breech presentation in 3rd trimester

Disclaimer » Advertising

• HealthyChildren.org

• Previous Article
• Next Article

Introduction

Definitions, incidence, risk factors, and natural history, risk factors, natural history, screening and diagnosis, physical examination, radiography, ultrasonography, referral, adjunctive imaging, and treatment, adjunctive imaging, risks of treatment, medicolegal risk to the pediatrician, best practices and state of the art, acknowledgments, lead authors, section on orthopaedics executive committee, 2014–2015, evaluation and referral for developmental dysplasia of the hip in infants.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose.

FUNDED: No external funding.

• Split-Screen
• Article contents
• Figures & tables
• Supplementary Data
• Peer Review
• CME Quiz Close Quiz
• Open the PDF for in another window
• Get Permissions
• Cite Icon Cite
• Search Site

Brian A. Shaw , Lee S. Segal , SECTION ON ORTHOPAEDICS , Norman Y. Otsuka , Richard M. Schwend , Theodore John Ganley , Martin Joseph Herman , Joshua E. Hyman , Brian A. Shaw , Brian G. Smith; Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics December 2016; 138 (6): e20163107. 10.1542/peds.2016-3107

Download citation file:

• Ris (Zotero)
• Reference Manager

Developmental dysplasia of the hip (DDH) encompasses a wide spectrum of clinical severity, from mild developmental abnormalities to frank dislocation. Clinical hip instability occurs in 1% to 2% of full-term infants, and up to 15% have hip instability or hip immaturity detectable by imaging studies. Hip dysplasia is the most common cause of hip arthritis in women younger than 40 years and accounts for 5% to 10% of all total hip replacements in the United States. Newborn and periodic screening have been practiced for decades, because DDH is clinically silent during the first year of life, can be treated more effectively if detected early, and can have severe consequences if left untreated. However, screening programs and techniques are not uniform, and there is little evidence-based literature to support current practice, leading to controversy. Recent literature shows that many mild forms of DDH resolve without treatment, and there is a lack of agreement on ultrasonographic diagnostic criteria for DDH as a disease versus developmental variations. The American Academy of Pediatrics has not published any policy statements on DDH since its 2000 clinical practice guideline and accompanying technical report. Developments since then include a controversial US Preventive Services Task Force “inconclusive” determination regarding usefulness of DDH screening, several prospective studies supporting observation over treatment of minor ultrasonographic hip variations, and a recent evidence-based clinical practice guideline from the American Academy of Orthopaedic Surgeons on the detection and management of DDH in infants 0 to 6 months of age. The purpose of this clinical report was to provide literature-based updated direction for the clinician in screening and referral for DDH, with the primary goal of preventing and/or detecting a dislocated hip by 6 to 12 months of age in an otherwise healthy child, understanding that no screening program has eliminated late development or presentation of a dislocated hip and that the diagnosis and treatment of milder forms of hip dysplasia remain controversial.

Early diagnosis and treatment of developmental dysplasia of the hip (DDH) is important to provide the best possible clinical outcome. DDH encompasses a spectrum of physical and imaging findings, from mild instability and developmental variations to frank dislocation. DDH is asymptomatic during infancy and early childhood, and, therefore, screening of otherwise healthy infants is performed to detect this uncommon condition. Traditional methods of screening have included the newborn and periodic physical examination and selected use of radiographic imaging. The American Academy of Pediatrics (AAP) promotes screening as a primary care function. However, screening techniques and definitions of clinically important clinical findings are controversial, and despite abundant literature on the topic, quality evidence-based literature is lacking.

The AAP last published a clinical practice guideline on DDH in 2000 titled “Early Detection of Developmental Dysplasia of the Hip.” 1 The purpose of this clinical report is to provide the pediatrician with updated information for DDH screening, surveillance, and referral based on recent literature, expert opinion, policies, and position statements of the AAP and the Pediatric Orthopaedic Society of North America (POSNA), and the 2014 clinical practice guideline of the American Academy of Orthopaedic Surgeons (AAOS). 1 , – 3  

A contributing factor to the DDH screening debate is lack of a uniform definition of DDH. DDH encompasses a spectrum of pathologic hip disorders in which hips are unstable, subluxated, or dislocated and/or have malformed acetabula. 1 However, imaging advancements, primarily ultrasonography, have created uncertainty regarding whether minor degrees of anatomic and physiologic variability are clinically significant or even abnormal, particularly in the first few months of life.

Normal development of the femoral head and acetabulum is codependent; the head must be stable in the hip socket for both to form spherically and concentrically. If the head is loose in the acetabulum, or if either component is deficient, the entire hip joint is at risk for developing incongruence and lack of sphericity. Most authorities refer to looseness as instability or subluxation and the actual physical deformity of the femoral head and/or acetabulum as dysplasia, but some consider hip instability itself to be dysplasia. Further, subluxation can be static (in which the femoral head is relatively uncovered without stress) or dynamic (the hip partly comes out of the socket with stress). The Ortolani maneuver, in which a subluxated or dislocated femoral head is reduced into the acetabulum with gentle hip abduction by the examiner, is the most important clinical test for detecting newborn dysplasia. In contrast, the Barlow maneuver, in which a reduced femoral head is gently adducted until it becomes subluxated or dislocated, is a test of laxity or instability and has less clinical significance than the Ortolani maneuver. In a practical sense, both maneuvers are performed seamlessly in the clinical assessment of an infant’s hip. Mild instability and morphologic differences at birth are considered by some to be pathologic and by others to be normal developmental variants.

In summary, there is lack of universal agreement on what measurable parameters at what age constitute developmental variation versus actual disease. Despite these differences in definition, there is universal expert agreement that a hip will fare poorly if it is unstable and morphologically abnormal by 2 to 3 years of age. It is the opinion of the AAP that DDH fulfills most screening criteria outlined by Wilson and Jungner 4 and that screening efforts are worthwhile to prevent a subluxated or dislocated hip by 6 to 12 months of age.

The Ortolani maneuver, in which a subluxated or dislocated femoral head is reduced into the acetabulum with gentle hip abduction by the examiner, is the most important clinical test for detecting newborn hip dysplasia.

The incidence of developmental dislocation of the hip is approximately 1 in 1000 live births. The incidence of the entire spectrum of DDH is undoubtedly higher but not truly known because of the lack of a universal definition. Rosendahl et al 5 noted a prevalence of dysplastic but stable hips of 1.3% in the general population. A study from the United Kingdom reported a 2% prevalence of DDH in girls born in the breech position. 6  

Important risk factors for DDH include breech position, female sex, incorrect lower-extremity swaddling, and positive family history. These risk factors are thought to be additive. Other suggested findings, such as being the first born or having torticollis, foot abnormalities, or oligohydramnios, have not been proven to increase the risk of “nonsyndromic” DDH. 3 , 7  

Breech presentation may be the most important single risk factor, with DDH reported in 2% to 27% of boys and girls presenting in the breech position. 6 , 8 , 9 Frank breech presentation in a girl (sacral presentation with hips flexed and knees extended) appears to have the highest risk. 1 Most evidence supports the breech position toward the end of pregnancy rather than breech delivery that contributes to DDH. There is no clear demarcation of timing of this risk; in other words, the point during pregnancy when the DDH risk is normalized by spontaneous or external version from breech to vertex position. Mode of delivery (cesarean) may decrease the risk of DDH with breech positioning. 10 , – 12 A recent study suggested that breech-associated DDH is a milder form than DDH that is not associated with breech presentation, with more rapid spontaneous normalization. 13  

Genetics may contribute more to the risk of DDH than previously considered “packaging effects.” If a monozygotic twin has DDH, the risk to the other twin is approximately 40%, and the risk to a dizygotic twin is 3%. 14 , 15 Recent research has confirmed that the familial relative risk of DDH is high, with first-degree relatives having 12 times the risk of DDH over controls. 16 , – 18 The left hip is more likely to be dysplastic than the right, which may be because of the more common in utero left occiput anterior position in nonbreech infants. 1 The AAOS clinical practice guideline considers breech presentation and family history to be the 2 most important risk factors in DDH screening. 3  

A lesser-known but important risk factor is the practice of swaddling, which has been gaining popularity in recent years for its noted benefits of enhancing better sleep patterns and duration and minimizing hypothermia. However, these benefits are countered by the apparent increased rates of DDH observed in several ethnic groups, such as Navajo Indian and Japanese populations, that have practiced traditional swaddling techniques. Traditional swaddling maintains the hips in an extended and adducted position, which increases the risk of DDH. However, the concept of “safe swaddling,” which allows for hip flexion and abduction and knee flexion, has been shown to lessen the risk of DDH ( http://hipdysplasia.org/developmental-dysplasia-of-the-hip/hip-healthy-swaddling/ ). Parents can be taught the principles of safe infant sleep, including supine position in the infant’s own crib and not the parent’s bed, with no pillows, bumpers, or loose blankets. 19 , – 24 The POSNA, International Hip Dysplasia Institute, AAOS, United States Bone and Joint Initiative, and Shriners Hospitals for Children have published a joint statement regarding the importance of safe swaddling in preventing DDH. 25  

In general, risk factors are poor predictors of DDH. Female sex, alone without other known risk factors, accounts for 75% of DDH. This emphasizes the importance of a careful physical examination of all infants in detecting DDH. 6 A recent survey showed poor consensus on risk factors for DDH from a group of experts. 26  

In general, risk factors are poor predictors of DDH. Female sex, alone without other known risk factors, accounts for 75% of DDH.

Clinical and imaging studies show that the natural history of mild dysplasia and instability noted in the first few weeks of life is typically benign. Barlow-positive (subluxatable and dislocatable) hips resolve spontaneously, and Barlow himself noted that the mild dysplasia in all 250 newborn infants with positive test results in his original study resolved spontaneously. 27 , – 32  

Conversely, the natural history of a child with hip dysplasia at the more severe end of the disease spectrum (subluxation or dislocation) by walking age is less satisfactory than children treated successfully at a younger age. Without treatment, these children will likely develop a limp, limb length discrepancy, and limited hip abduction. This may result in premature degenerative arthritis in the hip, knee, and low back. The burden of disability is high, because most affected people become symptomatic in their teens and early adult years, and most require complex hip salvage procedures and/or replacement at an early age.

The 2000 AAP clinical practice guideline recommended that all newborn infants be screened for DDH by physical examination, with follow-up at scheduled well-infant periodic examinations. The POSNA, the Canadian Task Force on DDH, and the AAOS have also advocated newborn and periodic screening. A 2006 report by the US Preventive Services Task Force (USPSTF) resulted in controversy regarding DDH screening. By using a data-driven model and a strong emphasis on the concept on predictors of poor health, the USPSTF report gave an “I” recommendation, meaning that the evidence was insufficient to recommend routine screening for DDH in infants as a means to prevent adverse outcomes. 1 , – 3 , 33 , – 35 However, on the basis of the body of evidence when evaluated from the perspective of a clinical practice model, the AAP advocates for DDH screening.

In its report, the USPSTF noted that avascular necrosis (AVN) is the most common (up to 60%) and severe potential harm of both surgical and nonsurgical interventions. 33 Williams et al 36 reported the risk of AVN to be less than 1% with screening, early detection, and the use of the Pavlik harness. In a long-term follow-up study of a randomized controlled trial from Norway, the authors reported no cases of AVN and no increased risk of harm with increased treatment. 37 The USPSTF also raised concerns about the psychological consequences or stresses with early diagnosis and intervention. Gardner et al 38 found that the use of hip ultrasonography allowed for reduction of treatment rates without adverse clinical or psychological outcomes. Thus, the concerns of AVN and psychological distress or potential predictors of poor health have not been supported in literature not referenced in the USPSTF report.

In 2 well-designed, randomized controlled trial studies from Norway, the prevalence of late DDH presentation was reduced from 2.6 to 3.0 per 1000 to 0.7 to 1.3 per 1000 by using either selective or universal hip ultrasonographic screening. Neither study reached statistical significance because of the inadequate sample size on the basis of prestudy rates of late-presentation DDH. Despite this, both centers have introduced selective hip ultrasonography as part of their routine newborn screening. 39 , 40 Clarke et al 32 also demonstrated a decrease in late DDH presentation from 1.28 per 1000 to 0.74 per 1000 by using selective hip ultrasonography in a prospective cohort of patients over a 20-year period.

The term “surveillance” may be useful nomenclature to consider in place of screening, because, by definition, it means the close monitoring of someone or something to prevent an adverse outcome. The term surveillance reinforces the concept of periodic physical examinations as part of well-child care visits until 6 to 9 months of age and the use of selective hip ultrasonography as an adjunct imaging tool or an anteroposterior radiograph of the pelvis after 4 months of age for infants with identified risk factors. 3 , 5 , 32 , 41  

Wilson and Jungner 4 outlined 10 principles or criteria to consider when determining the utility of screening for a disease. The AAP believes DDH fulfills most of these screening criteria ( Table 1 ), except for an understanding of the natural history of hip dysplasia and an agreed-on policy of whom to treat. The 2006 USPSTF report and the AAOS clinical practice guideline provide a platform to drive future research in these 2 areas. Screening for DDH is important, because the condition is initially occult, easier to treat when identified early, and more likely to cause long-term disability if detected late. A reasonable goal for screening is to prevent the late presentation of DDH after 6 months of age.

World Health Organization Criteria for Screening for Health Problems

The physical examination is by far the most important component of a DDH screening program, with imaging by radiography and/or ultrasonography playing a secondary role. It remains the “cornerstone” of screening and/or surveillance for DDH, and the available evidence supports that primary care physicians serially examine infants previously screened with normal hip examinations on subsequent visits up to 6 to 9 months of age. 3 , 41 , – 44 Once a child is walking, a dislocated hip may manifest as an abnormal gait.

The 2000 AAP clinical practice guideline gave a detailed description of the examination, including observing for limb length discrepancy, asymmetric thigh or gluteal folds, and limited or asymmetric abduction, as well as performing Barlow and Ortolani tests. 1 It is essential to perform these manual tests gently. By ∼3 months of age, a dislocated hip becomes fixed, limiting the usefulness and sensitivity of the Barlow and Ortolani tests. By this age, restricted, asymmetric hip abduction of the involved hip becomes the most important finding (see video available at http://www.aap.org/sections/ortho ). Diagnosing bilateral DDH in the older infant can be difficult because of symmetry of limited abduction.

Although ingrained in the literature, the significance and safety of the Barlow test is questioned. Barlow stated in his original description that the test is for laxity of the hip joint rather than for an existing dislocation. The Barlow test has no proven predictive value for future hip dislocation. If performed frequently or forcefully, it is possible that the maneuver itself could create instability. 45 , 46 The AAP recommends, if the Barlow test is performed, that it be done by gently adducting the hip while palpating for the head falling out the back of the acetabulum and that no posterior-directed force be applied. One can think of the Barlow and Ortolani tests as a continuous smooth gentle maneuver starting with the hip flexed and adducted, with gentle anterior pressure on the trochanter while the hip is abducted to feel whether the hip is locating into the socket, followed by gently adducting the hip and relieving the anterior pressure on the trochanter while sensing whether the hip slips out the back. The examiner should not attempt to forcefully dislocate the femoral head (see video available at http://www.aap.org/sections/ortho ).

“Hip clicks” without the sensation of instability are clinically insignificant. 47 Whereas the Ortolani sign represents the palpable sensation of the femoral head moving into the acetabulum over the hypertrophied rim of the acetabular cartilage (termed neolimbus), isolated high-pitched clicks represent the movement of myofascial tissues over the trochanter, knee, or other bony prominences and are not a sign of hip dysplasia or instability.

Plain radiography becomes most useful by 4 to 6 months of age, when the femoral head secondary center of ossification forms. 48 Limited evidence supports obtaining a properly positioned anteroposterior radiograph of the pelvis. 3 If the pelvis is rotated or if a gonadal shield obscures the hip joint, then the radiograph should be repeated. Hip asymmetry, subluxation, and dislocation can be detected on radiographs when dysplasia is present. There is debate about whether early minor radiographic variability (such as increased acetabular index) constitutes actual disease. 31 Radiography is traditionally indicated for diagnosis of the infant with risk factors or an abnormal examination after 4 months of age. 1 , 2 , 8 , 49  

Ultrasonography can provide detailed static and dynamic imaging of the hip before femoral head ossification. The American Institute of Ultrasound in Medicine and the American College of Radiology published a joint guideline for the standardized performance of the infantile hip ultrasonographic examination. 50 Static ultrasonography shows coverage of the femoral head by the cartilaginous acetabulum (α angle) at rest, and dynamic ultrasonography demonstrates a real-time image of the Barlow and Ortolani tests.

Ultrasonographic imaging can be universal for all infants or selective for those at risk for having DDH. Universal newborn ultrasonographic screening is not recommended in North America because of the expense, inconvenience, inconsistency, subjectivity, and high false-positive rates, given an overall population disease prevalence of 1% to 2%. 3 Rather, selective ultrasonographic screening is recommended either to clarify suspicious findings on physical examination after 3 to 4 weeks of age or to detect clinically silent DDH in the high-risk infant from 6 weeks to 4 to 6 months of age. 1 , 2 , 35 , 50 Two prospective randomized clinical trials from Norway support selective ultrasonographic imaging when used in conjunction with high-quality clinical screening. 39 , 40  

Roposch and colleagues 51 , 52 contend that experts cannot reach a consensus on what is normal, abnormal, developmental variation, or simply uncertain regarding much ultrasonographic imaging, thereby confounding referral and treatment recommendations. Several studies have demonstrated that mild ultrasonographic abnormalities usually resolve spontaneously, fueling the controversy over what imaging findings constitute actual disease requiring treatment. 5 , 30 , 51 , 53 , – 56  

The concept of surveillance for DDH emphasizes the importance of repeated physical examinations and the adjunct use of selective hip ultrasonography after 6 weeks of age or an anteroposterior radiograph of the pelvis after 4 months of age for infants with questionable or abnormal findings on physical examination or with identified risk factors. Ultrasonography is not necessary for a frankly dislocated hip (Ortolani positive) but may be desired by the treating physician. Physiologic joint capsular laxity and immature acetabular development before 6 weeks of age may limit the accuracy of hip ultrasonography interpretations. 39 , 40 There is no consensus on exact timing of and indications for ultrasonography among expert groups. 26 , 57 However, ultrasonographic imaging does have a management role in infants younger than 6 weeks undergoing abduction brace treatment of unstable hips identified on physical examination. 3  

Early detection and referral of infants with DDH allows appropriate intervention with bracing or casting, which may prevent the need for reconstructive surgery. Primary indications for referral include an unstable (positive Ortolani test result) or dislocated hip on clinical examination. Because most infants with a positive Barlow test result at either the newborn or 2-week examination stabilize on their own, these infants should have sequential follow-up examinations as part of the concept of surveillance. This recommendation differs from the 2000 AAP clinical practice guideline. 1 Any child with limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks) should be referred. Relative indications for referral include infants with risk factors for DDH, a questionable examination, and pediatrician or parental concern. 1  

Recommendations for the evaluation and management of infants with risk factors for DDH but with normal findings on physical examination continue to evolve. The 2000 AAP clinical practice guideline recommended hip ultrasonography at 6 weeks of age or radiography of the pelvis and hips at 4 months of age in girls with a positive family history of DDH or breech presentation. The AAP clinical practice guideline also stated that hip ultrasonographic examinations remain an option for all infants born breech. 1 The recent AAOS report found that moderate evidence supports an imaging study before 6 months of age in infants with breech presentation, family history, and/or history of clinical instability. 3 , 58 , – 60  

Consider imaging before 6 months of age for male or female infants with normal findings on physical examination and the following risk factors:

Breech presentation in third trimester (regardless of cesarean or vaginal delivery)

Positive family history

History of previous clinical instability

Parental concern

History of improper swaddling

Suspicious or inconclusive physical examination

Refinement in the term “breech presentation” as a risk factor for DDH is needed to determine whether selective hip ultrasonography at 6 weeks or radiography before 6 months of age is needed for an infant with a normal clinical hip examination. More specific variables, such as mode of delivery, type of breech position, or breech position at any time during the pregnancy or in the third trimester, have received little attention to date. The AAOS clinical practice guideline reported 6 studies addressing breech presentation, but all were considered low-strength evidence. 3 Thus, the literature is not adequate enough to allow specific guidance. The risk is thought to be greater for frank breech (hips flexed, knees extended) in the last trimester. 1  

Lacking expert consensus of risk factors for DDH, 26 the questions of whether to obtain additional imaging studies with a normal clinical hip examination is ultimately best left to one’s professional judgment. One must consider, however, that the overall probability of a clinically stable hip to later dislocate is very low.

Because of the variability in performance and interpretation of the hip ultrasonographic examination and varying thresholds for treatment, the requesting physician might consider developing a regional protocol in conjunction with a consulting pediatric orthopedist and pediatric radiologist. Specific criteria for imaging and referral based on local resources can promote consistency in evaluation and treatment of suspected DDH. Realistically, many families may not have ready access to quality infant hip ultrasonography, and this may determine the choice of obtaining a pelvic radiograph instead of an ultrasound. 61  

Recommendations for treatment are based on the clinical hip examination and the presence or absence of imaging abnormalities. Infants with a stable clinical hip examination but with abnormalities noted on ultrasonography can be observed without a brace. 3 , 56  

The initiation of abduction brace treatment, either immediate or delayed, for clinically unstable hips is supported by several studies. 3 , 62 , – 64 In a randomized clinical trial, Gardiner and Dunn 62 found no difference in hip ultrasonography findings or clinical outcome for infants with dislocatable hips treated with either immediate or delayed abduction bracing at 6- and 12-month follow-up. The infants in the delayed group (2 weeks) were treated with abduction bracing if hip instability persisted or the hip ultrasonographic abnormalities did not improve. 62  

Treatment of clinically unstable hips usually consists of bracing when discovered in early infancy and closed reduction with adductor tenotomy and spica cast immobilization when noted later. After 18 months of age, open surgery is generally recommended.

As previously noted, the 2006 USPSTF report noted a high rate of AVN, up to 60% with both surgical and nonsurgical intervention. 33 Other studies have reported much lower rates of AVN. 36 , 37 One prospective study reported a zero prevalence of AVN by 6 years of age in mildly dysplastic hips treated with bracing. 30  

However, abduction brace treatment is not innocuous. The potential risks include AVN, temporary femoral nerve palsy, and obturator (inferior) hip dislocation. 65 , – 67 One study demonstrated a 7% to 14% risk of complications after treatment in a Pavlik harness. The risk was greater in hips that did not reduce in the brace. 33 Precautions such as avoiding forced abduction in the harness, stopping treatment after 3 weeks if the hip does not reduce, and proper strap placement with weekly monitoring is important to minimize the risks associated with brace treatment. 68 , 69 Double diapering is a probably harmless but ineffective treatment of true DDH.

What remains controversial is whether the selective use of ultrasonography reduces or increases treatment. A randomized controlled study from the United Kingdom showed that approximately half of all positive physical examination findings were falsely positive (ie, normal ultrasonography results) and that the use of ultrasonography in clinically suspect hips actually reduced DDH treatment. 60 However, in the United States and Canada, 21 the reverse appears to be true. In the current medicolegal climate that encourages a defensive approach, liberal use of ultrasonography in the United States and Canada has clearly fostered overdiagnosis and overtreatment of DDH, despite best-available literature supporting observation of mild dysplasia. 33 , – 35 , 70  

Undetected or late-developing DDH is a liability concern for the pediatrician, generating anxiety and a desire for guidance in best screening methodology. 71 Unfortunately, this fear may also provoke overdiagnosis and overtreatment. “Late-presenting” DDH is a more accurate term than “missed” to use when DDH is first diagnosed in a walking-aged child who had appropriate clinical examinations during infancy. 72 , 73  

Although there is no universally recognized DDH screening standard, the AAP endorses the concept of surveillance or periodic physical examinations until walking age, with selective use of either hip ultrasonography or radiography, depending on age. The AAP cautions against overreliance on ultrasonography as a diagnostic test and encourages its use as an adjunctive secondary screen and an aid to treatment of established DDH. Notably, no screening program has been shown to completely eliminate the risk of a late-presenting dislocated hip. 69  

The electronic health record can be used to provide a template, reminder, and documentation tool for the periodic examination. It also can be useful in the transition and comanagement of children with suspected DDH by providing effective information transfer between consultants and primary care physicians and ensuring follow-up. Accurate documented communication between providers is important to provide continuity of care for this condition, and it is also important to explain to the parent(s) and document those instances when observation is used as a planned strategy so it is less likely to be misinterpreted as negligence.

The AAP, POSNA, AAOS, and Canadian DDH Task Force recommend newborn and periodic surveillance physical examinations for DDH to include detection of limb length discrepancy, examination for asymmetric thigh or buttock (gluteal) creases, performing the Ortolani test for stability (performed gently and which is usually negative after 3 months of age), and observing for limited abduction (generally positive after 3 months of age). Use of electronic health records can be considered to prompt and record the results of periodic hip examinations. The AAP recommends against universal ultrasonographic screening.

Selective hip ultrasonography can be considered between the ages of 6 weeks and 6 months for “high-risk” infants without positive physical findings. High risk is a relative and controversial term, but considerations include male or female breech presentation, a positive family history, parental concern, suspicious but inconclusive periodic examination, history of a previous positive instability physical examination, and history of tight lower-extremity swaddling. Because most DDH occurs in children without risk factors, physical examination remains the primary screening tool.

It is important that infantile hip ultrasonography be performed and interpreted per American Institute of Ultrasound in Medicine and the American College of Radiology guidelines by experienced, trained examiners. Developing local criteria for screening imaging and referral based on best resources may promote more uniform and cost-effective treatment. Regional variability of ultrasonographic imaging quality can lead to under- or overtreatment.

Most minor hip anomalies observed on ultrasonography at 6 weeks to 4 months of age will resolve spontaneously. These include minor variations in α and β angles and subluxation (“uncoverage”) with stress maneuvers. Current levels of evidence do not support recommendations for treatment versus observation in any specific case of minor ultrasonographic variation. Care is, therefore, individualized through a process of shared decision-making in this setting of inadequate information.

Radiography (anteroposterior and frog pelvis views) can be considered after 4 months of age for the high-risk infant without physical findings or any child with positive clinical findings. Age 4 to 6 months is a watershed during which either imaging modality may be used; radiography is more readily available, has a lower rate of false-positive results, and is less expensive than ultrasonography but involves a very low dose of radiation.

A referral to an orthopedist for DDH does not require ultrasonography or radiography. The primary indication for referral includes an unstable (positive Ortolani test result) or dislocated hip on clinical examination. Any child with limited hip abduction or asymmetric hip abduction after the neonatal period (4 weeks of age) should be referred for evaluation. Relative indications for referral include infants with risk factors for DDH, a questionable examination, and pediatrician or parental concern.

Evidence strongly supports screening for and treatment of hip dislocation (positive Ortolani test result) and initially observing milder early forms of dysplasia and instability (positive Barlow test result). Depending on local custom, either the pediatrician or the orthopedist can observe mild forms by periodic examination and possible follow-up imaging, but actual treatment should be performed by an orthopedist.

A reasonable goal for the primary care physician should be to diagnose hip subluxation or dislocation by 6 months of age by using the periodic physical examination. Selective ultrasonography or radiography may be used in consultation with a pediatric radiologist and/or orthopedist. No screening program has been shown to completely eliminate the risk of a late presentation of DDH. There is no high-level evidence that milder forms of dysplasia can be prevented by screening and early treatment.

Tight swaddling of the lower extremities with the hips adducted and extended should be avoided. The concept of “safe” swaddling, which does not restrict hip motion, minimizes the risk of DDH.

Treatment of neonatal DDH is not an emergency, and in-hospital initiation of bracing is not required. Orthopaedic consultation can be safely obtained within several weeks of discharge for an infant with a positive Ortolani test result. Infants with a positive Barlow test results should be reexamined and referred to an orthopedist if they continue to show clinical instability.

American Academy of Orthopaedic Surgeons

American Academy of Pediatrics

avascular necrosis

developmental dysplasia of the hip

Pediatric Orthopaedic Society of North America

US Preventive Services Task Force

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

The authors thank Charles Price, MD, FAAP, Ellen Raney, MD, FAAP, Joshua Abzug, MD, FAAP, and William Hennrikus, MD, FAAP, for their valuable contributions to this report.

Brian A. Shaw, MD, FAAOS, FAAP

Lee S. Segal, MD, FAAP

Norman Y. Otsuka, MD, FAAP, Chairperson

Richard M. Schwend, MD, FAAP, Immediate Past Chairperson

Theodore John Ganley, MD, FAAP

Martin Joseph Herman, MD, FAAP

Joshua E. Hyman, MD, FAAP

Brian G. Smith, MD, FAAP

Niccole Alexander, MPP

Competing Interests

Re: breech presentation in preterm infants.

Thanks for the excellent review highlighting the controversies around screening, imaging and management of DDH. I have a question to the authors re: preterm infants. If an infant is born premature in third trimester with breech presentation and a normal hip examination at birth, would the authors recommend considering a hip ultrasound after 6 weeks post-menstrual age or 6 weeks chronologic age?

RE: Late diagnosis of developmental dysplasia of the hip can be eradicated

The survey published by Shaw and al in the December issue of Pediatrics concluded that no screening program has eliminated late development or presentation of a dislocated hip (1).

In the literature, there is controversy over widespread ultrasound screening since its ability to prevent late DDH diagnosis has not been proven (2,3). Techniques mainly relied on acetabular morphology classifications with no clear cut-off for early DDH diagnosis. Results are not enough reproducible for a large screening program involving non-expert radiologists (4). Moreover the effect of hip instability on acetabular shape may not be seen at one month old. These three reasons explain the failure of almost all screening programs based on these techniques.

Our experience is based on dynamic assessment of the femoral head position based on pubo-femoral distance (PFD) measurements. The normal PFD is lower than or equal to 6mm, with no more than 1.5mm between the hips (5). This simple, reliable, and reproducible method was easily taught to general radiologists involved in the screening program. With the support of perinatal network pediatricians, ultrasound screening was offered to all girls and to boys presenting with risk factors or abnormalities on clinical examination at one month old. All reports indicate a prevalence of 90% for girls, 70% with no risk factors. All infants with positive screenings were immediately referred to multidisciplinary teams involving an expert radiologist and orthopedic pediatrician. At one month old, reducible hip instability was always successfully treated by abduction splint. In 2013, we published that late diagnosis of DDH was eradicated from our region (annual births: 14,000) over a 3-year period from 2009 to 2011 (5). This period has now reached 8 years in a region of more than 1 million inhabitants in which our institution is the only referral center. Brittany (France), country of Dr Le Damany who described this disease, has a high prevalence of DDH (6/1000).

These long-term results are unique and confirm that ultrasound measurement of PFD provides a clear cut-off for DDH detection. Based on this simple technique, widespread screening, at least in girls, could eradicate late DDH diagnosis.

References:

1. Shaw BA, Segal LS. Evaluation and Referral for Developmental Dysplasia of the Hip in Infants. Pediatrics. 2016;138(6):e20163107 2. von Kries R, Ihme N, Altenhofen L, Niethard FU, Krauspe R, Rückinger S. General ultrasound screening reduces the rate of first operative procedures for developmental dysplasia of the hip: a case-control study. J Pediatr. 2012;160(2):271–5. 3. Laborie LB, Markestad TJ, Davidsen H, Brurås KR, Aukland SM, Bjørlykke JA, et al. Selective ultrasound screening for developmental hip dysplasia: effect on management and late detected cases. A prospective survey during 1991-2006. Pediatr Radiol. 2014;44(4):410–24.

4. Roposch A, Moreau NM, Uleryk E, Doria AS (2006) Developmental dysplasia of the hip: quality of reporting of diagnostic accuracy for US. Radiology, 241(3):854-860.. 5. Tréguier C, Chapuis M, Branger B, Bruneau B, Grellier A, Chouklati K, et al. Pubo-femoral distance: an easy sonographic screening test to avoid late diagnosis of developmental dysplasia of the hip. Eur Radiol. 2013 Mar;23(3):836–44.

Advertising Disclaimer »

Citing articles via

Email alerts.

Affiliations

• Editorial Board
• Editorial Policies
• Journal Blogs
• Pediatrics On Call
• Online ISSN 1098-4275
• Print ISSN 0031-4005
• Pediatrics Open Science
• Hospital Pediatrics
• Pediatrics in Review
• AAP Grand Rounds
• Latest News
• Pediatric Care Online
• Red Book Online
• Pediatric Patient Education
• AAP Toolkits
• AAP Pediatric Coding Newsletter

First 1,000 Days Knowledge Center

Institutions/librarians, group practices, licensing/permissions, integrations, advertising.

• Privacy Statement | Accessibility Statement | Terms of Use | Support Center | Contact Us
• © Copyright American Academy of Pediatrics

This Feature Is Available To Subscribers Only

Sign In or Create an Account

Learn how UpToDate can help you.

Select the option that best describes you

• Medical Professional
• Resident, Fellow, or Student
• Hospital or Institution
• Group Practice
• Patient or Caregiver
• Find in topic

RELATED TOPICS

INTRODUCTION

This topic will provide an overview of major issues related to breech presentation, including choosing the best route for delivery. Techniques for breech delivery, with a focus on the technique for vaginal breech delivery, are discussed separately. (See "Delivery of the singleton fetus in breech presentation" .)

TYPES OF BREECH PRESENTATION

● Frank breech – Both hips are flexed and both knees are extended so that the feet are adjacent to the head ( figure 1 ); accounts for 50 to 70 percent of breech fetuses at term.

● Complete breech – Both hips and both knees are flexed ( figure 2 ); accounts for 5 to 10 percent of breech fetuses at term.

• Telemedicine
• Healthcare Professionals
• Go to MyChart
• Find a Doctor
• Make an Appointment
• Cancel an Appointment
• Find a Location
• Visit ED or Urgent Care
• Get Driving Directions
• Refill a Prescription
• Contact Children's
• Pay My Bill
• Estimate My Cost
• Apply for Financial Assistance
• Request My Medical Records
• Find Patient Education
• Refer and Manage a Patient

Hip Dysplasia: X-Ray Recommended for Breech Infants at 6 Months of Age

November 1, 2023

Breech presentation at birth or any point during the third trimester is a particularly strong risk factor for developmental hip dysplasia, even for infants with a normal physical exam. Orthopedics has  updated the algorithm for hip dysplasia  to reflect updates from the American Academy of Orthopedic Surgeons (AAOS) Clinical Practice Guidelines.   The update includes a recommendation to perform the following for breech babies (breech at birth or any point during third trimester):  a six-week screening ultrasound followed by a single AP pelvis radiograph at 6 months of age.

You can find algorithms for dozens of other conditions at seattlechildrens.org/algorithms .

Subscribe to Provider News

Monthly news about Seattle Children's programs, services, policies and people delivered to your inbox.

Subscribe Now

Access Dashboard

You can find information about current wait times in our specialty clinics using our Access Dashboard, updated monthly.

Healthcare Provider Resources

• Refer a Patient
• Algorithms for PCPs
• Educational Programs and Resources

Seattle Children’s complies with applicable federal and other civil rights laws and does not discriminate, exclude people or treat them differently based on race, color, religion (creed), sex, gender identity or expression, sexual orientation, national origin (ancestry), age, disability, or any other status protected by applicable federal, state or local law. Financial assistance for medically necessary services is based on family income and hospital resources and is provided to children under age 21 whose primary residence is in Washington, Alaska, Montana or Idaho.

By clicking “Accept All Cookies,” you agree to the storing of cookies on your device to enhance site navigation, analyze site usage and assist in marketing efforts. For more information, see  Website Privacy .

LISA HAUK, AFP Senior Associate Editor

Am Fam Physician. 2017;96(3):196-197

Author disclosure: No relevant financial affiliation

Key Points for Practice

• The AAP recommends against universally screening for DDH with ultrasonography.

• Imaging can be performed in infants considered high risk from six weeks to six months of age who have normal findings on physical examination.

• Radiography can be an option for children older than four months who have normal findings on physical examination.

• A child's legs should not be tightly swaddled with the hips extended and adducted.

From the AFP Editors

Developmental dysplasia of the hip (DDH) can range from a mild abnormality to dislocation. In infants and young children, it is asymptomatic; therefore, screening is required to diagnose it in otherwise healthy children. There are no agreed upon best screening techniques and important clinical findings because of a lack of quality evidence. In addition, there is no standardized definition of DDH, including what measurable criteria at what age can be considered differences in development and what indicates DDH.

It should be noted that, although there are different definitions of DDH, there is still an overall consensus from expert groups that prognosis is poor for hips that remain unstable or abnormal until two to three years of age. The American Academy of Pediatrics (AAP) has published this clinical report to provide updated information since the release of their practice guideline in 2000. The AAP indicates that screening for DDH is useful to prevent subluxated or dislocated hips in the first year of an infant's life. It should be noted that no method of screening has been determined to entirely remove the risk of DDH occurring late, and no high-quality evidence supports the idea that screening combined with early treatment will prevent mild DDH.

Physical Examination

DDH is most often diagnosed in children without risk factors; therefore, physical examination is the main screening method. Using occasional physical examination, physicians should aim to diagnose hip subluxation or dislocation by six months of age. Many expert groups recommend physical examination in newborns and occasionally thereafter to identify differences in limb length, uneven thigh or buttock creases, and restricted abduction. The examination should include the Ortolani test (hip dislocation) to evaluate stability. Electronic health records can be helpful in this regard, to remind clinicians to perform examinations and document results.

Referral to an orthopedist is based primarily on findings of instability or dislocation on examination and, in children four weeks or younger, restricted or uneven hip abduction. If a physician or caregivers are worried, there are risk factors for DDH present, or an examination is inconclusive, referral can also be considered.

Imaging with ultrasonography is an option in infants younger than six months with suspicious or inconclusive findings on physical examination. The AAP recommends against universally screening for DDH with ultrasonography; however, it can be selectively performed in infants six weeks to six months of age who have normal findings on physical examination, but are considered high risk: breech presentation in the third trimester; family history of DDH or a personal history of instability; history of incorrect tight lower extremity swaddling; or whose caregivers are anxious. However, ultrasonography or radiography does not have to be performed to refer an infant or child to an orthopedist for DDH. Selective imaging may be performed with consultation from a pediatric radiologist or orthopedist.

Ultrasonography should be performed and the results assessed by trained experts; guidelines from the American Institute of Ultrasound in Medicine and the American College of Radiology should be followed. Because imaging quality can vary by location, it would be helpful to create imaging and referral standards locally to encourage more consistent treatment. It should be noted that minor hip abnormalities visible on ultrasonography in infants six weeks to four months of age typically will resolve over time.

Radiography with anteroposterior and frog pelvis views can be an option for children older than four months who have normal findings on physical examination, but who are considered high risk, and for children of any age with positive findings. For children four to six months of age, radiography or ultrasonography can be used, taking into account the better availability, lower false-positive rate, and lower cost with radiography vs. its low radiation dose.

DDH does not need to be emergently treated, nor does bracing need to be started in the hospital. An orthopedist can be consulted within a few weeks of a positive result on the Ortolani test. For those with a positive result on the Barlow test, reexamination is indicated; however, if instability does not resolve, the patient can be referred to an orthopedist.

A child's legs should not be tightly swaddled with the hips extended and adducted. To decrease the risk of DDH, safe swaddling techniques that do not restrict hip movement should be used instead.

There are not data to recommend treatment instead of observation in infants six weeks to four months of age with minor hip abnormalities on ultrasonography; care should instead be individualized to the patient through shared decision making. Data do strongly indicate a need to treat children with hip dislocations, but to observe those with mild DDH and instability. Although observation, examinations, and imaging can be managed by a family physician or orthopedist, treatment should be managed by the orthopedist.

Guideline source: American Academy of Pediatrics

Evidence rating system used? No

Literature search described? No

Guideline developed by participants without relevant financial ties to industry? Yes

Published source: Pediatrics . December 2016;138(6):e20163107

Available at: http://pediatrics.aappublications.org/content/138/6/e20163107?utm_source=highwire&utm_medium=email&utm_campaign=Pediatrics_etoc

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, associate medical editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide .

Continue Reading

More in AFP

More in pubmed.

Copyright © 2017 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions  for copyright questions and/or permission requests.

Copyright © 2024 American Academy of Family Physicians. All Rights Reserved.

The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study

Affiliations.

• 1 Nuffield Department of Women's Reproductive Health, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom.
• 2 Oxford Fetal Medicine Unit, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom.
• PMID: 33449926
• PMCID: PMC7810318
• DOI: 10.1371/journal.pmed.1003503

Background: Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation.

Methods and findings: We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists.

Conclusions: In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.

• Breech Presentation / diagnosis*
• Breech Presentation / epidemiology*
• Breech Presentation / therapy*
• Cesarean Section / statistics & numerical data
• Pregnancy Outcome
• Pregnancy Trimester, Third
• Risk Factors
• United Kingdom / epidemiology

Grants and funding

Loading metrics

Open Access

Peer-reviewed

Research Article

Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study

Contributed equally to this work with: Samantha Knights, Smriti Prasad

Roles Data curation

Affiliation Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom

Roles Conceptualization, Data curation, Writing – original draft, Writing – review & editing

Affiliation Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom

Roles Conceptualization, Formal analysis, Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing

Affiliations Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey, Department of Obstetrics and Gynaecology, Koc University, School of Medicine, Istanbul, Turkey

Roles Conceptualization

Roles Conceptualization, Writing – review & editing

Roles Conceptualization, Methodology, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations Fetal Medicine Unit, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom, Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George’s University of London, London, United Kingdom, Fetal Medicine Unit, Liverpool Women’s Hospital, Liverpool, United Kingdom

• Samantha Knights, 
• Smriti Prasad, 
• Erkan Kalafat, 
• Anahita Dadali, 
• Pam Sizer, 
• Francoise Harlow, 
• Asma Khalil

• Published: April 6, 2023
• https://doi.org/10.1371/journal.pmed.1004192
• Peer Review
• Reader Comments

Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.

Methods and findings

This was a retrospective multicentre cohort study where we included data from St. George’s (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0).

Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening ( p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening ( p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period.

Conclusions

In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.

Author summary

Why was this study done.

• Accurate knowledge of fetal presentation is essential for optimal care during pregnancy and birth. Vaginal breech delivery is associated with adverse maternal and perinatal outcomes.
• Abdominal palpation has poor sensitivity (50% to 70%) for determination of fetal presentation.
• The role of a routine third ultrasound assessment of fetal presentation has been reported but the impact on neonatal outcomes is yet to be determined.
• There are limited reports on antenatal use of handheld point-of-care ultrasound (POCUS) for the determination of fetal presentation, but the impact of their systematic use for this purpose is largely unknown.

What did the researchers do and find?

• We analysed 2 cohorts of pregnant women from 2 large teaching hospitals in the United Kingdom where a policy of routine third trimester ultrasound or POCUS has been implemented.
• We studied the impact of routine third trimester ultrasound or POCUS on the percentage of all term breech presentations that were undiagnosed and adverse neonatal outcomes, in pre- and post-screening epochs.
• Due to the rarity of adverse outcomes, we employed Bayesian regression analysis with informative priors. This statistical tool permits updating previous findings with new data to generate new evidence.
• We found that the incidence of all term breech presentations that were undiagnosed reduced drastically in the post-screening epoch following the implementation of either a third trimester ultrasound (decreased from 14.2% to 2.8%) or POCUS (decreased from 16.2% to 3.5%). There was an associated improvement in neonatal outcomes.

What do these findings mean?

• Our findings imply that a policy of either a third trimester ultrasound by sonographers or POCUS by trained midwives was effective in reducing the proportion of all term breech presentations at the time of birth that were undiagnosed and associated neonatal complications.
• Cost-effectiveness of POCUS needs to be explored further for feasibility of implementation on a wider scale for assessment of fetal presentation at term.

Citation: Knights S, Prasad S, Kalafat E, Dadali A, Sizer P, Harlow F, et al. (2023) Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med 20(4): e1004192. https://doi.org/10.1371/journal.pmed.1004192

Received: August 19, 2022; Accepted: February 7, 2023; Published: April 6, 2023

Copyright: © 2023 Knights et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data cannot be shared publicly because consent was not obtained from women; permission for sharing data was not sought as part of ethical approval. Data is only available following approval from Research Ethics Committee and Confidentiality Advisory Group. Enquiries and requests should be made to the the Research Governance and Delivery team at St George's University of London ( [email protected] ).

Funding: The author(s) received no specific funding for this work.

Competing interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: AK is a Vice President of the Royal College of Obstetricians and Gynaecologists. AK is a Trustee (and the Treasurer) of the International Society of Ultrasound in Obstetrics and Gynecology AK has lectured at and consulted in several ultrasound-based projects, webinars and educational events.

Abbreviations: BAME, black, Asian, and minority ethnic; BMI, body mass index; CrI, credible intervals; ECV, external cephalic version; HIE, hypoxic ischemic encephalopathy; HRA, Health Research Authority; HTA, Health Technology Assessment; IMD, index of multiple deprivation; NICE, National Institute for Health and Care Excellence; NIHR, National Institute for Health Research; NNU, neonatal unit; NNUH, Norfolk and Norwich University Hospital; NSC, National Screening Committee; POCUS, point-of-care ultrasound; RR, risk ratio; SGH, St. George’s Hospital

Introduction

The incidence of breech presentation at term is 3% to 4% [ 1 ]. Breech vaginal birth is associated with an increase in both perinatal mortality and morbidity as well as maternal morbidity [ 2 – 7 ]. Correct knowledge of fetal presentation at term is essential for providing optimum antepartum and intrapartum care. Women with breech presentation at term can be effectively counselled about their options—external cephalic version (ECV), planned vaginal birth, or elective cesarean birth—with their inherent risks and perceived benefits [ 1 ]. There is substantial evidence that clinical examination is not accurate enough for determination of fetal presentation, with unacceptably high rates of missed breech/noncephalic presentations at term [ 8 , 9 ].

There are 2 modalities to screen for fetal presentation at term, each with its advantages and disadvantages: routine third trimester ultrasound or point-of-care/portable ultrasound (POCUS). Currently, routine third trimester ultrasound is not recommended by the United Kingdom National Institute for Health and Care Excellence (NICE) in low-risk pregnancies due to insufficient clinical and cost-effectiveness evidence [ 10 , 11 ]. In the UK, the current practice is to perform an early pregnancy risk assessment followed by referral pathways for low-risk and high-risk women. These risks relate to maternal, fetal, and placental pathology but are unrelated to the risk of breech presentation at term. Women deemed to be at high risk are referred for an ultrasound scan at 28 weeks’ gestation for fetal biometry with or without additional follow-up ultrasound scans. Low-risk women are followed up with clinical assessment (serial measurement of symphysio-fundal height) and referred for third trimester ultrasound if fetal growth restriction is suspected or if it is difficult to perform clinical examination, as in women with high body mass index (BMI), multiple pregnancy, or multiple uterine fibroids, or there is clinical suspicion of noncephalic fetal presentation at term [ 12 – 14 ]. Emerging data from observational studies and a systematic review indicate that it is feasible to accurately diagnose fetal presentation at term by third trimester ultrasound, thereby reducing the proportion of all term breech presentations that were undiagnosed at the time of labour and birth [ 15 – 18 ]. The clinical end point of any study of the diagnosis of breech presentation at term would be an improvement in neonatal outcomes, associated with reduction in incidence of undiagnosed breech. Hitherto published literature, however, could not demonstrate a translation of increased antenatal diagnosis of breech presentation into a statistically significant improvement in neonatal outcomes, most likely owing to the rarity of adverse outcomes.

Most of the data on the use of POCUS in antenatal settings are from low-resource settings where there is inadequate access to ultrasound owing to both material and physical constraints; hence, the focus is on task-shifting of obstetric ultrasound from sonographers to primary care providers [ 19 , 20 ]. A recently published review reported improved diagnostic accuracy with POCUS compared to clinical examination only, for high-risk obstetric conditions including fetal malpresentation, albeit studies were heterogeneous and referred to varying standards [ 21 ]. The Society of Obstetricians and Gynaecologists of Canada identifies POCUS as a useful modality for timely determination of fetal presentation [ 22 ]. A retrospective criterion-based audit performed in one of our study hospitals demonstrated that the use of POCUS by midwives in the antenatal ward/labour ward was associated with identification of previously unrecognized breech presentation, thereby preventing inappropriate induction of labour [ 23 ]. A recent validation study of POCUS in obstetric care showed near perfect agreement for assessment of fetal presentation [95.6% agreement, Kappa −0.887, 95% CI (0.78 to 0.99)] when compared to routine ultrasound [ 24 ]. There is, however, scanty literature on the diagnostic accuracy of POCUS in antenatal care settings for assessment of fetal presentation, compared to standard antenatal care, i.e., routine abdominal palpation, with referral for ultrasound when there is clinical suspicion of breech presentation.

In our study, we aimed to compare the impact of routine third trimester ultrasound or POCUS with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes.

The study included data from St. George’s University Hospital NHS Foundation Trust (SGH) and Norfolk and Norwich University Hospital NHS Foundation Trust (NNUH). For both centres, pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH).

Routine third trimester scan cohort

We included a cohort of pregnant women who gave birth between 4 April 2016 and 30 September 2021, at SGH, a large teaching hospital in South West London. The chosen starting point was the date when birth records were first systematically entered into the current electronic database. At SGH, a policy of routine third trimester (at 36 weeks) ultrasound scan by sonographers for all pregnant women has been implemented since January 2020; this includes assessment of fetal biometry, umbilical and middle cerebral artery Doppler, placental localization, amniotic fluid volume, and fetal presentation. Following a diagnosis of breech presentation during the ultrasound scan, women are counselled about their options: ECV, planned cesarean birth, or planned vaginal birth. If women declined ECV or if it was unsuccessful, they were offered elective cesarean delivery from 39 weeks of gestation. The population was divided into 2 study groups: Group 1 (women who were offered and accepted a routine third trimester scan) and Group 2 (women who received standard antenatal care in line with national guidance, without a routine third trimester scan).

POCUS cohort

The POCUS cohort included pregnant women from NNUH where a policy of routine POCUS at the 36-week antenatal visit was fully adopted from November 2020 following stage-wise implementation in 2016. The POCUS is performed by a midwife using Vscan Air (GE Healthcare). NNUH is a large teaching hospital with approximately 6,000 births per year, and approximately 250 midwives working across the hospital and community. We included 2 groups: a historical cohort of women who received routine care—abdominal palpation and referral for selective ultrasound on clinical suspicion of breech presentation (2015) and those who had POCUS at the 36- to 37-week visit (November 2020 to 2021). Through 2016 to November 2020, POCUS was variably used, either on the labour ward or via referral from community midwives, on clinical suspicion of noncephalic presentation, and these women were not included in this study.

Training of midwives for POCUS cohort

The midwives in NNUH underwent a structured 3-month training programme. The workshops consisted of daily handheld scanning sessions with an hour of dedicated lectures. The theoretical lectures were followed by practice on consenting women in the antenatal ward. All the trainee midwives maintained a competency logbook, detailing both successful and unsuccessful cases. Following the initial workshops, “midwife champions” were identified who were deemed competent or held other ultrasound qualifications and were suitable for cascade training. POCUS training was a part of preceptor ship training of newly qualified midwives, while midwives working in nonpermanent roles were supported and advised to work with one of the champions.

The primary outcome was the proportion of all term breech presentations that were undiagnosed. Undiagnosed breech presentation was defined as follows: (a) breech presentation after the onset of labour or rupture of membranes at term; and (b) breech presentation diagnosed immediately before commencing induction of labour. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE) 1 to 3, and perinatal mortality (includes stillbirths and early neonatal deaths).

Women with multiple pregnancies, preterm birth <37 weeks, and congenital abnormalities were excluded. Pregnancies undergoing planned cesarean section for breech presentation were excluded from the analysis of the study outcomes, except for the neonatal outcomes. Maternal demographic characteristics, antenatal, intrapartum, and perinatal data were extracted from Euroking E3 maternity information system and Viewpoint database (ViewPoint 5.6.8.428, ViewPoint Bildverarbeitung GmbH, Weßling, Germany). Routinely collected clinical data were collated from electronic health records and were deemed not to require ethics approval or signed patient consent as per the Health Research Authority (HRA) decision tool.

Statistical analysis

Descriptive variables were compared with Wilcoxon-signed rank test, t test, or chi-squared test, where appropriate. An adequately powered analysis is not practically feasible due to rarity of adverse outcomes following breech delivery. Therefore, we employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood) [ 18 ]. The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models and reported as RR (risk ratios) with credible intervals (CrI). Informative priors ( N ~ μ, σ ) for population mean were derived from Salim and colleagues and a weakly informative prior (Student t , df = 3) for model intercept. Prior parameters were estimated by using the log-risk ratios and log-confidence intervals from Salim and colleagues, and in case an effect could not be estimated in the original study due to a no-event situation, we added a single event to the corresponding group and reestimated the risk ratios. Two Markov chains were run for 1,500 iterations after an initial 500 burn-in period. Posterior probabilities were calculated using the probability density function of normal distribution. A sensitivity analysis using flat priors (noninformative) was also undertaken to investigate the weight of informative prior on the posterior density. Number needed to treat for important outcomes was calculated using current population numbers without incorporating external data. Convergence was checked with trace plots. All analyses were conducted using R for Statistical Software (v.4.2.0) using “brms” and “its.analysis” packages [ 25 , 26 ]. This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline ( S1 STROBE Checklist).

Study cohorts

In the SGH cohort, there were 24,128 singleton pregnancies during the eligibility period, of which 16,777 births were before the introduction of universal third trimester ultrasound scan and 7,351 after. Baseline characteristics of included pregnancies are presented in Table 1 . Women who gave birth before universal ultrasound scan were significantly younger (33.2 versus 35.7 years, p < 0.001), had similar BMI (25.6 versus 25.7 kg/m 2 , p = 0.194) and multiparity rate (49.6% [8,316/16,777] versus 49.2% [3,617/7,351], p = 0.612) compared to those who gave birth after. There was a slight drop in the proportion of births that were in women from black, Asian, and minority ethnic (BAME) background (39.3% [6,588/16,777] versus 37.9% [2,785/7,351], p = 0.044). The index of multiple deprivation (IMD) quintiles were similar between the 2 epochs ( p > 0.05 for all quintiles; Table 1 ), as was the total number of breech presentations at the time of birth (3.4% [578/16,777] versus 3.4% [251/7,351], p = 0.953), including all diagnosed and undiagnosed cases. A comparison of the baseline characteristics, as well as the gestational age at delivery in weeks and mode of birth of pregnancies with breech presentation at birth in the study epochs before and after the introduction of universal 36-week ultrasound scan is shown in Table 2 . Pregnancies with breech presentation at term were significantly more likely to be delivered by elective cesarean section (76.9% [193/251] versus 60.7% [351/278], p < 0.001) after compared to before the implementation of the universal 36-week ultrasound scan. Emergency cesarean section was lower (17.1% [43/251] versus 30.8% [178/578], p < 0.001) after compared to before the implementation of the universal 36-week ultrasound scan. A similar trend was noted for vaginal breech delivery ( Table 2 ). The gestational age at birth was 39.1 weeks in both groups with a mean difference of 1 day. Although the difference was statistically significant, it would be deemed clinically inconsequential.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pmed.1004192.t001

https://doi.org/10.1371/journal.pmed.1004192.t002

The percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before and 2.8% (7/251) after the implementation of universal screening ( p < 0.001) ( Table 3 ). The rate of elective cesarean delivery was higher during the universal scan epoch (13.0% [959/7,351] versus 12.0% [2,019/16,777], p = 0.029), while the emergency cesarean rate was lower (12.9% [2,169/16,777] versus 11.5% [845/7,351], p = 0.029) compared to the previous epoch. The total number of vaginal breech births reduced from 29 per 10,000 births to 20 per 10,000 births, but this difference did not reach statistical significance ( p = 0.276). A regression discontinuity (interrupted time series) analysis showed significant variation in the number of undiagnosed breech presentations between 2 epochs (before and after universal ultrasound, p < 0.001) ( Fig 1 ).

Dotted line represents the fitted regression curve with splines.

https://doi.org/10.1371/journal.pmed.1004192.g001

https://doi.org/10.1371/journal.pmed.1004192.t003

In the NNUH cohort, there were 9,694 singleton births during the eligibility period, of which 5,119 births were before the initiation of POCUS screening and 4,575 births after the complete implementation of POCUS. Women who gave birth before POCUS were significantly older (34.6 versus 31.6 years, p < 0.001) and had a lower BMI (25.6 versus 26.5 kg/m 2 , p < 0.001) than those who gave birth after. The percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before and 3.5% (5/142) after the implementation of universal POCUS screening ( p < 0.001) ( Table 4 ).

https://doi.org/10.1371/journal.pmed.1004192.t004

Perinatal outcomes

We analysed the SGH cohort using Bayesian regression analysis with both flat (noninformative) and informative priors (Using data from Salim and colleagues) [ 18 ]. Regression with informative priors showed the percentage of all term breech presentations that were undiagnosed was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9% ( Table 3 ). Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Analysis using flat priors (noninformative) also showed that the percentage of all term breech presentations that were undiagnosed was 74% lower (RR, 0.26; 95% CrI 0.10, 0.59) with very high posterior probability of 99.8%. The reduction in low Apgar scores was also observed in flat prior analysis that corresponded to a 65% reduction (RR, 0.35; 95% CrI 0.06, 1.42) with a moderate to high probability (89.8%). The number needed to scan to prevent one case of undiagnosed breech presentation was 255 (95% CI: 192 to 376).

We analysed the NNUH cohort using the same methods. Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9% ( Table 4 ). There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). Flat prior analysis also showed that undiagnosed breech presentation was lower by 80% (RR, 0.20; 95% CrI: 0.07, 0.51) with very high posterior probability of 99.9%. No inference could be made for HIE or extended perinatal mortality as there were no events in either period.

In our study, use of a policy of either routine third trimester scan or routine third trimester POCUS was associated with a significant reduction in the proportion of all breech presentations that were undiagnosed at term, when compared to standard antenatal care. Short-term adverse perinatal outcomes, including NNU admission and low Apgar scores, were significantly lower for the pregnancies with diagnosed breech presentation at term following a policy for screening by either routine third trimester scan or POCUS. Previous studies were unable to study perinatal outcomes due to their small numbers.

Our cohorts are derived from real-world data from 2 large teaching hospitals in the UK. Much of the previously reported literature on use of third trimester ultrasound for diagnosis of breech presentation is from research settings with a dedicated breech clinic and available expertise and skills for manoeuvres like ECV and vaginal breech births. Conclusions from research settings may not be generalizable to clinical settings and may be prone to bias. Furthermore, our study is the first to compare the impact of POCUS with routine antenatal care for diagnosis of fetal presentation. Routine ultrasound scan is effective at reducing the proportion of all term breech presentations that were undiagnosed, but the clinical impact of this change is hard to assess owing to the rarity of adverse outcomes [ 18 ]. We employed a Bayesian approach using both informative priors from similar studies and flat priors as a sensitivity analysis that allowed us to estimate the effect of universal ultrasound in probabilistic terms without depending on P values.

There are some limitations to our study. Firstly, we did not have reliable data on ECV for both our cohorts. The universal scan might have implications, not just for babies that were breech at birth (e.g., ECV could be performed, which could lead to not being breech and therefore not being included in the outcomes, or some other benefit, or indeed, theoretically, harm). Salim and colleagues included all babies diagnosed as breech. The method employed by Salim and colleagues also has drawbacks as it did not include those undiagnosed before the universal scan. Nevertheless, it is unlikely to have had a substantial impact on our results given the low acceptance and variable success rates. This is reflected in the almost identical incidence of overall (undiagnosed and diagnosed) breech presentation before and after screening. Salim and colleagues also reported no difference in the rates of overall breech presentations despite systematic use of ECV with acceptance rates of as high as 80% [ 18 ]. Secondly, the number of adverse neonatal outcomes such as extended perinatal mortality and HIE were not sufficient to estimate an effect in the NNUH cohort. Finally, the maternity records at NNUH were uploaded on electronic database only from April 2015. Therefore, reliable data on demographic parameters like BMI, ethnicity, and IMD were not available for the first quarter of 2015. These factors, however, are unlikely to influence the results.

Our findings of a reduction in the proportion of all term breech presentations that were undiagnosed at term after implementation of routine third trimester scan resonates with those of Salim and colleagues, who reported a reduction from 22.3% to 4.7% following the introduction of universal third trimester scan, compared to standard antenatal care [ 18 ]. Yet there are no published data from the UK on the impact of routine POCUS on the reduction of the percentage of all term breech presentations that were undiagnosed at term. Observational studies from Kenya [ 19 ], Uganda [ 27 ], and Guatemala [ 28 ] have reported that midwives who underwent focused basic obstetric ultrasound training for 3 to 8 weeks were able to identify fetal presentation with high sensitivity and specificity. The proportion of all term breech presentations that were undiagnosed at term, however, could not be eliminated in both cohorts, with 7 and 5 such cases in the routine third trimester scan and POCUS cohorts, respectively. Most of these cases were a consequence of spontaneous version to breech from cephalic presentation in multiparous women. Salim and colleagues also described spontaneous version to breech in multiparous women (76% of cases of undiagnosed breech) in their cohort. Wastlund and colleagues reported in their prospective cohort of 3,879 women that a policy of universal third trimester scan virtually eliminated undiagnosed breech presentations in labour [ 16 ]. It should, however, be noted that their cohort comprised of nulliparous women only in a strict research setting.

We also noted a significant improvement in short-term neonatal outcomes including low Apgar scores at 5 minutes and NNU admission. Salim and colleague demonstrated a nonsignificant improvement in short-term neonatal outcomes [ 18 ]. Although we were unable to demonstrate an effect on outcomes such as HIE and neonatal mortality, observational data from low-resource settings report a reduction in neonatal mortality when women were referred in a timely manner for fetal malpresentation [ 29 ].

Accurate knowledge of fetal presentation at term is crucial for optimal antenatal and intrapartum care. Both routine third trimester scan by a sonographer/clinician or use of POCUS by trained midwives can achieve this objective. Although evidence suggests that a planned breech vaginal birth may be offered after careful case selection and counselling, a large proportion of maternity units in the UK and worldwide lack skilled providers for vaginal breech births. Antenatal identification of breech presentation would allow healthcare providers to offer unbiased information such that pregnant women feel empowered to make an informed decision and have a positive birth experience. A meeting of the UK National Screening Committee (NSC) in March 2021 acknowledged that ultrasound for fetal presentation appears promising; however, the committee recommended that further work on screening for fetal presentation could not be commissioned at that time. The NSC agreed to add screening for fetal presentation to the recommendations list for reconsideration in 3 years’ time if significant evidence evolves in the interim [ 30 ]. Our findings add to that evidence base. A cost-effectiveness analysis study conducted in the UK showed that universal third trimester ultrasound would “virtually eliminate” the proportion of all term breech presentations that were undiagnosed and would be cost-effective if fetal presentation could be assessed at £19.80 pounds per woman or less [ 16 ]. A National Institute for Health Research (NIHR) Health Technology Assessment (HTA) review has suggested that handheld portable ultrasound can readily close this gap as a low-cost device that antenatal care providers like midwives could use for fetal presentation with minimal training [ 31 ]. The major obstacles to routine third trimester scan policy include the costs incurred, whereas a policy of using POCUS in community clinics and the labour ward by healthcare providers, after a short period of training, appears to be as effective as a policy of routine third trimester formal departmental ultrasound. Implementation of POCUS in the community for fetal presentation would also curtail indirect costs by reduction in referrals for facility-based ultrasound based on clinical suspicion, apart from also instilling a sense of empowerment among the care providers and satisfaction among pregnant women. The policy of POCUS was acceptable to pregnant women in our cohort who wanted to avoid nonessential hospital visits during the COVID-19 pandemic. A potential pitfall of the portable ultrasound cited when used in low-resource settings was dependence on internet coverage, which is unlikely to be a deterrent in the UK. Nonetheless, regular audits, ongoing training, and quality improvement measures should be in place to support community healthcare providers to ensure safe practice.

Our data suggest that a policy of either third trimester ultrasound or POCUS by healthcare providers could be effective in reducing the proportion of all term breech presentations that were undiagnosed at birth with an associated improvement in neonatal outcomes.

Supporting information

S1 strobe checklist. strobe checklist..

https://doi.org/10.1371/journal.pmed.1004192.s001

• 1. Management of Breech Presentation (Green-top Guideline No. 20b) [Internet]. Royal College of Obstetricians & Gynaecologists. [cited 2022 May 1]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20b/
• View Article
• PubMed/NCBI
• Google Scholar
• 10. Universal ultrasound in late pregnancy did not reduce serious harms to babies [Internet]. NIHR Evidence. [cited 2022 May 1]. Available from: https://evidence.nihr.ac.uk/alert/universal-ultrasound-in-late-pregnancy-did-not-reduce-serious-harms-to-babies/
• 11. National Guideline Alliance (UK). Identification of breech presentation: Antenatal care: Evidence review L [Internet]. London: National Institute for Health and Care Excellence (NICE); 2021 [cited 2022 May 1]. (NICE Evidence Reviews Collection). Available from: http://www.ncbi.nlm.nih.gov/books/NBK573936/
• 12. Overview | Antenatal care | Guidance | NICE [Internet]. NICE; [cited 2022 May 1]. Available from: https://www.nice.org.uk/guidance/ng201
• 13. Small-for-Gestational-Age Fetus, Investigation and Management (Green-top Guideline No. 31) [Internet]. Royal College of Obstetricians & Gynaecologists. [cited 2022 May 1]. Available from: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg31/
• 14. Perinatal Institute: Programme [Internet]. [cited 2022 May 1]. Available from: https://www.perinatal.org.uk/GAP/programme
• 23. British Journal of Midwifery—Detection of breech presentation: Abdominal palpation and hand-held scanning by midwives [Internet]. Br J Midwifery. [cited 2022 May 1]. Available from: https://www.britishjournalofmidwifery.com/articles/detection-of-breech-presentation-abdominal-palpation-and-hand-held-scanning-by-midwives/
• 26. English P The its.analysis R Package–Modelling Short Time Series Data (June 6, 2019). Available from: https://ssrn.com/abstract=3398189 . https://doi.org/10.2139/ssrn.3398189
• 30. UK NSC minutes March 2021 [Internet]. GOV.UK. [cited 2022 Jul 10]. Available from: https://www.gov.uk/government/publications/uk-nsc-meeting-march-2021/uk-nsc-minutes-march-2021
• 31. 21/582 Point of care ultrasound for breech presentation at term commissioning brief [Internet]. [cited 2022 May 1]. Available from: https://www.nihr.ac.uk/documents/21582-point-of-care-ultrasound-for-breech-presentation-at-term-commissioning-brief/29207

Contemporary Obstetrics and Gynecology for Developing Countries pp 193–201 Cite as

Breech Presentation and Delivery

• Uche A. Menakaya 5 , 6  
• First Online: 06 August 2021

1233 Accesses

Breech presentation refers to the presence of the fetal buttocks, knees or feet at the lower pole of the gravid uterus during pregnancy. At term, up to 4% of pregnancies are breech. The term breech foetus faces peculiar challenges in resource restricted countries with its lack of consensus on management and limited investments in health care systems and training of health care providers. This chapter describes the different types of breech presentation, the risk factors for term breech presentation and the antenatal management options including external cephalic version available to women presenting with a term breech foetus. The chapter also describes the techniques for performing external cephalic version and the maneuvers critical for a successful vaginal breech delivery and highlights the limitations of the evidence for and against vaginal breech delivery in the sub-Saharan continent.

This is a preview of subscription content, log in via an institution .

Buying options

• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Hofmeyr GJ, Lockwood CJ, Barss VA. Overview of issues related to breech presentation: Uptodate Topic 6776 Version 24.0.

Google Scholar  

Scheer K, Nubar J. Variation of fetal presentation with gestational age. Am J Obstet Gynecol. 1976;125(2):269–70.

Article   CAS   PubMed   Google Scholar  

Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstet Gynecol. 1992;166(3):851–2.

Albrechtsen S, Rasmussen S, Dalaker K, Irgens LM. Reproductive career after breech presentation: subsequent pregnancy rates, inter pregnancy interval, and recurrence. Obstet Gynecol. 1998;92(3):345.

CAS   PubMed   Google Scholar  

Ford JB, Roberts CL, Nassar N, Giles W, Morris JM. Recurrence of breech presentation in consecutive pregnancies. BJOG. 2010;117(7):830.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Nordtveit TI, Melve KK, Albrechtsen S, Skjaerven R. Maternal and paternal contribution to intergenerational recurrence of breech delivery: population based cohort study. BMJ. 2008;336(7649):872.

Article   PubMed   PubMed Central   Google Scholar  

Hofmeyr GJ. Abnormal fetal presentation and position. In: Chapter 34, Turnbull's obstetrics; 2000.

Thorp JM Jr, Jenkins T, Watson W. Utility of Leopold maneuvers in screening for malpresentation. Obstet Gynecol. 1991;78(3 Pt 1):394.

PubMed   Google Scholar  

Grootscholten K, Kok M, Oei SG, Mol BW, van der Post JA. External cephalic version-related risks: a meta-analysis. Obstet Gynecol. 2008;112(5):1143.

Article   PubMed   Google Scholar  

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015 Apr;4:CD000083.

De Hundt M, Velzel J, de Groot CJ, Mol BW, Kok M. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014;123(6):1327.

Article   PubMed   CAS   Google Scholar  

Tan JM, Macario A, Carvalho B, Druzin ML, El-Sayed YY. Cost-effectiveness of external cephalic version for term breech presentation. BMC Pregnancy Childbirth. 2010;10:3.

Gifford DS, Keeler E, Kahn KL. Reductions in cost and caesarean rate by routine use of external cephalic version: a decision analysis. Obstet Gynecol. 1995;85(6):930–6.

Ben-Meir A, Erez Y, Sela HY, Shveiky D, Tsafrir A, Ezra Y. Prognostic parameters for successful external cephalic version. J Matern Fetal Neonatal Med. 2008;21(9):660.

Kok M, Cnossen J, Gravendeel L, van der Post J, Opmeer B, Mol BW. Clinical factors to predict the outcome of external cephalic version: a meta-analysis. Am J Obstet Gynecol. 2008;199(6):630.e1.

Article   Google Scholar  

Ebner F, Friedl TW, Leinert E, Schramm A, Reister F, Lato K, Janni W, De Gregorio N. Predictors for a successful external cephalic version: a single centre experience. Arch Gynecol Obstet. 2016;293(4):749.

Buhimschi CS, Buhimschi IA, Wehrum MJ, Molaskey-Jones S, Sfakianaki AK, Pettker CM, Thung S, Campbell KH, Dulay AT, Funai EF, Bahtiyar MO. Ultrasonographic evaluation of myometrial thickness and prediction of a successful external cephalic version. Obstet Gynecol. 2011;118(4):913–20.

Fortunato SJ, Mercer LJ, Guzick DS. External cephalic version with tocolysis: factors associated with success. Obstet Gynecol. 1988;72(1):59.

Boucher M, Bujold E, Marquette GP, Vezina Y. The relationship between amniotic fluid index and successful external cephalic version: a 14-year experience. Am J Obstet Gynecol. 2003;189(3):751.

Hofmeyr GJ, Sadan O, Myer IG, Galal KC, Simko G. External cephalic version and spontaneous version rates: ethnic and other determinants. Br J Obstet Gynaecol. 1986;93(1):13.

Hofmeyr GJ. Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. Br J Obstet Gynaecol. 1983;90(5):392.

Collins S, Ellaway P, Harrington D, Pandit M, Impey LW. The complications of external cephalic version: results from 805 consecutive attempts. BJOG. 2007;114(5):636.

Holmes WR, Hofmeyr GJ. Management of breech presentation in areas with high prevalence of HIV infection. Int J Gynaecol Obstet. 2004;87(3):272.

American College of Obstetricians and Gynaecologists. External cephalic version. Practice Bulletin No. 161. Obstet Gynecol. 2016;127:e54.

Royal College of Obstetrics and Gynaecology. External Cephalic Version (ECV) and Reducing the Incidence of Breech Presentation (Green-top Guideline No. 20a). https://www.rcog.org.uk/en/guidelines-researchservices/guidelines/gtg20a/ . Accessed on 12 May 2016.

Ben-Meir A, Elram T, Tsafrir A, Elchalal U, Ezra Y. The incidence of spontaneous version after failed external cephalic version. Am J Obstet Gynecol. 2007;196(2):157.e1.

Hutton EK, Hannah ME, Ross SJ, Delisle MF, Carson GD, Windrim R, Ohlsson A, Willan AR, Gafni A, Sylvestre G, Natale R, Barrett Y, Pollard JK, Dunn MS, Turtle P. Early ECV2 Trial Collaborative Group. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG. 2011;118(5):564.

Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev. 2015;7:CD000084.

Hutton EK, Kaufman K, Hodnett E, Amankwah K, Hewson SA, McKay D, Szalai JP, Hannah ME. External cephalic version beginning at 34 weeks' gestation versus 37 weeks' gestation: a randomized multicenter trial. Am J Obstet Gynecol. 2003;189(1):245.

Nassar N, Roberts CL, Raynes-Greenow CH, Barratt A, Peat B. Decision aid for breech presentation trial collaborators evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]. BJOG. 2007;114(3):325.

Cluver C, Gyte GM, Sinclair M, Dowswell T, Hofmeyr GJ. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb;2:CD000184.

Rosman AN, Vlemmix F, Fleuren MA, Rijnders ME, Beuckens A, Opmeer BC, Mol BW, van Zwieten MC, Kok M. Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term, a qualitative analysis in the Netherlands. Midwifery. 2014;30(3):324.

Hofmeyr GJ. Sonnendecker EW Cardiotocographic changes after external cephalic version. Br J Obstet Gynaecol. 1983;90(10):914.

Menakaya UA, Trivedi A. Qualitative assessment of women experiences with ECV. Women Birth. 2013;26(1):41–4.

ACOG Committee on Obstetric Practice ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol. 2006;108 (1):235.

Royal College of Obstetricians and Gynaecologist (RCOG). The management of breech presentation. London: RCOG; 2006.

Westgren M, Edvall H, Nordström L, Svalenius E, Ranstam J. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol. 1985;92(1):19.

Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012;5:CD003928.

Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012;10:CD000051.

Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol. 2006;194(1):20.

Menticoglou SM. Why vaginal breech delivery should still be offered. J Obstet Gynaecol Can. 2006;28(5):380.

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet. 2000;356(9239):1375.

Vlemmix F, Bergenhenegouwen L, Schaaf JM, Ensing S, Rosman AN, Ravelli AC, Van Der Post JA, Verhoeven A, Visser GH, Mol BW, Kok M. Term breech deliveries in the Netherlands: did the increased caesarean rate affect neonatal outcome? A population-based cohort study. Acta Obstet Gynecol Scand. 2014;93(9):888.

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, Hutton E, Kung R, McKay D, Ross S, Willan A, Term Breech Trial Collaborative Group. Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: The International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004;191(3):864–71.

Adegbola O, Akindele OM. Outcome of term singleton breech deliveries at a University Teaching Hospital in Lagos. Nigeria Niger Postgrad Med J. 2009;16(2):154–7.

Hartnack Tharin JE, Rasmussen S, Krebs L. Consequences of the term breech trial in Denmark. Acta Obstet Gynecol Scand. 2011;90(7):767.

Vistad I, Klungsøyr K, Albrechtsen S, Skjeldestad FE. Neonatal outcome of singleton term breech deliveries in Norway from 1991 to 2011. Acta Obstet Gynecol Scand. 2015;94(9):997.

Lyons J, Pressey T, Bartholomew S, Liu S, Liston RM, Joseph KS. Canadian Perinatal Surveillance System (Public Health Agency of Canada) Delivery of breech presentation at term gestation in Canada, 2003-2011. Obstet Gynecol. 2015;125(5):1153.

Goffinet F, Carayol M, Foidart JM, Alexander S, Uzan S, Subtil D, Bréart G, PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 2006;194(4):1002.

Kotaska A, Menticoglou S, Gagnon R, Farine D, Basso M, Bos H, Delisle MF, Grabowska K, Hudon L, Mundle W, Murphy-Kaulbeck L, Ouellet A, Pressey T, Roggensack A. Maternal Fetal Medicine Committee, Society of Obstetricians and Gynaecologists of Canada. Vaginal delivery of breech presentation. J Obstet Gynaecol Can. 2009;31 (6):557.

Goffinet F, Blondel B, Breart G. Breech presentation: questions raised by the controlled trial by Hannah et al. on systematic use of caesarean section for breech presentations. J Gynecol Obstet Biol Reprod. 2001;30:187–90.

CAS   Google Scholar  

Glezerman M. Five years to the term breech trial: the risk and fall of a randomised controlled trial. Am J Obstet Gynecol. 2006;194:20–5.

Hauth JC, Cunningham FG. Vaginal breech delivery is still justified. Obstet Gynecol. 2002;99:1115–6.

Hull AD, Moore TR. Multiple repeat caesareans and the threat of placenta accreta: incidence, diagnosis, management. Clin Perinatol. 2011;38(2):285.

Moore WT, Steptoe PP. The experience of the John Hopkins hospital with breech presentation: an analysis of 1444 cases. South Med J. 1943;36:295.

Piper EB, Bachman C. The prevention of fetal injuries in breech delivery. J Am Med Assoc. 1929;92:217–21.

DeLee JB. Year book of obstetrics and gynaecology. Chicago: Year Book Medical Publishers; 1939.

Azria E, Le Meaux JP, Khoshnood B, Alexander S, Subtil D, Goffinet F. PREMODA Study Group Factors associated with adverse perinatal outcomes for term breech fetuses with planned vaginal delivery. Am J Obstet Gynecol. 2012;207(4):285.e1–9. Epub 2012 Aug 17

Alarab M, Regan C, O'Connell MP, Keane DP, O'Herlihy C, Foley ME. Singleton vaginal breech delivery at term: still a safe option. Obstet Gynecol. 2004;103(3):407.

Hofmeyr GJ, Lockwood CJ, Barss VA. Delivery of the fetus in breech presentation. Uptodate.com 2016 Topic 5384 version 18.

De Hundt M, Vlemmix F, Bais JM, Hutton EK, de Groot CJ, Mol BW, Kok M. Risk factors for developmental dysplasia of the hip: a meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2012;165(1):8.

Kenfack B, Ateudjieu J, Ymele FF, et al. Does the advice to Assumethe knee-chest position at the 36th to 37th weeks of gestation reduce the incidence of breech presentation at delivery? Clin Mother Child Health. 2012;9:1–5.

Dobbit JS, Foumane P, Tochie JN, Mamoudou F, Mazou N, Temgoua MN, Tankeu R, Aletum V, Mboudou E. Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study. BMJ Open. 2017;7(11):e017198.

Download references

Author information

Authors and affiliations.

JUNIC Specialist Imaging and Women’s Centre, Coombs, ACT, Australia

Uche A. Menakaya

Calvary Public Hospital, Bruce, ACT, Australia

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Uche A. Menakaya .

Editor information

Editors and affiliations.

Centre of Excellence in Reproductive Health Innovation, Department of Obstetrics and Gynaecology, University of Benin, Benin City, Nigeria

Friday Okonofua

College of Health Sciences, Chicago State University, Chicago, IL, USA

Joseph A. Balogun

Roswell Park Cancer Institute, Buffalo, NY, USA

Kunle Odunsi

Clinical Obstetrics and Gynaecology, Weil Cornell Medicine, Doha, Qatar

Victor N. Chilaka

Rights and permissions

Reprints and permissions

Copyright information

© 2021 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Cite this chapter.

Menakaya, U.A. (2021). Breech Presentation and Delivery. In: Okonofua, F., Balogun, J.A., Odunsi, K., Chilaka, V.N. (eds) Contemporary Obstetrics and Gynecology for Developing Countries . Springer, Cham. https://doi.org/10.1007/978-3-030-75385-6_17

Download citation

DOI : https://doi.org/10.1007/978-3-030-75385-6_17

Published : 06 August 2021

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-75384-9

Online ISBN : 978-3-030-75385-6

eBook Packages : Medicine Medicine (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

• Recent Searches Clear

Breech Rates Could be Cut 'Dramatically' by a Third Trimester Ultrasound

Disclosures.

Disclosure: Dr Sheena Meredith has disclosed no relevant financial relationships

Routinely offering all pregnant women an ultrasound scan in their third trimester could reduce rates of undetected breech presentation by more than two-thirds, according to a new study led by St George's University Hospital NHS Foundation Trust in London and Norfolk and Norwich University Hospital NHS Foundation Trust in Norwich.

In the study, published in PLOS Medicine ,  The team noted that the incidence of breech presentation at term is 3-4% and breech vaginal birth is associated with an increase in perinatal mortality and morbidity, as well as maternal morbidity. Women with known breech presentation at term can be effectively counselled about their options – external cephalic version, planned vaginal birth, or elective Caesarean section – and the inherent risks and perceived benefits of each.

Missed Breach Presentations 'Unacceptably High'

However, they said, there are "unacceptably high rates of missed breech/non-cephalic presentations", and there is "substantial evidence that clinical examination is not accurate enough for determination of foetal presentation". For example, the sensitivity of abdominal palpation is poor, at just 50-70%. 

The researchers set out to study whether implementing policies of either routine third trimester ultrasound by sonographers (at St. George's), or point-of-care ultrasound (POCUS)with a handheld device by trained midwives (at Norwich), had been effective in reducing the proportion of undiagnosed term breech presentations when comparing pre- and post-screening epochs.

Due to the rarity of adverse outcomes, they explained, they employed Bayesian regression analysis with informative priors – a statistical tool that permits updating previous findings with new data to generate new evidence. This enabled them to update prior estimates from a similar previous study with new data from their own study to yield likelihood estimates.

Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned Caesarean for breech presentation were excluded.

The observational retrospective study  also assessed the effects of routine ultrasound on  related adverse perinatal outcomes.

Undiagnosed Breech 'Reduced Drastically' by Ultrasound

Undiagnosed breech presentation – either women presenting in labour or with ruptured membranes at term who were subsequently discovered to have a breech presentation, or women attending for induction of labour at term and found to have a breech presentation before induction – "reduced drastically in the post-screening epoch" following the implementation of the screening policies, they reported.

The primary outcome of the proportion of all term breech presentations that were undiagnosed decreased from 14.2% to 2.8% with routine third trimester sonographer ultrasound, and from 16.2% to 3.5% with POCUS.

Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of the policy of universal ultrasound (relative risk [RR] 0.29; 95% credible interval [CrI] 0.20 to 0.38) with a posterior probability greater than 99.9%.

Along with the lowered rate of undiagnosed breech, the emergency Caesarean rate was reduced from 12.9% to 11.5% (P=0.029) comparing the periods before and after the introduction of the screening policies. However the rate of elective Caesarean delivery was higher during the universal scan epoch (13.0% versus 12.0%, P=0.029).

In addition, analysis of the secondary outcomes showed associated improvements in short-term adverse perinatal outcomes among pregnancies with diagnosed breech presentation at term, including reductions in:

• Low Apgar score (<7 at 5 minutes)
• Hypoxic ischaemic encephalopathy
• Unexpected neonatal unit admission
• Extended perinatal mortality rate

Policy Change Could Lead to a 'Significant Reduction' in Undiagnosed Breech Births

The team concluded that use of a policy of either routine third trimester ultrasound by sonographers or routine third trimester POCUS by trained midwives was associated with "a significant reduction in the proportion of all breech presentations that were undiagnosed at term", when compared with standard antenatal care.

They added that other studies had shown that universal third trimester ultrasound would "virtually eliminate" the proportion of all term breech presentations that were undiagnosed.

"Accurate knowledge of foetal presentation at term is crucial for optimal antenatal and intrapartum care," they said. "Routine third trimester scan by a sonographer/clinician or use of POCUS by trained midwives can both achieve this objective.

"Although evidence suggests that a planned breech vaginal birth may be offered after careful case selection and counselling, a large proportion of maternity units in the UK and worldwide lack skilled providers for vaginal breech births. Antenatal identification of breech presentation would allow healthcare providers to offer unbiased information such that pregnant women feel empowered to make an informed decision and have a positive birth experience."

They also noted that "the major obstacles to routine third trimester scan policy include the costs incurred", and that a National Institute for Health Research Health Technology Assessment review had suggested that handheld portable ultrasound might readily close this gap as a low-cost device that antenatal care providers like midwives could to detect foetal presentation with minimal training. 

The number needed to scan to prevent one case of undiagnosed breech presentation was 255 (95% CI 192 to 376), they said.

While the cost-effectiveness of POCUS needs to be explored further for feasibility, "a policy of using POCUS in community clinics and the labour ward by healthcare providers, after a short period of training, appears to be as effective as a policy of routine third trimester formal departmental ultrasound".

Offering Options for Breach Presentation Reduces Morbidity

Asked to comment by Medscape News UK , Professor Alexander Heazell, clinical director of the Tommy's Stillbirth Research Centre in Manchester, said: "This is a welcome study that confirms what an earlier study from the UK has already found, that scanning is a reliable way to detect breech presentation, and that offering options to manage breech presentation reduces morbidity. 

"The National Institute for Health Research recently had a call-out for a trial to address this research question to provide higher grade evidence; until then we should wait before instituting routine ultrasound scans to determine fetal presentation."

Also commenting to Medscape News UK , Elizabeth Duff, senior policy advisor at the National Childbirth Trust (NCT), said: "An additional scan in late pregnancy to detect breech positions could be helpful to women, enabling them to have more time to make decisions about their birth plan and discuss this with caregivers. 

"However, many maternity services are currently severely understaffed and under pressure, and sadly in reality, many hospitals may not be able to offer an additional scan at this current time."

The authors declared no external funding for the study. AK is a Vice President of the Royal College of Obstetricians and Gynaecologists, and a Trustee (and the Treasurer) of the International Society of Ultrasound in Obstetrics and Gynecology. AK has lectured at and consulted in several ultrasound-based projects, webinars, and educational events.

EDITOR'S RECOMMENDATIONS

UK Health Security Agency | Updated 17 April 2024

Adverse Pregnancy Outcomes Tied to Mortality 40 Years Later

Safety Risks Persist With Out-of-Hospital Births

YOU MAY ALSO LIKE

Webmd network.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List

A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case–control study

Anna e. toijonen.

1 Department of Obstetrics and Gynecology, University Hospital (HUS), University of Helsinki, Haartmaninkatu 2, 00290 Helsinki, Finland

3 School of Medicine, University of Helsinki, Helsinki, Finland

Seppo T. Heinonen

Mika v. m. gissler.

2 National Institute for Health and Welfare (THL), Helsinki, Finland

Georg Macharey

To determine if the common risks for breech presentation at term labor are also eligible in preterm labor.

A Finnish cross-sectional study included 737,788 singleton births (24–42 gestational weeks) during 2004–2014. A multivariable logistic regression analysis was used to calculate the risks of breech presentation.

The incidence of breech presentation at delivery decreased from 23.5% in pregnancy weeks 24–27 to 2.5% in term pregnancies. In gestational weeks 24–27, preterm premature rupture of membranes was associated with breech presentation. In 28–31 gestational weeks, breech presentation was associated with maternal pre-eclampsia/hypertension, preterm premature rupture of membranes, and fetal birth weight below the tenth percentile. In gestational weeks 32–36, the risks were advanced maternal age, nulliparity, previous cesarean section, preterm premature rupture of membranes, oligohydramnios, birth weight below the tenth percentile, female sex, and congenital anomaly. In term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, premature rupture of membranes, oligohydramnios, congenital anomaly, female sex, and birth weight below the tenth percentile.

Breech presentation in preterm labor is associated with obstetric risk factors compared to cephalic presentation. These risks decrease linearly with the gestational age. In moderate to late preterm delivery, breech presentation is a high-risk state and some obstetric risk factors are yet visible in early preterm delivery. Breech presentation in extremely preterm deliveries has, with the exception of preterm premature rupture of membranes, similar clinical risk profiles as in cephalic presentation.

Introduction

The prevalence of breech presentation at delivery decreases with increasing gestational age. At 28 pregnancy weeks, every fifth fetus lies in the breech presentation and in term pregnancies, less than 4% of all singleton fetuses are in breech presentation at delivery [ 1 , 2 ]. Most likely this is due to a lack of fetal movements [ 3 ] or an incomplete fetal rotation, since the possibility of a spontaneous rotation declines with increasing gestational age. Consequently, preterm labor itself is often associated with breech presentation at delivery, since the fetus was not yet able to rotate [ 4 – 9 ]. This fact makes preterm labor as one of the strongest risk factors for breech presentation.

Vaginal breech delivery in term pregnancies is not only associated with poorer perinatal outcomes compared to vaginal delivery with a fetus in cephalic presentation [ 6 , 10 , 11 ], but also it is debated whether the cause of breech presentation itself is a risk for adverse peri- and neonatal outcomes [ 3 , 12 , 13 ]. Several fetal and maternal features, such as fetal growth restriction, congenital anomaly, oligohydramnios, gestational diabetes, and previous cesarean section, are linked to a higher risk of breech presentation at term, and, furthermore, are associated with an increased risk for adverse perinatal outcomes [ 3 – 5 , 8 , 9 , 14 – 17 ].

The literature lacks studies on the risk factors of breech presentation in preterm pregnancies. It remains unclear whether breech presentation at preterm labor is only caused by the incomplete fetal rotation, or whether breech presentation in preterm labor is also associated with other obstetric risk factors. Most of the studies reviewing risk factors for breech presentation focus on term pregnancies. Our hypothesis is that breech presentation in preterm deliveries is, besides preterm pregnancy itself, associated with other risk factors similar to breech presentation at term. We aim to compare the risks of preterm breech presentation to those in cephalic presentation by gestational age. Such information would be valuable in the risk stratification of breech deliveries by gestational age.

Materials and methods

We conducted a retrospective population-based cross-sectional study. The population included all the singleton preterm and term births, from January 2004 to December 2014 in Finland. The data were collected from the national medical birth register and the hospital discharge register, maintained by the National Institute for Health and Welfare. All Finnish maternity hospitals are obligated to contribute clinical data on births from 22 weeks or birth weight of 500 g to the register. All newborn infants are examined by a pediatrician and given a personal identification number that can be traced in the case of perinatal mortality or morbidity. The hospital discharge register contains information on all surgical procedures and diagnoses (International Statistical Classification of Diseases and Related Health Problems 10th Revision, ICD-10) in all inpatient care and outpatient care in public hospitals.

Authorization to use the data was obtained from the National Institute for Health and Welfare as required by the national data protection law in Finland (reference number THL/652/5.05.00/2017).

The study population included all the women with a singleton fetus in breech presentation at the time of delivery. The control group included all the women with a singleton fetus in cephalic presentation at delivery. Other presentations were excluded from the study ( N  = 1671) (Fig.  1 ). Gestational age was determined according to early ultrasonographic measurement which is routinely performed in Finland and it encompasses over 95% of the mothers, or if not available, to the last menstrual period. We excluded neonates delivered before 24 weeks of gestation and birth weight of less than 500 g, because the lower viability may have influenced the mode of the delivery or the outcome. The study population was divided into four categories according to the World Health Organization (WHO) definitions of preterm and term deliveries. WHO defines preterm birth as a fetus born alive before 37 completed weeks of pregnancy. WHO recommends sub-categories of preterm birth, based on gestational age, as extremely preterm (less than 28 pregnancy weeks), very preterm (28–32 pregnancy weeks), and moderate to late preterm (32–37 pregnancy weeks).

Breech presentation for singleton pregnancies during the period of 2004–2014 in Finland

In our study, we assessed four factors that may be associated with breech presentation based on prior reports [ 3 – 5 , 14 , 17 – 20 ]. These factors were: maternal age below 25 and 35 years or more, smoking, pre-pregnancy body mass index (BMI) over 30, and in vitro fertilization. The following factors were also analyzed: nulliparity, more than three previous deliveries, and history of cesarean section. The obstetric risk factors including maternal hypo- or hyperthyroidism (ICD-10 E03, E05), gestational diabetes (ICD-10 O24.4) and other diabetes treated with insulin (ICD-10 O24.0), arterial hypertension or pre-eclampsia (ICD-10 O13, O14), and maternal care for (suspected) damage to fetus by alcohol or drugs (ICD-10 O35.4, O35.5) were assessed in the analysis. The variables that were also included in the analysis were: oligohydramnios (ICD-10 O41.0), placenta praevia (ICD-10 O44), placental abruption (ICD-10 O45), preterm premature rupture of membranes (PPROM) (ICD-10 O42), infant sex, fetal birth weight below the tenth percentile, fetuses with birth weight above the 97th percentile, and fetal congenital anomalies as defined in the register of congenital malformations.

The babies born in breech presentation from the four study groups were compared with the babies born in cephalic presentation with the equal gestational age, according to WHO classification. The calculations were performed using SPSS 19. Statistical differences in categorical variables were evaluated with the Chi-squared test or Fisher’s exact test when appropriate. We calculated odds ratios (ORs) with corresponding 95% confidence intervals (CIs) using binary logistic regression. Each study group was separately adjusted, according to gestational age at delivery, defined by WHO. The adjustment for the risk factors was done by multivariable logistic regression model for all variables. Differences were deemed to be statistically significant with P value < 0.05.

This analysis includes 737,788 singleton births, from these 20,086 were in breech presentation at the time of delivery. Out of all deliveries, 33,489 infants were born preterm. The prevalence of breech presentation at delivery decreased with the increase of the gestational age: 23.5% in extremely preterm delivery, 15.4% very preterm deliveries, and 6.7% in moderate to late preterm deliveries. At term, the prevalence of breech presentation at delivery was 2.5% (Fig.  1 ).

From all deliveries, 2056 fetuses were born extremely preterm (24 + 0 to 27 + 6 gestational weeks). The differences in the possible risk factors for breech presentation at delivery were higher odds of PPROM (aOR 1.39, 95% CI 1.08–1.79, P  = 0.010) and a lower risk of placental abruption (aOR 0.59, 95% CI 0.36–0.98, P  = 0.040). No statistically significant differences were observed for the other factors (Table ​ (Table1, 1 , Figs.  1 , ​ ,2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton extremely preterm 24 + 0 to 27 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, maternal intoxication, PPROM preterm premature rupture of membranes

Prevalence of obstetric risk factors for breech presentation compared to cephalic by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

Obstetric risk factors for breech presentation with adjusted odds ratios by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes, aOR adjusted odds ratio

The determinants of breech presentation by gestational age. PPROM preterm premature rupture of membranes, PROM premature rupture of membranes

The group of very preterm deliveries (28 + 0 to 31 + 6 gestational weeks) included 4582 singleton newborns. Breech presentation at delivery was associated with PPROM (aOR 1.61, 95% CI 1.32–1.96, P  < 0.001), oligohydramnios (aOR 1.65, 95% CI 1.03–2.64, P  = 0.038), fetal birth weight below the tenth percentile (aOR 1.57, 95% CI 1.19–2.08, P  = 0.002), and maternal pre-eclampsia and arterial hypertension (aOR 1.31, 95% CI 1.04–1.66, P  = 0.023). Details of risk factors in very preterm breech deliveries are described in Table ​ Table2. 2 . The risk of placenta praevia as well as having a birth weight above the 97th percentile was lower in pregnancies with fetuses in breech rather than in cephalic presentation (Table ​ (Table2, 2 , Figs. ​ Figs.2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton very preterm 28 + 0 to 31 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, PPROM preterm premature rupture of membranes

The moderate to late preterm delivery group (32 + 0 to 36 + 6 gestational weeks) included 26,851 deliveries. Breech presentation in moderate to late preterm deliveries was associated with older maternal age (maternal age 35 years or more aOR 1.24, 95% CI 1.10–1.39, P  < 0.001), nullipara (aOR 1.43, 95% CI 1.27–1.60, P  < 0.001), maternal BMI less than 25 (maternal BMI ≥ 25 aOR 0.75, 95% CI 0.62–0.91, P  = 0.004), previous cesarean section (aOR 1.31, 95% CI 1.12–1.53, P  < 0.001), female sex (aOR 1.22, 95% CI 1.11–1.34, P  < 0.001), congenital anomaly (aOR 1.37, 95% CI 1.22–1.55, P  < 0.001), fetal birth weight below the tenth percentile (aOR 1.31, 95% CI 1.10–1.56, P  = 0.003), oligohydramnios (aOR 3.60, 95% CI 2.63–4.92, P  < 0.001), and PPROM (aOR 1.58, 95% CI 1.41–1.78, P  < 0.001). Breech presentation decreased the odds of having a fetus with birth weight above the 97th percentile (aOR 0.60, 95% CI 0.42–0.85, P  = 0.004) (Table ​ (Table3, 3 , Figs. ​ Figs.2, 2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton moderate to late preterm 32 + 0 to 36 + 6 weeks of gestational age fetuses in breech and in cephalic presentations during 2004–2014 in Finland

The term and post-term group included 704,299 deliveries, among them 17,044 fetuses in breech presentation. The factors associated with breech presentation amongst these were: maternal age of 35 years or more (aOR 1.24, 95% CI 1.19–1.29, P  < 0.001), nullipara (aOR 2.46, 95% CI 2.37–2.55, P  < 0.001), maternal BMI less than 25 (BMI ≥ 25 aOR 0.90, 95% CI 0.85–0.96, P  < 0.001), maternal hypothyroidism (aOR 1.53, 95% CI 1.28–1.82, P  < 0.001), pre-gestational diabetes treated with insulin (aOR 1.24, 95% CI 1.00–1.53, P  = 0.049), placenta praevia (aOR 1.45, 95% CI 1.11–1.91, P  = 0.007), premature rupture of membranes (PROM) (aOR 1.58, 95% CI 1.45–1.72, P  < 0.001), oligohydramnios (aOR 2.02, 95% CI 1.83–2.22, P  < 0.001), congenital anomaly (aOR 1.97, 95% CI 1.89–2.06, P  < 0.001), female sex (aOR 1.28, 95% CI 1.24–1.32, P  < 0.001), and birth weight below the tenth percentile (aOR 1.18, 95% CI 1.12–1.24, P  < 0.001) Table ​ Table4 4 includes details for risk factors of term and post-term group (Figs.  2 , ​ ,3, 3 , ​ ,4 4 ).

Unadjusted and adjusted odds ratios for risk factors in singleton term pregnancies in breech and in cephalic presentations during 2004–2014 in Finland

BMI body mass index, IVF in vitro fertilization, PROM premature rupture of membranes

The main novel finding of our study was that the risk associations increase with each gestational age group after 28 weeks of gestation. With the exception of PPROM, the extremely preterm breech deliveries have similar clinical risk profiles as in cephalic presentation when matched for gestational age. However, as gestation proceeds, the risks start to cluster. In moderate to late preterm pregnancies as in term pregnancies, the breech presentation is a high-risk state being associated with several risk factors: PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. These are in line with the findings of previous studies [ 3 , 5 , 7 , 8 ], that associated breech presentation at term with obstetric risk factors. The prevalence of breech presentation was negatively correlated with the gestational age with a decline from 23.5% in extremely preterm pregnancies to 2.5% at term. The prevalence of breech presentation in preterm pregnancies observed in our trial is similar to that of comparable studies [ 1 , 2 ].

In extremely preterm deliveries, PPROM was the only risk factor for breech presentation and it stayed as a risk for breech presentation through the gestational weeks. This finding is comparable to the previous literature suggesting that PPROM occurs more often at earlier gestational age in pregnancies with the fetus in breech presentation compared with cephalic [ 21 , 22 ]. PPROM might prevent the fetus to change into cephalic presentation. Furthermore, Goodman and colleagues (2013) reported that in pregnancies with a fetus in a presentation other than cephalic had more complications such as oligohydramnios, infections, placental abruption, and even stillbirths. In our study, surprisingly, placental abruption seemed to have a negative correlation with breech presentation among extremely preterm deliveries. This inconsistency between our results and the literature might be due to the small number of cases. Many of the obstetric complications, for example gestational diabetes, late pre-eclampsia, and late intrauterine growth restriction develop during the second or the third trimester of the pregnancy which explains partially why the risk factors for breech presentation are rarer in extremely preterm deliveries.

In very preterm delivery, breech presentation was associated with PPROM, pre-eclampsia, and fetal birth weight below the tenth percentile. Fetal growth restriction is a known risk factor for breech presentation at term, since it is associated with reduced fetal movements due to diminished resources [ 23 – 25 ]. Furthermore, fetal growth restriction is known to be the single largest factor for stillbirth and neonatal mortality [ 26 – 30 ]. Maternal arterial hypertension disturbs placental function which might cause low birth weight [ 31 , 32 ]. Arterial hypertension and pre-eclampsia increased the risk for breech presentation in very preterm births, but not in earlier or later preterm pregnancies. This finding may be due to the bias that pre-eclampsia is a well-described risk factor for PPROM, fetal growth restriction, and preterm deliveries which are also independent markers for breech presentation itself [ 4 , 5 , 31 , 33 , 34 ]. The severity of early pre-eclampsia might affect the fetal wellbeing, reduce fetal movements and growth, which might reduce the spontaneous fetal rotation to the cephalic position [ 35 ]. In addition, the most severe cases might not reach older gestational age before the delivery.

The risk factor for breech presentation in moderate to late preterm breech delivery was PPROM, oligohydramnios, advanced maternal age, nulliparity, previous cesarean section, fetal birth weight below the tenth percentile, female sex, and fetal congenital anomalies. Oligohydramnios is a known significant risk factor for term breech pregnancies [ 25 ] and it is linked to the reduced fetal movements partly due to a restricted intrauterine space [ 24 , 35 ] and nuchal cords [ 35 ]. Additionally, oligohydramnios is associated with placental dysfunction, which might reduce fetal resources and thus has a progressive effect on the fetal movements and prevent the fetus from turning into cephalic presentation [ 3 , 4 , 18 ]. Fetal female sex in moderate to late preterm breech pregnancies remained as a risk factor, as identified previously for term pregnancies [ 3 – 5 ]. It has been debated whether this risk is due to a smaller fetal size or that female fetuses tend to move less [ 9 , 20 ]. The mothers of infants born in breech presentation in moderate to late preterm and term and post-term pregnancies seemed to be older and had an increased risk of having a fetus with a congenital anomaly. The advanced maternal age is associated with negative effects on vascular health, which may have an influence on the developing fetus and increase the incidence of congenital anomalies [ 19 , 34 , 36 ]. Furthermore, congenital anomalies may have a negative influence on fetal movements [ 19 , 35 ]. Whereas, the low birth weight was found as a risk for breech presentation, a birth weight above the 97th percentile was, coherently a protective factor for breech presentation in very to term and post-term pregnancies.

We found that in term pregnancies, breech presentation was associated with advanced maternal age, nulliparity, maternal hypothyroidism, pre-gestational diabetes, placenta praevia, PROM, oligohydramnios, fetal congenital anomaly, female sex of the fetus, and birth weight below the tenth percentile. A previous cesarean section is known to be positively related to the odds of having a fetus in breech presentation at term [ 5 , 14 ], and in our study, this risk factor started to show already in moderate to late preterm pregnancies. Instead of the scar being the cause of breech presentation, it is more likely that the women with a history of breech cesarean section have, during subsequent pregnancies, a fetus in breech presentation again or have a cesarean section for another reason [ 3 , 5 , 37 ]. Our data suggest that the advanced maternal age and nulliparity are the risks for breech presentation at term, but as well as in moderate to late preterm pregnancies. The tight wall of the abdomen and the uterus of nulliparous women might inhibit the fetus from rotating to cephalic presentation [ 9 ]. In a meta-analysis from 2017, older maternal age has been considered to increase the risk of placental dysfunction such as pre-eclampsia and preterm birth [ 36 ] that are also common risk factors for breech presentation [ 4 , 5 ]. Bearing the first child in older maternal age and giving birth by cesarean section may affect the decision not to have another child and might explain the higher rate of nulliparity among moderate to late preterm and term deliveries [ 1 ]. Our study found correlation between maternal hypothyroidism and breech presentation at term. Some studies have demonstrated an association between maternal thyroid hypofunction and adverse pregnancy outcomes such as pre-eclampsia and low birth weight which are, furthermore, risks for breech presentation and may explain partly the higher prevalence of maternal hypothyroidism in term breech deliveries [ 38 – 40 ]. However, the absence of screening of, for example, thyroid diseases may cause bias in the diagnoses.

Our study demonstrated that as gestation proceeds, more obstetric risk factors can be found associating with breech presentation. In the earlier gestation and excluding PPROM, breech deliveries did not differ in obstetric risk factors compared to cephalic. The risk factors in 32 weeks of gestational age are comparable to those in term pregnancy, and several of these factors, such as low birth weight, congenital anomalies and history of cesarean section, are associated with adverse fetal outcomes [ 1 , 4 , 5 , 8 , 14 , 17 ] and must be taken into account when treating breech pregnancies. Risk factors should be evaluated prior to offering a patient an external cephalic version, as the presence of some of these risks may increase the change of failed version or fetal intolerance of the procedure. This study had adequate power to show differences between the risk profiles of breech and cephalic presentations in different gestational phase. Further research, however, is needed for improving the identification of patients at risk for preterm breech labor and elucidating the optimal route for delivery in preterm breech pregnancies.

Our study is unique since it is the first study, to our knowledge, that compares the risks for breech presentation in preterm and term deliveries. The analysis is based on a large nationwide population, which is the major strength of our study. The study population included nearly 34,000 preterm births over 11 years in Finland and 737,788 deliveries overall. The medical treatment of pregnancies is homogenous, since there are no private hospitals treating deliveries. A further strength relates to the important information on the characteristics of the mother, for example smoking during pregnancy and pre-pregnancy body mass index. The retrospective approach is a limitation of the study, another one is the design as a record linkage study, due to which the variables were restricted to the data availability. Therefore, we were not able to assess, for example uterine anomalies or previous breech deliveries to the analysis.

Our results show that the factors associated with breech presentation in very late preterm breech deliveries resemble those in term pregnancies. However, breech presentation in extremely preterm breech birth has similar clinical risk profiles as in cephalic presentation.

Acknowledgements

Open access funding provided by University of Helsinki including Helsinki University Central Hospital.

Abbreviations

Author contribution.

AT: Project development, manuscript writing. SH: Project development. MG: Data collection and analysis, manuscript editing. GM: Project development, manuscript editing.

This study was supported by Helsinki University Hospital Research Grants. Authorization to use of the data was obtained from the National Institute for Health and Welfare as required by the national data protection legislation in Finland (reference number THL/652/5.05.00/2017).

Compliance with ethical standards

We declare that we have no conflict of interest.

For this type of study, formal consent is not required. The National Institute for Health and Welfare authorized to use the data (reference number THL/652/5.05.00/2017).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Anna E. Toijonen, Email: [email protected] .

Seppo T. Heinonen, Email: [email protected] .

Mika V. M. Gissler, Email: [email protected] .

Georg Macharey, Email: [email protected] .