Baby Is Breech, Now What?In reading this you may just have found out that your baby is breech, or you may be preparing in case this does happen 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. 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.
Many times the ultrasound determines a breech much too early and the babe just naturally turns when it's time. By 38 weeks, 97% of babies turn head down by themselves. In Silent Knife by Cohen & Estner, they say that three quarters of the babies turn in 2-3 weeks. In A Good Birth, A Safe Birth by Korte & Scaer, they say that in a 1977 study, 89% of 744 babies in breech position were turned to headfirst with the slant board exercise (outlined below). Weeks of Pregnancy % of Breech 28 25% 30 17% 32 11% 34 5% 36 5% 37 - 40 3.7% from Holistic Midwifery by Anne Frye
"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 labour 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." Excerpt from The Thinking Woman’s Guide to a Better Birth by Henci Goer.
The ideal vaginal breech presentation is a frank breech position in which baby’s buttocks are down and the legs in pike position, hips flexed and knees straight. Frank is the most common type of breech and with the buttocks about the same size as the head, this minimizes the concern that the cervix will not dilate enough and possibly trap the head. Also the umbilical cord prolapsing (coming down ahead of the baby) is greatly reduced. At the same time, 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 (with their heads tipped back) should be born via cesarean section due to the high risk of entrapment of their aft-presenting head. Note: Shortly before a planned cesarean birth it is recommended an ultrasound be done to confirm breech presentation and to rule out congenital anomalies incompatible with life. If baby is found in a vertex position, a cesarean section is then not needed.
Having a skilled and gently caregiver will greatly enhance your chance 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 baby is breech. If you are unable to find a caregiver who will attend you, the midwives at The Farm in Tennessee headed by senior midwife Ina May Gaskin, the renowned author of Spiritual Midwifery, are very skilled at vaginal breech birth.
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. Though 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 their impacting the sacrum (the back of the pelvis) and decreasing the diameter of the pelvis. Delayed pushing until full dilation is important as when you do push, 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.
In 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 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 following 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 labour 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 and 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.
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 awfully 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 somebody and review the ultrasound to look for clues about the placement of the placenta or any cord issues that might favor a breech position. You also probably should do some meditation to communicate with the baby and seek some inner guidance about what's going on. What are your fears? Exploring your fears and concerns involving 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 metaphysical paths for determining if it's safe to try to turn the baby back. In no case should you try to force anything as you could inadvertently pull on a tight 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 could probably 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. As well, when planning to try version techniques, drinking plenty of water - about a gallon a day - will help, as 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, taking to your baby in conjunction with pelvic tilts and music can be very effective. Or trying visualizations combined with handstands during deep-water immersion 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. In no particular order, here are the alternative breech turning techniques… Pelvic Tilt and Slant-board Exercise
Walking is an excellent way to help baby turn and stay vertex. Walking creates movement in the pelvis which helps baby to turn as 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 30 minutes a day to encourage baby to stay head down. Relaxation is a very important component in allowing baby to turn. When you are upset or tensed up, so is your baby. Your baby can sense when something is wrong and will even turn to a breech position until you are ready, at which time the baby will often also turn to a vertex position. As mentioned above, it may be Mom’s fear of birth or an aspect of giving birth. Positive visualization combined with a relaxed mind and body can often be the first and only step needed. Some visualizations that have worked are:
An extension of visualizations is talking to your 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 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." Excerpt from Pregnancy, Childbirth and the Newborn by Simkin, Whalley & Keppler. You can also put a radio or cassette/CD player in your pants, near your pubic bone or you can also try between your knees when you are on the ironing board (see slant board techniques below). Nice sounds such as soothing music, your 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 towards the sound. In contrast, place headphones on Mom’s abdomen in the fundal area and played "headbanger" music. The baby went vertex very soon after. Presumably the baby 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. "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, Burlington, 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 magazine, November-December 1995 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. An excellent start to other breech turning techniques as 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. The most successful do it yourself technique for turning a breech fetus is headstand done while totally 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 that you are *really* relaxed. Ideally, finding a therapeutic pool that is kept at a temperature higher than a regular pool where people heat themselves up swimming laps would be best. Get into the pool and spend at least 15 minutes just paddling around and having fun. Now go to where you can stand with your head just above water, then do 5 handstands in a row. Just plain swimming can also help the baby turn because of the stretching and crouching involved. This will help you to 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 your amniotic fluid, also helpful to the baby's turning. Being in deep water will squeeze the fluids in your tissues into your bloodstream and increase the volume of amniotic fluid. In contrast, if you are an avid swimmer and swim everyday, stopping swimming and try alternate techniques. When in the (breech tilt) position, use a little sweet almond oil to massage your belly over the area of your baby's back using a firm but gentle pressure. Excerpt from Aromatherapy for Pregnancy and Childbirth by Fawcett. This would help relax the stomach muscles and encourage baby with the massaging strokes of your hand. Massage in the direction you want baby to turn. As with all diagnosis, it is preferable to consult with a professional to ensure the correct remedy and dosage for each situation. Pulsatilla, a well known homeopathic remedy that is used for breech and other mal-presentations as well as prolonged labour. Here are three recommendations:
Combine this with the breech tilt exercise at least twice a day for 10 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, depression from suppressed grief, anger or shock. If Mom has excess water, try homeopathic Natrum Muriaticum as excess water may cause baby to float to a breech position. Mom can also eat lots of watermelon or cucumber with the seeds to reduce fluid as they are natural diuretics. And finally, Bach Bougainvillea flower essence has been found to work really well for turning breeches. Although not technically a homeopathic remedy, I will include it in this category. 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 your fingernail into this point. 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. 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% of breech presentations, documented successful versions by other chiropractors is 82%. The first step is to confirm presentation of baby and acquiring a maternal history of the pregnancy and other relevant factors is mandatory. 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 chiropractors 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 3 to 6 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 35 minutes. If little or no fetal movement is felt, some counter pressure 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. Thus it is important to initiate this technique as soon as possible and know that it is harder for the baby to move close to term. Pelvic Tilt and Slant-board Exercise Depending on the position of your baby will depend on which position works best. If baby has his/her back to your front, the slant-board exercise is most effective. If baby has his/her back to your 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 for 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?" These techniques do two very useful things.
Slant-board Exercise: Lie on your back with your hips raised high on pillows or lie on an ironing board slanted at a 45-degree angle against a sofa. For lightheadedness you can us 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 you have high blood pressure, heart problems or lung problems. Relax, breathe deeply, avoid tenseness. An alternative is for Mom to also use pillows on a flat surface to raise hips 12-18" above shoulders. Beanbag Chair or Pelvic Tilt Exercise: Made an indention for your tummy and lie down on your front, again with your head lower than your hips. An alternative to this is to adopt an all fours position and slowly lower your chest to the floor (knee chest position), again so your hips are higher than your head. (This looks like the position recommended for prolapsed cord). If done 10 minutes twice a day for 2-3 weeks after the 30th week the pelvic tilt had an 88.7-96% success rate in 744 patients. It is recommended that the pelvis be raised 9-12 inches above the head and be done on an empty stomach. OB/GYN News Vol12, No.1 You need to do this several times a day for 10-15 minutes and you have to be persistent, as they 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, though it can be greatly influenced by her caregiver. I sincerely hope these decisions have been made easier though the information I have provided in this article, and I wish you and your baby a great birth experience! Reference and further resources: Aromatherapy for Pregnancy and Childbirth by Fawcett Childbirth Without Fear by Grantly Dick-Read Chiropractic Management of Third Trimester In-Utero Constraint; Canadian Chiropractor, June 1997, Volume 2, No. 3. Concise Textbook for Midwives by Willson Clyne A Good Birth, A Safe Birth by Korte & Scaer Holistic Midwifery by Anne Frye Homeopathy for Pregnancy, Birth and Your Baby’s First Year by Miranda Castro Natural Health magazine, November-December 1995 Obstetric Myths Versus Research Realities by Henci Goer Open Season by Nancy Wainer Cohen Pregnancy, Childbirth and the Newborn by Simkin, Whalley & Keppler Silent Knife by Cohen & Estner The Thinking Woman’s Guide to a Better Birth by Henci Goer Wise Woman Herbal for the Childbearing Years by Susun S. Weed Your Baby, Your Way by Sheila Kitzinger Websites: http://www.gentlebirth.org/archives/breech.html http://www.fensende.com/Users/swnymph/Midwife/ http://www.well.com/user/cmty/farm/index.htmlhttp://www.childbirth.org/section/vagbreech.html Copyright Mother Care, 2000. Written by Connie Banack, CD. |
