How common breech is at term

RCOG's key points are reassuring in themselves: "Breech is very common in early pregnancy, and by 36–37 weeks of pregnancy most babies will turn into the head-first position. If your baby remains breech, it does not usually mean that you or your baby have any problems." The figure it gives is that "towards the end of pregnancy, only 3-4 in every 100 (3-4%) babies are in the breech position."

Factors that make it more likely include a first pregnancy, a low-lying placenta, too much or too little amniotic fluid, and carrying more than one baby. Very rarely breech signals a problem with the baby, which would usually be picked up at the 20-week scan.

The NHS confirms the timing: "If they're still breech at around 36 weeks' gestation, the obstetrician and midwife will discuss your options for a safe delivery."

Option one: external cephalic version

ECV means "applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head-first". NICE's caesarean birth guideline says to offer it to women with "an uncomplicated singleton breech pregnancy after 36+0 weeks".

What happens

RCOG describes the sequence. Before the procedure you have an ultrasound scan to confirm the baby is breech, and your pulse and blood pressure are checked. You are usually given an injection to relax the muscle of the uterus, which "has been shown to improve the chances of turning your baby" and "is safe for both you and your baby" — it may make you feel flushed and aware of a faster heartbeat for a short time. Afterwards the scan is repeated to see whether the baby has turned, and the baby's heart rate is monitored before and after.

On timing and comfort: ECV "is usually performed after 36 or 37 weeks of pregnancy. However, it can be performed right up until the early stages of labour. You do not need to make any preparations." It "can be uncomfortable and occasionally painful but your healthcare professional will stop if you are experiencing pain and the procedure will only last for a few minutes."

If your blood type is rhesus D negative you will be advised to have an anti-D injection afterwards and a blood test. You can normally go home the same day.

Does it work?

RCOG: "ECV is successful for about 50% of women. It is more likely to work if you have had a vaginal birth before." If it succeeds there is still a small chance the baby turns back, but "this happens to less than 5 in 100 (5%) women who have had a successful ECV." If the first attempt fails, another can be tried on a different day.

Is it safe?

"ECV is generally safe with a very low complication rate. Overall, there does not appear to be an increased risk to your baby from having ECV." The specific number to know: "Immediately after ECV, there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby's heartbeat." That is why it is carried out in a hospital where an emergency caesarean is available, by a doctor or midwife trained in the procedure.

RCOG lists when ECV should not be done: if you need a caesarean for another reason such as placenta praevia; if you have had recent vaginal bleeding; if the baby's CTG is abnormal; if your waters have broken; or if you are pregnant with more than one baby. NICE adds established labour, fetal compromise and other medical conditions such as severe hypertension. ECV "can be carried out on most women, even if they have had one caesarean section before."

Anything else that helps?

RCOG is direct: "There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn." It notes some evidence that moxibustion at 33 to 35 weeks may help, and says this "should be performed under the direction of a registered healthcare practitioner."

Option two: planned caesarean

RCOG: "If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth. Caesarean section carries slightly more risk for you than a vaginal birth."

It also flags the longer view: a caesarean "can increase your chances of problems in future pregnancies", including placental problems, more difficult repeat surgery, and a small increase in stillbirth in subsequent pregnancies.

NICE adds a procedural detail: before a caesarean for uncomplicated singleton breech, an ultrasound should confirm the baby is still breech, done "as late as possible before the caesarean birth procedure."

Both RCOG and the NHS cover what happens if labour starts first: your obstetrician will assess whether it is safe to proceed, and "if the baby is close to being born, it may be safer for you to have a vaginal breech birth."

Option three: planned vaginal breech birth

This requires a team trained in it, and a hospital setting. RCOG: "You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labour is not usually recommended."

On risk, RCOG is even-handed: "While a successful vaginal birth carries the least risks for you, it carries a small increased risk of your baby dying around the time of delivery. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects on your baby."

When it is advised against

RCOG and the NHS give the same list. A vaginal breech birth may be advised against if:

your baby is a footling breech — "one or both of the baby's feet are below its bottom"
your baby is larger or smaller than average
your baby's neck is very tilted back (hyperextended)
you have a low-lying placenta (placenta praevia)
you have pre-eclampsia or other pregnancy problems.

What labour looks like

RCOG: you have the same pain relief choices as with a head-first baby, though "if you choose to have an epidural, there is an increased chance of a caesarean section". Your baby's heart rate "will usually be monitored continuously as this has been shown to improve your baby's chance of a good outcome" — which matches NICE's inclusion of non-cephalic presentation among the antenatal risk factors warranting continuous CTG. A paediatrician attends the birth.

An episiotomy is more likely; the NHS lists breech birth among the situations where one may be needed to allow instruments to be used.

Twins, transverse and preterm labour

If you are having twins and the first baby is breech, RCOG says a planned caesarean is usually recommended. If the first baby is head-first, the position of the second matters less, because after the first birth "the second baby has lots more room to move."

If your baby is lying sideways (transverse), the NHS notes a very small risk of cord prolapse, which "is a medical emergency and the baby must be delivered very quickly" — which is why you may be admitted to hospital. If the baby is still transverse near your due date, a caesarean is likely to be advised.

If labour starts before 37 weeks, RCOG says "the balance of the benefits and risks of having a caesarean section or vaginal birth changes and will be discussed with you."

Breech Birth and ECV