Vaginal delivery in breech position and breech birth

A vaginal delivery is the birth of a fetus through the mother's birth canal, or vagina. The American College of Obstetricians and Gynecologists recommends that, whenever possible, a fetus in the breech position be delivered by cesarean section (C-section).¹ Breech infants delivered vaginally have a higher risk of injury or complications than those delivered by cesarean. About 5 of every 100 have serious problems after vaginal birth. (This means that 95 of every 100 newborns have no serious problems from vaginal breech birth.) To compare, less than 1 of every 100 breech infants have serious problems from cesarean delivery.²

Under unusual circumstances, such as when a second twin is breech or a breech vaginal birth is progressing quickly, a cesarean is neither recommended nor possible.

There are several different types of vaginal breech deliveries.

• The delivery can occur without help from a health professional (spontaneous breech birth). During a spontaneous breech birth, the fetus comes out of the vagina without problems. The health professional just supports the fetus's body as it emerges from the birth canal.
• A health professional may need to help deliver the upper part of the fetus's body (partial breech extraction). During a partial breech extraction, a health professional pulls gently downward on the fetus and rotates its body as needed to deliver the shoulders, arms, and head.
• Occasionally, a health professional may need to help the fetus during the entire delivery (total breech extraction). This is usually done only when the fetus is having problems and needs to be delivered as quickly as possible.

During a partial or total breech extraction, the health professional may need to reach into the birth canal in order to move part of the fetus into a better position for delivery. If the health professional is having difficulty delivering the fetus's head, forceps may be used to guide the head through the birth canal. Forceps may also be used to speed delivery if the fetus is in danger.

During some breech vaginal births, an episiotomy is necessary to enlarge the vagina to help deliver the infant. This is done by making an incision in the lower part of the vagina (toward the anus); the incision is closed with stitches after the birth.

Should a breech vaginal labor cause severe problems for the fetus or mother, an emergency cesarean section is done to deliver the fetus.

A few hours after an uncomplicated vaginal delivery, you can get up and move around. If you had an episiotomy, you may feel the need to spend a day resting before you start moving around too much. An episiotomy incision will heal in 1 to 3 weeks. The vaginal area is sore for several days.

Women are generally advised to avoid having sex for 4 to 6 weeks after giving birth in order to allow the vagina and the area around it to fully recover.

Recovery from a vaginal delivery is usually easier and quicker than from a C-section.

Vaginal delivery of a fetus in the breech position is recommended only if:¹

• Twin fetuses are present, with the first twin head-down.
• A mother is in the late stages of labor, and the fetus and mother are not having any problems. Such a vaginal delivery may be allowed to continue even if a cesarean delivery was planned.
• The fetus has died or is known to have a fatal condition and will not live after birth. In these cases, a C-section is not done because of the risks to the mother.

During the 1990s, some experts recommended vaginal breech delivery by experienced doctors, reasoning that avoiding a cesarean can benefit the mother. But the American College of Obstetricians and Gynecologists now recommends against planned vaginal breech birth.¹ This is based on a major study that found that 5 of every 100 breech infants delivered vaginally suffer serious complications such as organ and neurological damage. (This means that 95 of every 100 newborns have no serious problems from vaginal breech birth.) To compare, less than 1 of every 100 breech infants had serious problems when delivered by cesarean. All mothers in the study had a similar low level of complications, regardless of how they delivered.²

Sometimes, a cesarean breech birth is not possible or is not the best choice. When a breech labor progresses too quickly, a vaginal birth may be the only option. Risks are lowest for the newborn when a doctor has a lot of experience doing breech delivery.³

During a twin birth, a second twin who is breech may best be delivered vaginally.¹

Types of injuries that can occur during a vaginal breech delivery include:

• Fetal brain damage or death due to lack of blood flow through the umbilical cord. This can be caused by squeezing (compression) of the umbilical cord. The cord can get caught between the legs of the fetus or between the birth canal and the head of the fetus. It can also be caused when the umbilical cord drops out of the birth canal (cord prolapse) before the fetus is delivered.
• Damage to the fetus's head if the head gets caught in the pelvis and is difficult to deliver. These types of injuries include tears in the covering of the brain or swelling caused by bleeding under the scalp.
• Damage to an arm when it gets caught alongside the head during delivery (nuchal arm). This can result in a broken bone, bruising, or tearing of the muscle.
• Injury to the fetus's spinal cord.
• Damage to the fetus's genitals or internal organs.

The labor and delivery of a breech infant sometimes takes longer than that of an infant in the head-down position. The feet or buttocks of a breech infant do not put as much pressure on the cervix as the head would, slowing cervical opening, or dilation.

A vaginal delivery of a breech fetus should only be aided by a health professional who is experienced in breech delivery.

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Citations

1. American College of Obstetricians and Gynecologists (2001). Mode of term singleton breech delivery. ACOG Committee Opinion No. 265. Washington, DC: American College of Obstetricians and Gynecologists.

2. Hannah M, et al. (2000). Planned caesarean section versus planned vaginal birth for breech presentation at term: A randomized multicentre trial. Lancet, 356: 1375–1383.

3. Su M, et al. (2003). Factors associated with adverse perinatal outcome in the Term Breech Trial. American Journal of Obstetrics and Gynecology, 189: 740–745.