Phoenix Chapman

Homerton University Hospital 
Homerton Row 
London 
E9 6SR 

www.homerton.nhs.uk 

His Majesty’s Coroner for Inner North London 
HM Coroner’s Court 
Poplar 
127 Poplar High Street  
London 
E14 0AE 

11.09.2023 

Dear Ms Hassell, 

Response to Regulation 28 Prevention of Future Deaths Report  
Deceased: Baby Phoenix Grace Chapman  

I am writing in response to your Prevention of Future Deaths Report issued to Homerton Healthcare 
NHS  Foundation  Trust  (‘the  Trust’)  following  the  conclusion  of  the  inquest  into  the  death  of  Baby 
Phoenix Grace Chapman. 

This response has been prepared with input from the Chief Nurse/ Director of Clinical Governance, 
and various members of the maternity team.  

Firstly, on behalf of the Trust, I would like to extend my condolences to the parents of Baby Phoenix 
Grace Chapman and recognise how devastating his death has been and continues to be for the family 
and all the professionals involved.  

You raised the following two areas of concern in your letter which I hope will be addressed below: 

1)  At inquest, there was not a shared understanding among the clinicians within the Trust 

about how such a situation should be approached. 

The obstetricians were clear that, given her very high-risk status, Phoenix’ mum needed 
to come into hospital as soon as she showed the first signs of labour. And even if she 
had started to deliver, she could still only be treated effectively, and Phoenix given the 
best chance of a good outcome in hospital. 

However,  some  of  the  midwives  felt  strongly  that,  when  Phoenix’  dad  could  see  the 
baby’s  leg  emerge,  they  should  have  been  allowed  to  go  out  to  the  home  to  give 
whatever assistance they could. 

 All the clinicians need have the same understanding of the correct protocol. 

2)  A related point is that, before Phoenix was born, some of the midwives felt that their 
views  of  what  should  happen  in  the  event  of  precipitous  labour  had  not  been  taken 
seriously. 

If they are to be effective in their role, and if necessary to understand why a protocol 
does  fully  reflect  their  feelings  and  views,  the  midwives’  ability  to  communicate  with 
senior management needs to be enhanced. 

Incorporating hospital and community health services, teaching and research 

 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 If the team as a whole is to move forward in a way that provides the best possible care 
for  women  in labour  and  their  babies,  questions and  differing  opinions need  to  be in 
some way acknowledged and dealt with before the correct protocol can be embedded. 

- 2 - 

You  heard  evidence  at  the  inquest  that  a  multi-disciplinary  meeting  (MDT)  meeting  took  place 
surrounding this birth and a detailed birth care plan was drawn up for the mother in advance of Baby 
Phoenix Grace Chapman’s birth.  

You also heard evidence that prior to this inquest, the Trust individualises patient care plans in line 
with  the  mothers’  wishes,  a  Consultant  Midwife  institutes  a  birth  plan  for  women  choosing  to  birth 
outside of guidance. Following the death of Baby Phoenix Grace Chapman, the Trust has employed 
a Specialist Birth Options Midwife. Any mother requesting a birth out of guidance is referred to the 
Birth Options Midwife.  She then consults extensively with those individuals, to formulate a birth plan 
and ensures that these birth plans are sent to the relevant neonatology, anaesthetic, obstetrics, and 
midwifery teams as appropriate, so that there is familiarity and a shared understanding with the plans 
prior to labour  and  birth.  These  plans  are  also  documented  on  the  electronic  medical records,  and 
copies are sent to the mothers, with a request for agreement to be provided before the plan is finalised. 
The mothers are aware that their plans will be re-visited in the event of changes to the clinical picture. 
These plans ensure that all clinicians, including the midwives involved in the care of the mother, have 
the same understanding of the care plan that is in place and the correct protocol to follow. 

In addition to this, our Birth Options Midwife and the community matron have formulated a process 
and criteria with timings for midwives to escalate the out of guidance patients if there are any concerns 
regarding  the  current  birth  plan  that  is  in  place.  This  is  again  to  ensure  that  there  is  a  clear 
understanding regarding the birth plan.  

We would also like to reassure you that the homebirth midwifery team already meet monthly, and that 
meeting is attended by all the homebirth midwives unless they are attending a homebirth or on annual 
leave,  in  which  case  they  can  review  the  outcomes  of  the  meeting  on  a  shared  drive.  During  this 
meeting they discuss any management issues or service updates, for example if there are any new 
guidelines. At this meeting, they also discuss all women booked in with them that are out of criteria for 
homebirth and review any new referrals that are out of criteria. This information is held and updated 
on  a  spreadsheet  in  a  shared  drive.  The  Matron  for  the  Community  Midwifery  team  attends  this 
meeting, together with the Director of Midwifery, the Birth Options Midwife, and the named Midwife for 
Safeguarding.  

To  improve  communication  between  the  homebirth  midwives  and  the  consultant  obstetricians,  the 
Trust has now assigned a senior consultant obstetrician to the homebirth midwifery team who will also 
attend these monthly meetings. The presence of a consultant obstetrician will provide an opportunity 
for  the  midwives  to  discuss  complex  cases  with  the  obstetrician,  explore  more  ways  of  working 
collaboratively, help to ensure their views are heard and that they are being listened to and will also 
provide an opportunity to share learning and understanding between other members of the team.  

The Trust  would like to reassure  you that  in addition  to the  existing communication and  escalation 
pathways that the Trust has in place, there are a number of additional actions that the Trust has now 
embedded following this inquest in order to ensure the midwives feel supported and that they have 
the  ability  to  communicate  their  feelings  and  views  with  senior  management.    In  addition  to  those 
discussed above, we detail the various actions below: 

•  Following  this  inquest,  our  Chief  Nurse  /  Director  of  Clinical  Governance  has  met  with  the 
homebirth midwifery team specifically to listen to how they feel and to see what support can 
be provided to them. The new Director of Midwifery started at the beginning of September and 
will  lead  further  meetings  with  the  homebirth  midwifery team,  together with the  Chief  Nurse 
monthly so that there is a forum to discuss any concerns that the midwives have. The next 
meeting is scheduled for 13th September 2023.  

 
 
 
 
 
 
 
 
 
 - 3 - 

•  The Trust has also discussed with the midwives the process by which they are able to escalate 
their  concerns  or  any  disagreements  that  they  have  in  respect  to  birth  care  plans.  The 
homebirth midwifery team have been reassured that the Trust want them to feel confident and 
safe to escalate concerns if they feel there is a risk to the patient, and that there is an escalation 
pathway for them to use if they have any concerns.   

• 

In addition to the monthly team meetings referred to above, each midwife has a one-to-one 
meeting with the Matron for Community Midwifery where they have the opportunity to raise any 
concerns that they have. However, there is always the opportunity to raise concerns with their 
manager at any point.  

•  The Trust has a consultant email inbox which has three consultant obstetricians who can offer 
the  midwives  a  second  opinion  if  they  are  concerned  about  any  cases.  This  email  inbox  is 
reviewed daily.  

•  The Trust also has an open-door policy, and members of the Trust Board and in particular, the 
Director  of  Midwifery,  the  Chief  Nurse,  the  Medical  Director  and  the  Chief  Executive  are 
available to discuss any concerns that staff may have. 

•  The Trust has a Freedom to Speak Up Guardian, and six Freedom to Speak up Champions 
who are there to provide confidential advice and support to staff regarding concerns they may 
have, assist staff to raise concerns in the Trust and to make sure that staff receive feedback 
about  the  concerns  that  they  have  raised.  The  Trust  Executive  Team  has  a  daily  live 
communication on MS Teams for all Trust staff called 12 at 12. This is a live broadcast that 
takes  place  daily  at  midday  for  12  minutes.    Following  this  inquest,  this  communication 
reminded all Trust staff that they have access to the Freedom to Speak Up Guardian service if 
they would like to confidentially discuss any concerns.   

•  The maternity team specifically have the Professional Midwifery Advocate (PMA) team.  At this 
Trust we have one lead PMA and 8 sessional PMAs. The PMAs are linked to a clinical area, 
so for example, the home birth team, birth centre, or delivery suite or antenatal clinic. However, 
a midwife can contact any of the PMAs that they choose.  PMAs are experienced, practicing 
midwives  who  have  undertaken  additional  training  to  the  A-EQUIP  model  of  Midwifery 
Supervision at a Trust level. They are employed locally by our Trust and work within a team to 
offer support and guidance to midwives to deliver care and support safe practice. Their role is 
to support staff to provide safe care by offering restorative clinical supervision to allow space 
to think through and reflect on issues, concerns, or difficult cases.  They also provide support 
to  staff  with  work  or  personal  issues.  They  help  midwives  access  additional  education  and 
training  as  necessary  and  support  midwives  with  revalidation,  appraisal  preparation,  career 
development, statement writing and be a listening ear.  

•  The  maternity  team  also  have  a  quarterly  “Candour  and  Cake  Café”  and  the  next  one  is 
planned for mid-September 2023. The idea around this is for staff to be able to speak out about 
their thoughts and feelings, check in with staff, create a positive working culture and an open 
environment  that  avoids  judgment  with  the  aim  to  enhancing  safety  and  support.    This  is 
attended by all levels of staff within the maternity and obstetric team. 

•  The Trust also has exit interviews in place for all staff to ensure feedback is obtained so that 

the team can learn from this and implement any improvements to practices.  

In addition to the responses we have provided above, I would also like to take the opportunity to update 
you on behalf of the Trust on a few others matters which were raised in evidence at the inquest. 

Since the death of Baby Phoenix Grace Chapman, the Trust has been alerting the London Ambulance 
Service NHS Trust (LAS) in respect of any birth plans in place where mothers choose to birth outside 
of guidance so that they are aware of these cases and the plans for emergency management.  

 
 
 
 
 
 
 
 
 
 
 
 
 - 4 - 
As highlighted in the Prevention of Future Deaths Report, national maternity guidance is soon to be 
published which is to deal with the situation where a baby is ‘Born before Arrival’.  The Trust has been 
working collaboratively with the LAS, and the North East London Local Maternity and Neonatal System 
(LMNS) to formulate a separate standard operating procedure and guidance for cases where the birth 
is imminent as there is currently no national guidance on this. Although this is being worked on at a 
local level, it is proposed that this will be part of the Joint Royal Colleges Ambulance Liaison Committee 
(JRCALC) Guidance and shared nationally with the LMNS and national maternity units. This guidance 
would be specifically for cases of birth imminent and advancing and cases where labouring women 
decline  to  be  transferred  to  hospital,  against  the  clinical  advice  of  the  paramedics.  The  aim  of  this 
guidance  is  to  provide  a  clear  understanding  for  all  clinicians  including  the  midwifery  staff  that  are 
called  to  attend  these  births  regarding  their  remit  of  care  and  also  provide  some  clarity  to  the 
paramedics.  This guidance will also provide a clearly formalised escalation pathway if a midwife is 
not able to attend. 

I hope that the content of this letter addresses the two areas of your concern and reassures you that 
lessons have been learnt and that the Trust takes improving patient safety very seriously. Please do 
not hesitate to contact me if you require any further information. 

Yours Sincerely, 

Chief Executive and Place Based Leader 
Homerton Healthcare NHS Foundation Trust

\ 
\ 
\ 
\ 

.,1s M  Hassell 
HM Senior Coroner 
St Pancras Coroner's Court 
Carnley Street 
London 
NlC 4PP 

Private and Confidential 

r1!1:k1 
____ ___ ___ .:__-::;:-:- London Ambulance Service
NHS Trust 

tlOZ  d3S  8O 
OJ~All 31031 Pd] 

Clinical Directorate
Headquarters
220 Waterloo Road 
London 
SE1  BSD

1st  August 2023 

Your Ref:  Phoenix Grace CHAPMAN  {died  15.07.22) 

Dear Ma'am 

Thank you  for sending a copy of your Prevention of Future Deaths  Notice under the Coroners and Justice Act 2009,  paragraph 7, 

Schedule  5,  and  The  Coroners  (Investigations)  Regulations  2013,  regulations  28  and  29  addressed  to  the  Chief  Executive  of 
Homerton Healthcare NHS  Foundation Trust, dated 14th July 2023. 

I would like to initially extend the sincere sympathies of the London Ambulance Service to the parents of Phoenix and  his wider 

family on their tragic loss. 

Clinical  guidelines  for ambulance  clinicians  are  nationally  produced  by the Joint  Royal  Colleges  Ambulance  Liaison  Committee 

(JRCALC). This is a multi-disciplinary team that draws together expert representatives from the Medical Colleges along with senior 

ambulance  clinicians  to  author  guidelines  that  are  both  evidence-based  and  applicable  to  pre-hospital  emergency  care.  For 

maternity guidelines, representatives from both the Royal College of Obstetricians and Gynecologists (RCOG) and the Royal College 

of Midwives  (RCM)  are  formally  consulted.  The  JRCALC  Clinical  Guidelines  are  also  reviewed  and  approved  by  the  National 

Ambulance Service  Medical Directors Group {NASMED)  prior to publication. There is  an  active and continual process of evidence 

review and  refresh of the JRCALC guidelines. 

As you are aware the national JRCLAC breech birth guidance has been recently reviewed and updated. Along with representation 

from the RCOG and RCM,  there has also been input from the LAS maternity team and senior LAS paramedics to ensure that, as the 

busiest  ambulance service  in  the UK,  key  learning from  obstetric emergencies  has  informed the development of this guideline. 

Recent  evidence  around  recommended  timings and  advice for 'continuous pushing' following delivery of the buttocks has  ~een 

included in the new guideline. I have attached the final version of the national guidelines which was formally approved by NASMED 
on  11th July 2023 and will be published in the next update of the JRCALC guidelines. The JRCALC guidance has been enhanced with 

the use of diagrams and visual  prompts to aid  ambulance clinicians in  managing the rare occurrence of a breech  birth outside of 

the hospital. There is also a working group developing educational videos to accompany the guidance. 

JRCALC  always welcomes contributions into future guidance from  those with clinical expertise and  experience in  the application 

of the guidelines to out-of-hospital emergency care delivered by ambulance clinicians. 

We are aware that you heard in  evidence reference to a pathway that has been developed with the Local  Maternity and Neonatal 

System  in  North  East  London. The  pathway was  presented  in  evidence  as  relating to birth  imminent cases  and  it was  presented 

that the guidance was going to change to recommend  ambulance clinicians transport all women with birth imminent straight to 

hospital.  For  clarity the pathway referred  to has  been  developed  i~  conjunction with the LAS  lead  midwives and  only relates  to 

'Birth Before Arrival' cases.  When a baby is  born prior to the arrival of the ambulance or is  delivered by the ambulance clinician, 

this is known as  'Birth Before Arrival'.  Historically, where the baby is  physiologically well and of term gestation the LAS clinicians 

would  contact the nearest  maternity unit and  request  a midwife to attend the scene  to further assess  the baby and mother to 

facilitate them staying at home.  With the increasing demand on  maternity services, the ability for a busy maternity unit to send a 

 
 
 
 midwife to scene has  become increasingly challenging in  many areas of London. Therefore the pathway that has been developed 

with  North East  London  is  that unless  the woman has  had  a planned  homebirth, the woman  and  baby should  be  transferred  to 

hospital. If a mother declines conveyance to hospital, a midwife will still be requested to attend the scene. This guideline is explicit 

in  that it applies  to babies  born  prior to arrival  at the hospital  and  does not cover  either the  management of normal  labour or 

obstetric emergencies, including breech  birth which is covered  in the JRCALC national guidelines. I have attached the draft North 

East  London  pathway.  With  the  continuing  pressure  on  maternity  services,  the  London  Ambulance  Service  anticipates  this 

guideline may be adopted in other areas of London. 

The  consensus  expert view  is  that if a birth  is  imminent ambulance  clinicians  should  attempt to deliver the  baby on  the scene 
before transporting to hospital. This includes cases of cephalic or breech birth where the baby is imminently delivering and cases 

of shoulder dystocia. A baby that is visible and advancing would be classed  as  "birth imminent". There are several  reasons why it 

is safer to provide care on scene prior to extrication and conveyance.  Firstly it is  practically very difficult to extricate safely and in 

a timely  manner when  a patient  is  'pushing'  and  there  is  a presenting part  of the  baby  either visible,  advancing  or  delivered. 

Secondly, .the time taken to extricate and transport is likely to lead to increased hypoxia especially if part of the baby has already 

delivered and there is the potential of cord compression occurring. If manoeuvres are attempted and successful then the outcome 

is likely to be better than if no manoeuvres are attempted and the patient is transported into a hospital for the manoeuvres which 

is likely to increase the chance of severe hypoxia. Also, securing the patient in the vehicle according to correct driving standards is 

very challenging in this situation. Furthermore, as you heard in evidence from one of the LAS  paramedics, if the baby is delivered 

in  a moving ambulance there is  limited space,  lighting, heating,  and surfaces for resuscitation  of the baby or mother if required. 

The nuance of extrication and transport of patients is understandably not always well understood by clinicians without experience 

in  pre-hospital  emergency  care.  In  view  of these  challenges,  national  guidelines  recommend  that there  should  be  appropriate 

attempts to deliver the baby by ambulance clinicians and then to transport if such  manoeuvres have failed. 

We will ensure that this case will be shared anonymously for national learning with other ambulance service maternity leads and 

medical directors group, and the JRCALC development group. 

We  hope  the  above  assists  in  providing  assurance  that  the  clinical  guidelines  in  place  for  ambulance  clinicians  are  nationally 

developed  and  evidence-based with expert input from  the relevant Medical Colleges  as  well  as  robust review for their use  pre-

hospital.  Further to this, we are working with maternity units to aim to provide pathways of care that are appropriate and safe. 

We  keep  all  guidance  under review  and  will  ensure that the learning from  this  case  that we have  adopted  within  LAS  will  feed 

directly into JRCALC through our maternity and senior paramedic teams as well as through myself as chair of NASMED. 

I would like to take this opportunity to invite you to visit the London Ambulance Service; we would very much value the opportunity 

to share with you  some  of our improvement work and  how we  are  working to  improve  pre-hospital  clinical  care  and  response 

times when  there are  considerable  stressors  on  the Health Service.  You  would  be  welcome to view the Emergency Operations 

Centre  and  /  or spend  time with  one  of our frontl-line crews.  If you  would  like to undertake this please  contact  my Consultant 

Paramedic 

Finally, I would like again to express the LAS's sympathies to the parents of Baby Phoenix Grace. 

Yours faithfully 

j• 

Chief Medical Officer and Deputy Chief Executive,  London Ambulance Service 

Chair National Ambulance Service Medical  Directors Group 

Enc. 

cc: 

 Joint Royal Colleges Ambulance Liaison Committee 
, Joint Royal Colleges Ambulance Liaison  Committee 

 
 
 Breech birth JRCALC draft revised guideline 

Incidence, risk factors and diagnosis 

Vaginal  breech birth is where the feet or buttocks of the baby are born first, rather than the baby's 

head. 

Breech presentation affects 3-4% of births at term (37 weeks onwards) and is more common in pre-
term births. 10 

At onset of labour, breech presentation may be  known and  reported by the patient or recorded in 

the pregnancy notes. 

In  some circumstances,  breech presentation is  unknown and the first diagnosis is made when the 

buttocks/ or feet are visible and advancing through the vaginal entrance (introitus) 

Breech birth can cause fetal hypoxia. It is therefore likely that the baby will require resuscitation 
(refer to Newborn Life Support). 

Breech babies are more likely to pass meconium during the birth. Presence of meconium does not 

require different management, but should be documented and  handed over to maternity/neonatal 

staff. 

Cord  prolapse is more common with a breech presentation (refer to Birth Imminent: Normal Birth 
and Birth Complications). 

Consider seeking senior clinical support and  advice as per local procedures. This should not cause 

further delay on scene if the appropriate decision is to transport rapidly. 

Some  manoeuvres specific to breech birth require the clinician to insert their fingers into the 
woman's vagina. It is essential for clinicians to gain appropriate consent prior to performing these 

manoeuvres. 

When to leave scene immediately: 

Rapid  transport to the nearest hospital with an  obstetric service (or alternative as agreed locally), is 

indicated when: 

• 

• 

• 

• 

The birth is  not imminent (i.e. the buttocks/or feet are not visible or not advancing 

through the vaginal entrance (introitus) 

If manoeuvres are not physically possible, or do not restore progress leading to the birth 

of the baby. 

You  see a presenting body part other than the head or buttocks (e.g.  one foot or a 

hand/arm) 

Footling breech: 
o 

If a foot or feet are presenting and the buttocks do not immediately follow, this is a 

footling breech. This is an emergency and  must be conveyed immediately to an 
obstetric unit with a pre alert message.  DO  NOT encourage pushing. 

OFFICIAL - Business data that is not intended for public consumption.  However, this can  be shared with external partners, as required . 

1 

 Mother in 'all fours' position 

Note:  In the all fours position the baby can be  delivered on the floor or bed/sofa but ensure a safe 
landing area. 

Timing 

When both buttocks are born, the risk of hypoxia is increased as the baby descends further through 
the birth canal. The woman should be encouraged to push continuously from this point (do not wait 
for contractions as they may slow down/stop). It is crucial that clinicians recognise (and act upon) 
any delay in progress. 

Allocate someone to start a timer. Where possible, this person should not be involved in the clinical 
management to aid  situational awareness. 

When both' buttocks are born, start the timer - the baby must be fully born within 5 minutes 

Delay of more than 5 minutes from the birth of the buttocks is associated with poor outcomes. If 
manoeuvres do not result in the birth of the baby within this time rapid transport to hospital is 
indicated. 

All timings and any manoeuvres performed should  be clearly documented. 

'Hands poised' approach and when to intervene 

Many breech births occur spontaneously without intervention. Use a 'hands poised' approach, with 
a clinician ready to assist if required.  If delay does occur at any stage, the baby is at high risk of 
hypoxia and  manoeuvres must be  used to assist the birth (see Figure x.xx). 

Clinicians should observe the condition of the baby throughout the birth. Do  not wrap anything 
around the baby. 

If any of the following signs are seen,  it may indicate fetal hypoxia so  manoeuvres should be 
performed: 

The  parts of the baby that are born are not well perfused, and  have no movement or tone 
White, empty umbilical cord 
No  movement/ absent tone 

3 

OFFICIAL - Business data that is not intended for public consumption. However, this can  be shared with external partners, as required. 

 4
Right or left lateral position is suitable for conveyance.  •
offers reassurance, allowing her to face the clinician or relative: 

15  Positioning the woman on her right side 

•  Continually observe for signs of imminent birth en-route. 

•  Stop the vehicle to assist with the birth 

•  Provide early pre-alert message to the nearest obstetric unit and  request maternity staff to 

meet the ambulance at an  agreed entrance to avoid any delays. 

•  Stop the vehicle to assist with the birth if required. 

Management of a Breech Birth (See Figure x.xx) 

Recognition of breech birth imminent: remain on scene 

If baby's buttocks are visible and advancing through the vaginal entrance (introitus), birth is 
imminent so  remain on scene. 

Prepare: 

Request help and  additional resources as per local procedures. 

Prepare for newborn life support (Newborn Life Support). 

Assist the woman into a position that aids gravity (position at the edge of the bed/trolley or all-
fours) 

Mother semi-recumbent - vagina over edge of bed to allow birth 

Note:  In the Semi-recumbent position keep the mother's buttocks AT THE  EDGE of the bed, to allow 
the baby to 'hang down' under its own weight during delivery 

OFFICIAL - Business data that is not intended for public consumption. However, this can  be shared with external partners, as required . 

5 

 When the scapula (shoulder blade) is seen - the elbows/arms should now be visible. When the 
baby's elbow is visible: 

•  Hook your finger into the antecubital fossa  (inside the elbow) and draw the arm down & 

deliver alongside the baby's body. Do this for both sides to release the arms. 
If you cannot see the arms, you will need to rotate the baby to bring the arms into view. 

• 
•  Place your hands around the baby's pelvis. 
•  Rotate the baby until the shoulder is uppermost. 
• 

If the arm is not delivered, place your finger into the vagina  (gain consent first) finding the 
axilla and feel down the humerus until you reach the elbow. 

•  Place your finger into the antecubital fossa  (inside the elbow) and complete delivery as 

described above. 

• 

If the second arm does not then deliver, rotate the baby in the other direction and repeat. 

•  Once both arms are released,  rotate the baby to face  in  the correct direction - see images 

below: 

Mother semi-recumbent- baby's back must face towards you 

Mother in All fours - baby's abdomen must face towards you 

Watch video clip: 

video -arms 
delayed.MP4 

If the head is delayed and the mother is in a semi recumbent position: 

Baby's back should face towards you (see image above). 

OFFICIAL - Business data that is not intended for.public consumption. However, this can  be shared with external partners, as  required. 

7 

 Mother in 'All fours' - shoulder press applied to encourage flexion and  birth 

Watch video clip: 

VID-shoulder 
press.mp4 

OFFICIAL - Business data that is not intended for public consumption. However, this can  be shared  with external partners, as  required. 

9 

 References 

1.  Azria  E et al.  Factors associated with adverse perinatal outcomes for term breech fetuses 

with planned vaginal delivery. American Journal of Obstetrics and Gynecology 2012,  207(4). 

doi: 10.1016/j.ajog.2012.08.02 7. 

2.  Azria  E et al.  Neonatal mortality and  long-term outcome of infants born between 27 and 32 
weeks of gestational age  in breech presentation: The EPIPAGE Cohort Study. PLOS ONE 

2016, 11(1). doi:10.1371/journal.pone.0145768. 

3.  Bogner G. et al.  Breech delivery in the all fours position : A prospective observational 

comparative study with Classic Assistance . Journal of Perinatal Medicine 2014, 43(6): 707-
713. doi:10.1515/jpm-2014-0048. 

4.  Carbonne  Bet al.  Maternal position during labor: effects on fetal oxygen saturation 

measured by pulse oximetry. Obstetrics & Gynecology 1996, 88(5): 797-800. 

DOI:  10.1016/0029-7844(96)00298-0 

5.  Doyle  NM et al. Outcomes of term vaginal  breech delivery. American Journal of Perinatology 

2005,  22(06):  325-328. doi:10.1055/s-2005-871530. 

6.  Hofmeyr GJ  and  Ku lier R.  (2012)  Expedited versus Conservative approaches for vagina l 
delivery in breech presentation. Cochrane Database of Systematic Reviews [Preprint]. 

doi:10.1002/14651858.cd000082.pub2. 

7.  Louwen  Fetal. Does breech delivery in an  upright position instead of on the back improve 
outcomes and avoid Cesareans? International Journal of Gynecology &  Obstetrics 2017, 
136(2): 151-161. doi:10.1002/ijgo.12033. 

8.  Pasupathy D et al. Time trend in the risk of delivery-related  perinatal and  neonatal death 
associated with breech  presentation at term. International Journal of Epidemiology 2008, 

38(2): 490-498. doi :10.1093/ije/dyn225. 

9.  Reitter A et al.  Does pregnancy and/or shifting positions create more room in a woman's 

pelvis? American Journal of Obstetrics and Gynecology 2014, 211(6). 
doi: 10.1016/j.ajog.2014.06.029. 

10.  Royal  College of Obst etricians and Gynaecologists (RCOG)  (2017) Management of breech 

presentation (green-top guideline no. 208),  RCOG.  Ava ilable at: 

https://www.rcog.org. u k/gu ida nee/browse-a 11-gu ida nee /green-top-
gu ideli nes/ma nage ment-of-breech-presentation-green-top-guide Ii ne-no-20b/ (Accessed:  21 

June 2023). 

11.  Spillane  E,  Walker Sand Mccourt C.  (2021) Optimal time intervals for vaginal breech  births: 

A case-control study [Preprint] . doi:10.22541/au.163251114.49455726/vl. 

12.  Su  M et al.  Factors associated  with adverse perinatal outcome in the term breech trial. 

American Journal of Obstetrics and Gynecology 2003, 189(3): 740-745 . doi:10.1067 /s0002 -
9378(03)00822 -6. 

13.  Walker S,  Scamell Mand Parker P.  Principles of physiological breech  birth practice: A Delphi 

Study. Midwifery 2016, 43:  1- 6.  doi :10.1016/j.midw.2016.09.003. 

14.  Walsh  D. Physiological  positions for breech  birth . International Journal of Childbirth 2017, 

7(2):  58- 59 . doi:10.1891/2156-5287 .7.2 .58 . 

15.  Wu Set al.  Effects of right lateral position on changes of fetal hemodynamics in late 

pregnancy. J Ultrasound Med 2023, 9999:1- 7. doi:10.1002/jum.16261 

OFFICIAL - Business data that is not intended for public consumption.  However, this can  be shared with external partners, as  required. 

11 

 RECOGNISE 

Breech 

reported by patient/recorded In notes 

Thick meconlum or buttocks/feet seen at wlva 

+ 

BREECH BIRTH IMMINENT 
Baby's butto~ks vlslble and advanclng;thl'!)Ugll  ' 
the,vaglnal entrance 

+ 

BREECH BIRTH NOT IMMINENT 
Any other-presenting part vlslble •(l.a.Jeet, hand, 
ann).or buttocks are,not vlllble or not advancing 
through the vaglnal entrance 

+ 

PREPARE 
Recognise obstetric emergency and 
,wquaat additional IWIOIIR:el to 11Cane 
Prepa,w for newbom 198UIICitatlon 
(Refer-to Newborn Ufa lupport guideline) 
Assist the woma11,1n ~o e poalllon that ald1 
-tl~IIVity (Posltt~ at the end of ~e bed/troHey 
or all-fours) 

+ 

RAPID TRANSPORT 
Pre-alert and tranafllr to nearest obstetric 
unit without delay 
Continually ob~• for signs of Imminent 
birth en-route 
Stop vehlcle to assist with the 
birth If required 

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MANAGE 

Observe for descent, handa polled ready to
Intervene/receive the baby 

•  Both buttocks are bom: 
•  Stirt a timer. 
•  Encourage contlnuiM.11 puahlng (do riot wait for 

c:oiltractlons). 

(v  6 MINUTES TO COMPLETELY DELIVER BABY 

( \ :  

Apply pressure behind the baby's knees to release the 
legs. 

If   

delayed 

•  When tha'baby's elbow Is visible, hook your finger Into 
the antacubltal fossa.(Inside the elbow) and draw the 
arm down & deliver alongside.the baby's body, Do this 
for both sides to release the arms. 

•  If you cannot see the anns, rotate the baby to bring 

the armi Into view. 

•  Place.your hands around the baby's peMs. Rotate the 

baby until the shoulder Is uppermost. 

•  If the arm Is not delvared; place your flnger,lnto the 
vagina (gain consent first) finding.the axilla and feel 
down the humerus until you reach the'elbow. 

•  Place your finger Into the antecubltal fossa •(Inside.the 
elJoW) and complete delivery as described above. 
•  If iha second arm does not then-deliver, rotate the 

baby In the other.direction and repeat. 

•  Once both arms are released; rotate tha baby to face 

In the correct direction. 

If the head Is delayed • All four. 

If the head Is deleyed • Soml-reoumbent 

Baby's tummy should 
face 

you. 

Place both hands against 
the baby'S chest and 
apply pressure to flex the
baby's head forward as
lt'sbom. 

Baby's beck ahould face 

you. 

•  Place one hand through 

the baby's legs to support 
baby's body along your 
arm, Inserting the flngsr• 
Into the _.,.n's vagina. 
•  Place your two fingers on 

to t~• baby's cheekbones • avoid mouth and 
eyes. 
With Ille othsr hand, Insert your flngsrs Into 
Ille vagina elong the nape of,the baby'• neck. 
,  Apply flnn pressure to the back of the baby's 
head to bring the chin toward the chest 

•  Apply pressure with both hands at the same 

Ume to nex the baby's head. 

•  Rals_e the baby upward to" 11ft through the 
curve ol.the pelvis to deliver the baby. 

 BBA (Birth Befo,e Arrival)- Standard OperaUng  Procedure (SOP) Draft V.,.ion 

NEL LMNS & LAS 

t.!7#ki 
North East London 

Not booked for homeblrth OR 
mother/baby.not well OR 
<37140· 

~9_91 Call r,ecei~ed! b~ Ambulance 

Bab  ,Born Beforefon1arrival 

- ---------1-

Booked.for, homeblrth ANO 
mother!b_aby;we!l'ANO  .. 

>37/40 

Emergency Operation Centre to 
contact maternity unit to request 
Midwife on scene. 

Is Mldwlfe·able to attend 'within 
40mlns? 

-

Crew.remain on scene 
uniil handover.to Midwife 

Has·-the.Mldwlfe 
iditntifiecl'a red flag? 

,...If Mother Declines LAS T:ransfer,... 

l 

Maternity Responslbllltles: 

LAS Responslbllltles: 

Escalate to Maternity Duty Manager 

Make call to ·nearest maternity unit 

To remain on.scene •until handover 
to:Midwife 

Consider reason.fordecline 

Urgently mobilise 2 Midwives to attend 

If booked with another provider contact 
them to ·idenlify,if-any known 
safeguarding risks, mental health 
concerns or known diagnosis 

l:iaise with duty social.worker to establish 
safeguarding  concerns 

Liaise with police to establish safety 
concerns 

Nor th Ea~I  London (NEL) Born Before Arri',al  (BBA) Standard Operaling  Procedure (SOP)  Orah  Version 2023