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Turning a Breech Before Labor
Reprinted with permission from Woman to Woman the newsletter of the Reading Birth & Women's Center ( Reading, PA)
A breech presentation occurs when the lowest part of the baby in the vagina is either the rump or the feet. At term, approximately 95% of babies are vertex or head presentation, about 1% are face or shoulder presentations, and about 3-4% are breech. Earlier in pregnancy, the incidence of a breech presentation is greater. About 25% of babies are breech at 28 weeks; about 7% at 34 weeks, and at term about 3-4%. Consequently, most fetuses turn from a breech to a vertex presentation at some point in pregnancy.
The primary concern about breech presentations has been the fact that they are riskier to deliver than if the baby is a vertex presentation. Our options for delivery have traditionally involved either a vaginal breech delivery or a cesarean section. Because of the concern about delivering a breech baby vaginally and because of concern about cesarean sections, a procedure known as breech version was developed. Breech version has been practiced since antiquity; it is the turning of the fetus artificially while it is inside the uterus. This is done by the doctor placing his/her hands on the abdominal wall and manually rotating the baby into a vertex presentation. This has traditionally been done between 30 and 40 weeks of pregnancy.
The success rate of performing a breech version is around 50%, and once the baby is converted to a vertex presentation, it normally remains that way through the rest of the pregnancy. This is truer the closer the baby is rotated to its due date, although the ability to convert the baby to vertex presentation becomes more difficult the closer a baby gets to its due date.
Complications relating to breech versions are very rare. The most common complication is some transient alteration in the heartbeat as the baby is rotated. This corrects once the version is stopped whether it is successful or not. There is, however, always the potential for some accident occurring to the umbilical cord, for separation of the placenta, and, extremely rarely, the potential for intrauterine death. To prevent this most rare and dangerous complication, the baby is monitored after the version to make sure that the heartbeat is normal and that the baby's heart rate accelerates normally to motion. The baby's heart is monitored throughout the procedure, and if there should ever be an emergency, a baby at term can be delivered by cesarean section in just a few minutes. The other potential complication relates to Rh factor. There is mixing of fetal and maternal blood throughout pregnancy, and this mixing tends to increase after 28 weeks. When rotating the fetus, there is always the possibility that blood transferred from the fetus to the mother may sensitize her to the baby's blood if the baby is RH positive and the mother Rh negative. For this reason, women who are Rh negative are always given RhoGam at the completion of the procedure.
When the procedure is complete, the baby is monitored, and occasionally the patient will be kept and induced at that point. Prior to performing a breech version, there are several conditions that must be met:
- It is best for the fetus to be close to 36 weeks of gestation because the closer to the due date that version is attempted, the less successful it will be;
- The breech must not be settled into the pelvis;
- There should not be any underlying uterine contractions or irritability;
- There must be an adequate amount of fluid around the baby to allow movement; and
- The fetal heart rate must be normal before the version is attempted.
When the procedure is initiated, the patient is brought to the delivery room and monitored for approximately 20 to 30 minutes to confirm that the patient is not laboring, that there is a normally reactive heart rate, and that there is no abnormality with the heart rate. An abdominal exam and ultrasound are performed to confirm that the baby is breech. Once this is completed, an IV is begun and a medication (Ritodrine) is given intravenously to further quiet the uterus. This medication runs for approximately 30 minutes. Once these procedures have been completed, the version is begun. The version does not last longer than about 5 minutes. The obstetrician palpates both ends of the baby. He/she then attempts to rotate the head end of the baby toward the pelvis while pushing up the bottom and the feet. This part of the procedure is usually painful even when patients are given medication. Most often, the version is completed rapidly if it is to be successful. If it is unsuccessful after several tries, we will usually desist from the procedure, although it is felt that it can be continued for about 5 minutes. Once the version is completed, we then continue to monitor the baby for another 30 to 60 minutes. This again confirms that the fetus is doing well and that the patient can be safely sent home.