Breech position and breech birth

Breech position means that a baby is lying bottom-first or feet-first in the uterus. Most babies are head-down by the end of pregnancy. This is called a cephalic presentation and is usually the safest position for birth.

Breech position is common earlier in pregnancy because the baby still has room to move. Most babies turn head-down on their own. At the end of pregnancy, about 3 to 4 in every 100 babies remain breech.[1]

The main types of breech position are:

• Frank breech: The baby's bottom is down, with the legs extended upward and the feet near the face.
• Complete breech: The baby's bottom is down, with the hips and knees bent.
• Footling breech: One or both feet are below the baby's bottom and may enter the birth canal first.

A baby lying sideways is in a transverse lie, not a breech position. However, some of the evaluation and delivery concerns are similar.

Breech position does not usually cause problems during pregnancy. It matters mainly because birth can be more complicated when the head, which is the largest part of the baby, is delivered last. Care options may include trying to turn the baby, planning a cesarean birth, or, in selected circumstances, planning a vaginal breech birth.

The safest approach depends on the stage of pregnancy, the type of breech position, the health of the pregnant person and baby, and the experience and resources of the maternity team.

Breech position usually does not cause symptoms. Some people notice kicks low in the pelvis or feel a firm, rounded area under the ribs, but the location of movement cannot reliably show the baby's position.

A doctor or midwife may suspect breech position during a routine abdominal examination. It is then usually confirmed with ultrasound.

Contact your maternity unit promptly if you know or suspect that your baby is breech and:

• Your waters break, even if contractions have not started.
• You develop regular contractions or think labor has begun.
• Your baby's movements are reduced or have changed from their usual pattern.
• You have vaginal bleeding or persistent abdominal pain.

When a breech baby's waters break, there is a higher risk that the umbilical cord can slip through the cervix before the baby. This is called umbilical cord prolapse and can reduce the baby's oxygen supply.

Call emergency services if you see or feel the umbilical cord in the vagina, have a strong urge to push before reaching the hospital, or have severe bleeding. Do not try to push a visible cord back inside. Follow the emergency dispatcher's instructions while waiting for help.

In many pregnancies, there is no clear reason why a baby remains breech. It does not mean that the pregnant person caused the position through exercise, posture, sleep position, or daily activity.

Factors associated with breech position include:

• Earlier gestational age: Babies are more likely to be breech before term because they have not yet settled into a final position.
• Multiple pregnancy: Twins or other multiples have less room to change position.
• Placenta location: A low-lying placenta or placenta previa may affect how the baby lies. Placenta previa means the placenta partly or completely covers the cervix.
• Differences in the uterus: Fibroids or an unusual uterine shape may limit movement.
• Amniotic fluid differences: Too much or too little fluid around the baby can affect movement and position.
• Previous breech pregnancy: Breech position is more likely after a previous breech pregnancy.
• Certain fetal conditions: Some conditions that affect movement or development can make breech position more likely, although most breech babies do not have these conditions.

These factors increase the chance of breech position but do not predict what will happen in an individual pregnancy.

A doctor or midwife may check the baby's position by feeling the abdomen. The head usually feels firm and round, while the baby's bottom is often softer and less clearly shaped. A vaginal examination during labor may also suggest breech presentation.

Ultrasound is used to confirm the diagnosis. It can show:

• The type of breech position
• The direction the baby is facing
• The position of the head and limbs
• Placenta location
• The amount of amniotic fluid
• Relevant information about the baby's growth and anatomy

The baby's position is often assessed at about 36 weeks, although local maternity practices vary. If breech position is found earlier, the care team may simply recheck later because the baby still has time to turn.

If the position is uncertain when labor begins, an ultrasound can help guide immediate decisions. The team may also monitor the baby's heart rate and examine whether the cervix is opening.

Management depends on how far the pregnancy has progressed and whether there are other pregnancy concerns. A discussion with the maternity team should cover the expected benefits, limitations, and risks of each option.

Waiting for the baby to turn

Before the final weeks of pregnancy, observation is often appropriate because many babies turn without treatment. If breech position continues near term, the care team may discuss external cephalic version and birth planning.

Some people ask about posture exercises, acupuncture, or a heat-producing acupuncture technique called moxibustion. Evidence for these approaches is limited or uncertain, and they should not replace medical assessment. Discuss any complementary treatment with the maternity team, particularly if there are pregnancy complications.

External cephalic version

External cephalic version, or ECV, is a procedure in which a clinician presses on the abdomen to try to turn the baby into a head-down position. It is generally offered after about 36 or 37 weeks, with timing influenced by pregnancy history and local guidance.[2]

Before ECV, ultrasound is used to confirm the baby's position and assess factors such as placenta location and amniotic fluid. The baby's heart rate is checked before and after the attempt. A medicine that relaxes the uterus may be offered because it can improve the chance of success.

During the procedure, the clinician uses their hands to guide the baby through a forward or backward roll. ECV may be uncomfortable, but it should be stopped if the discomfort becomes unacceptable or there is another concern.

ECV turns the baby successfully in about half of attempts, although the chance varies.[1] A successful ECV may reduce the likelihood of cesarean birth. A small proportion of babies turn back to breech afterward.

ECV is performed where the baby can be monitored and an urgent cesarean birth is available if needed. Serious complications are uncommon, but changes in the baby's heart rate, bleeding, rupture of the membranes, or labor can occur. ECV may not be advised when vaginal birth would be unsafe for another reason or when certain pregnancy complications are present.

People with Rh-negative blood may need anti-D immune globulin after ECV to reduce the risk of developing antibodies against Rh-positive blood. The maternity team determines whether it is needed.

Planned cesarean birth

A planned cesarean is commonly recommended for a baby who remains breech at term. The baby is delivered through cuts in the abdomen and uterus.

For term breech presentation, planned cesarean birth lowers the baby's risk of death or serious short-term complications compared with a policy of planned vaginal breech birth.[3,4] However, a cesarean is major surgery. Maternal risks include infection, bleeding, blood clots, injury to nearby organs, and a longer recovery. Cesarean birth can also affect options and risks in later pregnancies.

The planned date and surgical process depend on individual circumstances and local practice. Labor can begin before the scheduled procedure, so the maternity team should explain what to do if contractions start or the waters break.

Planned vaginal breech birth

A planned vaginal breech birth may be an option for carefully selected pregnancies when an experienced team and immediate cesarean facilities are available.[3,5] Not every hospital offers this service.

Assessment may consider the type of breech position, the baby's estimated size, the position of the baby's head, pregnancy complications, and previous births. Footling breech presentation is generally less suitable because of the risk of cord prolapse.

During labor, the baby's heart rate is usually monitored continuously. Labor progress is assessed closely, and cesarean birth may become necessary if labor does not progress or concerns develop. Induction or augmentation of labor may not be appropriate in some breech situations, so plans should be discussed with the specialist team.

Most babies who are breech during pregnancy remain healthy. The main risks arise during birth.

With vaginal breech birth, possible complications include umbilical cord prolapse, compression of the cord, difficulty delivering the baby's head, reduced oxygen supply, and birth injury. These risks are why careful selection, skilled attendance, and access to emergency cesarean birth are important.

Cesarean birth avoids some of the mechanical risks of vaginal breech delivery but introduces surgical risks for the pregnant person. Recovery is usually longer than after an uncomplicated vaginal birth. In later pregnancies, a uterine scar can increase the risk of placenta previa, placenta accreta spectrum, and uterine rupture, although the individual likelihood varies.

Breech presentation is also associated with developmental dysplasia of the hip, in which the hip joint does not form or remain stable in the usual way. All newborns have a hip examination. Babies born breech may be offered additional imaging after birth according to local screening policy, even if the first examination is normal.

After an ECV attempt, the baby's heart rate is monitored before discharge. Ask when the baby's position will be checked again and what symptoms should prompt immediate contact.

If ECV is unsuccessful, follow-up usually focuses on choosing a delivery plan. This discussion should happen early enough to review the local team's experience with vaginal breech birth, the benefits and risks of cesarean birth, and what will happen if labor starts unexpectedly.

Continue to pay attention to the baby's usual movement pattern. Report reduced or changed movement promptly rather than waiting for a routine appointment.

After birth, the baby will receive a newborn examination, including a hip assessment. Ask whether follow-up hip imaging is recommended and when it should occur.

Maternal follow-up depends on the type of birth and any complications. After cesarean birth, seek prompt advice for worsening wound redness, discharge, fever, increasing pain, heavy bleeding, chest pain, shortness of breath, or swelling and pain in one leg. Chest pain, severe breathing difficulty, fainting, or uncontrolled bleeding requires emergency care.