I have always been interested in the problem of breech babies,2 having been one myself.
We do not know for certain what causes most babies to settle in the head-down position after months of floating and turning in the womb: it seems to be a programmed reflex action on the part of the embryo. Although at 30 weeks about one fifth of all babies are still in breech position, most of them turn spontaneously before birth. Why do some babies (about four per cent) persist in the awkward breech position until the very end? We do not know the complete answer; in most cases there is no obvious reason.
As we all know, a breech baby can be born vaginally; but complications may occur. Therefore obstetricians often recommend an elective Caesarean Section (CS), especially for first-time mothers. Things were very different before the advent of antibiotics, when operations were much more risky than they are today. My mother told me that when she was about 36 weeks pregnant, her obstetrician tried (unsuccessfully) to turn me by external manipulation. In recent decades, however, use of this technique (external cephalic version) has declined because it may occasionally cause complications.
I do not wish to discuss the pros and cons of this technique. In any case, even where it is still offered, it requires expert skill: the woman cannot do it herself. I am interested in procedures that the pregnant woman can be taught to apply herself. Later on I shall discuss and describe certain movements that may stimulate the baby to turn.
Nowadays most expectant mothers undergo several ultrasound examinations during the course of their pregnancy. The desirability of these scans as indeed of several other routine obstetric procedures is debatable. A woman may refuse to be scanned routinely, but if the midwife or the obstetrician suspect at around 3236 weeks that her baby lies in a breech presentation, they will usually advise her to have this confirmed by a scan.
Medical staff who provide antenatal care are often insufficiently trained in the skills of communication. Pregnant women are very vulnerable and sensitive. The last thing a pregnant woman needs is increased anxiety, which creates tension. This is bad both for her and for her baby.
The following story, written by a mother, illustrates what can be called anxiety-inducing communication.
At about the 36th week of my first pregnancy I had an ultrasound scan which showed that the baby was in breech position. I went immediately from the scan to see the registrar. The first thing she said to me was that I would probably need a CS. When I questioned this, she said I could have an X-ray to measure my pelvis and see if it might be possible to deliver a breech baby vaginally. Anyway, I made an appointment for another scan two weeks later. I left feeling that the registrar was already sharpening her knives.
At no point did anyone at the hospital say what my GP did tell me: that there was still plenty of time for the baby to turn by itself and that there was no need to worry. Nobody apart from my antenatal teacher told me that there might be something I could do to help the baby turn.
I spent the following two weeks crawling on all fours and lying with my hips higher than my head. By the date of my next scan the baby had turned and her head was engaged.
I dont know whether the exercises helped or if the baby would have turned anyway. (She was very active all along.) But it certainly made me feel less anxious and less helpless to have something positive to do.
If at the 36th week of pregnancy the baby is breech, there is no cause for alarm: it is quite probable that it will turn spontaneously before birth, and there are some simple steps the mother can take to encourage it to do so.
One technique, described in many popular guides for pregnant women, is to lie down on your back several times a day, for about ten minutes each time, with your hips slightly raised on cushions and knees flexed. This method may possibly be effective but has a drawback: in advanced pregnancy, lying on your back may be uncomfortable; more importantly, the pressure exerted on the vena cava may lead to dizziness and fainting and can also reduce the supply of oxygen to the baby.
Hofmeyr3 describes other techniques used to encourage a breech baby to turn inside the uterus. Among these is the Elkins knee–chest position, for which a high rate of success is claimed. Hofmeyr also reports an interesting chance observation: spontaneous turning occurred in several women just after they had been subjected to ultrasound examination to confirm breech position. He suggests that this may be due to the women rolling onto their hands and knees as they were getting off the examination table.
When I read Hofmeyrs account I was delighted, as it appeared to support an idea that I had developed independently. Drawing on my insights as a teacher of the Alexander Technique (AT), I devised a series of movements that combines dynamically the knee–chest position with kneeling on all fours. Over several years I have taught this technique at my special AT and movement classes for pregnant women, and my experience suggests that it is effective. Of course, in the absence of a scientific statistical study it cannot be ruled out that the cases where it seems to have worked were just a series of lucky turns. Proper research will be required in order to reach firmer conclusions. Be that as it may, most childbirth educators will agree that these movements have several beneficial effects during pregnancy and in childbirth, irrespective of the babys position.
The best way to learn the procedure is under the guidance of an AT teacher. While performing the movements it is very important to maintain a proper relationship between the neck, the head and the back as well as the appropriate level of muscular tension. To judge this subjectively is much more difficult than may be imagined: our kinaesthetic sense is frequently deceptive after years of incorrect use. It is for this reason that the guidance of an AT teacher is necessary at least initially.
The AT teaches us consciously to inhibit old tense habits of movement and to replace them by more economical patterns based on a new self-awareness a new set of conscious directions addressed by the mind to the body. Freeing the neck, allowing the head to go forward and up and the back to lengthen and widen, results in free and efficient breathing and in correct positioning of the other parts and organs of the body. This produces true relaxation. It requires learning a new body-grammar and allows us to discover the wisdom of the body and a new freedom for it. Having this freedom, the body moves with maximal balance and co-ordination and minimal effort.
All this should be borne in mind when reading the following description of the procedure. Look at the drawings but remember that they cannot convey the inner dynamic of movement.
If your baby is still in breech position at 36 weeks, set aside two or three periods of about 1520 minutes each day for the following sequence of movements. Prepare a clear floor surface, preferably carpeted, on which you can crawl unhindered. Wear loose comfortable clothes such as a tracksuit, and no shoes.
How might these movements help to encourage the breech baby to turn? Nothing can be said with certainty, but perhaps the undulation of the pelvis during crawling and the slope of the torso in the knee–chest position while the back lengthens and widens help to dislodge the babys bottom from the position in which it has got stuck. Thereafter the baby may be freer to perform the pre-programmed turning reflex.
The following story illustrates several points that recur in reports of mothers who have used this technique.
Having had a completely normal and relatively easy birth with my first child, it came as something of a shock to discover at 36 weeks that my second baby was firmly stuck in breech position and that the hospitals policy in such cases was to recommend an elective CS. While the consultant was keen to stress the advantages of this (absolute safety for the baby and less discomfort for me), he was also willing to support me if I wanted to try for a spontaneous vaginal delivery. However, the baby would be closely monitored throughout labour and signs of foetal distress would mean an emergency CS under general anaesthetic he rated my chances of achieving a normal delivery at no more than 50 per cent.
I went away to consider my options, slightly surprised that the hospitals collective obstetric wisdom could not suggest any strategies for trying to persuade my baby to turn. I consulted every book I could find on the subject, all of which suggested that breech babies could and did turn right up until the onset of labour. But hospital doctors, midwives and my GP all agreed that my baby was firmly stuck and, whether delivered normally or by caesarean, would remain a breech.
Even though the professionals thought it was hopeless, I knew it would make me feel better if I had at least tried to get the baby to turn. So, I spent several sessions a day lying on the floor with my pelvis raised on cushions. After a week or so without progress I consulted Ilana Machover, whose National Childbirth Trust antenatal classes I had attended during my first pregnancy. She immediately suggested that crawling might help and arranged an appointment to show me how to do it. Learning to do the exercise properly proved more difficult than I expected, but once I was crawling to Ilanas satisfaction I found it a curiously relaxing activity and crawled around the living room several times a day.
By this time I had little hope of anything changing but, two days later, as I lay in the bath before my 38 week hospital appointment, my stomach heaved with astonishing vigour as the baby conducted what was evidently a major manuvre. I didnt dare to believe that it had turned a full somersault but, to my delight and the total amazement of the consultant and all in attendance, an ultrasound scan later that morning revealed the baby settled in the normal position for birth.
It is worth mentioning that Caroline Flint4 recommends crawling, from the 36th week onwards, as a means of encouraging the baby to rotate into an anterior position. She notes however that many women ignore this advice because crawling is very boring. I think it can be made much more interesting by thinking about what one is doing and by tuning into the rhythm of the movement.
My own experience suggests that crawling (particularly in the manner that I have described) is beneficial to all pregnant women, irrespective of the position of the baby, because it is a good physical and mental preparation for the process of childbirth. (I hope to expand on this in another article.)
Most of the women to whom I have taught this technique report that the turning occurred not while they were actually going through the movements but later, when they were relaxed, for example (as in the story just quoted) when taking a bath. Do not expect your baby to turn after the first time you try the movements. Repeat it several times each day. Dont give up. The majority of breech babies will turn eventually. However, we must accept that a few will not, probably because they cannot:
Having had a history of breech pregnancies in the family, it did not come as a surprise to me, that my baby was sitting firm on his bottom, not willing to turn. Around 36 weeks a CS was mentioned, which made me very nervous. Ilana, My NCT teacher, showed me how to do the front crawl and lie on the floor with my bottom raised. I found the front crawl very relaxing and spent a lot of my time enjoying it.
The first 28 hours of labour were spent at home. I thought if I go to the hospital at the last possible moment, the medical staff would have to give me a chance to deliver the baby naturally. As soon as we arrived at the hospital I was being prepared for CS, which was very discouraging and distressing. After a lot of discussions with the medical staff I was left alone to cope with this, as I wanted. Another twelve hours passed and I was still only few centimetres dilated. My baby was in distress a CS was inevitable. After the birth we learned that the umbilical cord was wrapped twice around my babys neck: he didnt have a choice in turning!
1 This is an expanded version
of a chapter in The Alexander Technique Birth Book, by Ilana
Machover and Angela & Jonathan Drake, published in 1993 by Robinson in
the UK and Stirling in the US. A shorter version appeared in
Midwives, November issue, pp. 389391.
2 Breech presentation is the technical term for a foetal position in which the buttocks or the feet, rather than the head, face the birth canal.
3 Breech presentation and abnormal lie in late pregnancy in Murray Enkin et al, Effective Care in Pregnancy and Childbirth, OUP 1989, pp. 653665.
4 Sensitive Midwifery, Heinemann 1986, pp. 3940.
Copyright © Ilana Machover 1995
Drawings © Helen Chown 1993