Baby Is Breech, Now What?

You may be reading this because you just found out that your baby is breech, or you may be preparing in case this happens to you or someone you know. The most important thing to do is to relax and know that babies are often breech until the last trimester as they turn and move in Mom's uterus, strengthening muscles and improving coordination. To determine what to do about a breech baby, first let's look at the choices needed to be made, then at what can be done in regard to a vaginal breech birth and turning baby into a head-down or vertex position.

How Many Weeks Pregnant Is Mom when Baby Is Found Breech?

Many times the ultrasound determines a breech much too early and the babe just naturally turns when it's time. By 38 weeks, 97 percent of babies turn head-down by themselves. In Silent Knife, Cohen and Estner state that three-quarters of the babies turn in two to three weeks. In A Good Birth, A Safe Birth, Korte & Scaer say that in a 1977 study, 89 percent of 744 babies in breech position were turned to headfirst with the slant-board exercise (outlined below).

Has She Discussed a Vaginal Breech Delivery with Her Doctor or Midwife?

   Many studies have concluded that the shift to planned cesarean delivery has
   not improved breech outcomes. Both vaginal and cesarean delivery of a
   breech baby carries risks. More babies born vaginally will have birth
   injuries [often due to labor mismanagement] but almost all of them will
   recover. The same cannot be said for cesarean deliveries where the risk to
   the mother is much higher, including postpartum infection, a scarred uterus
   which will increase her risk of uterine rupture and placenta accretia (a
   condition in which the placenta grows into the uterine wall, causing
   complications with retained placenta and hemorrhage) in subsequent
   pregnancies. Though rare, cesarean sections do pose life-threatening risks
   to mothers and babies. Depending on the individual case, vaginal birth is
   as much a reasonable, responsible choice as is planned cesarean section.

--The Thinking Woman's Guide to a Better Birth by Henci Goer

Who Should Be Eligible for Labor?

The ideal vaginal breech presentation is a frank breech position in which baby's buttocks are down and the legs are in pike position, hips flexed, and knees straight. Frank is the most common type of breech and, because the buttocks are about the same size as the head, concern that the cervix will not dilate enough and possibly trap the head is minimized. Additionally, the chance of the umbilical cord prolapsing (coming down ahead of the baby) is greatly reduced. Conversely, other breech presentations are ideal for breech turning techniques because they tend to turn much more easily than those in the frank breech position.

Babies with hyperextended necks (heads tipped back) should be born via cesarean section due to the high risk of entrapment of their aft-presenting head. However, shortly before a planned cesarean birth it is recommended that an ultrasound be performed to confirm breech presentation. If baby is found in a vertex position, a cesarean section is then not needed.

Is Her Obstetrician or Midwife Experienced with Vaginal Breech Deliveries? If Not, Is There Someone in Her Community Who Is?

Having a skilled and gentle caregiver will greatly enhance the chances of a vaginal breech delivery. Unfortunately, the experience needed or desired to support a woman with a vaginal breech delivery is becoming harder to find as doctors and obstetricians rely on cesarean sections to be the only option available for breech babies.

Interview potential caregivers, ask about their complication rates, and find out what they recommend to minimize the chance of problems. Start looking and inquiring as soon as you find out the baby is breech.

Vaginal Breech Birth Protocols

Having a first baby should not disqualify a woman from a vaginal breech birth.

The jury is out on the routine use of epidurals during a vaginal breech birth. Although it prevents the premature urge to push and allows the use of forceps and manipulation of the baby without causing pain, it also hinders pushing, which is essential when a woman must rapidly and effectively push out the baby's head. Also, the common lithotomy (flat on the back) or semi-sitting positions are contraindicated for a vaginal breech birth (indeed, for almost all births) due to impacting the sacrum (the back of the pelvis) and decreasing the diameter of the pelvis.

Delayed pushing until full dilation is important because, when pushing occurs, you want the baby to be delivered quickly and without resistance.

Forceps should only be reserved for emergencies, not as a routine method to control the delivery of the head. The use of forceps is minimized with the absence of epidural anesthesia and with the mother in a good pushing position.

What Are Her Options in Regard to External Cephalic Version (ECV)?

According to Obstetric Myths Versus Research Realities by Henci Goer, even labor is not too late to attempt an external version.

External cephalic version for breech presentation is performed at about thirty-seven to thirty-eight weeks gestation. Most obstetricians skilled in this procedure report an approximate 50 percent success ratio and although there are several supportive studies in the medical literature, this procedure has not received widespread acceptance.

The iatrogenic (doctor-caused) results of this procedure may include uterine rupture, premature placental separation, fetal-maternal hemorrhage, and failure.

How External Version Is Done

An ultrasound diagnosis is done first to confirm fetal presentation and position, and to visualize the site of placental attachment. A non-stress test is routinely performed before and after the version attempt to confirm the well-being of the baby. A tocolytic drug such as Ritodrine, Terbulatine, or Relaxin is administered to the mom to relax the uterine muscle and reduce the risk of preterm labor contractions. The ultrasound is then continued for guidance and to monitor the fetal heart rate as the physician attempts to move the baby by pressing and pushing on the abdomen. Occasionally an epidural is given to both relax the mother and lessen the pain of the external version, but if done correctly, the mother should only experience mild discomfort.

Should the baby show signs of distress, the procedure is immediately stopped. In the rare circumstance where the placenta starts to separate during the version or the baby's distress continues, an emergency cesarean section may be performed. A successful version does not guarantee the baby will remain in the vertex position, but the benefit is that it lowers the cesarean rate for breech presentations.

Alternatives to an External Cephalic Version

There are a lot of alternatives to an ECV in trying to turn a baby--gravity manipulation, acupressure, homeopathy, herbs, visualization, and more. But the first thing to do is to try to figure out why the baby is currently breech. Your baby and your body working together can be very smart, and it may be that there's something about the pregnancy that requires a breech or cesarean delivery.

It would be helpful if you could sit down with a professional and review the ultrasound to look for clues about the placement of the placenta or any cord issues that might favor a breech position. It is also helpful to meditate to communicate with the baby and seek some inner guidance about what's going on. What are your fears? Exploring your fears and concerns about your upcoming birth or parenting a new baby can be very beneficial. Read Relaxation and Visualization (below) for more on this.

It is important to pursue both medical and intuituve paths for determining if it's safe to try to turn the baby. In no case should you try to force anything as you could inadvertently pull on a fight cord or cause placental problems. Generally, a woman will know when and where not to apply external force on herself.

If you want to do things specifically to help the baby turn, it would be really useful to learn how to determine whether or not the baby is breech by feeling your belly to locate the head. Ask your care provider or someone else with experience to help you learn to do this if you don't already know how. You may be able to teach yourself by simply pressing gently on your belly to feel the baby's outline and following the various body parts until you get a good picture of how it's lying, but it might be easier if someone else could show you. The reason it's important to be able to do this is so that you know when the baby has turned and don't unwittingly "unturn" the baby through your efforts.

When planning to try version techniques, drinking plenty of water--about a gallon a day--will help, because the extra amniotic fluid will make it easier for the baby to move and the technique more successful.

Finally, it is very important to avoid semi-recumbent positions. These positions, such as reclining on a sofa or in an armchair, can actually turn a vertex baby to breech due to the position of your pelvis and uterus.

Many of the techniques outlined below work best in combination. For instance, starting with a relaxing warm bath, then talking to your baby in conjunction with pelvic tilts and music can be very effective. Or, trying visualizations combined with deep-water immersion (see Deep Water Immersion below) can work very well. Regardless of which technique or combinations of techniques you try, repeat them often and try different ones until you are successful.

Alternative Breech Turning Techniques

Mobility

Walking is an excellent way to help baby turn and stay vertex. Walking creates movement in the pelvis, which helps baby to turn because the mother's upright stance provides more room making it easier to turn effectively. Regardless of which technique is used to turn baby, Mom needs to get upright, and stay in upright, active positions for at least thirty minutes a day to encourage baby to stay head down.

Relaxation and Visualization

Relaxation is a very important component in allowing a baby to turn. When the mom is upset or tense, so is the baby. The baby can sense when something is wrong and may even turn to a breech position until mom is ready, at which time the baby will often turn to a vertex position. As mentioned earlier, it may be the mother's fear of birth--or an aspect of giving birth--that causes a breech baby to stay breech. Positive visualization combined with a relaxed mind and body can often be the first and only step needed.

Some visualizations that work include:

* Imagine a helium balloon attached to the baby's foot, imagine the baby turning somersaults.

* Combined with deep-water immersion and handstands in the water, Mom can visualize the baby doing a forward somersault (see Deep Water Immersion below).

* Visualize baby not only un-engaging, but turning to the vertex, and re-engaging in a favorable position (be specific in your visualizations). The key to this is relaxation.

* Visualize the baby turning while practicing deep relaxation. Imagine the baby doing a front dive heading for the mom's backbone and then "splashing down" into the pelvis.

* Have the partner tell the baby where to be and visualize this as he or she talks baby through the turn.

Sound/Light Therapy

An extension of visualizations is talking to the baby and sound therapy. In Childbirth Without Fear by Grantly Dick-Read, he "encourages the mother to talk to her baby, encouraging it to turn around ... the baby may not understand the words, but the soothing tone of voice will ease any anxiety about shifting out of a disadvantageous position."

An alternative, according to Simkin, Whalley, and Keppler in Pregnancy, Childbirth and the Newborn is to "place earphones just above your pubic bone and play music for the baby. The theory is that babies can hear well and may move toward the music in order to hear better." Mom can also put a radio or cassette/CD player near her pubic bone or also try the CD player between her knees when she is on the ironing board (see Slant-Board Exercise below). Nice sounds such as soothing music, the mother's recorded voice, or whale sounds are the best. Talk to the baby about turning. Partner can even speak close to Mom, low down on her belly, to encourage baby to move toward the sound.

In contrast, place headphones on Mom's abdomen in the fundal area and play "headbanger" music. Some babies turn very soon after. Presumably the babies didn't appreciate the music and turned to get away from it. A variation is to use a flashlight so the baby may move toward the light. You can start by shining the light at the top of your belly and then slowly moving it down to where you want the baby's head to be.

Hypnosis

Hypnotherapy may help pregnant women turn their breech baby around to the normal head-first, or vertex, position. A researcher at the University of Vermont used hypnosis with one hundred pregnant women whose fetuses were in the breech (feet-first) position between the thirty-seventh and fortieth week of gestation.

The intervention group received hypnosis with suggestions for general relaxation and release of fear and anxiety. While under hypnosis, the women were also asked why their baby was in the breech position.

The study, which appeared in the Archives of Family Medicine, reported that 81 percent of the fetuses in the hypnosis group moved to the vertex position, compared with 48 percent of the control group. Not surprisingly, hypnosis was most effective for the women motivated to use the technique (Natural Health, November-December 1995).

Hot and Cold Therapy

In colder climates it's believed that heat around the pregnant belly can encourage baby to turn. This can be done with a hot water bottle or warm compress, or a tub full of warm water. This helps to relax the stomach muscles, allowing baby the extra room to move. This may be an excellent start to other breech turning techniques because this relaxes the stomach muscles, which makes other techniques more effective (see also Deep Water Immersion, below). Cold therapy is also beneficial. Using the "frozen peas" trick, have Mom place a bag of frozen peas on her fundus, which is where the back of the baby's head is, and the baby will move away from the cold. This can be done in conjunction with a warm bath, positioning, light therapy, and other techniques.

Deep Water Immersion

The most successful do it yourself technique for turning a breech fetus is a handstand done while completely immersed in water, according to Susun Weed in Wise Woman's Herbal for the Childbearing Year. It's important to find a pool that's warm enough so Mom is really relaxed. Ideally, finding a therapeutic pool that is kept at a temperature slightly higher than a regular pool where people heat themselves up swimming laps would be best.

Have Mom get into the pool and spend at least fifteen minutes just paddling around and having fun. Now, have her go to where she can stand with her head just above water, then do five handstands in a row. Just plain swimming can also help the baby turn because of the stretching and crouching involved. This will help relax those abdominal muscles to give the baby more room to turn. This may have to be repeated several times before baby will turn. It's best if she can judge vertex from breech because then she'll know when to quit. She may also want someone there to help her into this position.

Don't forget the benefits of deep-water immersion on increasing amniotic fluid (helpful to the baby's turning). Being in deep water will squeeze the fluids in the tissues into the bloodstream and increase the volume of amniotic fluid. However, if Mom is an avid swimmer and swims everyday, stop swimming and try alternate techniques.

Aromatherapy

When in the pelvic tilt position (see Pelvic Tilt below), use a little sweet almond oil to massage the belly over the area of the baby's back using firm but gentle pressure (Aromatherapy for Pregnancy and Childbirth by Fawcett). This helps relax the stomach muscles and encourages baby with the massaging strokes of the hand. Massage in the direction baby needs to turn.

Homeopathy

As with all diagnoses, it is preferable to consult with a professional to ensure the correct remedy and dosage for each situation.

Pulsatilla is a well known homeopathic remedy that is used for breech and other malpresentations as well as prolonged labor. Here are three recommendations:

* Pulsatilla 200C, one tablet. Repeat one more day if baby doesn't turn.

* Pulsatilla 30C, one tablet every two hours for up to six doses (during the course of one day). Don't take it for more than one day.

* Pulsatilla 6X, one tablet under the tongue four times a day, up to ten days.

Combine this with the breech tilt exercise at least twice a day for ten minutes each time. Have Mom take one Pulsatilla tab before beginning the breech tilt.

Is fear causing tightness of the lower uterine segment and keeping the baby high? Ignatia Amara 30C, one tablet every two hours has proven effective for anxiety and depression from suppressed grief, anger, or shock.

If Mom has excess water, try homeopathic Natrum Muriaticum because excess water may cause baby to float to a breech position. Mom can also eat lots of natural diuretics such as watermelon or cucumber with the seeds to reduce fluids.

And finally, Bach Bougainvillea flower essence has been found to work very well for turning breeches. Although not technically a homeopathic remedy, I believe it fits in this category.

Acupuncture and Acupressure

Acupressure or acupuncture (preferably with a professional) using the Bladder 67 point has been proven to turn breech babies. The Bladder 67 point is on the outside of the little toe on both feet, right next to the nail. To apply acupressure, rub and push the fingernail into this point.

Moxibustion 

Doctors in Italy and China use moxibustion, the application of heat from burning herbs, to acupuncture points. Moxibustion is applied to the Bladder 67 and is an alternative to acupuncture or acupressure techniques.

Webster's Technique

The contemporary chiropractic technique used for turning breech or other adverse fetal presentation is called the "Webster In-Utero Constraint Turning Technique" or Webster's technique after Dr. Larry Webster. Dr. Webster reports effecting successful version in 97 percent of breech presentations; documented successful versions by other chiropractors is 82 percent.

The first step is confirming presentation of baby and acquiring a maternal history of the pregnancy and other relevant factors. When the baby is found to be in a breech presentation, the mother is assessed clinically to determine, and correct, sacral alignment.

The mom then turns on her back and the baby's location is determined in relation to her belly button. The trigger point for the rectus abdominus muscle is then found on the mom's left side and the chiropractor's thumb is placed on this point. Pressure is exerted gradually and evenly straight down until the trigger point is found and pressure is maintained, but shifted slightly inward to isolate the broad ligament. As little as three to six ounces of pressure is often sufficient to induce relaxation of the trigger point. Pressure is maintained for a minimum of one to two minutes, more as necessary on evaluation of the trigger release, even up to thirty-five minutes. If little or no fetal movement is felt, some counterpressure with the opposite hand can be applied on the uterine wall opposite the side of the trigger point.

Following the adjustment, Mom is again assessed for sacral alignment and, in most cases, the alignment is achieved. If not, another sacral adjustment is needed. Additional adjustments should not be performed on the same day as the Webster technique.

As little as one procedure may work, but typically it can take from three to ten adjustments performed over a two to three week period; therefore, it is important to initiate this technique as soon as possible realizing that it is harder for the baby to move close to term.

Pelvic Tilt and Slant-Board Exercise

The position of the baby will determine which position works best. If baby has his/her back to Mom's front, the slant-board exercise is most effective. If baby has his/her back to Mom's back, the beanbag or pelvic tilt exercise will be most effective. The baby's back and head are the heaviest parts and these techniques use gravity to push the baby's head into the fundus, tuck it, and then do a somersault into the vertex position. Do this exercise on an empty stomach and discontinue if there is lightheadedness or shortness of breath. Realize that there will be some pressure exerted on the thorax (chest cavity) by the abdominal contents being pushed upward toward the mom's head.

One question often asked about these techniques is, "Wouldn't the heavier head keep the baby in that position?" The answer to that is that these techniques do two very useful things. They help to disengage the baby from the pelvis and when the baby's head comes up against the inside of the fundus, the baby is inclined to tuck the head and do a somersault into the vertex position.

Slant-Board Exercise

Have Mom lie on her back with hips raised high on pillows or lie on an ironing board slanted at a 45-degree angle against a sofa. For lightheadedness, use a small pillow under the right hip (if the "plank" is stable) to elevate some uterine pressure from the inferior vena cava (large vessel bringing blood back to the heart from the legs). This maneuver should not be tried if Mom has high blood pressure, heart problems, or lung problems. Relax, breathe deeply, avoid tenseness. An alternative is for Mom to use pillows on a flat surface to raise hips 12-18 inches above shoulders.

Beanbag Chair or Pelvic Tilt Exercise

Make an indention in a beanbag chair for Mom's tummy and have her lie down on her front, with head lower than hips. An alternative to this is to adopt an all fours position and slowly lower the chest to the floor (knee-chest position), again so hips are higher than head. (This looks like the position recommended for prolapsed cord.)

If done ten minutes twice a day for two to three weeks after the thirtieth week, the pelvic tilt has an 88.7 to 96 percent success rate in 744 patients. It is recommended that the pelvis be raised nine to twelve inches above the head and be done on an empty stomach (OB/GYN News Vol. 12, No. 1).

This needs to be done several times a day for ten to fifteen minutes and moms must be persistent--babies do not usually turn on the first try. If the baby does turn, stand up slowly, and talk a long walk or do some squats to try to help the baby settle into the vertex position.

In conclusion, there are many decisions to be made. The mother and her partner can only determine which choice or choices are best, although it can be greatly influenced by her caregiver.

--Connie Banack is the ALACE Regional Director for Western Canada.