In a normal pregnancy, the baby is supposed to automatically turn inside the womb into a head-down position in order to get ready for birth. However, in some cases, this doesn’t happen and instead, the buttocks, or feet, may come first before the head during the time of delivery.

According to medics, this is termed as a breech presentation/delivery.

UNDERSTANDING THE TERM

Most babies will move into delivery position a few weeks prior to birth, with the head moving closer to the birth canal. When this fails to happen, the baby’s buttocks and/or feet will be positioned to be delivered first. This is referred to as a breech presentation.

According to Dr Emmanuel Semwaga, a gynaecologist/obstetrician at Mediheal Diagnostic and Fertility Centre in Kigali, during pregnancy, the baby constantly moves in the uterus and may be in any position.

He says the baby and the shape of a woman’s uterus determine the presentation.

When breech birth happens, it presents a few different challenges for both mother and baby.

Semwaga says breech birth has significant implications in terms of delivery, especially if it occurs at 37 weeks.

"Breech deliveries carry higher perinatal mortality and morbidity, largely due to birth asphyxia/trauma, prematurity and an increased incidence of congenital malformations,” he says.

TYPES OF BREECH BIRTH PRESENTATIONS

There are three types of breech birth presentations and they include; complete, incomplete, and frank.

Complete breech is when both of the baby’s knees are bent and his feet and bottom are closest to the birth canal. Incomplete breech is when one of the baby’s knees is bent and his foot and bottom are closest to the birth canal. Frank breech is when the baby’s legs are folded flat up against his head and his bottom is closest to the birth canal.

There is also footling breech where one or both feet are presenting.

Semwaga says with all types of breech pregnancies, the baby is positioned with its bottom toward the birth canal instead of the head.

CAUSES

Although the causes of breech presentations are not fully understood, there are many different reasons why a baby might position itself the wrong way in the womb.

Iba Mayale, a gynaecologist at Galien Clinic in Remera, says the causes include; if a woman has had several pregnancies, pregnancies with multiples, and if a woman has had a premature birth in the past.

Also, if the uterus of the woman has too much or too little amniotic fluid, meaning that the baby has extra room to move around in or not enough fluid to move around.

Other conditions that can bring about breech presentations, he says, is if the woman has an abnormally shaped uterus or has other complications, such as fibroids in the uterus, or if a woman has placenta previa.

COMPLICATIONS

"A baby is not considered breech until around 35 or 36 weeks. In normal pregnancies, a baby usually turns head-down to get into position in preparation for birth. It’s normal for babies to be head down or even sideways before 35 weeks,” Dr Mayale says.

After that, though, as the baby gets bigger and runs out of room, it becomes harder for the baby to turn and get into the correct position, Mayale says.

In general, breech pregnancies aren’t dangerous until it’s time for the baby to be born, he says.

A major complication of breech presentation is cord prolapse, where the umbilical cord drops down below the presenting part of the baby and becomes compressed.

"With breech deliveries, there is a higher risk for the baby to get stuck in the birth canal and for the baby’s oxygen supply through the umbilical cord to get cut off,” he observes.

He adds that breech deliveries do have the risk of more complications than a normal delivery.

Other complications include foetal head entrapment, premature rupture of membranes, birth asphyxia, usually secondary to a delay in delivery, among others.

CAN YOU TURN A BREECH PREGNANCY?

Semwaga says there are ways one can try to turn the baby. Success rates for turning a breech pregnancy depend on the reason the baby is breech, but as long as one tries a safe method, he says there’s no harm.

He notes that it’s preferable to try turning a breech baby between the 32nd and 37th weeks of pregnancy.

"The methods of turning the baby vary and the success rate for each method can also vary,” he says.

Among many techniques that can be used to try to turn the baby in the right position, the common ones are external version (EV) and inversion methods.

John Muganda, a gynaecologist at Harmony Clinic in Kigali, says an EV is a procedure in which a gynaecologist tries to manually turn the baby into the correct position by manipulating the baby with their hands through the stomach.

He says this is a non-surgical technique to move the baby in the uterus. In this procedure, he says medication is given to help relax the uterus.

There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

"Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version, the baby’s heartbeat should be closely monitored so that if a problem develops, the healthcare professional can immediately put a hold to the procedure,” Muganda explains.

However, he adds that with this procedure, it becomes more difficult as the due date gets closer.

Another method is known as inversion.

This is another popular method for women with breech babies, where they invert the woman’s body to encourage the baby to flip.

Muganda says women can use different methods, like propping up their hips with pillows, or even using the stairs to help elevate their pelvis.

MANAGEMENT

Semwaga says the options for management of breech presentation are external cephalic version (ECV), caesarean section or vaginal breech birth.

External cephalic version, he says, is the manipulation of the foetus to a cephalic presentation through the maternal abdomen. This, he says, if successful, can enable an attempt at vaginal delivery.

Complications of ECV, Semwaga says, include transient foetal heart abnormalities (which revert to normal), and rarer complications such as more persistent heart rate abnormalities, for instance, foetal bradycardia which is referred to an abnormally low foetal heart rate, and placental abruption.

According to Semwaga, ECV is contraindicated in individuals with a recent antepartum haemorrhage, ruptured membranes, uterine abnormalities, or previous caesarean section.

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