Breech Birth

Key Messages

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These are the main health messages that should be conveyed to all future and new parents. They have been written in second person and at a reading level appropriate for the general public so that they can be shared with them directly. They are based on a consensus founded in scientific research and professional practice. Clicking an underlined word or group of words in the text will redirect you to the section in Supporting Evidence that deals with that topic.

key message

Most babies are positioned head down in the uterus by 36 – 37 weeks of pregnancy. This is so they can come out of the birth canal (vagina) head first. Sometimes, the baby is positioned so the feet or bottom will come out first during childbirth. This is called a breech presentation.

There are three ways a breech baby might be positioned.

  • Frank Breech: legs point up with feet by the baby’s head so the bottom would emerge first.
  • Complete Breech: legs folded with feet at the level of the baby’s bottom.
  • Footling Breech: one or both feet point down so the legs would emerge first.

There is often no clear reason why a baby settles into a breech position but a breech birth usually does not affect your baby’s long-term health.


key message

Your health care provider will check your baby’s position at prenatal visits and when your labour starts.

Your health care provider will examine your abdomen to feel the position of the baby’s head, back, and bottom. Ultrasound may be used to confirm if the position is breech towards the end of your pregnancy and/or when labour starts.


key message

Babies in breech position can be born by either caesarean or vaginal birth.

In Canada, most breech babies are born by a planned caesarean birth. In some circumstances, breech babies may be born through the vagina. Vaginal childbirth has health benefits for the mother such as a faster recovery and less pain, as well as a better chance of having a vaginal birth, and fewer complications for both mother and baby in future pregnancies. However, vaginal breech birth can present risks for the baby.


key message

You may be offered the choice to give birth to a breech baby vaginally if your health care provider is trained and comfortable with vaginal breech childbirth and there are no other risk factors.

You may be offered the option of having a vaginal breech birth if:

  • Your baby is a normal weight (i.e., neither under nor overweight for your stage of pregnancy).
  • Your baby is in a complete or frank breech position.
  • Your placenta is far enough away from your cervix.
  • You and your baby are otherwise healthy.
  • Your labour occurs at term (i.e., after 37 weeks of pregnancy).
  • You are pregnant with only one baby.
  • You are pregnant with twins and the first baby is head down.

In a breech vaginal birth, the head (which is the widest part of the baby’s body) comes out last. In some cases, an instrument called forceps is used to help deliver your baby’s head. Breech birth should happen in a hospital, where resources and skilled personnel are available in case an emergency caesarean birth is needed.

key message

There are several reasons why a caesarean birth would be recommended for a baby in breech position.

You will be advised that a caesarean birth is safest for you and your baby before labour begins if:

  • Your baby is in the footling breech position.
  • You are pregnant with twins and the first baby is in a breech position.
  • Your placenta is lying over the cervix.
  • You and/or your baby have other medical complications.
  • A health care provider trained and confident with vaginal breech birth is not available to you.

After labour begins, a caesarean birth would be safest if:

  • The umbilical cord comes out before your baby.
  • Your labour is not progressing normally.
  • You and/or your baby develop complications during labour.

A caesarean birth, like any major surgery, has risks and the recovery time is longer than for vaginal childbirth. Expect to stay in the hospital longer and to take special care once you go home. Talk to your health care provider about recovering from a caesarean birth.


key message

Your health care provider may offer to turn a breech baby to head down before labour starts.

If your baby is in a breech position near 36 weeks of pregnancy, your health care provider may offer to turn the baby around to a head-down position. This can increase your chance of having a vaginal birth. It is done using a technique called external cephalic version (ECV) in which the health care provider uses their hands on the outside of your abdomen to gently turn the baby around.
ECV is done in a hospital setting and has about a 50 percent chance of being successful in changing the baby’s position. It has been shown to be a safe procedure which can help avoid caesarean birth and lessen complications for the mother. Rarely, a change in the baby’s heart rate or an early labour may result in an immediate caesarean birth.

ECV is more likely to be successful if:

  • You have given birth before.
  • The baby is in the complete or frank breech position and is not engaged in the pelvis.
  • The uterus is relaxed during the procedure.
  • There are normal levels of amniotic fluid.
  • You are not overweight.

During the ECV procedure:

  • You may be given a medication to relax the uterus to make turning the baby easier.
  • Your baby’s heart rate will be monitored and ultrasound may be used to check the baby’s position.

There is about a five percent chance of the baby moving back into a breech position after an ECV. In that case, your health care provider may try an ECV again. However, as the baby grows in the final weeks of pregnancy, there is less room for movement in the uterus, and version is less likely to be successful.


key message

Learn more about breech birth

You can find out more about breech birth from the following resources. More suggestions can be found in the Resources and Links section.

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Supporting Evidence


The supporting evidence is written in third person and is aimed at prenatal education providers. It is not intended to be shared directly with new and expectant families; it is meant to provide the background information and evidence for the key messages.

About Breech Presentation and Birth

Definition

Most babies are positioned head down in the womb (i.e., cephalic presentation), by 36 – 37 weeks’ gestation. At term, about three to four percent of babies present in a breech position with the feet or the buttocks settling into the pelvis first. The incidence of breech presentation is higher at earlier gestations.1
There are three breech presentations.2

Breech

National and provincial statistics

Based on a three to four percent rate of breech presentation and 2011 birth statistics for Canada and Ontario, it is projected that there are between 11,329 and 15,105 cases of breech presentation in Canada and between 4,204 and 5,605 in Ontario per year.3 Ontario has a 3.6 percent rate of breech presentation at birth, which is in keeping with the rates reported in the literature.4 In 2001, 96 percent of babies in the breech position in Canada were born by caesarean birth, and of these 86 percent were by planned.5

Predisposing factors associated with breech presentation

There are a number of factors associated with an increased chance of breech presentation: 2,6,7

  • Multiples pregnancy.
  • An excess of amniotic fluid (i.e., polyhydramnios)or less than normal amount of amniotic fluid (i.e., oligohydramnios).
  • Uterine malformation or abnormal growths inside the uterus (i.e., fibroids).
  • Placenta covers all or some of the cervix (i.e., placenta previa).
  • Prematurity.
  • Fetal abnormalities.

Breech Birth Management

Historical perspective on management of breech birth

Breech birth has been associated with higher rates of perinatal mortality and morbidity due to prematurity, congenital malformations, birth asphyxia, or trauma.1 As the safety of caesarean birth generally improved during the 1960s and especially after the publication of the Term Breech Trial in 2000, 8 caesarean birth became the most prevalent and normal mode of birth for breech presentation.1,9

After the large multi-centred Term Breech Trial reported significantly increased perinatal and neonatal mortality and neonatal morbidity with vaginal breech birth, these findings became the basis for practice guidelines recommending planned caesarean birth for breech presentation at term in most countries. This remains the predominant practice.4,8 Caesarean birth has become the mode of birth for over 85 percent of pregnancies with breech presentation.4,10 As a result, the pool of expertise in performing vaginal breech birth shrunk rapidly.

In 2006, the PREMODA trial of vaginal breech birth in France and Belgium was completed. It involved over 8,000 women and demonstrated that in settings where planned vaginal breech birth is a common practice managed by experienced care providers and when strict criteria are met before and during labour, planned vaginal birth of a singleton fetus in breech presentation at term remains a safe option that can be offered to women.10

International debate and recommendations: mode of breech birth

Since the publication of the PREMODA study, which demonstrated the safety of vaginal breech birth with selected candidates in modern obstetrical units in Europe,9 a new debate emerged about whether a trial of labour (TOL) for vaginal breech birth should be offered. While recommendations vary among countries, most take a cautious approach. In Canada as of 2014, the guidelines of the Society of Obstetricians and Gynaecologists of Canada (SOGC) recommend a TOL for vaginal birth be offered for selected breech cases based on the PREMODA study findings of equivalent neonatal risks but increased maternal morbidity with a universal planned caesarean birth approach.8

In the U.K., the Royal College of Obstetricians and Gynaecologists (RCOG) recommends that women be informed that planned caesarean birth for breech presentation carries less risk of perinatal mortality and early neonatal morbidity but that there is no evidence that the method of birth makes a difference in the long-term health of babies. At the same time, this guideline acknowledges that planned caesarean birth increases immediate maternal risk compared with vaginal birth and sets out criteria under which vaginal breech birth can be offered.1 In contrast, The National Institute for Health and Care Excellence (NICE) guidelines recommend caesarean birth for breech presentation if a trial of external cephalic version (ECV) is unsuccessful in achieving a cephalic presentation.11

U.S. guidelines indicate that planned caesarean birth for breech presentation remains the recommended approach for most situations because of the diminishing expertise in vaginal breech birth. External cephalic version should be offered whenever possible. Planned vaginal birth of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labour management. Before a vaginal breech birth is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a caesarean birth is planned.4

In May of 2015, a study was published of breech births in all of Canada (except Quebec) from 2003 to 2011 (n=52,671). Although rates of vaginal birth increased from 2003 to 2011, breech vaginal birth was still rare (3.9 percent in 2011). Findings show a significantly increased ratio of neonatal mortality and morbidity among vaginal breech births versus planned caesarean birth (i.e., a 3.6 – 5.39 fold increase) as well as an increased risk of poor neonatal outcomes with caesarean birth with labour5. It is expected that Canadian and perhaps other international guidelines for vaginal breech birth may change, in light of this study.

However, the topic of the optimal approach for breech presentation remains controversial. Other reviews continue to recommend planned caesarean birth for breech presentation to reduce perinatal and neonatal death, neonatal morbidity, and to save costs, while recognizing that this approach is associated with more complications for mothers.12,13

Vaginal breech birth

There is a range of criteria which need to be met before it is considered advisable to offer women the choice of vaginal breech birth.1,2
Criteria for offering women the choice of vaginal breech birth include:

  • A single fetus weighing between 2500 to 4000 g (5 lb 8 oz to 8 lb 13 oz).
  • Availability of ultrasound to assess breech presentation, fetal size, and head position.
  • Absence of intrauterine growth restriction (IUGR), presentation other than frank or complete breech with neutral head position, fetal anomaly, clinical assessment of inadequate maternal pelvis.
  • Availability of a practitioner experienced in vaginal breech birth.
  • Availability of a neonatal care provider, anesthetist, and access to timely caesarean birth and neonatal resuscitation (i.e., operating room and personnel) if needed.
  • Access to continuous electronic fetal monitoring (EFM).

Most guidelines agree on the following in the management of labour for vaginal breech birth:1,2,6

  • Continuous electronic fetal monitoring (EFM) is recommended in the first stage of labour and mandatory in the second stage.
  • Induction of labour is not recommended.
  • Immediate vaginal examination after rupture of the membranes (ROM) should be done to assess for cord prolapse.
  • A passive second stage to allow descent of the presenting part is acceptable for up to 90 minutes.
  • After spontaneous birth to the level of the umbilicus, various interventions may be used to facilitate the birth of the arms, shoulder, and fetal head (e.g., supra-pubic pressure by another health care provider to promote flexion of the head, various manoeuvres to facilitate the birth of the arms and head, Piper forceps to maintain head flexion).
  • Caesarean birth is advised in the absence of progress in labour or if birth is not imminent after 60 minutes of active pushing.

There are several risks of vaginal breech birth, which need to be considered:6

  • Fetal head entrapment.
  • Neonatal trauma, including brachial plexus injuries from entrapped arms and cervical spine injury if the fetal head is hyperextended.
  • Cord prolapse.
  • Low one-minute Apgar scores.
  • Need for episiotomy or manoeuvres possibly leading to vaginal/perineal trauma.

Limitations

The need to improve training and experience for obstetricians and others in the management of vaginal breech birth is a universal concern and the availability of a skilled clinician is one of the eligibility criteria for offering this option to women.1,2,4 This remains important not only because of recommendations that vaginal breech birth be offered to selected women, but also because unplanned (precipitous) breech birth will continue to occur. The importance of continuing to teach these skills in obstetric, family medicine, and midwifery training is emphasized.

Supporting informed choice for women

Vaginal breech birth continues to be a topic of debate with commentaries describing this as “an idea whose time has come”14 and a “phoenix rising from the ashes.”15

Many emphasize this is a proven, safe option which women have a right to be offered. The choice of vaginal breech birth reduces the negative outcomes associated with caesarean birth for women, the costs to the system, and mitigates the risk of some women opting for the unsafe decision to attempt a breech birth at home.2,12,16 Women should not be coerced into having a planned caesarean birth if they meet the selection criteria for the vaginal birth option. If the provider is not skilled in vaginal breech birth, women should be referred to a unit where this option is available.1,2

External Cephalic Version (ECV)

Definition

External cephalic version is a procedure in which the fetus is rotated from the breech to the head-down position (cephalic presentation) by gentle manipulation with the practitioner’s hands on the mother’s abdomen. ECV is typically performed in non-labouring women with a singleton pregnancy at, or near, term to improve their chances of having a vaginal cephalic birth.17,18 ECV or version attempts to turn the breech baby around to the more favourable, cephalic presentation as there is less risk for the baby and mother when the baby is head down at the time of birth.

ECV has been shown to significantly reduce the chance of breech births and caesarean birth without increasing the risk of poor maternal or neonatal outcomes.16,17,19 ECV has a 30 percent to 80 percent success rate, and the RCOG guidelines advise that women should be told there is a 50 percent chance that the procedure will be successful in changing the baby’s presentation at birth from breech to vertex. There is about a five percent rate of reversion from vertex back to breech presentation after ECV.20 Although there is not enough evidence from randomised trials to assess complications of external cephalic version at term, large observational studies suggest that serious complications (i.e., placental abruption or stillbirth) are rare.

Recommendations

Guidelines from the WHO, the U.K. and the U.S., recommend ECV be made available to women with a breech presentation at 36 weeks’ gestation if the following criteria are met: a skilled practitioner performs the ECV, and the ECV is performed in a hospital setting where emergency caesarean birth is available if needed.4,20 Prior to attempting ECV, fetal presentation and gestational age are usually confirmed through both clinical examination and ultrasound.21 Although no official recommendation on version from SOGC was found for Canada, the SOGC patient resource on breech birth offers information about ECV consistent with the above guidelines.2

A number of treatments have been suggested to increase the success of ECV such as tocolytic drugs, acoustic stimulation, transabdominal amnioinfusion, epidural or spinal anesthesia and opioids to increase maternal relaxation. Tocolysis is recommended as it has been shown to be effective in increasing the success of ECV.17,20 Research is underway to assess the effectiveness of other approaches.17

A systematic review indicates that ECV is more likely to be successful when the woman is multiparous; the presenting part is not engaged; the uterus is relaxed; the fetal head is palpable; and the woman is not overweight.22

Women who accept an attempt at ECV are more likely to be well-informed, believe in its safety, desire a vaginal birth, and have been encouraged to undergo the procedure. Women less inclined to accept ECV are more likely to fear the procedure, prefer a planned caesarean birth, may have incomplete information about the procedure or may be hearing concerns about complications from family and friends.16

Referrals

When to refer

Any pregnant woman who is assessed as having a breech presentation by 36 weeks’ gestation should discuss available options with their health care provider.

Where to refer

Referral for specialist care by an obstetrician may be appropriate to support an informed decision about eligibility for external cephalic version and vaginal breech birth.

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Resources & Links

Professional Guidelines

Reports/Publications

  • Cluver, C., Gyte, G., Sinclair, M., Dowswell, T., Hofmeyr, G., (2012). Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD000184. DOI: 10.1002/14651858.CD000184.pub4
  • Goffinet F., Carayol M., Foidart JM., Alexander S., Uzan S., Subtil D., et al. PREMODA Study Group. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol, 194, 1002–11.
  • Hannah, M., Hannah, W., Hewson, S., Hodnett, E., Saigal, S., Willan, A., et al. (2000). Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-83.
  • Hofmeyr G., Hannah, M., Lawrie, L. (2011). Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD000166. DOI: 10.1002/14651858.CD000166.
  • Hofmeyr G., Kulier R. (2012). External cephalic version for breech presentation at term. Cochrane Pregnancy and Childbirth Group, Issue 10. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083.pub2
  • Lede R. (Last revised: 1 December 2011). External cephalic version for breech presentation at term: RHL commentary. The WHO Reproductive Health Library, Geneva: World Health Organization. Retrieved from http://apps.who.int/rhl/pregnancy_childbirth/childbirth/breech/cd000083_leder_com/en/.
  • Ontario Public Health Association

Professional Associations

Websites

Client Resources and Handouts

Apps

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References

  1. Royal College of Obstetricians and Gynaecologists (RCOG). (2006a). The management of breech presentation. [Valid until replaced by revision expected 2016]. Retrieved from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20b/
  2. The Society of Obstetricians and Gynaecologists of Canada (SOGC). (2009). Breech childbirth. Retrieved from http://pregnancy.sogc.org/wp-content/uploads/2014/05/PDF_breechchildbirth_ENG.pdf
  3. Statistics Canada. (2013). Births by province and territory. Retrieved from http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/hlth85a-eng.htm
  4. Personal Communication, BORN Ontario. (March 2015). Data from the BORN information system (2012-2015).
  5. Lyons, J., Pressey, T., Bartholomew, S., Liu, S., Liston, Robert, M., Joseph, K., for the Canadian Perinatal Surveillance System (Public Health Agency of Canada). (2015). Delivery of Breech Presentation at Term Gestation in Canada, 2003–2011. Obstetrics & Gynecology. 125 (5), 1153–1161. doi: 10.1097/AOG.0000000000000794 Retrieved from http://journals.lww.com/greenjournal/Citation/2015/05000/Delivery_of_Breech_Presentation_at_Term_Gestation.24.aspx
  6. The American College of Obstetricians and Gynecologists. (2006 , Reaffirmed 2014). Mode of Term Singleton Breech Delivery. ACOG Committee Opinion No. 340. Obstet Gynecol, 108, 235–7. Retrieved from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Mode-of-Term-Singleton-Breech-Delivery
  7. Fischer, R. (January, 2015). Breech presentation. Medscape. Retrieved from http://emedicine.medscape.com/article/262159-overview#aw2aab6b3
  8. Hannah, M., Hannah, W., Hewson, S., Hodnett, E., Saigal, S., Willan, A., et al. (2000). Term breech trial collaborative group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet, 356, 1375-83.
  9. The Society of Obstetricians and Gynaecologists of Canada (SOGC). (2009a). Vaginal Delivery of Breech Presentation. Retrieved from http://sogc.org/guidelines/vaginal-delivery-of-breech-presentation/
  10. Goffinet F., Carayol M., Foidart JM., Alexander S., Uzan S., Subtil D., et al. PREMODA Study Group. (2006). Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol, 194, 1002–11.
  11. National Collaborating Centre for Women’s and Children’s Health (UK) (2011). Caesarean section. Section 5.1 Breech presentation. London: RCOG Press. (NICE Clinical Guidelines, No. 132.). Retrieved from http://www.nice.org.uk/guidance/cg132/resources/guidance-caesarean-section-pdf
  12. Hofmeyr G., Hannah, M., Lawrie, L. (2011). Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD000166. DOI: 10.1002/14651858.CD000166
  13. Henderson, J., Petrou, S. (2006). The economic case for planned cesarean section for breech presentation at term. Canadian Medical Association Journal, 174 (8), 1118-1119.
  14. Lalonde, A. (2009). Vaginal breech delivery guideline: The time has come. J Obstet Gynaecol Can, 31(6), 483–484.
  15. Dresner-Barnes, H. & Bodie, J. (2014). Vaginal breech birth – The phoenix rising from the ashes. The Practicing Midwife, 17(8), 30-33. Retrieved from http://www.medscape.com/medline/abstract/25326964
  16. Kotaska, A. (2009). Breech birth can be safe, but is it worth the effort? J Obstet Gynaecol Can, 31(6), 553–554.
  17. Hofmeyer, G. (Dec. 2014). External cephalic version. UpToDate.com. Retrieved from http://www.uptodate.com/contents/external-cephalic-version#subscribeMessage
  18. Cluver, C., Gyte, G., Sinclair, M., Dowswell, T., Hofmeyr, G., (2012). Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD000184. DOI: 10.1002/14651858.CD000184.pub4
  19. Hofmeyr G., Kulier R. (2012). External cephalic version for breech presentation at term. Cochrane Pregnancy and Childbirth Group, Issue 10. Art. No.: CD000083. DOI: 10.1002/14651858.CD000083.pub2
  20. Lede R. (Last revised: 1 December 2011). External cephalic version for breech presentation at term: RHL commentary. The WHO Reproductive Health Library, Geneva: World Health Organization. Retrieved from http://apps.who.int/rhl/pregnancy_childbirth/childbirth/breech/cd000083_leder_com/en/
  21. Royal College of Obstetricians and Gynaecologists. (2006b). External cephalic version and reducing the incidence of breech presentation. [Valid until replaced by revision expected 2016]. https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf
  22. Kok, M., Cnossen, J., Gravendeel, L., van der Post, J., Opmeer, B., & Willem Mol, B. (2008). Clinical factors to predict the outcome of external cephalic version: A metaanalysis. American Journal of Obstetrics & Gynecology, 199(630), e1-e7. Retrieved from http://www.ajog.org/article/S0002-9378%2808%2900269-X/pdf

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