Most babies are born headfirst, 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. Before term, which is defined as 37 weeks, it doesn’t matter if the baby is breech, as there is always a good chance that she will turn spontaneously. Some babies do turn by themselves after this time, 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 late in labour!
Before 37 weeks the only time that it does matter if the baby is breech, is if labour begins. There are many factors that will be taken into account before advising on how to have your baby at this stage. Frequently, a caesarean section will be advised, particularly if your baby is between 27-30 weeks, but 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 been subject to much bias. The problems 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 preeclampsia, growth problems or another separate problem of pregnancy, then it is more likely that a caesarean section will be suggested rather than induction of labour with a preterm breech baby.
If a baby is found to be breech at 36 weeks, it is usual to refer to the hospital 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 normally alert to this problem. Often the scan at around 18-20 weeks may have already ruled this out.
¨ Baby & his position – now that ultrasound is so common at 18-20 weeks, it is extremely unusual to discover any abnormalities in the baby at this stage. The sonographer will check the amount of water around the baby, the exact position, 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.
- 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
Normal breech delivery
As with preterm breech deliveries, there are at present no ideal studies to tell us with 100% certainty whether delivery normally or by caesarean is safer for the baby. In North America, caesarean section has become nearly the normal mode of delivery for breech babies in an attempt to reduce the risk of problems for the baby. A rise in the section rate for breech from 22% to 94% was not accompanied by any improvement in outcome for babies. In 1996 the best quality study available to date comparing the long-term outcome for breech babies born by caesarean vs normal delivery was published. It was based in Aberdeen, included over 1600 breech babies and found no difference in long-term outcome between the two types of delivery.
At present it is fair to say that a normal breech delivery is safe if certain rules are followed. These include:
- 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 more recently been found, however, that this is unnecessarily limiting and a judgement 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.
- The availability of a doctor or midwife with experience of breech births.
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 heartrate 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.
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%, though some doctors are successful as often as 70% of the time. It is useful in that it definitely reduces the number of breech and caesarean births. Around 2.5% of babies flip back to breech after a successful ECV. The doctor places her hands on the womb, and guides the baby through a forward somersault – often the baby seems to get the idea and his kicking helps to complete the turn. Some doctors use a drug to help the womb relax, particularly for first-time mothers. It may be uncomfortable during the turn, but shouldn’t be painful. The baby’s heartbeat is monitored before and after ECV.
It is a safe procedure for the baby, but on the very 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 still 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 a more formal study are awaited.
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 feel strongly that there is still a place for normal breech births. A caesarean section means a stay in hospital of around 4-5 days, a more prolonged recovery, and implications for future pregnancies or operations. Overall the risk of dying following caesarean section is 5 times higher than after a normal birth. Death is, of course, extremely rare, but infections and above average blood loss are very common. Scar tissue formed during the healing can lead to pain and make future operations more difficult. 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.
There is rarely a straightforward way to advise on what is the best option if you find your baby to be breech toward the end of pregnancy. The most important thing is that you have considered all the options available and reach a decision that is right for you. Many women feel strongly that a caesarean section is the only acceptable option for them, and few obstetricians would deny them this. Others are very keen to avoid surgery and consider a breech birth just a variation of normal.
Article by Dr Danny Tucker