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Simple scan to identify breech babies supported by partner Jane Weakley and senior midwife Charlene Francois

Jane Weakley
26/06/2019
Partner Jane Weakley is regularly instructed to investigate cases where failed breech delivery has resulted in cerebral palsy. A recent paper by a Cambridge University research team highlights a simple solution to an aspect of childbirth that, if undiagnosed, can end in tragedy.

Breech births, whereby a baby's bottom or feet emerge first during labour, currently only tend to be identified by midwives and doctors feeling the shape of a mother's pregnancy bump. Three or four of every 100 babies sit in a breech position towards the end of a pregnancy and most turn to the 'head-first' position by around 36 weeks, ready for delivery.

However, the researchers found that out of 179 pregnancies within their study group identified as breech by a scan, only 19 of the women delivered vaginally, with 50 needing an emergency caesarean and 110 opting for a planned caesarean. Before the scan, less than half the babies had been identified as breech, a worrying indication of just how random it can be for the potential problem to be spotted.

Several years ago, I dealt with a terrible case of a mother who at 38 weeks had an abdominal examination by a midwife and was told the baby's head was correctly in the down position, despite explicitly telling the midwife she thought the baby had done a huge somersault.

Unfortunately, this was not the case and when she went into labour, the baby was suddenly discovered to be footling breech, resulting in a traumatic delivery and a delay in delivering the baby's head.

Expert evidence concluded it was unlikely that the baby would have turned breech following the abdominal examination. Sadly, the delay in delivering the head meant the baby suffered a hypoxic brain injury leading to cerebral palsy and all the associated challenges for the family in raising a seriously disabled child who will never be able to live independently

An ultrasound would have prevented this and it is little wonder that the Cambridge researchers are now calling for pregnant women to be routinely offered such a scan at 36 weeks to spot the risk of a breech delivery. Not only would this save the lives of the babies who die during a breech delivery, it would also avoid around 4,000 emergency caesareans, which brings its own associated risks.

If a breech baby can be identified at 36 weeks, it gives doctors and midwives more of a chance to manually encourage the baby to turn using the external cephalic version process (ECV). Where this method does not succeed in turning the baby, at least there is ample chance to organise a planned caesarean, completely avoiding the need to attempt a vaginal breech birth delivery, which is possible but often very stressful for a mother and clearly carries serious risk.

Professor Gordon Smith who led the study estimated that the cost of offering a scan during a standard midwife appointment using portable ultrasound machines would be less than £20 per patient. More research of bigger study groups has been called for despite the so-far promising evidence of the benefit. Not only would such ultrasounds save families from terrible tragedy, ultimately it would actually save the health service money in terms of the aftercare of mothers and babies badly affected by breech births.'

Expert midwife Charlene Francois

Charlene has been a practicing midwife for 35 years. She acts as an independent witness in cases involving breech birth that result in death or brain injury.

Citing an additional report from the British Journal of Midwifery (Should midwives learn to scan for presentation?) Charlene strongly supports Gordon Smith's recommendations. Charlene would recommend that Band 7 midwives (working at senior level and managing more junior midwives) be taught to perform presentation scans, not least because this would involve much shorter training than that of an ultrasonographer, meaning weeks rather than years.

One midwife or doctor per shift should be trained on presentation scanning, after which others below Band 7 can begin to learn.

Risks of breech birth

'If a doctor performs an ECV before 36 weeks and breech is diagnosed, it can be successful in helping a baby that is going to turn to turn. Once you’re beyond 36 weeks, it's much more difficult because the baby is bigger and there is a lack of room. You also can't perform an ECV once a woman is in labour.

'The problem is, even though they're trained to do so and refreshed annually, doctors and midwives lose the skill of performing a breech delivery, which is inherently full of risk, because they don't do enough of them and when they do, it's generally in an emergency situation.

'In 35 years of practice, I've only performed two. Unexplained breech – i.e. those that have not be diagnosed in advance - are terrible. I have never forgotten being presented with a mother whose breech baby was half delivered. In terrible circumstances, me and the doctor managed to deliver the baby, but it was brain damaged. And that is the fundamental risk of breech births – if they go wrong and the baby gets stuck, the result is death or brain damage.

'If, however, you know in advance that a baby is breech, you can inform the mother of the risks of choosing a caesarean versus the risks of a vaginal delivery with an experienced midwife.'

Presentation scans are routinely performed in the US and elsewhere in Europe. The UK is currently one of the only countries that doesn’t perform them routinely and this is primarily down to funding.

'Of course, the midwife must understand the machine, understand what they are looking for. They will then be observed performing the scan and can then begin to do perform them on the ward.'

British Journal study conclusions

The British Journal study, based on responses from 870 non-sonographer midwives and midwifery students, reports that currently bedside presentation scans are performed by junior doctors (often with no formal training), often leading to delays and frustration among staff and patients.

While highlighting concerns that such scans would increase the medicalisation of the birthing experience and could undermine clinical skills, there was overwhelming support from respondents (82.5 per cent) for accredited, short courses to teach midwives to accurately scan for fetal presentation.

Ultimately, the study also highlights that the choice regarding presentation scans is not between traditional midwifery skills and modern techniques, rather the opportunity to use the best opportunities available for care, old and new.

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