Breech presentation may be suspected by a healthcare professional when she examines a pregnant woman’s abdomen. Assessing presentation is part of all routine third trimester examinations, when professionals also assess fetal growth and listen to the fetal heart. The results of such examinations are discussed with women and are also recorded in women’s handheld maternity notes, so this information is freely available to them. Presentation is also noted at the 18-20 week anomaly scan and any subsequent ultrasound examinations a woman may undergo, reports of which are also included in their notes. This means that some women are aware their baby is, or could be, breech for a number of weeks.
I had one of those 3D scans, and she was still in the head down position then, that was at 28 weeks. But then just after that I’d gone for me midwife appointment and she’d had a feel and she [baby] had turned round and she was like that for the rest of the pregnancy… every midwife appointment I went to she was breech
constantly. (Louise, failed ECV and planned CS, postnatal interview)
I actually had more scans than a straightforward pregnancy… So, I think it was… 28 weeks when I came in, I had a scan with regards to the fibroids… but then he was breech… I knew mine was breech at 28 weeks and he had really stayed breech. I could actually feel his head. (Catherine, successful ECV, design workshop)
Breech is common at 28 weeks gestation, affecting 20% of babies, but most babies will spontaneously turn, leaving only 3-4% breech after 37 weeks (RCOG, 2006b). Hence, breech presentation, suspected or diagnosed before 36 weeks of pregnancy, is of low concern to health professionals. During interviews and workshops, professionals suggested they were reluctant to provide information earlier than 36 weeks because of the likelihood of
down]… I don’t see a tremendous downside to giving the information close to the point at which the diagnosis is made, because people do still have a little bit of time to make a decision and they come to no harm in the interim. So I’m not sure that providing the information well up front is valid in this group. (Dr Corn, professional workshop 2)
Such views are paternalistic and underestimate both the work women do to find information themselves as well as the anxiety they may have about breech presentation, which is discussed below.
After 36 weeks, if breech presentation is suspected, routine practice is to refer women for an ultrasound examination to confirm the diagnosis. This is because abdominal palpation is unreliable. Research shows that the sensitivity of abdominal palpation to diagnose non- cephalic presentation at term is 70% (Nassar et al., 2006a) and a midwife reported to me that an audit undertaken in Unit One had shown that 80% of women referred for a presentation scan were found to have a cephalic presentation (recorded in my field notes). Although no women respondents reported being told explicitly about the limitations of abdominal examination as a method of diagnosing breech presentation, many were aware that
community midwives were uncertain about the presentation of their baby and that the role of an ultrasound scan was to give a definitive diagnosis.
I went to see my midwife and… she felt again and still thought it felt cephalic. But because my movements hadn’t changed position she just wanted to be cautious so said, “We’ll send you for a scan at 36 weeks.” (Aisha, planned CS, antenatal interview)
Several respondents described how their community midwives had explained they were being cautious. During a design workshop, midwives who worked both in the community and in hospital reflected this might be because undiagnosed breech presentation was a risk
management issue and would always be investigated:
It’s certainly audited when it’s an undiagnosed breech. So, and looked into. So, you know, that can influence that decision to send somebody for a scan. (Midwife Blue, workshop 1)
appointment… and I said, “Can you check…?” So she checked and she said, “OK, I can’t feel the head so we will refer you.” (Danielle, unsuccessful ECV and planned CS, antenatal interview)
Other respondents reported that the diagnosis had explained symptoms that they had experienced. This was particularly true of parous respondents, like Melissa, who had previously had cephalic babies.
The pregnancy just felt different… I kept saying to my husband: “I think he’s going to come early.” Because he felt low down. But now I understand it was his legs pushing down. (Melissa, unsuccessful ECV and VBB, postnatal interview) However, for other women, the diagnosis of breech was a surprise and caused considerable anxiety for some of them.
They [the community midwives] were all sort of saying, “Oh, your head’s down,’… so I was under the impression normal birth, everything’s the way it should be. And it was when she [community midwife] came back off her
holidays that she was like, “Ah, I don’t think so.”… so I had to go to hospital… I was told by the first person in the hospital that they thought as well that the head was down and I was like, “Oh yeah, me too... I think she [community midwife] is wrong”… when they scanned me they were like, “Um, no she’s breech.”…That's when the panic set in I suppose. (Lynne, planned CS following decision not to attempt ECV due to low AFI, antenatal interview)
I went home that afternoon and started looking at breech births and what have you. And I was scared. I thought, “This is not something I expected to happen”. (Sophie, planned CS, workshop)
Health professionals reflected that breech presentation was often an unexpected complication for women:
I think quite a few, it’s never occurred to them that it might happen. I had one [woman] recently that was 39 weeks… and had come in for presentation scan and he [the baby] was breech. And it had never occurred to her that she would have to make any decisions about the delivery, it would just happen… (Midwife Indigo, professional workshop 1)
not a big problem, in the scale of things that can go wrong with a pregnancy, this is relatively minor, so you’ve got to roll with the punches a bit. (Danielle, planned CS following unsuccessful ECV, antenatal interview)
However, whilst disappointed, accounts such as Danielle’s suggest that women perceived breech presentation was less serious than other possible complications. For example, some respondents were aware of other women who had experienced tragedy during pregnancy and birth, and suggested this gave them a sense of perspective about breech presentation:
The important thing is she got here safe and the day after she was born, my cousin lost a baby at about 25 weeks. (Martha, unsuccessful ECV and emergency CS, postnatal interview)
A few women appeared to normalise breech presentation by attributing it instead to their baby’s personality, describing their babies as awkward, naughty or lazy. Other women perceived that their baby had chosen to be breech and was comfortable in that position.
I feel it’s one of those things. She’s breech, she’s going to be awkward. So be it. (Heather, unable to attempt ECV due to low AFI and planned CS, antenatal interview)
I think she’s been this way always… She just seems snug. (Tina, planned CS, antenatal interview)
Further analysis suggests that respondents believed that their babies’ personalities or preference to be breech might even account for the success of ECV.
I think if you’ve got an active baby that’s moving all the time, you give them a nudge and they’ll move anyway. If you’ve got a baby that’s quite lazy that has been stuck in a breech position for a long time, then you kind of think well that baby might not want to turn. (Nina, successful ECV, workshop)
Some women were anxious about the implications of breech presentation. For example, Aisha gave an account of her concerns about something being wrong with her baby:
I am just like: “Why is the baby breech? He [her partner] is like: “Just because he wants to be.” I am like: “It might not be because he wants to be…what if there is something wrong with him?” (Aisha, planned CS, antenatal interview)
caesarean. I suppose that’s when I probably first checked up on it. (Catriona, unplanned VBB, postnatal interview)
As discussed in Chapter 2, little previous research has explored women’s attitudes to breech presentation. Founds (2007) reported that some women in her study were anxious about the diagnosis but that other women appeared not to be concerned about it. Disruption of birth plans was not a theme in her work but this may reflect the differences in expectations for birth between women in a low-resource setting, rural Jamaica, and women in the UK.