Breech presentation in pregnancy – what is it and what are your choices?
Breech presentation is where your baby is positioned either bottom or feet first in your womb, rather than the usual position which is head down, called ‘cephalic’. It is very common in early pregnancy but by 36 weeks, your baby should be in a head down position.
Around 3-4% of babies at term are in the breech position. Your community midwife will examine your tummy at 36 weeks of pregnancy and if they think your baby might be breech, they will refer you for an ultrasound scan to check. If this confirms breech position, you will be referred to a specialist Midwife or Obstetrician to discuss one of three options: External Cephalic Version, Elective Caesarean Section or planned Breech Vaginal Birth.
Why might my baby be breech?
There are several things that can increase the chance of your baby being in the breech position such as:
- having too much fluid, enabling the baby to move position easily
- having too little fluid, meaning there may not be enough fluid to help your baby turn themselves
- having a placenta that is lying low in your womb, making it more difficult for your baby to turn and tuck their head into your pelvis
- if this is your first pregnancy or if you are having twins
What are the different types of breech position?
There are three main types of breech position. The most common is ‘Extended or Frank breech’ where your baby is lying bottom first, with their legs straight up against their body with their feet up by their ears. Another position is ‘Flexed Breech’, where your baby is bottom first with their feet next to their bottom and their knees are bent. The third option is called ‘footling breech’, where one or both of your baby’s feet are below their bottom.
What are my options if my baby is breech?
Overall, there are three options that the doctor or midwife may discuss with you. Not all options will be recommended to all women and there are pros and cons of each so your healthcare professional will tailor their advice based on your individual situation.
External Cephalic Version (ECV)
The first option is to have an ECV – this stands for External Cephalic Version. It involves a Doctor using their hands on the outside of your tummy and applying pressure to try and turn your baby into the head down position. This is the most commonly recommended option, because if successful, and your baby is turned head-down, you can reduce the chance of Caesarean Section and the associated risks.
What happens during an ECV?
If you and your healthcare professional decide to choose an ECV you will be given a time and date to come into hospital, usually within 1-2 weeks. On arrival, your basic observations will be checked, the doctor will scan your baby and confirm they are still breech and check your baby’s heartbeat. You will then be given an injection of a drug to help relax your uterus muscles and make turning your baby easier. This medication is safe for you and your baby but can make you feel hot and flushed and like your heart is beating faster than usual, but this is just temporary.
The obstetrician will then apply gentle but firm pressure to the outside of your tummy to help your baby turn into the head-down (cephalic) position. ECV can be uncomfortable but if at any point it is too painful you can ask them to stop.
An ECV is successful in around 50% of cases, but it is more likely to work if you have had a vaginal birth before and if your baby is in the flexed breech position. If your ECV is successful, your healthcare professional will often arrange a check-up for you at a later date to confirm that your baby is still head down as there is a 5% chance that your baby could turn back into the breech position.
After the procedure, regardless of whether it was successful or not, your baby’s heartbeat will be monitored again, and you will be able to go home, usually within an hour of the procedure.
ECV is generally safe with a very low complication rate. Immediately after ECV there is a 1 in 200 chance, or 0.5%, of needing an Emergency Caesarean because of bleeding or changes in your baby’s heartbeat. This is why an ECV is carried out in a hospital, rather than a community setting, where you can have an immediate Caesarean section if needed. If you have the rhesus negative blood type, you will also be recommended to have an Anti-D injection before you go home.
If the procedure was unsuccessful you and your doctor may decide to have another attempt on the same or a different day and there is still a small chance, up to 5-8% that your baby will turn spontaneously into the head-down position before labour. If the procedure wasn’t successful, the doctor will talk to you about your options for birth if your baby remains breech. These are choosing a planned Caesarean Section or choosing a planned vaginal breech birth.
Elective Caesarean Section
If you are unable to, or decline to have an ECV, or if the procedure is unsuccessful another option is to have a planned Caesarean Section, called an Elective Caesarean Section. This involves surgery to deliver your baby, which has been shown in most situations to be safer for your baby than a vaginal breech birth. Caesarean Section is major surgery so the doctor will discuss in detail the pros and cons of the operation for both you and your baby, take your full consent and should provide you with written information to take away with you to read.
Vaginal Breech Birth
The third option would be to have a planned breech vaginal birth. Depending on your individual circumstances, such as the position your baby is in, if you have had vaginal birth(s) before, the predicted size of your baby or if whether you have other complications in your pregnancy, your doctor will discuss the pros and cons of this option with you. Vaginal breech birth, if successful, caries lower risks for you, however there are increased risks to your baby and there is a 40% chance of needing an emergency Caesarean section during your labour. Because of this reason, you will be recommended to birth at a consultant-led unit, where there are healthcare professionals with experience and expertise in delivering breech babies and where facilities exist to perform an immediate caesarean section if needed.
If you are planning an elective caesarean section and go into labour before your operation date you should call and attend your local maternity unit as soon as possible. Once you arrive a midwife or doctor will ask to examine you vaginally and discuss whether proceeding to an emergency Caesarean Section is safe or, if your baby is close to being born vaginally, whether continuing labour and giving birth naturally may be better.
There are pros and cons to each of these three options and these are different depending on your individual circumstances so your healthcare professional will help you make the decision that is right for you. They should offer you supporting information, time to consider and will respect your decision regarding whatever choice is right for you. If you would like more information on Breech baby the Royal College of Obstetricians and Gynaecologist have resources for patients on their website.
About the Author
Dr Ellie Rayner, Obstetrician and Gynaecologist, Antenatal and Hypnobirthing Teacher and founder of The Maternity Collective.
Dr Ellie Rayner is a practicing Obstetrician and Gynaecologist and founder of The Maternity Collective. She is the only Obstetrician to offer private and group, expert-led Antenatal and Hypnobirthing Classes both Online and face-to-face. She is passionate about providing parent-centred, evidence-based care for all pregnancies and supports all methods of birth. Follow Dr Ellie Rayner @maternitymedic for the latest evidence-based information on pregnancy, birth and women’s health issues.
The Maternity Collective provide comprehensive online antenatal and birth preparation courses led by a team of NHS expert healthcare professionals, including a Community Midwife, Obstetrician, Internationally Board-Certified Lactation Consultant (IBCLC) and Newborn Sleep and Behaviour Expert. They offer a complete 7 hour online antenatal and birth preparation course that can undertaken from the safety of your own home, at your own pace with videos to re-watch as many times as needed. More information is available at https://www.thematernitycollective.co.uk/