Breech babies

The topic of how to prevent, turn and deliver breech babies (babies that have their bottom, feet, or both applied to the cervix instead of the head) is a much-debated topic among a full spectrum of birth professionals. Although most agree it is beneficial to try and turn them before birth, the method used depends on the opinion of the individual. Some believe you can prevent babies from turning breech while other don’t, and most controversial of all is whether or not it is safe to deliver a baby vaginally.

If your baby is breech, you and your care provider will discuss the action that should be taken for your particular case. If you are not satisfied with his/her decision, don’t be afraid to ask questions or to get a second opinion, but do try to be open to all possibilities, including both vaginal and cesarean deliveries.

The solution would be easiest if there was one clear answer for everyone – why the baby is breech, how it can be turned (if it should be turned at all), and what mode of delivery is safest. But there is no such answer. In fact, each side of the debate is backed by legitimate studies and reports. So the conclusion is to learn about breech babies, breech birth, and all your options for prevention and management. Let’s start with why babies turn breech in the first place.

Throughout most of pregnancy, your baby has free range of motion and will turn somersaults – head up, head down, head up, head down – until about 32-34 weeks when he/she becomes too large for big movements like that. The baby will then naturally assume a position in preparation for birth. At term, 3-4% of babies will be in the breech presentation.

Not all babies have a diagnosable cause for being in that position, not even the medical billing workers would know, but studies have confirmed that the following conditions and situations put a mother at increased risk of giving birth to a breech baby: previous breech presentation, late or lack of prenatal care, giving birth before 37 weeks, babies with lower birth weight or with birth deformities, pregnancies with multiple babies, history of premature delivery, too much or too little amniotic fluid, an abnormally shaped uterus, a uterus with abnormal growths (such as fibroids), placenta previa, and excessive stress. Other potential causes include eating certain “yin” foods (see below), and slouching and crossing your legs consistently during pregnancy. Obviously, these risk factors do not automatically set up a woman to have a breech baby, but baby’s turn breech more commonly when the mother fits into one or more of these conditions. Some of these risk factors can be avoided or corrected by the woman herself, but many require the assistance of a care provider to manage.

If despite these prevention methods your baby chooses to position itself right-side-up, here are the current methods for turning breech babies, and their pros and cons. As always, discuss these choices with your care provider before implementing any of them.

Breech Tilt Exercise. This is one of the oldest and most common methods for turning a baby in a malpresentation such as breech. With no known side-effects, this method consists of the mother lying with her hips higher than her head for 15 minutes, three times a day. This can be accomplished by resting in the air and chest on the floor. Another method is to rest with butt on pillows 9-12 inches high and back of shoulders on the floor. The last way to accomplish this exercise is to do hand stands in a pool, coming up for air frequently.

Visualizing/Hypnotherapy. Relaxation, especially when in combination with a bath, while picturing the baby moving into position has been known to work. Possibly because the peaceful feeling combined with relaxation of the abdominal and pelvic muscles allow the baby more room to move. If practicing this method, be sure not to remain on your back for too long – side-lying is a much better position. No known side-effects.

Music, Light, and Talking. Some babies cannot help but turn to face the direction where they see or hear something. Putting a flashlight, Walkman headphones, or having a loved one speak close to the lower belly may encourage your baby to turn head down.

Diet. Some call it the yin vs. yang conditions, but certain substances have been shown to encourage a breech position: cigarette smoking, stress and an overly busy life, in addition to fruit juices, tropical fruits, ice cream, sugars, oil, coffee, sweeteners, drugs, and chemicals. Foods that reportedly encourage a vertex (head down) position include animal proteins and miso which can be taken as a soup or tea.

Homeopathy. The homeopathic remedy Pulsatilla can be used in the 35th week of pregnancy to turn a breech baby, especially if the situation is stress related. However, not all women are advised to try this method, so speak to your care provider first. When using any homeopathic remedy it is safest if you work with a skilled homeopathic provider to determine the correct potency and frequency of treatment for you.

Webster’s Technique. This is a chiropractic technique used to ensure optimal alignment of the woman’s spine and pelvis by means of minimal pressure on a certain abdominal trigger point. According to one study, the Webster technique resolves breech presentations in 92% of cases (International Chiropractic Pediatric Association), and has been found to be helpful with other malpresentations. Because all trigger points in the body are very sensitive, and can be used inappropriately and dangerously, it is important that you use a skilled and qualified practitioner.

Acupuncture, Acupressure, and Moxibustion. The acupuncture point (Bladder 67) can be triggered by acupuncture, acupressure, or moxibustion to turn a breech baby. Although proven to be helpful, these methods can be harmful if misused, so only have them performed by a qualified acupuncture professional, after getting the approval of your care provider. Estimates of success range from 50-84%1.

External Cephalic Version. This is the most invasive method of turning a breech baby, and is safest and most likely to be successful, if performed by an experienced doctor. The procedure is carried out by manually rotating the baby from the outside of the abdomen, usually around 37 weeks of pregnancy. Depending on how many babies the mother has had, and the experience of the doctor, success rates vary from 50-90%, with the chance of success being greater to mothers who have delivered vaginally before. Although rare, performing a version can result in the placenta tearing away from the uterus. Thus it is best to use this technique as a last resort, and with an experienced doctor, in the hospital.

Ask Yourself, Why? Exploring your thoughts about why your baby is breech may bring up strong feelings about the upcoming birth, anxiety about parenting, or a sense that your baby is not quite ready to be born yet. Although such exploration has not been thoroughly studied, anecdotal evidence suggests that it may be helpful in turning a breech baby. Even if it doesn’t help your baby to turn, it may help you to feel more confident in your attitude and preparation. Your care provider may be open to discussing this question with you as well.

If after trying multiple techniques to move your baby to a vertex presentation are unsuccessful, it may be best to prepare your heart for a breech delivery. Changing plans, and adjusting to a difficult situation, are not easy, so take the time to relax, research your options, and visualize the birth of your child.

Until 1959, it was routine for all women with breech babies to deliver vaginally2. Since then, studies have been published to determine whether all breech babies should be born vaginally or by cesarean, or if each case depends on specific guidelines. Only three large scale, randomized controlled studies have been published comparing mode of delivery for breech babies.

The first two studies, Collea et al. 1980, and Gimovsky et al. 1983, both stated that vaginal birth for breech babies was safe in most circumstances. The third study (published in 2000) was most interesting because it stated that planned cesarean sections were safest for full-term singleton breech babies born to first-time mothers3.

Although the 2000 study seemed conclusive, and doctors all over the United States began practicing under the influence of this study, long-term follow-up of the babies in that study led researchers to question it’s conclusion. As a result, more studies and more reports have been made on the subject. In July 2006, ACOG issued a new Committee Opinion. It stated that some women may be better off planning a vaginal birth, as long as they have a care provider who is experienced in delivering breech babies vaginally, and that they were told that the risks to her baby might be higher than with a planned cesarean delivery4.

Despite the allowances made for vaginal breech birth, it is still difficult for women to make plans for this mode of delivery. This is mainly because doctors and midwives skilled in vaginal breech birth are getting hard to find. In 2003, only 12.8% of breech babies were born vaginally5. Hope remains, however, for women who are determined. Those that meet the generally accepted guidelines are able to find a care provider, even if it does mean traveling to a different location to give birth.

Here are the guidelines for being eligible to have a vaginal breech birth: Baby is full term (not less than 37 weeks), baby appears to be average sized and has no known congenital defects, mom has delivered vaginally before, or is determined to have a large enough pelvis, a doctor or midwife experienced with vaginal breech birth is managing your care, baby is in a frank or complete breech position (not a footling), baby’s head is in a flexed or military position (not tipped back), mother has had no more than one previous cesarean, if mother is carrying multiples, the first baby presenting must be head down, mother is confident in her ability to give birth to a breech baby, an emergency cesarean and anesthesia are available, no induction/augmentation drugs are used, more frequent monitoring of the baby’s heart rate is done during labor, labor progresses normally (at least a 1/2 cm per hour in the active phase), cord does not prolapse, and baby is not distressed in labor, no epidural is used, mom waits to push until fully dilated, mom does not push in the lithotomy or semi-sitting positions, and forceps are only used in an emergency.

Some care providers may offer you obstetrical care even if you don’t fit into all of the above guidelines. If that is the case, it is wise to ensure that an emergency care plan is prepared well in advance of labor.

Even though different organizations are continuing research in this area, it remains that no definitive answer is available for all women who have a breech baby. Thus it is left up to each mother and care provider to review the information available and to make a decision based on the mother’s health and preparation.

Sources:
1 – The Whole Pregnancy Handbook by Joel M. Evans, MD, OB/GYN
2,5 – “Breech Presentation” July 2006 http://www.emedicine.com/med/topic3272.htm
3,4- “Breech Birth” March 2007 http://www.babycenter.com
“Encouraging a Breech Baby to Turn” by Donna Broderick, Midwives of Maine Newsletter Winter 2005
“Breech Births Without Surgery” by Michelle Bitoun Blecher, Parenting Magazine March 1995


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