What is Breech Presentation?
Breech presentation is when the baby is positioned in the womb so that its bottom or legs, instead of its head, would come out first during childbirth. There are three types of breech positions: frank, complete, and incomplete. In a frank breech, the baby’s hips are bent, and its legs are straight and near its face, similar to a diving pose. In a complete breech, the baby is positioned as though it’s sitting, with its hips and legs both bent, much like a tucked position. The incomplete breech can have one or both of the baby’s hips straight, sometimes referred to as single footling (one leg straight down) or double footling breech (both legs straight down).
What Causes Breech Presentation?
A breech presentation, where the baby is positioned feet or bottom first in the womb, can be influenced by several health conditions. These conditions can impact the baby’s movement or the shape of the uterus.
Chances of breech presentation are higher in cases of premature birth, twins or multiple births, chromosomal abnormalities, birth defects, abnormalities in the female reproductive system, presence of fibroids in the uterus, or a specific placental condition known as placenta previa. Additionally, if a baby was in breech position in a previous pregnancy, there’s a higher chance of breech presentation in later pregnancies. These factors are discussed in more depth in the section on how the disease works.
Risk Factors and Frequency for Breech Presentation
Breech presentation, where the baby is positioned head-up in the womb in the last weeks of pregnancy, happens in about 3% to 4% of full-term pregnancies. Interestingly, the further away the pregnancy is from full-term (in weeks), the higher the likelihood of a breech presentation. By the 32nd week of pregnancy, 7% of babies are in a breech position, while at 28 weeks or less, 25% of babies are breech.
We also see breech deliveries recurring in subsequent pregnancies. Specifically, if a woman has had one breech delivery, there’s nearly a 10% chance that her next baby will also be breech. For a third pregnancy after a breech delivery, this recurrence rate jumps to 27%. Lastly, previous cesarean deliveries (C-sections), can double the likelihood of a breech presentation.
Signs and Symptoms of Breech Presentation
During a physical check-up, the doctor might use the ‘Leopold maneuvers’, which involves feeling specific areas of your belly. If they feel a round, hard, moving form at the top part of your womb and they can’t feel a baby’s part above your pelvic bone, it might indicate that the baby is in a breech position. A breech position means that the baby’s feet or bottom are set to come out first, contrary to the common head-first position.
During another exam of the cervix, there might not be any noticeable part of the baby, or the doctor may feel a foot. If the baby is in breech, the doctor might feel the soft part of the baby’s buttocks. If the mother has been in active labor, this soft tissue could be mistaken as the top of the baby’s skull. If the doctor notices any of these signs, they might suspect that the baby is in a breech position and will conduct an ultrasound for confirmation.
Testing for Breech Presentation
If a baby seems to be in a breech position, where their feet or buttocks come out first instead of their head, this can be suspected during a physical check on the mother’s belly combined with an examination of the cervix. This uses a method called the Leopold maneuvers. Doctors will use an ultrasound to confirm this. This procedure will help identify the baby’s position and presented part. The ultrasound findings are then noted down.
When a breech presentation is identified, doctors should record specific details. This includes the exact type of breech position, how much the baby’s head is bent, an estimate of the baby’s weight, the amount of amniotic fluid surrounding the baby, where the placenta is located, and a review of the baby’s anatomy (if this hasn’t been done before).
Treatment Options for Breech Presentation
Due to a decline in vaginal breech deliveries in the U.S. and other industrialized countries, expertise in this area is no longer as common. The Term Breech Trial (TBT), a significant international study released in 2000, examined the differences between planned vaginal deliveries and planned cesarean deliveries for term breech infants. This study found that planned cesarean deliveries led to significantly fewer cases of newborn mortality and severe health issues, while the rate of health issues for mothers were similar for both groups. Since the TBT study, there has been a substantial increase in planned cesarean deliveries for term breech babies.
Several studies conducted following the TBT did not find any significant change in the risk of death and neurological development in children from the different methods of delivery. However, these studies were believed to not have enough data for a definitive conclusion.
Since the TBT, some professionals have argued that in certain situations, vaginal breech delivery is a safe alternative to planned cesarean delivery. Several smaller studies, looking back at past data found no change in newborn health issues or deaths when these criteria were met.
The criteria used in these studies were: a gestation period more than 37 weeks, the breech baby is in the appropriate position, there are no fetal abnormalities on ultrasound, the mother’s pelvis was adequate, the estimated weight of the baby was between 2500g and 4000g. One report’s protocol also required confirmation of fetal head flexion and an adequate amount of amniotic fluid, no use of oxytocin to induce or speed up labor, as well as strict criteria for normal labor progress. A CT scan was used to confirm an adequate maternal pelvis.
Despite ongoing debate, the current recommendation for breech presentation involves offering a procedure to reposition the baby in the womb (external cephalic version) to suitable candidates. But, candidates who are not suitable for or decline this procedure are recommended a planned cesarean delivery after 39 weeks of pregnancy.
When it comes to premature breech babies, the baby’s gestational age guides the choice of delivery method. It’s unclear how best to deliver babies before 26 weeks as there are no high-quality studies to refer to. However, a large backward-looking study recently concluded that cesarean delivery led to a significant decrease in newborn health issues and deaths for babies between 28 and 31 6/7 weeks. No difference was found in these outcomes for gestational age of 32 to 36 weeks. There are no prospective clinical trials to study this issue further due to recruitment difficulties.
What else can Breech Presentation be?
When a baby is in the breech position, meaning it’s positioned feet-first in the womb, there could be several reasons why. Here are some possibilities:
- The baby is presenting with its face or forehead first
- There might be physical characteristics of the baby that are not typical
- Unfortunately, the baby may have passed away in the womb
- The mother has given birth five or more times before
- The mother is pregnant with more than one baby
- There’s not enough amniotic fluid around the baby in the womb
- The shape or size of the mother’s pelvis may not be conducive to a head-first birth
- The baby is preterm, meaning it may be coming too early
- This is the mother’s first pregnancy, which can sometimes cause complications
- The shape or size of the mother’s uterus might not be typical
