In breech of contract

Despite being head down and positioned perfectly at the 20 week scan, the alien has decided that this baby is for turning, and at almost 28 weeks has at some point rotated and is now gangnam styling it right (or in this case wrong) way up i.e. breech.

I probably knew this. For the past few weeks, there has sometimes been a very prominent bump I could feel through my skin in the top right hand side of my belly. Assuming that the alien was still in the right position, I assumed this was a rather protruding bottom – turns out it’s the head.

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Apparently I am not to panic, there’s still plenty of room in there and plenty of time for it to reassess its choice of orientation. Women’s Health has an excellent article on the subject; apparently “at the end of pregnancy, around 3% to 4% are found to be breech. Before 37 weeks of pregnancy, breech presentation is much more common – about 20% of babies at 28 weeks are breech, and 15% at 32 weeks”. So in all probability sometime in the next 9 weeks there will be a manoeuvere into the right position.

But what if this doesn’t happen? What are the options then?

If at 36 weeks, the alien is still breech then the first thing they’ll try is to manually rotate them to show them the exit. This procedure is catchily named external cephalic version (ECV) and basically involves lifting the bottom out of the cervix and then encouraging the baby to do a forward roll into the head-down position.

A study from Oxford looked at 805 consecutive ECVs. They found the risk of emergency caesarean section after the procedure was 0.5% (or 1 in 200). The risk of the placenta coming away (abruption) was 0.1% (1 in 1,000) and no babies died due to the procedure.

The bad news is they are only successful in 50% of cases and 3% of babies turn back to breech after successful ECV. The silver lining is that 3% of unsuccessful ECVs turn spontaneously to head-first afterwards!

What if it’s still breech at 37 weeks?

If still in the wrong position, your options are a caesarean section or a breech delivery – the former is likely to be recommended.

The Royal College of Obstetricians and Gynaecologists strongly advises against a vaginal birth if:
● “your baby is a footling breech
● your baby is large (over 3800 grams)
● your baby is small (less than 2000 grams)
● your baby is in a certain position: for example, if the neck is very tilted back (hyper-extended)
● you have had a caesarean delivery in a previous pregnancy
● you have a narrow pelvis (as there is less room for the baby to pass safely
through the birth canal)
● you have a low-lying placenta
● you have pre-eclampsia.”

“Where a vaginal breech birth is being considered, the RCOG supports this only when:
● the obstetrician is trained and experienced in delivering a breech baby vaginally
● there are facilities at your hospital for an emergency caesarean delivery (should this be necessary)
● there are no particular features about your pregnancy that make vaginal breech birth more risky.”

The point about the trained obstetrician is fascinating when combined with commentary from the Women’s Health article:

“In 2000, the results of the Term Breech Study were reported. This study included 121 hospitals throughout 26 countries. Babies were randomly allocated to either planned breech delivery or planned caesarean section. The results revealed that planned caesarean section was safer for the baby than attempt at vaginal birth, with vaginal delivery resulting in a 1% increased risk of death and 2.4% increase in risk of serious problems in the early months after birth…

Since 2000, there has been a significant fall in the number of vaginal breech births throughout the UK, Canada and the US. The result is that even if you do not agree with the findings of the research, or if you accept them and still want a normal breech birth, finding an obstetrician who has enough experience to offer breech delivery might be difficult. Not having an experienced obstetrician will mean that the risk for the baby will be greater than the findings of the Term Breech Study, as this was one of the study entry requirements.”

So an unintended consequence of the study was that less breech deliveries are made and hence doctors are less experienced in them and the risk involved in them increases.

Is there anything I can do in the meantime?

As I mentioned, most babies will move to the right position in the next 10 weeks without any encouragement. There are methods you can employ to try to get it to move in the right direction but they are controversial as to whether they make a difference. These include light / heat / music therapy, the breech tilt (involving unexpected use of an ironing board), acupuncture, moxibustion (burning a moxa stick at a point near your little toe to stimulate your uterus) and a chiropractic technique called The Webster Technique. My friend and yours, Robin from About.com provides a great summary of them all.

I suspect my cool and calm attitude to this will remain until my appointment at 35 weeks – if its still breech then, I suspect all of the above will be attempted whether they are proven to work or not, so the ironing board better watch out!

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