Vaginal breech birth — structured oral station (12 minutes)

Opening prompt — "She is 8 cm and it is a breech. What do you do?"

Model response — say it in this order: [1][6]

• "This is an undiagnosed breech in advanced labour. I would call for help now: the consultant obstetrician, an anaesthetist, the midwifery coordinator and the neonatal team, and I would tell theatre we may need them."
• "While they come, I would do a point-of-care ultrasound — RANZCOG C-Obs 11 says to do this wherever practicable when breech is first diagnosed in labour — to confirm the type of breech, the attitude of the neck, an estimated weight and the liquor."
• "Then I would run the contraindication list in my head, and have a short, honest conversation with her about the two options while there is still time to choose."[1]

Examiner is listening for: calling early, imaging before deciding, and the fact that a compressed conversation is still a conversation. [1]

Probe 1 — "Run me through your selection. Is she suitable?"

• "The contraindications in C-Obs 11 are cord presentation; growth restriction below the 10th centile or macrosomia above 3.8 kg; any presentation other than frank or complete breech; hyperextension of the fetal neck; evidence of antenatal fetal compromise; and a fetal anomaly incompatible with vaginal birth."[1]
• "She has none of them. She is a frank breech at 3.2 kg with a flexed neck and a normal CTG, and she is multiparous and progressing quickly. She is as favourable as an undiagnosed breech gets."
• "But selection is not only about the fetus. It is also about the facility and the operator — continuous electronic fetal monitoring, immediate access to caesarean, and a suitably experienced obstetrician and midwife available for the whole of the labour. I would say out loud whether I am that person, or whether my consultant needs to be in the room."[1][6]

Probe 2 — "She asks you: which is safer for my baby?"

This is the counselling mark, and it needs absolute numbers, not adjectives. [2][4]

• "I would tell her the Term Breech Trial found the composite of perinatal death, neonatal death or serious neonatal morbidity was 1.6% with planned caesarean and 5.0% with planned vaginal birth — a relative risk of 0.33."[2]
• "But I would also tell her the absolute risks from the meta-analysis that includes observational data: in the planned vaginal group, perinatal mortality about 0.3%, fetal neurologic morbidity about 0.7%, birth trauma about 0.7%, a 5-minute Apgar under 7 about 2.4%."[4]
• "And I would tell her the honest Australian figure: in a NSW population study of women eligible for vaginal breech birth, those intending it had more neonatal morbidity, 6.0% versus 2.1%, and more birth trauma, 7.4% versus 0.9%."[5]
• "I would say plainly that caesarean is safer for this baby on average, that the absolute risks of a well-selected vaginal breech birth are small, and that at 8 cm and progressing fast, a caesarean is also not risk-free or instant."

Probe 3 — "She chooses to continue. Talk me through the birth."

• Passive second stage first. "I would not push until the breech is visible at the perineum. C-Obs 11 says if the breech is not visible within 2 hours of the passive second stage, recommend caesarean."[1]
• Hands off. "No traction. I grasp the fetal pelvic girdle over the bony hips, never the abdomen, and I never hyperextend the neck. Tactile stimulation provokes reflex extension of the arms and neck, so I minimise it."[1]
• Back anterior. "If the back starts to rotate posteriorly I use gentle rotation without traction to keep it anterior."[1]
• Arms then head. "Once the scapula is visible: a finger into the antecubital fossa to sweep a flexed arm across the chest, or Lövset's manoeuvre — rotating the trunk 180 degrees with the back kept anterior — for nuchal or extended arms. Then the head slowly and in flexion, by Mauriceau-Smellie-Veit or forceps to the after-coming head, with suprapubic pressure to aid flexion."[1]
• The clocks. "I intervene for poor fetal tone, or if more than 5 minutes pass from buttocks to head, or more than 3 minutes from umbilicus to head."[1]

Probe 4 — "The body is out and the head will not come. What now?"

This is the discriminating probe. Escalate in a named order and do not hesitate. [1]

• "I would call it out loud as head entrapment so the whole room knows."
• "McRoberts position and suprapubic pressure first, to flex the head and open the outlet."
• "Tocolysis to relax the lower segment while I work."
• "Dührssen incisions in the cervix at 2, 6 and 10 o'clock — C-Obs 11 names those three positions, with or without tocolysis."[1]
• "If those fail, symphysiotomy or the Zavanelli manoeuvre are the last resorts, and at caesarean the uterine incision can be extended to a J or inverted T."[1]
• "Throughout, I am not pulling harder. Traction is what produces the injury I am trying to avoid."

Probe 5 — "She is frightened and her partner is asking what is happening."

Rapport, respect and communication are three of the eight scored domains. Demonstrate them out loud. [1]

• Get to her eye level, use her name: "Your baby is coming bottom-first. That happens in about three or four in a hundred pregnancies at the end. We have found it late, and I am sorry about that."
• Offer the choice honestly and in plain words: "There are two safe-ish ways forward and I want to tell you about both quickly, because your labour is moving fast."
• Name the team, allocate someone to stay with the partner, and commit to a debrief afterwards.
• Avoid narrating the emergency over her body while operating on the drape.[1][6]

Probe 6 — "Afterwards. What do you do and what do you tell her?"

• "Examine the baby for birth trauma, and arrange hip ultrasound — breech presentation is associated with developmental dysplasia of the hip regardless of how the baby was born."
• "Inspect her perineum and cervix, and manage the third stage actively."
• "Offer a structured debrief. This was frightening and it was undiagnosed, so I would explain what happened and why, and document the conversation carefully."
• "And I would raise it as a unit issue: an undiagnosed breech at 8 cm is a detection failure, and C-Obs 11 requires units to run regular simulation training precisely so that staff can manage this safely."[1]