Kristie McNealy, MD

Now that I’ve hit the 32 week mark, most of my worries over this baby and delivery have shifted away from preterm birth and towards more mundane pregnancy issues. Aside from wicked pelvic pain, the thing that has been on my mind most lately is breech presentation.

My second child was breech, but she was delivered at 31 weeks, so she still had plenty of time to turn around if I had stayed pregnant.  My other two children turned head down right around 20 weeks, and stayed that way for the duration of my pregnancies.  Baby number 4  seems to be taking after baby number 2 though.  So now, at 32 weeks, I type this with his head shoved firmly in my ribcage.

On top of the fact that I’d really like to avoid a c-section for breech presentation, in my experience, carrying a breech baby is more uncomfortable than carrying one that is in a head down (cephalic) position.  It might have something to do with how short waisted I am, but having a hard baby head right up against my ribs for a couple of months just isn’t my idea of fun these days!

Different Types of Breech Presentation

Not all babies who are breech are positioned exactly alike.  There are four main variations on the breech position:

1. Frank breech – The baby’s buttocks are pointed down into the pelvis and the legs are extended up so the feet are near the baby’s head.
2. Complete breech – The baby’s buttocks are pointed down and the legs are folded so the feet are near the baby’s bottom.
3. Incomplete breech – The baby’s buttocks are pointed down, and one leg is extended up towards the head, while the other is folded so the foot is near the baby’s bottom.
4. Footling breech - One or both of the baby’s feet are pointing down.  Footling breech presentation is very unusual at term, and usually happens in very preterm deliveries.

If I had to guess based on the movements I am feeling, baby boy is frank breech at the moment.

Risk Factors for Breech Position

At term, about 3.5% of babies will be breech.  If a baby is born premature, they are more likely to be breech at delivery.  Other risk factors for having a breech baby include:

• Having too much or too little amniotic fluid
• Carrying more than one baby
• Having an abnormally shaped uterus or other uterine abnormalities
• Having a previous breech baby
• Placenta previa
• Having a baby with certain birth defects.

Options for Delivery

If your baby is breech, you have three basic options.  You can:

1. Try to turn your baby into a head down position
2. Have a vaginal  breech delivery
3. Have a c-section.

It is increasingly difficult to find a practitioner in the United States that will allow a woman to attempt a breech vaginal delivery.  The main exception to this is when it is the second baby in a twin pregnancy that is in the breech position.

Complications of Breech Delivery

The reason that there are few breech vaginal deliveries in the US is because of the increased rate of certain complications in breech deliveries.  Because the baby’s head is the last part to deliver, there is an increased risk that the head will become entrapped after the body is delivered.  During that time, there is pressure on the cord that can cut off blood flow and oxygen to the baby.  There is also increased risk of cord prolapse in breech babies, because the cord can drop down into spaces between the baby’s legs or buttocks and the birth canal.

Turning a Breech Baby

If your baby is still breech and you are close to your due date (usually around 37 weeks), your doctor may want to attempt to turn them using a procedure called an external version.  In a version, mom is given medications to relax the uterus, and sometimes an epidural.  Then, the doctor uses their hands to press on the mother’s abdomen to try and get the baby to turn.  The procedure can be quite painful, and it isn’t always successful.  Overall, around 65% of babies turn head down with an external version, but there is no guarantee that a baby will remain in this position.

Some practitioners recommend other methods to get a breech baby to turn.  These include assuming certain body positions like the breech tilt, swimming, elephant walking, acupuncture, and a chiropractic maneuver called the Webster Technique.  Before trying any of these techniques, please discuss them with whomever is providing your obstetric care.

My Take

Personally, with  my less than stellar obstetric history, there is no way I’d attempt a vaginal breech delivery.  I have skinny babies with huge heads, who sometimes want to get stuck even when they are facing in the proper direction.  I’ve had one vacuum extraction already, and I’ve had a c-section.  On top of that, I have three kids at home who need a mom, and are already very attached to their new baby brother.  Given the increased risks of complications with both vaginal breech deliveries, and with VBACs, it’s just not worth it to me to consider that route. That’s just me though.  Everyone else needs to weigh their own options with the help of their own obstetric care providers.  In the meantime I’ll be doing whatever I can to get this kid to turn around so it’s not an issue!

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