Breech birth injury claims - what are the RCOG guidelines?

Mismanaged vaginal breech births, in which the baby is born bottom-first or foot-first instead of head-first, are a common cause of high-value, birth injury 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 (childbirth doctors) who are left to perform unplanned vaginal breech deliveries, often out of hours without the presence of a supervising consultant.

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines provide specific recommendations for the safe management of breech births.

Successful claims for cerebral palsy from negligent management of breech birth

The NHS’ legal claims defence organisation, NHS Resolution, has previously highlighted concerns about the disproportionate number of breech birth cases which give rise to high-value claims for cerebral palsy. Birth injury claims arising from breech deliveries often involve:

• births which take place outside standard working hours;
• previously undiagnosed breech presentations which are only identified in labour;
• lack of continuous CTG fetal-heart monitoring throughout labour;
• delivery by training grade doctors without a consultant present;
• attempted vaginal breech deliveries which later require emergency caesarean section.

Why are junior obstetricians less skilled in vaginal breech birth?

The increasing national trend towards elective caesarean section deliveries of babies with breech presentation and consequent reduction in vaginal breech deliveries means that when unplanned (or late diagnosed) vaginal breech deliveries occur, they are often carried out by training grade doctors, out of hours, without a consultant present.

Junior obstetricians now have less exposure to vaginal breech deliveries during their training 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.

What are the RCOG guidelines for breech births?

The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines,  Management of Breech Presentation, acknowledge that lack of experience has led to a loss of the skills that are essential for safe breech births. 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 guidelines include the following recommendations:

• Women with a breech presentation at term (37 weeks or later) should be offered external cephalic version (ECV), a safe and 50% successful procedure in which the baby’s position is turned by manipulation from the outside of the mother’s abdomen. Exceptions include where the ECV 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, 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 (such as with Syntocinon) 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 there is delay or concern about the unborn baby’s condition 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 (pulling) 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.

RCOG 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 correctly observes, it is nowhere near as expensive as compensating a child with cerebral palsy caused by medical errors.

Read more about breech birth injury claims.

Read about a recent breech birth injury case in which we secured an £18 million settlement for a child with cerebral palsy.

If your child has cerebral palsy or neurological disability as a result of medical negligence, or you have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by