Breech Baby: When and How Babies Are Turned

What Is Breech Presentation and Why Does It Matter?

Breech presentation means your baby is positioned with their buttocks or feet pointing downward toward the birth canal, rather than head-first. This occurs in approximately 3-4% of full-term pregnancies and matters because head-down position is considered optimal for vaginal delivery, as the head is the largest part of the baby and helps dilate the birth canal effectively.

During pregnancy, babies move freely within the uterus, regularly changing position as they grow. Most babies naturally settle into a head-down position (called cephalic presentation) by around 36-37 weeks of pregnancy. This happens because the head is the heaviest part of the baby's body, and gravity encourages it to move downward into the pelvis.

When a baby remains in breech position near the end of pregnancy, it presents unique considerations for delivery. The head is the largest and hardest part of the baby to deliver. In a normal head-first delivery, once the head passes through the birth canal, the rest of the body follows relatively easily. The baby's head also helps to gradually dilate the cervix during labor.

In a breech delivery, the body comes first, followed by the head. This means the largest part must pass through last, which can sometimes lead to complications. Additionally, if the baby is not doing well during labor, medical staff cannot use a vacuum extractor (suction cup) to assist delivery when the baby is in breech position - instead, emergency cesarean section becomes necessary.

Types of Breech Presentation

There are several different types of breech presentation, depending on the position of the baby's legs:

• Frank breech (most common): The baby's buttocks are pointing downward with legs extended upward along the body, feet near the head. This is the most favorable breech position for potential vaginal delivery.
• Complete breech: The baby is sitting cross-legged with both hips and knees flexed, buttocks pointing downward.
• Footling breech: One or both of the baby's feet are pointing downward, below the buttocks. This type carries higher risks for vaginal delivery.

How Is Breech Presentation Detected?

Breech presentation is typically detected during routine prenatal appointments when your midwife or doctor feels your abdomen to assess the baby's position. If breech is suspected, an ultrasound examination confirms the baby's exact position, along with placenta location and amniotic fluid levels.

Your healthcare provider regularly checks your baby's position during prenatal visits by feeling your abdomen with their hands - a technique called abdominal palpation. During the third trimester, this examination becomes particularly important as delivery approaches.

When your midwife or doctor suspects breech presentation, they will feel a hard, round shape (the baby's head) at the top of your uterus rather than near your pelvis. You might also notice that you feel kicks lower in your abdomen rather than up under your ribs, which is another sign that your baby may be breech.

If breech presentation is suspected, you will typically be offered an ultrasound examination to confirm the position. This ultrasound also allows healthcare providers to assess important factors that will influence whether ECV is appropriate, including the location of the placenta, the amount of amniotic fluid, and the baby's size and wellbeing.

When is breech position concerning?

Before 36 weeks of pregnancy, having a breech baby is not concerning because there is still ample time and space for the baby to turn naturally. Many babies who are breech at 32-34 weeks will spontaneously move to head-down position before labor begins.

After 36-37 weeks, however, there is less room for spontaneous turning. At this point, you will be offered the option of External Cephalic Version (ECV) if your baby remains breech. Early detection allows time for planning and discussing your options with your healthcare team.

Can I Turn My Breech Baby Myself?

You cannot reliably turn a breech baby yourself. While various techniques like positioning exercises, moxibustion, and acupuncture have been proposed, scientific evidence does not support their effectiveness. The position your baby assumes is primarily determined by factors beyond your control.

Many pregnant women wonder if there are natural methods they can use at home to encourage their breech baby to turn. It is completely understandable to want to try everything possible, but it is important to know that the baby's position is largely determined by factors you cannot influence.

Various techniques have been suggested over the years, including getting on all fours, lying with hips elevated, playing music near the pelvis, or shining a light to encourage the baby to move toward it. While these methods are generally harmless, there is no strong scientific evidence that they effectively turn breech babies.

Some alternative therapies like moxibustion (a traditional Chinese medicine technique involving burning herbs near specific acupuncture points) have been studied, but research results have been mixed and inconclusive. Major medical organizations do not recommend these as proven treatments for breech presentation.

The factors that influence whether a baby is breech include the shape of your uterus, the location of the placenta, the amount of amniotic fluid, the size and shape of your pelvis, and simply chance. These are not things you can control through exercises or positioning.

What Is External Cephalic Version (ECV)?

External Cephalic Version (ECV) is a medical procedure where a doctor manually turns a breech baby to head-down position by applying pressure through the mother's abdomen. The procedure has approximately 50% success rate and is typically performed between 35-37 weeks of pregnancy.

ECV is the primary evidence-based intervention for turning breech babies. During this procedure, a trained doctor uses their hands to gently but firmly guide the baby from breech to head-down position through the mother's abdominal wall. The baby is encouraged to do a forward roll (somersault) so that the head moves downward.

The procedure is performed in a hospital setting, typically on a labor and delivery unit or in a day assessment area. Hospital setting is essential because continuous monitoring is required, and very rarely, emergency delivery may be needed if complications arise.

When is ECV performed?

ECV is typically offered between 35 and 37 weeks of pregnancy. This timing represents a balance between competing factors. Earlier attempts (around 35 weeks) tend to be easier because there is more room for the baby to move and more amniotic fluid relative to baby size. However, earlier procedures also carry a slightly higher chance that the baby might turn back to breech afterward.

Later attempts (closer to 37 weeks) may be slightly more difficult due to less space, but if successful, the baby is more likely to stay head-down until delivery. Your healthcare provider will recommend the optimal timing based on your individual circumstances.

In some cases, ECV can be attempted even after 37 weeks or during early labor, though success rates tend to be lower. If you have had previous pregnancies and deliveries, ECV may be more likely to succeed because the uterus and abdominal muscles tend to be more relaxed.

Step-by-step: What happens during ECV

The entire hospital visit for ECV typically takes about two hours, though the turning attempt itself only lasts a few minutes. Here is what you can expect:

1. Initial Assessment: When you arrive, the doctor will examine your abdomen to confirm how your baby is positioned. An ultrasound examination is performed to verify the baby's exact position, check the placenta location, measure amniotic fluid levels, and estimate the baby's size.

2. Pre-procedure Monitoring: A CTG (cardiotocography) monitor is attached to check your baby's heart rate and ensure they are doing well before the procedure begins. This baseline recording is important for comparison afterward.

3. IV Line Placement: A small IV catheter (thin plastic tube) is placed in a vein in your hand or arm. This provides access for administering medication and is a safety precaution in case emergency treatment is needed.

4. Uterine Relaxation Medication: Through the IV, you receive medication (typically a tocolytic drug) that relaxes your uterine muscles. This makes the turning attempt easier and more comfortable. The medication commonly causes temporary side effects including feeling warm, experiencing shakiness or trembling, and rapid heartbeat. These effects are normal and subside quickly after the medication is stopped.

5. The Turning Maneuver: You lie on your back on an examination bed. The doctor places both hands on your abdomen - one hand on the baby's head and one on the buttocks. Using firm, steady pressure, the doctor lifts the baby's bottom out of your pelvis and guides the head downward, encouraging a forward roll. The baby should follow along relatively easily without causing you significant pain.

6. During the Attempt: You will feel definite pressure from the doctor's hands, which can be uncomfortable but should not be severely painful. The attempt takes only a few minutes. Communication with your doctor is important - let them know if you experience significant pain, as this may indicate the attempt should stop. The doctor will also stop if there is significant resistance or if the baby does not move easily.

7. Post-procedure Monitoring: After the attempt (whether successful or not), another CTG is performed to ensure your baby is tolerating the procedure well. You may be asked to walk around for a short while before a final ultrasound confirms the baby's position.

Is ECV Safe? What Are the Risks?

ECV is considered a safe procedure with low complication rates. Serious complications requiring emergency cesarean section occur in less than 1% of cases. Common experiences include temporary discomfort during the procedure and brief changes in baby's heart rate that resolve quickly.

Understanding the safety profile of ECV is important for making an informed decision. The procedure has been extensively studied, and major medical organizations including the Royal College of Obstetricians and Gynaecologists (RCOG), American College of Obstetricians and Gynecologists (ACOG), and World Health Organization (WHO) recommend offering ECV to appropriate candidates.

The most common experience during ECV is discomfort from the pressure applied to your abdomen. Most women describe this as strong pressure that is uncomfortable but tolerable, lasting only a few minutes. Severe pain is not expected and would be a reason to stop the attempt.

Some soreness in the abdominal muscles after the procedure is common and usually resolves within a day or two. This is similar to muscle soreness after exercise and does not indicate a problem.

Potential complications

While ECV is safe, like any medical procedure, there are potential risks to be aware of:

• Transient fetal heart rate changes: Brief changes in your baby's heart rate during or after the procedure are relatively common and almost always resolve quickly. This is why continuous monitoring is performed.
• Placental abruption: Very rarely, the placenta may separate from the uterine wall. This is a serious complication but occurs in less than 0.1% of ECV attempts.
• Emergency cesarean: Less than 1% of ECV attempts result in the need for emergency cesarean section, usually due to concerning fetal heart rate patterns that do not resolve.
• Rupture of membranes: Rarely, the amniotic membranes may rupture during the procedure.
• Cord complications: Very rarely, cord entanglement can occur.

It is important to note that serious complications are rare. The procedure is performed in a hospital setting specifically so that if any problems arise, immediate access to emergency care including cesarean section is available.

When Is ECV Not Recommended?

ECV is not recommended when there are factors that make the procedure unsafe or unlikely to succeed, including low amniotic fluid, placenta previa, multiple pregnancy, suspected fetal growth restriction, previous cesarean section (in some cases), or when cesarean delivery is already planned for other reasons.

Not everyone with a breech baby is a suitable candidate for ECV. Your healthcare provider will assess several factors before recommending the procedure. The goal is to ensure that ECV is both safe and has a reasonable chance of success.

Conditions where ECV is typically not offered:

Low amniotic fluid (oligohydramnios): Adequate amniotic fluid is necessary for the baby to move. When fluid levels are low, there is insufficient cushioning and space for safe turning.

Placenta previa or low-lying placenta: When the placenta is positioned near or covering the cervix, ECV poses additional risks and is generally not performed.

Suspected fetal growth restriction: If there are concerns that your baby is not growing appropriately, ECV may not be recommended due to potential underlying issues with placental function.

Multiple pregnancy: ECV is typically not performed for twins or higher-order multiples due to the complexity and reduced space.

Uterine abnormalities: Some women have a uterus with an unusual shape (such as bicornuate uterus) that may both contribute to breech presentation and make ECV inadvisable or unlikely to succeed.

Ruptured membranes: Once your water has broken, ECV should not be attempted due to infection risk and reduced cushioning.

Previous uterine surgery: If you have had previous cesarean sections or other uterine surgery, your doctor will carefully evaluate whether ECV is appropriate. Some guidelines recommend against ECV after multiple cesarean sections.

Fetal concerns: If there are concerns about your baby's wellbeing based on monitoring, growth, or other factors, the focus shifts to delivery planning rather than attempting to turn the baby.

Cesarean already planned: If cesarean delivery is already planned for other medical reasons, there is no benefit to attempting ECV.

What Happens After ECV - Success and Failure

After successful ECV, pregnancy continues normally with standard prenatal care, though there is a small chance (around 5%) the baby may turn back to breech. After unsuccessful ECV, you will discuss delivery options including cesarean section (most common) or potentially vaginal breech delivery under specific circumstances.

After successful ECV

If ECV successfully turns your baby to head-down position, your pregnancy continues with routine prenatal care. Most babies who are turned successfully stay in head-down position until delivery. However, approximately 5% of babies may turn back to breech after a successful ECV.

At subsequent prenatal appointments, your healthcare provider will continue to check your baby's position. If your baby turns back to breech, a second ECV attempt may be offered, though this is less common.

Labor and delivery after successful ECV proceed normally. Having had a breech baby that was turned does not change how your labor will be managed, and you can expect a normal birth experience.

After unsuccessful ECV

In approximately half of ECV attempts, the baby cannot be turned. This does not mean anything is wrong - some babies simply do not turn easily, often due to factors like the amount of amniotic fluid, placental position, or the baby's exact orientation.

If ECV is unsuccessful, you may be offered a second attempt at a later date, depending on your individual circumstances. However, if multiple factors suggest turning is unlikely, proceeding directly to delivery planning may be more appropriate.

After unsuccessful ECV, the main decision is how your baby will be delivered. For most women with a breech baby, cesarean section is recommended. However, in carefully selected cases, vaginal breech delivery may be an option.

Cesarean Section vs. Vaginal Breech Delivery

Cesarean section is recommended for most breech presentations due to safety considerations. Vaginal breech delivery may be offered when specific criteria are met: baby weighs 2-4 kg, adequate maternal pelvis size, labor starts spontaneously, adequate amniotic fluid, and experienced staff are available. Both methods are safe when appropriately selected.

When your baby remains in breech position, either because ECV was not attempted, was unsuccessful, or was declined, the decision about mode of delivery becomes the primary focus. This decision should be made together with your healthcare team, considering both medical factors and your preferences.

Cesarean section for breech

The vast majority of breech babies are delivered by cesarean section. This is the approach recommended by most medical guidelines for breech presentation, based on research showing lower rates of certain complications compared to vaginal breech delivery.

Cesarean section for a breech baby is performed similarly to cesarean for any other reason. The baby's position in the uterus (breech vs head-down) does not significantly change the surgical procedure. You can read more about what to expect from cesarean delivery in our dedicated article.

Planned cesarean section allows for controlled delivery timing and eliminates the risks associated with labor and vaginal breech delivery. Recovery is similar to recovery from any cesarean birth.

Vaginal breech delivery

While cesarean is recommended for most breech presentations, vaginal breech delivery remains an option under specific circumstances. This approach requires careful patient selection, experienced healthcare providers, and appropriate facilities.

Criteria that favor vaginal breech delivery:

• Estimated baby weight: The baby should weigh approximately 2,000-4,000 grams (4.4-8.8 pounds). Babies at the extremes of this range have higher risks.
• Maternal pelvis: Adequate pelvic dimensions are essential. This is assessed through pelvic X-ray (pelvimetry) because external appearance does not reflect internal measurements. The pelvis needs to be slightly larger for breech delivery than for head-first delivery.
• Spontaneous labor: Labor should start naturally rather than being induced. Induced labor for breech presentation is associated with higher complication rates.
• Adequate amniotic fluid: Normal fluid levels are important for safe vaginal breech delivery.
• Breech type: Frank breech (buttocks down, legs up) is most favorable for vaginal delivery. Footling breech (feet first) carries higher risks.
• Your motivation: Most importantly, you should want to attempt vaginal delivery. This is a decision you make together with your healthcare team.

Practices vary between hospitals regarding vaginal breech delivery. Some institutions have more experience and are more comfortable offering this option, while others primarily recommend cesarean. You can always discuss what is available in your area and what your healthcare provider recommends based on their experience.

Feeling Anxious About Breech Presentation

Feeling worried or anxious about having a breech baby is completely normal. Talking with your healthcare provider, bringing a support person to appointments, asking questions, and understanding your options can help manage anxiety and empower you to make informed decisions.

Learning that your baby is breech near the end of pregnancy can bring unexpected emotions. You may have been preparing for a certain type of birth, and now those plans may need to change. Feeling anxious, disappointed, or worried is a completely normal response.

Many women worry about the ECV procedure - whether it will hurt, whether it will work, and what happens if it does not. Others feel anxious about the possibility of cesarean section when they had hoped for vaginal delivery. These are all valid concerns.

Speaking openly with your healthcare provider about your concerns can be very helpful. Ask questions about what to expect, discuss your options in detail, and share your worries. Understanding the process and your choices can help reduce anxiety.

Bringing a partner, family member, or friend to your appointments, including the ECV procedure, can provide emotional support. Having someone there who can help you remember information and provide comfort can make a significant difference.

Remember that breech presentation is not your fault and is not caused by anything you did or did not do during pregnancy. It is simply one of the many variations that occur in childbirth, and healthcare teams are well-equipped to manage it safely.

Your Rights and Choices

You have the right to make informed decisions about your care, including whether to attempt ECV and how you prefer to deliver your baby. Your healthcare provider should explain options, benefits, and risks so you can make the choice that feels right for you.

Healthcare decisions during pregnancy and childbirth are ultimately yours to make. Your healthcare team's role is to provide you with information, recommendations based on evidence and experience, and support for whatever decision you make.

You have the right to:

• Full information: Your healthcare provider should explain your options, including benefits and risks of each approach
• Ask questions: Never hesitate to ask for clarification or more details about anything you do not understand
• Take time: For non-emergency decisions, you can take time to think things over and discuss with your support system
• Decline interventions: You have the right to decline ECV or other recommended interventions after being fully informed
• Request interpretation: If you are not comfortable in English, you have the right to an interpreter
• Change providers: If you are not comfortable with your care, you can request to see a different provider

Good communication with your healthcare team is essential. If something is not clear, ask for it to be explained differently. If you feel your concerns are not being heard, express this directly or seek support from a patient advocate.