Breech Delivery

In a normal delivery, the babies move their heads towards the vagina at the time of the delivery. It allows the baby's head to move out first from the vagina, called headfirst delivery. However, in some cases, the baby's buttocks, feet, or both are positioned to come out of the vagina first. Such babies are called breech babies, and the delivery of the breech baby is called breech delivery. Breech babies are rare and account for 1 out of 25 full-term pregnancies.  There is a 3% to 4% occurrence of breech presentation among all pregnancies. The occurrence of breech presentation increases with less advanced gestational age. 7% of the foetuses are breech at 32 weeks, while 25% of foetuses have a breech presentation at 28 weeks or less gestational age. 

Breech delivery carries a higher potential risk to the baby and the mother. It can lead to perinatal mortality and morbidity, premature delivery of the baby, increased risk of congenital malfunction, trauma to the mother, and birth asphyxia at the time of the delivery.

1. In a normal delivery, the babies move their heads towards the vagina at the time of the delivery. It allows the baby's head to move out first from the vagina, called headfirst delivery. However, in some cases, the baby's buttocks, feet, or both are positioned to come out of the vagina first. Such babies are called breech babies, and the delivery of the breech baby is called Breech delivery.
2. Breech babies are rare and account for 1 out of 25 full-term pregnancies.  There is a 3% to 4% occurrence of breech presentation among all pregnancies. The occurrence of breech presentation increases with less advanced gestational age.
3. 7% of the foetuses are breech at 32 weeks, while 25% of foetuses have a breech presentation at 28 weeks or less gestational age. 
4. Breech delivery carries a higher potential risk to the baby and the mother. It can lead to perinatal mortality and morbidity, premature delivery of the baby, increased risk of congenital malfunction, trauma to the mother, and birth asphyxia at the time of the delivery. 

Types of breech baby positions 

The four different types of breech positions are:

1. Frank breech:  In this, the baby is folded in half, with its legs sticking straight up his or her body and feet near the head. The baby's buttocks are aimed at the birth canal and come out first at the time of the delivery.
2. Complete breech: In this, the baby's legs are folded, and a buttock is aimed at the vagina.
3. Footling breech: In this, one or both feet are positioned to come out first at the time of delivery. 
4. Transverse breech: It is a rare position, and the baby is sideways at the time of the delivery.

The exact cause of the breech position isn't known. But there are many situations that increase the chances of the breech position of the baby at the time of delivery. Such as:

1. If the woman has a history of several pregnancies
2. If a woman is pregnant with multiples or twins
3. If the woman has a history of delivering prematurely 
4. If the woman has a condition called placenta previa
5. If the uterus is too little 
6. If the woman has an abnormal shape uterus or other problems such as fibroids or cysts
7. If the uterus has a too much or too little amniotic fluid

1. It is done through physical and cervical examination.
2. There is a suspicion of breech presentation during a physical examination if the doctor is unable to palpate the lower abdominal part which is superior to the pubic bone.
3. Physical examination is done through Leopold manoeuvres.
4. The cervical examination may indicate breech presentation if there is lower extremity palpation or palpation of foetal buttock soft tissue. 

Why is breech delivery challenging?

The baby’s head is the largest part of the body. The head is supposed to stretch the birth canal to allow the rest of the body to pass through. But, when the baby is in breech position, either his butt or feet pave the way for birth during delivery. It causes the birth canal not to stretch properly, causing the baby to get stuck at the time of delivery. It may lead to complications, injuries, and even death.

Can the baby in the breech position be turned? 

When you are at about 36 weeks pregnant, and the baby is still in breech position, the doctor may attempt the technique called "external cephalic version" (ECV). In this, the doctors try to rotate the baby in the uterus from the outside. It is performed in the hospital, and the doctor applies the pressure on the mother's stomach to turn the baby. Before the ECV, the doctor will perform an ultrasound to confirm the baby's position and monitor the baby's heart rate to ensure it is normal. Then, the doctor gives you the medicine through an IV to make your uterus relax. It allows easy turning of the baby. The doctor will make you lie down on the table. Once the baby's head is located, the doctor applies the pressure gently to turn the baby to the head first position. 

Can breech babies be delivered vaginally?

The doctor may consider planned vaginal delivery in case of single breech foetus in some cases. Both planner vaginal birth and caesarean delivery have risk in case of foetus breech. However, planned vaginal birth carries more risk compared to planned caesarean delivery. The foetus may wedge in the mother’s pelvis and there is also increased risk for umbilical cord prolapse. Thus, planned caesarean delivery is more preferred compared to planned vaginal delivery.

What are the risks and complications associated with breech delivery? 

The risks and complications associated with the breech delivery are:

1. Foetal head entrapment: It occurs when the cervix is not completely dilated or the uterus has failed to relax, causing the head to be stuck at the time of delivery. In this cervix, the incision may be needed to release the baby.
2. Umbilical cord prolapse:  In this condition, the umbilical cord is squeezed as the baby moves towards the birth canal. It results in slowing the blood and oxygen supply to the baby.
3. Cervical spine injury: In this condition, the foetal head is hyperextended during the delivery leading to long-term neurologic sequelae.
4. Postpartum haemorrhage: The breech delivery leads to an overdistended uterus leading to severe bleeding after the delivery, which can be catastrophic to the mother. It should be managed carefully with medical treatment followed by surgical intervention. 
5. Maternal trauma: The breech delivery can lead to vaginal and perineal lacerations and should be managed carefully, as it can lead to maternal trauma.
6. Intracranial haemorrhage: It occurs due to the rapid compression of the head during the delivery. 

There are two ways of delivering a breech baby, depending on the situation, which are:

1. A planned caesarean delivery: It is considered the safest and most effective method to deliver the breech baby compared to the vaginal delivery. The doctor plans the C- section at the 39 weeks of pregnancy. In this method, the doctor cuts the abdomen, and then the baby is delivered out through this area. It is usually performed to reduce the risk to the infant. It has been found to lower both the perinatal and neonatal death rates. Emergency C-sections are performed when women with breech babies go into preterm labour. 
2. Vaginal delivery:  The three types of vaginal breech delivery are:
3. Spontaneous vaginal breech delivery:  In this delivery, the baby is delivered spontaneously without any manipulation or traction to the baby.
4.  Total breech extraction: In this type of delivery, first, the feet of the baby are grasped, and then the entire foetus is extracted out from the vagina. It is only used during the delivery of the 2nd twin. It is not used in single foetus delivery, as the cervix may not be adequately dilated to allow the baby to completely pass. 
5. Assisted breech delivery: It is one of the common types of vaginal breech delivery. In this delivery, the infant is allowed to deliver up to the umbilicus spontaneously and then, using the manoeuvres, the delivery of the remaining body, head, and arms are initiated.