Why breech presentation of the fetus is considered dangerous, what causes it and how labor proceeds?

Your thoughts turn to your unborn child as soon as you find out you are expecting. However, as your pregnancy goes on, you may hear frightening terms like "breech presentation." Breech presentation, to put it simply, is when the baby is not in the optimal position for birth—head down—but rather is positioned feet or bottom first.

This can cause complications during delivery, which may require special care or even a C-section, so it can be cause for concern. However, why does this occur? And as the big day draws near, what does it mean for you and your child?

This post will discuss the causes of breech presentation, the dangers associated with it, and what to expect during labor if your baby is in this position. You can prepare and make the best choices for your health and the health of your unborn child by being aware of what’s going on.

Danger of Breech Presentation	Reasons and Labor Process
Breech presentation is risky because the baby"s head, the largest part, comes out last, increasing the chances of complications like umbilical cord compression or head entrapment.	The causes can include premature birth, multiple pregnancies, or abnormalities in the uterus. During labor, special care is needed, often leading to a C-section to minimize risks.

What is it?

The term "breech presentation" refers to a fetus’s position inside the uterus where its lower limbs or buttocks face the exit to the pelvic area, rather than the head. The head is situated at the uterine base. In actuality, the infant is sitting.

Pregnancy disorders related to breech presentation are referred to as pathological, and childbirth associated with it is also deemed pathological. The fetus in this position is not in a natural state. However, breech presentation of the fetus is a contributing factor in 4-6% of all pregnancies.

Every one of these cases is a true litmus test for obstetricians. The medical team needs a great deal of experience and knowledge managing pregnancies when the baby is breech and giving birth in this position.

A woman whose baby is positioned bottom down is increasingly being offered a cesarean section in modern obstetrics. However, you should be aware that a natural birth is an alternative to the surgery. Although there is a greater chance of complications during childbirth when there is a pelvic presentation, a skilled and prepared physician can still carry out the general procedure without much trouble.

Types

"Pelic presentation" refers to more than just potential mothers. An experienced physician must be able to pinpoint the exact location of the baby’s lower body in relation to the small basin in addition to knowing where the baby’s head is. This means that a fairly straightforward and intelligible classification exists for all pelvic presentations.

Burnicoper

Eighty to ninety percent of breech cases are flexion breech presentations.

• Purely breech (incomplete) (Fig. a) – the buttocks are facing the entrance to the pelvis, and the legs are extended along the body, t. e. bent at the hip and straightened at the knee joints, the feet are located in the area of ​​​​the chin and face;
• Mixed buttocks (full) (Fig. b) – the buttocks are facing the entrance to the pelvis together with the legs bent at the hip and knee joints, slightly straightened at the ankle joints, the fetus is in a "squatting" position.

Foot

10% to 15% are accounted for by foot presentations (extension):

• Complete (Fig. c) — both legs of the fetus are presented to the entrance to the pelvis, slightly extended at the hip joints and bent at the knee joints;
• Incomplete (Fig. d) — one leg is presented, extended at the hip and knee joints, and the other, bent at the hip and knee joints, is located higher; more common than complete;
• Knee (0.1–0.3%) — the legs are extended at the hip joints and bent at the knees, and the knees are presented to the entrance to the pelvis.

The most hazardous foot presentation variations are those that increase the risk of developing complications during childbirth.

Dangers and risks

Breech presentation during childbirth carries a high risk of serious complications developing. The umbilical cord, its components, and even pieces of the fetus’s body could leak out early along with them. When contractions do not cause the cervix to open, women frequently experience weakening of the labor forces. When a baby is born with its pelvis and legs first, it frequently results in acute hypoxia, the baby’s death, and permanent brain damage.

The baby may throw back its arms and chin during labor. The latter is particularly risky since it may result in a crippling birth injury that involves fractures, cervical vertebral displacement, brain damage, and spinal cord displacement. These births are risky for the mother because they can result in severe bleeding, vaginal tears, and cervical ruptures.

Breech presentation can have very unpleasant consequences for the child, such as congenital hip dislocation, diseases of the gastrointestinal tract, kidneys, and urinary system, injuries, and the onset of cerebral palsy.

Causes

Since the mechanisms underlying the development of pathology are not fully understood by medical professionals or scientists, it is challenging to explain why a baby, who should naturally be head down, chooses to adopt a different posture that is inconvenient for both him and his mother. As a result, it is not customary to discuss the reasons per se; instead, we discuss the requirements for breech presentation. Additionally, they can vary widely.

Pathologies of the uterus and pelvis

This requirement is thought to be the most typical. The presence of postoperative scars on the uterus, tumors, uterine fibroids, and a narrow pelvis can all hinder the baby from adopting the proper head position. Prerequisites are often a woman’s anatomical features, such as her saddle-shaped or bicornuate uterus. There’s also a chance that the baby will adopt an incorrect body position due to the uterine muscles’ increased tone.

Women who have given birth frequently experience breech presentation because their uterine muscles are weak and "stretched," making it difficult for the fetus to be reliably fixed. The baby presents breech when a woman who has had numerous abortions and uterine curettage is faced with this situation. Naturally, the baby tries to position itself so that its head is in the area of the uterus where spasms happen less frequently. The lower part of the uterus is where women who have had multiple abortions typically find themselves. It has a tense lower section.

Fetal pathologies

Babies with severe developmental defects and chromosomal abnormalities frequently present breech. Thus, up to 90% of infants born head up in the womb have one of the following conditions: hydrocephalus (dropsy of the brain), anencephaly (absence of the brain), or microcephaly (reduced brain volume).

If there are multiple pregnancies, breech presentation is frequently indicative of one of the twins; in this instance, the baby’s position within the uterus may not be connected to any of its pathologies.

In some cases, a child’s incorrect body position with respect to the exit into the small pelvis is an indirect indicator of vestibular apparatus issues.

Amount of amniotic fluid

A fetus with polyhydramnios has greater space for twists, turns, and tumbles. And occasionally, this has an impact on the baby’s body positioning inside the uterus, which is incorrect. In contrast, a baby with oligohydramnios finds it difficult to turn into the proper position and to move around.

Umbilical cord and placenta

A breech presentation of the fetus is frequently accompanied by entanglement around the neck or limbs, and a short umbilical cord restricts the baby’s range of motion. Another requirement for breech presentation is the placenta’s pathological location, or placenta previa, or its low location.

Heredity

Obstetricians have long observed that pregnant women who were born breech or who remained in this position during their pregnancy are more likely to have babies that present breech.

To be fair, it should be mentioned that this fact is not always explained by the aforementioned requirements. A baby without any of these requirements may occasionally be recorded as having a breech presentation. Just as it is not always possible to understand why a baby who was positioned head up suddenly does the impossible just a few hours before birth and turns over into a cephalic presentation, not all cases of breech or oblique breech presentation can be explained. Although this is an uncommon occurrence, there are plenty of examples in obstetrics and gynecology.

Diagnostics

The position of the fetus does not significantly contribute to the diagnosis before the third scheduled screening ultrasound, or more specifically, before 32–34 weeks of pregnancy, since the baby still has enough room inside the uterus to move its body around on its own. As a result, a breech presentation at an earlier stage is merely a fact and not a diagnosis. The fetus’s "caught" position during the ultrasound is described by the doctor.

There is less likelihood of a coup after 34 weeks. The diagnosis of breech presentation already sounds reasonable at 32–34 weeks. The methods of keeping an eye on the expectant mother are altered, and the delivery technique is predetermined.

The breech position of the baby is first determined by the obstetrician. For this, he uses the so-called Leopold method. The height of the fundus of the uterus exceeds the norm, palpation with the hands of a doctor through the anterior abdominal wall of the expectant mother determines a rounded element, quite mobile, slightly shifted to the right or left of the midline passing through the navel. This is the baby"s head. To exclude error, the obstetrician uses auxiliary methods: the presenting part is palpated at the bottom of the abdomen, if it is the bottom, then it is not capable of movement. The baby"s heartbeat is also heard. A tiny heart with a breech position usually beats above the mother"s navel, slightly to the right or slightly to the left of it.

With a phonendoscope, a woman can use it to determine her baby’s presentation based on the location of the heartbeat. A head-up baby’s pushes and kicks are felt more keenly and painfully in the lower abdomen, right above the pubis.

An examination of the vagina clarifies the presumed diagnosis. The doctor finds the softer presenting part by looking through the anterior fornix of the vagina. In the cephalic position, the fetus’s head feels denser and harder to the touch.

The woman will be offered to have an ultrasound examination, which should put everything in its proper place, following the gynecologist’s examination. Not only will an ultrasound reveal the baby’s position, but it will also reveal crucial details for delivery, such as the baby’s head extension, entangled umbilical cord, anticipated body weight, potential developmental disorders, placenta location, and level of maturity.

The head’s angle of extension is the most significant factor. There can be no discussion of an independent birth if it is extended and the infant appears to be looking up. This is because there is an excessive risk that the baby will suffer severe spinal injuries during delivery.

In order to gather all the information on potential hypoxia-related disorders in the baby’s condition, a Doppler ultrasonography and CTG are required if the ultrasound proves that the baby is lying.

The doctor won’t be able to respond in detail regarding the likelihood of continued pregnancy management or the preferred mode of delivery until the examination is finished.

Breech presentation, in which the baby is positioned in the womb with their feet or buttocks first, is dangerous because it raises the possibility of complications during childbirth, including prolapse of the umbilical cord and difficulties during delivery. Factors such as early labor, multiple pregnancies, or uterine problems can result in this positioning. In cases where the baby is breech, labor frequently needs to be closely monitored, and many doctors advise a cesarean section to protect the mother and child.

Natural turning of the fetus

The woman needs to do nothing at all until 28–30 weeks. Physicians adopt an observational approach and strongly advise the expectant mother to minimize her risk of fetal hypotrophy and fetoplacental insufficiency by getting more sleep, rest, eating normally, and taking vitamins and medications that lower uterine tone. The doctor might advise the woman to start doing corrective gymnastics at 30 weeks.

Dikan, Shuleshova, and Grishchenko’s exercises are designed to maximally relax the muscles of the pelvis and uterus so that the child can adopt the proper position as soon as possible. When combined with breathing exercises, gymnastic exercises are thought to be approximately 75% effective. If gymnastics was helpful, the child usually turns over on their own, without force, during the first week of classes.

Women with conditions affecting the heart, liver, or kidneys should not participate in fetal gymnastics. Exercise is not advised for women who have scars on their uterus from surgeries or cesarean sections in the anamnesis, for expectant mothers who show symptoms of gestosis, or who run the risk of giving birth prematurely. Gymnastics is not advised if vaginal discharge (watery, bloody) develops that is not typical for the gestational period.

In roughly one-third of first-time mothers and 70% of women who give birth again, babies can naturally assume the cephalic position. Not only does gymnastics help achieve the desired outcome, but swimming in a pool and psychological manipulation are also employed. Most obstetricians believe that a child may "heed" his mother’s persuasion and turn over. In the event that he fails to accomplish this by 35–36 weeks, there is a 99% chance that the baby will be born breech.

It is not advisable to depend on the 1% of his turning over that occurs during or just prior to contractions.

See the list of fetus-turning exercises below.

Obstetric turning

Should the baby have benefited from gymnastics, swimming, proper breathing, and adhering to clinical guidelines for the first 35 weeks of pregnancy, the physician may have performed a forced obstetric turning. Obstetric turnings have virtually disappeared from use in the modern world. However, it is worthwhile to discuss this approach. Another name for it is the Arkhangelsky turning technique. External turning is only done in a medical facility. Although doctors attempted to perform the procedure at 32–34 weeks, it is now thought to be most reasonable to manually turn the baby at 35–36 or 36–37 weeks.

A sufficient amount of amniotic fluid must be present in the woman, and the turning process is done under continuous ultrasound observation. Using CTG, doctors keep an eye on the baby’s heart activity both before and for a while after the turn. The key to the procedure is moving the fetus’s head and buttocks in unison, smoothly, and either clockwise or counterclockwise, depending on where the back is located. Not every baby can be turned, and no one can ensure that the Arkhangelsky method will produce the desired outcome.

Women who are over 30 years old at the time of their first birth, have a very narrow pelvis, or are at risk of preterm birth should not undergo obstetric coupling. If the mother has gestosis and the baby is not mobile enough, the doctors will not force the baby to turn.

The use of Arkhangelsky’s method is contraindicated in cases of multiple pregnancies, uterine scarring, and either an excess or insufficient amniotic fluid (polyhydramnios).

Manual coupling is also not done if the baby’s breech presentation is caused by uterine anatomical abnormalities. Obstetricians are progressively giving up manual coup as a principle these days. The probability of placental abruption, fetal entanglement and asphyxia, and harm to the integrity of the fetal membranes is thought to increase. There are documented cases in medicine of obstetric coup leading to fetal harm, uterine rupture, and premature birth.

Many obstetricians continue observation tactics until 37–38 weeks of pregnancy, when they routinely hospitalize the expectant mother in the maternity hospital and decide on the delivery method, reasoning that while there might be no effect, there might be side “effects”.

Caesarean section or natural childbirth?

The pregnant woman and her attending physician are plagued by a persistent question. Before the 38th week of pregnancy, this is precisely what needs to be taken care of. It is incorrect to believe that the only option for delivering a baby who presents breech is through cesarean section.

Previously, physicians used a unique childbirth safety scale to determine the best delivery strategies. At the moment, physicians have essentially stopped using it.

This scale indicated that a woman was thought to be able to give birth on her own with a breech presentation if her total score was higher than 16. Following were the points awarded:

• gestation period – 37-38 weeks – 0 points;
• gestation period over 41 weeks – 0 points;
• gestation period 40-41 weeks – 1 point;
• gestation period 38-39 weeks – 2 points;
• large fetus (over 4 kilograms) – 0 points;
• fetus weight 3500-3900 grams – 1 point;
• baby weight from 2500 to 3400 grams – 2 points;
• foot presentation – 0 points;
• combined (mixed) presentation – 1 point;
• breech – 2 points;
• highly extended fetal head – 0 points;
• moderately extended head – 1 point;
• flexed head – 2 points;
• immature cervix – 0 points;
• insufficiently mature cervix – 1 point;
• mature cervix – 2 points.

Additionally, a woman’s pelvic width was assigned a point value between 0 and 12; the wider the pelvis, the more points she will receive. The question of whether it is preferable to rely on the training and experience of the surgical team and give birth by cesarean section or to take a chance and give birth on your own was only answered by adding up all of the points.

It should be mentioned that many pregnant women’s claims, which frequently surface in forums for women discussing pregnancy and childbirth, that they will not consent to the procedure are unfounded. If the number of points is less than 16, a caesarean section was performed for medical reasons and only in cases where there was a significant risk to the child’s health during a natural childbirth.

A balanced decision should always be made regarding the planned cesarean section with the pelvic presentation. You should get in touch with the head of prenatal advice and request the appointment of a medical expert commission to provide an opinion if a woman believes that the reason she was sent for an operation was only the doctor’s unwillingness to "mess" with problematic pathological births.

It’s crucial for a woman whose choice was to give birth naturally to lie down in a hospital as soon as possible. You’re eager for the domestic disputes to begin. A trained physician should be present at all times to provide constant supervision during the very first stages of the birthing process.

The woman is advised to remain in bed until her contractions stop. She is not permitted to walk through the prenatal ward or the corridor. She has to lie down and repeat her baby’s position (the doctor will instruct you on which side to lie on).

Premature rupture of the amniotic sac and water outflow, particularly at a rapid rate, should be avoided at this point because the water may cause the umbilical cord loops and even pieces of the baby’s body to fall out.

Antispasmodic medications and painkillers are administered to the woman to prevent an uncontrollably rapid labor as soon as the contractions start to become regular and the cervix opens by 3–4 centimeters. The fetal heart rate will be continuously monitored during the entire labor process.

As soon as the water breaks, the doctor will perform an intravaginal examination to check for prolapse of the baby’s body parts or the umbilical cord loops, as well as a careful assessment of the baby’s condition using CTG. The woman will be sent immediately to the operating room for a cesarean section if the loops have fallen out. If they are unable to be tucked back in at this point.

Unbelievably, 30% of breech births that occur naturally require a cesarean section. Furthermore, the woman and her family members ought to be psychologically ready for it.

Whether the baby is coming out legs or bottom first, no one can predict how labor will progress.

If all goes according to plan, the woman will start receiving oxytocin in the second stage of labor, which will encourage contractions and hasten the cervix’s opening. The medical team performs an episiotomy, a surgical dissection of the perineum and the vaginal back wall, as soon as it opens enough to allow the baby’s buttocks through. This will ease the baby’s passage and shield the mother from unplanned ruptures.

If the head emerges no later than five minutes after the body of the baby is born, this is regarded as a positive sign. Several techniques can be employed by the obstetrician during the baby’s delivery. In one, the baby is carefully removed by one or both legs using the inguinal fold; in another, the buttocks are supported manually without attempting to pull them out or expedite the process in any way.

Staff negligence or tardiness towards a laboring woman can result in severe injuries that could permanently disable the child, acute hypoxia, or even the fetus’s death.

A woman who is about to give birth in a breech presentation should therefore carefully consider all the risks before selecting an obstetric facility and a physician.

Postpartum period

Following such births, the postpartum phase is not notably different. A woman shouldn’t worry that she won’t be able to care for the baby or that she will spend more time in bed. The baby is sent to the children’s department, where he will receive special care, and the new mother is moved from the delivery room to a ward where she can rest if there are no complications and the bleeding does not stop.

Even in cases where there were no obvious complications during labor, neurologists closely monitor all babies who were born feet first or bottom first because some of the long-term effects of pathological births can be quite distant. Such a baby might be brought in for feeding later than other kids because, frequently, newborns who have problems with their lower bodies need resuscitation support first.

Up until the age of three, these infants require neurologist dispensary observation.

The child’s dispensary registration may be permanent if pathologies manifest.

Reminder for mothers

A woman should keep in mind that having a pregnancy with a breech presentation has its unique characteristics.

• She is strictly prohibited from making sudden movements in the third trimester of pregnancy, sleeping on her back, bending forward;
• A prenatal bandage, if the child is head up, can only be worn until the 30th week of pregnancy. If the baby"s body position in space remains incorrect, you cannot wear a bandage.
• Before or shortly before childbirth, the pregnant woman"s belly drops – the fetus"s head in a cephalic presentation is pressed against the exit to the small pelvis. In a breech presentation, the belly does not drop until the very birth.

Making educated decisions is facilitated for parents and healthcare professionals when they comprehend why a fetus presented breech is deemed dangerous. Head down position increases the risk of a difficult or protracted labor, but it can also cause complications during delivery when a baby is positioned feet or buttocks first.

A breech baby can result from a number of factors, including the baby’s premature birth, the uterus’s shape, and the amount of amniotic fluid present. Pregnant women who are aware of these causes can talk to their doctors about any possible worries and look into safe management options.

As the due date draws near, medical professionals may recommend turning a breech baby or schedule a cesarean section to guarantee a safer delivery. Even though a breech birth can be difficult, risks can be greatly decreased and a good outcome for the mother and the child can be supported with early detection and careful planning.

Video on the topic

Breech presentation of the fetus: causes, diagnosis, method of delivery

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What you need to know about breech presentation? / Why breech presentation of the fetus is considered dangerous?