Breech presentation

This information is for women with a baby in a breech position who want to know more about external cephalic version (ECV), vaginal breech birth and planned caesarean sections. We hope their partners, family and anyone else supporting them will find it useful too. If there is anything you don’t understand please ask your midwife or doctor. If you have any feedback please email breechstudy@ncl.ac.uk or leave your comments on our Facebook page.

This website has been designed by the research team with help from women with experience of breech presentation, health professionals and experts in patient involvement in decision making.

We have used high quality medical research to write the factual information. References for the research studies included can be found here.

The case studies were developed from interviews and design workshops. Polly and Rachel are fictional but were inspired by the women who took part in the study. All respondents gave written consent for us to use information they gave us to develop decision support.

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What is breech presentation

  • Breech presentation means your baby is bottom first or feet first in your uterus (womb)
  • Cephalic presentation means your baby is head first in your uterus (womb)

How common is breech presentation?

  • In early pregnancy breech presentation is very common
  • Most babies turn themselves by 36 weeks of pregnancy
  • At the end of pregnancy three in every 100 babies (3%) are breech, 97 in every 100 babies (97%) are head down

Why are babies breech?

Often there is no obvious reason why your baby is breech. Sometimes the doctor or midwife will be able to find a cause.

Further information

Further information

Why are babies breech?

Possible causes include:

  • If you have too much or too little fluid around the baby in the uterus (womb)
  • The position of the placenta
  • The shape of your uterus (womb)
  • A problem with the baby (although most breech babies are born healthy). Any problems are likely to be picked up on ultrasound or at the time of the newborn examination. You can ask your doctor/ midwife more about this if you are worried.

How is breech presentation diagnosed?

  • During pregnancy, breech presentation is diagnosed by an ultrasound examination (scan). This is usually carried out because a midwife or doctor has examined your abdomen (bump) and thinks the baby might be breech.
  • Some women have an ultrasound examination for another reason and find out that their baby is breech

What does having a breech baby mean?

Women with a breech baby have two decisions to make at the end of pregnancy:

  • Whether or not to allow a doctor or midwife to try and turn the baby inside the womb (called external cephalic version or ECV)
  • How to plan to give birth: either by vaginal breech birth or planned caesarean section

Click here for a diagram that summarises the decisions you need to make and what might happen to you.

External cephalic version (ECV)

What is ECV?

ECV means turning your baby into a head first position in the womb. A doctor or midwife uses their hands to put gentle pressure on your abdomen (bump) to help the baby turn a somersault. They do not need to examine you internally (in the vagina) to do an ECV. Each try at ECV lasts a few minutes. The doctor/ midwife may try more than once to turn your baby. If the ECV is unsuccessful you can discuss trying another day with them.

When can I have an ECV?

ECV can be tried any time from 36 weeks of pregnancy until your waters break.

Further information

Further information

You will not be offered ECV if:

  • You have a low lying placenta
  • You have had recent vaginal bleeding
  • There is too little amniotic fluid around the baby
  • Your baby is too small
  • The baby has an abnormal heart rate

You can ask the doctor/ midwife to explain why they think it is not a safe option for you.

What are the benefits of ECV?

Having an ECV increases your chance of having a vaginal birth and decreases your chance of having a caesarean section.

You can use Table 1 to see how many women who have a successful ECV go on to have a normal birth, an assisted vaginal delivery (either forceps or ventouse) or a caesarean section.

Is it safe?

  • ECV is safe with few risks for mother or baby
  • ECV does not increase the risks of your baby dying or being unwell at the time of birth
  • Trying ECV will not cause labour to begin
  • One in 200 (0.5%) babies are delivered by an emergency caesarean section immediately after trying ECV
Further information
Head-down (cephalic) babyBreech baby
Type of birthPlanned vaginal birthFollowing successful ECVPlanned vaginal birthPlanned caesarean section
Normal, head-down, birth76 in 100 births62 in 100 birthsNot applicableNot applicable
Vaginal breech birthNot applicableNot applicable71 in 100 births1 in 100 births
Ventouse delivery7 in 100 birthsEither ventouse or forceps 10 in 100 birthsNot applicableNot applicable
Forceps being used during delivery6 in 100 births3 in 100 birthsNot known
Planned caesarean sectionNot applicableNot applicableNot applicable86 in 100 births
Emergency caesarean section after labour has started10 in 100 births28 in 100 births29 in 100 births13 in 100 births

Further information

An emergency caesarean section may be necessary if health professionals are worried about the baby's heart rate. They may also be worried in case there is bleeding from the placenta. You may be asked to have nothing to eat or drink for six hours before the ECV in case you need an emergency caesarean section. You may also be asked to take medicine (called ranitidine) to reduce the acid in your stomach.

Your baby's heart rate will be checked before and after the ECV. In some hospitals the doctor/ midwife will also monitor the baby using ultrasound before, during and after the ECV. She or he may check the growth, fluid and wellbeing of the baby. She or he does not need to check where the baby's cord is before an ECV as this does not affect the safety of an ECV.

Will it hurt?

Some women find ECV uncomfortable or painful. If you find ECV too painful you can ask the doctor/midwife to stop. If there is pain, usually it only lasts while the doctor/midwife is trying to turn your baby. Some women report that their abdomen (tummy) feels tender for a few hours afterwards.

Will it work?

  • Overall 50 in every 100 ECVs (50%) are successful and 50 in 100 ECVs (50%) are unsuccessful
  • If you have had children before, 60 in every 100 ECVs (60%) are successful and 40 in every 100 ECVs (40%) are unsuccessful
  • If this is your first baby usually 40 in every 100 ECVs (40%) are successful and 60 in every 100 ECVs (40%) are unsuccessful

Can the baby turn back?

It is possible for the baby to turn back to a breech presentation after an ECV (spontaneous reversion). This occurs after less than five in 100 (5%) successful ECVs which means in 95 in 100 cases (95%) the baby stays head-down.

Further information

Further information

Will it hurt?

The amount of pain varies from no pain (10 in 100 women) through a little pain or some pain (63 in 100 women) to a lot or extreme pain (27 in 100 women). Women who have a successful ECV report less pain than women who have an unsuccessful ECV.

To increase the chance of success medication is usually given to relax the muscles of the womb. Medication can be given by an injection under your skin (terbutaline) or by tablets by mouth (nidefipine). These medications are safe for you and your baby. Some women notice that their heart beats quickly or irregularly (palpitations) or they feel light headed for a short time after they have been given the medication.

You can discuss your own individual chance of a successful ECV with your doctor/ midwife. Other than having had children before, ECV has been found to be more successful if:

  • The doctor/ midwife can feel the baby's bottom in your tummy rather than it being low in your pelvis (they may call this not engaged)
  • If the doctor/ midwife can feel the baby's head easily
  • If the doctor/ midwife thinks your womb feels relaxed
  • If you weigh less than 65kg
  • If your placenta is attached to the back wall of your womb (posterior)
  • If there is plenty of amniotic fluid around the baby (measured on an ultrasound scan)
  • If the baby's legs are below the bottom (sometimes called a complete breech position) on an ultrasound scan

Vaginal Breech Birth

Vaginal breech birth means giving birth to your breech baby through your vagina. The baby's bottom or feet come first, followed by the body and finally the head. As with a baby who is head first, the birth may take several hours. You have the same choices for pain relief as with a baby who is head first.

In some situations doctors and midwives may advise you that it is not safe to try a vaginal breech birth. You can ask them to explain why they think it is not a safe option for you.

Is it safe?

There are some risks to your baby associated with vaginal breech birth. You can compare the risks and benefits of vaginal breech birth and caesarean section in Table 2

  • Some research (link 1, link 2, link 3) has shown that caesarean section may be safer for babies than vaginal breech birth
  • Other research has shown no increased risk to babies born by vaginal breech birth
  • There is no evidence from any studies that the long-term health of the baby is affected by how she or he is born

Click here to find out more on the research about giving birth to a breech baby

Research about giving birth to a breech baby

The recommendation that caesarean section may be safer for babies than vaginal breech birth was based on randomised controlled trials (link 1, link 2, link 3). In this type of study, women are not given a choice about how they give birth. Instead, half are randomly chosen to have a vaginal breech birth and the other half to have a planned caesarean section. What happens to the women and their babies is then compared. This sort of study is often thought to be the gold-standard in medical research.

The biggest trial about breech presentation, called the Term Breech Trial (link 1, link 2), has been criticised for a number of reasons. For example, some of the vaginal births were attended by professionals with little or no training or experience of breech birth. Some of the women had labour induced (started) or augmented (sped-up) which would not be usual practice with breech presentation. Also the measure of harm to the baby included a wide variety of risks from deaths (some of which were not caused by the baby being breech) to the baby needing to be fed with a tube (see Table 2). The risks were not given separately which makes the information hard to understand.

The PREMODA Study which found no difference in the risk of harm to babies between planned caesrean section and vaginal breech birth was a large study of real-life practice in Europe in hospitals which had trained professionals with experience of breech birth.

Due to the possible risks of vaginal breech birth, your doctor or midwife will usually recommend that your baby's wellbeing should be monitored during the birth. Usually this would be continuously using a heart rate monitor (cardiotocograph or CTG). She or he is also likely to recommend that you give birth in a place where a caesarean section could be performed if needed.

Sometimes the doctor or midwife will need to help you give birth to a breech baby. As the baby's head is the last and largest part to come through the birth canal a doctor may need to use forceps to help deliver the head. You can use Table 1 to compare the chance of this happening during a vaginal breech birth to the chance during a vaginal head-first birth.

Head-down (cephalic) babyBreech baby
Planned vaginal birthFollowing successful ECVPlanned vaginal birth or planned caesarean section
Baby harmed during birth10.4 in 100 (link) Not known2-5 in 100 babies (link)
1.5-2 in 100 babies (link)

1For head-down babies this included: deaths during or shortly after birth; neonatal encephalopathy (damage to brain); breathing problems as a result of the baby inhaling meconium (first poo); injury to the nerves in the shoulder; broken humerus (arm bone); and broken clavicle (collar bone).For breech babies this included: deaths during or shortly after birth; birth trauma (including bleeding in the brain, having a broken skull, injury to the spinal cord, injury to nerves, injury to the genitals); having seizures; being in a poor condition at the time of birth (as judged by a doctor or by blood tests); being unable to breathe so needing to have a tube inserted into the lungs so a machine can give the baby oxygen; being admitted to the special care baby unit for more than four days; and needing tube feeding for more than four days.

The PREMODA Study gave more information about the risks to breech babies during birth, shown in the table below.

Planned vaginal birthPlanned caesarean section
Baby dying during birth0.1 in 100 babies0.1 in 100 babies
Baby dying in 28 days following birth0 in 100 babies0 in 100 babies
Baby dying or showing signs of brain damage (neurodevelopmental delay) before two years of age3 in 100 babies3 in 100 babies
Baby needing to go to neonatal intensive care unit following birth2 in 100 babies2 in 100 babies
Baby injured during birth (broken bones, nerve injuries and bruising). Full recovery would be expected in most cases.2 in 100 babies0.5 in 100 babies

What are the benefits of vaginal breech birth?

You can experience a vaginal birth and avoid the risks of caesarean section (link 1, link 2).

Will it hurt?

Most women who have a vaginal birth report pain in the bottom or genital area (perineum) during and immediately after birth.

There is no difference in the number of women who report having any pain three months following delivery between women who plan a caesarean section and women who plan a vaginal breech birth.

What is my chance of having a vaginal breech birth if I choose to try one?

If you plan a vaginal breech birth your baby may still be born by caesarean section (you can use Table 1 to see how often this happens). This is usually either because health professionals are concerned about the baby's safety or because labour is not progressing.

Further information

Further information

Six in 100 women (6%) will still have pain there three months following a vaginal breech birth meaning that 94 in 100 women (94%) will not.

Caesarean section

A caesarean section is an operation to deliver your baby through a cut in your abdomen (tummy). A spinal anaesthetic (injected into your back) is usually used so you are awake but cannot feel any pain. A planned caesarean section usually takes 30-45 minutes but you will usually be in the operating theatre for about one hour.

If you plan a caesarean section you will be given a date and time to come to hospital for the operation. Knowing when your baby is likely to be born is convenient for some women.

What are the benefits of having a caesarean section?

Some research (link 1, link 2, link 3) has shown that caesarean section may be safer for babies than vaginal breech birth.

Other research has not shown this benefit. You can find more links to research here.

Is it safe?

The risks of a planned caesarean section are shown in Table 3.

A doctor will go through the risks with you before the surgery and ask you to sign a consent form. Risks you will usually be informed of include:

  • Heavy bleeding (haemorrhage) which may need further treatment (usually iron tablets or a blood transfusion) - five in every 1000 women
  • Infection (needing treatment with antibiotics) - six in every 100 women
  • Blood clots in the legs (deep vein thrombosis) or lungs (pulmonary embolism) - 4-16 in every 10,000 women
  • Injury to the bladder - one in every 1000 women
  • Increased risk of needing an emergency caesarean section if trying to have a vaginal birth in a future pregnancy - one in four women
  • Cut to baby (laceration) during surgery (usually on the bottom if the baby is breech) - one to two in every 100 babies. This usually does not require any treatment but occasionally may need to be stitched.
Planned vaginal birthPlanned caesarean section
Heavy bleeding in the first 24 hours following birth (early postpartum haemorrhage)6 in 100 births1-4 in 100 births
Baby needing to be admitted to the special care baby unit (neonatal intensive care unit)6 in 10014 in 100
Length of hospital stay3 days3-4 days

No difference has been found between planned vaginal birth and planned caesarean section in relation to:

  • Mother reporting pain in her perineum (bottom or genital area) or abdomen (tummy) four months following birth
  • Injury to bladder or ureters (tubes carrying urine from the kidneys to the bladder)
  • Injury to the neck to the cervix (womb)
  • All injuries which may be caused by a surgeon during birth (iatrogenic surgical injury)
  • Blood clot in lungs (pulmonary embolism)
  • Wound infection
  • Womb bursting open (uterine rupture)
  • Need for mother to have help with breathing following birth (assisted ventilation or intubation)
  • Mother having kidney failure (acute renal failure) following birth
  • Baby having signs of brain damage (hypoxic-ischaemic encephalopathy)
  • Baby bleeding in brain (intracranial haemorrhage)
  • Baby experiencing breathing problems following birth

Will it hurt?

Most women who have a planned caesarean section report pain in the abdomen (tummy) immediately after birth.

There is no difference in the number of women who report having any pain three months following delivery between women who plan a caesarean section and women who plan a vaginal breech birth.

What happens if I go into labour before my planned caesarean section date?

If you choose to have a planned caesarean section and then go into labour before the operation you should contact the hospital straight away. A doctor will advise you about the safest way for your baby to be born. If your baby is close to being born the doctor may advise that a vaginal breech birth is safer than a caesarean section.

Further information

Further information

Nine in 100 women (9%) will still have pain there three months following a planned caesarean section for breech presentation meaning that 91 in 100 women (94%) will not.

Thirteen in one hundred (13%) of women who plan a caesarean section will have an emergency caesarean section because labour starts before their planned caesarean section date. One in one hundred (1%) of women who plan a caesarean section will have a vaginal breech birth because labour starts before their planned caesarean section date.

Recovery

No studies have compared the length of hospital stay following a vaginal breech birth to a planned caesarean section. The National Institute for Health and Care Excellence (NICE) ' Caesarean section guideline' (a national guideline based on thorough review of medical evidence) states that the average length of hospital stay following a planned vaginal birth (when the baby is head-down) is 3 days and 3-4days following a planned caesarean section.

In studies which have compared planned vaginal breech birth and planned caesarean section, no difference has been found in:

  • how easy mothers think it is to care fore their babies following birth
  • how happy women are with their sexual relationships following birth
  • how many women express postnatal depression

Breastfeeding

In studies which have compared planned caesarean section to vaginal breech birth, no difference was found in the number of women starting breastfeeding or the length of time the baby was breastfed. You can ask your midwife for advice about breastfeeding.