Footling breech an obstetric emergency

21 March 2023

An assistant coroner has prepared a Prevention of Future Deaths Report, declaring footling breech to be an obstetric emergency.

A BBC Article (Burgess Hill family campaigns to prevent breech home birth deaths - BBC News) reports that the parents of Arthur Trott, who died at 4 days old, are campaigning for changes to maternity healthcare to increase awareness of the warning signs of footling breech.

What is breech?

Babies lying bottom first or feet first in the womb instead of the usual head-first position are called breech babies. Breech is very common in early pregnancy and by 36-37 weeks of pregnancy, most babies turn naturally into the head-first position.

Towards the end of pregnancy, a small percentage of babies are in the breech position. There are three types of breech position:

  • Extended or frank position – baby is bottom down with thighs straight up and feet up by its ears
  • Flexed position – baby’s bottom is down with thighs against chest, knees bent and feet down
  • Footling position – baby’s bottom is down but one or both feet are down, below bottom level.

Circumstances of Arthur Trott’s birth and death

At around 03:00am on 24 May 2021, Arthur’s mother, Stephanie, began spontaneous labour. She was 37 weeks and 2 days. The labour progressed at home; the family having sought guidance from their local maternity unit at Princess Royal Hospital, Haywards Heath.

At around 5:35am it became clear that Arthur was an unanticipated footling breech, descending feet first, with the feet below the bottom.

Arthur’s father, Matt, called the maternity unit and a midwife advised him to call 999 immediately for urgent admission to the labour ward. Matt made the 999 call and the ambulance arrived within 12 minutes. On arrival the ambulance operator spoke to the midwife by telephone and the midwife repeated the advice for immediate transfer to the labour ward. However, the ambulance operator sited guidance provided by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) that if breech birth was “imminent” then to try to deliver the baby.

This led to a delay in transfer to the labour ward with arrival at 06:35am. Arthur was delivered at 06:38am in very poor condition. Despite active resuscitation and care on the neonatal ward, Arthur sadly died 4 days later on 28 May 2021 from complications from catastrophic brain injury following oxygen deprivation.

Prevention of Future Death Report

An inquest into Arthur’s death was held. The coroner found that the delay in transfer to hospital had materially contributed to Arthur’s death.

Coroners have a duty to make reports where the coroner believes that action should be taken to prevent future deaths. In this case the coroner made such a report to the JRCALC and to the CEO of the Association of Ambulance Chief Executives. Assistant coroner Karen Henderson stated that “The JRCALC guidance on the emergency management of footling breech presentation by the emergency services is insufficiently robust”.

Teri Gauge-Klein, senior associate at Shoosmiths, has reviewed the assistant coroner’s recommendations and summarises them as follows:

  1. “The JRCALC guidance fails to treat footling breech presentation as different from other breech presentation.
  2. The JRCALC guidance should consider footling breech as an acute obstetric emergency requiring immediate transfer to the nearest hospital obstetric unit.
  3. The JRCALC guidance should state that no attempts should be made for a home delivery with a footling breech.
  4. That there are only two consultant midwives employed by the ambulance services despite there being 11 ambulance organisations in England.
  5. The majority of ambulance services have no obstetric support, guidance or ongoing teaching and training.
  6. As a matter of urgency there is a need to provide resources to employ more consultant midwives - at least one to two per service - throughout all the ambulance organisations.”

Following on from Arthur’s death, parents who live in Sussex and who wish to have home births are being offered additional scans to establish the lie of their baby when they are close to term.

Susan Prior, a partner in Shoosmiths’ Clinical Negligence team in the Thames Valley office, Reading, commented:

“It is clear that the midwife consulted in relation to Arthur’s home birth recognised the risk to Arthur but was hampered by the JRCALC guidelines, for which there have been recommendations of change. The assistant coroner in this case has also sent her report and recommendations to the president of the Royal College of Obstetrics and Gynaecologists; hopefully, this will bring about positive change for the protection of future footling breech babies and other trusts follow suit and bring in late positioning scans for planned home births”.



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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