The delivery of a baby in a breech presentation—where the buttocks or feet are positioned to exit the birth canal first instead of the head—presents unique challenges for expectant parents and medical providers. While most babies naturally turn head-down, approximately 3% to 4% of full-term pregnancies still involve a breech presentation. This significantly affects the decision-making process for delivery, necessitating careful consideration of maternal and fetal well-being. Understanding the options for turning the baby or planning a safe delivery route is a primary concern for those facing this situation.
Pre-Delivery Interventions to Change Position
The first line of medical intervention for a breech presentation at term is often an attempt to manually change the baby’s position before labor begins. This procedure, known as External Cephalic Version (ECV), involves an obstetrician applying firm, continuous pressure to the mother’s abdomen to guide the fetus into a head-down, or cephalic, presentation. ECV is typically offered around 36 to 37 weeks of gestation, as this timing balances the likelihood of spontaneous turning with the risk of the baby reverting to breech after a successful turn. The procedure is performed in a hospital setting with ultrasound guidance and continuous fetal heart rate monitoring, and medications like terbutaline may be used to relax the uterine muscle and increase the chance of success.
The overall success rate for ECV is approximately 58% to 65%, but this rate is variable based on factors such as amniotic fluid volume and parity. Multiparous women tend to have higher success rates than first-time mothers. Risks associated with ECV are low; serious adverse effects like placental abruption or umbilical cord prolapse occur in less than 1% of cases, but immediate access to an operating room is mandatory in case of complications.
Some complementary methods, such as specific maternal positioning techniques, lack the scientific evidence of ECV. These non-medical methods, like performing pelvic tilts or spending time on hands and knees, are sometimes used as supportive measures. ECV remains the most effective medical intervention to increase the likelihood of a cephalic presentation and avoid the need for a Cesarean delivery.
Choosing Between Vaginal or Cesarean Delivery
Once a baby remains breech near term, medical providers assess various factors to determine the safest mode of delivery, which is a highly individualized decision. The type of breech presentation is a significant consideration, with three main types: frank, complete, and footling. In a frank breech, the hips are flexed with the legs extended toward the head, which is the most common and often the most favorable for a potential vaginal delivery.
A complete breech involves both the hips and knees being flexed, while a footling or incomplete breech has one or both feet positioned to deliver first, significantly increasing the risk of cord prolapse and making a vaginal delivery generally inadvisable. Other factors include the estimated fetal weight, which ideally should be between 2,500 grams and 4,000 grams, as fetuses outside this range present greater risk. Adequate maternal pelvic measurements must also be confirmed, often assessed clinically or through imaging. Finally, the fetal head attitude—whether it is flexed or hyperextended—is checked via ultrasound.
A planned Cesarean delivery is the preferred and safest route for a persistent breech presentation, based on evidence showing a reduced risk of short-term neonatal morbidity and mortality compared to a planned vaginal breech birth. This preference stems from the risk of the largest part of the baby, the head, getting entrapped after the smaller body has delivered. A planned Cesarean section is typically scheduled after 39 weeks of gestation.
The Cesarean Procedure for Breech
A Cesarean delivery for a breech baby follows the general protocol of the procedure but often requires specific modifications and extra precautions to facilitate a safe extraction. The surgical steps begin with the standard abdominal and uterine incisions, usually a low-transverse incision in the uterus. However, the surgeon must ensure the uterine incision is wide enough to allow the after-coming head to pass through without becoming entrapped, which is a particular concern with breech presentation.
In certain instances, especially with preterm babies or a narrow lower uterine segment, the surgeon may need to make a low vertical extension of the uterine incision (a “T” or “J” shape), or even a classical vertical incision in the upper segment, though this is less common. This wider opening prevents the fetal head from getting stuck, a complication that can lead to injury. Once the uterus is opened, the surgeon carefully extracts the baby, often by grasping the feet or buttocks.
The delivery of the fetal head, known as the after-coming head, requires controlled maneuvers to maintain flexion and prevent rapid decompression. Techniques like the Mauriceau-Smellie-Veit maneuver may be used to deliver the head while an assistant applies pressure above the pubic bone to stabilize the head. The procedure involves additional, careful manipulations to protect the baby from trauma during the extraction process.
Specific Requirements for Vaginal Breech Birth
An attempted vaginal breech delivery is only considered an option under stringent criteria, which must be met to maximize safety. The presentation must be frank or complete; footling breech is a contraindication due to the high risk of umbilical cord prolapse. The estimated fetal weight is limited, typically requiring the baby to weigh between 2,500 and 4,000 grams, and the mother must have a clinically adequate pelvis.
During labor, continuous electronic fetal heart monitoring is mandated to detect any signs of distress, and labor should be allowed to progress spontaneously without the induction or artificial augmentation of contractions. An experienced clinician proficient in the specific obstetric maneuvers necessary for an assisted breech delivery must be present. This delivery must also take place in a facility with immediate, 24-hour access to an operating room and anesthesia services for an emergency Cesarean section if complications arise.
The approach to the delivery itself involves a “hands-off” philosophy initially, allowing the baby to descend with maternal expulsive efforts until the umbilicus is visible. Traction is generally avoided until the baby’s body has delivered up to the level of the shoulders, at which point specific maneuvers are used to free the arms and deliver the head safely. Planned vaginal breech birth is not widely offered and is a carefully managed procedure when undertaken.