authority decision tool ( http://www.hra-decisiontools.org.uk/research/ ) showed that ethics approval was not required for the evaluation, as it was classified as a quality improvement activity, in which all of the participants were invited to join the authorship group and to be acknowledged in the project’s outputs. Participants were provided with information about the training and evaluation before participation, had the possibility to ask questions and withdraw their involvement at any time and gave their written consent to take part and agree to recording of this quality improvement activity.

IMAGES

  1. PPT

    the presentation of the fetal head is referred to as

  2. Fetal Presentation

    the presentation of the fetal head is referred to as

  3. Cephalic presentation of baby in pregnancy

    the presentation of the fetal head is referred to as

  4. Fetal Positions for Labor and Birth

    the presentation of the fetal head is referred to as

  5. the fetal presentation is cephalic

    the presentation of the fetal head is referred to as

  6. PPT

    the presentation of the fetal head is referred to as

VIDEO

  1. Level 3: Normal Fetal Head Anatomy, and Common Malformations

  2. Mechanism of normal Labour simplified on Maternal pelvis & Fetal skull #normaldelivery #obstetrics

  3. fetal skull presentation

  4. Crowing Fetal Head||Pregnancy||Pain😭😭😫😫#viral #love @iqraahmadfamilyvlogs

  5. Cephalic position of during delivery time /baby head down position

  6. InSimo & AGOF

COMMENTS

  1. Delivery, Face and Brow Presentation

    The term presentation describes the leading part of the fetus or the anatomical structure closest to the maternal pelvic inlet during labor. The presentation can roughly be divided into the following classifications: cephalic, breech, shoulder, and compound. Cephalic presentation is the most common and can be further subclassified as vertex, sinciput, brow, face, and chin. The most common ...

  2. Fetal Presentation, Position, and Lie (Including Breech Presentation

    In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.. In brow presentation, the neck is moderately arched so that the brow presents first.. Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor.

  3. Delivery, Face Presentation, and Brow Presentation: Understanding Fetal

    Causes: Brow presentation may result from abnormal fetal positioning, poor engagement of the fetal head, or other factors that prevent full flexion or extension. Complications: Brow presentation is associated with a higher risk of prolonged labor, difficulty in descent, increased chances of fetal head entrapment, birth injuries, and the ...

  4. Fetal Positions For Birth: Presentation, Types & Function

    Possible fetal positions can include: Occiput or cephalic anterior: This is the best fetal position for childbirth. It means the fetus is head down, facing the birth parent's spine (facing backward). Its chin is tucked towards its chest. The fetus will also be slightly off-center, with the back of its head facing the right or left.

  5. Face and Brow Presentation

    In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying in a longitudinal axis. The presenting portion of the fetus is the fetal face between the orbital ridges and the chin. The fetal chin (mentum) is the point designated for reference during an ...

  6. Leopold Maneuvers

    It is used to determine the position, presentation, and engagement of the fetus in utero. Fetal presentation refers to the fetal anatomic part proceeding first into the pelvic inlet. When the fetal head is approaching the pelvic inlet, it is referred to as a cephalic presentation. The commonest presentation is the vertex of the fetal head.

  7. Position and Presentation of the Fetus

    Toward the end of pregnancy, the fetus moves into position for delivery. Normally, the presentation is vertex (head first), and the position is occiput anterior (facing toward the pregnant patient's spine) with the face and body angled to one side and the neck flexed. Abnormal presentations include face, brow, breech, and shoulder.

  8. Fetal Malpresentation and Malposition

    Fetal presentation refers to the fetal anatomic part proceeding first into and through the pelvic inlet. Most commonly, the fetal head is presenting, which is referred to as cephalic presentation. Once cervical dilation has occurred and the fetal fontanels may be appreciated, if the head is flexed, the presenting anatomy of the fetal head is ...

  9. Fetal Malpresentation and Malposition

    Fetal presentation refers to the fetal anatomic part proceeding first into and through the pelvic inlet. Most commonly, the fetal head is presenting, which is referred to as cephalic presentation. Once cervical dilation has occurred and the fetal fontanels may be appreciated, if the head is flexed, the presenting anatomy of the fetal head

  10. Cephalic presentation

    A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations ...

  11. Mechanism of Normal Labor

    Descent: As the fetal head engages and descends, it assumes an occiput transverse position because that is the widest pelvic diameter available for the widest part of the fetal head. Flexion: While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller ...

  12. Normal Labor

    Cephalic presentations are subclassified according to the relationship between the head and body of the fetus ().Ordinarily, the head is flexed sharply so that the chin contacts the thorax. The occipital fontanel is the presenting part, and this presentation is referred to as a vertex or occiput presentation.Much less often, the fetal neck may be sharply extended so that the occiput and back ...

  13. Birth

    Birth - Fetal Presentations, Complications, Delivery: The child may lie so that the back of its head is directed backward and toward either the right or left side. The leading pole is then in the right or left posterior quadrant of the mother's pelvis, and the presentation is referred to as occipitoanterior position. In such cases the back of the child's head usually rotates to the front ...

  14. 10.02 Key Terms Related to Fetal Positions

    This is usually referred to as a transverse lie. Figure 10-1. Typical types of presentations. (2) Percentages of presentations. (a) Head first is the most common-96 percent. (b) Breech is the next most common-3.5 percent. ... In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military ...

  15. Breech

    The term "fetal presentation" refers to the part of your baby's body that is closest to the birth canal. In most full-term pregnancies, the baby is positioned head down, or cephalic, in the uterus. Review Date 11/21/2022

  16. Fetal head

    Fetal head. The fetal head, from an obstetrical viewpoint, and in particular its size, is important because an essential feature of labor is the adaptation between the fetal head and the maternal bony pelvis. Only a comparatively small part of the head at term is represented by the face. The rest of the head is composed of the firm skull, which ...

  17. Sonographic evaluation of the fetal head position and attitude during

    The fetal vertex is the portion of the head lying in the midline between the 2 fontanels, and vertex presentation is the most favorable presentation for a vaginal delivery because it features a sharp flexion of the fetal head on to the chest. 1, 2 In the cephalic-presenting fetus, the flexion of the fetal head is among the cardinal movements of ...

  18. CH 15 Flashcards

    The presentation of the fetus head is referred to as _____. CROWNING. Although not always a sign of fetal distress, _____ _____ is highly correlated with its occurrence. MECONIUM STAINING. A patient you care for in labor asks you what causes labor to begin. Which of the following statements is a possible explanation?

  19. Fetal Presentation, Position, and Lie (Including Breech Presentation

    During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one ...

  20. Labor and Birth

    The relationship of the fetal spine to the maternal spine is referred to as fetal lie. Fetal lie can be described as longitudinal, transverse, or oblique. ... When the fetus is in cephalic presentation, the head is the first part to contact the cervix and expel from the uterus during delivery. About 95% of all fetuses are in cephalic ...

  21. Sonographic evaluation of the fetal head position and attitude during

    The fetal vertex is the portion of the head lying in the midline between the 2 fontanels, and vertex presentation is the most favorable presentation for a vaginal delivery because it features a sharp flexion of the fetal head on to the chest.

  22. Fetal Presentation Flashcards

    Fetal head may be distorted at birth as an oblong shape; may have some swelling from fluid (caput succedaneum) or blood (cephalohematoma); these are all normal and should go away on their own Fetal attitude

  23. Training for managing impacted fetal head at caesarean birth

    Introduction. Impacted fetal head (IFH) is a technically challenging obstetric emergency increasingly encountered during unplanned caesarean births. 1-3 Complicating up to 10% of caesarean births in the UK (1.5% of all births), 4-6 it is associated with significant risks to mother and baby, including postpartum haemorrhage, trauma to uterus and bladder, hypoxic ischaemic brain injury and ...