Breech

Breech Pregnancy and Birth

Breech presentation is an absolutely normal variation of pregnancy. Since the baby is in longitudinal lie, he can be born spontaneously.

Four Major Types of Breech:

  1. Frank breech: it means the baby’s legs are extended and touch the head. It occurs about 65% of breech birth.
  2. Complete breech: both knees are flexed and the feet tucked in beside the buttocks.
  3. Knee presentation: One or both hips are extended, with the knees flexed. This is very rare.
  4. Footling breech: neither hips nor knees are fully flexed. The feet are lower than the buttocks. This is also very rare.
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Facts about breech presentation and birth:

  • Breech presentation at term occurs in about three to four percent of all pregnancies.
  • In births prior to 28 weeks the incidence is about 25%. (One-fourth of all breech babies are born = or < 30 weeks gestation).
  • As pregnancy advances the baby moves to the head down position by the 34thweek.
  • Ninety-three percent of breech babies are born with no congenital abnormality of any kind.
  • Less than ten percent of women whose first baby was in a breech presentation go on to have a second breech baby.
  • Truly diabetic moms are 3 times more likely to have a breech baby.
  • Maternal smoking during pregnancy is associated with a 30% higher risk of breech birth.

What causes breech presentation?

  • Extended legs: the baby can’t turn head down because his legs are extended.
  • Prematurity: Since babies turn head down usually after the 34th week of pregnancy, breech presentation is common when preterm labor occurs.
  • Twins, multiple pregnancy limits the space available for each baby to turn and can result in one or more babies presenting breech.
  • Polyhydramnios: the mother has more amniotic fluid than average. It causes distention of the womb that can result in a breech presentation.
  • Oligohydramnios: too little amniotic fluid. The baby doesn’t have enough space to turn head down.
  • Hydrocephaly: the size of the baby’s head may be increased because there is water on the brain and it might be more comfortable for him to be head up.
  • Uterine abnormalities: any distortion of the cavity of the womb (e.g. fibroid tumors or a deviated septum) may result breech presentation.
  • Cord entanglements or short cords around the baby’s neck or body.
  • Amniotic bands: the amnion ruptures and some parts of the baby can entangle in the rolls which results in decreased freedom of movement.
  • Tense, tight uterine and abdominal walls which prevent the baby from turning or poor abdominal or uterine muscle tone.

Risks of vaginal breech delivery:

Breech births are riskier than the birth of a head down baby. Just how risky depends on the presentation, the reason for the presentation and maternal factors. Below you can read about the possible risks and complications of breech vaginal delivery.

  • Longer labors are associated with term breech babies as the weight and pressure of a head is not helping to dilate the cervix.
  • If full cervical dilation is not reached there is a possibility of head entrapment.
  • The head doesn’t have the opportunity to mold if the delivery happens fast as it does in head down presentation. This might result in bleeding within the baby’s skull.
  • Cord prolapse: this is where the cord presents prior to the baby. This can occur because the buttocks, legs or knees don’t fit as tightly against the body. It is more common during premature birth. It is important to keep the membranes intact because it helps to cushion the cord. If cord prolapse happens early in labor, cesarean section (C-section) will be recommended. If it occurs during the second stage, the birth may be continued but with an urgency. This complication is seen in three point seven to seven percent of breech babies and in approximately zero point 3 percent of head down babies.
  • The cord may become pinched between the head and the navel when the baby is born to the navel. However, cord compression is inevitable as the head passes through the pelvis.
  • Injuries to internal organs: this is often caused by severe manipulation or incorrect handling of the breech birth. These increase the likelihood of internal organ injuries. Most common injuries are liver, kidney or adrenal gland damage from pressure on the torso; neck or spinal injuries; and dislocated arms or legs.
  • It is possible for the placenta to separate when the baby’s head is still not born. This is called placental abruption.
  • Fetal hypoxia: the baby doesn’t get enough oxygen. This may be due to cord prolapse, cord compression or premature separation of the placenta.
  • Shoulder dystocia: extended arms over the head and behind the neck may result difficulty of delivering of the arms and shoulders.
  • Increased fetal morbidity and mortality rate: baby is more likely to die during breech birth because of the reasons stated above. Mortality is highest for the double footling presentation. Fetal anomalies are twice as frequent with breech babies as with those presenting head down. “The use of cesarean section for breech delivery in the belief that it is safer may become a self-fulfilling prophecy, as attendants become less skilled at breech delivery.” (Etkin et al., 2000)

Risks of cesarean section and benefits of vaginal birth:

  • Cesarean section is major abdominal surgery.
  • Risk of short term infection.
  • Higher risk of maternal death.
  • The scar on the uterus may complicate later pregnancies; it may decrease fertility; it can cause future miscarriages; ectopic pregnancies; premature separation of the placenta (placenta abruptio); or abnormally adherent placenta which may grow into the wall of the womb (placenta accreta); or placenta attached to lower segments of the womb (placenta previa).
  • Picking up older children is discouraged for weeks or months after a cesarean section to allow proper healing after major abdominal surgery.
  • Continuous support is needed both for your recovery and care of children and the house.
  • Vaginal birth improves the baby’s chances of survival since the process of birth stimulates hormonal reactions in the baby.
  • During vaginal birth you are actively involved in the birth process.
  • The risk of maternal death is two point eight four times greater after an elective cesarean section with no emergency present than if the mother had a vaginal birth
  • There is a three to 13 times increase in maternal mortality with cesarean section versus vaginal delivery when emergency and elective sections are included.
  • There is the risk of morbidity with any abdominal surgery. These come from anesthetic accidents, damage to blood vessels during the procedure, an accidental extension of the uterine incision, or damage to internal organs, etc.
  • Hemorrhage, anemia, infections and thrombosis are more common with a cesarean section than with a vaginal birth.
  • There is a six percent chance for a breech baby to be accidentally cut by the surgeon during the cesarean procedure.
  • Cesarean section is a potential risk factor for respiratory distress in infants.
  • Prematurity is a related risk factor because elective cesareans are scheduled for the 38th week of pregnancy but the calculation of the time is often false. (When cesarean section is necessary or chosen, it should be performed after labor starts on its own.)

You are the only one who can make the decision of whether to have a vaginal birth or elective cesarean and whether to birth at home or hospital. If you chose a vaginal birth, it is essential to have a practitioner experienced with breech deliveries — whether at home or hospital.

Can a breech presentation be changed?

Yes, it can! Here you can find techniques self-help and some that are performed by an experienced health care provider:

  • Visualization of the baby: try to imagine your baby head down during pregnancy.
  • Emotional factors may influence the presentation of the baby. If you are too busy, you live in an unstable emotional environment or you are afraid of birth your baby is prone to turn breech. Try to slow down and solve your problems. Pay attention to your baby and pregnancy. Talk to your baby, visualize your baby and have your partner to pay attention to your child. Have him talk to the baby right above the pubic bone.
  • Breech tilt: you can start doing breech tilt exercises if you know your baby is breech from 30 to 32 weeks. Use an ironing board or other long flat surface and put one end to the height of a couch seat. Pad the board with a blanket and lay on it head down for 15 to 20 minutes, six to eight times daily. Massage your belly gently with both of your hands, put one hand above the baby’s bottom and the other above his head, move the face forward and the bottom upward in a rotating motion.
  • Put a headphone on your belly close to your pubic bone and play soft music.
  • There are some other techniques that can be performed by an experienced midwife, chiropractor or doctor. These external versions involve risk factors, talk to your health care provider to make an informed decision on the use of these techniques.

What will you feel during pregnancy?

  • You will probably feel a hard lump under your ribs that can contribute to the discomfort of pregnancy.
  • You will feel lots of movement low in your pelvis.
  • Closer to the end of the pregnancy you can feel a hard round mass at the fundus, which is your baby’s head.

Delivery of the baby:

  • The membranes may rupture earlier than with a head down baby. Your midwife will check to verify that there is no cord prolapse.
  • The water may be stained with meconium that is the baby’s first stool because his belly is compressed.
  • You can labor in any position. You can use tub, birth stool, and your bed, anything that appeals to you. It is recommended to be in an upright position as much as possible because gravity helps baby to be seated on the cervix.
  • Eat and drink regularly and pee hourly during labor.
  • When you feel an urge to push, your midwives will ask you not to push until they check the cervix. It is very important that the cervix is fully dilated. You can feel the urge early and it may be hard not to push. Pay attention your midwives, they will help you and coach you through this hard part.
  • The midwives will wrap the baby in a warm blanket.
  • The baby’s weight and the contractions will help the baby to be born to his shoulders. Then the baby will turn in order to deliver the shoulders.  Then the body turns again and baby will be left to hang without support for one to two minutes. The baby’s weight will bring the head down. When the hairline appears, the midwife will grasp the baby’s ankle and lift the baby up until the nose and mouth are born. Then the midwives will most likely suction the mouth and nose.
  • It seems to be common for breech babies to be slower to breath after being born. Be prepared that your baby may need some form of resuscitation. It occurs in about ten percent of cases.
  • Visualize your baby during your pregnancy with the cord floating high in the womb, arm on his side, his chin tucked to the chest, being born easily with very little blood loss, being pink, breathing right away after delivery and nursing well. Imagine your baby head down, in rare cases he may turn even during labor!

Suggested reading:

Maggie Banks: “Breech Birth, Woman-Wise.”

Benna Waites: “Breech Birth.”

Resources:

B. Langer; E. Boudier; G. Schlaeder:  “Breech presentation after 34 weeks – a meta-analysis of corrected perinatal mortality/ morbidity according to the method of delivery.”

Baldwin: “Special Delivery.”

Anne Frye: “Holistic Midwifery, Vol. I.”

Myles: “Textbook for Midwives.”

Enkin et al.: A guide to effective care in pregnancy and childbirth

Waites, Benna: “Breech birth”, 2003.


Occiput posterior: This position is similar to occiput anterior (the normal position), except that the baby faces the mother’s front, instead of her back. About 1 in 50 babies are positioned this way.

Transverse: A baby in the transverse position is sideways, usually with his shoulders or back over the cervix. Sometimes referred to as a shoulder or oblique position, a transverse position occurs in 1 in 2,500 births. The risk for having a baby in the transverse position increases if you go into labor prematurely, have given birth four or more times, or have placenta previa.

Types of breech birth

A) Complete, baby sits cross legged.

B) Incomplete  is when one of the baby’s knees is bent and his foot and bottom are closest to the birth canal.

C) Frank breech, bottom first, legs up around the ears. this is the most common type of breech presentation.

C) Footling, either foot or feet coming first. This is the most common breech presentation for premature babies.

Heads Up! All about Breech Babies (turning techniques, studies, videos for sale, stories, & articles)

ICAN (International Cesarean Awareness Network)

Maggie Banks Website about Breech Birth

Incredible detailed pictures of a great natural breech birth (hospital born)

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