Breech birth: how does the delivery unfold?

Around 3–4% of all pregnancies reach term with babies in a breech presentation[1]. A breech pregnancy refers to a baby (or babies) positioned head-up in the uterus. This can be observed via ultrasound scan. 

You need to wait until 35 or 36 weeks before a baby can be considered to be in a breech position. In "normal" pregnancies, the baby generally turns head-down. However, as the baby grows and space becomes limited, it becomes more difficult for them to turn and get into the right position.

There are 3 types of breech birth presentation 

Frank breech or footling breech (2/3 of cases): the buttocks are lowermost and the lower limbs are extended in front of the body, bringing the feet up to the level of the baby's head. 

Complete breech (fewer than 1/3 of cases): the baby is sitting cross-legged. 

Incomplete breech or semi-complete breech (rare): one leg is raised in front of the body and the other is tucked beneath the buttocks [2]. 

Risk factors for a breech birth

Several factors are associated with this risk: 

A multiple pregnancy (twins or more)

A contracted pelvis

Advanced maternal age 

Uterine abnormalities, such as fibroids

Foetal growth restriction

An issue with amniotic fluid levels (too much or too little)

Placenta praevia (placenta inserted in the lower uterine segment)

A short umbilical cord

A premature baby

Low birth weight [3]

What are the current recommendations? 

According to the Haute Autorité de Santé (HAS), this is not in itself an indication for a planned caesarean section [4]. A natural birth, vaginally, remains possible.

Eligibility criteria for vaginal birth

The acceptability criteria in this case are:

Favourable relationship between pelvimetry and estimated foetal measurements. The pelvis is wide enough for the foetus to pass through.

Absence of head deflexion (extension of the foetal head, which is normally flexed)

Patient cooperation. 

Possibility of performing an external cephalic version

In cases where a planned caesarean section is indicated for breech presentation, it is recommended that an external cephalic version be offered to the patient beforehand. By placing hands on the mother's abdomen, the foetus's buttocks are lifted and pressure is applied to its head to encourage movement. This allows the baby's arms, legs and head to be repositioned. One review notably showed that performing these manoeuvres made it possible to avoid a caesarean in 35 to 86% of cases [5].

Conditions for performing a caesarean section

One may be performed in the following situations: an unfavourable relationship between pelvimetry and estimated foetal measurements, persistent deflexion of the foetal head, or lack of patient cooperation. 

Is a caesarean section really preferable?

A trial of vaginal birth is attempted for one third of mothers in maternity units where the foetus is in breech presentation. The success rate is 70% [6].

In a study of more than 2,000 pregnant women carrying a baby in breech presentation, half were directed towards a planned caesarean section and the other half towards a vaginal birth [7]. According to the results, 90% of the 1,041 planned caesarean sections took place. Of the 1,042 who were to deliver vaginally, 57% did indeed give birth vaginally. The group who had planned caesarean sections had significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity than the group who had a planned vaginal birth. According to the data, there was no difference between the groups in terms of maternal mortality or serious maternal morbidity.

However, in a study of more than 8,000 breech births, no significant difference was found for neonatal health when comparing vaginal births and caesarean sections. The authors concluded that, in settings where planned vaginal birth is common and when strict criteria are met, planned vaginal birth of a foetus in breech presentation remains a safe option that can be offered to the mother [8].

Should labour be induced?

Induction of labour is not in fact routine. According to 2006 data, it is observed that in the case of breech birth, the induction of labour was performed frequently by 12.5% of French obstetric teams, occasionally by 59.7%, and never by 27.8% [9].

An analysis of 7 studies showed that induction was notably associated with a significant increase in the caesarean rate in the induction group compared with the spontaneous labour group: 33.59% versus 24.93% respectively [10].

There is still limited research on the subject, but it may be possible to act through external cephalic version (ECV), as recommended by the HAS (see above).

A number of studies have looked at techniques and their outcomes for these births. It is worth bearing in mind that there is no miracle solution, even the best pregnancy supplements taken as a preventive measure will have no impact on the risk of a breech birth. 

Giving birth on all fours — is it a viable option?

A study of 750 breech births compared 315 planned caesarean sections with 435 attempted vaginal deliveries. According to this study, 269 (61.8%) of the women gave birth vaginally, of whom 229 were in the "all-fours" position and 40 in the dorsal decubitus position (lying on their back) [11]. 

The reported results were in favour of the "all-fours" position. There were indeed fewer obstetric interventions, fewer foetal traumas, and the duration of the second stage of labour was reduced by an average of 42% (45 minutes less). A severe neonatal complication occurred in 10% of cases where the mother was lying down, compared with 3.1% where she was in the "all-fours" position.

Can acupuncture help turn baby?

Moxibustion, a form of traditional Chinese medicine, involves burning the moxa herb (Folium Artemisiae argyi, or mugwort) on acupuncture points. It is notably used in China to facilitate cephalic version in cases of breech presentation. Studies have shown that it can encourage this, with a 1.3 times greater chance [12].

Furthermore, an analysis of 65 studies showed that stimulation of the BL67 point resulted in a breech presentation rate of 28% after treatment, compared with 56% in women who had not received this stimulation [13]. 

These data are further supported by a study that examined the combined effect of BL67 point stimulation via moxibustion and acupuncture, comparing it with an equivalent group that received no treatment. According to the results, at the time of delivery, the proportion of cephalic version was lower in the observation group (36.7%) than in the active treatment group (53.6%). Consequently, the proportion of caesarean sections indicated for breech presentation was significantly lower in the treated group than in the observation group (52.3% vs 66.7%) [14]. No foetal heart rate abnormalities, no premature uterine contractions, and no maternal cardiovascular changes were observed immediately after the procedure.

To find out more, read our article acupuncture pregnancy.

Fewer than 1% of breech births result in traumatic injuries to the baby. The most commonly reported injuries include clavicle fractures, haematomas or bruising, and brachial plexus injuries. It is also associated with an increased risk of hip dysplasia. Caesarean sections do not, however, appear to be a protective factor [15]. 

Another problem that can also occur during a vaginal breech birth is the umbilical cord prolapse (or prolapse). It can slip into the vagina before birth. If pressure is applied to it or it becomes compressed, the flow of blood and oxygen to the baby through the cord may decrease. This risk is low under normal circumstances but rises to 1.3% in this case [16].

A breech birth is fairly rare and occurs in 3 to 4% of cases. This does not necessarily mean induction or a caesarean section will be required. It is indeed possible to have a vaginal birth in a maternity unit or hospital if conditions are favourable. 

If you are in this situation, do not hesitate to seek advice from your medical team (GP, midwife, gynaecologist).