Episode 10: Breech presentation
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Episode 10 Content and Overview
In episode 10 of the Pregnancy and Childbirth podcast, Dr Greg Jenkins, obstetrician and gynaecologist, talks about breech presentation; when your baby is trying to come out bottom first instead of head first.
Listen to this episode to learn about:
When does breech position matter?
Three options for giving birth if your baby is breech coming into the last month of pregnancy: external cephalic version (ECV), vaginal breech birth and elective caesarean
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Transcription
00:00:00
Hi, I'm Greg Jenkins and welcome to this edition of my pregnancy podcast. Today we're going to talk about breech presentation. So breech presentation is when your baby is trying to come out bottom first instead of head first.
00:00:14
This issue matters because delivering your baby as a vaginal breech birth is a little bit more risky for the baby and a bit more complicated than delivering your baby vaginally from a head first position.
00:00:29
So when does breech position matter? We know that at 30 weeks gestation, so 30 weeks into your pregnancy, that about one in three babies are in a breech position.
00:00:39
We also know that by the time you get to 37 weeks gestation that only about 3% of babies remain in a breech position. So if your baby is breech at 30 or 32 weeks, we don't need to be too worried about this because we know that 90% of these babies are going to turn around all by themselves by the time you get to 36 or 37 weeks.
00:01:02
Now, if it's your first baby and your baby breech at 36 weeks, the chance of it turning around on its own after that are quite small. Similarly, if it's your second or subsequent baby, we tend to give baby another week to turn on its own. But if your baby is still breech at 37 weeks, then it's probably not going to turn around on its own after that.
00:01:25
So, depending on whether or not this is your first pregnancy, 36 to 37 weeks is the time when we become really interested in the position of your baby in terms of whether your baby is head first or bottom first.
00:01:38
Even if your baby is breech at 36 to 37 weeks, there is still a small chance your baby will turn around on its own, and most babies don't. If your baby is breech coming into the last month of pregnancy, we need to make some decisions about how you're going to give birth. There are three options.
00:02:00
We can do a procedure called an ECV, which is an external cephalic version, and that's where we attempt to turn the baby around from a breech position into a head first position and we'll talk about that in a bit more detail in a minute.
00:02:16
The second option would be to leave your baby in a breech position and attempt a vaginal breech birth and we'll talk about that also. And the final option would be to do an elective caesarean, and if all else is well with your pregnancy and assuming that you don't come into labour prior, this would usually be done close to 39 weeks gestation.
00:02:38
It's worth mentioning that this decision is very much a shared decision made between you, your partner and your pregnancy care provider, and in my podcast on birth after caesarean section I spend a little bit of time talking about the process of shared decision making.
00:02:56
Let's start by talking about ECV or external cephalic version. So this procedure is generally done at around 37 weeks gestation. It's done in a supervised environment, such as in a birth unit environment or similar, somewhere where we have an ultrasound so we can verify the baby's position and somewhere where we can continuously monitor the baby's heartbeat throughout the procedure to make sure that we're not doing anything that's going to compromise the baby's well-being.
00:03:26
So what do we know about ECV? We know that if it started around 37 weeks gestation, that it's a safe procedure, so the risks associated with ECV are really very small provided it's done in those circumstances I mentioned previously. We know that it doesn't always work.
00:03:46
If it's your first baby, the success rate is probably around about 30%, and if it's your second or subsequent baby, then success rates of over 50% would usually be expected. We also know that if the ECV works, your baby is very unlikely to turn back, so less than 5% of babies will spontaneously turn back to breech position if the ECV was successful. And for those women where the baby remains in a head first position, the pregnancy can then be allowed to continue on with labour managed just as per normal.
00:04:25
So what would happen if you decided to have an ECV? So the procedure would generally be booked in with your birth unit at the hospital where you're having your baby. You would come in on the designated day. The midwife in birth unit would attach a CTG or a foetal heartbeat monitor, and we'd run that monitor for a while before we do anything, just to make sure that your baby is happy and in good condition before we attempt the ECV.
00:04:52
We would often give you an injection of a drug called terbutaline and this helps to slow down uterine contractions. So in the background, your uterus is tightening all the time, particularly in the last month of pregnancy. And if we go poking around our new uterus, we stimulate some tightening of the uterus and those tightenings make it a little bit harder to turn the baby around. So there is some quite good evidence that if we use a drug like terbutaline, it helps to relax those contractions and makes the success of the procedure a little bit higher.
00:05:30
What does this mean for you? Terbutaline has a common side effect of making your heartbeat race a little bit, but otherwise it's a very safe drug and it's very unlikely to have any other significant side effects for you, and it's very safe for your baby. So once we've given you some terbutaline, and we've done a CTG to make sure that your baby is happy, we will then do an ultrasound just to confirm the position of your baby. We'd get you laying quite flat.
00:05:57
Probably a bit more flat than you would usually be comfortable lying during pregnancy and then by massaging your tummy we can gently but firmly try and assist your baby to rotate to do a somersault either forwards or backwards into a head first position. So the process of actually doing the ECV doesn't usually take more than five to 10 minutes.
00:06:20
It is mild to moderately uncomfortable, but should always be done within the limits of what you're able to comfortably tolerate and it's not a procedure that would use pain relief medication for.
00:06:34
We will monitor the baby's heartbeat during the ECV to make sure that the baby stays happy during the procedure and if at any time the baby seems to be unhappy, we can turn the body back to its original position.
00:06:46
We can use ultrasound also to monitor our progress and to verify the position of the baby at the conclusion of the ECV procedure.
00:06:55
Once the ECV has been completed, whether successful or unsuccessful, it would then be placed back on the foetal monitor for a period of time to ensure that we haven't done anything that's going to cause the baby any concern or distress. Once we're happy that the CTG monitoring is fine at the end of the ECV you would then be able to go home.
00:07:15
We would advise you that if you have any vaginal bleeding, if you have any abdominal pain or if your waters break to call up the birth unit and come back for assessment.
00:07:27
ECV does not appear to increase the likelihood of labour happening in the days following the procedure. There's good evidence that ECV is a safe and reasonable way to approach babies that are breech in the last few weeks of pregnancy. And if we offer every woman with a breech in the last part of pregnancy, we do reduce the number of breech babies presenting in labour at the end of pregnancy. So it is a worthwhile intervention to consider.
00:07:54
An alternative to this, or an option if your ECV is not successful, would be to consider a vaginal breech birth. Fundamentally, the concerns around vaginal breech birth relate to the fact that for most babies, the head is the largest part of the baby and with a breech birth, the baby's head is the last thing to emerge. And if we have difficulty in delivering the baby's head, that can be very serious in terms of the outcome for the baby.
00:08:24
Now there was a very large study published in medical literature in the year 2000 which aimed to solve the question as to whether vaginal breech birth was safe or not. Now, this study, known as the Turnbridge trial, drew some conclusions that have subsequently been questioned. However, the Turnbridge trial concluded that planned caesarean section was safer for the baby when compared with vaginal breech birth.
00:08:55
It's reasonable to say that a number of subsequent analyses have identified some shortcomings with this trial, and have called into question the conclusions that were drawn. So we now believe that for a selected group of women who are motivated to water attempted vaginal delivery that this can be done in a reasonably safe way.
00:09:19
It's also worth mentioning that vaginal breech delivery is a bit more risky for the baby than a vaginal birth of a head first baby. There are a number of factors that influence this risk, such as whether you've had a successful vaginal birth in the past, the size of your baby, the type of breech presentation that your baby's in, whether the feet are under the bottom, or whether the feet are sitting up in front of the baby's face. And these are all issues that need to be discussed on an individual basis with yourself and your pregnancy care provider.
00:09:57
It's also important to realise that some clinicians feel more comfortable with attempting vaginal breech birth than other clinicians. So if your clinician is not somebody who's comfortable considering a vaginal breech birth and this is something you're wishing to pursue, there are resources available which can guide you to clinicians who have some interest and expertise in managing vaginal breech birth.
00:10:26
Another thing to consider, if you are contemplating vaginal breech birth is to seek out a hospital that supports vaginal breech birth and has the necessary support mechanisms and structures in place to ensure this can be carried out for you in the safest way possible.
00:10:45
Finally, there is the option of elective caesarean section. Some women are not keen on the idea of ECV and this is very much an individual decision.
00:10:57
In the setting of an elective caesarean just for the reasons of breech presentation, as I mentioned earlier, this will usually be done as close to 39 weeks as possible, accepting that there is a small chance that your labour may begin spontaneously before 39 weeks, in which case there will usually be ample time to arrange a caesarean with the onset of labour. When it comes to breech presentation in the last few weeks of pregnancy, those are the available options.
00:11:29
Information I've discussed today is of a very general nature and there will often be things that are quite specific to you, to your baby, or to your pregnancy that will have an important bearing on the applicability of these options to your circumstance. So it's really important that if your baby is breech in the last month of pregnancy that you have a discussion with your pregnancy care provider about how these options can be applied to you and come to a decision that is in the best interests of the things that you want to achieve and also the health and well-being of your pregnancy and your baby.
00:12:13
I hope you have found this content informative and enjoyable. If you have any feedback or suggestions for future episodes, please get in touch and bye for now.
