Breech baby - possible causes, options and choices

June 30, 2017

Breech baby - possible causes, options and choices

My baby is breech

- what does that mean and what are my options?

This blog was inspired by a recent conversation with a mum who had been told her baby was breech at 32 weeks, she felt tearful and anxious after her consultation and this is not a good place for a mum to be in. After we spoke she felt better and more confident, so I thought it important to share some of the things that we discussed.

I wanted to shine some light on the topic to help mums further understand what breech is, why it may occur, that it is normal (yes, unusual but still normal) and that it doesn’t automatically mean your options for birth are limited. This blog is by far not exhaustive of the topic and I have added some pointers for further information and guidance at the end.

There are many positions a baby might adopt naturally within the uterine cavity, while some are more unusual it is good to remember there is no such thing as a ‘wrong’ position - all positions are natural and normal.

It annoys and saddens me, how some mothers come away from their 32 / 34 week appointment feeling worried, even scared and in tears as they were told baby is in the ‘wrong’ position. All this does is to create tension in her body and mind. Causing worry, stress and tension to mum is probably the single most unhelpful thing to do if you want to encourage a baby to turn! Further information from the midwife or obstetrician, guidance on what it means, what her options are – all this would be infinitely more helpful.

We talk a lot about how stress can negatively affect labour and why this is the case on my hypnobirthing courses, but this would take us too far off topic for now.

For more information on Hypnobirthing go to www.anjaneyayoga.co.uk

Breech presentation – what is this?

A small percentage of babies (3-4%) has always been born bottom or feet first and until the 1960s / 1970s a breech presentation, while considered more unusual, was still seen as normal in the UK and many were born at home with a midwife in attendance. It is interesting to note that a breech presentation was not seen as criteria for a hospital birth or a transfer from home to hospital for birth, let alone a C-section.

During pregnancy (up until 30 weeks) it is in fact quite normal for baby to be growing with bottom or feet nearest to the cervix, and at around 32 weeks the majority of babies will have settled into a head-down (cephalic) position, the most usual position for birth. Some babies, however remain in breech and I will discuss that there might be some very good reasons for this and that it is worth to also take into account that sometimes ‘baby knows best’.

Breech presentation can describe several positions that baby might adopt:

1. Extended, frank or incomplete breech

Basically this means, baby’s head is up towards the top of the uterus, and its bottom is down towards the pelvis and cervix and the legs are straight up against baby’s body with feet at the top of the uterus often toes in baby’s mouth, thus forming a V shape. It can be difficult for baby to turn with legs up like this as they baby has less ability to ‘kick’ itself around. First time mother’s abdominal and uterine muscles can also be tighter and therefore holding the baby more firmly, allowing less room for baby to turn as baby grows bigger. This position of incomplete breech is more likely to occur in first time mums.

2. Complete, full or flexed breech

This position describes a baby that is sitting cross-legged in the pelvis. Baby’s bottom is below the legs, which are flexed, and feet are also above baby’s bottom. This position is more common in second time mothers as they abdominal and uterine muscles are less tight and allow more room for baby. Baby is also more likely to be able to turn using feet against the uterine walls to turn to a head-down (cephalic) position.

3. Footling breech

This describes a position where both feet are below baby’s bottom and it is quite rare, estimated to be about 14 in 1000 breech births.

4. Knee presentation

In this position where one or both hips are straight but one or both knees are bent and one or both are below baby’s bottom. This is very rare.

(image from www.spinningbabies.com)

What causes a breech presentation?

There are many reasons why a baby might be in a breech presentation and I will explore these below, the list might not be exhaustive but it reflects the most common causes a midwife or obstetrician will consider.

Gestational causes

Gestation describes the length of a pregnancy which can vary quite significantly from woman to woman. The World Health Organisation regards anything from 37 to 42 weeks as a normal length of pregnancy.

As mentioned above, it is normal and natural for baby to be in breech presentation for part of the pregnancy, usually up to around 28-30 weeks. Therefore a mother might have a breech baby, simply due to prematurity, if baby is born before term and baby hadn’t yet gone into the head-down position.

Here some interesting statistics taken from the AIMS booklet ‘Breech birth – what are my options’ by Jane Evans (www.aims.org.uk):

At 28 weeks of pregnancy 25% of babies (one in four) are found in breech presentation.

By about 34 weeks this has gone down to around 15% (approx. one in six) of babies in breech the others having turned spontaneously to a head-down position.

By 38-40 weeks only 3-4% remain in breech presentation (three or four in 100).

In effect, this tells us that the breech position is normal in the earlier stages of pregnancy and that the chance of baby being in breech presentation decreases as pregnancy progresses (usually by 32 weeks) and is very small by the time a mother has reached term. This can be re-assuring to know and even if baby remains breech at term, it does not mean that mum cannot have a natural vaginal birth depending on the diagnosis and with the right care and guidance from an experienced midwife.

Maternal causes

Maternal causes can range from the shape of a woman’s uterus, a bi-cornuate uterus - a uterus which is divided, to a soft tissue obstruction such as a uterine fibroid or ovarian cyst or placenta praevia, where the placenta blocks the exit to the cervix, as well as the length of the cord.

All of these can make it more difficult for baby to turn and will determine the position baby needs to be in.

The shape of the pelvis might also influence the way baby is within the womb, this might be congenital or due to an injury or surgery that can restrict movement in mother’s back and pelvis and possibly restrict baby’s ability for rotation and movement.

Breech position may be caused by imbalance (asymmetry) in the mother’s pelvis or soft tissues. In other words, a tension or a twist in the lower uterine segment may be a “soft tissue” issue.

Below are some common causes for this to occur:

·         Pressing the gas pedal while driving
·         Crossing our legs;
·         Sports injuries;
·         Abrupt stops as in a “fender bender” torquing our torso;
·         Carrying a toddler on a hip; falls; or even
·         A head or ankle injury

All of these can twist the pelvis and, in turn, twist the uterus, resulting in asymmetry.

When any part of the pelvis is out of symmetry then the ligaments supporting the womb are pulled and twisted, too. The shape of the lower womb can be altered by this. The baby then has to find a way to fit. A twisted sacrum is common for breech (and posterior).

Aligning the pelvis, and relaxing tight uterine ligaments attached to the fascia near the pelvis can often help breech babies flip to a head-down position.

Fetal causes

These can range from the cord being around babies neck or body to the cord being short and potentially restricting baby’s ability to turn to head-down. Some fetal anomalies such as hydrocephaly (water on the brain) which can be related to conditions such as spina bifida or Down’s syndrome and conditions involving generalised laxity, for example, brittle bone sydnrome, can lead to a breech presentation and these conditions should be excluded where possible.

In a twin pregnancy, one twin is often breech because it is just more comfortable and they fit more easily into the mother’s uterus that way.

What are my options?

Once baby has been identified as being in breech there are many options for you to try to encourage baby to turn head-down, this will depend on the diagnosis and how far you are in your pregnancy.

I recommend taking time out to be still, to check in with yourself and your baby and allow your instincts to guide you on how to move forward. If you and your baby feel confident to proceed then I recommend starting with the least invasive methods first.

You don’t have to do them all, choose the ones that appeal to you instinctively and always seek guidance from an experienced practitioner or midwife if unsure. If in doubt – don’t.

Ways to encourage baby to spontaneously turn to a head-down position

1. Visualisations

Visualising baby in the most usual position for birth is incredibly powerful in assisting baby to turn to a head-down position. It may sound surprising that this actually works but many midwifes including Mary Cronk recommend this. Your baby will get the message and reposition itself.

In the Hypnobirthing courses I encourage women to visualise baby in the most usual position for birth throughout their pregnancy. I ask them to hang up the attached image in their house and every time they pass it to look at it and internalise the image of unborn baby within the womb so that it may come to fruition. This can also wonderfully be included in any relaxation.

2. Relaxations

Relaxing regularly and often in supported savasana or left side lying can help release stress, fear and tension. If a mother’s body is holding a lot of tension there might not be enough space for baby to turn as the tight uterine and abdominal muscles and ligaments might be holding baby in situ. It is nice to use a Yoga Nidra, soft music or a Hypnobirthing relaxation or simply enjoy silence.

left side lying

3. Hypnotherapy

According to a study by Dr Lewis E Mehl in 1994 (quoted in the KG Hypnobirhting book) hypnotherapy had a 81% success rate in encouraging a breech baby to turn to a head-down position.

4. Working with the physical body

Before 28-30 weeks I recommend doing positions daily that encourage a head-down position. We have very sedentary lifestyles where we sit a lot and forward leaning upright positions can counter some of this slouching when sitting where we effectively restrict movement of baby in the uterus. These positions use gravity and are easy to do. They can also give a wonderful release for the lower back. Crawling on all fours helps baby to stay out of the pelvic area and relaxes the abdominal muscles thereby allowing space for baby to turn.

If baby is in breech after 30 weeks I recommend also doing the all fours forward leaning positions on the floor or using a sofa and the breech tilt using and ironing board or stairs (for more guidance go to www.spinningbabies.com). These positions will encourage baby’s bottom to dislodge from the pelvis and encourage baby to turn naturally.

5. Osteopathy, chiropractics, cranial-sacral therapy or physio therapy

All of these might help to release myofascia, tight muscles or ligaments that might be contributing to asymmetry in the pelvis or lower back. This can help to create more space and flexibility for mum’s movements in the pelvic region thereby creating space for baby to turn spontaneously.

6. Acupressure / Acupuncture

Acupressure and acupuncture can be very helpful in encouraging a baby to turn by working with certain points on the body; they are also both deeply relaxing for mum. Seek out an experienced practitioner.

7. Homeopathy

Homeopathic remedies such as pulsatilla are said to aid a baby turning head-down. Always get advice from an experienced and accredited homeopath before taking any remedies in pregnancy.

8. Warmth / cooling / light / music on tummy

Some women believe that playing music at the lower part of their abdomen or shining a light can encourage baby to turn. Others apply a bag of frozen peas to the top of the abdomen or warmth to the lower part of the abdomen. The success rate is more anecdotal but there is no harm in trying.

9. Swimming

Swimming can be a good way of encouraging baby to turn into different position.

10. Baby knows best

Acknowledge that your baby might be in the best position for her or him to be in - ‘baby knows best’. So, if baby does not turn there might be a very important reason why not and we don’t always know why.

Assisted turning of baby to a head-down position

External Cephalic Version

At 37-39 weeks your midwife will discuss the option of an ECV with you in order to help baby turn to a head-down position. Please remember, this is an option and entirely your choice. You could just simply take the stance that ‘baby knows best’ and politely decline.

An ECV is a powerful external manipulation carried out by an experienced practitioner. Using very firm touch on a mother’s tummy the practitioner will aim to turn baby from the outside. Sometimes muscle relaxant drugs are given. The procedure can last up to 30min and can be uncomfortable but should not be painful. Success rates vary amongst practitioners, the average is 58%, so it is useful to ask what their success rate is as it can vary from 25-90%.

Even if an ECV is successful some babies spontaneously turn back to breech presentation, although the nearer term you are the less likely this will occur.

There are risks associated with an ECV:

The muscle relaxant drugs given to mum can also occasionally affect baby. Other risks include part of the placenta being knocked off the uterine wall or baby being wrapped in its cord. These can lead to baby becoming distressed and needing to be born immediately by C-section operation. There is a 1:200 (0.5%) risk of this happening.

Closing words

Remember, breech is a normal position, more unusual but normal. Only 3-4% of babies are still in breech presentation at term and just because baby is in breech doesn’t mean that you cannot experience a natural vaginal birth (diagnosis depending), some babies however will be born safest by C-section and your midwife will help and support you in making the best decision for you and your baby.

Mary Cronk says about breech that ‘Just like in a cephalic presentation, if labour is progressing and all is well, the woman is supported and cared for, the baby will be born.’

For more information, questions or to share your experience – please contact me.
Lisa Toth
lisa@anjaneyayoga.co.uk / 07812 474471

Further information and local practitioners

www.anjaneyayoga.co.uk
Hypnobirthing and Yoga for pregnancy with Lisa Toth

www.spinningbabies.com

Excellent videos, explanations and more on turning babies

www.AIMS.org.uk

Booklet by JaneEvans ‘Breech birth – what are my options?’ and more very helpful information on all topic relating to pregnancy labour and birth

Bellenden Therapies, Peckham SE15

www.bellendentherapies.co.uk

Sunflower Centre, Brockley SE4

www.thesunflowercentre.co.uk

The Honor Oak Wellness Rooms, Honor Oak Park SE23