Breech baby: causes, turning (ECV) and birth options

Babies spend much of pregnancy twisting and turning. Breech simply means the baby is lying with the bottom or feet pointing down towards the cervix instead of the head. The RCOG explains that this is very common in early pregnancy and that by 36 to 37 weeks most babies have turned head-first on their own. If yours has not, the RCOG stresses that this does not usually mean that you or your baby have a problem.

Breech babies are described by how the legs are placed. This matters later because it affects which birth options are safe.

• Extended or frank breech: bottom first, thighs against the chest and feet up by the ears. Most breech babies lie this way.

• Flexed breech: bottom first, with the knees bent and the feet right next to the bottom.

• Footling breech: one or both feet hang below the bottom. The NHS and RCOG both list this as a reason a healthcare team may advise against a vaginal birth.

Often there is no reason beyond chance. Some factors make it harder for a baby to turn, and the RCOG and Tommy's list similar ones. Having a first pregnancy, a low-lying placenta (placenta praevia), too much or too little amniotic fluid, carrying more than one baby, or an unusually shaped womb can all leave less room or less freedom to move.

The RCOG adds that, very rarely, a breech position can be linked to a problem in the baby. Such problems may already have been picked up at the 20-week scan. The majority of breech babies are otherwise healthy.

The NHS says that if your baby is breech at 36 weeks you will usually be offered an ECV (NICE guideline NG192 likewise says to offer ECV after 36+0 weeks for an uncomplicated breech pregnancy, unless, for example, you are in established labour, the baby is compromised, the waters have broken or you have vaginal bleeding), where a trained professional uses their hands on your abdomen to encourage the baby to turn head-down. The RCOG says it is usually offered at around 36 or 37 weeks but can be attempted right up to the early stages of labour.

Before the procedure you have an ultrasound scan to confirm the position, and your pulse, blood pressure and the baby's heart rate are checked. The RCOG says a medicine to relax the womb, usually terbutaline, is given by injection first; it may make you feel hot, light-headed or aware of a faster heartbeat for a short time. The scan is repeated afterwards. ECV can be uncomfortable or painful, and the person doing it should stop if you are in pain. If the first attempt does not work, you may be offered another on a different day.

If your blood group is rhesus D negative, the RCOG says you will be advised to have an anti-D injection and a blood test after ECV.

• Success: about 1 in 2 (RCOG). It is more likely to work after a previous vaginal birth.

• Turning back: fewer than 5 in 100 women whose baby was turned successfully see the baby return to breech (RCOG).

• Not offered if: you need a caesarean for another reason such as placenta praevia, you have had recent vaginal bleeding, the heart tracing is abnormal, your waters have broken, or you are expecting more than one baby (RCOG and Tommy's agree on these).

• After ECV, contact the hospital if you have bleeding, abdominal pain, contractions or a change in the baby's movements.

The RCOG says there is no scientific evidence that lying or sitting in a particular position helps a baby turn. Tommy's says some people find it worthwhile to kneel with the head low and the bottom raised for 15 to 20 minutes a day, stopping at once if there is pain or dizziness, but that this is not proven.

Moxibustion, the burning of the herb mugwort near an acupuncture point at 33 to 35 weeks, has some supporting evidence according to the RCOG, but it should be done under the direction of a registered practitioner. Tommy's describes more proof as needed and calls the Webster chiropractic technique unproven with limited safety research. Check with your midwife before trying any of these.

You should be given a real choice between a planned caesarean and a planned vaginal breech birth. The RCOG says a planned caesarean is safer for the baby: it quotes a risk of a breech baby dying of 1 in 2,000 with a planned caesarean, 4 in 2,000 with a planned vaginal breech birth, and 2 in 2,000 for a planned vaginal birth of a head-first baby. Tommy's adds that a vaginal birth may be safer for the mother. Caesarean birth can affect future pregnancies, for example through placental problems or a small rise in stillbirth in later pregnancies, as the RCOG notes.

A vaginal breech birth should be planned in hospital with a team experienced in breech birth, with continuous heart-rate monitoring and a neonatal team present, and induction is not usually recommended (RCOG). A healthcare team may advise against it if the baby is footling breech, is larger or smaller than average, has the neck tilted well back, or if you have placenta praevia or pre-eclampsia.

If you plan a caesarean but go into labour first, the NHS says your obstetrician will assess whether it is safe to go ahead; if the baby is close to being born, a vaginal breech birth may be the safer route. If labour starts before 37 weeks, or you have twins, the balance of risks changes and your team will discuss it with you.

A baby can also lie across the womb, called a transverse lie. The NHS says many babies lie sideways early on and most turn head-down by the third trimester. If yours has not, you may be admitted to hospital depending on how far along you are, because of the very small risk of the cord coming out of the womb ahead of the baby (cord prolapse), which is a medical emergency. The RCOG cord prolapse leaflet says admission from 37 weeks may be discussed if the baby is transverse or changing position often (an unstable lie).

Sometimes the baby can be turned by hand. If the baby is still sideways near the due date or when labour begins, the NHS says a caesarean is most likely to be advised. A transverse lie is one of the reasons doctors check where the placenta lies, since the RCOG notes placenta praevia can be suspected when a baby lies in an unusual position.

NHS inform, the Scottish public information service, says a baby who is transverse when labour starts or at full term will need either an ECV to turn the baby head-down or a caesarean, and that you are likely to be admitted to the maternity hospital for a week or two before the birth because of the additional risk of complications. It also says that around 1 in 5 babies are breech at 30 weeks, falling to about 3 in 100 by the end of pregnancy. Admission arrangements are not identical across the UK, so ask your own unit.

Contact your maternity unit straight away, using the number on your notes, if your waters break, you have contractions or bleeding, or your baby's movements change, particularly if you know the baby is breech or sideways. If you can see or feel the cord in your vagina after your waters have broken, the RCOG says to phone 999, say you are pregnant and think you have a prolapsed cord, and get onto your knees with your elbows and hands on the floor and bend forward until help arrives. Services and thresholds differ between England, Scotland, Wales and Northern Ireland, so follow your own unit's instructions.