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.

The Home Water Birth Breech Delivery of Liam

By the time I received the surprising news that I was pregnant with my fifth baby, I had given birth to two of my babies in the hospital completely medicated and to the other two in the hospital without any medication. I had learned a lot about my body, mind, and spirit, and what they are capable of. I had worked with a doula to achieve the natural birth I had always wanted, and I had even started the process of training to become a birth doula myself. At the time I was reading everything I could get my hands on about pregnancy and birth. I felt like a sponge. I had discovered a deep passion and I was soaking up every bit of information I could.

In my studies I had learned about the option of home birth. It was something I had never considered before in my life because I didn't know until then how safe and wonderful it could be. I knew then that I had some options I had never even thought about with my previous pregnancies. I had always been interested in water birth (giving birth in a tub of warm water), but it was not an option in the hospital because of the policies in place. Even after the birth of my fourth child I had felt a sense that something was still missing from my birth experiences. I felt that home birth would fill that void. As I thought about my options, the idea of a water birth at home gave me great peace. The peace I felt surprised me, but I welcomed it. I prayed about planning to birth my baby at home, and that resounding peace filled my soul. That peace stayed with me throughout my entire pregnancy. I never felt fear about my choice to birth at home.

Along my journey I had been blessed to meet people with wonderful skills. Through his work in massage therapy, my husband had gotten to know a midwife who specialized in home birth, and had been working in that field for 15 years. I called her and we started meeting regularly for prenatal visits and monthly forum meetings at her home. She did all of the clinical work that my obstetrician had done at the prenatal visits, but she also offered emotional support that I had never experienced with a birth care provider before. Over the months my midwife and I developed a close bond and friendship that I had never expected. I was able to meet all of her birth attendants (all trained birth doulas who were either midwifery apprentices or midwives themselves), and to familiarize myself with the people who would be at my baby's birth.

I went to my obstetrician's office three times in my pregnancy for various medical tests that my midwife didn't offer (such as an ultrasound). I knew which medical screenings and tests I wanted and didn't want, and I knew my reasons for choosing them or declining them, and I felt informed and comfortable in my decisions. I felt that I got the best of both worlds on my own terms.

My children had already started to become familiar with birth terms and concepts from the many times I read about and talked about pregnancy and birth with my friends. My older children had started asking me questions about what the terms meant and I answered their questions in simple ways that they could understand. They were interested and I decided to use that curiosity to teach them. I didn't know whether I wanted my children to witness the birth, but I knew I wanted them to be prepared for it. I didn't want them to be scared and I hoped they would understand what was happening whether they were present in the room for the birth or not. I wanted them to understand what we were planning and why, especially because it was so different from what most people in our society do.

As the baby's due date came close, my husband and I worked to organize our home to avoid unnecessary clutter and chaos. We tried to foster an environment of peace and love. It was difficult at times with four rambunctious children, but we worked together, prayed often as a family and worked hard to turn the moments of chaos and confusion into bonding times in changing those moods into positive moments.

I had several days of early labor, spread out over more than a week. The contractions were mild and I could walk and talk through them and go about my day. I started to feel very anxious about having my baby, and at times I got frustrated when the contractions would stop for a day or so. My mood was all over the place. I had never experienced such violent mood swings before, and my husband was a life saver in helping me calm down. My midwife assured me that the mood swings were a symptom of the hormonal changes my body was experiencing while preparing for the birth. What was good for labor was hard on my family. I tried to used this time to make peace with myself and resolve any emotional issues that came up.

While driving to my midwife's home for a prenatal visit the day before the due date, I was thinking about having my children witness the birth. I had been hoping to birth in the middle of the night while everyone slept. For the first time I felt a strong desire to have them there. I felt it would be a special bonding experience for our family, and I decided I would like to have my two oldest children at the birth. I decided to see how labor played out and go with the flow, with the hope that they would be able to be there.

At the visit my midwife checked my cervix and found I was dilated to a 1 and my cervix was soft. She did some things to try and help stimulate labor naturally, and she was able to help stretch my cervix to a tight 3. We discovered that the baby's head seemed to be in front of the cervix, rather than on top of it. It was not lined up properly. She recommended some positioning (such as knee-chest) to try to move the baby out of his position and encourage him to move into a favorable position by alternating the downward and upright positions. I used these positions over the next few days, hoping the baby would move where he needed to be for labor to progress well.

About four days after the due date, my midwife brought the birth tub to our house and we set it up in our bedroom. My midwife checked the baby's heartbeat and the kids all got to hear it, with grins and wide eyes. She also checked my cervix and found it was dilated to a 4, almost a 5, and 80% effaced. After she left, my contractions gradually started to build in intensity and frequency. It was evening and I was cautiously hopeful that we would have a baby sometime that night or the next morning. I stayed busy doing things around the house, doing whatever I could think of to prepare and keep my mind off of the growing pressure. I called my midwife to let her know what was happening, and she suggested I go for a walk and call her back if things changed. I walked through the neighborhood around midnight and the contractions started coming every two minutes. I could still walk through them, but it was becoming less comfortable to do so. I called my midwife and she started on her way to our home.

My midwife arrived and my husband helped her set up her things as I moved about the house doing what I could to help and get comfortable. She checked me and found my cervix was at a 5. I was completely calm, able to move about freely as I wanted to. I had my birth ball in our front room, and would lean my torso against it in a kneeling position during each contraction. I was using focused breathing through them at this point, but was managing well without needing additional support. Our 18 month-old fell out of bed and woke up, and I held her as I labored for a while. We all decided to lie down and try to rest while my contractions were so manageable, and get her back to sleep. By the time the contractions were strong enough to wake me I was focusing intently on breathing through them, and my little one was asleep. She was placed back in her bed and I got into the birth tub. At some point my midwife checked me again and I was dilated to a 7. She called her attendant to come assist.

As I stepped into the warm water, the pressure seemed to completely melt away and I felt instant relief. My husband sat behind the tub as I leaned against the back of it. He held my hands to support my arms, and pressed some acupressure points to alleviate the pain. It worked wonders. It seemed to me that my contractions were slowing down and much less intense, and my midwife assured me that I was still having them, but feeling them much less because of the water. Between contractions we chatted and enjoyed each others company, and during contractions I closed my eyes and focused while my husband held me and pressed the points on my hands. The next time my midwife checked, I was dilated to a 9. We were elated, and anxious to have a baby! She stepped out to talk with her attendant and my husband and I talked about how this was the easiest birth by far, and how wonderful it was to be at home and for everything to be so calm and comfortable.

When my midwife came back in to see if it was time to push yet, she found that my cervix had started to close back up! I was back to a 7, and my cervix was swollen and hard. We were perplexed and disappointed. We had no idea why my body had gone backwards. We talked about our options. If I had energy we could try some things (like walking and going up and down the stairs) to get things going. I was tired, and we all decided to lie down and try to rest. My husband laid down behind me to press on my sacrum during contractions to help relieve the pressure in my back. It felt good to breathe deeply in and moan as I exhaled, and I slept between the contractions. My water broke a little bit when I was in bed, and my midwife broke it the rest of the way for me.

The kids started waking up and the midwife's attendant helped them get cereal and keep them busy for a little while. I sat on the birth stool to encourage progress and allow gravity to help. My husband pressed on my sacrum and my midwife applied counter pressure on my hips. My children helped by placing their hands on me or stroking my feet. We soon realized that our littlest one was upset and confused about why mommy couldn't give her attention. We called grandma and asked her to take the kids, but the oldest two wanted to stay and help. We promised to call them back home when the baby was ready to come out. I got back into the birth tub in an upright position and my husband pressed on my back.

It was only about 20 minutes after the kids left that my midwife checked me and found I was at a 9. We called the kids and the older two came home. I was finally able to push, and my kids stood at the side of the tub while my husband sat behind my head and supported my back. It felt good to stretch my body out as long as I could and arch my back. The urge to push wasn't as strong as I remembered it being with my other births, and I had to will myself to push harder than the urge.

With the first really good push it felt to me that the baby's head was about to come out, but it went back in. My midwife asked me to stop while she cleaned some stool out of the water. She soon realized it was meconium from the baby and wondered why there was so much of it. When she checked, she found that it wasn't the baby's head that was about to come out, but his bottom! I sensed worry in her face and her voice as she announced that the baby was breech, but I wasn't worried. I knew my baby would be fine and I waited to be instructed on the next step. My midwife told me to stop pushing and was about to have me get out of the tub. She later told me that she thought she should have me on the bed so she could help manipulate the baby to come out. Her attendant quickly stepped in and said “No, it's alright, let's just keep her here and keep going”.

They instructed me to push and don't stop; just keep on pushing! I forced myself to push harder than my body wanted to as the baby's bottom came out, then one leg, then the other leg. As my midwife reached to help the baby I heard the attendant say “No. See how he's kicking? He's doing just fine!” I closed my eyes, focused and kept on pushing, and they told me his torso came out, then one arm and then the other arm. I felt every movement as the pressure eased with each body part that came out. Then, as my 6 year-old describes it, the baby “put the feet and the hands on the bum cheeks and pushed his head out!”

My baby was out! They immediately lifted him out of the water and placed him in my arms. He was beautiful and perfect, and I just held him against my body in the warm water. The midwife had me hold him above the water with his face down and he immediately spit out the fluid from his lungs and took in a big breath. He let out two little cries and instantly started to pink up.

My husband and midwife described to me how the baby had kicked his legs in the water while I was pushing, and moved his body to help wiggle his way out. I didn't realize until I talked with my kids later that he had actually used his arms and legs to leverage himself against my body and help get his own head out. My kids had the best vantage point, and had seen the process better than my husband, who had been sitting at my head. My midwife herself had been amazed. She didn't have a lot of experience with breech babies, but her attendant who was there had experience birthing more than 20 breech babies, including 3 of her own grandchildren. The attendant had known exactly what to do. It was good for me to be in the water and allow the baby to feel the weightlessness similar to the womb and be able to manipulate his own body in ways I never would have imagined possible. I was immediately grateful I was at home in the tub.

A second attendant had arrived sometime around the time the baby was born. I held my baby as I was helped out of the tub and onto the birth stool to deliver the placenta, which came out in one push. The placenta was then wrapped in a chux pad and placed at his feet while I held him. We were helped into bed and snuggled for a while and enjoyed each others company with my husband and other children while the midwives cleaned up. I had no concept of time, but it was a while later that the midwives came back in and clamped the cord. The kids put on latex gloves and our oldest son got to cut the cord. The midwives inspected the placenta and explained it to the kids. They then weighed the baby at 7 pounds, 15 ounces. I was given a cayenne drink to minimize bleeding and told to drink as much as possible.

I had a small tear, and my midwife stitched me while her attendants examined the baby near me on the bed and went through the long checklist, making sure everything was good. The baby was completely calm as they checked him, and my husband held him. The baby's legs were straight up with his feet by his face because of the way he had come out of the womb, and it took some time for him to let his legs down. One of his hips had been dislocated during his birth, and the midwife suggested that my husband do some craniosacral therapy on him to help his hip. He was given an APGAR score of 9/10 and measured at 21 inches long (once his legs were down).

I don't know what would have happened had I been in the hospital, whether or not they would have wanted to do a cesarean section due to the strange pattern of labor or the fact that the baby was breech. My labor with this baby was different than with my other children. There was no clear pattern to me. The contractions did get more intense as things progressed, but they stayed fairly far apart, and I never felt I experienced a clear transition stage. Even the urge to push was not very strong compared to what I had felt with previous births. I wonder how much the baby's position contributed to these differences. Despite the strange labor, the whole process was very peaceful and beautiful for us. My husband and I both felt calm through the whole thing, even with the surprises that came up, and we are both very happy we made the decision to have this baby at home.

We're not sure why we didn't know the baby was breech beforehand. The midwife is still wondering if she could have detected it earlier. When she had checked me earlier in labor she had noticed that the “head” didn't feel normal, but thought what she felt was the molding of the crown in the cervix. I don't fault anyone for not knowing he was breech. We didn't know, but God knew, and provided us with what we needed to handle it. My husband and I feel that everything happened as it should, and we are thrilled to have our beautiful, healthy baby.

Breech Baby (Breech Position or Presentation)

What is Breech?
Breech presentation is when a baby is in a position other than head-down. There are three types of breech presentation. Frank breech is the most common, with the baby's buttocks down and legs straight up toward the face. Complete breech is when the baby is in a sitting position with legs crossed. Footling breech is when the the baby has one or both feet down. The baby's position is checked at each prenatal visit in late pregnancy. By 34 to 36 weeks most baby's have assumed the position they will birth in.

Why is a breech presentation risky?

• The chances of a prolapsed cord increase with a breech baby because the buttocks or feet don't prevent the umbilical cord from being swept below the baby or into the vagina.
  
• When the baby's feet or buttocks are delivered first there is a possibility the head can press on the cord at the cervix and possibly reduce the baby's oxygen supply.
  
• Sometimes the baby's feet or buttocks are small enough that they can be born before the cervix is fully dilated, and the head doesn't have enough room to come out. This could lead to fetal distress and delay the birth of the head.
• Spinal cord injury is also a risk if the baby's head is hyperextended (bent back).

What can be done about a baby in a breech position?
If by 36 weeks your baby is in a breech position, you can try one of the following:

• The breech tilt position: The idea behind this is to tilt your body so that your hips are higher than your head. Ask your caregiver if this is safe for you to do. If you are healthy and the baby is doing well, most caregivers encourage this position. Lie on your baby with your feet flat on the floor. Raise your pelvis and slide firm cushions underneath your buttocks, enough to raise them 10-15 inches above your head. You may need help from your partner or a family member or friend with the pillows. You can also use a flat surface like an ironing board or plank, tilt it by putting one end on a chair and the other end on the floor. Lie down on the board with your head toward the bottom. If it's unsteady at all, have someone help steady it for you. Lie in this position for 10 minutes, 3 times each day at times when your baby is active. It helps encourage the baby to move up away from the birth canal so the baby can move to get into a more favorable head-down position. It's not the most comfortable position, but if you empty your bladder and make sure you don't have a full stomach, it will help ease some discomfort. While you lie in the tilt position, try to relax your abdominal muscles as much as possible and imagine your baby turning a somersault so the head turns toward the cervix. The baby will probably squirm as the head presses into the fundus. There is no medical proof that this method helps turn a baby, but many women swear by it, and it doesn't do any harm. After lying in this position, it's a good idea to assume an upright position to encourage the baby to move back down after being pulled up be gravity.
• Knee-chest position: This position uses the same principles as the breech tilt position, and you may want to try it and see if it's more comfortable for you. For this position, assume a hands and knees position with your knees about shoulder-width apart. Place firm pillows under your pelvis to help hold your hips and pelvis up in that position, and then lower your head and shoulders to the floor. You may want to use a blanket or thin pillow to soften the surface for your head, but be sure to keep your head and shoulders as low to the floor as possible to allow gravity to help pull your baby out of the breech position. Once you're support by enough pillows to keep your pelvis up, you should be able to maintain this position comfortably for 10 minutes or so, also 3 times a day just like the tilt position.
• Use of sound: You can try this by either placing earphones from a music player just above the pubic bone and playing music for the baby when the baby is active. You can also have your partner place his or her head in your lap and talk to the baby. The idea is that babies can hear outside sounds while in the womb, and the baby may reposition itself so that his or her head is down toward the comforting or familiar sound. This method is also completely harmless and comfortable, and many women have reported that it helped turn their baby.

What's the medical approach to turn a breech baby?
If your efforts at home haven't been successful in turning your breech baby, your caregiver may want to try external version. This is done at 37 to 38 weeks. An ultrasound is usually done to determine the exact position of the baby, check how much amniotic fluid is present, and see where the placenta is attached to the uterus. A non-stress test may be done to check the well-being of the baby before or after the version. You may be given a drug to relax your uterus, and some caregivers like to use an epidural to reduce any discomfort. The caregiver uses ultrasound as a guide while he or she presses on your abdomen and tries to manually turn the baby into a head-down position. If the baby shows fetal distress, the procedure is stopped. If the placenta starts to detach from the wall of the uterus, a cesarean section must be done to deliver the baby. Sometimes the version is unsuccessful and the baby does not turn at all. Some babies will turn from the version and then resume a breech position afterward. Studies have shown that external versions are safe and successful about 60% of the time. It can be quite uncomfortable because of the amount of pressure that's used to turn the baby. It can be helpful to have your partner or doula with you to help with breathing techniques and relaxation to give you comfort and allow the caregiver the time needed to turn the baby during the procedure.

Vaginal Birth versus Cesarean Birth for a Breech baby.
It used to be that vaginal breech births were done all the time. Even though there are complications with a vaginal breech birth, it can still be done safely with the right expertise. After the 1970's the overall cesarean section became increasingly common, and doctors began to abandon vaginal breech delivery and use surgery more and more to deliver breech babies. As vaginal breech births declined, fewer doctors learned the techniques to perform a vaginal breech birth. It can be difficult now to find a physician who is willing and has the skills to allow you to birth your breech baby vaginally.

Personal note: I know a woman who interviewed her physician before the birth of her second child. She showed him her birth plan and asked specifically that if the baby were to present in a breech position she be allowed to attempt a vaginal delivery. Her wonderful doctor (who happened to be an older man who had assisted in a multitude of vaginal breech births and has the necessary skills to do so) said that he would love to help her do that. This is rare, and I think it emphasizes the importance of interviewing your caregiver and being clear about your wishes for birth! If your baby is presenting breech and all efforts to turn the baby have been unsuccessful, you may need to prepare yourself for a cesarean birth, as that is the most common method of delivery for breech babies today.

My midwife recently assisted in a vaginal breech birth at a home. She did not have experience with breech delivery, so she called in a senior midwife who knew what to do, and the baby was delivered safely and vaginally. I find it truly amazing what can be done with the right knowledge and approach.

*Information presented can also be found in Pregnancy, Childbirth and the Newborn by Penny Simkin, Janet Whaley and Ann Keppler. This is a fantastic book that I would recommend to all expectant parents.