About 3-4% of babies will be bottom-down, or in breech presentation, at the end of pregnancy. Although a hotly-debated topic, a large body of research suggested that babies that remain "breech" at term are best delivered by elective caesarean section.(1) The concern with planned vaginal birth of a breech baby is the risk (albeit small) of delay in delivery of baby's head after baby's body has delivered. However, newer research has suggested that vaginal breech birth may still be a safe alternative in selected cases.(2)
Nevertheless, there has been a large decline in the number of women who attempt a vaginal birth with a breech baby, and most obstetricians would still recommend a caesarean section for breech babies, usually at around 39 weeks of pregnancy.
Caesarean sections are not risk-free procedures, however, and it is reasonable to try to avoid one, if possible. Besides immediately planning a caesarean section or a vaginal breech birth, other options for women with a breech baby near term include:
ECV involves the practitioner using their hands on the woman's belly to gently turn baby to a head-down, or "cephalic" presentation. Medication is often given to help relax the uterus to facilitate the procedure. ECV is usually performed after 36 weeks, and has been proven through research to reduce the number of caesarean sections for breech presentation at term by up to 40%.(3) It is a very safe procedure, although there are some rare risks that need to be thoroughly discussed beforehand, and there are some situations where it should not be attempted. When attempted, ECV is successful in about half of cases. Some factors affect the chance of success (such as whether it is the woman's first baby, the location of the placenta, and the size and amount of fluid around baby) and, when all factors are in favour, success may be over 85%.(4) Although the chance of needing an unplanned caesarean section in labour is higher after a successful ECV (around 20%, compared to 12% when mums had head-down babies that didn't require ECV), it remains a simple, safe, and efficient procedure to avoid caesarean section, with one caesarean being avoided for every three ECVs attempted.(5)
Mums with breech babies are often advised to adopt various postures (such as the knee-chest position) to encourage baby to turn spontaneously. Although very safe, available research suggests these practices are ineffective.(6) Similarly, acupuncture and moxibustion (a form of Chinese medicine which involves burning mugwort herb near to the smallest toe - acupuncture point BL67) are sometimes tried, but robust evidence for their effectiveness is also lacking.(7,8)
Ultimately, all women should be fully and frankly informed about the implications of a breech presentation near term, including evidence-based advice regarding their various management options. As for most situations in pregnancy, there is no one-size-fits-all approach, and each woman's management needs to be individualised to her (and her baby's) particular circumstances.
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David is a Fellow of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and undertook his specialist training in Queensland. He is highly skilled in the management of complex and high-risk pregnancies, and has special training in minimally-invasive surgery, endometriosis, pelvic floor and incontinence surgery. David has completed a Master of Reproductive Medicine and is skilled in the assessment and management of fertility problems, and can offer the full range of assisted reproductive treatments. He is a Senior Lecturer with The University of Queensland Medical School, and has published both medical journal and textbook contributions.
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