Wednesday, August 12, 2009

Breech Presentation: Risks and Options

After the birth of my fifth child ended with a surprise breech delivery at home, I decided to look back in my books and learn more about breech presentation and the risks and options available.

At prenatal visits, the doctor or midwife routinely checks the position and presentation of the baby by palpating the mother's belly. As the due date approaches, most babies assume a presentation with the head down, called cephalic position, prepared to descend into the birth canal with its head pushing through for birth. About 3% to 4% of babies don't move into a head-down presentation, and it's called a breech presentation. There are three types of breech presentation: frank, complete, and incomplete.
  • Frank breech is when the baby is presenting with its buttocks in the birth canal. The legs are generally extended up with the feet by the baby's head.
  • Complete breech is when the baby is in a normal fetal position (sitting cross-legged) but the baby's rear end is presenting over the birth canal.
  • Incomplete breech includes kneeling and footling positions. The baby's knees may be bent with the knees presenting over the birth canal, or one or both feet may be down.
Vaginal delivery of a breech baby can be safe, but there are some risks involved, which can include:
  • Cord prolapse: This occurs when the cord is swept into the cervix, because the baby's feet or buttocks don't completely cover the cervix to prevent this. This can happen if the membranes rupture in a gush and the cord comes down as the fluid comes out. This is dangerous because the cord can be compressed during contractions and cut off vital oxygen and blood supply to the baby. The risk of cord prolapse is much less with frank breech position, because the buttocks are about the same size as the head and can fill the pelvic area enough to prevent the cord from slipping down.
  • Prolonged delivery or fetal distress: The feet or buttocks can be delivered before the cervix is complete and may not allow the cervix to open all the way to deliver the head. This can lead to fetal distress or delayed delivery of the head.
  • Spinal cord injury: This is rare, but can occur if the baby's neck is hyper-extended (the baby looking upward). A baby in this position is sometimes referred to as a "stargazer" and can be detected if an ultrasound is done to determine the baby's position. Experts agree that stargazers have the best outcomes when delivered by cesarean section.
What You Can Do
Most babies assume their birth position by about 36 weeks gestation. Some turn later, even in labor. Ask your care provider to pay extra attention to the position of the baby at 36 weeks and later. If your baby is found to be in a breech position, you can try these methods at home to encourage the baby to turn:
  • Open knee-chest: From a hands and knees position, move your knees backward and outward and lower your head and chest to the floor or bed. Make sure your buttocks are high in the air and your thighs are angled away from your belly so that your knees are slightly behind your buttocks. Try to stay in that position for 30 - 45 minutes, or as long as you can. Your partner can help you maintain the position by kneeling next to you, facing your head, placing his or her hands on your shoulders, and pulling up and back slightly. After using this position it can be helpful to go for a walk, crawl on the floor, or dance in a swaying motion. By alternating the downward and upward positions (i.e. knee-chest, walk, knee-chest, walk, etc.) you can encourage the baby to move out of a unfavorable position and into a favorable position.
  • Breech tilt position: The concept is to get your hips higher than your head. Lie on your back with your knees bent and feet flat on the floor. Have your partner help place pillows under your hips, enough to raise your hips 10-15 inches higher than your head. Stay in this position for about 10 minutes, 3 times a day. You can also use an ironing board or other flat board in a tilted position to do this.
  • Sound: Research shows that a fetus will respond to sound. Have your partner talk to the baby with his or her head in your lap, or place headphones with pleasant music just above the pubic bone. The concept is that the fetus could turn to get its head closer to the familiar or pleasant sound.
Medical Care:
A doctor or midwife can perform an external cephalic version, or ECV, to try to turn a breech baby. An ultrasound is usually done prior to the version to verify the baby's position. A medication can be given to help relax the uterine muscles, but it is not necessary. A non-stress test is often done before and after the procedure to check the baby's well-being, and fetal monitoring throughout the procedure is common. If fetal distress is detected, the procedure will be stopped. Depending on the caregiver performing the version and the amount of pressure used, it could be quite uncomfortable. It's a good idea to have your birth partner come with you and help you practice your birth comfort measures such as focused breathing. External version has a success rate of about 60%. If the version is unsuccessful, your care giver will discuss your delivery options with you.

Vaginal delivery versus Cesarean Section:
Up until the 1970's breech babies were routinely delivered vaginally. Doctors were trained how to handle them and it was a common practice. However, as c-sections became increasingly widespread, doctors came to rely more upon surgery as the preferred birth method for breech babies. Doctors now are not trained to deliver breech babies vaginally, and most women with breech babies are limited to cesarean section.

The best candidate for vaginal breech delivery is a woman with a full term baby of average size who is in frank breech position. This is because the buttocks are the same size as the head and can prevent cord prolapse. Frank breech is the most common breech position.

If you desire a vaginal birth, it would be good to discuss the possibility of vaginal breech with your care giver. Your care giver may or may not be comfortable attempting a vaginal breech delivery, and it would be good to know this when selecting your care giver in the beginning of your pregnancy, if possible.

Personal note
: We didn't know my baby was breech until I started pushing. There was no preparation I could have made. However, I don't consider the breech position to have been a complication in my baby's birth. We had birth professionals with us who had the training and experience necessary to guide us in the birth of our baby, and I was able to birth him vaginally in the birth tub at home. The water enabled my baby to manipulate his body to assist in his own delivery, and I don't think he could have done that if we had been out of the water. I feel that my overall calm approach to the birth helped things go much more smoothly than they would have if I had been afraid. It's important to prepare yourself physically, mentally and emotionally for your baby's birth, and be prepared for the unexpected. It also helps to have a good support team! Click here to read my breech home birth story. The video below is not of my own baby's birth, but it's a wonderful example of a breech water birth.

For more information about breech presentation, or any other pregnancy or birth topic, please see The Thinking Woman's Guide to a Better Birth by Henci Goer, and Pregnancy, Childbirth and the Newborn, by Simkin, Whalley and Keppler.

1 comment:

  1. Thank you for the great information in such a concise and unbiased way! I am sure this will help many women who are facing a breech birth! I also birthed a frank breech baby vaginally and am so thankful for how things turned out!!