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Breech presentation

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Following an increased number of women diagnosed with breech presentation in established labour, a unit is considering scanning all nulliparous women on admission to confirm presentation.
 
Do you know of any other Trusts considering a similar move? Should midwives and obstetricians receive more training to identify breech presentations prior to labour?

Breech presentation
Topic created By - Rhea Johnson (14 May 2010 - 12:29:06) Following an increased number of women diagnosed with breech presentation in established labour, a unit is considering scanning all nulliparous women on admission to confirm presentation. 
 
Do you know of any other Trusts considering a similar move? Should midwives and obstetricians receive more training to identify breech presentations prior to labour?

Responses

Re: Breech presentation
Submitted By - Guest 17/05/2010 12:00:09 I don't understand why the policy would just incorporate nulliparous women, since breech presentation is more common in multiparous women. 
 
I am not aware of any of the trusts in my locality adopting this approach. 
 
Introducing ultrasound as routine will de-skill midwives and obstetricians in palpation, just as we became de-skilled in conducting breech deliveries following the flawed term breech trial. We would yet again lose another core defining midwifery skill. 
 
I understand that palpation can be inaccurate and subjective, and I feel that scanning should only be utilised were there is uncertainty. I do believe that the effects of scanning on the fetus and the women are not entirely known. 
 
Perhaps ensuring that ALL staff perform abdominal palpations prior to vaginal examinations will maybe decrease the chances of breech remaining undiagnosed. (I know that this is what should happen anyway, but I have noticed in practice that many of my colleagues do not always do this.) 
 
However, I do NOT think that midwives and obstetricians need more training in identifying breech presentations. We spend years training to do just that already. Perhaps the causation of the increase in breech in established labour may not be our clinical skills, but due to the increased difficulty in palpating the fetus due to maternal obesity. 
 
Perhaps new research into the safety of vaginal breech delivery is warranted, and maybe this may not be even seen as a problem in the first place. Or maybe research into methods to prevent breech even occurring would be useful. 
 
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:03:25 There is no plan at this present time in our trust to start scanning all nulliparous women on admission, however I strongly feel that all women who are booked for a home delivery should have a presentation scan. 
 
In our area in the past year we have had two undiagnosed breech deliveries at home.  Thankfully the outcomes have been satisfactory, but it is traumatic for the mother, baby and of course the midwife. 
 
Home deliveries have not got the luxuries of paediatricians or the ideal resuscitation equipment. Sometimes we have not even got another midwife present. In this day and age with the expertise and equipment to carry out a presentation scan that literally takes minutes, I think it is foolhardy not to offer this procedure as a matter of routine. 
 
It is only a matter of time that there will be a fatal outcome following such a delivery at home.  Who will be to blame? The midwife, who rarely or if ever sees a real breech delivery except in false emergency scenarios, or the trust, who have never addressed this as a potential risk when offering home deliveries.  Who ever it would be, I would not like that burden of blame resting on my shoulders.
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:06:36 The answer posed in the question is yes-unexpected breech presentations can occur unexpectedly!!
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:08:36 I am not aware of any other Trusts adopting this procedure. What happened to training? Are we now so overworked and understaffed that we no longer have time to either palpate a pregnant uterus in the correct fashion, or train our students and medical students correct methods of palpation? Of course, errors will always occur, but a Trust that is scanning all nullips on admission obviously is experiencing more than the occasional incorrectly documented presentation.
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:10:05 This sounds like another intervention to undermine our clinical confidence.  I know it can sometimes be very hard to determine presentation, especially in an obese lady. As a community midwife I know that I personally, and many of my colleagues, send our ladies for a scan around 36 weeks if we are unsure of presentation. This gives a chance for ECV to be performed prior to labour. 
 
Perhaps there should be more emphasis on training for vaginal breech delivery?  I have been a midwife for 16 years and have only ever delivered one breech - and that was undiagnosed and a home delivery.  Outcome - perfect!
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:10:49 Whatever happened to abdominal palpation? Is it a lost skill that midwives and obstetricians have forgotten about??
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:13:21 Staff should have more training on how the ‘Hannah breech trial’ was found to be flawed, and that if a breech goes into labour then she should have a try at a normal delivery! Regardless of parity, and only go for section if abnormal labour... no IOL, no arm, no synt, no epidural, just give it a chance!! 
 
Have a rule – only section if no spontaneous labour! 
 
The RCOG guidelines suggest a trail is appropriate. Why are we so keen to diagnose, and interfere, surely any spontaneous labour, breech or cephalic deserves a chance…
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:43:29 Surely the answer to an undiagnosed breech in labour is to permit a vaginal breech delivery, all else being equal!! It is ample time that re-training for delivering the breech baby vaginally is supplied to our doctor colleagues, as I suspect at present more are being delivered by midwives by accident! We need to do it soon, or all the experienced consultants will have retired, and it will have to be re-discovered.
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:14:25 My Trust isn't thinking of this, however, as an antenatal ward sister I do think it is wise to perform a presentation scan when inducing someone for term plus, who have a high presenting part. In fact it became my standard, and I was going to write it into policy. Nothing is more embarrassing than inducing, then discovering breech!
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:15:08 Where have our basic midwifery palpation skills gone? Absolutely no to routine scans.
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:17:15 I do not think it is a question of more training, more a case of returning to relying more on our skill as midwives! 
 
I am horrified to think that routine scans are even being seriously considered – what next?... A return to admission CTG's, 'just in case'. 
 
Inevitably breech presentations will occasionally be missed and ok, it would be nice for the couple to have some additional knowledge before labour to discuss the options for delivery, but admission scans is NOT the answer! 
Re: Breech presentation
Submitted By - Guest 17/05/2010 12:18:32 Perhaps we should be training midwives and obstetricians in physiological breech rather than resorting to surgery. If a woman enters labour at term spontaneously, progresses normally and is 'allowed' to follow her body's lead, maybe we can facilitate birth that doesn't carry risks for the next pregnancy and birth.
Re: Breech presentation
Submitted By - Guest 09/08/2010 10:39:09 As part of our training and regular update on peripartum care, we practice breech maneuvers. Why are we then not encouraged to utilise these skills to facilitate normal breech births? We live in an increasingly litigious society where it appears defensive practice is the name of the game. How sad for our women. 
 
I had an accidental primip breech waterbirth at home. Whilst I know this was not the ideal place (my heart was beating a little faster once I realised she was breech but there was no time to move her), the woman had a lovely home birth, the baby was born in excellent condition (kept warm and unstimulated in the water during the birth) and the family were over the moon.  It was an excellent learning experience for me and my colleague as watched the natural birthing mechanisms unfolding before our eyes - but neither of us want to be faced with the same situation again!
Re: Breech presentation
Submitted By - Guest 17/05/2010 13:15:17 I used to work at a Trust and after a dramatic intrapartum transfer from the midwifery led unit to the local obstetric unit, we did consider scanning women on admission to the unit. 
 
We went through a training programme so as many midwives as possible were able to do a presentation scan. 
 
But it was not implemented as a policy but the staff were able to have the skill on admission if they were concerned it might be breech. Access to scanning facilities is limited in many units especially out of hours. We were lucky and had a scanner on site. 
 
I now work at a Trust and know of no such policy to scan all nulliparous women. 
 
By the way if you cannot do a basic palpation and ascertain presentation you should not be practicing. We are all caught out by the odd one, (I was as above) but generally we do well. 
 
Also spontaneous breech births are exactly that - they tend to do well (Mary Cronk) it is our anxiety to get them to CS that is concerning. 
Re: Breech presentation
Submitted By - Guest 18/05/2010 09:28:18 I think this is another intervention that will deskill midwives and obstetricians alike. What happened to the art of palpation? I once worked at a unit where they were so understaffed that midwives would just plonk women on the CTG without even a palpation, so I do not think that scanning women in labour is the answer. The fact of the matter is that breeches will get missed and maybe we need to have training to support women who wish to give birth vaginally. We all know the Hannah trial was flawed so why are still abiding by its rules?
Re: Breech presentation
Submitted By - Guest 18/05/2010 09:28:58 I am not aware of any maternity units which routinely scan women on admission to confirm presentation at term. In January I started a four-year study to explore how best to improve the detection and management of term breech presentation and neonatal hip dysplasia.
Re: Breech presentation
Submitted By - Guest 18/05/2010 12:23:03 The trust where I work has one consultant who insists on a presentation scan of all women booked under his care, nulliparous or multiparous.  He also insists on admission CTGs to be done on all women under his name who attend in labour. 
 
These can be women who are booked under consultant-led care because they are over 35, or have a BMI of 30.  Not necessarily high risk women, but don't quite meet the criteria for midwifery-led care. 
 
(In the majority of cases he hasn't even met the women antenatally)
Re: Breech presentation
Submitted By - Guest 18/05/2010 16:43:39 I am really concerned that there is even a suggestion of scanning for breech presentation... but even more concerned as to some of the responses in being presented with the unexpected breech presentation. 
 
How is this different from suddenly been thrown into any other unexpected situation such as an aph or a pph? We all take part in mandatory training to keep these skills updated and for the most we are not confronted with such situations on a daily basis, but when we are we get on with it - However, I would suggest that if we continue to send out the wrong message by including breech vaginal birth as an obstetric emergency skill, then we should also include a 'hands off' approach as part of the 'normal birth skills' mandatory training...? 
 
I too have been that woman desperate to have a vaginal breech birth (prior to becoming a midwife) and was treated with a similar 'fear' as some have been demonstrated in response to suddenly being confronted with 'A BREECH!!!!' 
 
Please, please read through the Hannah term breech trial, which is fraught with unreliable evidence, but also look at the recent evidence published by Canada (June/July 2009), which now suggests that CS may not be the most beneficial modem of birth for a breech baby. 
 
As some of you have already said... as autonomous practitioners we should be reclaiming the skills of vaginal breech birth (not extraction) as long as it is spontaneous and progressing - otherwise, without augmentation, this IS the time to perform a CS for breech presentation. 
Re: Breech presentation
Submitted By - Guest 19/05/2010 09:49:16 I agree with you 100%. I had an undiagnosed breech at home. She didn't pick up he was breech until I was 9 1/2cm. She performed 2 episiotomies and still couldn't get him out. The outcome was death. I have asked the NHS supervisors to try and get all homebirths a scan at 37 weeks, they said this wasn't possible. It would have prevented my son’s death!  Please let us save further lives...
Re: Breech presentation
Submitted By - Guest 19/05/2010 09:53:15 An emphatic ‘no' to routine scanning for breech presentation! As has already been stated in other replies- it will lead to basic palpation skills being lost. A scan has its place if there is real uncertainty, as happened in the last unit in which I worked, as breech presentation there was treated as an obstetric emergency which should be delivered by CS. I was however fortunate during my employment there of six years to admit several women in advanced labour who turned out to have breech presentations– all who delivered beautifully vaginally with no meddling from obstetricians. Why automatically rush women to have a CS? If labour is progressing well and is spontaneous I believe women should have the choice to deliver vaginally. I accept the threshold for intervention should be low in these cases, but breech vaginal delivery is a skill that is lost to most midwives and doctors, as CS routinely takes precedence.
Re: Breech presentation
Submitted By - Guest 25/06/2010 10:03:40 Seeing as the evidence surrounding breech is flawed shouldn't we start delivering breeches vaginally again whilst there are midwives and obstetricians still in practice that have experience in this skill? If we don't, soon they will be retired and we will have no choice but to continue with c/s deliveries for breech babies. 
 
Breech should be seen as a variation of normality rather than being treated so abnormally. 
 
Another issue surrounding c/s and breech is, 'are women currently receiving TRUE informed choice with regards to breech and mode of delivery?' I.e. are they informed that the research surrounding breech is flawed? 
Re: Breech presentation
Submitted By - Guest 13/07/2010 09:43:08 It is very difficult to tell a woman when you palpate her abdomen that you are (as a midwife) 100% sure that her baby is head down (cephalic).  I always say I am as sure as I can be that the presentation is cephalic or breech.  I never say it is definitely one or the other.  Recently I had to answer a complaint because I stated 'I think the presentation is cephalic'.  I am being sent on an assertive course as a result of that complaint.  It will not change the fact that I will never say I am 100% sure of the presentation. Yes, 98% of the time I will be right, but what happens when I am wrong?  See the response three about me.  A home delivery where the woman was 9.5 cm dilated before it was noticed the baby was breech with tragic results. 
 
Every midwife can be caught out.  In today’s society where the risk of litigation is so high I am afraid we have to pay attention to the person who plays the tune, that is the government/NICE.  The cost of litigation is huge. 
 
I also agree we are becoming de-skilled, so are registrars/consultants.  I agree with comments regarding our practice being undermined.  The government requires breech-presenting babies to be delivered by LSCS and until the pendulum swings, perhaps we should be implementing routine scanning.   
 
None of us have x-ray fingers.  Nor can we ever say we know for sure the presentation is cephalic or breech.  We can be as sure as our expertise allows us to be... but is that enough??
Re: Breech presentation
Submitted By - Guest 20/07/2010 09:41:36 The use of scanning as a routine screening tool on admission can only lead to the deskilling of midwives even more, which will only further disempower us as a professional body and undermine our clinical judgement.
Re: Breech presentation
Submitted By - Guest 08/08/2010 19:46:34 One of the hospitals I have dealings with automatically sections ALL breeches, even if they are multips!
Re: Breech presentation
Submitted By - Guest 12/08/2010 09:32:09 I feel that as a community midwife in very busy clinics, the margin for error on palpation will inevitably become greater. I have always listened to women who express discomfort under the ribs, and the fetal heart is not a reliable indicator of breech, as I have found from experience e.g. if fetal heart on lower abdomen then it’s head down, it is not always the case.  I feel that midwives could gain greater insight by listening to women and when we do get undiagnosed breeches, we should ask women what that felt like antenatally.  I feel that a structured retrospective study or audit of undiagnosed breeches may inform all clinicians of women’s experiences of carrying a breech baby, in ways we have not considered before. I am not totally dismissing scans in some circumstances but I feel that other avenues ought to be explored, and would add to the current evidence and debate regarding the undiagnosed breech.
Re: Breech presentation
Submitted By - Guest 01/09/2010 16:36:53 I would like to say that having had an undiagnosed breech baby at home in less than 5 hours from start to finish (less than 1/2 an hour from contractions at 6 mins to appearance of baby's bottom) without a midwife until it was too late. 
 
More information about the possibility or a fast first baby and clearer information on when to call the hospital when you are in labour may have meant a better outcome for my baby. 
 
I know midwives don't want to scare new mums but if I was more scared I might have now have my baby. 
Re: Breech presentation
Submitted By - Guest 11/11/2010 16:46:33 OK then let me throw this scenario at you all... what if there is evidence in a patient's pregnancy file of carrying breech during pregnancy, then evidence in file to suggest baby is now ceph, then patient is induced at 42 wks then baby is found to be breech at 6cms resulting in emcs.  Do you think a routine scan should be introduced for induction of labour at term onwards?