Breech Baby: External Version, Caesarean or Vaginal Birth?

At the eight-month scan, the doctor turns the screen: “Baby is breech.” In other words, baby is bottom or feet down, head near your ribs. The questions come at once: will baby turn? Will I need a caesarean? And those positions seen on social media to “turn baby”, do they work?

A breech baby is not an abnormality, just a position. It often changes by itself before the end of pregnancy, and when it persists, there are several options. Here are the figures, how an external cephalic version goes, and the criteria that guide the choice between vaginal birth and caesarean.

Breech baby: how common is it?

Very common in mid-pregnancy, rare at term. In Quebec, the INSPQ estimates that about 24% of babies are breech at 28 weeks. Most settle head down by about 34 weeks. At term, only 3 to 4% remain, and the HUG in Geneva speak of 3 to 5% of babies born at term.

That is why breech presentation is only discussed late in pregnancy: the diagnosis is made after 34 weeks, and confirmed around 35 to 36 weeks, by palpation and ultrasound. In the great majority of cases, no cause is found. Sometimes a malformation of the uterus, a twin pregnancy, too much or too little amniotic fluid or a particularity of the baby plays a role (HUG).

The different breech presentations

These details are not just anatomical: they matter in choosing the mode of delivery.

External cephalic version: how does it go?

External cephalic version (ECV) consists of turning the baby by pressing on the belly with the hands, to bring baby head down. It is offered around 36 weeks in the UK (NHS) and in France, and around 36 or 37 weeks in Quebec.

The course described by the Pitié-Salpêtrière maternity unit in Paris:

1. Checking baby's position (palpation and ultrasound) and recording baby's heart rate.
2. The doctor moves the baby through the abdominal wall. The manoeuvre itself lasts a few minutes.
3. Baby's heart is recorded again, then in most cases you go home the same day.
4. If you are rhesus negative, an injection of anti-D immunoglobulin is given.

The chances of success are about 50% (Pitié-Salpêtrière, HUG), with figures of 40 to 50% according to the INSPQ. They are better if you have given birth before, if baby is not engaged, if baby is a complete breech, if the placenta is at the back and if the amount of fluid is normal. After a successful version, about 5% of babies go back to breech.

The risks are low: fewer than 1% adverse events according to the INSPQ. They may include a loss of waters, bleeding, contractions or, more rarely, abnormalities of baby's heart rhythm requiring a rapid caesarean. That is why ECV is done in the maternity unit, never at home. It is not offered in certain situations, which your doctor will assess with you.

Postures, acupuncture, “tricks”: what are they worth?

Advice for turning baby is everywhere: raised pelvis, all-fours position, light or music at the lower belly, acupuncture, moxibustion. None of the hospital and public health documents we consulted recommends them. Only ECV is presented there with figures for success rates.

If a posture feels good, nothing stops you practising it, provided it is neither painful nor prolonged, and does not delay your medical appointment. However, do not let anyone other than a doctor in a maternity unit press hard on your belly to try to turn baby: it is precisely because the manoeuvre carries rare risks that it is done under monitoring.

Vaginal birth or caesarean: how is the choice made?

If baby stays breech, two options exist: a planned caesarean, or a vaginal birth under well-defined conditions. The decision is made with the team, depending on your history, baby's exact position and the experience of the maternity unit.

The arguments in the debate. In 2000, a large international trial, the Term Breech Trial, led many countries to favour planned caesarean, because of a higher short-term risk for the baby; no difference was observed at 2 years, however. In 2006, the PREMODA study, carried out in 174 centres in France and Belgium, showed that in well-selected women, serious mortality and morbidity of babies were not significantly different between vaginal birth and caesarean (INSPQ). Canadian professional societies have since suggested vaginal birth for complete or frank breech, and caesarean for footling breech.

In practice, countries differ. In Switzerland, 95% of breech presentations end in a caesarean, vaginal birth remaining the exception, even though the HUG have created a dedicated pathway to offer it when possible.

Situations where a vaginal birth is not advised (British Royal College, cited by the NHS, and Pitié-Salpêtrière):

• baby in footling breech;
• baby estimated as large or, on the contrary, small;
• baby's head tilted well back (deflexed);
• low-lying placenta (placenta praevia);
• pre-eclampsia, or a health problem that rules out pushing efforts;
• narrow pelvis or a uterus already operated on (previous caesarean).

When a vaginal birth is considered, the team assesses the pelvis (sometimes by scan), the estimated weight and the position of the head, then reassesses around 40 to 41 weeks. Be aware that about one attempt in two ends in a caesarean during labour (Pitié-Salpêtrière). To understand the stages of a natural birth, see our article on vaginal birth.

What if labour starts before the planned caesarean?

Go to the maternity unit at the first regular contractions or when your waters break, without waiting as you would with a head-down baby. There, the team checks whether caesarean is still the best option. If baby is already very low and the birth is near, a vaginal birth may then be safer (NHS).

In Morocco as elsewhere, not every team offers vaginal breech birth. If this option matters to you, ask early of your gynaecologist and the clinic or hospital: who will be present, at night and at weekends? Our guide to choosing your maternity unit helps you prepare these questions, and our maternity bag page helps you be ready from the 36th week. The other steps of this end of pregnancy are in our article on the ninth month.