A Simulation Study of Forces Applied to Managing an Impacted Fetal Head: A Review and CommentaryAuthor: Lawrence DevoeAffiliation: Medical College of Georgia, Obstetrics & GynecologyCorresponding Author: Lawrence Devoe. ORCID ID: 0000-0003-1026-8388Funding Statement: No funds were used in writing this reportConflicts of Interest Disclosure: No conflicts of interest were identifiedEthics Approval Statement: No ethics approval was required for this reportA deeply impacted fetal head in the second stage of labor presents significant management challenges for obstetricians wishing to avoid serious fetal and maternal complications at the time of cesarean delivery (CD) (Peak AG et al. Techniques for managing an impacted fetal head at cesarean section: A systematic review. Eur J Obstet Gynecol Reprod Biol 2023 Feb 281: 12-22). However, a debate persists about the optimal approach to disimpaction techniques (Jeve YB et al. Comparison of techniques used to deliver a deeply impacted head at full dilation: a systematic review and meta-analysis. BJOG. 2016 Feb; 123: 337-45). When a decision is made to manually disimpact a fetal head, a major issue is the amount of force applied by the obstetrician to accomplish this procedure successfully and safely.The present study (Xue Y et al. Characterising forces applied during the simulatedmanagement of impacted fetal head: pre-clinical methods study. BJOG.In press )returns to the drawing board to address this issue. The investigators developed a simulation model that provided participants with surgical gloves fitted with sensors distributed along fingertips, palmar and dorsal surfaces while two additional pairs of gloves were worn above and below the sensorized pair. These sensors enabled measurements of all the forces applied by the study participants and showed the greatest consistency and highest maximal forces applied at the fingertips. While only one of the thirteen participants failed to disimpact the model head, there was considerable variability in the amount of force applied by the successful participants.Xue et al. concluded that they found the sensor glove was useful for training. However, I am not entirely certain how they reached this conclusion, particularly in view of the participants’ recommendations that future sensors should be made wireless and fewer plain gloves be employed. Moreover, the authors readily admit that future work is needed that includes direct comparisons of subjective estimates of applied forces with those actually measured. The authors also mention the need for an assessment of changes in participant confidence and skill after repeated uses of both active and inactive gloves. They also note that the position of the fetal head was always in occiput anterior and future trials with other fetal head positions should be considered.This report provides novel and potentially useful information for designing and deploying a low-risk training platform for obstetricians at all levels of training and experience to optimize their practices when encountering this delivery complication. While simulation is not a “real life” situation, the feedback that the participants in this study received regarding technique and applied forces could well help them to improve their handling of this clinical scenario in the future.
