When will a baby settle into a head down position before birth?

Babies often twist and turn during pregnancy, but most will have moved to a head-down position (cephalic presentation) by 36-37 weeks, and often by the time labour begins. However, sometimes babies may be bottom or feet-first (breech presentation) or lying sideways (transverse).

Babies lying bottom or feet first in the womb, instead of the usual head first position, are called breech babies. It is common in early pregnancy, but only 3-4% of babies are breech at the end of pregnancy. If your baby is breech, you may feel discomfort under your ribs as your baby’s head presses up under your diaphragm. You may also feel sharp kicks to your bladder.

The different types of breech presentation

There are three main types of breech presentation.

• Extended or frank breech: baby in bottom-first, with the thighs against the chest and feet up to the ears. Most breech babies are in this position.
• Flexed breech: baby is bottom-first, with the thighs against the chest and the knees bent.
• Footling breech: baby’s foot or feet are below the bottom.

Why does a breech presentation happen?

It may be pure chance that your baby has not turned to the head-first position and if your baby has not turned it does not usually mean that your baby will have any problems. There are, however, certain factors that make it more difficult for a baby to turn during pregnancy and therefore more likely to stay in the breech position.
Potential reasons for breech presentation include:

• Low lying placenta
• Too much or too little fluid around baby
• More than one baby in the womb
• First pregnancy
• The shape of your womb or pelvis

Can the baby be turned before labour?

If your baby is in breech position at 36 weeks, you’ll usually be offered an external cephalic version (ECV). This is done by a healthcare professional, usually an obstetrician, who tries to turn your baby to the head down position. It is a safe procedure involving the application of gentle pressure to your tummy and although it should not be painful, it may be uncomfortable. About 30-50% of breech babies can be turned using ECV, allowing a normal vaginal birth. Successful ECV lowers your chances of a caesarean section and its associated risks. Read more about external cephalic version here.

What are the options for birth if my baby remains breech or I do not want an ECV?

There are two options: a planned caesarean section or a planned vaginal delivery.

Caesarean section birth

Research has shown that a planned caesarean birth is safer for your baby than a vaginal breech birth but the decision must be weighed up against the risks of the surgery.

The perinatal mortality rate (the number of deaths of babies over 28 weeks gestation and less than 7 days old) is:

• 5 in 1000 for planned caesarean section at 39 weeks
• 1 in 1000 for cephalic vaginal deliveries (baby in head-down position)
• 2 in 1000 for breech vaginal deliveries

The numbers involved are very small, but a vaginal breech delivery has a 4x higher perinatal mortality compared to a planned caesarean birth. The reduction in mortality with a c-section is mainly due to avoidance of stillbirth (as planned c-sections are usually performed at 39 weeks, the risk of stillbirth later in the pregnancy is removed), avoidance of risks of labour and also avoidance of risks specifically associated with vaginal delivery of breech babies.

However, a caesarean section has risks for the mother including the risks of the surgery itself. It also involves a longer recovery, and comes with important implications for future pregnancies including:

• increased risk of problems with the way the placenta implants ( i.e. placenta praevia or placenta accreta)
• Risks of scar rupture (the scar opening) during contractions in a subsequent vaginal delivery
• Higher risk surgery for following caesarean sections as there may be scar tissue inside the abdomen

If you have planned a caesarean birth but you go in into labour with a breech baby before your operation date, a midwife or an obstetrician will examine you and assess the safest way to deliver your baby. In some cases, it may be safer to have a vaginal breech birth especially if your baby is close to being born.

Vaginal Breech Birth

Along with careful discussion with the obstetrician or midwife, you may opt for a vaginal breech birth if you and your baby are suitable. You should deliver on a labour ward where there are facilities to perform an emergency caesarean section if required (around 40% of women planning a vaginal breech birth will need a caesarean). If successful, a vaginal breech birth will usually mean that you will have a straightforward recovery.

A vaginal breech birth is not recommended if:

• Your baby is ‘footling breech’. This is when the baby’s feet are below the bottom
• Your baby is larger or smaller than average
• You have a low-lying placenta
• You have pre-eclampsia or other pregnancy complications

If your baby is breech at the end of pregnancy and you are not in labour, you should be offered a caesarean birth. This is because an induction of labour is not recommended for breech babies.

What does a breech baby mean for labour?

Breech birth options for pain relief are the same as for delivery of a baby who is head-first. Your baby’s heart rate will be monitored continuously on a CTG (cardiotocograph) and you will be examined in the same way as women having a head-down vaginal birth. If there are concerns with your baby’s heart rate that cannot be resolved or if your labour is not progressing, you may need a caesarean section in labour. Around 40% of women who are planning a vaginal breech delivery will need an emergency caesarean section. For the 60% who have a successful breech delivery, a paediatrician (doctor specialising in the care of babies and children) will be present to ensure that your baby receives neonatal care and support if required.

Who will decide how you give birth to a breech baby?

You should discuss your options with the obstetrician and midwife who are looking after you. You may also want to talk through your options with your family and friends. You should never feel as though you are left on your own to make a decision.

It’s important to discuss your breech birth options with your obstetrician and midwife, and also with family and friends.

Main Points

• Around 3 – 4 % of babies are in a breech presentation by the end of pregnancy.
• Most babies are in a ‘head-down’ position (cephalic presentation) by weeks 36 – 37.
• There are three main types of Breech presentation: Extended (or frank), flexed and footling.
• Most breech babies will be in the extended breech position.
• If your baby is in a breech position at 36 weeks you will be offered ECV (external cephalic version), a manual procedure to turn the baby in the womb.
• Around 40% of women who plan a vaginal breech birth will go on to have a caesarean section.
• A paediatrician will be present at a breech birth to provide appropriate care to the baby if required.