Definition, Description, Causes and symptoms, Diagnosis, Treatment, Prevention
Breech birth is the delivery of a fetus (unborn baby) hind end first. Between 3-4% of fetuses will start labor in the breech position, which is a potentially dangerous situation.
Throughout most of pregnancy, the developing fetus is completely free to move around within the uterus. Between 32-36 weeks, it becomes so large that movement is restricted. It is much harder for the fetus to turn over, so whatever position it has assumed by this point is likely to be the same position that he or she will be in when labor begins.
For reasons that are not fully understood, almost all unborn babies settle into a head down position. The fetus is upside down in the uterus, and the head will lead the way during the birth process.
Unfortunately, some fetuses do not cooperate. Most of these are in the breech position. The buttocks lead the way out of the uterus, and the legs are folded in front of the body (frank breech). Delivery from the breech position poses far more risks than delivery head first (vertex position).
The biggest part of the fetus's body is usually its head. If the head fits through the mother's pelvis, then the rest of the fetus's body should slip out fairly easily. If the fetus is born bottom first, it is possible that the body will fit through the mother's pelvis, but the baby's head will get stuck at the level of the chin. This condition, known as a trapped head, is very dangerous.
When the baby's head comes first, it has a chance to "mold" during labor. The bones of the baby's skull are not yet fastened together the way they are in a child or adult's skull, meaning that the bones of the baby's skull can move. During the long hours of labor the skull can change shape to fit through the pelvis more easily, which is why many babies are born with a "cone head". If the baby is born from the breech position, the skull does not have a chance to change shape to fit the pelvis, and it is even more likely to get stuck.
If the baby's head gets trapped, the possibility of injury is high. Once the baby's body is born, the umbilical cord usually stops pulsating (just as it would during a normal delivery). This cuts off the oxygen supply from the mother to the baby. If the baby's head is still inside the uterus the baby cannot yet breathe on its own. Therefore, it is essential to deliver the baby as quickly as possible.
The life saving attempts to deliver the baby's head can cause injury to the baby's neck or head resulting in permanent handicaps. In extreme cases, if the baby cannot be delivered within a few minutes, the baby might die. Obviously, it is critical to avoid a breech delivery with a trapped head.
Of course, many babies are safely delivered from the breech position. There are certain factors that make a breech delivery more likely to be successful: if ultra-sound (a technique that uses sound waves to visualize the fetus) shows that the fetus is in the frank breech position, the fetus's head is tucked on its chest, and the fetus is not big, it is less likely that its head will get stuck.
Among breech babies born after the full nine-month term, smaller babies usually do better. This is not true for premature babies. Premature babies are more likely to have a trapped head because the body of a premature baby is usually much smaller than his or her head. Premature babies are generally not delivered from the breech position.
The risks of vaginal breech delivery can be avoided by delivering the baby through a surgical procedure (cesarean section, also known as c-section). For the past twenty years, cesarean section has been recommended when the fetus is breech. More recently, many providers have offered the option of version, attempting to turn the fetus within the uterus to a head first position before labor begins.
Version is based on a very simple idea. If a fetus in the breech position does a somersault, it will end up head down. During a version, the obstetrician tries to make the fetus do a somersault.
A version should only be done in a hospital, with an ultrasound machine used to guide the obstetrician in turning the fetus. The fetus should be monitored with a fetal monitor before and after the version. Some obstetricians give the mother an injection of medication to relax the mother's uterus and prevent any contractions.
During the procedure, the obstetrician places his or her hands on the mother's abdomen to feel the location of the unborn baby's buttocks and head. The buttocks are lifted up slightly and the doctor pushes on the baby's head to encourage him to perform a somersault. It may take several tries before the fetus cooperates, but over half will eventually turn.
A version is not appropriate for every fetus who is in the breech position at the end of pregnancy. It can only be tried if there is one fetus in the uterus, if the placenta is not lying in front of the fetus, and if the umbilical cord does not appear to be wrapped around the fetus at any point.
Causes and symptoms
The cause of breech birth is not known. There are generally no identifiable symptoms. However, some women can tell the position of the fetus by where they feel the fetus kicking. Most women cannot tell what position the fetus is in at any given moment.
A health care provider can often tell the position of the fetus by feeling it through the wall of the mother's
abdomen. Another clue to the position is the location where the heartbeat is heard best. If the fetus's heartbeat is best heard below the level of the mother's navel, it is likely to be positioned head first. On the other hand, if the heartbeat is best heard above the level of the navel, it is likely to be breech.
The only way to really be sure, however, is to do an ultrasound exam. Using this technique it is very easy to tell the position of the fetus.
If a fetus is in the breech position in the last weeks of pregnancy, there are three possible courses of action: Cesare-an section, attempted version, or vaginal breech delivery.
Cesarean section is the most common way to deliver a breech baby. This surgical procedure carries more risk for the mother, but many women prefer to take the risk of surgery on themselves rather than let the baby face the risks of breech delivery.
Version is gaining in popularity. Version is a medical procedure in which the obstetrician tries to turn the breech fetus to the head first position. Version is successful more than 50% of the time. However, some babies who are successfully turned will turn back to the breech position after the procedure is done.
Some women choose breech vaginal delivery. This should only be attempted if ultrasound shows that the fetus is in a favorable breech position. Most babies will do very well during a breech delivery, but it is always possible that the fetus will be injured, perhaps seriously.
There is no way to prevent a fetus from settling into the breech position at the end of pregnancy. A woman who has had one breech fetus is more likely than average to have another.
Amy B. Tuteur, MD
"Techniques for Breech Delivery." In Williams Obstetrics. 20th ed. Ed. F. Gary Cunningham, et al. Stamford: Appleton & Lange, 1997.
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