In the last few weeks of pregnancy, most babies turn and move into a head-down position (cephalic or vertex position), facing the mother’s spine, with the little chin neatly tucked in. This is the ideal position for standard vaginal delivery. However, about 3 in 100 babies don’t turn. Instead, they remain head up, in an almost sitting position in the uterus. As a result, the baby’s bottom, feet or both remain at the entrance to the birth canal; this is known as a breech position.
Catherine was 26 weeks pregnant. She had grown accustomed to feeling her baby wriggle around, particularly in the early mornings. However, Catherine had yet to feel her baby move by 10.30 am on this particular day. She contacted her obstetrician’s rooms, who advised her to have a sugary drink and to let them know if there was any change. By 3 pm, there was still no movement. Again, she called her obstetrician. She was advised to make her way through to labour ward at the clinic.
Once in the labour ward, the nursing sister attached monitors to Catherine’s tummy. The baby’s heart rate was a bit slow, and there was no movement. About 30 minutes later, the monitors were reattached, and the heart rate remained slow. The obstetrician was called in, and a scan was performed. On the scan, the obstetrician saw that the baby had turned and had her feet down the birth canal. Catherine was advised that her baby was in the breech position. The heart rate had returned to normal. The obstetrician advised that the baby may have been putting pressure on the cord earlier, which would have accounted for a slower heart rate. All the poking and prodding that had taken place while running the tests had made the baby move and most likely released the cord.
Catherine was advised that it was still early in the pregnancy and the baby may well turn again. However, if her baby did not turn, then a caesarean section would need to be considered.
The impact of a breech position
How common is it for a baby to be breech?
About 20% of babies are in the breech position at 28 weeks of pregnancy. Then, as the time comes closer to the baby’s birth, they usually turn into the cephalic position (head down). However, there is a chance that baby won’t turn into the head-down position by 37 weeks of pregnancy. Statistics indicate that 3 to 4% of full-term babies remain in the breech position.
Are there different types of breech positions?
Yes, there certainly are.
- Complete Breech: This is the most common position. Baby appears to be sitting cross-legged in the uterus. The legs are, in other words, flexed at the hip and knees.
- Frank Breech: In this position, it would appear that the baby is folded in half. The baby’s bottom is aimed at the vaginal canal, and the legs stick straight up in front of the body with the little feet near the head.
- Footling Breech: The baby has one or both feet in the downward position. The feet will deliver before the rest of the body if the baby is delivered vaginally.
- Transverse lie: In this position, baby is lying sideways in the uterus. If delivered vaginally, the shoulder would go down the birth canal first.
What are some of the causes of a breech position?
As in Catherine’s case, the baby simply had the best time turning around and around in the amniotic fluid. At some point, baby’s little feet found their way into the birth canal and got stuck there. There are other factors which may make breech positions more common. These include:
- Prematurity – As we said previously, babies usually move into the head-down position by 37 weeks. If a baby is born before this stage of pregnancy, then there is a higher chance of being breech.
- Multiple births – If two or more babies are in the uterus, space becomes limited, making it more difficult for the babies to turn head-down.
- Abnormally shaped uterus – If the uterus has an abnormal shape or the mom has a growth like a fibroid, the baby may not be able to turn easily and will remain in a breech position.
- If there is a family history of breech babies.
Why is a breech position problematic?
The Royal College of Obstetricians and Gynaecologists (RCOG), The American Association of Obstetrics and Gynaecologists (ACOG) and many more associations around the world recommend the following:
Babies in the breech position are usually born by planned caesarean section. Both a vaginal delivery and caesarean birth carry risks. However, the risk of complications is higher in a vaginal delivery. Therefore, a vaginal delivery should only be considered if the obstetrician is highly experienced in breech-vaginal deliveries and if the parents sign acknowledgement of the risks.
These risks include:
- Cord collapse – This is the most common complication. The umbilical cord drops below the presenting body part (bottom or legs) and gets entrapped. The cord gets compressed and cuts off oxygen to the baby.
- Foetal head entrapment – In the breech position, a baby’s bottom or legs come out of the mother’s body first. The body parts are not big or solid enough to stretch the cervix, and the head gets stuck in the mother’s pelvis. This is dangerous for the mother and baby.
- Birth asphyxia – The birth is delayed since the baby’s head may get stuck. During this time baby may suffer from a lack of oxygen, and this results in asphyxia.
- Injuries – The baby’s legs or arms may break during a standard vaginal delivery due to their position. It is also possible for the shoulder to be dislocated. This is why medical personnel will allow the normal birth to proceed with as little intervention as possible to avoid injury. Intervention will be necessary if baby gets stuck.
- Intracranial Haemorrhage – A brain bleed may occur if the baby’s head is compressed too quickly during the birth.
- Developmental Hip Dysplasia – Since the baby is trapped in a fixed position, with the legs bent, it may affect the hips. The condition is known as Developmental hip dysplasia (DDH). After birth, the baby’s hips will be checked. If necessary, steps will be taken by the paediatrician to correct the condition. ( DDH will affect a caesarean baby in the same way, It is due to the length of time the baby stays in a breech position, prior to birth)
- Long labour – Contractions begin in the same way for a breech or cephalic presentation. Since a baby’s bottom or foot is soft, it takes a lot longer for labour to be established than when the bony head is pushing down. This means that a breech labour takes much longer and can be exhausting for the mother.
Why did Catherine’s obstetrician suggest that a caesarean section may be necessary?
A breech presentation does cause concern to parents and is undoubtedly a controversial subject amongst obstetricians. Ultimately, everyone wants the safest option for both baby and mother. The obstetrician and parents must consider the pros and cons of a vaginal delivery versus a caesarean section. Parents need to be well acquainted with the risks of both delivery methods.
In the case of a caesarean, the mother may develop complications such as anaemia, urinary tract infections, wound issues, endometritis and so on. The likelihood of a normal delivery after a caesarean section is also less likely.
A normal vaginal delivery, on the other hand, poses greater risks to the baby unless one has an experienced medical team. These risks have already been mentioned.
In other words, the choice of how to deliver your baby is personal, taking into account the individual risks, the parent’s preference, and the obstetrician’s advice. In Catherine’s case, her obstetrician was planting the seed for her to start considering her options for a safe delivery if her baby remained in the breech position.