Undiagnosed breech birth: when baby has other plans, trust carries us through.

There are births that stay with you. Not because they were complicated or dramatic, but because they were exactly what birth is meant to be when trust and relationship sit at the centre of care. (To be honest working in this way, means I remember every birth, but this was one of those births that reminded me of some important truths).

The birth

She laboured beautifully in water, with the rhythm that comes when a woman feels safe, held, and undisturbed. Supported incredibly by her birth partner (baby’s Dad). I’d known this client for months. We’d built something together, not just a birth plan, but a relationship. A knowing between us that would hold steady even when plans shifted.

And shift they did.

As her baby began to descend, I saw thick toothpaste meconium in the water (that distinctive external sign that this baby is coming bottom first).

And in that moment, there was no panic. Not from her. Not from me. Not from Hannah, the second midwife supporting us. Not from her partner, who later told me he didn’t feel any panic or sense of urgency. Just a quiet, calm pivot.

“Love, we need to get you out of the water for baby’s arrival.”

She moved, she trusted and baby descended further she birthed her baby, into my waiting hands with the same power and grace she’d carried throughout labour.

Hannah was overjoyed. In 17 years of midwifery, she hadn’t witnessed a physiological breech birth. I’ve no idea how she remained so calm in that moment, she continued supporting the couple throughout the birth of their baby, steadfast at my side.

We stood together afterwards, this couple glowing with their baby on Mama’s chest, and marvelled at what birth can be when we hold our nerve and hold space. There were tears (I always cry at births).

In the days that followed, as I reflected on this birth, I found myself caught between wonder and something else. Something that’s been nagging at me throughout my career, judgement. I know so many other midwives will relate to this!

The clinical picture

Let me paint you the clinical picture, because this matters.

Throughout pregnancy, every palpation suggested this baby was head down. Mum described hiccups low in her pelvis, exactly where you’d expect them with a cephalic (head down) presentation. She had head-fitting pain as she approached term that deep, pressure sensation that comes when a baby’s head engages into the pelvis. There was no discomfort under her ribs, at any point, no hard round mass wedged up high that might suggest a breech position.

When I palpated her on the day of birth, I lingered over what I assumed was baby’s bottom. There was nothing ballotable about it (you couldn’t bounce it between your hands the way you can with a head). It felt broad, like a bottom, but I lingered because I could tell this felt different than 5 days before. Not once did it cross my mind in that moment that this baby might now be breech. Both myself and client convinced ourselves the change in palpation and change in where she felt movement was due to baby now being ‘so low’ (following an episode of 4:10 contractions for a few hours, 5 days prior).

But here’s the detail; this baby was just shy of 4.5kg and head circumference was 38.5cm. Feel a head that size within a bag of waters, through an abdominal wall, and tell me it couldn’t feel like a broad bottom. ;)

This Mama is adamant her baby was head down until a couple of days before labour. She’s deeply intuitive with her body, she knows herself. And I believe her. I’ve heard of babies scanned days before birth showing cephalic, only to be born breech. Babies have their own plans.

However, following this birth I heard familiar words from when I’d ’missed’ a breech presentation a few years earlier. I’ve been told twice in my career by other independent midwives (colleagues who work in the same relationship-based model I do) :

“I’ve never missed a breech I use a pinard"

The Pinard myth

There is a persistent belief in maternity care that careful abdominal palpation or the use of a pinard stethoscope means a breech presentation will never be missed. However, research and clinical experience demonstrate that undiagnosed breech presentations still occur, even with routine antenatal assessment. This highlights that palpation and auscultation are valuable skills, but they are not infallible.

Undiagnosed breech and the limits of screening tools

Dr Shawn Walker from the Breech Birth Network, who has observed thousands of hours of breech birth footage, has reminded me on more than one occasion that the theory of the pinard as a fail-safe is not evidence-based. Her message is not that palpation or auscultation with a pinard lack value, but that no single screening method is fail-safe.

Undiagnosed breech remains a recognised reality in maternity care. Unless we scan every woman in labour for presentation, we will continue to occasionally encounter this unexpected situation. This is precisely why maintaining the skills to recognise and safely manage breech birth is so important, particularly when birth does not follow the expected plan.

Undiagnosed breech births happen in midwifery-led units, in birth centres, in consultant-led settings, in independent midwifery practice. They happen to experienced midwives. They happen to newly qualified midwives.

I’ve felt reassured on many occasions when palpating and using a pinard stethoscope has helped me diagnose a baby in breech position, either in pregnancy or during labour. I’ve used belly mapping where a client describes where kicks are felt. I’ve used all these skills throughout my career. But this situation shows us that even with all these tools, it isn’t a guarantee.

The culture of judgement

Here’s what’s interesting: I’ve never heard these words about the pinard and never missing a breech in ‘experienced breech circles’. Where midwives, obstetricians, researchers, service users are working tirelessly to establish breech services (across the globe) they all talk about the role that ultrasounds play in this situation. Every breech team will include an ultrasound for presentation in the pathway. No one in those settings has ever suggested that using a pinard results in never being taken by surprise with a breech baby.

But as an independent midwife, the judgement comes from within our own community. It’s important to acknowledge this because if we create a culture where IMs believe they should never miss a breech, we create a culture where IMs might panic when they do. We lose the very skills we need most, the ability to stay calm, to hold space, to support a family through an unexpected situation with confidence and capability. The pinard becomes a false security blanket. “I use a Pinard, therefore I’ll never miss a breech, therefore I never need to develop the skills to support an undiagnosed breech birth.”

That’s worrying, surely it’s safer to talk openly about how sometimes, despite our best efforts, despite our experience, despite our tools, we don’t know baby is breech until baby arrives.

What prepared me for this moment

My ability to support this family calmly, to pivot without panic, to facilitate a physiological breech birth at home. It came from years of learning and experience that I’m deeply grateful for.

My formative years as a student midwife were spent at a trust well reputed for supporting physiology, particularly breech birth. My time facilitating learning with Baby Lifeline, skills and drills sessions, and countless other training opportunities built a foundation of knowledge and confidence that held me steady in this moment. It also came from having Hannah as my second midwife. She is an exceptional midwife, and we have a mutual trust that is perfectly suited to working in this way. Your birth team matters. Who you work alongside matters.

The trust between me and this Mama, between Hannah and me, between all of us in that space, meant that when I said “we need to get you out of the water,” she moved without question. The relationship we’d built over months held us all steady.

The real conversation we need to have

Birth is wild, it’s incredible, whichever part of your baby appears first.

But if we, as midwives, are going to truly serve families in out-of-hospital settings, we need to be having honest conversations about what’s possible, what’s likely, and what’s rare-but-real.

We need to stop perpetuating the myth that “good midwives never miss a breech.”

We need to start celebrating the skills that matter most: staying calm under pressure, pivoting with confidence, supporting physiological birth in all its forms safely, and holding families with unwavering trust even when their baby has different plans.

This Mama trusted me completely, and I trusted her, this mutual trust of the whole birth team is important. Together, we welcomed her baby into the world in the most beautiful way possible, even though it wasn’t the birth any of us expected. It was perfect. That’s the skill, the art. That’s what relationship-centred care makes possible.

Trust, capability, confidence and the courage to hold steady when birth surprises us.

References:

Walker, S. (2014). Undiagnosed breech: Towards a woman-centred approach. British Journal of Midwifery.