Breech presentation occurs when a baby is positioned in the uterus with the buttocks, feet, or both aimed toward the birth canal instead of the head. While this positioning is common during the early stages of pregnancy, it is generally considered a variation of normal presentation only until approximately 32 weeks of gestation. When the baby remains in a breech position as the pregnancy nears term, it requires careful medical evaluation and management to determine the safest delivery plan. The persistence of a breech presentation after the third trimester increases the likelihood of specific complications during labor, making it a topic that warrants detailed discussion between the patient and healthcare provider.
Understanding Breech Presentation: Types and Risk Factors
A breech presentation is categorized into three classifications based on the baby’s leg and hip positioning. The most common type is a Frank breech, where the baby’s hips are flexed and both legs are extended straight up toward the head. In a Complete breech, both the hips and knees are flexed, placing the baby in a cross-legged position with the feet near the buttocks. The third type, a Footling breech, is where one or both feet are positioned to exit the cervix first.
Several factors can increase the probability of a baby settling into a breech position near term. Premature birth and carrying multiple babies, such as twins or triplets, are significant factors. An abnormal volume of amniotic fluid, either too much (polyhydramnios) or too little (oligohydramnios), can restrict the baby’s movement or prevent a spontaneous turn. Structural issues with the uterus, like a bicornuate uterus or large uterine fibroids, may also physically impede the baby from achieving the typical head-down position.
Detecting and Monitoring a Breech Position
The initial identification of a breech position often begins with a physical examination of the abdomen. The healthcare provider uses a systematic approach called Leopold’s Maneuvers, which involves palpating the uterus to determine the baby’s size, orientation, and which part is lying in the lower pelvis. During this examination, the provider feels for the soft mass of the buttocks near the pelvis and the hard, round mass of the head near the top of the uterus.
If the physical exam suggests a breech presentation, the diagnosis is confirmed using an ultrasound. Ultrasound provides a clear image to determine the baby’s exact position, the specific type of breech, and the location of the placenta. This imaging is typically performed around 36 weeks of gestation, as most babies who will spontaneously turn have done so by this time. The ultrasound also assesses the amount of amniotic fluid and the baby’s size, which are factors in delivery planning.
Options for Turning the Baby: External Cephalic Version
Once a breech position is confirmed near term, the primary intervention offered to achieve a head-down presentation is the External Cephalic Version (ECV). This non-surgical procedure is performed by a physician, typically in a hospital setting around 37 weeks of pregnancy. The doctor applies firm, deliberate pressure to the mother’s abdomen to manually rotate the baby from the outside.
During the ECV procedure, the patient is closely monitored using ultrasound and fetal heart rate surveillance to ensure the baby’s well-being throughout the attempt. Medications may be administered to relax the uterine muscle, which can improve the likelihood of a successful turn. The average success rate for ECV is approximately 58%, though success is often higher for women who have had previous pregnancies.
Success of the ECV allows for a trial of labor with the baby in the preferred head-down position, potentially avoiding a Cesarean section. For those who are not candidates for ECV or whose ECV attempt is unsuccessful, some providers may mention maternal positioning techniques, such as the breech tilt or certain inversions. However, the medical evidence supporting the effectiveness of these positional techniques is not as conclusive as that for the ECV procedure.
Delivery Planning and Considerations
If the baby remains in a breech position after attempts to turn it, or if ECV is not a viable option, the delivery plan focuses on minimizing risk for both the mother and the baby. The current medical consensus is that a planned Cesarean section is the safest route for most breech presentations at term. This approach substantially reduces the risk of complications that can occur during a vaginal breech birth, such as umbilical cord prolapse or the baby’s head becoming momentarily trapped in the birth canal.
While a planned Cesarean section is the most common management choice, a vaginal breech birth may be considered in very specific, highly selective circumstances. These include cases where the baby is in a Frank or Complete breech position, the estimated fetal weight is within a safe range, and the mother has an adequately sized pelvis. The attempt must be managed by an experienced obstetric provider in a facility with immediate access to an operating room for an emergency Cesarean section. The decision for the mode of delivery involves a comprehensive assessment of the specific risks and benefits for the mother and baby, with the overarching goal of a safe outcome.