Newborn baby feet in parents hands. Love simbol as heart signI’ve been told that my baby is ‘breech’!

If you are told that your baby is breech, it means that they are lying inside the uterus (womb) with their ‘bottom down’ and the buttocks or feet closest to your cervix (the neck of the womb). By contrast, where your baby is lying ‘head down’ – this is called a cephalic presentation.

During the early months of pregnancy, your baby is small and is surrounded by plenty of amniotic fluid (liquor); this means there is lots of room to move around. Consequently, you may find that your baby is cephalic one day, then breech several days later, only to revert back to cephalic again. This is perfectly normal in early pregnancy and plenty of fetal (baby) movements are a healthy sign! As you approach your baby’s due date however, the baby has much less room for movement and is more likely to remain in one position.

Research shows us that the vast majority of babies will have spontaneously moved into a head down position during the last few months of pregnancy and are cephalic by term (between 37 and 42 weeks of pregnancy). This means that a much smaller number of babies are breech at term. Studies suggest that 1 in 30 babies are breech after 37 weeks’ of pregnancy.

Being told by your midwife or doctor that your baby is breech can have different implications, depending on how far you are into your pregnancy and whether or not labour has started spontaneously or is being induced. To find out more about methods of induction of labour, see also our article,

 

‘What happens when your baby is overdue?’

Where your baby is found to be a breech presentation this requires more complex care, which is why breech is described as being ‘complicated’ in midwifery and obstetrics. Therefore, it is important that you understand how having a breech baby can affect your options for labour and birth. It is for this reason that we have written this article to explain the different aspects of care that you will need to consider and the options available to you. It is important that you have sufficient information in order to make an informed choice that feels right for you and your baby. We therefore, strongly recommend that you discuss your preferences in more detail with your own midwife and doctor.

 

What are the concerns about breech births?

Where your baby is cephalic; the head, which is the widest part of them, is the very first thing to be born. Therefore, if there are any concerns with how your labour is progressing and your baby’s descent down the birth canal, these will be identified quickly. However, where the baby is breech, their head is the very last part of them to be born. When the baby is being born head first, the bones of their skull (head) are designed to overlap to change the shape of the baby’s head so that it fits through the pelvis. However, when the baby’s head is the last part of them to pass through the pelvis, the bones don’t have time to overlap. This means the baby’s head is a rounder shape and a slightly larger diameter which means it may not be able to fit through the pelvis.

The concern with a vaginal breech birth is that no one is able to tell if the head will fit through the pelvis until the baby is actually born. If the baby’s head does become stuck, then this can have serious consequences. However, if a woman has previously given birth vaginally to a good-sized baby(s), she has proven that her pelvis can accommodate a baby passing through it. Therefore, giving birth to a breech baby may not be a problem for her.

 

What does the research say?

The findings of a large research study that was published 14 years ago – the Term breech Trial, has resulted in the vast majority of women in the UK and across Europe, delivering their breech babies by caesarean section. The Term breech Trial found that where babies were born by elective (planned) caesarean section, this reduced the risk of babies dying or being significantly harmed during a vaginal breech birth. This is based on the belief that breech babies who are born vaginally, sustain trauma as a result of the actual birth process compared with those breech babies who are born by caesarean section.

However, others have questioned this assumption given that a significant proportion of all breech babies born vaginally, include those who deliver prematurely (too early) and multiple births (ie twins), and, for these reasons, also tend to be born smaller than average. Research studies also show that breech babies are more likely to be born with a congenital abnormality (present at birth). These facts have led some practitioners to question the blanket policy of advocating caesarean section birth for all babies presenting by the breech. They argue that breech babies are more likely to encounter complications and poorer outcomes regardless of the method of delivery. They also question the way in which the Term breech Trial was conducted and whether the clinicians involved in the trial possessed sufficient expertise in safe breech delivery. Similarly, since the Term breech Trial was completed, subsequent research has not shown conclusively that caesarean birth is safer than a vaginal birth for a breech baby, providing that pre-birth criteria are met.

Other research has found that where senior obstetric staff experienced in conducting vaginal breech births, are on standby and women’s informed choice and strict pre-birth selection for vaginal breech birth are followed; then vaginal birth outcomes are comparable to caesarean section. Consequently, many maternity units will support the option of a planned vaginal birth for women with a breech baby in accordance with strict pre-birth selection criteria and labour care management guidelines.

Nevertheless, offering women a planned caesarean section for breech presentation at term has been widely embraced as the preferred method of delivery in reducing the risk of birth trauma and baby deaths. This has prompted concerns from some practitioners that skills in conducting vaginal breech births are at risk of being lost. However, exceptions do remain where NHS and independent midwives have maintained their skills with breech birth and are sought out by women who have been denied the choice of a vaginal birth elsewhere.

Should you find out that your baby is breech, there are three options which your midwife and doctor will discuss with you. These are:

  • The doctor turns the baby – called external cephalic version (ECV)
  • Choosing whether to have a vaginal breech birth – this can include using forceps to assist the delivery of the baby’s head. NB. You cannot use a ventouse on a breech baby!
  • Choosing to have a planned caesarean section.

Finding out that your baby is breech can come as quite a shock; particularly if you have planned a homebirth or wanted to use immersion in water. See also our articles, ‘Choosing where to have your baby: place of birth’ and ‘Waterbirth: Immersion in water for labour and/or your baby’s birth’. The doctors and midwives will discuss the benefits, disadvantages and alternatives that are associated with each option. They will however, also want to hear about your plans and wishes for your labour and baby’s birth. The doctors and midwives will always do their best to balance your wishes against the potential risks to you and your baby. These risks will be very different depending on the individual circumstances. For example, the risks associated with one baby being found to be breech at term, are very different to the risks associated with a woman going into preterm labour or being in labour with a multiple pregnancy and one or both babies are breech presentation.

Of course, there can always be situations when events takeover and you may find that there simply isn’t time to consider which option feels right for you and your baby. This can be the case, where a woman goes into preterm labour or has spontaneous rupture of the membranes – SRM (the ‘waters’ break), or the baby’s breech presentation isn’t diagnosed until after labour has already started. In these situations, the midwives and doctors will explain the benefits and disadvantages/risks associated with the various options and will explain whether it is advisable for the baby to be born vaginally, or safer to be born by caesarean. If you have had a caesarean birth previously, the midwives and doctors will monitor you and your baby closely, as this can be a concern. However, having had a previous caesarean birth doesn’t necessarily mean that a woman cannot choose to have a vaginal birth. This is termed vaginal birth after caesarean – VBAC.

 

External cephalic version (ECV)

It is recommended that all women with a breech baby at term should be offered ECV. The procedure attempts to turn the baby around in a somersault-action, so that they are ‘head down’ before labour starts. It is recommended that ECV is performed from 36 weeks’ of pregnancy where women are expecting their first baby and from 37 weeks’ where this is their second or subsequent baby. Depending on your situation, ECV can be performed right up until you give birth. For more detailed information see also our article, ‘External Cephalic Version (ECV)’.

 

Mode (method) of delivery

Of course, there will always be circumstances where ECV proves unsuccessful and the baby cannot be turned. There are also occasions where ECV and other treatments to help turn the baby are declined. If this is the case, you will need to consider the options for your labour and birth with your midwife and doctor. There are two options:

  • Undergoing vaginal breech birth
  • Having an elective caesarean section

As previously discussed, the Term breech Trial has resulted in many doctors recommending that where your baby is breech, they are delivered by elective caesarean section. This is particularly the case where this is your first baby. However, subsequent studies have found that breech babies can, in certain circumstances, be born vaginally with fewer risks than previously believed. Vaginal breech birth is considered to be a suitable option where the following apply:

  • The size of the woman’s pelvis will allow the breech baby (specifically the baby’s head) to pass through it
  • The baby’s birth weight is estimated to be no more than 3800g and no less than 2500g
  • The breech baby’s legs are extended (in a straight position) and not flexed (bent at the knee)
  • The baby’s head is in the optimal position – this can be checked by ultrasound scan (USS)

Because breech birth is considered ‘complicated’ midwifery and obstetrics, it will always be recommended that the baby’s heart beat is monitored continuously during labour. This ensures that any fetal distress is detected early.

 

Vaginal breech birth

Where you wish to opt for a vaginal breech birth; your midwife and doctor will discuss the various labour options available to you. This can include having an epidural in labour, because women with breech babies can sometimes get the urge to push before they are ready to do so (ie before the cervix is fully dilated). See also our article, ‘Pain relief options for labour and birth’.

Another approach is ‘active breech birth’; this is where different strategies are used to ensure women are fully supported during labour and birth. Active breech birth includes the use of apparatus such as, birthing chairs, as well as, supporting the woman to remain upright and mobile. Remaining upright and walking around during labour is recommended so that gravity aids the baby’s descent down through the birth canal. Being upright and mobile in labour is also effective in easing the pain from labour contractions and associated backache. See also our article ‘Who can support me during labour?’

 

Premature breech births

Should your labour start prematurely, it is likely that your doctor will recommend that your baby is delivered by caesarean section. This is because premature babies are smaller and often don’t cope so well with labour contractions. If your baby’s heart beat shows that they are becoming distressed, the doctor will recommend that your baby is delivered by caesarean. However, where, other than labour starting before 37 weeks, everything else is straightforward; the doctor may offer you the same options as women whose babies are breech at term. This means you are likely to be offered the options of either having a vaginal breech birth or a caesarean section.

 

Birth trauma

Because the baby’s bottom sits over the cervix as it dilates and women have vaginal examinations during labour; a breech baby’s bottom will often appear a little bruised initially. However, this is no different to the bruising seen on the heads of babies born cephalic. Babies’ genitalia (nappy areas) can also become quite bruised and swollen – male babies in particular can have a swollen scrotum. Rest assured however, that although this can sometimes look quite alarming, it will have usually resolved within a few days post birth.

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