BREECH

• What does it mean if my baby is breech?

  By around 8 months, there's not much room in the uterus. Most babies maximize their cramped quarters by settling in head down, in what's known as a cephalic presentation. But if your baby is breech, it means he's poised to come out buttocks or feet first.
  When labor begins at term, nearly 97 percent of babies are set to come out head first. Most of the rest are breech. (In rare cases, a baby will be sideways in the uterus with his shoulder or arm presenting first — this is called a transverse lie.)
  
  There are several types of breech presentations, including frank breech (bottom first with feet up near the head), complete breech (bottom first with legs crossed Indian-style), or footling breech (one or both feet are poised to come out first).
  
  By the beginning of your third trimester, your practitioner should be able to tell what position your baby is in by feeling your abdomen and locating the baby's head, back, and bottom. About 25% of babies are breech at this point, but most will turn on their own over the next two months.
  As you're approaching term, if your baby's position isn't clear during an abdominal exam, your caregiver may do an internal exam to try to feel what part of the baby is in your pelvis. In some cases, she may use ultrasound to confirm the baby's position.
• What if my baby is still breech near term?

  Babies who are still breech near term are unlikely to turn on their own. So if your baby is still bottom down at 37 weeks, your caregiver should offer to try to turn your baby to the more favorable head-down position, assuming you're an appropriate candidate.
  This procedure is known as an external cephalic version (ECV). It's done by applying pressure to your abdomen and manually manipulating the baby into a head-down position. (If your caregiver is not experienced in this procedure, she may refer you to someone who is.)
  ECV has about a 58 percent success rate in turning breech babies (and a 90 percent success rate if the baby is in a transverse lie.) But sometimes a baby refuses to budge or rotates back into a breech position after a successful version. ECV is more likely to work if this isn't your first baby.
  Not all women can have ECV. If you're carrying twins or your pregnancy is complicated by bleeding or too little amniotic fluid, you won't be able to have the procedure. And, of course, you won't have a version if you're going to deliver by cesarean anyway — for example, if you have a placenta previa, triplets, or have had more than one previous c-section.
• What is an ECV like?

  Having a version isn't entirely risk-free and some women find it very uncomfortable. You'll want to discuss the pros and cons with your caregiver.
  
  Severe complications, while relatively rare, can occur. For example, an ECV may cause the placenta to separate from the uterine wall so that your baby has to be delivered right away by c-section. The procedure may also cause a drop in your baby's heart rate, which, if it doesn't resolve quickly on its own, will require an immediate delivery.
  For these reasons, a doctor should do the procedure in a hospital with facilities and staff available for an emergency c-section in case any complications arise. You'll be told not to eat or drink anything after midnight the night before the procedure, in case you end up needing surgery.
  When you go in, you'll have blood drawn and an IV will be started. Women who are Rh-negative should get an injection of Rh immune globulin for the procedure unless the baby's father is also Rh-negative. Your baby's heart rate will be monitored for a time before and after the procedure.
  You'll have an ultrasound beforehand to check your baby's position, the location of the placenta, and the amount of amniotic fluid. The ultrasound will be repeated after the maneuvers are performed. (Some doctors also use ultrasound during the procedure.)
  Some studies show higher success rates for ECV when uterus-relaxing drugs are used.
• If my baby doesn't turn, will I have a c-section?

  It depends. You may have a vaginal breech delivery if you have a twin pregnancy where the first baby is in the head-first position and the second baby is not, or if your labor is so rapid that you arrive at the hospital just about to deliver.
  However, the vast majority of babies who remain breech arrive by c-section. A large international study published in 2000 showed that planned c-sections resulted in the safest outcomes for full-term singleton breech babies. The following year the American College of Obstetricians and Gynecologists (ACOG) published a Committee Opinion advising against planned vaginal delivery of these babies.
  
  Longer-term follow-up of the babies in this study led the researchers question this conclusion. And other recent reports suggest that certain patients may have safe vaginal deliveries. This includes women whose pelvis seemed large enough, whose labor started and progressed well on its own, and whose babies were full-term frank or complete breeches and appeared to be of average weight with no abnormalities shown by ultrasound.
  
  In recognition of these studies, ACOG issued a new Committee Opinion in July 2006. This time the organization noted that it may be reasonable for some women to plan to deliver vaginally. ACOG cautioned that the caregiver must be experienced in performing vaginal breech deliveries (fewer and fewer of them are) and the woman must be made aware that the risks to her baby may be higher than with a planned cesarean delivery.
  
  If a c-section is planned, which is likely for most women, it will usually be scheduled for 38 or 39 weeks. To make sure your baby hasn't changed position in the meantime, you'll have an ultrasound at the hospital to confirm his position just before the surgery.
  
  There's also a chance that you'll go into labor or your water will break before your planned c-section. If that happens, be sure to call your provider right away and head for the hospital.
• What alternative techniques might I try to coax my baby to turn?

  The scientific jury is still out on whether the following techniques are effective, and you'll want to talk your practitioner before trying them.
  Let gravity help. Get into one of the following positions twice a day, starting at around 32 weeks. The idea is to employ gravity to help your baby somersault into a head-down position.
  Be sure to do these moves on an empty stomach, lest your lunch comes back up. And make sure there's someone around to help you get up if you start feeling lightheaded.
  
  Lie flat on your back and raise your pelvis so that it's 9 to 12 inches off the floor. Support your hips with a pillow and stay in this position for five to 15 minutes.
  
  Alternately, get on your knees with your forearms on the floor in front of you, so that your bottom sticks up in the air. Stay in this position for five to 15 minutes.
  
  Be aware that no studies to date have showed that the mother's position has any effect on the baby's position. And if you find these positions uncomfortable, stop doing them.