Delivery of the deeply engaged head: a lacuna in training

The percentage of second stage caesarean sections is on the rise. The delivery of a deeply engaged head in the second stage by caesarean section is an experience feared by most junior registrars. Among the different delivery techniques described, the pull technique has been proven to have a lesser morbidity than the push technique. However, trainees do not receive any structured training in either of these methods. We undertook a survey among 150 UK trainees in SPROGS 2008 in order to understand their experience in dealing with a deeply engaged head in second stage by CS, to ascertain whether trainees feel that they need training to deal with the situation and to discover the means by which this training can be delivered. The questionnaire return rate was 94%. More than 80% agreed that they had faced difficulties in the past while trying to deliver a deeply engaged head. Only 20% used the recommended semi-lithotomy position during caesarean section for an impacted head. Among the trainees who had received only UK training, only 42% were confident of doing a pull method if the need arose. More than 80% of the trainees agreed that supervised sessions to teach alternative techniques for delivery, such as the reverse breech/pull method would be useful and that it would improve their confidence when doing a trial of vaginal delivery. The RCOG agreed that there is little formal training in delivery of a deeply engaged head and is considering recommending trainees complete 2 OSATS (Objective Structured Assessment Tools) in this area. It has also asked the authors to form a skills and drills protocol, which the authors have done and submitted to the RCOG.