Most babies are born head first, but at the end of pregnancy, around 3-4% are found to be breech. Before 37 weeks of pregnancy, breech presentation is much more common - about 20% of babies at 28 weeks are breech, and 15% at 32 weeks. The medical definition of 'term' is in fact any time from 37 weeks, Before this time, it doesn't usually matter if the baby is breech, as there is a good chance that he or she will turn spontaneously. Some babies do turn by themselves after this, but it is much less likely, and some preparations should be made to decide how delivery is going to take place. About 10-15% of breech babies are discovered for the first time in labour!
Preterm breech
Before 37 weeks the only time that it does matter if the baby is breech, is if labour starts early. There are many factors that will be taken into account before advising on how to have your baby if this happens. Frequently, a caesarean section will be advised, although this is not always the case. Some obstetricians feel very strongly that a caesarean is always safer, others advise a vaginal delivery if there are no other problems. It is generally accepted that the studies which have tried to find the safest delivery for the baby have not been able to give us a definitive answer. The types of problems that babies have when they are born early are very much related to prematurity, rather than the type of birth. Unfortunately, it is unlikely that an adequate study to discover the best type of delivery for a premature breech baby will ever be done.
If a planned early delivery is needed, for example because of pre-eclampsia, growth problems or another separate problem of pregnancy, then it is more likely that a caesarean section will be advised rather than induction of labour with a preterm breech baby.
Term breech
If a baby is found to be breech at 36 weeks (a week before term), it is usual to be referred to an obstetrician to discuss and plan the mode of delivery. A scan is done to check the following things:
Placenta position - a low lying placenta (praevia) can lead to breech presentation, and one third of women with a praevia do not have any bleeding, which would have normally alerted us to this problem. Often the scan at around 18-20 weeks may have already ruled this out too.
Baby and his or her position - we will check the amount of liquor around the baby, the exact position of the baby's legs, and whether the baby has his neck extended looking upwards (stargazing). A weight estimation is also made.
Breech babies sit in one of three positions:
- Extended or frank breech - hips flexed, with the thighs against the chest, and feet up by their ears, in a kind of V shape.
- Flexed breech - hips flexed with thighs against the chest, but knees also flexed with the calves against the back of the thigh and feet just above the bottom.
- Footling breech - as above, but hips not flexed so much, and the feet lying below the bottom.
The options available to you for the birth will then be discussed. They include the following:
- Normal breech delivery
- Attempt at turning the baby (external cephalic version or ECV) then normal breech delivery if this is unsuccessful
- ECV followed by caesarean section if unsuccessful
- Elective caesarean section without attempt at ECV
Normal breech delivery
Until recently there was not enough research available to guide us on the safest way for a term breech baby to be born. In 2000 the results of the Term Breech Study was reported. This study included 121 hospitals throughout 26 countries. Babies were randomly allocated to either planned breech delivery or planned caesarean section. The results revealed that planned caesarean section was safer for the baby than attempt at vaginal birth, with vaginal delivery resulting in a 1% increased risk of death and 2.4% increase in risk of serious problems in the early months after birth.
There has been a lot of back and forth discussion, analysis and re-analysis of the information provided to us by the Term Breech Study, including some criticisms of the study design. If you want to read more about that, then these papers (link 1, link 2) and correspondence (link 3) might be of interest.
Since 2000 there has been a significant fall in the number of vaginal breech births throughout New Zealand, the UK, Canada and the US. The result is that even if you do not agree with the findings of the research, or if you accept them and still want a normal breech birth, finding an care provider who has enough experience to offer breech delivery might be difficult. If you do not have a birth attendant experienced in breech deliveries, the risk for the baby will be greater than the findings of the Term Breech Study, as this was one of the study entry requirements.
If you do choose to go for a breech delivery, the following 'rules' will normally be required:
- The baby is not excessively small or large
- Your pelvis is not judged as excessively small. Previously we used to do a pelvic x-ray to check the exact measurements of the pelvis. It has since been found, however, that this is unnecessarily limiting and a judgment based on previous births and/or pelvic examination is as useful. There is also a very small but definite increased risk of childhood cancers in babies exposed to this type of x-ray.
- Baby is not a footling breech. Extended breech is the most favourable, but flexed breech is OK as long as the bottom moves down & engages into the pelvis. Footling breech babies don't fit so well onto the cervix, leading to a risk of the cord falling out during labour (cord prolapse).
- Baby is not 'stargazing'.
- Labour starts spontaneously.
When labour starts you come into hospital as usual. Some doctors advise an epidural for every woman having a breech birth, but this is not strictly necessary. There is some evidence that epidurals increase the risk of a caesarean section being needed during labour. Many women who have a breech birth choose this type of pain relief in any case.
Labour is never excessively long and continuous monitoring of the baby's heart rate is advised. When it comes to the actual birth, some doctors use forceps to control the delivery of the baby's head, others prefer to just assist it with their hands. An episiotomy (cut) is frequently needed for first-time mothers, but it really depends on how well the skin stretches, the progress at the time of delivery and the size of the baby.
A paediatrician will be present at the birth to check the baby over, but you will be able to have him with you straight after this. Congenital hip problems are more common in breech babies and this explains why some are breech in the first place. The paediatrician will examine your baby more fully before you go home.
The findings of the Term Breech Study do not apply to twin pregnancies and if the second twin is breech, this does not rule out a normal birth.
External cephalic version
It is possible to manoeuvre the baby from breech to a head-first position. This is done after 37 weeks and the success rate is around 50%. ECV can reduce the number of both breech and caesarean births. Around 2.5% of babies flip back to breech after a successful ECV.
The doctor places his hands on the uterus, and guides the baby through a forward somersault - often the baby seems to get the idea and his kicking helps to complete the turn. Sometimes a drug is used to help the uterus to relax, particularly for first-time mothers. It may be quite uncomfortable during the turn, but shouldn't be excessively painful. The baby's heartbeat is monitored before and after ECV.
It is a safe procedure for the baby, but on the rare occasion the baby becomes distressed a caesarean delivery will be necessary at that time. Because the baby is mature and facilities for surgery are close at hand, this rare occurrence is not harmful for the baby.
If an ECV is unsuccessful, it is still possible to have a normal breech birth as discussed above.
Is there anything I can do to make him turn?
There has been a suggestion that spending 15 minutes every 2 hours of the waking day in the knee-chest position will help the baby to turn (Elkin's manoeuvre). Although the first report of this was very encouraging, subsequent studies have not found it to be useful. There is some evidence that hypnotherapy may be useful, though only one study has looked at this. Acupuncture has been suggested and the results of more formal research are awaited.
Caesarean section
There is no doubt that caesarean section is a safe operation, but it is not without problems, and this is why many doctors and midwives still feel that there is still a place for normal breech births - particularly if you have had a vaginal delivery before. A caesarean section means a stay in hospital of around 4-5 days, a more prolonged recovery, and implications for future pregnancies or operations. Other risks include infections and above average blood loss. Scar tissue formed during the healing can lead to pain and make future operations more difficult. It may take longer to fall pregnant in the future if you have had a caesarean section.
For elective surgery you normally come into hospital either the night before the operation or the morning if it is to be done in the afternoon. Most often an epidural or spinal anaesthetic is advised. This involves a very small needle in the back, which numbs everything below the navel so you feel no pain. Most women feel a bit of tugging & pulling, but it should not be uncomfortable. This type of pain-relief is safer for you than being asleep (general anaesthetic). It also means that you can see your baby immediately, and usually hold him before the operation is finished. You will need to have a drip in your hand and a catheter in the bladder to ensure it is empty. Both of these will be removed the day after the operation.
Summary
Although vaginal breech birth is now less commonly offered, ECV is a useful option to help avoid the need for caesarean section. If you are keen for a breech delivery then it would be sensible to discuss this with your obstetrician or midwife who can advise on the availability of delivery staff who have appropriate experience.