Breech Position

Every day, many women are told that their baby is breech. For many it creates fear and anxiety of the unknown. Hopefully the next few paragraphs will answer some of your questions and give you an idea of what to expect.

What is a breech presentation?

Put simply, your baby is coming “bottom first”. The normal way for babies to be born is head first. This way the hardest part of the body comes out first, quickly followed by the softer bit. Breech babies are a bit more complicated and there are ways of avoiding these complications.

How common is a breech presentation?

Firstly, it should be said that not all babies that are breech at the time of your midwife or doctor’s appointment or scan, will be breech at the time of delivery. At 28 weeks of pregnancy, approximately 20% of all babies are breech (1 in every 5 pregnancies). By 37 weeks of pregnancy, this has reduced to 3% (only 3 out of every 100 pregnant women). This means that most of them will have turned by themselves.

Causes

There are usually no reasons why a baby has chosen to sit in a breech position. Maybe it is just more comfortable for that particular baby or they just haven’t asked directions yet! Some women, however, do have unusual shaped wombs. This increases the chance of a breech baby and should be diagnosed on scan during your pregnancy. Some women know this even before they are pregnant. Some women have fibroids. If they are large or situated in an awkward place, it can cause the baby to be breech. Your placenta may be low lying and stopping the baby getting its head into the right place.

Why is it important?

Babies that are breech can born normally but it has been noted that they have a higher risk of injury during delivery. This can be caused by many things, but does not mean that babies cannot be born normally in a breech presentation.

There was a good study called “The Term Breech Trial” which found that in the short term, breech babies born by elective caesarean section were healthier and had less physical injury than babies born by vaginal breech birth. There was, however, little difference in other problems and there is no evidence of any long term benefit. Since that trial it has been normal practice to explain these findings to women whose babies are breech.

What will happen now?

Here is the page for the RCOG Breech guideline

If you are 36 weeks pregnant and your midwife suspects that your baby is sitting in a breech position, you should be referred to the hospital for a consultant appointment. They should go through the following options with you:

  1. Normal delivery – They should explain the breech trial to you and ensure that you do not have any reasons not to deliver normally (very big or small baby, low placenta, fibroids, etc.)
  2. External Cephalic Version – Also known as ECV, a method of trying to turn the baby to a head first position to allow safer normal delivery.
  3. Caesarean Section – Planned caesarean section for breech carries a small increase in serious immediate complications for you compared with vaginal birth. Planned caesarean section does not carry any additional risk to long-term health outside pregnancy, but its long-term effects on future pregnancy outcomes for you and your babies is uncertain.

After the discussion of the situation, and confirming on scan that your baby is breech (some are already head first!) you should have a plan of action decided and written in your notes.

What is an ECV?

Here is the link to the ECV guideline

An ECV is a way of turning babies from a breech position to a head first one. Techniques vary from doctor to doctor, but there are some things that should be the same because the Royal College of Obstetricians & Gynaecologists recommends them as ‘good practice’ or that they have ‘good evidence’ for their use.

The first thing to say is that most babies will be totally oblivious to the act of turning them. Protecting them is your skin, fat (we all have some!), muscles, womb and the waters surrounding baby. This adds up to five layers of protection, so do not worry about your baby! About 1 baby in every 200 attempts at ECV shows a sign of being unhappy and requires delivery.

Secondly, ECV should not be painful. Admittedly it is not the most comfortable procedure, but it should not be painful. If it is, you can ask for the procedure to be stopped and the plan can be re-thought.

Success rates for ECV depend on the doctor performing the procedure. As with all things in life, some are better than others. Rates vary from 30% to 80% with an average of 50%. Success is better in women who have had babies before. Usually the midwives in the antenatal clinic will know who is the best at them!

You should have all reasons for not having your baby turned ruled out beforehand. These are:

  1. Your waters have broken
  2. You have an abnormally shaped womb
  3. Your baby is already unwell
  4. Recent vaginal bleed
  5. You have twins and the first twin is breech

Some other factors should be considered, but do not rule out ECV totally:

  1. Previous caesarean section
  2. Pre-eclampsia
  3. Small baby that is showing signs of stress
  4. Low fluid levels
  5. Babies with multiple problems (i.e heart defects, spina bifida etc.)
  6. Babies that have an unstable lie (these babies will go from breech to head first to sideways all the time and ECV is likely to be a waste of time!)

You should have a normal heart tracing for baby (CTG) and then be given an injection (usually terbutaline, salbutamol or ritodrine) to relax your womb. (Tablets and patches do not work). After a short period of time to allow the womb to relax, the doctor should gently press on your tummy.

The first task is to lift your baby’s bottom away from your pelvis. After this it is easier to move baby’s head away from its current place under your ribs. This can be quite an odd sensation and has been described “like turning a tight steering wheel”. Once your baby is laying across your tummy, the last bit is quite quick, because their head drops nicely into the right place. Most women find relief after their baby has been turned because the head is no longer under their ribs and movement and breathing are easier.

What about caesarean section?

Some women will be advised to have a caesarean section because of complications, but most will be offered ECV as the first line treatment. If ECV has failed, then a caesarean section will be offered. This will be performed after 39 weeks of pregnancy which is the safest time for your baby to be born. If you go into labour before this time, then you should go to the labour ward immediately.

Remember, some babies will turn despite a failed ECV, or decide to come prior to a planned caesarean section date. They just don’t read the script properly! If your baby is head first at the time you go into labour, a caesarean section will not be performed unless you need it for a medical reason.

On the day of your caesarean section you will be scanned to make sure that your baby is still breech. Again, if your baby has turned in the meantime, caesarean section will not be performed unless there is a medical reason to do so. This can be frustrating because plans have been made, but is your baby’s way of getting things right, albeit at the last minute!