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Breech Birth

Breech birth

Definition

Breech birth is the delivery of a fetus (unborn baby) in a bottom- or foot-first position. Between 3 to 4 percent of fetuses start labor in the breech position, which is a potentially dangerous situation.

Description

Throughout most of pregnancy the developing fetus is completely free to move around within the uterus. Between 32 and 36 weeks, however, the fetus becomes so large that movement is restricted. It is much harder for the fetus to turn over, so whatever position it has assumed by this point is likely to be the same position that he or she will be in when labor begins.

For reasons that are not fully understood, almost all unborn babies settle into a head down, or vertex, position. The fetus is upside down in the uterus, and the head will dilate the cervix (or vaginal opening) and lead the way during the birth process.

Some fetuses, however, present in a breech position. There are three breech positions: frank, complete, and incomplete. In a complete breech, the buttocks lead the way out of the uterus, and the legs are folded in front of the body. A frank breech baby also has his buttocks down, but his legs will stretch straight up with his feet by his head. An incomplete breech, also known as a footling breech, presents with one or both legs down so that the feet drop into the birth canal at delivery.

Of course, many babies are safely delivered from the breech position. There are certain factors that make a breech delivery more likely to be Successful; if ultrasound (a technique that uses sound waves to visualize the fetus) shows that the fetus is in the frank breech position, the fetus's chin is tucked on its chest, and the fetus is not big, it is more likely that an uncomplicated breech delivery is possible.

The biggest part of the fetus's body is usually its head. If the head fits through the mother's pelvis, then the rest of the fetus's body should slip out fairly easily. In addition, when the baby's head comes first, the soft bones of the skull "mold" to the shape of the birth canal during labor (which is what gives newborns that cone-headed appearance). If the fetus is born bottom first, it is possible that the body will fit through the mother's pelvis, but the baby's head will get stuck at the level of the chin. This condition, known as a entrapment, has the potential to cause serious injury to the fetus, and surgical intervention may be required to complete the birth.

There is also a possibility of umbilical cord prolapse with a breech birth. The baby continues to get its oxygen supply from its mother exclusively from the blood in the umbilical cord until the head is delivered and baby breathes on her own. In some cases of breech birth, part of the umbilical cord enters the birth canal before or with the baby's feet or buttocks and pressure on the cord cuts off the blood and oxygen supply. This situation is known as cord prolapse.

Demographics

Breech presentation occurs in 3 to 4 percent of all births, and up to 95 percent of women with a breech fetus choose cesarean section for birth. The earlier a birth occurs in pregnancy, the higher the chances are that the fetus will be in a breech position. Twenty-five percent of premature infants born before 28 weeks are breech.

Causes and symptoms

The cause of breech birth is not known. Women with multiple gestations (i.e., twins or more) are more likely to have at least one fetus in a breech position simply due to space constraints in the womb. There are generally no identifiable symptoms of a breech fetus. However, some women may be able to detect the position of the fetus by where they feel the fetus kicking.

Diagnosis

A healthcare provider can often tell the position of the fetus by feeling it through the wall of the mother's abdomen. Another clue to the position is the location where the heartbeat is heard best. If the fetal heartbeat is best heard below the level of the mother's navel, it is likely to be positioned head first. On the other hand, if the heartbeat is best heard above the level of the navel, it is likely to be breech. The most accurate way to determine breech position is using ultrasound.

Treatment

If a fetus is in the breech position in the last weeks of pregnancy, there are three possible courses of action: cesarean section (or c-section), attempted external cephalic version, or vaginal breech delivery.

Some women choose vaginal breech delivery. This should only be attempted if ultrasound shows that the fetus is in a favorable breech position. The frank breech position is the preferred position for successful vaginal breech birth, and the majority of breech fetuses are in this position. Most babies will do very well during a breech delivery, but there is a risk of fetal injury. Some providers may use forceps or a vacuum extraction device to help a breech baby out of the birth canal, a procedure known as assisted breech birth.

During an external cephalic version (also known as version), the obstetrician attempts to turn the fetus to a head first position before labor begins by manipulating the outside of the abdomen. The obstetrician places his or her hands on the mother's abdomen to feel the location of the unborn baby's buttocks and head. The buttocks are lifted up slightly and the doctor pushes on the baby's head to encourage him to perform a sideways somersault. It may take several tries before the fetus cooperates, but about half will eventually turn.

A version should only be done in a hospital, with an ultrasound machine used to guide the obstetrician in turning the fetus. The fetus should be monitored with a fetal monitor before and after the version. The mother is given medication to relax the uterus, minimize discomfort, and prevent premature contractions.

A version is not appropriate for every fetus who is in the breech position at the end of pregnancy. It can only be tried if there is one fetus in the uterus, if the placenta is not lying in front of the fetus, and if the umbilical cord does not appear to be wrapped around the fetus at any point.

Cesarean section is the most common way to deliver a breech baby and is the method recommended by the American College of Gynecology and Obstetrics if a version has failed. A c-section is performed by an obstetrician, who makes an incision in the lower abdomen through which the baby is delivered. Like any surgical procedure, c-section carries a risk of infection and hemorrhage. Postpartum recovery is also longer with c-section than with vaginal delivery. However, in difficult breech presentations, or in cases where there are multiple fetuses and one or more are breech, it may be considered the best option for delivery.

Prognosis

Version is successful in turning a breech baby approximately 50 percent of the time. However, some babies who are successfully turned will turn back to the breech position after the procedure is done, particularly if version is attempted too early before the onset of labor.

Manipulations to deliver an entrapped head or stuck shoulder or arm can cause injury to the baby. Both entrapment and cord prolapse can be potentially fatal to an infant if delivery is delayed.

Among breech babies born after the full nine-month term, smaller babies usually do better. The exception to this is premature babies. C-section is generally the delivery mode of choice for premature babies due to the other risks these infants face (such as lung immaturity).

Prevention

There is no way to prevent a fetus from settling into the breech position at the end of pregnancy. A woman who has had one breech fetus is at an increased risk for having another breech fetus in subsequent pregnancies.

KEY TERMS

Complete breech A breech position in which the baby is "sitting" bottom first on the cervix with legs crossed.

External cephalic version Manual manipulation of the abdomen in order to turn a breech baby; also known as version.

Frank breech A breech position where the baby is bottom first and his legs are extended upward so that his feet are near his head.

Incomplete breech Also called a footling breech, in this position the baby has one or both feet down towards the pelvis so that his leg(s) are poised to deliver first.

Umbilical cord prolapse A birth situation in which the umbilical cord, the structure that connects the placenta to the umbilicus of the fetus to deliver oxygen and nutrients, falls out of the uterus and becomes compressed, thus preventing the delivery of oxygen.

Vertex The top of the head or highest point of the skull.

See also Cesarean section; Childbirth.

Resources

BOOKS

Ford-Martin, Paula. The Everything Pregnancy Book, 2nd ed. Boston, MA: Adams Media, 2003.

Moore, Michele. Cesarean Section. Baltimore, MD: Johns Hopkins University Press, 2003.

PERIODICALS

Gaskin, Ina May. "The Undervalued Art of Vaginal Breech Birth." Mothering no. 125 (July-August 2004): 529.

Sachs, Jessica Snyder. "C-Sections by Choice." Parenting 18, no.2 (March 2004): 22.

ORGANIZATIONS

March of Dimes. 1275 Mamaroneck Avenue, White Plains, NY 10605. Web site: <www.marchofdimes.com>.

WEB SITES

"Breech Birth." Available online at <www.babycenter.com/refcap/pregnancy/childbirth/158.html> (accessed November 9, 2004).

Goer, Henci. "Scheduled cesareans: The best option for breech babies?" Available online at <www.parentsplace.com> (accessed November 9, 2004).

Amy Tuteur, MD Paula Ford-Martin

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Breech Birth

Breech Birth

Definition

Breech birth is the delivery of a fetus (unborn baby) hind end first. Between 3-4% of fetuses will start labor in the breech position, which is a potentially dangerous situation.

Description

Throughout most of pregnancy, the developing fetus is completely free to move around within the uterus. Between 32-36 weeks, it becomes so large that movement is restricted. It is much harder for the fetus to turn over, so whatever position it has assumed by this point is likely to be the same position that he or she will be in when labor begins.

For reasons that are not fully understood, almost all unborn babies settle into a head down position. The fetus is upside down in the uterus, and the head will lead the way during the birth process.

Unfortunately, some fetuses do not cooperate. Most of these are in the breech position. The buttocks lead the way out of the uterus, and the legs are folded in front of the body (frank breech). Delivery from the breech position poses far more risks than delivery head first (vertex position).

The biggest part of the fetus's body is usually its head. If the head fits through the mother's pelvis, then the rest of the fetus's body should slip out fairly easily. If the fetus is born bottom first, it is possible that the body will fit through the mother's pelvis, but the baby's head will get stuck at the level of the chin. This condition, known as a trapped head, is very dangerous.

When the baby's head comes first, it has a chance to "mold" during labor. The bones of the baby's skull are not yet fastened together the way they are in a child or adult's skull, meaning that the bones of the baby's skull can move. During the long hours of labor the skull can change shape to fit through the pelvis more easily, which is why many babies are born with a "cone head". If the baby is born from the breech position, the skull does not have a chance to change shape to fit the pelvis, and it is even more likely to get stuck.

If the baby's head gets trapped, the possibility of injury is high. Once the baby's body is born, the umbilical cord usually stops pulsating (just as it would during a normal delivery). This cuts off the oxygen supply from the mother to the baby. If the baby's head is still inside the uterus the baby cannot yet breathe on its own. Therefore, it is essential to deliver the baby as quickly as possible.

The life saving attempts to deliver the baby's head can cause injury to the baby's neck or head resulting in permanent handicaps. In extreme cases, if the baby cannot be delivered within a few minutes, the baby might die. Obviously, it is critical to avoid a breech delivery with a trapped head.

Of course, many babies are safely delivered from the breech position. There are certain factors that make a breech delivery more likely to be successful: if ultrasound (a technique that uses sound waves to visualize the fetus) shows that the fetus is in the frank breech position, the fetus's head is tucked on its chest, and the fetus is not big, it is less likely that its head will get stuck.

Among breech babies born after the full nine-month term, smaller babies usually do better. This is not true for premature babies. Premature babies are more likely to have a trapped head because the body of a premature baby is usually much smaller than his or her head. Premature babies are generally not delivered from the breech position.

The risks of vaginal breech delivery can be avoided by delivering the baby through a surgical procedure (cesarean section, also known as c-section). For the past twenty years, cesarean section has been recommended when the fetus is breech. More recently, many providers have offered the option of version, attempting to turn the fetus within the uterus to a head first position before labor begins.

Version is based on a very simple idea. If a fetus in the breech position does a somersault, it will end up head down. During a version, the obstetrician tries to make the fetus do a somersault.

A version should only be done in a hospital, with an ultrasound machine used to guide the obstetrician in turning the fetus. The fetus should be monitored with a fetal monitor before and after the version. Some obstetricians give the mother an injection of medication to relax the mother's uterus and prevent any contractions.

During the procedure, the obstetrician places his or her hands on the mother's abdomen to feel the location of the unborn baby's buttocks and head. The buttocks are lifted up slightly and the doctor pushes on the baby's head to encourage him to perform a somersault. It may take several tries before the fetus cooperates, but over half will eventually turn.

A version is not appropriate for every fetus who is in the breech position at the end of pregnancy. It can only be tried if there is one fetus in the uterus, if the placenta is not lying in front of the fetus, and if the umbilical cord does not appear to be wrapped around the fetus at any point.

Causes and symptoms

The cause of breech birth is not known. There are generally no identifiable symptoms. However, some women can tell the position of the fetus by where they feel the fetus kicking. Most women cannot tell what position the fetus is in at any given moment.

Diagnosis

A health care provider can often tell the position of the fetus by feeling it through the wall of the mother's abdomen. Another clue to the position is the location where the heartbeat is heard best. If the fetus's heartbeat is best heard below the level of the mother's navel, it is likely to be positioned head first. On the other hand, if the heartbeat is best heard above the level of the navel, it is likely to be breech.

The only way to really be sure, however, is to do an ultrasound exam. Using this technique it is very easy to tell the position of the fetus.

Treatment

If a fetus is in the breech position in the last weeks of pregnancy, there are three possible courses of action: Cesarean section, attempted version, or vaginal breech delivery.

Cesarean section is the most common way to deliver a breech baby. This surgical procedure carries more risk for the mother, but many women prefer to take the risk of surgery on themselves rather than let the baby face the risks of breech delivery.

Version is gaining in popularity. Version is a medical procedure in which the obstetrician tries to turn the breech fetus to the head first position. Version is successful more than 50% of the time. However, some babies who are successfully turned will turn back to the breech position after the procedure is done.

Some women choose breech vaginal delivery. This should only be attempted if ultrasound shows that the fetus is in a favorable breech position. Most babies will do very well during a breech delivery, but it is always possible that the fetus will be injured, perhaps seriously.

Prevention

There is no way to prevent a fetus from settling into the breech position at the end of pregnancy. A woman who has had one breech fetus is more likely than average to have another.

Resources

BOOKS

Cunningham, F. Gary, et al., editors. "Techniques for Breech Delivery." In Williams Obstetrics. 20th ed. Stamford: Appleton & Lange, 1997.

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breech birth

breech birth (also breech delivery) • n. a delivery of a baby so positioned in the uterus that the buttocks or feet are delivered first.

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Breech Birth

Breech Birth

Definition

In a breech birth, the presenting part of the fetus, or the part that enters the woman's birth canal first, is the buttocks or leg(s).

Description

In almost 97% of vaginal births, the head is the part of the baby to be born first (i.e., vertex presentation). During a woman's pregnancy, the fetus moves freely inside the uterus, cushioned by the amniotic fluid. At 20 weeks' gestation, the midway point in the pregnancy, about 24% of fetuses are in a breech position. By 34 weeks, only about 7% are in a breech position. As the pregnancy progresses towards term (37-42 weeks), the growing fetus has less room in which to turn around, and usually remains more in an inverted (head down) position. However, in about 3-4% of births, the buttocks or feet present first.

There are three types of breech presentations:

  • Complete breech, in which the buttocks present first, the baby's thighs are tight against the abdomen, the legs are crossed, and the feet are flexed. In this position, the fetus is curled up tightly in a ball.
  • Frank breech, in which the knees are straight (i.e., not bent), and the legs are held tightly against the abdomen and head. This breech position comes closest to filling the pelvic inlet, as would the fetus's head.
  • Footling breech, in which one or both legs enter the birth canal first. The fetus appears to be standing in an upright position.

Risks

Risks of a vaginal breech delivery include:

  • Prolapse of the umbilical cord. This is especially true in a footling presentation, where the feet and legs are small and provide room for the umbilical cord to slip alongside and into the birth canal. Any pressure on the cord compresses the sides of the cord, decreasing blood flow and oxygen to the fetus. This may result in anoxia.
  • Entrapment of the head. This occurs when the body of the neonate passes through the cervix, but the head, which is the largest part of the body, cannot fit through the cervical opening. This may occur because the cervix was incompletely dilated at the time of the birth of the baby, or when the head is larger than the pelvic opening.
  • Trauma to the head or neck of the neonate during delivery. This could result in permanent brain damage or paralysis of the infant.
  • Trauma to the spine or an arm resulting in fracture of a bone.
  • Meconium aspiration. The breech position may cause an early rupture of the amniotic fluid membranes, and meconium (the infant's first stool) may be released. If the neonate breathes in any of the meconium, he or she risks obstruction of the airway by the meconium, and pneumonia.
  • Dysfunctional labor. Because of the fetal breech position, the labor can be drawn out, exhausting the mother, and diminishing her ability to push as the time of delivery approaches.
  • Higher level of perinatal morbidity and mortality.

Accurate imaging of the fetus in utero has decreased the number of breech births by alerting obstetricians and midwives to this presentation prior to the time of delivery. A technique called external version may be used to encourage the fetus to rotate into a vertex position. However, as the practice of external version has increased, practitioners have had less experience delivering a breech baby vaginally. A successful vaginal delivery of a breech presentation depends to a great extent on the skill and experience of the practitioner.

Twins present a special challenge, and will take one of several possible birth positions:

  • Vertex-vertex. In this, the safest of positions for delivery, the twins both present in the vertex, or head down position. It occurs in about 40-45% of twin births.
  • Vertex-breech or breech-vertex. This position offers the most efficient use of the uterine space, but is not the best presentation for delivery. Vertex-breech and vertex-transverse positions occur in about 35-40% of twin births. Breech-vertex positioning occurs in about 15-20% of births.
  • Breech-breech presentation occurs in about 15-20% of twin births, and almost always results in cesariansection birth.

If the second twin entering the birth canal is the larger, there will be a concern that he or she may become stuck because the smaller, first twin did not adequately enlarge the cervical opening. Twins are often born prematurely, and are smaller than full-term infant. The more premature the infant, the greater the chance it will have a smaller body-to-head proportion than the full-term infant. This creates a greater hazard for breech birth, because the small body can come through a less-dilated cervix, and there is a greater chance that the head will get trapped. Accurate imaging of twin positions will play a major role in determining the safest delivery method. An external version of the second twin may be proposed. Version of the first twin in unlikely, as the procedure poses a threat to both twins.

Causes and symptoms

The cause of a particular breech presentation may not be understood about 80% of the time. However, causes of breech presentation may include:

  • an inability of the fetus to have full movement inside the uterus
  • the position of the placenta, such as a low-lying placenta previa, and a short umbilical cord
  • decreased muscle tone of the fetus
  • a congenital disorder of the fetus, especially neuromuscular in nature
  • a space-related problem for the fetus, such as with uterine fibroids
  • fetal anomaly, such as hydrocephalus
  • uterine structural anomaly, such as a septum trapping the fetus in a breech position
  • gestation of less than 40 weeks
  • multiple gestation
  • hydramnios, a condition in which excess amniotic fluid is produced and the fetus has too much room in which to move

Diagnosis

There are three primary ways in which a breech position is discovered, including imaging, position of the fetal heartbeat, and external palpation on the mother's abdomen.

Imaging. There are a variety of imaging technologies, varying in safety, cost, and ease of access. Magnetic resonance imaging (MRI) is very accurate, but is extremely expensive, not as readily available, and would rarely provide more information than an ultrasound to justify its use. Ultrasound is the most widely used method of imaging during pregnancy, as it uses sound waves instead of radiation, is available in most health care centers, and is cost efficient. Ultrasound is considered safe to use at all stages in pregnancy.

Leopold's maneuvers consist of a series of four external palpations of the mother's abdomen to determine fetal position in the uterus. The fetal head is hard and can move separately from the rest of the body. The buttocks feel soft and move with the body. As the time for delivery draws near, a vaginal examination may be required, however, as Leopold's maneuvers can sometimes be misleading. In a vaginal examination, the baby's fontanelles are palpated.

Treatment

When dealing with a breech presentation, there are three choices for delivery: attempt to rotate the fetus into a vertex presentation prior to delivery; attempt a trial of vaginal delivery in the breech position; or deliver by cesarian section. Some hospitals may not have the mother attempt a vaginal delivery and instead opt for cesarian section.

The preferred mode of delivery is a vaginal birth with the fetus in vertex presentation. Attempts are therefore made to rotate the fetus from a breech into a vertex position. One method has been to have the mother assume different positions (e.g., knee-chest) in the hope that this would cause the fetus to move into a more favorable position. Research studies have not shown this to be very successful, although periodic anecdotal accounts of success have been reported. In the November 11, 1998, issue of the Journal of the American Medical Association, researchers reported on the use of traditional Chinese medicine to cause the fetus to rotate. In this study, moxa, a combustible Chinese herb, was used over a two-week period to stimulate an acupuncture point on the toe. Stimulation of this point is believed to increase fetal activity, during which the fetus then moves into the vertex position. After two weeks of treatment with moxa, 75% of the 130 fetuses studied rotated into the vertex position, while only 48% of the control (no intervention, just routine obstetrical care) fetuses rotated. However, the results of this study has not been replicated.

A more traditional and more commonly used treatment within Western medical standards is external version. In external version, the fetus is rotated manually by the physician, who exerts pressure on the mother's abdomen to cause the fetus to somersault into the vertex position. Medication may be given to the mother to relax the uterine muscles prior to the procedure. The vertex position allows the fetus more mobility and decreases the chance of uterine contractions, which lead to early labor. Before attempting version, however, an ultrasound is performed to confirm the position of the fetus. The timing of version is important. Done too early, the fetus may rotate back into a breech position if too much space is still available. Performed at 35-37 weeks gestation, the success rate has shown to be up to 65%. In approximately 1-2% of cases, complications arise following version, leading to the need for immediate delivery via cesarian section.

Version should always be done in a hospital, where there are facilities for immediate cesarian delivery available in the cases of cord compression or placental abruption. Some research has indicated that giving the mother an epidural for the version procedure increases its success rate. The version can be accomplished by two health care professionals. Mineral oil may be applied to the mother's abdomen so that the obstetrician's hands can smoothly slide over the surface. The fetal heart rate should be monitored closely for any signs of fetal distress, and should be continued for about an hour after the procedure to assure fetal stability. Mothers who are Rh-negative may be given Rh immune globulin, which would prevent incompatibility should fetal-to-mother transfusion occur during the version. About 90% of babies turned by version will remain in this position for delivery.

Version has risks and is contraindicated in the following situations:

  • uterine structural anomalies
  • third-trimester bleeding
  • hydramnios, excess amniotic fluid production
  • nuchal cord, or the cord around the baby's neck, (not always seen on ultrasound)
  • previous uterine surgery, such as cesarian section, that has weakened the uterine walls
  • cephalopelvic disproportion (CPD), a condition in which the baby's head is too big for the mother's pelvic inlet, as evidenced on ultrasound or other imaging tools

When a vaginal breech birth is attempted, the pace of the delivery is very important. Fetal heart rate and uterine contractions need to be closely monitored. During a vertex vaginal delivery, the head is molded coming down the birth canal, and the labor process slows the pace of the delivery. In a breech vaginal birth, the smaller body may slip more quickly through the canal. If the head becomes caught, fetal anoxia (lack of oxygen) can occur. The head does not mold during a rapid breech birth, and if the neonate is allowed to deliver quickly, perhaps due to a detected prolapsed cord, the rapid change in pressure can result in intracranial hemorrhage. To assist the breech delivery, the mother may be asked to assume a squatting position, as this increases the birth canal volume by about 28%. (This position is not popular in the United States.) Forceps may be used to protect the neonate's neck and head from trauma and to assist in the delivery. If the vaginal birth attempt causes fetal distress, an emergency cesarian delivery may be required.

In a cesarian birth, an incision is made through the mother's abdominal wall into the uterus. The amniotic fluid membranes are broken and the neonate is extracted. A vertical incision in the uterus along the mother's abdominal midline is called a classical cut. This provides the fastest access to the infant and may be chosen in the event of an emergency delivery. The fetus can be removed from the uterus in minutes. If a woman has had the classical uterine incision, she will not be allowed to attempt to deliver vaginally in the future, because the uterine wall rupture can during the next labor. When time permits, the preferred incision is a transverse one, just above the pubic bone. This incision is sometimes referred to as a bikini cut. Healing time is decreased and may allow a woman to successfully deliver vaginally in the future.

KEY TERMS

Cephalopelvic disproportion— When the fetus' head is larger than the mother's pelvic inlet.

Nuchal cord— The term used when the umbilical cord is looped around the fetus' neck in utero.

Presentation— Presentation refers to that part of the fetus' body that enters into the birth canal first.

Prolapsed umbilical cord— When the cord falls into the birth canal, and may even hang out of the mother's vagina. This can cause compression of the cord and lead to decreased oxygen and blood flow to the fetus.

Transverse— In the transverse position, the fetus lies sideways against the birth canal, with a shoulder or arm possibly entering the canal.

Prognosis

About half the attempts of a vaginal breech delivery will result in a cesarian birth. Discovery of breech presentation prior to the time of delivery allows attempts to be made to rotate the fetus. If these attempts prove unsuccessful, a cesarian birth can then be scheduled. A scheduled cesarian allows the mother and her partner to be informed and participate, to some degree, in the process. Anesthesia can be chosen that allows the mother to be awake during the birth of her child. If emergency cesarian delivery is required, the mother will be given a general anesthesia to shorten the time required to extract the fetus in distress. If complications do not occur, the prognosis is excellent.

Health care team roles

During a breech birth more nursing personnel may be needed to assist the obstetrician and provide support for the mother. A neonate that has been in a breech position in utero may maintain an unusual position for a few days after birth. An explanation by the nurse can greatly reduce the mother's concern that there is something wrong with her baby.

Prevention

None of the known causes of breech presentation mentioned above are preventable, and in many breech presentations, there is no known cause. However, while it is not possible to prevent this presentation, attempts such as version are made to prevent a breech delivery, or to minimize its inherent risks.

Resources

BOOKS

Creasy, Robert K. and Robert Resnik. Maternal-fetal medicine. Philadelphia, Pennsylvania: W. B. Saunders Company, 1999.

Feinbloom, Richard I. Pregnancy, birth, and the early months, 3rd ed. Cambridge, Massachusetts: Perseus Publishing, 2000.

Pillitteri, Adele. Maternal & child health nursing: care of the childbearing & child rearing family, 3rd ed. Philadelphia, PA: Lippincott, 1999.

PERIODICALS

Cardini, F. and H. Weixin. "Moxibustion for correction of breech presentation: a randomized controlled trial." Journal of the American Medical Association 11 (November 1998): 1580-84.

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