Transcript episode #19: all about breech babies
Click here to download a transcript.
00:00 Today we're talking all about breech babies. Welcome to the All About Pregnancy and Birth podcast. I'm your host Dr. Nicole Calloway Rankins, a board certified Ob Gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, confident and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.
00:41 Hello and welcome to another episode of the podcast. Thank you so much for being here today. All right, so today I'm talking about what happens if your baby is breech. And breech just means that your baby's bottom, your baby's butt, is closer to your vagina than your baby's head. That's it. Maybe it's kind of upside down in a sense and what I'm going to talk about today is how common breech presentation is. And spoiler alert, it's actually not that common. I'll talk about some risk factors for breech presentation. How we suspect a baby is in breech presentation, the different types of breech presentation because it matters in terms of the management, and then I'll go over the options for management and how that management has changed over time and some of the controversy that has generated as a result.
01:32 Now, before we get into the episode, let me do a couple of quick things. First, number one, let me give a shout out and this is to Lisa Kay. Lisa left me this sweet comment in Instagram and I'm going to paraphrase it a little bit. She says about she and her husband Brian, not only do we sincerely love your informative podcast and mini course, your Birth Preparation Course is very helpful in easing both of our fears about the unknown due to your expertise and reassuring words and voice. We are in our late thirties and we feel like your podcast is right on time and helping us build confidence. Thank you for your hard work and thank you for your diverse topics, guests and addressing concerns for women of color. We can't wait for your next episode. Thank you so much for that sweet comment Lisa. As I told you, it really touched and warmed my heart and I really, really appreciate it and am glad that you are finding the information helpful.
02:32 Now, the second thing that I want to talk about is this. If you are considering a childbirth education class, which you should be, you should be preparing for your birth. Then enroll in my signature class, The Birth Preparation Course, and I want you to do that for three reasons or at least consider it for three reasons. All right, number one, it is a great course. I put my heart and soul into really developing the content for this course. It took me a year to put everything together. It's very comprehensive. It covers everything from getting in the right mindset for your birth to how to create a warm, comfortable environment in your labor room, how to choose the right people to support you. I talk about the stages of labor, your options for pain management, options for monitoring your baby, what you can eat and drink, how to push and avoid vaginal tears. I talk about the golden hour after birth. I cover some possible things that could happen that you should be aware of just in case like labor induction, episiotomy, how to make the best of a cessarean birth if it gets to that and then some things in the postpartum period like steps for successful breastfeeding. What happens in the hospital after you have your baby, I talk about the vitamin K injection, the hepatitis B vaccine, antibiotic eye ointment, the risks and the benefits of those. And I talk about male circumcision, warning signs to look out for in the postpartum period and then how to make your birth wishes or what's commonly referred to as a birth plan. There are over eight hours of content in the course and it's a modern day way to do childbirth education. Everything is online. You can go through the material on your own time and at your own pace with your partner.
04:25 There's support there as well. We have a private Facebook community where I am in the group regularly and I also have an experienced Doula who is the community manager of the group, so she's there as well. The course is affordable. It's $147 and I made it that price for a reason. It's a lot less than many childbirth education classes. And I did that because I wanted it to be accessible for most women. And speaking of access, you get lifetime access to The Birth Preparation Course, so you buy it once and you have it for every future pregnancy.
05:00 So the first reason I want you to enroll in The Birth Preparation Course is because quite simply it is a great course and great childbirth education. Now, the second reason I want you to enroll in The Birth Preparation Course is that enrollment in the course helps support some of the other things that I do. I love giving you information for pregnancy and birth through this podcast and my free mini course on how to make a birth plan and my website where I have downloadable tip sheets. But I gotta be honest. These things cost money. I have things like podcast and website hosting fees, webinar software, lots of other little things that go into providing you high quality information. And enrollment in The Birth Preparation Course again is how I'm able to help support those things and bring those things to you and I want to be able to continue to do that for you in the high quality way that you deserve.
05:53 And then the third reason to enroll in the birth preparation course is that by doing so you are supporting organizations that help pregnant women. For every 100 women who enroll in The Birth Preparation Course, I'll donate $1,000 to an organization that helps support pregnant women. I have a couple of organizations in mind that I like to support, but of course I want to also support organizations that you know that help pregnant women as well. So to enroll in The Birth Preparation Course, go to www.ncrcoaching.com/enroll or go to my main website www.ncrcoaching.com and just navigate to it there. Again, it's a great childbirth education course. It helps me do some of the other things like the podcast and the free webinar and my website, and you will be supporting other organizations that help pregnant women.
06:46 Okay. With that being said, let's go ahead and get into today's episode on breech presentation. All right, so let's start off by talking about how common is breech presentation? Well, babies are fairly commonly breech in the early part of pregnancy. In the early part of pregnancy, babies can move around a lot within the amniotic fluid because there's a lot of fluid relative to their size, so we'll see that anywhere from about 20 to 25% of babies under 28 weeks are breech, that number decreases at 32 weeks where it gets to be between 7 and 16% of babies are breech. But then by full term, only 3 to 4% of babies are breech, so the vast majority of babies will settle head down and will not be breech.
07:39 Now, most of the time breech presentation is a random thing, but we do know that there are some risk factors that can increase your chances of having a breech baby. Number one is if you've had a baby that was previously a breech presentation. When you have something once before it increases the chances of it happening again. Number two, if you have something different about the shape of your uterus that causes the baby to settle into a breech presentation, that's a risk factor. So for instance, if you have a fibroid. Fibroids are smooth muscle growth in the uterus and depending on where a fibroid is located, it may just make it that the shape of the inside of your uterus, the baby can't quite settle with their head down and they end up settling in a breech presentation.
08:29 Another thing that can increase your chances of having a breech baby is extremes of amniotic fluid. So if you have a lot of amniotic fluid, that is something called polyhydramnios. Poly refers to water and amnio says the amniotic fluid. So with polyhydramnios you have lots of extra fluid and the baby just has a lot of extra room to flip around and that can increase the risk of the baby being breech or what's called an unstable lie, where the baby is breech and then flips to head down and then flips to breech or flips sideways. So that's a risk factor with polyhydramnios. And then on the flip side oligohydramnios means low fluid. That can increase your chances of your baby being breech. If they settle into a breech presentation and the fluid is low, then it's hard for them to spin out of it because there's not a lot of fluid, not a lot of space for them to move around. And then the final thing is as moms get older, the risk of breech presentation has increased. Not sure why, but that's just kinda the way it is.
09:39 Okay. So how would you suspect "is my baby breech or not? You know, I'm just wondering what's going on." Well, one thing, you may feel discomfort under your ribs. So if a baby is breech and that head, which is the largest part of your baby, is sitting right underneath your ribs, it may cause you to feel a lot of discomfort. Another thing that you may feel is that you feel the kicks in the lower part of your abdomen or even in your vagina, you may feel like, it feels like this baby is kicking in my vagina! And it may be because your baby IS kicking in your vagina. Literally. If your baby's breech and they're kicking down towards your vagina and you may feel that kicking lower, we may pick up your baby's heart ratein the higher part of your belly.
10:26 Think about where your heart is in relation to your head, and we know that your heart is closer to your head than it is to the bottom part of your body. So if we're picking up the heart rate in the higher part of your belly, then that's a higher chance that you know, the head is up there as well. Just because our heart is closer to our head. Now on vaginal exam, I may have a suspicion that your baby is breech when the head is down and pressure is well applied, you can feel something round and smooth. You can feel it there. However, if it's a butt that's sitting right there, you may not necessarily know that it's a butt until your water's broken and you can actually feel the part, your cervix is open enough, like three or four centimeters that you can feel what's there.
11:15 And a butt will feel different. It'll feel a lot squishier than a head, which you can't always tell by vaginal exam. The definitive way to diagnose a breech presentation is by ultrasound and it's very easy to tell by ultrasound where the head is. The bones of the head are very clearly visible on ultrasound and where it is.
11:36 All right, now let's talk about the types of breech presentation. Now the first one I want to talk about is complete breech and that's when the hips and the knees are flexed. Y'all, I'm sitting here now like flexing my hips and knees, trying to do the position as if you can see me, obviously you can't. But I do have a picture on the show notes page that shows you the different types of breech. So you can go to the show notes and look at the picture and get an idea. In the meantime, let me try to explain it as best I can. So it's kind of like a cannon ball position. Like if you were jumping into a swimming pool ina cannon ball where your hips are bent up and the knees are flexed. This position, complete breech, happens not that common. It's in about5 to 10% of breech babies.
12:32 Now the second type of breach presentation, and this one is the most common, this is called frank breach and this is when the hips are flexed so the hips are bent up, however the knees are extended so the legs are straight. So what that means is it's like the legs are sticking straight out and again I'm sitting here recording and sticking my legs straight out. Anyway, the legs are extended straight out and the feet are up by the head. So like a pike position I guess would be. So hips are flexed, knees are extended feet are up by the head. This is the most common type, 50 to 70% of babies at term if they're breach will be in the frank breech presentation.
13:19 And then the third one is basically not the other two, and that's called incomplete breech position. And that is when one of the hips may be flexed. Both of the hips may not be flexed. It's kind of everything else. And that can be anywhere from 10 to 40% of babies are incomplete breach. So the presenting part may be the butt or it may be one or both of the feet. And that's called a footling breech. Rarely it could be the knees. That's a kneeling breech. I've never seen that happen before. So there's complete breech, which is like the cannon ball presentation, not very common. Frank breech, which is most common, the feet are up by the head and then incomplete breech.
14:02 Now the reason why breech presentation matters is specifically for a vaginal breech delivery. In general, when babies deliver with their head down the head and the shoulders are the widest part of your baby. So if your baby's head and shoulders come through the cervix, then the rest of the body is going to come through just fine. We don't have to worry about a baby getting stuck, particularly at the level of the cervix. However, if a baby is breech, now think about it, kind of picture it. If a baby is coming down in breech presentation, say they're coming down in that rear position of a footling breach, then the feet, the legs, those are the skinnier parts, the hips, the baby could come down, down, down, up until the chest and the armpits. And what happens if they get stuck at that spot because the cervix was wide enough to let that the body come through, but the upper part that's the widest part of the body is not coming through, and that can be a true medical emergency.
15:15 If a baby gets stuck like that, it's very difficult to get a baby out like that. You have to cut incisions in the cervix, which can be difficult to repair. So you definitely don't want to try a vaginal breech for the incomplete breech. That's the one that's the scariest. The other thing that could happen is that a cord could come through the vagina first. That's called a cord prolapse. And that is a true emergency because that can cut off the blood supply to your baby very quickly and the head sitting there or even a butt sitting there will help prevent the cord from prolapsing because you know the head is filling the space. But if the feet are there for instance, or one foot is there, then a cord could easily sneak down and again, that is a disaster. So we care about the different types of breech because that incomplete breech presentation in particular has a lot of risk associated with it.
16:12 All right, now let's go and talk about the options for breech presentation. The first one that I want to talk about, and this has become the most common option, is a planned cesarean delivery. And when that happens, the c-section is scheduled at 39 weeks. We know from research that 39 weeks is the time that we know that babies are, well babies born at 39 weeks almost always do well and that's like the optimal time for a delivery. So as c-section is scheduled at 39 weeks. This was not always the case that a planned cesarean delivery was the birth method of choice for a breech delivery. Vaginal breech deliveries used to be done more commonly. However, there was a study in 2000 called the Term Breech Trial and what that study showed is that by doing a scheduled cesarean section, it reduced neonatal morbidity and mortality by a bit in neonatal is that first period.
17:23 It's within 28 days after birth I believe. So it reduced neonatal morbidity, which is bad things happening short of death and then reduced mortality, which is a baby dying. So doing a planned cesarean delivery as opposed to a vaginal birth, decreased neonatal morbidity and mortality. However, there was a slight increase in maternal morbidity and that's to be expected because a c-section is a bigger procedure than a vaginal delivery and a c-section is going to carry more morbidity with it, then a vaginal birth. So this Term Breech Trial in 2000 showed that improved outcome for babies, slight increase in bad outcomes for mom. Now interestingly, it shows that there was no effect on longterm outcomes for either children or moms at two years of age. Now this has completely changed the way obstetrics is practiced in the United States and really throughout the world and now 95% of babies are delivered by cesarean section.
18:33 This has been a little bit of a point of contention among women and understandably so, who want a vaginal breech delivery if possible. And the vaginal breech delivery is possible. ACOG says that a vaginal breech delivery is appropriate for patients who have characteristics that are believed to place them at a low risk of labor and delivery related complications. And ACOG is the American College of Obstetricians and Gynecologists. They set maternity care standards for obstetricians in the United States. So that's their statement on vaginal breech delivery. And appropriate candidates for vaginal breech delivery are the baby has to be in a good position for a vaginal breech. So a frank breech position tends to be okay because if the butt is coming down and the legs are up by the head, it makes a wide part for the baby and everything comes through okay. You don't have that risk of the baby getting stuck like I talked about.
19:32 If women have had vaginal deliveries before and then have a a vaginal breech baby then they are great candidates. In fact that's one of the few vaginal breech deliveries that I've done. This was her third baby and the baby was coming breech and you know, everything went fine. So those are the two circumstances where vaginal breech may be appropriate. But let me tell you what else ACOG says about it. AGOC says the decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery. And here in lies the controversy. Quite simply, there just aren't a lot of providers who are trained in offering vaginal breech delivery. It's just not something that's really done because this trial, now almost 20 years ago, changed practice, there just aren't many folks still practicing who do vaginal breech deliveries. And because breech presentation is very rare or not very common I should say, and only happens in about 3 to 4% of pregnancies, there's not a lot of opportunity to learn and it's challenging to go back once you're out in practice to learn how to do vaginal breech delivery. So it's not necessarily straight forward.
21:07 It's certainly something that I think a lot of providers would like to be able to offer. And I know I've worked at a hospital where there are more experienced older providers who do do vaginal breech deliveries. But it just isn't that common and we want to be able to offer the mode of delivery that's the safest. And if we know that we can safely do cesarean section and don't have that experience for vaginal breech delivery, then really that is what should be done.
21:36 Now I get it. This brings up all types of issues because really in order to decrease this cesarean section rate, we really need to focus on preventing the first cesarean. And then women can get in this situation where they have a cesarean section for a breech presentation and then all of a sudden the second time around they have limited options in terms of being able to do a VBAC. So I get it that it's a very controversial issue and it has implications, that first cesarean section. But I just want to give you a little bit of the background about why that's the case and the challenges in finding a provider who will do vaginal breech delivery. You really want someone who is doing something that they're comfortable with and not something that they don't have any experience with.
22:29 Now, ideally what we should be doing is something called external cephalic rotation before labor. And what that is is a fancy way of saying turn the baby around to be head down. So literally we put our hands on the belly and we try to push the baby up out of the pelvis and turn the baby into a head down presentation. It's done at around 37 weeks of pregnancy. The average success rate is about 58%. So a little better than a 50/50 chance, you know, almost 60% chance that it'll work. The issue with this, as you may imagine, it can be painful. It can be uncomfortable having someone turn your baby while they're in your belly. So some things that we do in order to help improve the success, are anesthesia, some women will get a spinal placed. It's the same thing you get for a c section. And where it will last for about two hours and it'll make it less uncomfortable.
23:31 And then also medications to relax the uterus that can help make it easier to turn the baby. And there are some risks to doing it. They happen less than 1% of the time, but some of the risks include olacenta abruption, where the placenta separates away from the wall of the uterus early. That can be a true emergency because that's your baby's lifeline. So if the placenta abrupts we need to maybe do an emergency c section. It can also potentially cause your water to break. But again, the rates of those things happening are less than 1%. So ACOG says that obstetricians should offer and perform external cephalic version whenever possible. So really what we should be doing is offering to turn the baby into a head down presentation and we do that on labor and delivery just in case some of those other things happen, then we are able to do an emergency c section quickly if needed. We can monitor the baby. You know about a 50 to 60% success rate. So again, that should be the first thing that we do. Try to turn the baby and then if not, I can tell you the most likely next thing is going to be a recommendation for a cesarean section. Just because most providers do not have experience with doing a vaginal breech delivery. Or you may be able to find a provider who does have that experience and is willing to offer you that option.
24:59 Now the last thing I want to talk about is something called moxibustion and I hope I'm saying that right. I'm not sure if I'm saying that right, but that's what it sounds like. Moxibustion is a form of traditional Chinese medicine, in which an herb, it's called Artemisia vulgarian, this herb is held close to the outer edge of the little toe. And doing that along with acupuncture is shown to maybe help increase your chances of turning a breech baby. Evidence suggests that it is safe. There is a lot about it that we still don't know for sure. Like we don't know which type of method works best for turning breech babies. It does appear that using it twice a day for two weeks during weeks 33 to 35 of pregnancy works for about one in eight women. So, the chances are there, it's not super duper high chances, but again, it's something that is low risk and safe that you may consider. If you're interested in using Chinese medicine, you know, the moxibustion acupuncture, then be sure to consult a licensed acupuncturist who specializes in the treatment of pregnant women and they do exist. So just like anything else, make sure you do your research and do it with someone who has experience.
26:28 Okay, so that's it for breech presentation. I would love to hear in the All About Pregnancy and Birth Podcast community Facebook group if your baby is breech and what your experience has been with your provider on talking through the different options for management. You can find that group on Facebook. It's a great place to be to talk about things after the show. I also do inspirational quotes and helpful tips. So come join us in the All About Pregnancy and Birth Facebook group. You can search for it on Facebook or the link is in the show notes. And I will put one more plug in for enrolling in The Birth Preparation Course. Remember that it is great, outstanding childbirth education. It's how I'm able to support things like this podcast and the mini course and my website and you will also be helping other pregnant women in the process. So head to www.ncrcoaching.com/enroll or go to my main website and you can get to it there.
27:27 Be sure to subscribe to the podcast in iTunes or wherever you listen to podcasts and if you feel so inclined I'd really appreciate you leaving an honest review on iTunes. It helps other women find the show. Next week on the podcast I have one of my best friends, like Kim and I have known each other literally since we were babies. She is coming on to talk about her experience having not one but two successful VBACs, and incidentally her first c section was because her first baby was breech. All right, so come on back next week and until then I wish you a healthy and happy pregnancy and birth.
28:08 Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan, as well as my comprehensive online childbirth education class, The Birth Preparation Course, with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident, and empowered going into your birth. Head to www.ncrcoaching.com to learn more.