During the final few weeks of a normal pregnancy the baby is supposed to slowly move into the correct, head down position in preparation for delivery. This repositioning, which is supposed to happen naturally, is very important because the baby's head should be aimed down towards the opening of the birth canal to enable a safe vaginal delivery. The baby's head is specifically designed and shaped to push its way into and through the birth canal like the head of spear.
This repositioning is critically important to a safe vaginal childbirth, however, a certain percentage of babies fail to move into the head down presentation at the end of pregnancy. These babies that do not rotate themselves end up positioned with the feet first or butt down towards the birth canal opening and the head at the top of the womb. This abnormality is called "breech" presentation or breech position.
In full term pregnancies, approximately 5 out of every 100 babies will be in breech presentation at the time of delivery - an occurrence rate of 5%. In preterm deliveries (37 weeks or earlier) the occurrence rate of breech presentation is significantly higher because the baby has not had an opportunity to reposition in preparation for birth.Different Types of Breech
Any positioning in which the baby's head is not facing down in the womb, towards the birth canal opening, is classified as breech presentation. There are different categories or subtypes of breech position. The exact subtype classification of breech presentation depends on the specific angle or positioning of the baby's lower body in relation to the birth canal opening. The 3 main breech subtypes are as follows:
- Frank Breech: This is the most common breech presentation subtype, accounting for around 60% of all breech cases. Frank breech occurs when the baby's butt is positioned downward towards the birth canal opening. The legs are straight sticking up towards the face (in a "jackknife" position).
- Footling Breech: Footling is the second most common subtype. In a footling breech the baby's feet are positioned downward and poised to enter the birth canal ahead of the butt. Footling breech is particularly common in premature deliveries.
- Complete Breech: This breech subtype is relatively rare, accounting for less than 10% of all cases. In a complete breech, the baby is still in the classic "fetal position" with the knees bent in to the chest and feet at the butt. The butt and feet are aimed down at the birth canal opening.
Like many other pregnancy complications, doctors do not really know exactly why certain babies do not rotate themselves and end up in breech presentation. It is very well understood, however, that there are certain conditions that significantly increase the risk of breech presentation occurring. Pregnancy conditions that have been linked to an increase risk of breech presentation include:
- Placenta previa
- Polyhydramnios (excess amniotic fluid)
- Twins / Multiples
- Uterine abnormalities (fibroids)
- Maternal age and pregnancy history
All of these conditions during pregnancy are known to increase the likelihood of a baby ended up in breech. However, many cases of breech presentation occur in the absence of any of these known risk factors.Diagnosis and Management of Breech Presentation
Repositioning in preparation for delivery is something that is supposed to occur naturally towards the very end of pregnancy. This means that breech presentation cannot really be diagnosed until the very end of pregnancy and sometimes just prior to delivery. At a minimum, doctors cannot definitively diagnosis breech until after the 35th week of pregnancy. Diagnosis is made through a combination of manual prenatal examination and ultrasound imaging.
When a formal diagnosis of breech presentation is made doctors must make a pivotal decision. When a baby is in breech position, attempting a normal vaginal childbirth is inherently risky. There are a number of reasons of this. First, the physical mechanics of a successful vaginal childbirth are largely dependent on the head pushing through the birth canal first. Without a head first position the whole process becomes even more difficult for both mother and baby.
Another reason why vaginal delivery from the breech position is so potentially hazardous is because breech deliveries come with a significantly higher risk of umbilical cord prolapse. A prolapsed umbilical cord is an extremely dangerous delivery complication in which the vitally important umbilical cord drops down into the birth canal ahead of the baby instead of after the baby. When the cord drops down first it creates an extreme danger because the cord will get compressed as the baby's body enters the birth canal. This compression of the cord can disrupt or even completely cut off the baby's oxygen during delivery.
Besides umbilical cord prolapse, there are other complications that may arise during a vaginal breech delivery. If the cervix is not fully dilated or the head is large - these babies are often large - head entrapment and asphyxia are grave risks. There can be physical trauma to the baby's head, neck, stomach, and spine. The baby can also suffer intracranial bleeds (subdural, subarachnoid, intraventricular and intraparenchymal). Skull fractures are a risk and can also lead intracranial bleeds.
Depending on the subtype of breech presentation, many OB/GYNs will not even attempt to deliver a breech baby vaginally. A preemptive C-section delivery is therefore a standard response.Breech Presentation and Malpractice
Medical malpractice claims based on mismanagement of a baby in breech presentation are almost always based on failure to perform C-section negligence theories. Failure to diagnose breech presentation prior to delivery is almost unheard of in modern obstetrics. Between sonograms, ultrasounds and simple manual examination doctors can easily determine what position the baby is in. This means that at some point prior to actual delivery, the doctor will know if the baby is breech (and usually what subtype).
Once the doctor determines that the baby is in a breech position, they must use their best medical judgment to determine whether or not it is safe to attempt a vaginal delivery. Many OB/GYNs will always opt for a C-section anytime a baby is in breech. But attempting vaginal delivery of breech babies is becoming more and more common. In many circumstances attempting vaginal delivery of a breech baby is considered a breach of the applicable standard of care. In these situations, a doctor can be subject to medical malpractice claims if the baby ends up getting injured during delivery.
Our lawyers also see vaginal breech delivery cases where there are informed consent issues. Moms have a right to be an active and informed participant in her health care. Given the significant risks involved in the handling of a breech delivery, it is important to make the mother aware of all of the relevant risks before subjecting her to them.Breech Malpractice Verdicts & Settlements
Below are summaries of actual birth injury malpractice cases involving mishandling of babies in a breech position. These only include cases resulting in verdicts or publicly reported settlements.
- Plaintiff v Defendant (Massachusetts 2019) $5,000,000 Settlement: During labor, it was determined that a baby girl was in the footling breech position. The defendant OB/GYN utilized a manual obstetric technique to maneuver the baby and facilitate vaginal delivery. Plaintiff claimed that defendant negligently performed the technique by using excessive force and failing to properly flex the head resulting in permanent damage to the spine. The injury left the plaintiff permanently paralyzed from the neck down. Defendant argued that spinal cord damage occurred during gestation and not from injury during delivery. The case went to trial and settled on the day of closing arguments.
- McCloud v Montefiore Hospital (New York 2019) $18 million: Plaintiff mother was admitted to defendant hospital for premature delivery of her baby. Sonography images prior to delivery confirmed that baby was in breech presentation (very common for premature babies). Doctors decided to deliver the baby vaginally despite the breech position. Delivery was prolonged and difficult as the baby's head became stuck while passing through the cervix causing damage to the brachial plexus nerves resulting in Erb's palsy and permanent brain damage. Plaintiff sued, arguing that the hospital should have done a C-section instead of attempting vaginal delivery from the breech position. The hospital claimed that vaginal delivery was appropriate and suggested the injuries were caused by the mother's obesity. A jury in the Bronx awarded the plaintiff $18 million in damages.
- Charlton v Troy (Pennsylvania 2018) $40 million: Plaintiff mother presented to the hospital for delivery of twins at 34 weeks. Defendant OB/GYN decided to deliver vaginally. The first twin was delivered without incident, but the second twin was in footling breech presentation. The defendant attempted to deliver the second twin vaginally but her head became stuck and nerves in her spinal cord were torn as defendant attempted to dislodge her. As a result of nerve damage, the baby was left permanently paralyzed and confined to a wheelchair for life. Plaintiff claimed that defendant should have never attempted vaginal delivery and that injuries could have been avoided by C-section. The jury agreed and awarded a stunning $40 million damages.
- Delgado v United States (Florida 2013) $2 million: Plaintiff contended that despite two sonograms confirming the baby was in breech presentation, the defendant OB/GYN negligently failed to either perform a C-section or have in place a plan to emergently address complication arising if a decision to delivery vaginally was made. The plaintiff maintained that because of an umbilical cord prolapse during the footling breech delivery, the baby suffered oxygen deprivation, resulting in brain damage and cerebral palsy. The case settled for $2 million.
If your baby was injured because the doctor attempted vaginal delivery from a breech position, contact the birth injury lawyers at Miller & Zois for a free consultation.