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"Missed breech lie in pregnancy"

About: Maternity care (Wards 47, 48 & 50) / Maternity Assesment/Triage New Victoria Hospital / Maternity Care (outpatients) Queen Elizabeth University Hospital Glasgow / Maternity care (Wards 47, 48 & 50)

(as a service user),

In February this year I went into labour with my son 9 hours after a cervical sweep performed at my midwife appointment at the New Victoria Hospital, at 40 weeks+6. My waters broke at home but after detecting a lot of meconium I attended the Queen Elizabeth University Hospital maternity assessment unit to be checked over. Once at hospital they quickly ascertained by way of a bedside scan that my baby was in fact in a breech position and I was left with no other option but to have an emergency caesarean section to ensure the safe and swift delivery of my child. Thankfully everything went well as can be and my son came safely into the world.

I have been left wondering how his breech lie was not detected until that very last critical point, how was it missed at my many community midwife appointments and could I have avoided unnecessary surgery and emotional turmoil if my midwife examinations had been accurate?
 
At my midwife appointment at the New Victoria the afternoon before my son was born, the midwife palpated my bump and described how the baby was head down, during my sweep she explained how she could feel wrinkles on his scalp. In my previous midwife appointment the week before I was also palpated and told my baby was head down. All of these facts are recorded in my maternity notes. My son did not flip in the 9 hours between my last examination and his birth, it just isn’t possible. His breech lie must have therefore been missed on multiple occasions by at least 2 midwives.
My pregnancy was categorised as low risk, green pathway. With no complications to be checked up on, my last scan was performed way back at just 20 weeks gestation. I was therefore totally reliant on the expertise of the midwives at the New Victoria to monitor the positioning of my son inside the womb. How could they get it so wrong, a mistake that ultimately put my son at great risk and resulted in emergency surgery? 
Had his breech lie been detected earlier then I could have explored the options available to help turn him. Those efforts may or may not have been effective. But had they not, I would at least have been able to plan for a caesarean delivery. To emotionally and psychologically prepare for that. That would have avoided my waters breaking as they did, putting my son at great risk of ingesting the meconium he was excreting. It would have avoided the distress caused to me as I was rushed to surgery with zero prior knowledge of any issue with my pregnancy. 
From what I understand this isn’t a regular occurrence, breech babies are not routinely missed. I can’t work out why it went wrong in my case, why it was missed by at least 2 healthcare professionals if not more. The whole experience has been pretty traumatic, I am still processing what happened and it has undoubtedly impacted my trust in maternity care in Glasgow. 

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Responses

Response from Mairi McDermid, Associate Chief Midwife, Maternity and Gynaecology, NHS Greater Glasgow & Clyde nearly 2 years ago
Mairi McDermid
Associate Chief Midwife, Maternity and Gynaecology,
NHS Greater Glasgow & Clyde
Submitted on 27/04/2022 at 16:55
Published on Care Opinion at 16:55


Dear frostnh68,

Firstly, I would like to sincerely apologise for your recent experience within our maternity services. This undoubtedly has been an extremely difficult time for you, and one that I would like the opportunity to discuss further.

We value any feedback from our women and use this as both an opportunity to reflect and improve the standard of care we provide.

If you would feel that this maybe helpful to explore your experience, please contact me directly on mairi.mcdermid@ggc.scot.nhs.uk.

Best Wishes,

Mairi McDermid

Associate Chief Midwife

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