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Birthing options for a breech baby
Q: My doctor thinks my baby is in the breech position. I'm 32 weeks pregnant, and this is my second pregnancy. I really want a vaginal birth. What are my options?
A: At 32 weeks gestation with a breech (buttocks-first) baby, there is a good possibility that your baby will reposition itself. Babies still tend to move around within the uterus, and only 3 percent remain breech at term. At 36 weeks, your baby will be larger and have less room for large position changes.

If your baby is breech at 36 weeks, your doctor may suggest an external version. This technique, done in the hospital, physically guides the baby into a headfirst position. Your doctor checks the position and anatomy of your baby with an ultrasound, ensures that you have adequate amniotic fluid, that the umbilical cord is not around your baby's neck and that the head is in a flexed position. Your baby's heartbeat pattern will be evaluated on a fetal monitor. After a healthy fetal heart rate is documented, you are given a medication to relax your uterus and then asked to relax your abdominal muscles. Then your doctor touches your abdominal wall to maneuver the baby into the vertex (head-first) position, encouraging the baby to roll forward or flip backward. This can be uncomfortable, but it's usually quite tolerable. This technique is usually successful about half the time. It should be immediately followed by further fetal heart rate testing.

Occasionally, an external version induces the onset of labor, or stresses the baby's heart rate by pulling on the umbilical cord. Usually the baby's heart rate returns to normal. In rare cases, a sustained drop in the fetal heart rate may prompt an emergency cesarean section. For this reason, external versions are not attempted until the baby is considered mature enough for delivery, usually around 37 weeks.

Delivering a baby in the breech position is trickier than a cephalic (head-first delivery), and there are higher risks to the baby. Studies have shown higher rates of short-term infant morbidity (illness) with breech vaginal deliveries compared to cesarean deliveries. With a cephalic delivery, there is sufficient time during the pushing stage of labor for the baby's skull to slowly accommodate itself to the shape of its mother's pelvis. With a breech delivery, the baby's body is delivered first, compressing the umbilical cord before the baby's head has been delivered. This limits the amount of time available to deliver the baby's head. And because the head is a spherical, bony structure, one concern is that the head could become entrapped, requiring additional maneuvers for eventual delivery. The safety of a vaginal breech delivery is dependent on the skill of the birth attendant. In some countries, vaginal deliveries of breech babies are encouraged, particularly for women who have already had a child, and whose obstetricians have ample experience in breech vaginal deliveries.

If your first baby was large and you had an easy vaginal delivery, you could be a good candidate for a vaginal delivery again. However, finding a skilled obstetrician willing to deliver your baby vaginally could be challenging. Many doctors in the United States have not received adequate training in delivering breech babies vaginally, and prefer to provide a safer surgical delivery instead.
Laura E. Stachel M.D. Obstetrician & Gynecologist