Breech birth - what are the RCOG Guidelines?

Mismanaged vaginal breech births, in which the baby’s position means that it is born bottom first or foot first instead of head first, have been found to give rise to a disproportionate number of successful, high value compensation claims. As the numbers of vaginal breech deliveries have declined, in favour of caesarean births, so has the skill and experience of the junior obstetricians who are faced with performing unplanned vaginal breech deliveries, often out of hours without the presence of a supervising consultant. The Royal College of Obstetricians and Gynaecologists (RCOG) 2017 guidelines provide specific recommendations for the safe management of breech deliveries.

Successful claims for cerebral palsy from breech birth

Back in October last year I commented on the findings of NHS Resolution’s five-year review of successful cerebral palsy claims, Five Years of Cerebral Palsy Claims: A thematic review of NHS Resolution Data.

One of the concerns raised in the report was the disproportionate number of breech birth cases which gave rise to high value claims for cerebral palsy.  Six out of the 50 successful cerebral palsy claims that were reviewed, or 12%, arose from the poor management of breech births, a figure far exceeding the proportion of pregnancies with breech presentation within the population served by the NHS. 

Of those six cases:

• all were born outside standard working hours
• five were previously undiagnosed breech presentations which were only identified in labour
• the five late diagnosed cases were not continuously fetal-heart monitored throughout labour
• five were delivered by a registrar (a training grade doctor) without a consultant present
• all were attempted vaginal breech deliveries with three becoming emergency caesareans
• four were full term and the remaining two were delivered at 34 weeks gestation

Fewer vaginal breech deliveries means doctors are less skilled

Despite an increasing national trend towards elective caesarean section deliveries of babies with breech presentation and a consequent reduction in vaginal breech deliveries, the review found that when they occurred, unplanned (or late diagnosed) vaginal breech deliveries were more often carried out by training grade doctors, out of hours, without a consultant present. Junior obstetricians now have less exposure to vaginal breech deliveries and are, therefore, less experienced and less skilled in managing these difficult procedures. It is known that having an experienced practitioner in attendance at vaginal breech delivery is a vital component for safe delivery. Where the consultant is absent and the junior obstetrician doesn’t have the requisite skills and experience in vaginal breech delivery, maternal and child safety is inevitably compromised, as is demonstrated by the high number of successful claims.

New RCOG Guidelines

The Royal College of Obstetricians and Gynaecologists (RCOG) have issued new guidelines, Management of Breech Presentation March 2017,  which acknowledge that lack of experience has led to a loss of the skills that are essential for safe breech deliveries. The guideline makes specific recommendations for the care of women with an unplanned breech presentation in labour, with the emphasis on individualised care according to stage of labour and risk levels, safe management and informed consent. The guideline  states that the essential components of a planned vaginal breech birth are appropriate case selection, management according to a strict protocol and the availability of skilled attendants.

The recommendations include:

• Women with a breech presentation at term should be offered external cephalic version (ECV), a safe and 50% successful procedure in which the baby’s position in late pregnancy is turned by manipulation from the outside of the maternal abdomen. Exceptions include where the procedure is contraindicated owing to factors such as the position of the placenta, lack of amniotic fluid, rhesus disease or multiple pregnancy. ECV should be performed in a unit with facilities for electronic fetal monitoring and surgical delivery, with monitoring taking place before, during and after the procedure. If the mother experiences abnormal abdominal pain or vaginal bleeding after the ECV, the baby should be delivered immediately by caesarean section.
• In a persistent breech presentation, where any of the risks for vaginal birth are present, the mother should be counselled about the risks and caesarean section recommended.
• Increased risk factors for planned vaginal breech birth include hyperextension of the baby’s neck on ultrasound, abnormally high or low estimated fetal weight, footling presentation (where the baby’s foot will be delivered before its pelvis) or evidence of antenatal compromise.
• Planned caesarean section is recommended in twin pregnancy where the presenting twin is in breech position.
• The presence of a skilled birth attendant is essential for safe vaginal breech birth. If necessary, the mother should be transferred to a unit with access to greater levels of skill and experience.
• All maternity units are required to provide skilled supervision and protocols for the management of vaginal breech birth where the mother is admitted in advanced labour.  The skilled healthcare professionals (senior obstetricians and midwives) in each unit must also develop mandatory guidance for the case selection and management of vaginal breech.
• Induction of labour is not recommended, and augmentation should only be considered where contractions are infrequent in the presence of epidural anaesthesia.
• Continuous electronic fetal monitoring is recommended.
• The birth must take place in a unit with facilities for immediate caesarean section.
• Where delay or poor fetal condition are evident in the active second stage of labour, assistance should be given and all midwives and obstetricians must be familiar with the recommended techniques for assisting  vaginal breech delivery. Traction must not be applied.
• Where the mother is already in spontaneous labour, the mode of delivery should be decided based on individual risk factors such as the stage and progress of the labour, the baby’s position, fetal wellbeing and the availability of an operator skilled in vaginal breech delivery.

The RCOG’s guidance also recommends that simulation equipment is used to train doctors and midwives so that they can rehearse, together, the skills that are needed during vaginal breech birth. Multidisciplinary obstetric training is expensive but, as the RCOG quite rightly observes, it is nowhere near as expensive as compensating a child with cerebral palsy caused by medical errors.

If you are caring for a child with cerebral palsy caused by medical negligence at or around the time of birth, contact us by email at cerebralpalsy@boyesturner.com.