A baby boy sadly died as a result of mistakes made during his delivery at Frimley Park Hospital NHS Trust. Theo Ellis was in a breech position but the midwives failed to recognise this until his mother was in advanced labour. There were also missed opportunities to check Theo’s position in the weeks and months leading up to his birth and again during the early stages of delivery. Even after Theo was found to be in breech position, the staff didn’t recognise the emergency situation and there were delays in his delivery thereafter.
The Trust have admitted liability for Theo’s death and have since implemented a number of changes, including requiring a full emergency response whenever a baby is found to be breech and a consultant present in all breech births.
Breech position is whereby a baby presents bottom first instead of head first. It is relatively rare; occurring in 3-4% of term deliveries. Most midwives should be able to assess that a baby is in a breech position by a physical examination. If in doubt; a scan can be requested to confirm the position. If a baby is in breech position at term; the mother should be offered an external cephalic version – this involves manipulating the baby to try and encourage it to turn into the correct position in-utero. If this is unsuccessful then a discussion should take place between the mother and a doctor to discuss the option of a caesarean section and risks/benefits compared to that of a vaginal birth so that she can make an informed decision on the best mode of delivery for herself and her baby.
Unfortunately, in the sad case of Theo Ellis it is clear that these steps were not taken with catastrophic consequences.