{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T06:10:03Z","timestamp":1780467003881,"version":"3.54.1"},"reference-count":65,"publisher":"Wiley","issue":"9","license":[{"start":{"date-parts":[[2024,5,24]],"date-time":"2024-05-24T00:00:00Z","timestamp":1716508800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["obgyn.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Acta Obstet Gynecol Scand"],"published-print":{"date-parts":[[2024,9]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Introduction<\/jats:title><jats:p>Despite increasing incidence of impacted fetal head at cesarean birth and associated injury, it is unclear which techniques are most effective for prevention and management. A high quality evidence review in accordance with international reporting standards is currently lacking. To address this gap, we aimed to identify, assess, and synthesize studies comparing techniques to prevent or manage impacted fetal head at cesarean birth prior to or at full cervical dilatation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Material and Methods<\/jats:title><jats:p>We searched MEDLINE, Emcare, Embase and Cochrane databases up to 1 January 2023 (PROSPERO: CRD420212750016). Included were randomized controlled trials (any size) and non\u2010randomized comparative studies (<jats:italic>n<\/jats:italic>\u2009\u2265\u200930 in each arm) comparing techniques or adjunctive measures to prevent or manage impacted fetal head at cesarean birth. Following screening and data extraction, we assessed risk of bias for individual studies using RoB2 and ROBINS\u2010I, and certainty of evidence using GRADE. We synthesized data using meta\u2010analysis where appropriate, including sensitivity analyses excluding data published in potential predatory journals or at risk of retraction.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We identified 24 eligible studies (11 randomized and 13 non\u2010randomized) including 3558 women, that compared vaginal disimpaction, reverse breech extraction, the Patwardhan method and\/or the Fetal Pillow\u00ae. GRADE certainty of evidence was low or very low for all 96 outcomes across seven reported comparisons. Pooled analysis mostly showed no or equivocal differences in outcomes across comparisons of techniques. Although some maternal outcomes suggested differences between techniques (eg risk ratio of 3.41 [95% CI: 2.50\u20134.66] for uterine incision extension with vaginal disimpaction vs. reverse breech extraction), these were based on unreliable pooled estimates given very low GRADE certainty and, in some cases, additional risk of bias introduced by data published in potential predatory journals or at risk of retraction.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>The current weaknesses in the evidence base mean that no firm recommendations can be made about the superiority of any one impacted fetal head technique over another, indicating that high quality training is needed across the range of techniques. Future studies to improve the evidence base are urgently required, using a standard definition of impacted fetal head, agreed maternal and neonatal outcome sets for impacted fetal head, and internationally recommended reporting standards.<\/jats:p><\/jats:sec>","DOI":"10.1111\/aogs.14873","type":"journal-article","created":{"date-parts":[[2024,5,24]],"date-time":"2024-05-24T14:50:01Z","timestamp":1716562201000},"page":"1702-1713","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["Management of impacted fetal head at cesarean birth: A systematic review and meta\u2010analysis"],"prefix":"10.1111","volume":"103","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5690-5656","authenticated-orcid":false,"given":"Katie","family":"Cornthwaite","sequence":"first","affiliation":[{"name":"Royal College of Obstetricians &amp; Gynaecologists  London UK"},{"name":"University Hospitals Bristol and Weston  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4368-0355","authenticated-orcid":false,"given":"Jan W.","family":"van der Scheer","sequence":"additional","affiliation":[{"name":"THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care University of Cambridge, Strangeways Research Laboratory  Cambridge UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Kelly","sequence":"additional","affiliation":[{"name":"THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care University of Cambridge, Strangeways Research Laboratory  Cambridge UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mia","family":"Schmidt\u2010Hansen","sequence":"additional","affiliation":[{"name":"National Institute for Health and Care Excellence  London UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0037-274X","authenticated-orcid":false,"given":"Jenni","family":"Burt","sequence":"additional","affiliation":[{"name":"THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care University of Cambridge, Strangeways Research Laboratory  Cambridge UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5915-0041","authenticated-orcid":false,"given":"Mary","family":"Dixon\u2010Woods","sequence":"additional","affiliation":[{"name":"THIS Institute (The Healthcare Improvement Studies Institute), Department of Public Health and Primary Care University of Cambridge, Strangeways Research Laboratory  Cambridge UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"Draycott","sequence":"additional","affiliation":[{"name":"Royal College of Obstetricians &amp; Gynaecologists  London UK"},{"name":"North Bristol NHS Trust  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rachna","family":"Bahl","sequence":"additional","affiliation":[{"name":"Royal College of Obstetricians &amp; Gynaecologists  London UK"},{"name":"University Hospitals Bristol and Weston  Bristol UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2024,5,24]]},"reference":[{"key":"e_1_2_12_2_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2021.04.021"},{"key":"e_1_2_12_3_1","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.13593"},{"key":"e_1_2_12_4_1","article-title":"Techniques for assisting difficult delivery at cesarean section","volume":"1","author":"Waterfall H","year":"2016","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_2_12_5_1","volume-title":"The Second Report: the Evolution of the Early Notification Scheme","author":"NHS Resolution","year":"2022"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.1111\/1471-0528.13613"},{"key":"e_1_2_12_7_1","first-page":"459","article-title":"'Negligent' technique for dis\u2010impacting the fetal head at cesarean section: a scientific opinion paper","volume":"120","author":"Walker K","year":"2013","journal-title":"BJOG"},{"key":"e_1_2_12_8_1","volume-title":"Inquest into the Death of Nixon Martin Tonkin","author":"Lock J","year":"2017"},{"key":"e_1_2_12_9_1","volume-title":"The Early Notification Scheme Progress Report: Collaboration and Improved Experience for Families","author":"NHS Resolution","year":"2019"},{"key":"e_1_2_12_10_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jogc.2021.01.005"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1080\/01443615.2019.1593333"},{"key":"e_1_2_12_12_1","doi-asserted-by":"publisher","DOI":"10.1515\/jpm-2021-0572"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2022.12.017"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ejogrb.2022.03.004"},{"key":"e_1_2_12_15_1","unstructured":"National Institute for Health and Care Excellence (NICE).Balloon disimpaction of the baby's head at emergency cesarean during the second stage of labour. 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