As a pregnancy progresses, it is common for a baby to wiggle and move into all different positions within the uterus—head down, feet down, sideways, and everything in between. Even in the third trimester, it is not uncommon for a baby to hang out in a breech position, only to turn head down (the vertex position) on its own as the end of pregnancy nears. The vertex position is the optimal position for a vaginal delivery, and a breech baby most likely will have to be delivered by C-section. Breech position includes when the baby’s bottom, feet, or both are positioned as the presenting part (closest to the birth canal) instead of the head. The most common type of breech position is frank breech, where both of the baby’s hips are flexed, knees are extended, and the feet are up by the head. Complete breech occurs when both of a baby’s knees are bent and both feet and bottom are closest to the cervix, and an incomplete breech is when one knee is bent. A footling breech is also possible, where the presenting part includes one or both of a baby’s feet. At 28 weeks’ gestation or less, approximately 25 percent of babies are breech, but only about 3-5 percent of babies remain in the breech position at term.
Breech position includes when the baby’s bottom, fee, or both are positioned as the presenting part (closest to the birth canal) instead of the head.
What causes breech positioning?
There is no one factor that causes a baby to position itself breech within the uterus, but there are factors that increase the likelihood of a breech baby. These factors include:
· Having been pregnant before
· Previous C-section delivery
· Pregnant with multiples
· Placental positioning
· You or your partner were breech
· Previous breech pregnancy
· Too much or too little amniotic fluid
· Abnormally shaped uterus or uterine anomalies like fibroids
· Placenta previa (where the placenta covers all or part of the cervix)
· Preterm baby
· Fetal abnormality
Having a prior breech pregnancy increases your risk for additional ones. After one breech baby, the chance that your next baby will also be breech is around 10 percent. After two breech babies, the likelihood that a subsequent pregnancy will be breech as well is around 27 percent.
How to turn a breech baby
Providers can determine whether your baby is breech by palpating the baby within the womb, but an ultrasound is the gold standard for determining breech positioning. If you are nearing the end of your pregnancy and your baby is breech, what can be done to turn a breech baby?
After one breech baby, the chance that your next baby will also be breech is around 10 percent.
External cephalic version (ECV) is a procedure used to try and turn a breech baby, and it can increase your chances of having a vaginal birth, with an average success rate of 58 percent. ECV is done between 36 and 42 weeks of pregnancy, but usually around 37 weeks. During an ECV, your provider will confirm your baby’s positioning with an ultrasound, as well as check the position of the placenta and the amount of amniotic fluid around your baby. You might also receive medication to relax your uterus and/or help with discomfort. Your provider will then use both hands on the outside of your abdomen to attempt to move your baby into a head-down position. The procedure can be very uncomfortable for the mother, especially if the uterus contracts in response to the physical manipulation of the baby. If at any point your baby is in distress, the procedure will be stopped. Serious complications are rare, but ECV is performed in a hospital setting where an emergency C-section can be performed if necessary.
When is ECV not an option?
ECV will generally not be pursued if the following are true:
· You are carrying multiples
· There is concern about the health of your baby
· Your placenta location prevents a vaginal birth (e.g., placenta previa)
· Placental abruption
· Your water has broken
· Your baby’s head is hyperextended (which means its neck is straight instead of having a tucked chin)
· It’s suspected your baby might have a birth defect
· Your baby has dropped into the pelvis and engaged
· Abnormal uterine shape
· Too little amniotic fluid
What risks are associated with ECV?
While ECV is generally considered to be a safe procedure, there are risks to be aware of:
· Compression of the umbilical cord
· Premature rupture of the amniotic sac and start of labor
· Placental abruption
· Uterine rupture
· Umbilical cord damage
· Risk of fetal and maternal blood mixing (if mom is Rh negative, she will receive an injection to prevent Rh sensitization)
Other options to turn a breech baby
In addition to ECV, there are some non-medical interventions that have been touted to help turn a breech baby. These include exercises, acupuncture and moxibustion, chiropractic care, pelvic tilts, and swimming. Though most of these are not evidence-based methods to get breech babies to turn, they are also not associated with adverse effects.
Often, the best treatment is no treatment at all.
Often, the best treatment is no treatment at all: it is important to remember that while 25 percent of babies are breech going into the third trimester, that number drops to 7 percent by 32 weeks, and by the time babies are full-term, most have already moved themselves head-down, with only around 3-5 percent remaining in the breech position.
What if my baby stays in a breech position?
If time and other interventions don’t help move your baby into the vertex position (or if a vaginal birth would not be safe, like with placenta previa), your doctor will likely schedule you for a C-section delivery. While there are risks of complications with both a C-section delivery and a vaginal breech delivery, a vaginal breech delivery is considered more high-risk. Complications can include entrapment (where the baby’s body does not stretch the cervix enough and the baby’s head gets stuck during delivery), umbilical cord prolapse, and birth trauma. C-section delivery risks include infection, bleeding, and organ damage, as well as potential complications with future pregnancies. Vaginal breech delivery expertise is also becoming rarer, with fewer and fewer vaginal breech deliveries occurring in the United States and other industrialized countries.
If your baby remains in the breech position, your provider can discuss the risks and benefits associated with both options to help determine what type of delivery is going to work best and be safest for you and your baby.