Just weeks away from her due date, there were clear signs that Sarah Bedingfield Shutt’s first baby was in a breech position, where the baby’s feet or buttocks, rather than the head, face the pelvis.
“She had a smaller, more compact bump and the baby hiccups, which inevitably came at 4 in the morning, she could feel it higher up – she was curled up like a joey, all the signs were there,” Sarah says, using a reference from her native Australia. her to a baby kangaroo in her mother’s pouch.
Other possible signs that the baby is in the breech position include a hard bulge (the baby’s head) near the ribcage, that the baby does not “latch” (ie, the head moves into the pelvis) later in pregnancy and discomfort and pain in the pelvic area. the mother’s upper body while the baby’s head presses on the lungs and ribs.
However, at the time, Sarah – a brand manager and bridal consultant, in her 30s and living in London with her husband Peter, an investment banker – had no idea that her daughter, Beatrix, was breech, which making a normal delivery difficult, if not impossible, and increasing the risk of complications for both mother and child.
About 4 percent of babies (about 25,000 a year in England and Wales) are in the breech position in the later stages of pregnancy.
Sarah Bedingfield Shutt (pictured) had no idea that her daughter, Beatrix, was breech, making a normal delivery difficult, if not impossible, and increasing the risk of complications for both mother and child.
In many cases this is simply due to chance, but it is more common if the placenta is low or there is too much or too little fluid around the baby, or if you are having more than one baby; all of these can prevent the baby from assuming the normal head-down position.
With a breech presentation after 36 weeks of pregnancy, doctors may apply external pressure to try to manually turn the baby in the uterus (a procedure called external cephalic version); this is successful in half the cases.
If a vaginal delivery is attempted without skilled midwives trained in breech births, the baby is at risk of dislocation injuries to arms or legs during delivery.
You could also get stuck in the birth canal and, although rare, suffer brain damage from lack of oxygen. In 0.5 percent of breech deliveries, the baby may die (compared to 0.1 percent of normal vaginal deliveries).
According to the Royal College of Obstetricians and Gynecologists, in 40 percent of cases the mother needs an emergency caesarean section.
A planned caesarean section is usually the safest option and is offered if the baby is known to be breech.
However, between 15 and 33 percent of women whose babies are breech discover it only when they go into labor, since routine ultrasounds are only done between 12 and 20 weeks of gestation, too early to detect the problem.
This results in many of these women needing an emergency caesarean section, which can be risky, as highlighted by a recent case at Guy’s and St Thomas’ NHS Foundation Trust in London.
The trust has been ordered to pay £37 million – one of the largest payments in NHS history – to the parents of a baby left with severe brain damage after staff failed to detect that it was in the breech position before it was delivered. his mother went into labor.
She was rushed into surgery for an emergency C-section, but the delays meant her brain was starved of oxygen and will need 24-hour care for the rest of her life.
Now, UK researchers have found a solution that they say could reduce the number of unexpected breech deliveries by 70 percent: identify those at risk by adding a third routine scan at 36 or 37 weeks into pregnancy.
This would allow mothers to have a planned caesarean section or a natural birth with the support of midwives trained in breech births.
Researchers from St George’s University Hospital NHS Foundation Trust, London and Norfolk and Norwich University Hospital NHS Foundation Trust compared the rate of unexpected breech births and newborn health before and after third-trimester scans were introduced.
At St George’s, 16,777 women received just two ultrasound scans, while 7,351 had an additional ultrasound scan at 36 weeks. In Norfolk and Norwich, 5,119 women received the two standard ultrasound scans, while 4,575 underwent a third, using a handheld device that displayed the scan on a tablet.
The results, published this year in the journal PLOS Medicine, revealed that adding a third scan significantly reduced the rate of unexpected breech deliveries: by 71 percent using the standard ultrasound scan (from 14.2 percent to 2.8 percent). percent); and 69 percent with the portable device (from 16.2 percent to 3.5 percent). Babies of women who had their third ultrasound and were in the breech position were also 16 percent less likely to be admitted to the neonatal unit for closer follow-up, and 40 to 77 percent less likely to be admitted to the neonatal unit for closer follow-up. odds of having a low Apgar score five minutes after birth (this assesses the well-being of the newborn based on skin color, heart rate, reflexes, muscle function, and breathing).
The mothers were also less likely to need an emergency C-section.
Asma Khalil, Professor of Obstetrics and Maternal-Fetal Medicine at St George’s, who led the study, said: “For the first time we have shown that just one extra scan could save mothers-to-be from trauma, an emergency C-section and their babies from having health complications that could otherwise have been prevented.
“It is vital that we know how the baby is doing towards the end of the pregnancy, as we want to avoid a breech birth as much as possible.
‘The current two scans are too early to tell us how the baby will be positioned at delivery. A third scan at 36-37 weeks could be a game changer in pregnancy and delivery care, as there is more chance of turning the baby while there is still some space.’ Sarah discovered her daughter was breech after undergoing a further scan at 36 weeks as part of the St George trial: Beatrix was in the ‘frank breech’ position, with her legs folded up against her head and her bottom down .
About 4 percent of babies (about 25,000 a year in England and Wales) are in the breech position in the later stages of pregnancy.
Although hoping to go into labor naturally, Sarah opted for a planned C-section and Beatrix was delivered safely at 39 weeks, just before Christmas 2020.
“I decided on the option that seemed safest for me and my baby,” says Sarah.
Currently, additional scans are offered only if the pregnancy is complicated, for example, if the mother has diabetes or high blood pressure.
In contrast, in standard pregnancies, midwives examine a woman’s abdomen late in pregnancy by touch and “guess if the baby is in the breech position,” says Professor Khalil.
She says this approach is only 60 to 70 percent accurate “and misses about a third of breech presentation diagnoses.”
She believes that training more midwives to use cheaper portable devices “provides the NHS with a clear solution to help maternity units better prepare for safer and healthier deliveries.”
The Government has set itself a target of halving stillbirths and neonatal deaths (deaths within 28 days of birth) in England by 2025.
But others have questioned how useful a third scan would be.
Susan Bewley, emeritus professor of obstetrics and women’s health at King’s College London, told Good Health: “A scan only gives a snapshot of a moment; it doesn’t tell where the baby will be tomorrow or a week from now.”
‘Babies can move in and out of the breech position right up to delivery.
‘Competing 700,000 pregnant women a year to one additional scan would have significant cost implications for the NHS and provides only marginal benefits.
‘There is also a risk that mothers and maternity staff are given the false assurance that they have ticked the box to check for breech and will not look for other signs.
“This study had a weak design, comparing results before and after a third scan was done,” he says.
“To find out if a third scan is truly beneficial, and the magnitude of any benefit, a proper randomized controlled trial is needed.”
The National Institute for Health and Care Excellence is reviewing the study to see if its prenatal screening guidelines need to be updated.
For Sarah, the third scan meant “having the opportunity to make a positive decision about how to give birth rather than it being a hasty, emergency decision at my most vulnerable moment.”
“An unexpected breech birth can be tremendously traumatic, physically and mentally, and has the potential to cause significantly worse outcomes for babies,” she says.
“Surely that choice is a right that all women should have.”
