Recurring concern

Unsafe management of impacted fetal head at caesarean section

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First reported 9 Oct 2020•Latest report 27 Oct 2025

Definition

What this concern includes

Includes failures in the dedicated obstetric process for recognising, escalating and managing impacted fetal head at caesarean section, including guidance, role allocation, training and competence, choice and performance of disimpaction manoeuvres, communication between obstetricians and midwives, and immediate review of resulting maternal or neonatal risks.

Not included

Excludes general caesarean-section, midwifery, fetal-monitoring or emergency-obstetric deficiencies where impacted fetal head is not the material safety concern.
Excludes routine delivery-mode decisions and birth-planning failures that do not concern management of an impacted fetal head.
Excludes unrelated neonatal resuscitation, cord-blood sampling and postpartum-care failures after the impacted fetal head has been safely managed.
Excludes generic training or communication deficiencies unless they directly impair the impacted-fetal-head management process.

Reports: 2
Individual concerns: 3
Date range: 2020–2025
Stated actions: 4

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Royal College of Obstetricians and Gynaecologists2

Royal College of Nursing and Midwifery (source wording)1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

27 Oct2025
Berkshire
Concerns raised2
1. Absence of relevant training for impacted fetal head at caesarean section
2. Lack of consistent guidance for managing impacted fetal head at caesarean section
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Produce and publish the second edition of Scientific Impact Paper No. 73 on managing impacted fetal head at caesarean birth.
  Stated by Royal College of Obstetricians and GynaecologistsStated completed
2. Action
  Continue reviewing emerging evidence on impacted fetal head at caesarean birth.
  Stated by Royal College of Obstetricians and GynaecologistsStated in progress
3. Action
  Consider developing a formal guideline when the evidence base permits.
  Stated by Royal College of Obstetricians and GynaecologistsStated planned
Respondent positions 1
1. Position
  The evidence base is insufficient to support a formal Green-top Guideline on impacted fetal head; guideline development will be considered when evidence permits.
  Stated by Royal College of Obstetricians and GynaecologistsUnable to act
AI-generated summary

Louisa Walker · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Louisa Walker was born on 25 May 2024 and died on 28 June 2024 after her head became impacted in her mother’s pelvis during a caesarean section. She suffered skull fractures and intracranial bleeding during attempts to disimpact her head. The principal concerns were the absence of national guidance for impacted fetal head at caesarean section, uncertainty and potentially inadequate training, and the increasing frequency of this emergency.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Absence of relevant training for impacted fetal head at caesarean section
Wider context from the report
“2. Whilst the algorithm referred to in RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency. ”
Source location
Louisa Walker · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of consistent guidance for managing impacted fetal head at caesarean section
Wider context from the report
“1. There is no national guidance (by way of green top guideline or otherwise) dealing with impacted fetal head seen at caesarean section. 2. Whilst the algorithm referred to in RCOG scientific impact paper number 73 may well have been adopted by many trusts, there is a risk of uncertainty and absence of relevant training in respect of this obstetric emergency. ”
Source location
Louisa Walker · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Produce and publish the second edition of Scientific Impact Paper No. 73 on managing impacted fetal head at caesarean birth.

Verbatim wording from the response
“RCOG Scientific Impact Paper No. 73, Management of Impacted Fetal Head at Caesarean Birth (2025 Second Edition), was produced as part of the ABC programme. It provides a working definition of impacted fetal head, reviews the current evidence regarding prediction, prevention and management, and describes the recognised techniques for managing the emergency.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 29 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue reviewing emerging evidence on impacted fetal head at caesarean birth.

Verbatim wording from the response
“The 2025 second edition was developed to reflect current evidence and clarify its strengths and limitations. We will continue to review emerging evidence and consider guideline development when the evidence base permits.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 29 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Consider developing a formal guideline when the evidence base permits.

Verbatim wording from the response
“Scientific Impact Papers (SIPs) are used where the evidence base is still evolving and insufficient to support a formal Green-top Guideline. While Green-top Guidelines aim to provide clinical instructions, SIPs give expert analysis on the new scientific findings and highlight the future implications on practice. Although a SIP does not carry the status of a Green-top Guideline, it is a formal, peer-reviewed RCOG publication intended to inform national standards and practice.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 29 October 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The evidence base is insufficient to support a formal Green-top Guideline on impacted fetal head; guideline development will be considered when evidence permits.

Verbatim wording from the response
“Scientific Impact Papers (SIPs) are used where the evidence base is still evolving and insufficient to support a formal Green-top Guideline. While Green-top Guidelines aim to provide clinical instructions, SIPs give expert analysis on the new scientific findings and highlight the future implications on practice. Although a SIP does not carry the status of a Green-top Guideline, it is a formal, peer-reviewed RCOG publication intended to inform national standards and practice.”

Source location
Response from Royal College of Obstetricians and Gynaecologists
Page 2 · response
Published 29 October 2025
Open published response
9 Oct2020
Nottinghamshire
Concerns raised1
1. Lack of training for midwives performing vaginal pushes in theatre
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Scale impacted fetal head training nationally to improve outcomes.
  Stated by Royal College of Obstetricians and GynaecologistsStated planned
AI-generated summary

Noah Richard Poole · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Noah Richard Poole died aged 8 days from complications of a head injury sustained during difficult extraction at his caesarean delivery. The report identified failures to counsel his mother properly about delivery options and to agree a birth plan, as well as a lack of professional guidance and training concerning vaginal pushes and fetal pillows during difficult fetal extraction.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of training for midwives performing vaginal pushes in theatre
Wider context from the report
“(1) Lack of professional Guidance regarding the use of a vaginal push to disimpact the fetal head Almost all of the Midwives in this case told me that they had been asked perform a ‘vaginal push’ in theatre at some point in their career, but it is not something that frequently occurs, nor is it something they are trained to do. Furthermore, practice varies between doctors as to whether they ask a fellow doctor to provide the vaginal push, or a midwife, and whether they provide the individual with any guidance on exactly what they should do. The Midwife did exactly what was asked of her to “push” Noah’s head. She performed this in the usual way that midwives perform a vaginal examination, that is, with two pointed digits. I have been unable to determine whether it was the Doctor’s fingers or the Midwife’s fingers that caused the depressed fracture to Noah’s head, but both are a possibility, and the issue remains that midwives are asked to perform a manoeuvre in a theatre environment for which they have received no training nor is there any professional guidance. Equally, there is no guidance for the Doctor as to whether and what information they ought to impart to the midwife before they embark on the procedure. ”
Source location
Noah Richard Poole · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Scale impacted fetal head training nationally to improve outcomes.

Verbatim wording from the response
“Summary The RCOG recognises that there is a current dearth in both guidelines and training for the management of IFH and we are committed to addressing this:”

Source location
2020-0206-Response-from-Royal-College-of-Obstetricians-and-Gynaecologists-Redacted.pdf
Page 2 · response
Published 3 December 2020
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Absence of relevant training for impacted fetal head at caesarean section

Lack of consistent guidance for managing impacted fetal head at caesarean section

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of training for midwives performing vaginal pushes in theatre

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 3

Respondent positions 1

Actions described in response 1