I can still remember a pregnant woman whose baby, at 36 weeks' gestation, was still not thinking about turning her head down into the mother's pelvis. However, this head-down position is the most favourable starting position for a vaginal birth. But no, this baby continued to "squat" upright in mum's belly with its legs bent and its head held high. It remained in the breech presentation (BEL). All of the mother's efforts to motivate the unborn baby to turn head downwards as planned were unsuccessful.
As a result, the so-called "external turn" was performed at the maternity clinic (more on this below) by the hospital doctor in the 38th week of pregnancy. However, even this "gentle external pressure" did not lead to the desired success. After detailed medical counselling, the mother-to-be decided to have her baby naturally despite the breech presentation.
As if by a small miracle, her baby turned on her own shortly before birth and was finally lying with her head down in the best starting position, the so-called cephalic position. The mother gave birth to a healthy baby girl and joked on the little one's first birthday that she had shown her own head right from the start.
Sometimes these "little miracles" happen and the unborn child does the hoped-for somersault in time for the birth. According to the medical guideline S3 (2020) of the Association of the Scientific Medical Societies in Germany (AWMF), however, three per cent of children are still on the Calculated date of birth in the pelvic presentation. The Bonn University Hospital even speaks of five per cent, other sources state up to six per cent. But even then, not all children affected by a breech presentation are automatically recognised by Caesarean section delivered. After careful consideration of the risks and under certain conditions, a vaginal birth is also possible with a breech presentation. In Germany, a good 10% of breech deliveries are currently delivered naturally.
What does breech presentation mean?
The closer the due date approaches, the tighter it gets for the baby in mum's womb. This is why it assumes its optimal birth position until around the 34th week of pregnancy. This means that it turns in the uterus so that its head sinks down into the mother's pelvis. This is the best position for the baby to move through the birth canal. After the birth, the baby's Maternity passport Accordingly, this is noted as "SL" (cephalic position). If, on the other hand, the baby's head is still pointing upwards at birth and the legs or buttocks are pointing towards the birth canal, this would later be recorded as "BEL" (breech presentation) in the maternity record.
In every pelvic presentation, the baby's head is at the top and its pelvis at the bottom of the womb. However, as the baby's legs can assume different positions, a distinction is made between the following positions:
- With the "pure breech position" the baby's bottom sits in the mother's pelvis while its legs are "folded up" so that the little feet are in front of the face. This is the most common position in BEL. Here the baby is born breech first.
- In the "perfect breech-foot position" the unborn child has its knees forwards bent and pulled towards his tummy.
- The "imperfect breech-foot position" in turn consists of a combination of the two aforementioned positions: one leg points completely upwards as in the "pure breech position", the other is drawn up towards the abdomen as in the "perfect breech-foot position".
- With the "perfect foot position" both legs stretch downwards towards the birth canal. They are then also born first.
- With the "imperfect foot position" the baby does the splits in the mother's womb: one leg is stretched downwards as in the "perfect foot position", the other leg stretches upwards as in the "pure breech position".
- In the "perfect kneeling position" Again, both legs are bent backwards, as if the child were kneeling in the tummy.
- The "imperfect knee position" again shows a combination of two positions: One leg is bent backwards as in the "perfect kneeling position", the other leg is stretched upwards as in the "pure breech position".
However, in all vaginal breech deliveries, the baby's head is always last born. However, as it is the baby's largest body part, this can cause problems (more on this below).
Incidentally, many parents whose baby has made itself comfortable in mum's womb in the breech position are often told that their baby is lying "the wrong way round". Although the cephalic position is the best starting position for the birth, the BEL should not be described as "wrong", especially as this description fuels fears and worries among parents. I therefore prefer to describe the baby as lying "the other way round".
What are the reasons for a breech presentation?
Let's get straight to the point: In most cases, no specific reasons for a breech presentation can be identified. However, we do know that the following possible causes can lead to a breech presentation:
This includes unfavourable positions of the Placenta inside the uterus. This is the case, for example, if the placenta is too close to the cervix or even covers it. Also Malformations of the Uterus Fibroids in the uterus or a narrowed maternal pelvis can be responsible for a breech presentation. Sometimes it is also due to Umbilical cord too shortthat the baby cannot turn. Or that Child is exceptionally tall. Furthermore Too much or too little amniotic fluid play a role.
Even with a Premature birth the unborn baby may still be in the breech position - depending on how prematurely it is born. And with Twins or multiple pregnancies In most cases, a baby is in the breech position.
By the way: A Norwegian study years ago came to the conclusion that a breech presentation could even hereditary can be: According to this, the probability of a breech presentation doubles if one of the child's parents was born in a breech presentation.
You can try these "turning manoeuvres" yourself
Delivering a baby naturally in a cephalic position is less risky than a breech presentation. For this reason, both the pregnant women concerned and the obstetric teams are very keen to ensure that the unborn child turns in the cephalic position before birth.
There are various ways in which you can try to "persuade" your baby to turn without medical intervention. Consult your midwife about this. You can also contact me at my online counselling for this purpose. However, all methods are without guarantee of success.
You can try the following:
The Indian Bridge is a gentle yoga exercise for which you need no prior knowledge. Here's how: Lie on your back on a mat and place your legs about hip-width apart. While your arms lie relaxed next to you and you breathe calmly, lift your pelvis upwards. Hold it there, continue to breathe calmly and then slowly lower your pelvis again. If you find this too strenuous, you can also place a thick cushion under your bum so that your pelvis is slightly higher than your upper body for a few minutes. Some pregnant women also rest their lower legs on a chair or similar. After a maximum of 10 to 12 minutes, release this position again and stand up with a little swing over the side. This should encourage the child to turn round. If it doesn't do this, you can try the Indian bridge again a few days later.
Ideally, a second person should be present during this exercise. If you feel dizzy or nauseous, please stop immediately.
The knee-elbow stance: Stand on four feet and support yourself on your forearms. In this position too, your pelvis is now higher than your upper body. Stay in this position for a maximum of 10 minutes. This should also free the baby's bottom from the mother's pelvis so that the baby can turn better.
Moxibustion: This treatment, also known as moxa therapy, has its origins in traditional Chinese medicine. A specific acupuncture point is stimulated using a mugwort stick burnt in its immediate vicinity. In the case of a breech presentation, this point - known as the Zhiyin point (p. 67) - is located on the outside of the pregnant woman's little toe. The application is best carried out between the 33rd and 35th week of pregnancy by a person trained in moxibustion, preferably twice a day over several days. According to various studies, it has been proven to stimulate the baby to move more and, if possible, to turn. Because this is successful in quite a few cases, moxibustion is considered a successful method.
Bell trick: Still safe in the amniotic sac, the baby still perceives sounds from outside. The little bell trick aims to utilise this early hearing ability. You make a little bell at the bottom of your belly ring. This is intended to arouse the baby's curiosity and encourage it to move its head in this direction. Some pregnant women wear a bell on a long string or attach it to the front of their trousers with a safety pin to "point the child in the right direction".
Torch method: The unborn child can not only perceive sounds in your belly, but can also distinguish light from dark through your abdominal wall. That's why you can use a light source, such as a switched-on torch, instead of a sound source, using the same principle as the bell trick. You can shine it over your tummy and try to lure your baby in the direction you want it to turn.
What is an external rotation of the pelvic presentation?
The Guideline of the AWMF recommends that pregnant women with an uncomplicated singleton breech presentation be offered a so-called external turn from the 36th week of pregnancy. Ask your doctor about this if you have not received this offer!
The external reversal is usually carried out in the maternity clinic by an experienced doctor in the 37th or 38th week of pregnancy. A preliminary consultation takes place first, as it must be clarified whether this intervention should be used on you. The position of the baby, the amount of amniotic fluid, the position of the placenta and the course of the umbilical cord must also be checked again by ultrasound.
Known for centuries and established for decades, external turning is now regarded as a gentle and very safe method. The Complication rate for external labour is less than one percent. Nevertheless, the clinics regularly put themselves on standby for caesarean sections - just in case. This could be due to vaginal bleeding or a problematic CTG, for example. This is why a blood test and a discussion with the anaesthetists are routinely part of your preparation for the external delivery.
For the reversal procedure itself, the pregnant woman is then admitted as an inpatient for a short time in some clinics, while other clinics plan the reversal attempt on an outpatient basis. On the day of the external reversal, a CTG before and during the "turning manoeuvre" to find out how the baby is doing. Depending on the clinic, the pregnant woman may also be given a prophylactic to prevent labour.
How is the external turn performed? The doctor will first stimulate the unborn child with massage-like hand movements on the mother's abdomen. The baby's bottom should then be mobilised out of the mother's pelvis and gently pushed upwards. Sometimes the baby's head is carefully guided downwards at the same time. Ideally, this method causes the baby to somersault and turn into a cradle position. Some babies are easily "persuaded" to do this. Sometimes the procedure can also feel very uncomfortable for the mother. If she experiences severe pain or too much pressure has to be applied, the attempt to turn is usually cancelled.
The Success rate of the outer turn is up to 70 % in Germany, depending on the clinic. First-time mothers are less likely to turn than women who have already given birth to one or more children. It is recommended that affected pregnant women visit a specialised birthing centre for the external turn if possible. The "manoeuvre" is followed by a control CTG lasting up to 60 minutes. If mother and child are doing well, the pregnant woman can usually go home on the same day. If the external labour was not successful, a second attempt can be made a few days later.
However, I don't want to withhold from you the fact that an unborn baby can turn back again even after a successful external turning manoeuvre into the breech position. However, this only occurs in three to four per cent of cases - and is therefore just as common as the spontaneous turning of the baby after an unsuccessful external "turning manoeuvre".
In order to keep the baby in the cephalic position after the external turn, it is important that the baby's head is firmly attached to the mother's pelvis. You can support this by practising the birth movements of pelvic circles and the deep squat. This will help you during labour and support your baby's correct birth position.
So take another look at the video lesson on birth positions in the Online birth preparation course from midwife Katharina. If you only have a little time, you can also find this in the "Online crash course to prepare for the birth" by emergency midwife.
How does breech presentation affect the birth?
In principle, a vaginal birth is also possible with a breech presentation. However, it must be accompanied by a very experienced, well-qualified obstetric team with a lot of practice in breech births. In the last three decades, however, babies in the breech position have been regularly delivered by planned labour in more and more hospitals. Caesarean section delivered. As a result of this practice, obstetricians have lost a great deal of experience in vaginal deliveries of breech babies.
If your child is also in a breech presentation and you want to give birth naturally, you should preferably do so in a specialised maternity clinic. Also be prepared for this: You will be thoroughly examined beforehand. After all, it must be crystal clear what your individual requirements are for a vaginal birth. This also includes intensive medical counselling. The respective advantages and disadvantages of a vaginal and surgical birth with a breech presentation will be discussed with you. This is because the existing risks must be carefully weighed up against the benefits. If the gynaecologist comes to the conclusion that a vaginal birth from breech presentation carries too many risks for you and/or your child, you will be advised to have a planned caesarean section. Take your gynaecologist with you to this consultation. Birth plan with.
You should also know: The ideal birth position for a breech presentation is the quadrupedal position. This is because the baby has to wind its way through the birth canal with its bottom first, just like a baby in a cephalic position with its head first. Once the bum is born, the head still has the same path and the same turns ahead of it. It now slips into the mother's narrow pelvic ring and presses on the umbilical cord. Because of the oxygen supply to the baby, the birth must now proceed quickly. If you are in a quadrupedal position, the pelvic space is wider. This gives the head and umbilical cord more space. At the same time, the oxygen supply for the baby is better than with a supine birth. Women who give birth to their babies in the supine position often find the labour more strenuous and painful. This is especially true if the baby has to be born in a breech position. Obstetricians can support the birth of the head with special manoeuvres so that the baby's head birth does not take too long. The quadrupedal position also protects against perineal tears and injuries in the vaginal area. This birthing position protects the Pelvic floor and protects it from long-term damage.
Some important requirements for a vaginal BEL birth:
- The pregnant woman wants this type of birth.
- It is not a premature birth before the 37th week of pregnancy.
- The pregnancy was uneventful, mother and child are doing well. There is nothing that would speak against a vaginal birth.
- Depending on the position of the breech presentation, the obstetricians are confident enough to accompany the baby. Sometimes this is only the case in the "pure breech position" or the "complete breech-foot position".
- The baby is not too heavy (over 4,000 grams), but also not too light (under 2,500 grams) for this type of delivery in BEL.
- The woman's pelvis is sufficiently large and is not disproportionate to the child's head circumference.
- The size ratio of baby's stomach and head circumference is also correct. The abdominal circumference should not be much smaller than the head circumference.
