Delivering a Breech Baby

July 06, 2008

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Delivering a Breech Baby

by Marjorie Greenfield, M.D.
reviewed by Marjorie Greenfield, M.D.

Over the past two decades, there has been great controversy about how best to deliver breech babies: Try for vaginal birth, or go right to caesarean? New research shows that if a breech baby can't be turned into the headfirst position, the risk of serious problems including neonatal death is significantly higher if the child isn't born by cesarean.

The large international study, published in the British medical journal The Lancet in 2000, compared routine cesareans to attempted vaginal births for single (that is, no twins or other multiples were involved) full-term breech babies. It showed a 0.4 percent incidence of major problems in the cesarean breech babies, while the vaginal breech group showed a 5.7 percent chance of major complications. This held true even for hospitals in industrialized countries, like ours. These results have led the American College of Obstetrics and Gynecology to advise obstetricians not to offer vaginal birth for full-term breech babies. The risks of having a cesarean section are discussed in our article on cesarean birth.

Two exceptions apply
There are two exceptions to the no-vaginal-breech rule: 1) It is currently still considered safe to deliver a second twin breech if the first twin was born headfirst. 2) It is also acceptable to deliver a breech baby vaginally if the mother doesn't arrive in the hospital until late in her labor, because the risks of trying to do an emergency cesarean might be greater than allowing the baby to just come out.

Trying for a vaginal birth with a breech baby
If your baby is breech and you are near term, the best plan is to try to get the baby to change into a headfirst presentation. If this isn't possible and you still are tempted to try for a vaginal breech birth despite the above findings, I will give you the old standards used in the past decade to assess whether or not a mother-to-be was a reasonable candidate. (Keep in mind, though, that these standards were probably being followed in the study noted above, and babies who remained breech at term did much better with planned cesarean birth.)

Is the baby the right size? Understandably, a large baby may be a tight fit through the birth canal. In addition, a premature baby's head is relatively bigger than his body. This can allow the body to fit through, while the head gets caught above an incompletely dilated cervix. For this reason, some sources recommended that the baby should be smaller than 7 1/2 pounds and larger than 5 pounds (2,500 grams). Ultrasound typically was used to help assess fetal size.

Is the baby's head tucked down? A baby looking up, away from his chest presents a greater diameter of his head to his mother's pelvis, whereas when the head is tucked down, it is narrower and fits through more easily. If the baby wasn't looking down, a cesarean would be done. Head position can be checked with ultrasound or x-ray.

Is the mother's birth canal an adequate size? A mother who has already delivered good-sized babies vaginally was considered the best candidate to try for vaginal breech delivery. If a woman hadn't already had a baby, vaginal examination, an x-ray, or a CAT scan of her pelvic bones could be done to see if there was room for the baby's head to fit through after his body. If the pelvis wasn't ample, cesarean was preferred.

Is labor progressing normally? A labor that is overly long can be a sign that the baby is not fitting through the birth canal. If the labor wasn't progressing well, the plans would be changed and they would proceed to cesarean.

Is the baby's body in the right position? If the baby is tucked into a pike position (picture Jane Fonda on the cover of her famous first exercise video), the body plus the legs together have to pass through the birth canal before the head. This is good-it helps to assure that the head will have room to follow. Also, if the baby is coming feet first, it allows room for the umbilical cord to drop down between the baby's legs (cord prolapse) after the amniotic sac has ruptured. Cord prolapse is much less common in headfirst births because the fetal head fills up the pelvis and blocks the cord from falling through. In cord prolapse, the umbilical cord gets compressed between the pelvis and the baby's body as the birth proceeds, requiring an emergency cesarean.

Is the doctor experienced in delivering vaginal breech births? This has often been the stickiest problem. Many doctors just aren't trained to deliver a breech baby vaginally, and know that it will be much safer for mother and baby for them to do a cesarean. Even though there was a trend to offer vaginal breech birth for about the past decade, most breech babies in the United States have been delivered by cesarean for at least the past 20 years. As fewer and fewer breech babies were born vaginally, fewer obstetrical residents gained experience with vaginal breech births. As these doctors went into practice, they were aware they were not proficient at managing complications that can arise during a breech vaginal delivery. Between the new recommendations from the American College, and the lack of experienced physicians, breech vaginal delivery will soon be relegated to books on the history of obstetrics.


RELATED INFORMATION

			Cesarean Birth
			Your Newborn in the Delivery Room
			Breech Babies
			Birth Procedures

Created March 20, 2001
Reviewed July 27, 2004

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