Breech presentation

What is a breech presentation?

Breech presentation means that your baby is lying bottom first or feet first in the womb (uterus) instead of in the usual headfirst (cephalic) position. In early pregnancy breech is very common. As pregnancy continues, a baby usually turns by itself into the headfirst position. Between 37 and 42 weeks (term), most babies are lying headfirst, ready to be born.

A breech baby at the end of pregnancy

Three in every 100 (3%) babies are breech at the end of pregnancy. A breech baby may be lying in one of the following positions:

Extended or frank breech – the baby is bottom first, with the thighs against the chest and feet up by the ears. Most breech babies are in this position.

Flexed breech – the baby is bottom first, with the thighs against the chest and the knees bent.

Footling breech – the baby’s foot or feet are below the bottom.

Why are some babies breech?

Sometimes a baby does not turn and remains in the breech position. At other times certain factors make it difficult for a baby to turn during pregnancy. These might include the amount of fluid in the womb (either too much or too little), the position of the placenta or if there is more than one baby in the womb.

What if my baby does not turn naturally?

Vaginal breech birth can be more complicated than headfirst birth, so your Obstetrician or Midwife may advise trying to turn your baby to a head-first position. This technique is called external cephalic version (ECV). During this procedure, the Obstetrician applies pressure to your abdomen to help your baby turn a somersault in the womb to lie headfirst.

What is the main benefit of ECV?

ECV can increase the likelihood of you having a vaginal birth.

When can it be done?

ECV is usually tried after 36 weeks. Depending on your situation, ECV can be done right up until you give birth.

Does ECV always work?

ECV is successful for about 40—60% of breech presentations. Relaxing the muscles of the womb with medication during an ECV is likely to improve the chance of success. This medication will not affect your baby. You can help by relaxing your abdominal (tummy) muscles.

If your baby cannot be turned, or turns back, your Obstetrician or Midwife will discuss your options for birth.

Is ECV safe for me and my baby?

ECV is generally safe and does not cause labour to begin. Your baby’s wellbeing will be monitored before and after the ECV by listening to his/her heartbeat. Like any medical procedure, complications can sometimes occur. About one in 200 (0.5%) babies need to be delivered by emergency caesarean section immediately after an ECV because of bleeding from the placenta and/or changes in the baby’s heartbeat. This is why an ECV should be carried out in a place where the baby can be delivered by emergency caesarean section if necessary.

ECV should not be carried out if:

• you need a caesarean section for other reasons
• you have had vaginal bleeding during the previous seven days
• your baby’s heart rate tracing (also known as a CTG) is abnormal
• your womb is not the normal shape (some women have a heart-shaped womb, known as a bicornuate uterus)
• your waters have broken before you go into labour
• you are expecting twins or more

Is ECV painful?

ECV can be uncomfortable. Tell your Obstetrician or Midwife if you are experiencing pain so they can move their hands or stop.

I am rhesus negative

You will be offered a blood test before the procedure and within the next 7 days following it. It is recommended to have an injection of anti-D immunoglobulin in case there has been any concealed bleeding during the procedure.

The procedure involves:

1. Coming to Labour Ward, Claydon Wing, Stoke Mandeville Hospital at ……………on ……………………..
2. On arrival the Midwife will check your observations and your baby’s heart rate will be monitored for about 20 minutes. The position that your baby is lying in will be confirmed by ultrasound scan.
3. You may be given a subcutaneous (under the skin) injection of Terbutaline® in your upper arm to relax your womb before an attempt is made to turn your This may make you feel a little jittery and you may feel your heart beating faster.
4. The Obstetrician will try to turn the baby when your womb has relaxed. You will be asked to lie on your side or your back and talcum powder will be put on your abdomen. The baby’s heart rate will be checked after each attempt at turning the baby. The procedure usually takes less than 10 minutes.
5. When the Obstetrician has finished, the baby’s heart rate will be monitored for a further 20 minutes and then, all being well, you can go home.

If the procedure is not successful, a plan will be made with you, and your birth choices will be discussed and documented (see more information below). If you have any questions about the procedure, please ask in clinic, speak to your Midwife, or contact the Maternity Day Assessment unit for more information (01296 316106).

At home after ECV

You should telephone the hospital if you have any worries but particularly if, after ECV, you have bleeding, abdominal pain, contractions or your baby’s movements are reduced.

Is there anything else I can do to help my baby turn?

There is no robust scientific evidence that lying or sitting in a particular position will alter your baby’s position within the uterus. Some alternative therapies are available outside of the NHS, however there is no robust scientific evidence to support these.

What are my choices for birth?

If your baby turns head down either naturally or through ECV you can usually wait for labour to start by itself. If your baby remains breech your choices may include:

• caesarean birth – this is a surgical operation where a cut is made in your abdomen and your baby is born
• vaginal breech birth

There are benefits and risks associated with both caesarean birth and vaginal breech birth and these should be discussed between you and your Obstetrician and/or Midwife, so that you can choose the best plan for you and your baby.

Caesarean birth

The Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institute for Health and Clinical Excellence (NICE) recommend that caesarean birth is safer for your baby if performed after 39 weeks gestation.

Caesarean birth carries a slightly higher risk for you, compared with having a vaginal breech birth and there may be long-term effects in future pregnancies for either you and/or your next baby. These risks will be discussed in more detail with you as part of giving informed consent for caesarean section.

If a caesarean birth is planned and then you go into labour before the operation, your Obstetrician will assess whether it is safe to proceed with the caesarean birth. If the baby is close to being born, it may be safer for you to have a vaginal breech birth.

Vaginal breech birth

After discussion with your Obstetrician about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth. However, it may not be recommended in all circumstances. It can be a more complicated birth, as the largest part of your baby (the head) is the last to be born and in some cases this may be difficult.

Where a vaginal breech birth is being considered, the RCOG supports this when:

• the Midwife or Obstetrician is trained and experienced in vaginal breech birth
• there are facilities at your hospital for an emergency caesarean birth (should this be necessary)
• there are no particular features about your pregnancy that make vaginal breech birth more risky

Before choosing vaginal breech birth, it is advised that you and your baby are assessed. Your Obstetrician may strongly advise you against a vaginal birth if:

• your baby is a footling breech
• your baby is large (over 3800 grams)
• your baby is small (less than 2000 grams)
• your baby is in a certain position: for example, if the neck is very tilted back (hyper- extended)
• you have had a caesarean birth in a previous pregnancy

What can I expect in labour with a breech baby?

You can have the same choices of pain relief as with a baby who is headfirst. We would not recommend use of the birthing pool.

If you have a vaginal breech birth, we advise that your baby’s heart rate be monitored continuously. Forceps may be used to assist the baby to be born. This is because your baby’s head is the last part to emerge and may need to be helped through the birth canal. In some circumstances, you may need an emergency caesarean birth during labour.

What if my baby is coming early?

If your baby is born before 37 weeks, the balance of benefits and risks of having a caesarean birth or vaginal birth changes and this will be discussed with you at the time of admission to hospital.

What if I am having more than one baby and one of them is breech?

If you are having twins and the first baby is breech, your Obstetrician will usually recommend a caesarean birth. The position of the second twin before labour is less important at this stage because this baby can change position as soon as the first twin is born. This is because it then has lots more room to move.

If you would like any further information on any aspects of breech, speak with your Obstetrician or Midwife.

Sources and acknowledgements

This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) patient information leaflets.