Breech Pregnancy: 8 Important Questions, Answered!

In the last few weeks of pregnancy, as if in preparation for the final curtain call for their real-world debut, babies turn so that their head is positioned to come out of the vagina first. This is called a vertex (cephalic) position, which is an ideal position for delivery. However, there are cases where this doesn’t happen. Some babies end up in a breech position which comes with risks and considerations during delivery.

1. What is a breech baby?

In the last few weeks of pregnancy, there are instances where the baby is positioned with the buttocks or feet first. This is called a breech presentation, and it occurs in 3-4% of full-term births.

At 36 weeks of gestation, your baby is expected to have made that downwards turn. But if they remain upright or even lie sideways (transverse position), your obstetrician will discuss options for safe delivery.

2. What causes a baby to be in breech position?

Most of the time, there is no clear reason why a baby remains in a breech position. This may be a matter of chance, but there are also recognised factors that could potentially make it difficult for the baby to turn downwards in utero. These include: 

• if this is your first pregnancy
• if you are expecting more than one baby (multiples/twins)
• if you have too much or too little amniotic fluid surrounding your baby
• if the uterus is not normal in shape or has abnormal growths such as fibroids
• if the fetus is preterm
• if you have a low-lying placenta, or if it covers part or the entire opening of the uterus (placenta previa)

You can read more about a low-lying placenta and the dangers it can pose to your pregnancy, here.

3. Will there be any signs that will indicate that a baby is breech?

You won’t readily know if the baby is breech, but there are some giveaways that you may notice. If you’re on your 36th week of pregnancy or more, and you feel the baby’s head pressing high up on your belly, or if you feel some kicking to your lower belly that may be a clue. 

But it’s also expected that as your due date nears, your doctor will also check the position by palpation and ultrasound. They will feel outside of your abdomen and uterus to locate the baby’s head, back, and buttocks.

If a baby is in a breech position the head can be felt at the top of the uterus as a firm and rounded shape.  Click To Tweet

It feels like an apple bobbing in water. Meanwhile, the softer, less rounded bottom can be felt in the lower portion. Ultrasound will confirm the presentation.

4. Do breech babies have problems? 

Breech pregnancies aren’t a cause for concern until it’s time to deliver the baby. Almost all breech babies are born healthy. However, they also have a slightly elevated risk for certain problems than babies in the normal position. Most problems are detected around your 20^th week ultrasound scan. If nothing is detected at this point, then most likely, your baby is normal. 

5. What happens if the baby is breech towards the end of pregnancy? 

If your baby remains breech at 36 weeks, your doctor will now start to discuss an external cephalic version (ECV) or a planned caesarean section.

6. What is External Cephalic Version (ECV)

ECV is a procedure where the fetus is externally rotated from a breech or transverse position. By applying gentle and firm pressure over the distended belly, the baby can be ‘ massaged’ by turning in the uterus to lie head-first. When successful, this makes it possible for you to try a vaginal birth.

This procedure is typically done around 36 to 37 weeks of pregnancy. Rarely, it’s also performed during labour before the amniotic sac ruptures. But to ensure that the fetus remains safe, close monitoring must be made through fetal ultrasound and electronic fetal heart monitoring. It will be done before and after the ECV procedure.

A medication may occasionally be administered through an injection to relax the uterus and prevent contractions. This medication is safe for you and your baby. However, it can make you feel flushed and your heartbeat can get faster than usual, but this usually won’t last long. 

As the uterus relaxes, the doctor will now start to carefully turn the fetus. Your OB will place both hands on your abdomen, one positioned on the fetus’ head and the other by the buttocks. A gentle push is made and the baby is rolled to a head-down position.

Generally if the baby is willing to turn its head down, it will  move quite easily in the first few minutes. Click To Tweet

Since the doctor applies a firm and steady pressure, a moderate amount of discomfort can be felt during the procedure, which is tolerated well by most women. Any discomfort will depend on your tolerance level and how hard the doctor presses on the abdomen. However, you should always tell your doctor if the pain becomes intolerable so she can stop right away. The same should be done if your baby appears to be in distress, which is evidenced by a drop in heart rate.

An ECV is successful half of the time, but in cases where the baby doesn’t turn, a second attempt can be done with your consent.  Click To Tweet

However, this has to be scheduled for another day. Even if ECV is successful there’s still a small chance that your baby will turn back to a breech position.

This procedure is generally safe with a low complication rate both for the mom and the baby. After ECV, you will normally be able to go home on the same day. If you experience abdominal pain, contractions, bleeding, or reduced fetal movements after ECV, you need to contact the hospital right away.

7. What is a Planned C-Section?

If the baby remains breech towards the end of pregnancy, and ECV wasn’t effective, a planned cesarean section will be advised. Research ( Term breech trial) has shown that a C-section is safer for your breech baby than a vaginal birth, although it carries slightly more risk for you (bleeding, infection, blood transfusion, hysterectomy).  It is the recommended and preferred mode of delivery by most OBs and hospitals.

A planned caesarean breech birth may not be possible on certain occasions. If a breech labor progresses too quickly and the buttocks are already seen emerging, a vaginal birth may be the only option. During a twin birth in which the first twin is head-down and the second twin is breech, both babies may be delivered vaginally. Once the first baby is out, there is a chance that the breech twin will turn or can be ECV ed since there will be more room.

The likelihood of delivering one twin via vaginal delivery and the second via C section is about 5%. Click To Tweet

8. What is a Planned Vaginal Breech Birth

A breech baby can be delivered vaginally in the minority of circumstances with an OB experienced and confident in breech deliveries and immediate availability of Caesarean section facilities. Usually it is more successful in women who have delivered at least one previous baby vaginally. 

Women should be informed that planned vaginal breech birth increases the risk of neonatal morbidity and mortality compared to normal cephalic vaginal delivery.  There is an increase in serious short-term complications in a trial of vaginal breech labour versus a planned Caesarean section (5% in vaginal breech versus 0.4% in caesarean section) as well as a slight increase in the risk of perinatal mortality.

The overall combined risk of perinatal mortality and serious neonatal morbidity was 1.6% with planned caesarean section versus 3.3% with planned vaginal birth.  Click To Tweet

The main feared complication of a vaginal breech delivery is head entrapment where the body is delivered but the head is still trapped in the cervical canal or pelvis as the head circumference is generally larger than the abdominal circumference especially if preterm.

If you have a vaginal breech birth, your baby’s heart rate will be monitored continuously for any signs of distress. If there are irregularities observed with your baby’s heart rate, or if your labour is not progressing, you may need an emergency caesarean section. A paediatrician will attend the birth to immediately assess if your baby is doing well.

According to the Royal College of Obstetricians and Gynaecologists in UK, vaginal breech delivery must be avoided in the following situations:

• Footling breech, which is when the feet of the baby is below its bottom
• The peculiar position of the fetus (i.e., the neck of the baby is tilted back)
• Large babies weighing over 3.8 kg
• Small baby weighing less than 2 kg ( < 2.5 kg for the American College of Obstetrician and Gynaecologist guidelines)
• Narrow pelvis with less space for the fetus to safely pass through the birth canal
• C-section delivery in a previous pregnancy
• Pre-eclampsia
• Low-lying placenta

If you are concerned about a breech pregnancy, we encourage that you seek close monitoring with an OB-GYN. Each case is unique, and that is why you need the personalised care that you and your baby need. If you are in Singapore, you can book a non-obligatory consultation with Dr Pamela Tan. Our team would be happy to be a part of this special journey.