Breech birth

A breech birth is when the baby is born with their bottom, legs or knees coming out first, rather than their head. Currently in Australia, it is estimated that around 3-4 % of all babies at term are in the breech position but not all of them are born vaginally. Between 29 and 32 weeks of gestation, the estimate is 15% of babies are presenting bottom first. It is considered normal in the second trimester for babies to be in the breech position. Essentially, the risks of having a breech birth are closely matched to the weeks of pregnancy.

At the start of labour, most babies are lying on their side, with their head facing towards either the mother’s left or right side. With a breech birth, the baby’s head is generally sitting just below the mother’s diaphragm and rib cage. Feeling a distinctive hard and bony head in this region, rather than a softly rounded bottom, is one of the key factors in diagnosing a breech presentation.

Types of breech birth

• Complete breech – This is when the baby’s bottom is presenting first, their knees are bent and their thighs extended upwards. Think of the classic foetal position.
• Frank breech – This is when the baby’s bottom is presenting first and their legs are extended upwards along their body. Imagine an Olympic diver doing a classic furling move just as they jump off diving platform and before they rotate to enter the water head first.
• Footling breech – This is when the baby’s legs are positioned below the baby’s bottom. Once the membranes have ruptured one or both of the legs drops down through the cervix and into the vagina.

How will I know if my baby is in a breech position?

You may not know until your midwife or obstetrician tells you. There are some fairly classic signs which can raise the suspicions of a health care practitioner. Sometimes though, it’s not evident that the baby is in the breech position until labour has begun and even then it’s not always clear.

Signs of breech presentation include:

• Seeing a bottom, legs or feet being born first.
• Feeling the baby’s head in the upper part of the mother’s uterus. A head feels hard, bony and can move freely from side to side – this is known as ballotable. Whereas a bottom is softer and more irregular; it doesn’t move as freely as a baby’s head does.
• A mother may complain of feeling a hardness under her rib cage and struggles to get comfortable because of this.
• If the membranes have been ruptured and there is thick meconium present. Meconium is the baby’s first bowel motion and if the baby’s anus is close to the mother’s vagina, fresh meconium is easy to see.
• Cord prolapse.
• An abnormal Cardiotocograph (CTG).
• If a breech presentation is diagnosed by ultrasound, or less commonly by X-ray.

What makes a breech birth more likely?

Prematurity is by far the most important factor which influences the likelihood of having a breech birth. Around 25% of all babies are in the breech position from 32 weeks of gestation and over the next eight weeks, this reduces to just 3%. Because the baby grows so much in the last couple of months they aren’t able to move as freely and once their head goes into the “down” position in the mother’s pelvis, they tend to stay there. Because the baby’s head is so heavy it tends to move into the head first position and find its comfortable niche in the mother’s pelvis. There is sits (hopefully) until it is ready to be born.

Other factors include:

• Multiple births such as twins, triplets or quads.
• When there is an abnormal volume of amniotic fluid – either too much, known as “polihydramnios” or insufficient, known as “oligohydramnios”. Both of these can be indicators of other complications with the mother and/or her baby.
• When there is a problem with the baby e.g. an abnormality – even when the amount of amniotic fluid is normal.
• When a mother has had more than four babies. This results in uterine and abdominal muscle stretching and laxity.
• If there are abnormalities with a mothers uterus. The shape of the uterus is a major influence on how the baby is positioned and how it presents at birth.
• If the placenta is positioned low in the uterus e.g. with placenta praevia.
• If a mother has a very small pelvis or she has had trauma e.g. a fractured pelvis in the past.
• If a mother has previously had a caesarian section delivery.

What are a mother’s choices if her baby is in a breech position?

This really depends on each mother’s individual history and the position of her baby. If the baby is in a frank breech position e.g. with their bottom coming first, then a “trial of labour” is more likely. There are no guarantees of a vaginal delivery though.

It is common for the baby to have an electrode placed on their bottom and for the mother to be connected to a monitor. This way any change in the status of the mother and her baby is quickly detected. If necessary, plans are made for a caesarian section delivery before either of them is compromised.

It is also common for an epidural to be inserted for mothers who are having a trial of labour. This helps to stop the urge to push before the cervix is fully dilated. It is also more likely that stirrups are used, so the obstetrician and midwife have easier access and can have better control of the delivery.

What are the risks of having a vaginal birth?

• Uterine contractions start the same way when a baby is in a breech position as they do when the baby is head down. But because the pressure of a soft bottom or foot is not as great as a bony head, labour can take longer to establish. Breech labours and births can be more exhausting and fatiguing for the mother, particularly in the first stage. Despite their best intentions, some women defer to having a caesarean section delivery because of the extent of their fatigue and exhaustion.
• Umbilical cord prolapse is more common with breech births. This is because the baby’s bottom/legs/feet don’t fit as well into the mother’s pelvis as the baby’s head does. Think of a plug in the bathroom sink and you’ll have a fair idea of “good fit”. The cord is slippery and can easily slide through the cervix and out of the vagina if there is space between the baby’s presenting part and the open cervix. Once the cord is exposed to the outside air and temperature, it constricts. The blood flow containing oxygen and nutrients to the baby then shuts down.
• Another risk is that the umbilical cord can become compressed and the flow of oxygen to the baby is diminished. This constitutes an obstetric emergency and a caesarian section delivery becomes necessary.
• The baby’s head can become entrapped. When the rest of their body is out of the mother’s vagina but their head is still not out, there are major concerns with the baby’s oxygenation and obstructed labour. In a worst case scenario, a caesarian section delivery then needs to be done. This is more likely if the mother’s cervix has not fully dilated when the baby’s lower body was delivered. Because the head is the largest part of the baby the cervix has to be fully dilated to allow it to pass through. If the baby is looking upwards to the top of the mother’s uterus then this makes the presenting part even bigger. This is more likely when the baby is close to full term because at that stage, the distance between their hips and the widest part of their skull measures the same. In preterm babies their head is bigger and their bottom is narrower.

What does it mean to turn the baby?

It is estimated that around 25% of all babies who are in the breech position after 35 weeks of gestation will turn themselves without any help at all.

The decision whether to try an ‘external version/rotation’ of the baby is made very carefully. The obstetrician needs to be confident that there are fewer risks doing this than if the mother is supported to go on and have a vaginal breech birth. It is important that the exact position of the umbilical cord and placenta are identified before an external version is done. Otherwise, there is a potential for the placenta to be sheared off the wall of the uterus or the baby to become entangled in the umbilical cord. Sometimes a mother is given a drug beforehand which relaxes her uterine muscle. The success rate of an external version is around 40-70% depending on the skill of the individual practitioner.

Even if an external version is effective in turning the baby to a head down position, some babies will automatically flip back into a head up position. The earlier in the pregnancy the version is done, the greater the likelihood of this happening. This is why turning the baby at around 37 weeks of gestation is thought to be the ideal time.

Some women believe that if they lie in a particular way, do specific exercises or sleep in a special position that their baby will rotate to head down. But there is no scientific evidence to support these claims. Likewise, accupuncture, candling (moxibustion), homeopathic drops and/or aromatherapy are not effective in changing the way a baby is first presenting themselves to the world.

What are the risks to my baby with a breech birth?

• When the labour is well managed and the baby monitored, the risks are minimised. Some women choose to have a home birth with a midwife, and feel confident that all will go well. It is important to have a backup plan in case there are complications.
• Some babies develop a bruised hip from a breech birth; most commonly the hip which came first through the mother’s pelvis.
• The baby may have swollen genitals and occasionally bruising. Baby boys may develop a hydrocele – this is where there is a collection of water within their scrotum.
• Babies who were born in a frank breech position tend to extend their legs in the same position for a few days after birth.
• Breech babies tend to have more rounded heads. This is because their skull bones have not had the same opportunity to mould as if they were born head first.
• Congenital hip dislocation is more common in babies who were born in a breech presentation.
• There is a risk of trauma to the baby’s head, especially if the birth is rapid and the baby is premature. For this reason, forceps are often used to control the “after coming head”. Forceps aren’t always necessary though. An alternative is when the obstetrician uses her/his hands to control the delivery of the baby’s head.

Tips for breech birth

• When a baby is in a breech position, the onset of labour can be very similar to when it is head first.
• Artificial rupture of the membranes is not recommended.
• With good progress in labour, the likelihood of having a vaginal breech birth is higher.
• The descent of the baby, its condition, the mother’s progress and her physical and emotional state will all influence the likelihood of vaginal delivery.
• Many midwives and obstetricians use a “hands off” approach when it comes to observing a breech birth. Unless it is really necessary and it becomes obvious that intervention is necessary, the baby may not be touched until after it is born. This is because generally, the baby descends, flexes, rotates and extends its body instinctively in order to be born.
• There are specific techniques used by midwives and obstetricians to support a breech birth. Because of the current increase in litigious actions, many healthcare practitioners do not consider “allowing” mothers in their care to have a vaginal breech delivery. Finding a practioner who is skilful and willing to support a “trial of labour” can be a challenge.
• In Australia, most babies who are in the breech position are delivered via caesarian section. This is especially the case when a mother has not had a previous vaginal birth.