Overview

Ideally, towards the end of your pregnancy, your baby is in a cephalic presentation, positioned head-down, facing your back, with their chin tucked to their chest and the back of their head ready to enter your pelvis. Although humans are ideally born head first, some babies will be breech, meaning they are bottom first rather than head first. In recent decades there has been a growing trend of doctors recommending an elective cesarean for a breech baby at term. An elective cesarean aims to avoid the risks of some complications possible with a vaginal breech birth. To turn your baby head down for a vaginal birth, there are several techniques you or your doctor can utilize before you go into labor. This episode examines the evidence on the risks and efficacy of methods to turn a breech baby, including acupuncture, optimal fetal positioning, spinning babies, and an external cephalic version.

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Your Baby’s Position

Your baby starts with a lot of room to move around at the beginning of your pregnancy. They can stretch out and even do somersaults. As they get bigger, they have less room to move around. Ideally, towards the end of your pregnancy, your baby is in a cephalic presentation, positioned head-down, facing your back, with their chin tucked to their chest and the back of their head ready to enter your pelvis.

Some babies will be bottom first rather than head first, which is called breech. There are four classifications for breech positions. Complete breech is bottom down with legs crossed and knees up at the chest. Imagine sitting with your legs crossed, then bringing your knees to your chest. Frank breech is bottom down with their legs straight, so their feet are near their face. Picture sitting down with your legs straight before you and leaning forward until your head is against your knees. An incomplete breech combines a complete and frank breech when one leg is straight, and one is bent. Footling breech occurs when one or both feet are presenting closest to the birth canal. At 36 weeks, 94% of babies are in a cephalic (head down) presentation. Up to 24% of babies in a breech presentation will move into a cephalic presentation after 36-37 weeks.

See this episode for more in-depth information on how to tell what position your baby is in and how your baby’s position can affect your labor and birth.

Why Some Babies are in a Breech Position

It is not always known why some babies are breech, but there are some common causes. Uterine abnormalities can make it difficult for your baby to move its head down. Uterine abnormalities could include an abnormally shaped uterus, fibroids, scar tissue from surgery, a previous cesarean, or a past uterine infection. A placenta in an abnormal position can limit the room a baby has to move. Too little or too much amniotic fluid could impact a baby’s ability to move. Other abnormalities, like a short umbilical cord, could restrict their movement. If you are having twins or multiples, your babies have even less room to move, and it is common for one or more babies to be in a breech position. A previous breech baby, premature birth, smoking, and a higher weight or BMI can increase your odds of having a breech baby.

Possible Complications of Vaginal Breech Birth

Humans are ideally born head first, and there are risks of some complications with a vaginal breech birth. Your baby’s head is soft, which helps it fit through the birth canal. Often a head-down baby born vaginally will have a cone-shaped head temporarily after the birth. If the head is the last part of your baby to come out, your cervix may not stretch enough to allow room for your baby’s head to come out easily. As a result, your baby could be at risk for their head or shoulders being wedged against your pelvis.

Since the head is the largest part, a head-down baby blocks the birth canal. If your baby is not head down, it can be at risk of umbilical cord prolapse, when the umbilical cord slips into the birth canal ahead of your baby. When this occurs, as a baby moves into the birth canal, it can compress the cord, restricting blood flow and oxygen. Lastly, there is an increased risk of perineal tears or an episiotomy.

Vaginal Breech Birth

A significant factor in decreasing the potential risks of vaginal breech birth is your doctor or midwife’s experience and skill level. A study published in 2000 by the Term Breech Trial Collaborative Group concluded that elective cesareans offered better results than vaginal deliveries in full-term breech babies. This began a trend to favor an elective cesarean for breech babies. In the decades since the release of this study, the practice has been adopted by medical organizations, and fewer medical students are learning how to manage the risks of a vaginal breech delivery. There are a small number of practitioners who are skilled in vaginal breech birth. Most doctors and midwives do not have training or experience with vaginal breech birth and would likely recommend a cesarean delivery for a breech baby.

Techniques to Turn a Breech Baby

You or your doctor can utilize several techniques before you go into labor to try and turn a breech baby.

Acupuncture

Acupuncture is a key component of traditional Chinese medicine. It involves inserting extremely thin needles through your skin at strategic points on your body. The objective is to balance the flow of energy, known as chi. According to traditional Chinese medicine, chi is believed to flow through pathways called meridians in your body. By inserting needles into specific points along these meridians, acupuncture practitioners believe your energy flow will re-balance. Many Western practitioners view acupuncture points as places to stimulate nerves, muscles, and connective tissue.

Acupuncture is most often used in pregnancy to attempt to induce labor or to try to get a breech baby to turn. Moxibustion is an additional technique applied with acupuncture to turn a breech baby. Moxibustion involves burning mugwort near acupuncture point bladder 67 (BL67), located at the outside corner of the nail of your smallest toe. Mugwort is believed to increase blood flow to the pelvic area and uterus. The heat from the burning herb is intended to stimulate the acupuncture point.

The Evidence on Acupuncture

Fortunately, we have some research available on acupuncture to flip a breech baby. A systematic review on moxibustion for a breech baby included eight randomized controlled trials involving 1346 women. Overall the review found limited evidence to support the use of moxibustion for correcting breech presentation. Most included studies combined moxibustion with other techniques.

One study examined moxibustion to correct a non-vertex presentation. This included 406 low-risk pregnant women with breech babies between 33-35 weeks. Participants were divided into three subgroups. One group received moxibustion at point BL67. This was called the true moxibustion group. Another group received moxibustion at a non-specific acupuncture point called the sham moxibustion group, similar to a placebo. The third group received no intervention. For the groups who received moxibustion, the expecting mother and a partner or support person received training on how to perform moxibustion to perform it at home. Researchers advised participants to apply the treatment for 20 minutes a day for two weeks, changing from one foot to the other as soon as the heat became uncomfortable at the point of application. You will feel the heat with moxibustion, but it shouldn’t be so close to your skin that it burns you.

In the true moxibustion group, 58.1% of the full-term presentations were cephalic (head down), compared with 43.4% in the sham moxibustion group and 44.8% of those in the usual care group. The study concluded that moxibustion at acupuncture point BL67 is effective and safe for correcting a non-vertex presentation between 32 and 34 weeks. Moxibustion is well-accepted by women, and the straightforward nature of the procedure means it can be easily applied at home. Moxibustion, therefore, represents a treatment option that should be considered to achieve version of the non-vertex fetus.

Evaluating Acupuncture as a Tool to Flip a Breech Baby

There is some evidence that moxibustion and acupuncture may help turn a breech baby. It isn’t overwhelming, but it is indeed promising. This is also a procedure with minimal risk. You may experience soreness where acupuncture needles are inserted. The risk is low for infection, and you want to ensure you visit a reputable practice that uses sterile disposable needles. The acupuncturist treating you must be licensed and should have knowledge and experience treating pregnant women. An additional downside is the cost of the procedure, which should be reasonable, but it is an additional expense. The possible benefit is that your baby does move head down, and you can have a vaginal birth.

Optimal Fetal Positioning and Spinning Babies

Optimal Fetal Positioning is the term coined by Jean Sutton, a midwife, and Pauline Scott, a childbirth educator. This describes ways a mother can assist her baby in assuming the best position to have the simplest, safest birth. They define the best position as vertex, left occiput anterior. This means your baby is head down, with the back of their head against the left side of your belly. The idea of Optimal Fetal Positioning is that by practicing specific movements and positions, you can encourage your baby to get into this position before birth.

Midwife Gail Tully created spinning Babies, an approach that focuses on balance, gravity, and movement to improve your baby’s position for an easier birth. Balance refers to body balancing. Body balance is “not too tight and not too loose, and not too twisty.” It is looking at the biomechanics of your pelvis, and soft tissues using stretches that you do yourself or someone trained in the Spinning Babies technique assists with, or massage, pressure, or positions. Gravity focuses on being in upright positions during pregnancy and labor to encourage your baby to be head down. Movement is a specific way of jiggling and stretching muscles to relax what you can’t relax by intention. Spinning Babies builds on some of the ideas from Optimal Fetal Positioning, but it is much more comprehensive.

The Evidence on Optimal Fetal Positioning and Spinning Babies

The Spinning Babies website links to a lot of research. I did not find studies that specifically looked at whether practicing the Spinning Babies techniques during pregnancy is evidence-based for a head-down baby at term. Spinning Babies acknowledges, “These studies support the approach though they were not research based on the approach. If more information is wanted on why or how safe it is that we do what we do, these studies give credence. Some of the conclusions are not in sync with our conclusions, but the data shows important information about our topics of discussion.”

While I was very disappointed not to find more research, we can break these concepts down and better understand the pros and cons.

Left vs. Right Side

One limitation of Optimal Fetal Positioning is that it focuses on one specific position, the left occiput anterior. The episode on your baby’s position addresses the lack of evidence to show why the left is preferred. According to the creators of Optimal Fetal Positioning, the right occiput anterior position works almost as well. Still, the modified banana or pear shape of the first-time mother’s uterus means that it is an option only for second or later babies, but few of them choose it.

According to Spinning Babies, the left side is preferred due to the uterus’s natural shape (called right obliquity) being rounder on the left and steeper on the right. The effect is that babies from the left are more likely to be curled to aim the crown of the head into the pelvis. A baby on the right may rotate to the posterior in labor due to the steep side extending the back and pointing the top of the baby’s head into the pelvis.

The Three Principles of Spinning Babies

Let’s take a deeper look into the three principles of Spinning Babies. Remember that Spinning Babies builds on the ideas of Optimal Fetal Positioning, and it is much more comprehensive.

Body Balancing

The first principle of Spinning Babies is body balancing so that you are “not too tight and not too loose, and not too twisty.” Modern lifestyles have dramatic effects on our bodies. Most humans are less active today than 100 or more years ago. We spend more time sitting and less time moving our bodies. You have relaxed ligaments from the hormone relaxin and weight gain during pregnancy. Plus, tension in your muscles, an injury, or inflammation can all put your body out of balance. Pregnancy is physically challenging, and your body is under a lot of stress.

In my last pregnancy, I had some issues with pain in my hip. It was bad enough that I was concerned about going into labor and being in pain. I was so fortunate that my midwife also happened to be a Spinning Babies instructor. We had a couple of sessions of body balancing that changed my life. This was primarily stretching and putting pressure to release muscle tension.

Given that this is anecdotal, it made a significant difference for me. I also had a massage from someone trained in Spinning Babies, who was amazing. I don’t know whether any of that had to do with my baby being head down or in an anterior position in labor. It relieved the pain I was having, and I was so thankful to have access to knowledgeable professionals.

Gravity

Spinning Babies recommends good posture and specific positions during pregnancy. It makes sense that having a good posture can open up more room for your baby. If you do not have good posture, you compress everything in your torso, your lungs, organs, and uterus. Sitting or standing more upright will allow more room for your baby. Spinning Babies also recommends specific sleeping positions, like on your side with a pillow between your knees, which takes some pressure off your hips. Assuming these positions are comfortable for you, there is no downside. At a minimum, the upside is that you are more comfortable, potentially helping your pelvis and creating more room for your baby to get in the best position before entering labor.

Upright positions during labor are evidence-based for a shorter labor. See this episode for more information on labor positions.

Movement

The third principle of Spinning Babies is movement. Proponents of Spinning Babies advocate for a specific way of jiggling and stretching muscles to relax what you can’t relax by intention alone. Similar to positions that work with gravity, this has no downside. We can agree that movement, whether walking, stretching, or having someone jiggle your hips, isn’t bad, assuming the motions you are doing are comfortable for you. Movement will benefit your flexibility and range of motion, all good things during pregnancy and birth.

Benefits and Risks of Spinning Babies

Overall, the potential benefits of Spinning Babies are all wonderful. What about the risks? There are two things you need to watch out for. The first is that if you are in a position or stretch that doesn’t feel right, is painful, or uncomfortable, don’t do it. You don’t want to overextend anything, pull a muscle, or injure yourself. Listen to your body; it will tell you if something isn’t right.

The second thing that you need to be cautious about is psychological. There has been some criticism of Spinning Babies for putting stress on mothers who practiced it and still had babies in a malposition. Some obvious things, like a misshaped uterus, could make it difficult or impossible for your baby to get into an ideal position. Some babies don’t want to get in the anterior vertex position. If you spend your whole pregnancy practicing the positions and the exercises, seeing professionals and chiropractors, and your baby is breech at term, you may feel like you failed. There have been parents in this position who think they should have done more or didn’t do the right things. I do not want you to feel that way. There is always an element of pregnancy and labor that will be out of your control.

External Cephalic Version

An external cephalic version is a medical procedure usually done after 37 weeks in which your doctor or midwife puts pressure on the outside of your belly to try and get your baby to turn head down. Sometimes two people will be assisting with this procedure, and they may use an ultrasound to help guide them.

More than 50% of ECVs are successful. Sometimes the baby returns to a breech position, and it may be possible to attempt another ECV. ECV does get more difficult the closer you are to your due date.

Some other methods may be combined with an ECV procedure, including tocolytic drugs, fetal acoustic stimulation, regional analgesia, or transabdominal amnioinfusion. Let’s examine how these methods are used and what the evidence is for their use. A Cochrane Review of 28 studies is a good resource for evidence on these methods.

Tocolytic Drugs

Tocolytic drugs are anti-contraction medications that help your uterus relax. Data shows beta stimulants increase the likelihood of a successful version and cephalic presentation in labor. There was insufficient data comparing different groups of tocolytic drugs. Regional analgesia, like an epidural or spinal, can be combined with a tocolytic. This was more effective than the tocolytic alone in increasing successful versions. However, no difference was identified in a cephalic presentation in labor or cesarean sections. As with any medication, talk to your doctor about the risks and efficacy of your available options. They will be your expert resource in navigating these options.

Vibroacoustic Stimulation and Amnioinfusion

Two other interventions that can be used with an ECV are vibroacoustic stimulation and amnioinfusion. Vibroacoustic stimulation applies a vibratory sound to your abdomen. This aims to induce fetal heart rate accelerations and speed up your baby’s heart. Amnioinfusion involves an injection of fluid into your uterus to increase the amount of amniotic fluid. In the Cochrane Review, there was insufficient data on using vibroacoustic stimulation or amnioinfusion.

Risks of an External Cephalic Version

Risks of ECV include premature rupture of the membranes, changes in the baby’s heart rate, placental abruption, and preterm labor. In a review of 84 studies involving nearly 13,000 version attempts, the overall complication rate was 6.1%. This was 0.24% for serious complications and 0.35% for emergency cesarean deliveries.

Timing of an External Cephalic Version

The American College of Obstetricians and Gynecologists recommends an ECV at 37 weeks. A study shows that an ECV done earlier, between 32-34 weeks, increases the chances that your baby will be head down at full term. This focused on three trials, including 1888 women. Compared to women who had an ECV done after 37 weeks, the women who had it earlier had a 19% decrease in the rate of breech babies at birth, a 10% reduction in the risk of failing to achieve a cephalic vaginal birth and a considerably reduced chance of a breech vaginal delivery. This study did find that an early ECV may significantly increase the chances of late preterm birth. If you are considering an ECV, please talk to your care provider about the optimal time for this procedure.

Alternative Methods to Get Your Baby to Move Head Down

There are a lot of alternative methods of getting your baby to move head down, from playing music near the bottom of your belly to placing a bag of frozen peas near the top of your belly. Unfortunately, there is no scientific evidence to support these methods. If you are nearing your due date and your baby is breech, you could try some of these ideas, but there is no evidence to support their efficacy.

Breech Babies and Cesarean Birth

The vast majority of babies that are still breech at term are born via cesarean. If you plan to have your baby at home or a birth center, having a breech baby may require changing plans.

Your doctor or midwife and their experience is a significant factor in whether you attempt a vaginal birth or have a planned cesarean. If your care provider has experience with vaginal breech birth, that may be a viable option for you. If you are interested in additional research on vaginal breech birth, there is an excellent study that examines outcomes of 60 breech home and birth center births attended by Dr. Stuart Fischbein. Dr. Stu is a wonderful example of an OBGYN who has the expertise and experience to safely support mothers who want a vaginal breech birth.

Making an Informed Choice

A meta-analysis compared the risks of a planned vaginal delivery versus a planned cesarean section for term breech birth. This included nearly 259,000 women. This meta-analysis concludes that even taking into account the relatively low absolute risks of vaginal breech delivery, the current study substantiates the practice of individualized decision-making on the route of delivery in a term breech presentation. This is exactly what the Pregnancy Podcast is about. You inform yourself to make the best decision for you and your baby. If your baby is breech towards the end of your pregnancy, you need to discuss your options with your care provider.

Educating Yourself About Cesarean Birth and Your Options Even if you plan on vaginal breech birth, you should be knowledgeable about cesarean delivery. You have many options for cesarean, but you need to know what those options are. Educating yourself about cesarean can make a massive difference in feeling prepared and confident going into labor. There are episodes of the Pregnancy Podcast on cesarean birth and gentle cesarean and vaginal seeding that can prepare you for what to expect and explain your options.

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