Patient information

Breech presentation

1. Summary 2. What is breech presentation? At the end of the , some In breech presentation, the head of the children lie in breech presentation: with child lies towards the top of the . the buttocks down and the head up. If the buttocks lie by the exit of the Early in the pregnancy breech , it is referred to as frank breech. presentation is quite normal but at the The legs can also lie underneath the end of the pregnancy the child typically buttocks, which is referred to as lies with its head at the bottom. It is complete breech. usually unclear as to why a child remains in breech presentation at the end of a pregnancy. There are some situations with an increased chance of breech presentation:

 if you are pregnant with twins or more;  if the uterus or pelvis has an unusual shape;  if the or a uterine fibroid lies in front of the exit;  if the child has congenital abnormalities. Complete breech: with the knees bent so If your child still has breech presentation that the feet lie next to the buttocks. 36 weeks into the pregnancy, the gynaecologist or obstetrician can try to rotate the baby. In the event of a breech presentation at the end of the pregnancy you can choose between a or a vaginal . A child with breech presentation can usually be born vaginally. The buttocks or feet of the baby will appear first. In the Netherlands, gynaecologists have agreed on a number of conditions under which a standard, vaginal birth is safe, also for a . Frank breech: with the legs upwards

along the body.

Bestelnummer: 3749 www.ziekenhuisamstelland.nl/en Versie: februari 2018 of the placenta and potential uterine fibroids or other abnormalities that may block the entrance of the pelvis.

6. What happens if the baby is still in breech presentation at 36 weeks? If your child is still in breech presentation at 36 weeks or later there are three further options:

 the physician tries to “rotate” your child into cephalic presentation;  a vaginal birth in which the buttocks Incomplete breech: one leg in frank or feet emerge first; breech, one leg in complete breech.  a caesarean section 39 weeks into the pregnancy. 3. How often does breech presentation occur? Your physician will discuss with you Early in the pregnancy many children which options are realistic in your have breech presentation. Most children situation. rotate during the pregnancy themselves. Around the expected due date less than 7. Rotating a child in breech 3% of children have breech presentation. presentation

4. Why does a child have breech Why is a child in breech presentation presentation? rotated? In more than 85% of , it is The risks for child and mother are the unknown as to why a child has breech lowest during a vaginal birth with presentation around the expected due cephalic presentation. date. There are some situations with an increased chance of breech presentation: When is a breech presentation rotated? Many children will rotate themselves into  in a multiple pregnancy; cephalic presentation before 36 weeks  if the uterus or pelvis has an unusual into the pregnancy. Therefore, it is shape; practical to rotate the child right after  if the placenta or a uterine fibroid lies this period. Sometimes it is better to do at the entrance to the pelvis; it a bit sooner or later. This typically has  if the child has congenital to do with the amount of . abnormalities. It is almost always possible to try to rotate the child right up until the birth 5. Breech presentation examination In the event of breech presentation, your How is rotation performed? abdomen will be examined via In some hospitals, a child with breech ultrasound. The physician or ultrasound presentation is rotated at the outpatient technician observes whether your child clinic but it is also possible that you will has significant congenital abnormalities. be admitted for it. The gynaecologist, a This rarely occurs but such abnormalities resident or an obstetrician who works at can be the cause of breech presentation. the hospital will try to rotate the child. The physician or ultrasound technician You will lie on a bed or an examination also looks at the position of the baby’s table. Before one begins the rotation, the head, the amount of amniotic fluid, the physician will monitor the heart sounds (CTG, cardiotocogram) and the position  The smaller and heavier you are the of the child. In some hospitals you will more difficult rotation becomes. receive an injection or tablet with a pain-  During the first pregnancy, the suppressing medication to ensure that uterus is still firm and rotation has a the uterus does not contract. This can lower chance of success than in the cause your heartbeat to increase for a second or third pregnancy. few hours and you may suffer from heart palpitations. The average chance of success is approximately 40%. It is important that you lie as relaxed as possible so your abdominal muscles do During pregnancy with twins, it is not not tighten. A pillow under your knees possible to rotate either child and in the may feel better. When you find a event of high blood pressure or scarring comfortable position the obstetrician or in the uterus, the gynaecologist can physician will hold the child. One hand sometimes decide not to rotate the child. holds the buttocks of the child, just Possible consequences and complications above the pubic bone and tries to rotate from rotation them upwards. The other hand holds the There are no dangers for the mother. top of your abdomen and tries to push You may receive medication to relax the the head down. This way the child turns uterus. This medicine can cause side its head downwards. The length of the effects but these will always pass. The rotation varies from less than 30 seconds wall of the abdomen can be sensitive and to more than 5 minutes. Sometimes, if painful for a few days because of the the buttocks of the child have settled pushing. This is uncomfortable but does into the pelvis, the assistant pushes no real harm. them upwards via the vagina to facilitate the rotation. Afterwards, the heartbeat After the rotation the heartbeat of the of your child will be monitored again via baby sometimes slows a bit but it almost a CTG. always returns to normal. In very rare cases (less than 1%), the heart sounds How often is rotation of the child remain abnormal and a caesarean successful? section is immediately necessary. It is not predictable whether rotation of the child will be successful. In general: After the rotation the earlier in the pregnancy it is and the If the child is rotated successfully, you more amniotic fluid there is, the easier it can, in principle, give birth at home is to rotate the child. This also has a (unless you have another reason for a drawback: if it is easy to rotate the child hospital birth). The child can return to then the chance that child will return to breech presentation on its own. that position is also high. Your physician or obstetrician can In a number of situations rotation is consider another rotation, which usual more difficult: occurs after a week. If the child remains in breech presentation then you must  In a far advanced pregnancy the stay at the hospital for monitoring of the amount of amniotic fluid is lower, pregnancy and the birth. which makes it more difficult to rotate the child. Women with rhesus negative blood  If the placenta lies by the front wall groups receive an injection of anti-D of the uterus it is more difficult to after a rotation attempt, whether the grasp the child for rotation. rotation of the child is successful or not. For more information, see the pamphlets breech occurs the same way, but one or Pregnant, general information and Blood both of the legs exits first. group, rhesus factor and irregular antibodies. Monitoring of the heartbeat typically occurs, either externally, via the 8. Vaginal birth with breech abdomen, or internally, via an electrode presentation on the buttock of your child.

How does a standard birth with breech Possible complications for the mother presentation progress? The chance of complications for the In many ways, a breech birth is similar mother is not greater during a breech to a birth with a child in cephalic birth than during a birth with cephalic presentation. There are also three presentation. There is, however, a phases: dilation, expulsion and the greater chance that the gynaecologist period after the birth. decides for a caesarean section.

The dilation phase often progresses Possible complications for the child somewhat differently in a breech birth. Directly after the birth Children in breech The buttocks, legs and feet lie at the presentation who undergo a standard bottom and press on the . These (vaginal) birth, are more often admitted are smaller than the head and can get to the incubator room shortly after the through the cervix more quickly. You birth than children born via caesarean may feel the need to push before section. After a standard birth after 38 complete dilation occurs because of this. weeks of pregnancy, approximately 1 in The physician or obstetrician will then 20 children require time in an incubator ask you to stop pushing. and that is ten times more frequent than after a caesarean section. There are Expulsion occurs exactly as with a child various reasons for admission. After the in cephalic presentation. Towards the birth, the child sometimes requires end, if the body of the baby is additional oxygen or respiratory support. approximately half of the way outside, Sometimes injury occurs during the the gynaecologist will ask you to take a birth, such as bone fracture, nerve deep breath and stop pushing. During damage or intracranial haemorrhage. the following contraction, the head can This rarely occurs (in approximately 1% come out in one attempt. Upon exit of of all children with breech presentation), the head, an assistant will often press but approximately two times more above the pubic bone to ensure that frequently than after a caesarean head has fully passed through the pelvis. section.

During a breech birth a special bed is After the birth almost always used: the foot of the For the long term there is no difference delivery bed is removed and you will between children with breech place your legs in supports (just as with presentation born via caesarean section internal examination in a gynaecologist’s than those born vaginally. Development chair). The gynaecologist can then stand proceeds the same way and there is no between your legs to help with the birth. greater chance of mortality. With a child in frank breech, with the legs up, the buttocks exit first, then the Examination of two-year-old children rest of the body and the arms and finally shows that the health of children who the head. The birth of a child in complete have been in an incubator is no different from children who have not been in an for example, tear open, the placenta can incubator. sit in front of the opening, or the placenta can grow very tightly with the 9. Caesarean section with breech uterus which causes more bleeding after presentation the birth. A rare consequence is that the uterus must be removed after a Possible complications for the mother caesarean section. These complications The chance of serious complications for occur very infrequently but more often healthy pregnant women due to after a caesarean section than a caesarean section is extremely small, but standard birth (see also The caesarean still always greater than after a standard section). birth (see also The caesarean section). These are not life-threatening 10. Making a choice complications. Some of these also occur after a standard birth, such as anaemia When is a vaginal birth possible? or thrombosis. At the end of the pregnancy, the gynaecologist will discuss with you and Others are the result of caesarean your partner whether a standard birth is section, such as secondary bleeding in safe, or if it is better to perform a the abdomen, bruising or infection of the caesarean section. For a safe vaginal wound, injury to the bladder or birth, some conditions apply: intestines which are not going well. A bladder infection occurs more frequently  There must have been no serious after a caesarean section than after a problems during a previous birth, standard birth. such as technically difficult performance of the delivery via Possible complications for the child vacuum or forceps (a previously In very rare cases, it is difficult to easily performed vacuum or forceps remove a child in breech presentation delivery is no trouble). from the uterus via caesarean section  The estimated weight of the child is and (nerve) injury can occur. not too high. Sometimes, the caesarean section must  The head of the child is bent forward be planned very early in the pregnancy and not backward. to avoid a spontaneous labour. Then the  There is some settling of the breech child can develop lung problems, for into the pelvis. which admission to the incubator room is  The dilation and expulsion are necessary. That is why caesarean advancing well during the labour. sections are generally not performed before the pregnancy has reached 38 Do you actually have a choice? weeks. Your gynaecologist gives advice during a breech presentation. Many women can After the caesarean section choose between a caesarean section and A caesarean section causes a scar on the a vaginal birth themselves. One uterus. This is a disadvantage for the condition is that the gynaecologist who following birth. will guide the vaginal birth, believes this is safe. In that case there is little reason After a caesarean section, you will be to choose a caesarean section. In a advised to give birth at the hospital for a number of situations, you have no subsequent pregnancy because the scar choice: increases the chance of complications during the following birth. The scar can,  It is too late to have the caesarean Dit is een Engelse vertaling van de NVOG-folder section done: the child is just about ‘Stuitligging’. to be born. © 2009 NVOG  It is too early to do a caesarean section: if labour has yet to begin, Het copyright en de verantwoordelijkheid voor deze folder the gynaecologist must wait until 38 berusten bij de Nederlandse Vereniging voor Obstetrie en completed weeks of pregnancy. Gynaecologie (NVOG) in Utrecht. Leden van de NVOG mogen deze folder, mits integraal, onverkort en met Before this time, the risk of bronvermelding, zonder toestemming vermenigvuldigen. respiratory problems for your baby is too high. Folders en brochures van de NVOG behandelen verschillende verloskundige en gynaecologische klachten, The gynaecologist finds it unsafe to  aandoeningen, onderzoeken en behandelingen. Zo krijgt u let you give birth vaginally, for een beeld van wat u normaliter aan zorg en voorlichting example, if the child is too large or is kunt verwachten. Wij hopen dat u met deze informatie not positioned beneficially, because weloverwogen beslissingen kunt nemen. Soms geeft de gynaecoloog u andere informatie of adviezen, you have had a technically difficult bijvoorbeeld omdat uw situatie anders is of omdat men in delivery previously, because dilation het ziekenhuis andere procedures volgt. or expulsion is not advancing well or because the heart sounds of the child Schriftelijke voorlichting is altijd een aanvulling op het gesprek met de gynaecoloog. Daarom is de NVOG niet are getting worse. juridisch aansprakelijk voor eventuele tekortkomingen van deze folder. Wel heeft de Commissie Communicatie The difference between a vaginal birth van de NVOG zeer veel aandacht besteed aan de inhoud. and a caesarean section has only been Dit betekent dat er geen belangrijke fouten in deze folder examined for so-called ‘term breeches’. staan, en dat de meerderheid van de Nederlandse gynaecologen het eens is met de inhoud. These are children in breech presentation who are born after a normal Andere folders en brochures op het gebied van de pregnancy duration (between 37 to 42 verloskunde, gynaecologie en voortplantingsgeneeskunde weeks). kunt u vinden op de website van de NVOG: www.nvog.nl, rubriek voorlichting.

Making a choice Auteurs: dr. G. Kleiverda, dr. M.D.A. Lambers. If you as the expectant parents can Illustraties: B. Blanckevoort choose between a standard birth or a caesarean section, it is important to put all arguments side by side. Many parents think that a caesarean section is the safest way but a caesarean section also has drawbacks. We have placed both forms side by side (see overleaf).

11. In conclusion A child in breech presentation usual leads to many questions. You can, of course, discuss your ideas, any doubts and concerns with your gynaecologist. This text will help prepare you for the conversation.

Notes on this leaflet If any information in this leaflet is unclear or incomplete, please notify us. You can share your remarks with us via [email protected].