MNSI Safety Spotlight: Preventing Late Diagnosis of Breech During Induction of Labour

The Maternity and Newborn Safety Investigations (MNSI) programme plays a central role in England’s national maternity safety strategy. Through independent investigations into early neonatal deaths, intrapartum stillbirths, severe brain injuries in babies and maternal deaths, MNSI identifies thematic safety concerns and issues system level recommendations.

Although individual investigation reports are not shared publicly, trends emerging from these cases are disseminated as “Safety Spotlights” for NHS Trusts to implement proactively.

One such recent spotlight focuses on a pattern repeatedly identified in MNSI investigations, cases where breech presentation was only identified late, after induction of labour had already begun, or even during established labour. Late recognition of breech presentation presents significant safety risks, including delays in clinical decision making, urgent operative intervention, and increased potential for adverse maternal and neonatal outcomes.

Why Breech Diagnosis Matters

A ‘breech presentation’ occurs when a baby is positioned bottom or feet first, rather than head-down in the uterus which is known as a ‘cephalic presentation’. Breech presentation occurs in 3–4% of term pregnancies, and around 25% of breech presentations are first identified during labour. 

The cause of a breech presentation is often unknown, with many breech babies having no identifiable risk factors at all. Where a breech presentation is not recognised until advanced labour, there is limited scope to consider options for delivery, plan a caesarean section, or ensure the presence of staff with appropriate breech delivery skills. Babies presenting breech at term are known to have poorer outcomes than those in cephalic presentation, irrespective of mode of delivery, due to the higher risk of complications and the requirement for urgent decision making. This elevates clinical and medico legal risk considerably. 

MNSI’s Four Safety Prompts 

The MNSI safety spotlight sets out four key safety prompts for  NHS Trusts to consider to strengthen their local processes, aimed at reducing the likelihood of undiagnosed breech presentations and to support safe planning for vaginal or caesarean birth.

1. Presentation checks to confirm fetal position prior to induction

In several investigations, breech presentation was not detected before starting induction. MNSI recommends routinely undertaking presentation checks, such as an ultrasound scan, before induction of labour to confirm the baby’s position. It is suggested that additional checks be undertaken to help prevent breech presentations going unnoticed until labour is advanced.

2. Pre induction checklist 

The report recommends that local guidance includes a standardised robust pre-induction checklist to ensure consistency and mitigate variation in practice, particularly in busy units. It should include:
Confirmation of fetal presentation
Review of risk factors
Review of the appropriate equipment availability, in breech deliveries specific forceps are recommended due to the head being high up. 

3. Access to portable ultrasound machines in induction areas

Limited access to ultrasound is a recurring feature of late diagnosis cases. It is recommended that all clinical areas where induction takes place should have access to portable ultrasound machines to enable rapid confirmation of presentation and ensure increased accuracy where palpation is challenging (e.g. high BMI, polyhydramnios) and safe escalation where fetal lie is uncertain or changes.

4. Training programme or competency assessment for staff performing presentation scans

A recognised challenge across NHS maternity services is the decline in breech presentation management skills, following long term reductions in planned vaginal breech birth. Effective training is therefore central to both safety and risk management.

Accurate identification of fetal presentation is essential to preventing late diagnosis and reducing the risk of emergency intervention. MNSI encourages NHS Trusts to ensure staff receive appropriate training and regular competency review. 

Improving Safety 

NHS Trusts should look to review and update local induction guidelines to include consistent pre-induction investigations of fetal position and, if not already in place, implementation of a pre-induction checklist and reviewing their access to portable ultrasound machines. Consideration should also be given to implementing training pathways, including refresher training, for midwives and obstetric staff unless such training is already in place.

Implementation of the MNSI’s recommendations could mitigate reliance on obstetric availability and reduce the risk of late diagnosed breech presentations.

Litigation implications 

This is a complex area with the potential for serious and sometimes devastating consequences for women and their babies. From a litigation standpoint, the focus of claims related to breech presentation in established labour will likely relate to the four key areas set out above, and will require careful consideration of the variability in pre-induction processes, equipment constraints and variation in local practices. 

The timing of delivery, the competence of the attending clinicians, and adherence to PROMPT training will be central to any breach of duty analysis. In the medico-legal context where a woman comes in following induction, or following spontaneous onset of labour, consideration will need to be given as to at what point in time no competent midwife or obstetrician would have failed to make a breech position diagnosis and whether any late diagnosis has impacted the outcome.

Consideration will also need to be given to whether it would it have been reasonable or possible for the Trust to perform an ultrasound scan to confirm the position in each individual circumstance.  The undeniable issue is that many units may not have the resources, whether in terms of equipment and staffing levels, to perform a presentation ultrasound scan in every case.

Conclusion 

Late diagnosed breech presentations during induction of labour highlight the need for NHS Trusts to strengthen system level reliability across maternity pathways. NHS Trusts should look to review their guidelines and consider the introduction of checklists if they have not already done so. 

The recommended measures could help enhance clinical safety and mitigate the risk of litigation associated with missed or delayed diagnosis. However, resource constraints may remain a challenge. If NHS Trusts cannot introduce universal portable ultrasound equipment due to resource constraints, this should be clearly documented as part of the governance review process. 

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