A childbirth educator and doula wondered why the doctor of a mom she is helping wasn't 100% sure about the signs of a breech baby. He suggested an Ultrasound (sonogram). Is telling up from down really that hard to tell by hand?
Keep reading for tips on discerning a breech position and see pictures of palpation.
Using Ultrasound sonography (imaging) is a parent's decision. There are considerations in making the decision to use Ultrasound.
- Your provider may want a more sure way of telling baby's position than their hands can detect.
- Your provider may want you to have a concrete way of knowing for sure your baby's position to help you make decisions from fact.
- You and your provider may both want to seek visual indications of whether or not a vaginal breech birth might be reasonably safe for your baby.
Ultrasound is justified if your care plan will change based upon what was found by an Ultrasound examination. But Ultrasound is not without risk.
Jane Evans of the United Kingdom raises a unique question around ultrasound and breech. Since babies often cover their faces in response to ultrasound, can an ultrasound exam be the cause of the complication of extended arms (drawing, above right)? This is an important question and birth outcomes could be compared with and without prenatal Ultrasound (or use of Ultrasound in labor). It would also be necessary to make sure that no one is touches the breech baby during the entire birth process, because touch is another cause of extended arms. With these two variables and many dozens of breech vaginal births, we might be able to tell if Ultrasound is a risk in breech birth. Though it does seem possible.
There is another way to tell baby's position other than Ultrasound imaging, and that is by palpation, or feeling the baby through the abdomen. Palpation is not as reliable as Ultrasound. Not all women are easy to palpate. It takes less skill to interpret an Ultrasound image of a breech baby than palpate the baby's position accurately, especially in women that aren't easy to palpate.
Parents may well want to see "proof" of breech presentation as well, to prepare themselves and make choices for childbirth. Finding out that the baby is breech can definitely change birth plans, whether to plan a cesarean or make the necessary preparations, sometimes including travel, to find a safe breech practitioner.
Learn more using the The Belly Mapping Workbook. There is a pretty good section with illustrations on figuring out if your baby is breech (after 30 weeks or so) and what to do about it.
Breech is sometimes difficult to tell with palpation (feeling the abdomen with the hands), and other times quite easy to tell. Even if the doctor is sure, s/he'll recommend an ultrasound (sonogram) to get hard data to enter into the mother's chart.
Here are some pictures of palpation and drawing the findings of the breech presenting baby on a Sunday, when baby was still breech. The mom did a forward-leaning inversion that night and the next day, Monday, before her scheduled Ultrasound. Then we found out the baby had flipped head down! (photos by Clare Welter, CNM)
With palpation, we look for a cylinder shape coming from the firm bulge at the top of the fundus. This is the thigh coming off of the buttocks.
If we find cylinders low in the abdomen and a firm ball at the top we are considering a possible breech position.
Listening with a fetoscope or doppler is helpful, but not diagnostic.
Location of the heart beat is not a reliable indicator.
Sometimes the heart beat can be heard far from the heart when the physician or midwife uses a doppler. A doppler is a hand held monitor that uses ultrasound (sonogram) to detect the heartbeat. A firm tummy allows the heart rate to be heard a distance away from the baby. So does ample amniotic fluid. Water carries sound.
"I had one child, breech vaginally. I would not let them do an ultrasound so I escaped the knife." -Dr. Lucia Lein, DC about her own birth.
There are three major types of breech presentations and the rare kneeling breech. Variations include one leg up and one down, or one knee up and one down.
To help tell what position the baby is in, the parents may look at the four breech types.
Types of breeches
- Frank breech (50-70%) - Hips flexed, knees extended (pike position)
- Complete breech (5-10%) - Hips flexed, knees flexed (cannonball position)
- Footling or incomplete (10-30%) - One or both hips extended, foot presenting
- Kneeling (rare) - both knees are coming first, the feet are folded up behind the baby's thighs.
Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22% of births prior to 28 weeks' gestation to 7% of births at 32 weeks' gestation to 1-3% of births at term.
See more in About Breech.
Belly Map of a Breech Baby
The drawings here begin with the four quadrants of a Belly Map. A simple circle can be drawn on a piece of paper. Then draw two crossing lines; the lines cross at the navel.
Next, the bumps and wiggles that the mother with a breech might feel are drawn.
Finally, we see the breech baby drawn in for this Belly Map. This particular breech baby is in the complete breech position. He or she is a bit oblique, not unusual at 32 weeks gestation, but less common, and certainly less favorable at 40 weeks gestation.
Details that will help you think about what you are feeling:
When the feet are folded near the baby's buttocks the pelvis and feet together make a hard ball.
Feeling the folded feet and hips of the baby through the abdominal muscles and uterus can, at times, feel much like a head.
The head however, tilts on the neck when moved by hand. Grasping and tipping the buttocks will move the entire trunk of the baby.
Sometimes the uterus over the fetal head in the fundus (top of uterus) feels warm and tender.
When the baby is stretching a leg away from his body, the hips will have a cylinder shape emerging from it-the thigh. The head doesn't have a cylinder coming out of it.
There may, at times, be a cylinder shape overlapping the head, when the baby has their arm up. Sometimes fingers can be felt near the face.
Lower in the pelvis, the foot movement of a breech is quite memorable. One mother said, "The baby has made a treadmill of my bladder." Compare that to the Frank breech position the legs are up towards the tummy and chest and there is little movement from the feet in the lower part of the abdomen.
A transverse baby will lay sideways. Nothing will be in the pelvis. Limbs will cross the belly, high or low or right across, depending on how the baby is lying. The limbs might even be towards the back which would make the baby seem less active. The bottom and head will still slide against the mother's abdomen on a regular basis, reassuring everyone with the baby's wellbeing.
Benefits of a sonogram/ultrasound
The doctor won't do a cesarean for a head down baby s/he mistook for a breech. And, if the parents desire a vaginal breech birth, a sonogram can locate the placenta, check for head flexion and help the parents and physician predict what type of breech position the baby may be in once labor begins. The legs can change position in early labor, so the actual position is not for sure until the baby is coming through the pelvis in the pushing stage of labor.
Even some ultrasound technicians are not accurate at telling the finer details of fetal position, so parents should ask, if they decide on an ultrasound, to have the baby's position explained to them in detail.
Of interest are:
- Which side the baby's back is on (when planning a physiological breech birth, breech babies whose back is on the right may have an easier rotation)
- Location of the placenta
- Amount of head flexion (how much and which way the neck is bent)
- What type of breech position the baby is in at the moment
- Head size in relation to body
- Baby's weight (not always accurate, but we want the head and body to be in teh same proportion rather than having the baby's head much bigger than usual for the size of the body a baby has. If the full term baby's frank breech bottom fits, we expect the head to fit, but it must be flexed chin down).
Learn how and why to do the maternal inversion on the Spinning Babies blog at http://spinningbabies.blogspot.com/2007/02/how-to-do-inversion.html