BREECH PRESENTATION

When a baby is coming bottom or feet first it is called a ‘breech’ presentation. Many
babies are in breech positions during pregnancy, but as time progresses most of them turn
to be head first. Breech deliveries can be associated with more risks, and these need to be
understood and evaluated so that the most appropriate way of delivering the baby is
performed.

Types of Breech Presentation

‘Extended’ or ‘frank’ breech = the baby’s bottom is the lowest presenting part, and the
baby’s legs are extended along their body.
‘Complete’ breech = the baby’s legs are bent at the knees so the feet are down near the
bottom.

Reasons for Breech Presentation

There may be no reason at all, or there may be a condition in the mother or the baby
preventing it from turning around.
Maternal reasons include: abnormal shaped uterus, fibroids, low placenta
Fetal reasons include: dislocated hips, other congenital disorder.
Usually, if the mother is planning to have a vaginal breech birth, an US will be done to
try to rule out these conditions, although problems such as dislocated hips in the baby can
only be diagnosed after birth. The actual birth does not cause the dislocated hips or make
them worse.

Reasons for Concern About Breech Births

One large study found that babies born by vaginal breech delivery had a higher incidence
of cerebral palsy (brain injury) than those born by caesarean section. Since planned
caesarean section (CS) is a very safe operation in this day and age, many doctors and
patients feel this is the best way to deliver breech babies. On the other hand, many
doctors and patients have a different view and believe that if the mother and baby are
carefully assessed to try to rule out such problems as large babies and small pelvises, they
could safely have a vaginal birth. At this stage there are no tests which accurately tell
whether a baby will ‘fit’ vaginally; at best we rely on US (up to 20% wrong) for the
baby’s size and position of its head, neck and cord and on the mother’s past obstetric
history and general body habitus for the size of her pelvis.

Delivery Options

1. VAGINAL BREECH BIRTH

The mother comes into labour as usual. Usually an epidural is recommended in case
of problems requiring a caesarean or other procedure. Once the mother gets into
second stage she pushes as usual. The feet or bottom (or both together) come into
view. With progress in the second stage, the legs come out and then the baby’s trunk.
When the shoulder blade comes into view, the baby is gently turned to one side and
the obstetrician flicks down one arm, then turns the baby the other way to bring down
the other arm. Now the baby is delivered up to the neck, and it is usual to let the body
 be held below the mother to allow the neck and head to flex forward. The baby’s legs
are then elevated again to allow the obstetrician to place a finger in the baby’s mouth
to keep its head flexed in the correct position as the head is lifted out. Sometimes
forceps are required at this stage to help the head deliver. The vacuum or ventouse is
not used to deliver breech babies.
In most cases, the delivery is no more difficult that for a head first baby – all the same
bits come out, just in reverse order! Unfortunately, there are some risks which do not
happen with head-first babies.

Less serious risks include:

- failure to go into labour, as the presenting part is soft and doesn’t provide the
correct stimulus.
- slow labour ending in a caesarean section (CS)
- bruising and swelling of the baby’s presenting parts, particularly the genitals
- those risks general to all vaginal births such as tearing and episiotomy (stitches)

Serious risks are rare but include:

- nuchal arm = where the baby’s arm is wrapped the wrong way around the neck,
and difficult to deliver, with a risk of bone and nerve damage, and of delayed
delivery and lack of oxygen to the baby’s brain (cerebral palsy) or death.
- cord prolapse = where the cord slips out before the baby is ready to deliver. This
is a very serious emergency requiring immediate delivery and could lead to lack
of oxygen to the baby’s brain or death. This is more common with ‘complete’
breech than ‘frank’ breech
- difficulty/inability to deliver the baby’s head, leading to delay in delivery, and
lack of oxygen, neck or skull damage or death.
- those serious risks to the mother general to all vaginal births such as bad tearing
including into the anus and rectum, pelvic floor weakness and the long term
consequences

Benefits of vaginal breech birth:

- maternal satisfaction if she wished to avoid CS
- quicker recovery for the mother than after CS
- avoid the complications to the mother short and long term of CS
- less breathing problems in the first 48 hours for the baby than after CS

It is not possible to do tests to predict which babies will have the serious complications,
and if they occur it may be too late to prevent damage to the baby, thus the mother has to
accept these risks in deciding to proceed with a vaginal breech birth. It must be reiterated
that these risks are low, and it may be that the risks of ECV and caesarean section are
higher or worse to individual mothers and babies than the risks of vaginal breech birth.

2. EXTERNAL CEPHALIC VERSION (ECV)

ECV means trying to turn the baby from breech presentation to the more usual head
first presentation, after which the mother then waits to go into labour as usual. It is
not commonly performed, and is best done by someone doing them regularly, thus I
refer all patients who wish to have ECV to one of three doctors at the Royal Women’s
Hospital (RWH). These doctors do ECV’s each week. The procedure involves an US
to check the baby’s position and to work out which way will be best to turn. Firm
pressure is then applied to the mother’s tummy to move the baby, periodically
scanning to check how the baby is shifting. It is successful in only 30-50% of women,
less so if it is the mother’s first baby.

Less serious risks of ECV:

- failure to turn the baby
- soreness to the mother
- the baby turns to head first but then turns back to breech

Serious risks of ECV:

- placental abruption – a condition where the placenta separates early, and which
can lead to bleeding and lack of oxygen to the baby. This is rare, but if it occurs
would require immediate caesarean section at the RWH and performed by the
RWH doctors. The mother and baby would then remain in the RWH as private
patients but in the public hospital.

Benefits of ECV:
- if it is successful the mother can labour as usual with a head first baby. Of course,
this still does not guarantee a vaginal birth.

3. ELECTIVE CAESAREAN SECTION (CS)

After consideration of the options, the mother may elect to have a planned caesarean
section. This is an operation where a cut approximately 15cm is made across the top
of the pubic hair line, and the abdomen is entered and the uterus incised and the baby
lifted out. The baby comes out the uterus and abdomen in the same way as described
for the vaginal breech birth, but because the abdomen is soft and can be further
opened, it does not have the same potential for harm as the baby delivering through
the rigid bony pelvis. It is still common for the head to be a little awkward to deliver
as it is excessively round (unlike the ‘conehead’ appearance of headfirst babies born
vaginally) and the baby will often be a little ‘stunned’ at birth and take a minute or
two to breathe, but quickly comes right. A paediatrician is present at the birth to make
sure all is well with the baby. The placenta is then removed and the layers all sewn
up. The whole operation takes about 30 minutes, and is most commonly performed
under a spinal block so the mother is awake and can see and hold her baby.

Less serious risks/problems of CS:

- wound infection, usually easily treated with antibiotics
- bladder infection, usually easily treated with antibiotics
- more pain than after a vaginal birth (in most cases, but not all), usually well
treated with painkillers
 - less mobility than after a vaginal birth, in particular difficulty lifting other
children, inability to do housework and inability to drive for 3-4 weeks.

Serious risks of CS:

- blood clot in the leg or lungs
- heavy blood loss (haemorrhage)
- damage to other internal organ(s), possibly requiring further surgery
- risk that the uterine scar will rupture in a future pregnancy/labour
- risk of the placenta growing inside the uterine scar in a future pregnancy, leading
to serious blood loss/hysterectomy after the baby is born
- psychological trauma to the mother who did not wish to have a CS
- increased risk of ‘wet lung’ to the baby, a form of breathing trouble, although
chance of needing transfer to a neonatal intensive care unit is rare

Note that bladder infections, blood clots and haemorrhage can still occur after any
vaginal birth, and are more common after an emergency CS or difficult vaginal birth
than they are after a planned CS.

Decision Making
Sometimes I will have a strong feeling that a CS is clearly indicated and will tell you that,
but when all is otherwise normal it will be your decision how to have your baby.
Factors to weigh up are:
- how important it is to have a vaginal birth
- how many more children you wish to have
- how much help will you have at home
- how risk averse are you

What Happens If You Go Into Labour Before Decisions Are Made or Before Your
Planned CS?
You should make plans to go into hospital shortly. Do not have anything to eat or drink.
Call the hospital to tell them you are coming in, and that your baby is in a breech
presentation.
On arrival the midwives will assess you and contact me.
If you have ruptured membranes or are only in early labour, I will make arrangements to
perform a CS at the next most convenient time (within a few hours).
If you are in established labour, I will make arrangements to perform a CS shortly, such
as within an hour.
If you are rapidly progressing then you may have a vaginal breech birth even if I am
getting a caesarean organized. If that is the case, then it is ‘destiny’ and usually quick
births mean the baby will fit without a problem and all will go very well.