Delivering Breech Babies by C-Section

When a baby is in a breech presentation, a vaginal delivery is more likely to result in injury and death than a C-section delivery.  A C-section birth is generally considered the safer delivery option to reduce the risk of birth trauma or hypoxic-ischemic encephalopathy.

Failure to recommend or perform an emergency C-section in these cases may constitute medical negligence. This situation can lead to severe consequences for the newborn and legal ramifications for healthcare providers.

A breech presentation occurs when the baby’s legs or buttocks are positioned to descend the birth canal first. There are four different breech positions.

• Frank breech: This is when the baby’s buttocks present first, and her legs are flexed at the hip and extended at the knees, with the feet near the ears.
• Complete breech: In this position, the baby’s hips and knees are flexed so that the baby is sitting cross-legged, with feet beside the buttocks.
• Footling breech: In footling position, one or both feet come first, with the buttocks at a higher position than the feet.
• Kneeling breech: This is when the baby has one or both legs extended at the hips and flexed at the knees.

When a baby is in a breech position, labor can be prolonged because physicians usually try to maneuver the baby into the normal, head-first position manually. Doctors do this by pushing the baby into place from outside the mother’s abdomen. Prolonged labor puts a baby at risk of suffering oxygen deprivation and hypoxic-ischemic encephalopathy (HIE).

If the doctor cannot maneuver the baby into a head-first position, vaginal delivery should only be attempted if the baby is in the frank breech position and the following conditions are met:

• The baby’s heart rate is being closely monitored, and the baby is not in distress.
• Cephalopelvic disproportion (CPD) is not present. This means X-rays and ultrasound show that the size of the mother’s pelvis will allow a safe vaginal birth.
• The hospital is equipped for, and the physician is skilled in performing an emergency C-section.

If these conditions are not present, vaginal birth should not be attempted. In fact, most experts recommend C-section delivery when the baby is in breech presentation because it is the safest method of delivery, and it helps avoid birth injuries.

Birth injuries from mismanaged breech presentation can cause trauma, brain bleeds, oxygen deprivation, hypoxic-ischemic encephalopathy (HIE), seizures, and cerebral palsy.

Complications that often occur when a baby is in breech position include the following:

• Umbilical cord prolapse or compression: This is an emergency situation that occurs when the baby’s umbilical cord becomes compressed as the baby’s body descends through the birth canal. This can partially or completely cut off the supply of oxygen-rich blood going to the baby. A baby with a compressed cord must be delivered immediately to prevent oxygen deprivation and brain injury.
• Nuchal cord: A situation where the cord is wrapped around the baby’s neck. Nuchal cord is also an emergency because the knots that occur with this condition can partially or completely stop the flow of blood from the umbilical cord to the baby. In addition, the cord can put so much pressure on the baby’s neck that blood flow to the baby’s brain is significantly decreased. This lack of oxygen to the brain puts the baby at significant risk of HIE and permanent brain injury.
• Fetal distress: Sometimes, the forces and pressure of difficult labor cause the baby to be deprived of oxygen and in distress. When fetal distress occurs, the baby must be delivered immediately by C-section in order to prevent conditions such as HIE and cerebral palsy.
• Traumatic injury: Injury to the brain or skull may occur during the passage of the baby’s head through the birth canal, or the spine or spinal cord may become injured due to improper positioning of the baby by the physician. Furthermore, attempts to position the baby can damage internal organs, or the brain may bleed, which can cause oxygen deprivation.  The head may also get caught in the birth canal, and this can cause brain bleeds and hemorrhages. All of these conditions can cause HIE and cerebral palsy.
• Forceps injury: Sometimes, forceps are used to assist in delivering the baby’s head. Many injuries are associated with this risky delivery instrument, which resembles a pair of salad tongs. Improper placement of the forceps can cause compression of the head, spinal cord injury, tearing of the vasculature in the brain, and brain bleeds and hemorrhages. The brain can swell, which can lead to seizures and ischemia. All of these conditions can deprive the brain of oxygen and cause HIE and cerebral palsy.

Although the causes of breech presentations are not fully understood, there are predisposing factors that appear to make breech presentation more likely. These include:

• Premature births or a history of premature delivery
• Previous breech presentation
• Multiples pregnancy (twins, triplets, etc.)
• Amniotic fluid levels: Too much amniotic fluid (polyhydramnios) or too little amniotic fluid (oligohydramnios)
• Uterine anomalies such as an unusual shape or fibroids
• Placenta previa (the placenta grows in the lowest part of the uterus and covers all or part of the opening to the cervix)
• Small pelvis or uterus
• Fetal abnormalities

When a baby is in a breech position, the decision between vaginal delivery and C-section becomes critical. While skilled physicians can sometimes safely deliver breech babies vaginally, generally, C-sections are safer for breech presentations. Choosing vaginal delivery in these cases, or delaying a C-section, can potentially lead to medical malpractice if a birth injury occurs.

• Failure to diagnose breech position: If a doctor fails to identify a breech presentation before labor begins, they may be unprepared for the associated risks.
• Inappropriate choice of delivery method: Opting for vaginal delivery when risk factors indicate a C-section would be safer could be considered negligence.
• Delayed decision-making: Hesitating to perform a C-section when complications arise during a breech vaginal delivery may lead to preventable injuries.
•  Lack of informed consent: Not adequately informing parents about the risks of vaginal breech delivery versus C-section could be grounds for a malpractice claim.
• Inadequate skill or experience: Attempting a vaginal breech delivery without proper training or experience may be deemed negligent.

Breech deliveries carry higher risks of certain birth injuries, including:

• Oxygen deprivation (birth asphyxia)
• HIE
• Head trauma
• Spinal cord injuries
• Brachial plexus injuries
• Fractures

If these injuries occur and can be linked to the physician’s decision to proceed with vaginal delivery or delay a C-section, it may support a medical malpractice claim.

Establishing Malpractice

To prove medical malpractice in these cases, it must be shown that:

1. A doctor-patient relationship existed
2. The doctor’s care fell below the accepted standard of care
3. This substandard care directly caused the injury
4. The injury resulted in damages

Expert testimony is often crucial in establishing these elements, particularly in determining whether the decision to attempt vaginal delivery or delay a C-section deviated from the standard of care.

Each case requires careful evaluation by medical experts and birth injury lawyers of the specific circumstances and medical decisions involved.