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 French National Authority for Health (HAS), this is not, in itself, an indication for a planned caesarean section [4]. A natural birth, by vaginal birth, remains possible.

Eligibility criteria for vaginal birth

The criteria for considering vaginal birth in this case are:

A favourable assessment of pelvic measurements in relation to the baby’s estimated size. The pelvis is wide enough for the baby to pass through.

No extension of the baby’s head (the head is tilted back rather than in its usual flexed position)

The patient’s cooperation. 

Possibility of performing an external cephalic version

If a planned caesarean section is indicated because the baby is breech, it is recommended that the patient first be offered an external cephalic version. By placing their hands on the mother’s abdomen, the healthcare professional lifts the baby’s bottom and presses on their head to turn them. This moves the baby’s arms, legs and head. A review found that performing this manoeuvre avoided a caesarean section in 35 to 86% of cases [5].

When a caesarean section is performed

A caesarean section may be performed in the following situations: an unfavourable assessment of pelvic measurements in relation to the baby’s estimated size, persistent extension of the baby’s head, or lack of cooperation from the patient. 

Is a caesarean section really preferable?

A vaginal birth is attempted for one-third of mothers giving birth to a breech baby in hospital. The success rate is 70 % [6].

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

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

Does labour need to be induced?

In fact, labour is not always induced. According to data from 2006, in cases of breech birth, 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 of labour was associated with a significantly higher caesarean section rate than spontaneous labour: 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 common include collarbone fractures, bruising or contusions, and brachial plexus injuries. Breech birth is also associated with an increased risk of hip dysplasia. Caesarean sections, however, do not appear to offer protection against it [15]. 

Another problem that can occur during a vaginal breech birth is umbilical cord prolapse (also called cord presentation). The cord can slip into the vagina before the baby is born. If it is pressed on or compressed, the flow of blood and oxygen to the baby through the cord may decrease. This possibility is normally low but increases to 1.3% in this situation [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).