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Childbirth Cubby

A Baby in the Breech Presentation
by Bobbi Kimsey, SNM
Medical University of South Carolina, College of Nursing

What is a breech presentation?

During pregnancy, a fetus is said to be in a breech presentation when the buttocks of the baby are presenting first at the bottom of the uterus, and the head is in the upper part, or fundus of the uterus.

A breech presentation might be found during a routine prenatal visit when the nurse-midwife or physician feels the mother's abdomen for the outline of the fetus. A baby's head in the fundus of the uterus will feel very hard, round and will "bounce" back and forth between the examiner's hands. The breech in the fundus (ie, head-down) is less hard and round, and when moved, the baby's body moves with it. Mothers sometimes suspect a breech presentation when the baby's movements are felt very low in the pelvis, or even in the rectum or bladder.

There are a number of variations of the breech presentation, determined by the position of the baby's body parts, like arms and legs, in relation to his or her head and trunk. In the case of the breech, it is significant whether one or both legs are folded at the knees ("complete" breech), fully extended with the feet near the face ("frank" breech), or a foot or knee (or two!) descending first. The significance of these is explained below under "Delivery of a Breech."

Why are some babies breech?

Actually, it is perfectly normal for babies to be breech frequently during pregnancy. As the child grows, the uterus gets more crowded and it is most common for him or her to assume the head down presentation. The uterus is shaped rather like an upside-down pear, so the baby's head fits in the lower part, with more room at the top for movement of the extremities. Generally, the placenta is attached at the side of the uterus, which seems to encourage the head-down presentation, too.

Ninety-seven percent of full-term babies are born head first. Usually, by the time labor begins, a fetus will have chosen a head-down presentation, and will most likely stay there. If he or she is breech near the due date, turning around is still a possibility, although some medical studies find as much as 80% of breech babies stay breech until birth. See "What can be done . . ." below.

Some situations make a breech presentation at the time of labor more likely. These might include:

  • preterm labor and birth - if labor starts when the baby is still small enough to move rather freely in the uterus.
  • a placenta in the fundus - the placenta takes up some of the space in the top of the uterus.
  • an unusual shape of the mother's uterus, or fibroids in the lower part of the uterus.
  • more than one fetus (such as twins)
  • a very relaxed uterus from many previous children
  • too much or too little amniotic fluid

What can be done to help a baby turn to head-first during pregnancy?

Suggestions for encouraging a breech baby to turn have been around for centuries. Elevating the mother's hips on a stack of pillows, above the shoulders, for 20 minutes a couple of times each day has been reported to help keep the baby out of the pelvis and encourage the head-down presentation. A mother may want to tilt to her side, rather than be on her back. Women with heartburn sometimes cannot tolerate this "upside-down" position. It is difficult to determine whether these suggestions really work, as many babies will turn around on their own near the due date or just before labor.

An external cephalic version, or manually turning the baby from outside the mother's abdomen, may be attempted to turn a breech to head first. Success varies from 50 to 80 percent (Cunningham). It does carry a small risk (less than one percent) of serious cord entanglement or damage to the placenta, so external cephalic version is nearly always attempted in a hospital with emergency cesarean facilities ready. The mother may be given an intravenous line, and possibly drugs to keep the uterus relaxed. The baby's heart beat will be monitored throughout the process, and for an hour or so following.

Moving the baby around through the abdomen has been described as moderately to quite uncomfortable by women who have experienced an external version. Pain medications, if given at all, are sometimes limited so that the mother's level of discomfort can guide the physician and/or nurse-midwife in providing the right amount of pressure. When external cephalic version is successful, almost all babies will remain head first until birth.

Delivery of a breech presentation - is it always by cesarean?

Delivery of a breech through the birth canal can be risky. Normally, with the head-first presentation, the largest part of the baby (the head) gradually stretches open the soft tissues and ligaments of the birth canal through the hours of labor. The fetal skull also gradually changes shape to fit into the mother's bony pelvis ("molding"). With a breech, the largest part is last, and the baby's head hasn't had a chance to "mold", or adjust to the pelvis by the time of birth. If it takes too long for the baby's head to be born after the body is out, he or she could have some damage from lack of oxygen. For this reason most breech births (90%) are by cesarean in the US. Because of additional manipulation of the breech baby during delivery, mothers may have more infections or tears in the birth canal than normal.

Some authorities argue that breech presentations can safely be delivered vaginally with certain precautions:

  • The baby should be a frank breech and near full term. The thighs, hips and back combined are nearly as large as the fetal head in a full term baby. Any other leg position will not dilate the birth canal adequately.

  • The head of the fetus should be flexed, with the baby's chin on his or her chest. If the head is looking straight forward or upward ("stargazing"), then the forces of labor can cause too much pressure on the spinal cord in the neck.

  • The mother should have a "proven" pelvis, meaning she has delivered a child previously that was as big or bigger than the estimated weight of the breech fetus. It is important to note that estimated weights of babies in the uterus can be pretty far off, even with expert and ultrasound estimations.

  • The doctor or nurse-midwife should be experienced in attending breech births. Finding an experienced person has become more difficult as cesarean deliveries for breech presentation has been the "rule" for many years.

  • Spontaneous and normally progressing labor.

  • A healthy and well mother and fetus.

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What should I do if my baby is breech?

Be sure to ask questions. If the baby is not due for several weeks, it is likely he or she will turn around, so don't worry about it at this point. You could try some of the positions or exercises to turn a breech, but ask your nurse-midwife or doctor first. If the baby is near full term, talk with your doctor or nurse-midwife about what your options are. If he or she does not offer external cephalic version or breech delivery, perhaps they can refer you to someone who does, if you are interested.

In the end, if a cesarean is scheduled for breech, be sure to have the baby's presentation re-checked before the surgery. Every once in a while a baby waits til the last minute . . . !

Author: Bobbi Kimsey, CNM, MSN
Carolina Nurse Midwives, Concord, NC

References
 » Cunningham, F. G., MacDonald, P. C., et. al. (1997). Williams Obstetrics, 20th Ed. Stamford, Connecticut: Appleton & Lange. 435-443; 495-507.
 » Varney, H. (1997). Varney's Midwifery, 3rd Ed. Sudbury, Massachusetts: Jones and Bartlett Publishers. 398-399, 502-509.

The author gives permission to reproduce this article for the benefit of women, provided it remains complete and unchanged in any way.

Additional Resources on StorkNet:
 » What is the Webster Technique for turning breech babies?
 » External Version for Breech Baby
 » Tips for Turning a Breech Baby
 » Breech at 35 Weeks
 » Footling Breech Delivery
 » Footling Breech Baby

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