Breech Baby - Preg Med

What is the normal position of a baby in the womb

Your baby continues to rotate and turn in the womb throughout the first and second trimesters. However, as your pregnancy advances, your baby has less and less room for his acrobats ^[1]. Finally, sometime between weeks 32 and 38 he settles down in the characteristic head-down position, facing your back with his head near the cervix ^[2], ready for delivery.

Breech baby definition

Having a breech baby means that your baby is lying in a head-up position inside your womb. In the earlier weeks, it is quite common and not a matter of concern as there is enough space for him to flip into position again ^[3]. However, some babies remain in a breech position even as labor starts, increasing the chances of certain complications, often requiring a c-section ^[4].

Types of breech presentation

It is classified into the following types based on the exact position of the baby:

Frank breech

Accounting for about 85% of all breech babies ^[5], frank breech (also called an extended breech) occurs when the baby has his legs extended with his feet near his head while his bottom is just above the cervical opening ^[6].

Complete breech

In a complete breech, the baby has his legs folded at the knees, in front of his chest with his buttocks placed near the cervix ^[7].

Footling breech

Here your baby has his feet pointing downward, nearest to the birth canal, meaning they would come out first during delivery ^[8].

Transverse baby

Sometimes, the baby lies in a sideways position within the womb, with his shoulders or back covering the cervical opening, resulting in a transverse presentation ^[9].

What causes a baby to be breech

It is not always possible to determine the exact causes responsible for it. However, there are certain risk factors that may make your baby more likely to be in a breech position as the delivery day approaches. These include:

Being pregnant with twins or more
Premature labor
The amniotic fluid levels being too high or too low (polyhydramnios or oligohydramnios) ^[10]
Any uterine abnormality, such as fibroids or an abnormally shaped uterus ^[11]
Having some placental irregularities like placenta previa
Fetal problems including certain central nervous system or muscular abnormalities ^[2]
The umbilical cord being shorter than normal, restricting the baby’s movements ^[12]

Risk Factors

Second or subsequent pregnancy
History of premature labor and delivery ^[8]
Having a history of a breech baby
The mother or the father being breech at their own birth ^[13]
Being overweight or gaining more than the recommended weight during pregnancy ^[2]
Smoking

Are there any signs of a breech baby

It is often not possible for the mother to know if her baby is breech as there are no signs in most cases. Some women may feel sharp kicks too low in their belly as the baby is in a feet-down position ^[3]. Your baby’s head pressing on your diaphragm may also lead to symptoms like breathlessness and pressure or pain in your ribs ^[14]. However, these signs may be mistaken for normal fetal movements and shortness of breath.

How to know if your baby is in a breech position

During a routine prenatal checkup late in the third trimester, your doctor examines your upper and lower abdomen to feel the head of your baby and make sure he is in a proper position for birth. If a breech is suspected, your doctor may use an ultrasound scan to check your baby’s exact position ^[8].

A breech baby may also be diagnosed during a routine cervical exam ^[3].

How to turn a breech baby

Babies lying feet-down in the third trimester usually settle in a proper birth position on their own by week 36. However, if your baby remains breech even after the 36th-37th weeks, certain measures should be taken to try and turn him before delivery.

Things you can try to turn your baby yourself

Maintaining proper posture as it may induce your baby to spin into position by opening up the pelvic area
Playing some music near the lower belly area as your baby may listen and follow the sound
Placing a cold pack, such as some frozen vegetables wrapped in a cloth (not too cold), over your upper belly as some believe that the sensation of cold may make the baby turn in the opposite direction
Rubbing some peppermint essential oil in the upper belly area, as the baby may turn to escape the strong aroma (make sure to ask your doctor before trying this measure)

There is no evidence to prove the efficacy of these tips. However, they are safe to try with many women claiming that they work.

You may also consider contacting a licensed chiropractor as they may be able to successfully turn your baby ^[15].

Exercises to turn a breech baby

Get on your hands and knees, keeping your buttocks high and your head at the ground level. Make sure your legs remain folded at your side instead of pressing on your bump. Stay in this position for 10-15 minutes at least 2-3 times every day. The object is to give your baby enough space to turn head down ^[16].
Lie down on your back, flexing your hips and knees while keeping your hips a little elevated. You can put a pillow under your hips to keep them high. Now, gently roll from one side to the other for about 10 minutes, repeating this process around 3 times a day. Make sure to talk to your doctor about the safety of this exercise in case you are experiencing any back, pelvic or hip pain in pregnancy ^[17].
Sit on an exercise ball for about 10 minutes a few times a day ^[18].

Acupuncture and moxibustion

Moxibustion is an acupuncture technique that involves the use of a burning mugwort stick to stimulate the acupuncture point in your little toe that is believed to increase your baby’s activity levels ^[19]. Research has confirmed its usefulness for turning a baby in a proper birth position ^[20], with the method being associated with a success rate as high as over 80% ^[17].

External cephalic version (ECV)

External cephalic version is the technique used to try and turn your baby within the womb by applying pressure on your belly ^[21]. Also referred to as just version, it is usually attempted only after the 36th week as the baby still has a considerable chance of turning before that ^[22]. Turning the baby manually into a proper birth position gives you a chance of having a normal vaginal birth ^[23].

ECV has a success rate of around 50% in first pregnancies, while in second time pregnancies it is associated with a 75% success rate ^[24]. The baby may be delivered by an emergency c-section in case of a failed ECV ^[25].

Delivering a breech baby

Vaginal delivery

Normal vaginal birth is often not recommended for breech babies as there is a considerable chance of various complications. The head is the largest part of your baby’s body. When the head delivers first during birth, it stretches the birth canal enough for the rest of his body to pass through relatively easily. However, in case of a breech baby, the bottom will come first leaving the head to be delivered last. So, there may be some problems while delivering the head ^[26].

Sometimes, a breech baby may be delivered vaginally, with a doctor expert in delivering breech babies monitoring the process closely ^[27]. Special x-ray scans are used for checking the position of the baby and the size of your pelvis to determine the safety of natural birth. The doctor also uses an electronic device to monitor the fetal heartbeat throughout the process of birth ^[8]. A vaginal delivery may be attempted only if your baby is small with no sign of any distress ^[28].

C-section delivery

Studies show about 90% of all women with a breech baby give birth by a cesarean section ^[2]. Even in case of a successful ECV, the baby may turn back to a bottom-down position, necessitating a c-section delivery ^[29].

According to a 2011 Cochrane review, a scheduled c-section is a much safer option for a singleton breech delivery. But at the same time, it was associated with higher number of short-term problems in the mother compared those who give birth vaginally ^[30]. There is also little information regarding any possible risks in a future pregnancy.

Transverse babies are usually delivered by a c-section as attempting a vaginal delivery may lead to life threatening complications ^[23].

When are you more likely to have a c-section

Having a footling breech, meaning your baby’s feet are below his buttocks ^[23]
Being diagnosed with a complication like preeclampsia
Having a baby with an estimated weight over 8.13lb
Having a baby with an estimated weight below 4.4lb ^[26]
Expecting twins with the first baby being breech
Having a structural problem such as a low lying placenta or a narrow pelvis ^[14]
Having had delivered a baby by c-section in a previous pregnancy
The baby being in certain positions (having his neck tilted back) that increases the risks of complications in a vaginal delivery
The baby having the umbilical cord around his neck in the uterus

Breech babies, especially the ones in a frank breech presentation tend to have their legs over their head for a few weeks even after birth. However, it goes away over time with no further developmental problems.

Having a breech baby: Complications and risk of birth defects

There is a slight risk of complications associated with the ECV procedure, including the baby getting tangled with the umbilical cord or the placenta being torn away from the uterine wall (placental abruption) ^[31]. In rare cases, it may lead to premature delivery or heart rate abnormalities in the baby ^[22]. All these cases require an emergency c-section.

Both breech and transverse babies are at risk of suffering an umbilical cord prolapse where the umbilical cord comes out of the uterus before your baby ^{[23, 32]}. Sometimes, the cord may also squeeze during a vaginal birth, cutting off oxygen supply to the baby ^[8]. An umbilical cord prolapse increases the risks of certain neurological problems unless your baby is delivered as soon as possible.

It is normal for your baby’s head to have flattish shape due to the pressure from your diaphragm as he laid in a breech position within the uterus. It gradually becomes round over the first few days of his life ^[33]. Breech babies are also more at risk of having a skull malformation that results in an odd head shape and possible brain damage (craniosynostosis) ^[34].

Breech babies have a higher risk of developing hip dysplasia, a condition where the hip joint fails to form properly, leading to an unstable hip and walking difficulties ^[35].

How common is it to have a breech baby

In around 3%-4% of all cases, the babies fail to turn into the proper head-down birth position before the day of delivery ^{[3, 14]}. The transverse presentation occurs in about 0.25% pregnancies ^[9].

ICD-9 and ICD-10 codes

The ICD-9 code used for breech babies is 652.1 ^[36], while its ICD-10 codes are O32.1 ^[37], O64.1 ^[38], O80.1 ^[39], O83.0 ^[40] and P03.0.

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