Why Doctors Perform C-Sections for Babies in Breech

In the United States, 3% to 4% of babies are breech at the end of a full-term pregnancy. This means that the feet or butt—rather than the head—are closest to the cervix and positioned to be delivered first. It can be stressful, disappointing, or unsettling to find out that your baby is breech—and the news may upset any plans for a vaginal birth.

Before 1959, virtually all breech babies were delivered vaginally. Today, however, most are born by cesarean section (C-section). Learn more about the reasons behind this change, and what to do if you want to attempt a vaginal breech delivery for a singleton baby.

Why Breech Babies Are Usually Delivered by C-Section

When babies are in a breech position, several potential delivery complications emerge. For starters, their feet or bottom may tangle with the umbilical cord, causing issues such as umbilical cord prolapse. Their body may also emerge from the cervix before it's fully dilated, and the head (the biggest part of the baby) may get stuck in the birth canal.

Beginning in the 1960s, obstetricians started delivering breech babies via C-section because they preferred the predictability and presumed greater safety for both the pregnant person and the baby. Research generally supports this surgical approach.

For example, in a 2014 study, Dutch researchers evaluated the outcomes of more than 58,000 pregnant people who had term breech deliveries. They found a 10-fold increase in neonatal mortality in breech babies delivered vaginally compared to those delivered by elective C-sections. (Researchers found a death rate of 1.6 per 1,000 babies delivered with a planned vaginal breech birth; there were no deaths in the C-section group.)

This isn't the first study to find improved outcomes among breech babies delivered via C-section. In 2000, a study known as the Term Breech Trial (TBT) found significantly fewer newborn deaths among breech babies who were delivered via planned C-section compared to those who were delivered vaginally.

"The impact of this study was stunning," says Heather Weldon, M.D., an OB-GYN at Southwest Medical Group OB/GYN Associates in Vancouver, Washington. "Within months, breech C-sections went from 50% to 80% and, by 2006, 90%."

The Reality of Vaginal Delivery for Breech Babies

Despite these findings, research also shows that vaginal deliveries can be safe for breech babies in certain situations. For example, if a pregnant person has previously delivered one or more babies vaginally and this baby is about the same size or smaller (as determined by abdominal palpation and ultrasound), a vaginal delivery might be considered if the buttocks come first (not feet) and the head is flexed forward.

The biggest challenge, though, is that the 2000 TBT study changed how American doctors are trained. Since the TBT, "There's an entire generation of OB-GYNs who aren't practicing in a day when planned vaginal delivery is an acceptable approach for term breech babies," says Alison G. Cahill, M.D., Chief of the Division of Maternal-Fetal Medicine at the Washington University in St. Louis School of Medicine. "So, they haven't been trained [in] how to do them."

The American College of Obstetrics and Gynecology's Committee Opinion on Mode of Term Singleton Breech Delivery highlights this reality: "Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery," the statement says.

Oregon Health & Science University (OHSU) in Portland is among the few hospitals nationwide to support vaginal breech delivery. "Without hospital-based options, some patients attempt high-risk deliveries at home," says Leonardo Pereira, M.D., OHSU's chief of maternal-fetal medicine. "OHSU has established safety criteria for patients, and we are training clinicians to deliver breeches vaginally in order to make the service available at more hospitals in the future."

Of course, complications can happen in any delivery—even with highly trained professionals. In fact, in 2013, OHSU was involved in a malpractice lawsuit over a vaginal breech delivery that resulted in brain damage in the baby. That said, when the conditions are right and the delivery is managed by experienced medical practitioners, most vaginal breech deliveries go smoothly.

While many studies have shown C-sections to be safer for the baby than vaginal delivery with a breech baby, it's important to note that a C-section itself isn't without risks. Additionally, assuming you are a good candidate and your provider is experienced, the risk of complications from a breech vaginal delivery is lower than average. If you're at term and your baby is breech, discuss your options with a trusted doctor or midwife to determine the best approach for you and your baby.

Options for Breech Babies

Before you decide between types of delivery, know that it's possible that your baby may move out of the breech position before labor begins. This is most likely to happen spontaneously before or around 36 weeks. In fact, at 28 weeks, 25% of babies are breech, but by term, only 3% to 4% are still breech. So, your baby may right themselves before delivery. If not, there also are interventions that can be tried to encourage a baby to flip.

External cephalic version (ECV)

External cephalic version (ECV) involves the medical practitioner using their hands on the outside of your abdomen to lift and turn your baby from breech to head down. This procedure is only tried if you're at least 36 weeks pregnant because if it's performed before then, the baby could change position again or need to be delivered too early. Although unlikely, the procedure can stimulate labor.

A "version" is about 50% effective. Multiple factors influence whether or not the procedure is successful, including the provider's experience, your medical history, and the specifics of your pregnancy. An ECV is more likely to work with low-risk singleton pregnancies in people who have been pregnant before. The procedure is less effective with larger babies, pregnant people over age 35, and in pregnancies that are at or near term.

Waiting it out

Another option is simply waiting it out. "If you don't attempt a version, there's a small chance your baby might flip itself to the head-down position by the time you're in labor," Dr. Cahill says. The main disadvantage of doing an ECV is that the procedure can be quite uncomfortable. Other than that, it is relatively low risk assuming you and your baby are otherwise in good health.

If your baby is showing signs of distress or if there are obstetrical issues such as abnormal placentation, ECV may not be recommended. If ECV isn't performed and the baby doesn't flip on their own, then you will likely need to deliver by C-section unless your provider believes a vaginal breech delivery is safe for you.

Scheduling a C-section

The TBT suggests performing a C-section at 39 weeks if your baby is in the breech position, says Dr. Cahill. This is because, in general, C-sections that are unplanned or performed after you're already in labor have more risks than scheduled C-sections, explains Dr. Cahill. However, if you are a good candidate for a vaginal breech delivery—and you are comfortable with this route—then, you can discuss this option with your medical provider.

Should I Attempt a Vaginal Breech Delivery?

While there's no official guidance on vaginal breech delivery, a Committee Opinion developed by the American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice says the following: "Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for eligibility and labor management. If a vaginal breech delivery is planned, a detailed informed consent should be documented—including risks that perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned."

Typically, pregnant people who have low-risk pregnancies that go into labor on their own and are progressing well are more likely to be successful with a vaginal breech delivery. If you'd like to pursue a vaginal breech delivery, discuss your options with a prenatal care provider. If your current medical provider doesn't have the expertise to deliver a breech baby vaginally, you can consider switching to one that does. Your current provider may be able to recommend an appropriate alternative.

Alternatively, to find a trained doctor or midwife, call your closest academic health center and ask whether vaginal breech delivery is offered or whether they can refer you to experienced providers who offer it. You can also look for providers at the American College of Nurse-Midwives website.

The Bottom Line

While it's understandable to be worried if you're nearing the end of pregnancy and your baby is breech, know that you can still have a safe delivery. While in most cases, a C-section will be recommended if your baby is breech, attempting a vaginal birth can be a feasible option for some under the right circumstances.

Having a breech baby often requires a change in plans. Letting go of your desired birth plan or hopes for an uncomplicated delivery can be hard. Give yourself the grace to process any disappointment or concern you may feel.

It may help to focus on the baby at the end of your pregnancy journey rather than the delivery itself. Your medical provider can help you decide what type of delivery is right for you and your baby. If you have any questions about their recommendations, discuss your concerns with them and/or ask for a second opinion.