Approximately 3-4 percent of term infants are breech with their bottoms, and not their heads, down in the birth canal. When a baby is bottom-down at term the risk of injury to that baby increases. The risk is decreased, but not totally eliminated, even if the mother undergoes a cesarean section. The way the upper body, arms and head come after the legs and body are delivered is very unpredictable and can be difficult to control.

I prefer, if possible, to use a skill I acquired in my training to turn the baby's head down. The term for turning a breech baby to the vertex or head down position is external cephalic version. The position of the baby is changed by applying outside force to the uterus. It is kind of like getting a red M&M up to the top of the bad by squeezing the bag the right way. In years passed this version fell out of favor because of injuries sustained by mother and child.

The big change that has made this procedure safer and brought it back into popularity is making it more painful. Let me explain: Years ago, anesthesia was used, and that allowed the physician to exert too much force on the woman and child. Now, I do the procedure with no anesthesia. The mother limits the amount of force I can use to turn the infant around.

The other significant changes in this technique are the use of ultrasound to determine the position of the baby in the womb and the use of medication to relax the uterus before the procedure is done.

I usually do this at about 37 weeks and if successful, I induce labor about a week later. If I am unsuccessful, I do a cesarean a week later, because if I canít turn the baby with the force I can exert, the baby will not turn on its own. The reason I donít just do it at 38 weeks and just induce or do a cesarean is the fluid level decreases after 37 weeks and the baby gets bigger. This is another reason the baby will not turn on its own after a failed version. For a time I did try to vert my patients at 37 weeks, but I have had much more success at 38 weeks.

Versions are always done in Labor and Delivery because there is still some risk of placental injury and the cord could end up jeopardizing the baby if it ends up in the wrong position. After the procedure the patient is generally monitors in L&D for a couple hours to be sure the inter-uterine environment has not change for the worse.

I try to identify breech babies prior to labor. I attempt "turning" the infant at about eight-and-a-half months, at this time there is a little more fluid around the baby and the baby is smaller than at nine months.

Version is not always successful, but even if it doesn't work it gives you some useful information. I have yet to have a baby spontaneously turn head down after I was not able to turn the child around myself. This gives me confidence in scheduling the cesarean delivery knowing it is very unlikely the baby will become vertex on its own if we just wait until labor.

Cesarean section before labor can avoid another complication called cord prolapse, that occurs more frequently in breech pregnancies. This is when the umbilical cord drops out ahead of the baby and blood blow in it can be cut off. This is life-threatening to the infant and emergency cesarean section is induced.

Why not wait anyway and deliver normally? It's a consideration, there are certain criteria for a vaginal breech delivery: size and position of infant, size of the mother's pelvis, previous vaginal births and willingness to accept some increased risk of injury to the child. The ultimate decision is between you and your doctor.


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