Breech Birth Options (Is a Vaginal Breech Birth Right For You?)
If your baby is breech and you’re nearing your due date, rest assured you still have options for your birth. Vaginal breech birth can be a good option for many women. In this blog post, learn about the benefits and risks of both vaginal breech birth and c-section breech birth (and more!).
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Of all the topics in the realm of birth, breech birth may be one of the most misunderstood.
In truth, breech is just a variation of normal.
A large majority of the time, breech births can happen vaginally and have great outcomes when two things are in place:
- The birth is attended by a doctor or midwife who is highly-skilled in breech
- Mom and baby meet certain criteria which make safe vaginal birth more likely
That said, there are real risks to both vaginal breech birth and cesarean (c-section) breech birth. There’s no denying that.
If you’ve heard that c-section is always the best way to handle breech, there’s a reason for that! But it’s not always true.
So let’s talk about what options you really have when your baby is breech.
Basics of Breech Position
To make sure we’re all on the same page, let’s talk about what breech is.
Generally, breech positioning is when your baby’s head is at the top of your uterus instead of at the bottom. Ideally, your baby’s head is down, settled into your pelvis by the end of the third trimester. That will make for the least complicated birth.
But around 3% of babies will not be in a head-down position by the time their due window rolls around.
3 Kinds of Breech
Beyond the general upright orientation of breech babies, there are 3 different ways they may be positioned and each has a different name.
Frank breech is when the baby’s legs are extended and their feet are up by their head. This is by far the most common form of breech.
Complete breech is when the baby’s knees are bent but still pulled into their body, as if they were sitting cross-legged. Complete breech is the least common form of breech.
Incomplete or footling breech is when one of the baby’s knees is bent and one is extended down toward the cervix. This is more common than complete breech but less common than frank. It is also the most complicated form of breech.
Why the Fear?
So why is breech birth such a controversial topic? Why is it so feared?
There’s not a simple answer to that.
But a big part of it is that most care providers just aren’t trained to attend breech births like they used to be.
According to some, this is one reason c-sections are a safer alternative in some situations.
Vaginal breech birth can require very specific care and maneuvers. If a care provider doesn’t know them, they risk doing more harm than good when trying to help.
And when a vaginal breech birth does go poorly, it just reaffirms beliefs that it’s dangerous and that a c-section would have been better.
But women want a vaginal birth. They want the full labor experience and they don’t want to take on the risks of having a c-section.
Yet they want their baby to be safe and healthy, too!
So, in short, it’s complicated.
Breech Birth Options
So what are the options?
In reality, a woman whose baby is still in a breech position when she nears full term has 3 options. (Many babies will be breech at some point during pregnancy but will turn on their own, or with encouragement in the form of chiropractic care, herbal remedies, mother’s exercise, etc., by 40 weeks.)
The options are…
- Get an external cephalic version or “ECV”
- Schedule a c-section
- Find a provider who is trained in and comfortable with breech vaginal birth
ECV
An external cephalic version (ECV) is a procedure that can help turn a baby into a head-down position. It’s all done externally—just a provider’s hands on a woman’s belly.
To get an ECV, you’ll lie down on a bed and your care provider will touch your belly, finding the baby’s head and backside, and gently push and maneuver to encourage the baby to turn. They may use a jelly-like cream to reduce friction on your belly.
Your provider will monitor your baby’s heart rate throughout the process and likely for 30 minutes afterwards.
The entire procedure doesn’t usually take more than a few minutes. Most women find it a bit uncomfortable, but it shouldn’t be painful.
You can see an ECV in this video.
Do ECVs work?
ECVs are successful about 50–70% of the time. They are usually harder the farther along you are, since the baby has less wiggle room in your uterus.
ECVs tend to work best for women who have given birth before and for babies in the complete breech position.
The other 30–50% of the time—when an ECV is unsuccessful—the baby simply didn’t turn or did turn but then flipped back upright before birth.
Risks of ECVs
Most ECVs will happen without complication. Only 1-2% of ECVs will have any problems. And the most common problem—changes in the baby’s heart rate—will resolve on its own once the ECV attempt is stopped.
Severe complications happen less than 1% of the time (less than 1 out of 100 mother-baby pairs) but can include premature rupture of membranes (water breaking before labor begins), umbilical cord prolapse, vaginal bleeding, placental abruption, fetomaternal hemorrhage, emergency c-section, and stillbirth.
Vaginal Breech Birth
When care providers are well-trained in handling breech births, success rates range from 56.7% to 84%. That’s more than half, even at the lowest!
As I mentioned in the intro, it’s widely agreed that women and babies should meet certain criteria before deciding on a vaginal breech birth, in order to achieve the best outcomes.
These criteria vary slightly depending on the provider, but generally there are eight:
- Frank or complete breech presentation (no incomplete or footling breech)
- Flexed or neutral head (chin tucked into chest, confirmed by ultrasound)
- Estimated weight of baby between 5 and 9.5 lbs
- Sufficiently wide pelvis in mom (known through history and/or pelvic exam)
- No fetal anomalies (no unusual complications or conditions in baby)
- Spontaneous labor (no induction or augmentation)
- Tolerance of labor (mom and baby handle labor well)
- Well-informed and motivated parents (positive mindset and trust in the process)
As a side note, some care providers have found that when a mother stays upright during birth (rather than lying on her back), breech birth is much easier.
I also want to point out that some places, like California, have made it illegal for providers to attend breech vaginal births outside of the hospital.
I believe that is wrong. But regardless, if you live in an area with these laws, you may have a much harder time finding a provider willing to attend a vaginal breech birth, even if you meet these criteria.
Benefits of Vaginal Breech Birth
The benefits of choosing a vaginal breech birth over a cesarean breech birth are, to a large degree, the same as choosing a head-down vaginal birth over a head-down cesarean.
- You avoid the risks of surgery (higher blood loss, damage to organs, possible infection, longer recovery, complications for future births)
- You get to experience vaginal birth
- Your baby receives healthy bacteria and a surge of hormones as they move through your vagina and are born
- Your baby’s airways are naturally cleared out by the pressure of being pushed through your vaginal opening
- You are more likely to have success breastfeeding
Risks of Vaginal Breech Birth
The risks of vaginal breech birth get a bit more nuanced and complicated but I’ll break it down to make it as easy to understand as possible.
There are two big risks of vaginal breech birth. They sound scary but they are rare, more rare than most people believe.
First is head entrapment.
This is when a baby’s head gets stuck either at the cervix, somewhere in mom’s pelvis, or at the vaginal opening. To make sure I made myself clear: THIS IS VERY RARE, especially if mom is relaxed, unmedicated, and following her body’s intuitive direction.
A few things to know about head entrapment:
- It’s far more likely in premature breech births (because baby’s heads are bigger around than their body until they reach full term)
- It occurs in less than 10% of breech births
- It can also occur during c-sections
Entrapment can be resolved with special maneuvers and/or incisions in mom’s cervix or perineum.
The second main risk is umbilical cord prolapse.
Prolapse is when the umbilical cord comes out of the uterus and vagina before the baby does. It is dangerous because as the baby comes out after the cord, the cord gets compressed and can cut off oxygen and blood flow to the baby.
In head-down births, cord prolapse happens about 0.1–0.6% of the time. When a baby is breech, that number increases to about 1%.
How likely cord prolapse is also depends on what kind of breech we’re talking about.
Frank breech has the least likelihood of cord prolapse—about the same rate as a head-down baby.
Complete breech has a risk of 4–6%.
Incomplete or footling breech is the most likely to have cord prolapse at 15–18% of the time. (And if you noticed above, for many care providers a footling breech is already a reason not to try a vaginal birth, so this wouldn’t be an issue.)
Even if cord prolapse and compression happens, a baby will usually be okay as long as the cord isn’t obstructed for more than 3 minutes.
Other risks of vaginal breech birth include…
- bruising (which can happen in any birth)
- broken bones (especially in cases when providers have to pull the baby out to some degree)
- hip dysplasia (hip looseness or dislocation)
- nerve or muscle damage
- need for resuscitation (help breathing)
Keep in mind that these risks are uncommon, they can happen in other kinds of births as well, and they will be even less common if you find an experienced breech provider.
How to Find a Breech Provider
If you want to have a vaginal breech birth, it can be hard to know how to find a provider who is trained and willing to attend your birth. You can search in your area and get on the phone or meet in person with local providers to ask about their experience with breech.
If you aren’t finding anyone, try searching the Breech Without Borders directory.
Breech Without Borders is a nonprofit organization dedicated to breech training, education, and advocacy. They have a public directory of providers all over the world who are willing to attend breech vaginal births.
You can find the directory here.
If you are serious about giving birth to your breech baby vaginally, don’t give up if there are no providers in your area. While it may be tricky, you might consider traveling to where a breech provider is located.
Vaginal birth really is worth that much, if it feels like the right choice for you.
Cesarean (C-section) Breech Birth
Most breech births now happen by c-section. As I’ve already mentioned, part of the reason for this is that care providers aren’t trained in how to handle breech birth—because it is different from head-down birth!
And to compound the simple human preference for something you are familiar with over something unfamiliar, outcomes are often worse vaginally if the provider is inexperienced in breech birth.
Now to add on to that.
Some Babies Don’t Make It
Obviously, the underlying fear here is the possibility of death. But we have numbers for how often that happens in different scenarios.
Evidence from one large study suggests that the rates of the baby dying during planned head-down vaginal birth, planned breech vaginal birth, and breech c-section are…
- Head-down vaginal: 1 in 3333
- Breech vaginal: 1 in 1111
- Breech c-section: 1 in 1250
Here is one of the big points I want to make.
Said one way, according to this study, breech vaginal birth is 3 times more dangerous than head-down vaginal birth. And it’s a little more dangerous, in terms of death, than a c-section.
However, said another way…
- Head-down vaginal birth has a success rate of 99.97%
- Breech vaginal birth has a success rate of 99.91%
- Breech c-section birth has a success rate of 99.92%
So, yes, some babies don’t make it. Sometimes bad things happen. But the vast majority of the time—almost every time!—baby is going to be okay.
And a c-section hardly makes a difference in that regard.
With that said, let’s get to the pros and cons.
Benefits of Cesarean Breech Birth
If you choose to give birth to your breech baby by c-section, these are the benefits:
First, you avoid those cases where vaginal breech birth is more risky (i.e. situations where mom and baby don’t meet the 8 criteria from above).
Second, your OBGYN can attend your birth. If you choose to have a c-section rather than finding a care provider who is comfortable with breech birth, you don’t have to switch care providers. So the OB you’ve been meeting with can attend your birth at the hospital you’ve been planning on.
Third, you avoid some injury that may occur during a vaginal birth. For example, though bruising and broken bones can happen during c-sections, they are more common when a breech baby is born vaginally.
Fourth, as we already covered, the chance of your baby dying is reduced by a very small amount.
Finally, for some women, choosing a c-section will allow for more peace of mind. If you are worried about how labor will go, chances are it won’t go as well as it could. For that reason, and simply because your mental health matters, if you cannot overcome fears about giving birth to a breech baby vaginally, a c-section might be your best option.
Risks of Cesarean Breech Birth
To a large degree, the risks of choosing a cesarean breech birth over a vaginal breech birth are the same as choosing a head-down vaginal birth over a head-down cesarean.
- You are undergoing surgery, which means you’re at risk for higher blood loss, damage to organs, possible infection, and longer recovery
- You may have complications during future births because of your scar and higher frequency of placental problems
- Your baby misses out on the healthy bacteria and hormonal surge that they would get during a vaginal birth
- Your baby is more likely to have fluid in their airways and struggle to breathe
Other risks are similar to those breech babies born vaginally, including:
- Possibility of head entrapment (though it’s even less common during c-sections)
- Broken bones
- Hip dysplasia
- Nerve damage
- Bruising
- Cuts or scrapes
There may also be a higher chance of your baby needing to be in the NICU and of longer NICU stays.
What About Mom?
We went over how rare it is for the baby to die during a breech birth. But what about Mom?
Again, death is rare. Most moms will make it, if with a long recovery ahead, whether her breech baby is born vaginally or by c-section.
However, choosing a breech c-section birth over a breech vaginal birth does increase a woman’s risk of dying.
A study done in 2010 found evidence that though a c-section doesn’t guarantee better outcomes for baby, it does make the birth more dangerous for mom, as well as potentially complicating future pregnancy and births.
Though the study was small, it found that 7% of maternal deaths in the study were a direct result of choosing a c-section over a vaginal labor and birth solely because the baby was breech.
A Few More Things to Consider
Now you should have a much better understanding of your options if your baby is in a breech position.
There are just a few more things I want to invite you to consider.
Avoid Induction
First, it’s recommended that women giving birth to a breech baby vaginally avoid induction and other interventions during labor. Altering labor through the use of Pitocin, epidurals, etc. can decrease the likelihood that a vaginal breech birth will go well.
The main reason for this recommendation seems to have to do with head entrapment.
Two of the biggest risk factors for head entrapment are incomplete dilation (opening) of the cervix and insufficient time for the baby’s malleable head to mold to the shape and size of their mother’s pelvis.
Incomplete dilation may be more common in augmented labors because contractions are being stimulated by medication rather than a woman’s natural hormones, so she may have a harder time knowing when her body is truly ready and open enough to push the baby out.
Induction or augmentation of labor (using Pitocin or breaking the waters) also makes it harder for the baby’s head to have sufficient time to make its way effectively through mom’s pelvis.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists also states that “the effect of epidural analgesia on the success of vaginal breech birth is unclear, but it is likely to increase the risk of intervention.”
Don’t Worry About Meconium
Second, don’t stress about the possibility of meconium aspiration. Meconium aspiration is when a baby breathes in their first poop (meconium) with amniotic fluid before birth and it causes breathing problems.
It is talked about a lot and is possible during any birth.
And, yes, meconium in the fluid is common during breech births.
However, the evidence-informed official guidelines clearly state that routine suctioning or intubation is not necessary. Why? Because most of the time, infants who have breathed in meconium are not in distress and will recover just fine, especially when left on their mother’s chest.
Conclusion: You Have Options
So there it is…your options for breech birth and the truth behind each. Whatever you decide, now you can do it knowing exactly what you’re choosing.
Until next time,
Allison
READ MORE:
C-sections: Why and How to Avoid Having One
