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Normal Breech Delivery | External Cephalic Version | Caesarian Section | Summary |

Introduction

Most babies are born head-first, but at the end of pregnancy, around 3-4% are found to be breech. Before the end of pregnancy, breech presentation is much more common - about 20% of babies at 28 weeks are breech, and 15% at 32 weeks. Before the end of pregnancy it doesn't matter if the baby is breech, as there is always a good chance that he will turn spontaneously. Some babies do turn by themselves after 36-37 weeks, but it is much less likely as time goes by and some preparations should be made to decide how delivery is going to take place. About 10-15% of breech babies are discovered for the first time late in labour!

What to do?
If your baby is found to be breech at 36 weeks, it is usual to be sent up to the hospital to discuss and plan how you will have your baby. A scan is done to check the following things:

Placenta position - a low lying placenta (praevia) can lead to breech presentation. Often the scan at around 18-20 weeks may have already ruled this out.

Baby & his position - the sonographer will check the amount of water around the baby, the exact position, and whether the baby has his neck extended looking upwards (stargazing). An estimation of the baby's weight is also made.

Breech babies sit in one of three positions:

• With their legs fully stretched outwards - extended.
• With their knees bent and feet by their bottom - flexed.
• As above, but with the feet below the bottom, coming first - footling.

• Normal breech delivery
• Attempt at turning the baby (external cephalic version or ECV) then normal breech delivery if this is unsuccessful
• ECV followed by caesarean section if unsuccessful
• Elective caesarean section

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Normal Breech Delivery

For a breech delivery, you will come into hospital as usual when labour begins. Some doctors advise an epidural for every woman having a breech birth, but this is not strictly necessary. There is some evidence that epidurals increase the risk of a caesarean section being needed during labour. Many women who have a breech birth choose this type of pain relief in any case.

Labour is never excessively long and continuous monitoring of the baby's heart rate is advised. When it comes to the actual birth, some doctors use forceps to control the delivery of the baby's head, others prefer to just assist it with their hands. An episiotomy (cut) is frequently needed for first-time mothers, but it really depends on how well the skin stretches, the progress at the time of delivery and the size of the baby.

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External cephalic version

It is possible to manoeuvre the baby from breech to a head-first position. This is done after 37 weeks and the success rate is around 50%, though some doctors are successful as often as 70% of the time. It is useful in that it definitely reduces the number of breech and caesarean births. Around 2.5% of babies flip back to breech after a successful ECV.

The doctor places her hands on the womb, and guides the baby through a forward somersault - often the baby seems to get the idea and his kicking helps to complete the turn. Some doctors use a drug to help the womb relax, particularly for first-time mothers. It may be uncomfortable during the turn, but shouldn't be painful. The baby's heartbeat is monitored before and after ECV.

It is a safe procedure for the baby, but on the very rare occasion the baby becomes distressed a caesarean delivery will be necessary at that time. Because the baby is mature and facilities for delivery are close at hand, this rare occurrence is still not harmful for the baby.

If an ECV is unsuccessful, it is still possible to have a normal breech birth as discussed above.

Is there anything I can do to make him turn?
There has been a suggestion that spending 15 minutes every 2 hours of the waking day in the knee-chest position will help the baby to turn (called Elkin's manoeuvre). Although the first report of this was very encouraging, subsequent studies have not found it to be useful. There is some evidence that hypnotherapy may be useful, though only one study has looked at this. Acupuncture has been suggested and the results of another study are awaited.

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Caesarean Section

There is no doubt that caesarean section is a safe operation, but it is not without problems, and this is why many doctors and midwives feel strongly that there is still a place for normal breech births. A caesarean section means a stay in hospital of around 4-5 days, a more prolonged recovery, and implications for future pregnancies or operations. Overall the risk of dying following caesarean section is 5 times higher than after a normal birth. Death is, of course, extremely rare, but infections and above average blood loss are very common. Scar tissue formed during the healing can lead to pain and make future operations more difficult.

For elective surgery you normally come into hospital either the night before the operation or the same morning if it is to be done in the afternoon. Most often an epidural or spinal anaesthetic is advised. This involves a very small needle in the back, which numbs everything below the navel so you feel no pain. Most women feel a bit of tugging and pulling, but it should not be uncomfortable. This type of pain-relief is safer for you than a general anaesthetic. It also means that you can see your baby immediately, and usually hold him before the operation is finished. You will need to have a drip in your hand and a catheter in the bladder to ensure it is empty. Both of these will be removed the day after the operation.

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Summary

There is rarely a straightforward way to advise on what is the best option if you find your baby to be breech toward the end of pregnancy. The most important thing is that you have considered all the options available and reached a decision that is right for you. Many women feel strongly that a caesarean section is the only acceptable option for them, and few obstetricians would deny them this. Others are very keen to avoid surgery and consider a breech birth just a variation of normal.

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