breech presentation differential diagnosis

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Breech presentation

• Overview  
• Theory  
• Diagnosis  
• Management  
• Follow up  
• Resources  

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Breech presentation in pregnancy occurs when a baby presents with the buttocks or feet rather than the head first (cephalic presentation) and is associated with increased morbidity and mortality for both the mother and the baby. [1] Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997. [2] Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002. There is good current evidence regarding effective management of breech presentation in late pregnancy using external cephalic version and/or planned cesarean section.

History and exam

Key diagnostic factors.

• buttocks or feet as the presenting part
• fetal head under costal margin
• fetal heartbeat above the maternal umbilicus

Other diagnostic factors

• subcostal tenderness
• pelvic or bladder pain

Risk factors

• premature fetus
• small for gestational age fetus
• nulliparity
• fetal congenital anomalies
• previous breech delivery
• uterine abnormalities
• abnormal amniotic fluid volume
• placental abnormalities
• female fetus

Diagnostic tests

1st tests to order.

• transabdominal/transvaginal ultrasound

Treatment algorithm

<37 weeks' gestation and in labor, ≥37 weeks' gestation not in labor, ≥37 weeks' gestation in labor: no imminent delivery, ≥37 weeks' gestation in labor: imminent delivery, contributors, natasha nassar, phd.

Associate Professor

Menzies Centre for Health Policy

Sydney School of Public Health

University of Sydney

Disclosures

NN has received salary support from Australian National Health and a Medical Research Council Career Development Fellowship; she is an author of a number of references cited in this topic.

Christine L. Roberts, MBBS, FAFPHM, DrPH

Research Director

Clinical and Population Health Division

Perinatal Medicine Group

Kolling Institute of Medical Research

CLR declares that she has no competing interests.

Jonathan Morris, MBChB, FRANZCOG, PhD

Professor of Obstetrics and Gynaecology and Head of Department

JM declares that he has no competing interests.

Peer reviewers

John w. bachman, md.

Consultant in Family Medicine

Department of Family Medicine

Mayo Clinic

JWB declares that he has no competing interests.

Rhona Hughes, MBChB

Lead Obstetrician

Lothian Simpson Centre for Reproductive Health

The Royal Infirmary

RH declares that she has no competing interests.

Brian Peat, MD

Director of Obstetrics

Women's and Children's Hospital

North Adelaide

South Australia

BP declares that he has no competing interests.

Lelia Duley, MBChB

Professor of Obstetric Epidemiology

University of Leeds

Bradford Institute of Health Research

Temple Bank House

Bradford Royal Infirmary

LD declares that she has no competing interests.

Justus Hofmeyr, MD

Head of the Department of Obstetrics and Gynaecology

East London Private Hospital

East London

South Africa

JH is an author of a number of references cited in this topic.

Differentials

• Transverse lie
• Caesarean birth
• Mode of term singleton breech delivery

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

• Key Points |

Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery , or cesarean delivery .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for vertex presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery or cesarean delivery is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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Breech presentation

Highlights & basics.

• Diagnostic Approach
• Risk Factors

History & Exam

• Differential Diagnosis
• Tx Approach
• Emerging Tx
• Complications

PATIENT RESOURCES

• Patient Instructions

Breech presentation refers to the baby presenting for delivery with the buttocks or feet first rather than head.

Associated with increased morbidity and mortality for the mother in terms of emergency cesarean section and placenta previa; and for the baby in terms of preterm birth, small fetal size, congenital anomalies, and perinatal mortality.

Incidence decreases as pregnancy progresses and by term occurs in 3% to 4% of singleton term pregnancies.

Treatment options include external cephalic version to increase the likelihood of vaginal birth or a planned cesarean section, the optimal gestation being 37 and 39 weeks, respectively.

Planned cesarean section is considered the safest form of delivery for infants with a persisting breech presentation at term.

Quick Reference

Key Factors

Other Factors

Diagnostics Tests

Treatment Options

Epidemiology

Pathophysiology.

Key Articles

Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. Mar 2017 [internet publication]. [Full Text]

Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

Referenced Articles

1. Cunningham F, Gant N, Leveno K, et al. Williams obstetrics. 21st ed. New York: McGraw-Hill; 1997.

2. Kish K, Collea JV. Malpresentation and cord prolapse. In: DeCherney AH, Nathan L, eds. Current obstetric and gynecologic diagnosis and treatment. New York: McGraw-Hill Professional; 2002.

3. Scheer K, Nubar J. Variation of fetal presentation with gestational age. Am J Obstet Gynecol. 1976 May 15;125(2):269-70. [Abstract]

4. Nassar N, Roberts CL, Cameron CA, et al. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ. 2006 Sep 16;333(7568):578-80. [Abstract] [Full Text]

5. Roberts CL, Peat B, Algert CS, et al. Term breech birth in New South Wales, 1990-1997. Aust N Z J Obstet Gynaecol. 2000 Feb;40(1):23-9. [Abstract]

6. Roberts CL, Algert CS, Peat B, et al. Small fetal size: a risk factor for breech birth at term. Int J Gynaecol Obstet. 1999 Oct;67(1):1-8. [Abstract]

7. Brar HS, Platt LD, DeVore GR, et al. Fetal umbilical velocimetry for the surveillance of pregnancies complicated by placenta previa. J Reprod Med. 1988 Sep;33(9):741-4. [Abstract]

8. Kian L. The role of the placental site in the aetiology of breech presentation. J Obstet Gynaecol Br Commonw. 1963 Oct;70:795-7. [Abstract]

9. Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol. 1996 Jan;174(1 Pt 1):28-32. [Abstract]

10. Westgren M, Edvall H, Nordstrom L, et al. Spontaneous cephalic version of breech presentation in the last trimester. Br J Obstet Gynaecol. 1985 Jan;92(1):19-22. [Abstract]

11. Brenner WE, Bruce RD, Hendricks CH. The characteristics and perils of breech presentation. Am J Obstet Gynecol. 1974 Mar 1;118(5):700-12. [Abstract]

12. Hall JE, Kohl S. Breech presentation. Am J Obstet Gynecol. 1956 Nov;72(5):977-90. [Abstract]

13. Morgan HS, Kane SH. An analysis of 16,327 breech births. JAMA. 1964 Jan 25;187:262-4. [Abstract]

14. Luterkort M, Persson P, Weldner B. Maternal and fetal factors in breech presentation. Obstet Gynecol. 1984 Jul;64(1):55-9. [Abstract]

15. Braun FH, Jones KL, Smith DW. Breech presentation as an indicator of fetal abnormality. J Pediatr. 1975 Mar;86(3):419-21. [Abstract]

16. Albrechtsen S, Rasmussen S, Dalaker K, et al. Reproductive career after breech presentation: subsequent pregnancy rates, interpregnancy interval, and recurrence. Obstet Gynecol. 1998 Sep;92(3):345-50. [Abstract]

17. Zlopasa G, Skrablin S, Kalafatić D, et al. Uterine anomalies and pregnancy outcome following resectoscope metroplasty. Int J Gynaecol Obstet. 2007 Aug;98(2):129-33. [Abstract]

18. Acién P. Breech presentation in Spain, 1992: a collaborative study. Eur J Obstet Gynecol Reprod Biol. 1995 Sep;62(1):19-24. [Abstract]

19. Michalas SP. Outcome of pregnancy in women with uterine malformation: evaluation of 62 cases. Int J Gynaecol Obstet. 1991 Jul;35(3):215-9. [Abstract]

20. Fianu S, Vaclavinkova V. The site of placental attachment as a factor in the aetiology of breech presentation. Acta Obstet Gynecol Scand. 1978;57(4):371-2. [Abstract]

21. Haruyama Y. Placental implantation as the cause of breech presentation [in Japanese]. Nihon Sanka Fujinka Gakkai Zasshi. 1987 Jan;39(1):92-8. [Abstract]

22. Filipov E, Borisov I, Kolarov G. Placental location and its influence on the position of the fetus in the uterus [in Bulgarian]. Akush Ginekol (Sofiia). 2000;40(4):11-2. [Abstract]

23. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ. 2001 May 5;322(7294):1089-93. [Abstract] [Full Text]

24. Beischer NA, Mackay EV, Colditz P, eds. Obstetrics and the newborn: an illustrated textbook. 3rd ed. London: W.B. Saunders; 1997.

25. Impey LWM, Murphy DJ, Griffiths M, et al; Royal College of Obstetricians and Gynaecologists. Management of breech presentation: green-top guideline no. 20b. BJOG. 2017 Jun;124(7):e151-77. [Full Text]

26. Royal College of Obstetricians and Gynaecologists. Antepartum haemorrhage: green-top guideline no. 63. November 2011 [internet publication]. [Full Text]

27. American College of Obstetricians and Gynecologists. Practice bulletin no. 175: ultrasound in pregnancy. Obstet Gynecol. 2016 Dec;128(6):e241-56. [Abstract]

28. Enkin M, Keirse MJNC, Neilson J, et al. Guide to effective care in pregnancy and childbirth. 3rd ed. Oxford: Oxford University Press; 2000.

29. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000083. [Abstract] [Full Text]

30. Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev. 2015 Jul 21;(7):CD000166. [Abstract] [Full Text]

31. Royal College of Obstetricians and Gynaecologists. External cephalic version and reducing the incidence of term breech presentation. Mar 2017 [internet publication]. [Full Text]

32. Rosman AN, Guijt A, Vlemmix F, et al. Contraindications for external cephalic version in breech position at term: a systematic review. Acta Obstet Gynecol Scand. 2013 Feb;92(2):137-42. [Abstract]

33. ​American College of Obstetricians and Gynecologists. Practice bulletin no. 221: external cephalic version. May 2020 [internet publication]. [Full Text]

34. Bogner G, Xu F, Simbrunner C, et al. Single-institute experience, management, success rate, and outcome after external cephalic version at term. Int J Gynaecol Obstet. 2012 Feb;116(2):134-7. [Abstract]

35. 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 May;90(5):392-9. [Abstract]

36. Beuckens A, Rijnders M, Verburgt-Doeleman GH, et al. An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives. BJOG. 2016 Feb;123(3):415-23. [Abstract]

37. Nassar N, Roberts CL, Barratt A, et al. Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term. Paediatr Perinat Epidemiol. 2006 Mar;20(2):163-71. [Abstract]

38. Sela HY, Fiegenberg T, Ben-Meir A, et al. Safety and efficacy of external cephalic version for women with a previous cesarean delivery. Eur J Obstet Gynecol Reprod Biol. 2009 Feb;142(2):111-4. [Abstract]

39. Pichon M, Guittier MJ, Irion O, et al. External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention [in French]. Gynecol Obstet Fertil. 2013 Jul-Aug;41(7-8):427-32. [Abstract]

40. Nassar N, Roberts CL, Raynes-Greenow CH, et al. Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]. BJOG. 2007 Mar;114(3):325-33. [Abstract] [Full Text]

41. Cluver C, Gyte GM, Sinclair M, et al. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015 Feb 9;(2):CD000184. [Abstract] [Full Text]

42. US Food & Drug Administration. FDA Drug Safety Communication: new warnings against use of terbutaline to treat preterm labor. Feb 2011 [internet publication]. [Full Text]

43. European Medicines Agency. Restrictions on use of short-acting beta-agonists in obstetric indications - CMDh endorses PRAC recommendations. October 2013 [internet publication]. [Full Text]

44. Magro-Malosso ER, Saccone G, Di Tommaso M, et al. Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2016 Sep;215(3):276-86. [Abstract]

45. de Hundt M, Velzel J, de Groot CJ, et al. Mode of delivery after successful external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2014 Jun;123(6):1327-34. [Abstract]

46. American College of Obstetricians and Gynecologists. Committee opinion no. 745: mode of term singleton breech delivery. Aug 2018 (reaffirmed 2023) [internet publication].​ [Full Text]

47. Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG. 2016 Jan;123(1):49-57. [Abstract] [Full Text]

48. Lydon-Rochelle M, Holt VL, Martin DP, et al. Association between method of delivery and maternal rehospitalisation. JAMA. 2000 May 10;283(18):2411-6. [Abstract]

49. Yokoe DS, Christiansen CL, Johnson R, et al. Epidemiology of and surveillance for postpartum infections. Emerg Infect Dis. 2001 Sep-Oct;7(5):837-41. [Abstract]

50. van Ham MA, van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol. 1997 Jul;74(1):1-6. [Abstract]

51. Murphy DJ, Liebling RE, Verity L, et al. Early maternal and neonatal morbidity associated with operative delivery in second stage of labour: a cohort study. Lancet. 2001 Oct 13;358(9289):1203-7. [Abstract]

52. Lydon-Rochelle MT, Holt VL, Martin DP. Delivery method and self-reported postpartum general health status among primiparous women. Paediatr Perinat Epidemiol. 2001 Jul;15(3):232-40. [Abstract]

53. Wilson PD, Herbison RM, Herbison GP. Obstetric practice and the prevalence of urinary incontinence three months after delivery. Br J Obstet Gynaecol. 1996 Feb;103(2):154-61. [Abstract]

54. Persson J, Wolner-Hanssen P, Rydhstroem H. Obstetric risk factors for stress urinary incontinence: a population-based study. Obstet Gynecol. 2000 Sep;96(3):440-5. [Abstract]

55. MacLennan AH, Taylor AW, Wilson DH, et al. The prevalence of pelvic disorders and their relationship to gender, age, parity and mode of delivery. BJOG. 2000 Dec;107(12):1460-70. [Abstract]

56. Thompson JF, Roberts CL, Currie M, et al. Prevalence and persistence of health problems after childbirth: associations with parity and method of birth. Birth. 2002 Jun;29(2):83-94. [Abstract]

57. Australian Institute of Health and Welfare. Australia's mothers and babies 2015 - in brief. October 2017 [internet publication]. [Full Text]

58. Mutryn CS. Psychosocial impact of cesarean section on the family: a literature review. Soc Sci Med. 1993 Nov;37(10):1271-81. [Abstract]

59. DiMatteo MR, Morton SC, Lepper HS, et al. Cesarean childbirth and psychosocial outcomes: a meta-analysis. Health Psychol. 1996 Jul;15(4):303-14. [Abstract]

60. Greene R, Gardeit F, Turner MJ. Long-term implications of cesarean section. Am J Obstet Gynecol. 1997 Jan;176(1 Pt 1):254-5. [Abstract]

61. Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery in primigravidae who have an elective caesarean section for breech presentation? BJOG. 2002 Jun;109(6):624-6. [Abstract]

62. Hemminki E, Merilainen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol. 1996 May;174(5):1569-74. [Abstract]

63. Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstet Gynecol. 2002 Jun;99(6):976-80. [Abstract]

64. Morrison JJ, Rennie JM, Milton PJ. Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol. 1995 Feb;102(2):101-6. [Abstract]

65. Annibale DJ, Hulsey TC, Wagner CL, et al. Comparative neonatal morbidity of abdominal and vaginal deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med. 1995 Aug;149(8):862-7. [Abstract]

66. Hook B, Kiwi R, Amini SB, et al. Neonatal morbidity after elective repeat cesarean section and trial of labor. Pediatrics. 1997 Sep;100(3 Pt 1):348-53. [Abstract]

67. Stock SJ, Thomson AJ, Papworth S, et al. Antenatal corticosteroids to reduce neonatal morbidity and mortality: Green-top Guideline No. 74. BJOG. 2022 Jul;129(8):e35-60. [Abstract] [Full Text]

68. American College of Obstetricians and Gynaecologists. Committee opinion no. 713: antenatal corticosteroid therapy for fetal maturation. Aug 2017 (reaffirmed 2024) [internet publication]. [Full Text]

69. Nassar N, Roberts CL, Cameron CA, et al. Outcomes of external cephalic version and breech presentation at term: an audit of deliveries at a Sydney tertiary obstetric hospital, 1997-2004. Acta Obstet Gynecol Scand. 2006;85(10):1231-8. [Abstract]

70. Nwosu EC, Walkinshaw S, Chia P, et al. Undiagnosed breech. Br J Obstet Gynaecol. 1993 Jun;100(6):531-5. [Abstract]

71. Flamm BL, Ruffini RM. Undetected breech presentation: impact on external version and cesarean rates. Am J Perinatol. 1998 May;15(5):287-9. [Abstract]

72. Cockburn J, Foong C, Cockburn P. Undiagnosed breech. Br J Obstet Gynaecol. 1994 Jul;101(7):648-9. [Abstract]

73. Leung WC, Pun TC, Wong WM. Undiagnosed breech revisited. Br J Obstet Gynaecol. 1999 Jul;106(7):638-41. [Abstract]

74. Wilcox C, Nassar N, Roberts C. Effectiveness of nifedipine tocolysis to facilitate external cephalic version: a systematic review. BJOG. 2011 Mar;118(4):423-8. [Abstract]

75. Qureshi H, Massey E, Kirwan D, et al. BCSH guideline for the use of anti-D immunoglobulin for the prevention of haemolytic disease of the fetus and newborn. Transfus Med. 2014 Feb;24(1):8-20. [Abstract] [Full Text]

76. Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev. 2015 Jul 29;(7):CD000084. [Abstract] [Full Text]

77. Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev. 2012 May 16;(5):CD003928. [Abstract] [Full Text]

78. Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database Syst Rev. 2012 Oct 17;(10):CD000051. [Abstract] [Full Text]

79. National Institute for Health and Care Excellence. Caesarean birth. Jan 2024 [internet publication]. [Full Text]

80. Hannah ME, Whyte H, Hannah WJ, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial. Am J Obstet Gynecol. 2004 Sep;191(3):917-27. [Abstract]

81. Eide MG, Oyen N, Skjaerven R, et al. Breech delivery and Intelligence: a population-based study of 8,738 breech infants. Obstet Gynecol. 2005 Jan;105(1):4-11. [Abstract]

82. Whyte H, Hannah ME, Saigal S, et al. 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 Sep;191(3):864-71. [Abstract]

83. Brown S, Lumley J. Maternal health after childbirth: results of an Australian population based survey. Br J Obstet Gynaecol. 1998 Feb;105(2):156-61. [Abstract]

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Management of Breech Presentation (Green-top Guideline No. 20b)

Summary: The aim of this guideline is to aid decision making regarding the route of delivery and choice of various techniques used during delivery. It does not include antenatal or postnatal care. Information regarding external cephalic version is the topic of the separate Royal College of Obstetricians and Gynaecologists Green-top Guideline No. 20a,  External Cephalic Version and Reducing the Incidence of Term Breech Presentation .

Breech presentation occurs in 3–4% of term deliveries and is more common in preterm deliveries and nulliparous women. Breech presentation is associated with uterine and congenital abnormalities, and has a significant recurrence risk. Term babies presenting by the breech have worse outcomes than cephalic presenting babies, irrespective of the mode of delivery.

A large reduction in the incidence of planned vaginal breech birth followed publication of the Term Breech Trial. Nevertheless, due to various circumstances vaginal breech births will continue. Lack of experience has led to a loss of skills essential for these deliveries. Conversely, caesarean section can has serious long-term consequences.

COVID disclaimer: This guideline was developed as part of the regular updates to programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers , and prior to the emergence of COVID-19.

Version history: This is the fourth edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests:

Mr M Griffiths  is a member of Doctors for a Woman's right to Choose on Abortion. He is an unpaid member of a Quality Standards Advisory Committee at NICE, for which he does receive expenses for related travel, accommodation and meals.

Mr LWM Impey  is Director of Oxford Fetal Medicine Ltd. and a member of the International Society of Ultrasound in Obstetrics and Gynecology. He also holds patents related to ultrasound processing, which are of no relevance to the Breech guidelines.

Professor DJ Murphy  provides medicolegal expert opinions in Scotland and Ireland for which she is remunerated.

Dr LK Penna:  None declared.

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This page was last reviewed 16 March 2017.

Breech Delivery Differential Diagnoses

• Author: Philippe H Girerd, MD; Chief Editor: Ronald M Ramus, MD  more...
• Sections Breech Delivery
• Practice Essentials
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Prehospital Care
• Emergency Department Care
• Consultations
• Further Inpatient Care
• Media Gallery

Differential Diagnoses

Face and Brow Presentation

Pregnancy, Delivery

ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol . 2018 Aug; reaffirmed 2023. 132 (2):e60-e63. [QxMD MEDLINE Link] . [Full Text] .

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 Oct 21. 356(9239):1375-83. [QxMD MEDLINE Link] .

Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. Number 265, December 2001. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet . 2002 Apr. 77 (1):65-6. [QxMD MEDLINE Link] .

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, et al. 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 Sep. 191 (3):864-71. [QxMD MEDLINE Link] .

External Cephalic Version: ACOG Practice Bulletin Summary, Number 221. Obstet Gynecol . 2020 May. 135 (5):1239-41. [QxMD MEDLINE Link] .

Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. Cochrane Database Syst Rev . 2015 Dec 19. 12:CD006553. [QxMD MEDLINE Link] .

Aviram A, Barrett JFR, Melamed N, Mei-Dan E. Mode of delivery in multiple pregnancies. Am J Obstet Gynecol MFM . 2022 Mar. 4 (2S):100470. [QxMD MEDLINE Link] .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios. J Chiropr Med . 2013 Jun. 12(2):74-8. [QxMD MEDLINE Link] . [Full Text] .

Tunde-Byass MO, Hannah ME. Breech vaginal delivery at or near term. Semin Perinatol . 2003 Feb. 27(1):34-45. [QxMD MEDLINE Link] .

Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol . 1996 Jan. 174(1 Pt 1):28-32. [QxMD MEDLINE Link] .

Toijonen AE, Heinonen ST, Gissler MVM, Macharey G. A comparison of risk factors for breech presentation in preterm and term labor: a nationwide, population-based case-control study. Arch Gynecol Obstet . 2020 Feb. 301 (2):393-403. [QxMD MEDLINE Link] .

Caning MM, Rasmussen SC, Krebs L. Maternal outcomes of planned mode of delivery for term breech in nulliparous women. PLoS One . 2024. 19 (4):e0297971. [QxMD MEDLINE Link] . [Full Text] .

Bergenhenegouwen LA, Meertens LJ, Schaaf J, Nijhuis JG, Mol BW, Kok M, et al. Vaginal delivery versus caesarean section in preterm breech delivery: a systematic review. Eur J Obstet Gynecol Reprod Biol . 2013 Oct 16. [QxMD MEDLINE Link] .

Knights S, Prasad S, Kalafat E, et al. 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 . 2023 Apr. 20 (4):e1004192. [QxMD MEDLINE Link] . [Full Text] .

Miwa I, Sase M, Nakamura Y, Hasegawa K, Kawasaki M, Ueda K. Congenital high airway obstruction syndrome in the breech presentation managed by ex utero intrapartum treatment procedure after intraoperative external cephalic version. J Obstet Gynaecol Res . 2012 Mar 22. [QxMD MEDLINE Link] .

• Footling breech presentation. Once the feet have delivered, one may be tempted to pull on the feet. However, a singleton gestation should not be pulled by the feet because this action may precipitate head entrapment in an incompletely dilated cervix or may precipitate nuchal arms. As long as the fetal heart rate is stable and no physical evidence of a prolapsed cord is evident, management may be expectant while awaiting full cervical dilation.
• Assisted vaginal breech delivery. Thick meconium passage is common as the breech is squeezed through the birth canal. This is usually not associated with meconium aspiration because the meconium passes out of the vagina and does not mix with the amniotic fluid.
• Assisted vaginal breech delivery. The Ritgen maneuver is applied to take pressure off the perineum during vaginal delivery. Episiotomies are often performed for assisted vaginal breech deliveries, even in multiparous women, to prevent soft tissue dystocia.
• Assisted vaginal breech delivery. No downward or outward traction is applied to the fetus until the umbilicus has been reached.
• Assisted vaginal breech delivery. With a towel wrapped around the fetal hips, gentle downward and outward traction is applied in conjunction with maternal expulsive efforts until the scapula is reached. An assistant should be applying gentle fundal pressure to keep the fetal head flexed.
• Assisted vaginal breech delivery. After the scapula is reached, the fetus should be rotated 90° in order to deliver the anterior arm.
• Assisted vaginal breech delivery. The anterior arm is followed to the elbow, and the arm is swept out of the vagina.
• Assisted vaginal breech delivery. The fetus is rotated 180°, and the contralateral arm is delivered in a similar manner as the first. The infant is then rotated 90° to the backup position in preparation for delivery of the head.
• Assisted vaginal breech delivery. The fetal head is maintained in a flexed position by using the Mauriceau maneuver, which is performed by placing the index and middle fingers over the maxillary prominence on either side of the nose. The fetal body is supported in a neutral position, with care to not overextend the neck.
• Piper forceps application. Piper forceps are specialized forceps used only for the after-coming head of a breech presentation. They are used to keep the fetal head flexed during extraction of the head. An assistant is needed to hold the infant while the operator gets on one knee to apply the forceps from below.
• Assisted vaginal breech delivery. Low 1-minute Apgar scores are not uncommon after a vaginal breech delivery. A pediatrician should be present for the delivery in the event that neonatal resuscitation is needed.
• Assisted vaginal breech delivery. The neonate after birth.
• Ultrasound demonstrating a fetus in breech presentation with a hyperextended head (ie, "star gazing").
• Table. Gestational age and frequency of breech birth

Contributor Information and Disclosures

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Medical Society of Virginia , AAGL Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

John G Pierce, Jr, MD Chairman of Women’s Health and Medical Specialties, Liberty University College of Osteopathic Medicine; Obstetrician/Gynecologist, Women’s Health of Central Virginia John G Pierce, Jr, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , Association of Professors of Gynecology and Obstetrics , Christian Medical and Dental Associations , Medical Society of Virginia , Society of Laparoscopic and Robotic Surgeons Disclosure: Nothing to disclose.

Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Medical Society of Virginia , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Assaad J Sayah, MD, FACEP President and Chief Executive Officer, Cambridge Health Alliance Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians , Massachusetts Medical Society Disclosure: Nothing to disclose.

Andrew D Jenis, MD Chair, Department of Emergency Medicine, Memorial Hospital, York, PA

Andrew D Jenis, MD is a member of the following medical societies: American College of Emergency Physicians and Medical Society of the State of New York

Disclosure: Nothing to disclose.

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Breech Presentation

Introduction.

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The 3 types of breech presentation are frank, complete, and incomplete. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of 1 or both hips extended, also known as footling (one leg extended) or double footling breech (both legs extended). [1] [2] [3]

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Clinical conditions associated with breech presentation may increase or decrease fetal motility or affect the vertical polarity of the uterine cavity. Prematurity, multiple gestations, aneuploidies, congenital anomalies, Mullerian anomalies, uterine leiomyoma, and placental polarity as in placenta previa are most commonly associated with a breech presentation. Also, a previous history of breech presentation at term increases the risk of repeat breech presentation in subsequent pregnancies. [4] [5]  These are discussed in more detail in the pathophysiology section.

Epidemiology

Breech presentation occurs in 3% to 4% of all term pregnancies. A higher percentage of breech presentations occurs with less advanced gestational age. At 32 weeks, 7% of fetuses are breech, and 25% are breech at 28 weeks or less.

Specifically, following 1 breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Some have also described prior cesarean delivery as increasing the incidence of breech presentation twofold.

Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in breech presentation affect fetal motility or the vertical polarity of the uterine cavity. [6] [7]  Conditions that change the vertical polarity or the uterine cavity or affect the ease or ability of the fetus to turn into the vertex presentation in the third trimester include:

• Mullerian anomalies: Septate uterus, bicornuate uterus, and didelphys uterus 
• Placentation: Placenta previa as the placenta occupies the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
• Uterine leiomyoma: Larger myomas are mainly located in the lower uterine segment, often intramural or submucosal, and prevent engagement of the presenting part.
• Prematurity
• Aneuploidies and fetal neuromuscular disorders commonly cause hypotonia of the fetus, inability to move effectively
• Congenital anomalies:  Fetal sacrococcygeal teratoma, fetal thyroid goiter
• Polyhydramnios: The fetus is often in an unstable lie, unable to engage
• Oligohydramnios: Fetus is unable to turn to the vertex due to lack of fluid
• Laxity of the maternal abdominal wall: The Uterus falls forward, and the fetus cannot engage in the pelvis.

The risk of cord prolapse varies depending on the type of breech. Incomplete or footling breech carries the highest risk of cord prolapse at 15% to 18%, complete breech is lower at 4% to 6%, and frank breech is uncommon at 0.5%.

History and Physical

During the physical exam, using the Leopold maneuvers, palpation of a hard, round, mobile structure at the fundus and the inability to palpate a presenting part in the lower abdomen superior to the pubic bone or the engaged breech in the same area, should raise suspicion of a breech presentation.

During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower extremity, usually a foot, or for the engaged breech, palpation of the soft tissue of the fetal buttocks may be noted. If the patient has been laboring, caution is warranted as the soft tissue of the fetal buttocks may be interpreted as caput of the fetal vertex. Any of these findings should raise suspicion, and an ultrasound should be performed.

An abdominal exam using the Leopold maneuvers in combination with the cervical exam can diagnose a breech presentation. Ultrasound should confirm the diagnosis. The fetal lie and presenting part should be visualized and documented on ultrasound. If a breech presentation is diagnosed, specific information, including the specific type of breech, the degree of flexion of the fetal head, estimated fetal weight, amniotic fluid volume, placental location, and fetal anatomy review (if not already done previously), should be documented.

Treatment / Management

Expertise in the delivery of the vaginal breech baby is becoming less common due to fewer vaginal breech deliveries being offered throughout the United States and in most industrialized countries. The Term Breech Trial (TBT), a well-designed, multicenter, international, randomized controlled trial published in 2000, compared planned vaginal delivery to planned cesarean delivery for the term breech infant. The investigators reported that delivery by planned cesarean resulted in significantly lower perinatal mortality, neonatal mortality, and serious neonatal morbidity. Also, the 2 groups had no significant difference in maternal morbidity or mortality. Since that time, the rate of term breech infants delivered by planned cesarean has increased dramatically. Follow-up studies to the TBT have been published looking at maternal morbidity and outcomes of the children at 2 years. Although these reports did not show any significant difference in the risk of death and neurodevelopmental, these studies were felt to be underpowered. [8] [9] [10] [11] (B2)

Since the TBT, many authors have argued that there are still some specific situations in that vaginal breech delivery is a potential, safe alternative to a planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these criteria.

The initial criteria used in these reports were similar: gestational age greater than 37 weeks, frank or complete breech presentation, no fetal anomalies on ultrasound examination, adequate maternal pelvis, and estimated fetal weight between 2500 g and 4000 g. In addition, the protocol presented by 1 report required documentation of fetal head flexion and adequate amniotic fluid volume, defined as a 3-cm vertical pocket. Oxytocin induction or augmentation was not offered, and strict criteria were established for normal labor progress. CT pelvimetry did determine an adequate maternal pelvis.

Despite debate on both sides, the current recommendation for the breech presentation at term includes offering an external cephalic version (ECV) to those patients who meet the criteria, and for those who are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age determines the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide the mode of delivery. One large retrospective cohort study recently concluded that from 28 to 31 6/7 weeks, there is a significant decrease in perinatal morbidity and mortality in a planned cesarean delivery versus intended vaginal delivery, while there is no difference in perinatal morbidity and mortality in gestational age 32 to 36 weeks. Of note is that no prospective clinical trials examine this issue due to a lack of recruitment.

Differential Diagnosis

The differential diagnoses for the breech presentation include the following:

• Face and brow presentation
• Fetal anomalies
• Fetal death
• Grand multiparity
• Multiple pregnancies
• Oligohydramnios
• Pelvis Anatomy
• Preterm labor
• Primigravida
• Uterine anomalies

Pearls and Other Issues

In light of the decrease in planned vaginal breech deliveries, thus the decrease in expertise in managing this clinical scenario, it is prudent that policies requiring simulation and instruction in the delivery technique for vaginal breech birth are established to care for the emergency breech vaginal delivery.

Enhancing Healthcare Team Outcomes

A breech delivery is usually managed by an obstetrician, labor, delivery nurse, anesthesiologist, and neonatologist. The ultimate decision rests on the obstetrician. To prevent complications, today, cesarean sections are performed, and experience with vaginal deliveries of breech presentation is limited. For healthcare workers including the midwife who has no experience with a breech delivery, it is vital to communicate with an obstetrician, otherwise one risks litigation if complications arise during delivery. [12] [13] [14]

Hinnenberg P, Toijonen A, Gissler M, Heinonen S, Macharey G. Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study. Archives of gynecology and obstetrics. 2019 Apr:299(4):969-974. doi: 10.1007/s00404-019-05091-2. Epub 2019 Feb 8     [PubMed PMID: 30734863]

Schlaeger JM, Stoffel CL, Bussell JL, Cai HY, Takayama M, Yajima H, Takakura N. Moxibustion for Cephalic Version of Breech Presentation. Journal of midwifery & women's health. 2018 May:63(3):309-322. doi: 10.1111/jmwh.12752. Epub 2018 May 18     [PubMed PMID: 29775226]

Niles KM, Barrett JFR, Ladhani NNN. Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians. 2019 Apr:32(7):1142-1147. doi: 10.1080/14767058.2017.1401997. Epub 2017 Nov 20     [PubMed PMID: 29157039]

Grabovac M, Karim JN, Isayama T, Liyanage SK, McDonald SD. What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG : an international journal of obstetrics and gynaecology. 2018 May:125(6):652-663. doi: 10.1111/1471-0528.14938. Epub 2017 Nov 2     [PubMed PMID: 28921813]

Andrews S, Leeman L, Yonke N. Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version. Birth (Berkeley, Calif.). 2017 Sep:44(3):222-229. doi: 10.1111/birt.12290. Epub 2017 May 8     [PubMed PMID: 28481464]

Walker S, Breslin E, Scamell M, Parker P. Effectiveness of vaginal breech birth training strategies: An integrative review of the literature. Birth (Berkeley, Calif.). 2017 Jun:44(2):101-109. doi: 10.1111/birt.12280. Epub 2017 Feb 17     [PubMed PMID: 28211102]

Hofmeyr GJ, Barrett JF, Crowther CA. Planned caesarean section for women with a twin pregnancy. The Cochrane database of systematic reviews. 2015 Dec 19:2015(12):CD006553. doi: 10.1002/14651858.CD006553.pub3. Epub 2015 Dec 19     [PubMed PMID: 26684389]

Ainsworth A, Sviggum HP, Tolcher MC, Weaver AL, Holman MA, Arendt KW. Lessons learned from a single institution's retrospective analysis of emergent cesarean delivery following external cephalic version with and without neuraxial anesthesia. International journal of obstetric anesthesia. 2017 May:31():57-62. doi: 10.1016/j.ijoa.2017.03.012. Epub 2017 Apr 2     [PubMed PMID: 28499551]

Hutton EK, Simioni JC, Thabane L. Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses. Acta obstetricia et gynecologica Scandinavica. 2017 Aug:96(8):1012-1020. doi: 10.1111/aogs.13161. Epub 2017 May 27     [PubMed PMID: 28449212]

Adjaoud S, Demailly R, Michel-Semail S, Rakza T, Storme L, Deruelle P, Garabedian C, Subtil D. Is trial of labor harmful in breech delivery? A cohort comparison for breech and vertex presentations. Journal of gynecology obstetrics and human reproduction. 2017 May:46(5):445-448. doi: 10.1016/j.jogoh.2017.04.003. Epub 2017 Apr 13     [PubMed PMID: 28412313]

Poole KL, McDonald SD, Griffith LE, Hutton EK, Early ECV Pilot and ECV2 Trial Collaborative Group. Association of external cephalic version before term with late preterm birth. Acta obstetricia et gynecologica Scandinavica. 2017 Aug:96(8):998-1005. doi: 10.1111/aogs.13153. Epub 2017 May 16     [PubMed PMID: 28414857]

Domingues AP, Belo A, Moura P, Vieira DN. Medico-legal litigation in Obstetrics: a characterization analysis of a decade in Portugal. Revista brasileira de ginecologia e obstetricia : revista da Federacao Brasileira das Sociedades de Ginecologia e Obstetricia. 2015 May:37(5):241-6. doi: 10.1590/SO100-720320150005304. Epub     [PubMed PMID: 26107576]

Delotte J, Oliver A, Boukaidi S, Mialon O, Breaud J, Benchimol D, Bongain A. [Who limit vaginal birth for breech presentation: medical practice or Law? Discussion between a medical doctor, a lawyer and the head chief of an university hospital]. Journal de gynecologie, obstetrique et biologie de la reproduction. 2011 Oct:40(6):587-9. doi: 10.1016/j.jgyn.2011.05.011. Epub 2011 Jul 16     [PubMed PMID: 21763083]

Burke G. The end of vaginal breech delivery. BJOG : an international journal of obstetrics and gynaecology. 2006 Aug:113(8):969-72     [PubMed PMID: 16827824]

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STEPHEN K. STORER, M.D., AND DAVID L. SKAGGS, M.D.

Am Fam Physician. 2006;74(8):1310-1316

A more recent article on this topic is available .

See related editorial on page 1284.

Patient information: See related handout on hip problems in infants .

Author disclosure: nothing to disclose.

Developmental dysplasia of the hip refers to a continuum of abnormalities in the immature hip that can range from subtle dysplasia to dislocation. The identification of risk factors, including breech presentation and family history, should heighten a physician’s suspicion of developmental dysplasia of the hip. Diagnosis is made by physical examination. Palpable hip instability, unequal leg lengths, and asymmetric thigh skinfolds may be present in newborns with a hip dislocation, whereas gait abnormalities and limited hip abduction are more common in older children. The role of ultrasonography is controversial, but it generally is used to confirm diagnosis and assess hip development once treatment is initiated. Bracing is first-line treatment in children younger than six months. Surgery is an option for children in whom nonoperative treatment has failed and in children diagnosed after six months of age. It is important to diagnose developmental dysplasia of the hip early to improve treatment results and to decrease the risk of complications.

The term developmental dysplasia of the hip (DDH) has replaced congenital dislocation of the hip because it more accurately reflects the full spectrum of abnormalities that affect the immature hip. DDH can predispose a child to premature degenerative changes and painful arthritis. Careful physical examination is recommended as a screening tool; early diagnosis helps improve treatment results and decrease the risk of complications.

Definitions

Hip dysplasia refers to an abnormality in the size, shape, orientation, or organization of the femoral head, acetabulum, or both. Acetabular dysplasia is characterized by an immature, shallow acetabulum and can result in subluxation or dislocation of the femoral head. In a subluxed hip, the femoral head is displaced from its normal position but still makes contact with a portion of the acetabulum. With a dislocated hip, there is no contact between the articular surface of the femoral head and the acetabulum. An unstable hip is one that is reduced in the acetabulum but can be provoked to subluxate or dislocate. Teratologic hip dysplasia, which is outside the scope of this discussion, refers to the more severe, fixed dislocation that occurs prenatally, usually in those with genetic or neuromuscular disorders.

Epidemiology and Etiology

The incidence of DDH is variable and depends on many factors. Approximately one in 1,000 children is born with a dislocated hip, and 10 in 1,000 may have hip subluxation. 1 – 3 Factors contributing to DDH include breech presentation, female sex, positive family history, firstborn status, and oligohydramnios. Intrauterine position, sex, race, and positive family history are the most important risk factors.

A family history positive for DDH may be found in 12 to 33 percent of affected patients. 4 , 5 The risk of DDH for a child has been documented at 6 percent when there is one affected sibling, 12 percent with one affected parent, and 36 percent if a parent and a sibling are affected. 6 Eighty percent of children with DDH are females. 7 This is postulated to be related to the effects of additional estrogen produced by the female fetus, which increases ligamentous laxity.

The left hip is affected in 60 percent of children, the right hip in 20 percent, and both hips in 20 percent. 8 The left hip is more commonly involved because it is adducted against the mother’s lumbosacral spine in the most common intrauterine position (i.e., left occiput anterior).

DDH occurs more often in children who present in the breech position. 9 It is believed that in utero knee extension of the infant in the breech position results in sustained hamstring forces around the hip and contributes to subsequent hip instability. First-born children are affected twice as often as subsequent siblings, presumably because of an unstretched uterus and tight abdominal structures in the mother. In utero postural deformities and oligohydramnios also are associated with DDH. For unknown reasons, DDH is less common in black persons. 10

The postnatal extrauterine environment also plays a role in DDH. The incidence of DDH is high in Native American cultures that use swaddling, which forces the hips into adduction and extension. 11

Physical Examination

No first-line method exists for diagnosing DDH during the newborn period. However, a careful physical examination is recommended as a screening tool, particularly for high-risk infants. 12 Evaluation of the hip begins with observation of both lower extremities. 12 The diaper should be removed and the infant relaxed. Provocative dynamic tests, such as the Ortolani and Barlow maneuvers, should be performed to assess its stability. 13 Because these tests often are difficult to interpret, they should be performed routinely in children three months or younger.

Each hip must be examined separately. The child should be supine with the hips flexed to 90 degrees. The examiner should place his or her index and long fingers laterally over the child’s greater trochanter with the thumb medially along the inner thigh near the groin crease. The examiner stabilizes the child’s pelvis by holding the contralateral hip still while the opposite hand examines the hip. The examiner should gently abduct the hip being tested while simultaneously exerting an upward force through the greater trochanter laterally ( Figure 1 ) . The sensation of a palpable “clunk” is a positive Ortolani test and represents the reduction of a dislocated hip into the bony acetabulum.

To perform the Barlow test, the pelvis is stabilized and the patient is positioned similar to the Ortolani test position. The difference is that the examiner adducts the child’s hip and exerts a gentle downward force in an attempt to subluxate or dislocate an unstable hip posteriorly ( Figure 1 ) . These tests generally are only useful in infants three months or younger. Thereafter, soft-tissue contractures limit the motion of the hip, even if it is dislocated.

In the first few months of life, an unstable hip may be noted on physical examination. If the Ortolani or Barlow test is equivocal or inconclusive on examination at birth, the physician should have the newborn return for follow-up in two weeks. 12

Asymmetric skinfolds or leg length inequality are common findings with unilateral hip dislocation ( Figure 2 ) , although asymmetric skinfolds are not specific to DDH. The Galeazzi sign is elicited by placing the child supine with both hips and knees flexed ( Figure 3 ) . An inequality in the height of the knees is a positive Galeazzi sign and usually is caused by hip dislocation or congenital femoral shortening. An infant with hip dislocation will develop limited hip abduction on the affected side by three months of age ( Figure 4 ) . Maximal abduction of the hips should be greater than 60 degrees, or a dislocated hip should be suspected.

Noting limited abduction is particularly important in identifying children with bilateral hip dislocations because the leg lengths (i.e., Galeazzi sign) are equal. In addition, in children who are walking, Trendelenburg’s symptom (a limp on the affected side) may be the first sign of a dislocated hip. In children with established dislocations, the action of the gluteus medius in pulling the pelvis downwards in the stance phase is ineffective or weak because of a lack of a stable fulcrum.

For a child with a right hip dislocation, the pelvis drops on the opposite side (i.e., left), causing instability. To restore the stability and prevent falls to the left, the body lurches to the right side and shifts the center of gravity over the stance side (i.e., right hip). The top of the greater trochanter telescopes upward and mechanically hitches on the ilium to stabilize the joint. This movement at every stance phase is called the Trendelenburg gait. 14

Radiographic Examination

Radiographs of newborns with suspected DDH are of limited value because the femoral heads do not ossify until four to six months of age. Ultrasonography is the study of choice to evaluate for DDH in infants younger than six months because it is capable of visualizing the cartilaginous anatomy of the femoral head and acetabulum. 15 – 17 It is useful in identifying dysplasia of the cartilaginous portion of the acetabulum, confirming subluxation of the hip, and documenting reducibility and stability of the hip in the infant undergoing treatment for known DDH. Ultrasonography is overly sensitive as a screening tool in the first six weeks of life, and in general should not be ordered until after that. 18

Plain radiographs are useful after four to six months of age. Several reference lines and angles are useful in evaluating the anteroposterior radiograph of the infant’s pelvis ( Figure 5 ) . Hilgenreiner’s line is drawn horizontally through the triradiate cartilages of the pelvis. Perkin’s line is drawn perpendicular to Hilgenreiner’s line at the lateral edge of each acetabulum. The femoral head should lie within the inferomedial quadrant formed by Hilgrenreiner’s and Perkin’s lines. In a dysplastic hip, the lateral edge of the acetabulum may be difficult to identify, and the femoral head may lie in the superior or lateral quadrants.

Shenton’s line is curvilinear. It is defined by the medial border of the femoral neck and the superior border of the obturator foramen. A break in Shenton’s line suggests displacement of the femoral head from the bony acetabulum ( Figure 5 ) .

The U.S. Preventive Services Task Force (USPSTF) recently concluded that evidence is insufficient to recommend routine screening for DDH in infants as a means to prevent adverse outcomes. Evidence shows that screening leads to earlier identification of DDH; however, the USPSTF concluded that 60 to 80 percent of the newborn hips identified by physical examination and more than 90 percent identified by ultrasonography as abnormal or as suspicious for DDH resolve spontaneously and require no intervention. 19

The goal of treatment in DDH is to achieve and maintain reduction of the femoral head in the true acetabulum by closed or open means. The earlier treatment is initiated, the greater the success and the lower the incidence of residual dysplasia and long-term complications.

Subluxation of the hip at birth often corrects spontaneously and may be observed for two weeks without treatment. The double- or triple-diaper technique, which theoretically prevents hip adduction, has not demonstrated improved results when compared with no intervention at all. When subluxation persists beyond two weeks of age, treatment is indicated and the appropriate referral should be made. 12

In newborns and infants up to six months of age, closed reduction and immobilization in a Pavlik harness is the treatment of choice ( Figure 6 ) . The Pavlik harness dynamically positions the hips in flexion and abduction while allowing motion. Avascular necrosis of the femoral head has been reported with Pavlik harness treatment and may be related to hyperabduction. 20 In addition, hyperflexion has the potential to cause femoral nerve palsies.

Reduction of the hip should be confirmed by ultrasonography within three weeks of harness placement. Treatment usually is continued for at least six weeks full-time and six weeks part-time in young infants, and possibly longer in older children. The end point of brace treatment is a stable hip with normal imaging studies. If a dislocated hip is not reduced within three weeks, the harness should be discontinued and an alternative treatment selected. This usually involves closed reduction under anesthesia with hip spica casting ( Figure 7 ) . 21

The long-term results of Pavlik harness treatment (e.g., nonoperative treatment) show a 95 percent success rate for acetabular dysplasia and subluxation. 22 , 23 The success rate drops to 80 percent for frank dislocation.

In children older than six months, closed reduction under general anesthesia and hip spica casting is the treatment of choice. Postoperative computed tomography or magnetic resonance imaging should be used to confirm concentric reduction ( Figure 8 ) . 24 , 25 Immobilization in the hip spica cast after closed reduction usually continues for at least 12 weeks after closed reduction. 26

If the hip is irreducible by closed means, or a concentric reduction is not achieved, successful treatment requires open reduction. 27 Open reduction of the hip in a child with DDH involves lengthening tendons about the hip, removing obstacles to reduction, and tightening the hip capsule once reduction is obtained. Complications include femoral head osteonecrosis and redislocation. 28 Surgery becomes more technically demanding in older children with established dislocations. By 18 months, femoral osteotomies with or without pelvic osteotomies may be necessary to reconstruct and safely maintain the hip in a reduced position.

The goal of operative treatment of DDH is to normalize the hip joint to delay or prevent the premature onset of osteoarthritis. Intervention in early childhood, when remodeling potential is greater, provides the best opportunity for the development of a normal joint. 29 Children with untreated hip dysplasia have been shown to develop premature degenerative changes by the time they reach skeletal maturity, and develop painful arthritis in their thirties. 30 Children with hip dysplasia who are diagnosed in adolescence and undergo surgical treatment fare somewhat better but often require secondary procedures as adults for painful arthritis. 31

Joint-preserving salvage osteotomies and total hip arthroplasty are surgical options once a child has achieved skeletal maturity. Both procedures have mixed long-term results and are inferior to surgical treatment initiated at earlier ages. 32 , 33 Children in whom Pavlik harness treatment is initiated before six months of age have excellent results, although long-term studies are lacking. The majority have no symptoms of arthritis, with mild radiographic abnormalities by skeletal maturity. 34 , 35 A child with DDH usually requires long-term follow-up with radiographic evaluation until skeletal maturity is reached to ensure normal hip development. 36 – 38

In general, the goal of the family physician in examining for DDH should be early diagnosis and referral. This is because treatment earlier in life, especially within the first six months, is safer and more successful than treatment after the child is walking.

Barlow TG. Early diagnosis and treatment of congenital dislocation of the hip. Proc R Soc Med. 1963;56:804-6.

Gross RH, Wisnefske M, Howard TC, Hitch M. The Otto Aufranc Award Paper. Infant hip screening. Hip. 1982:50-67.

Tredwell SJ. Neonatal screening for hip joint instability. Its clinical and economic relevance. Clin Orthop Relat Res. 1992:63-8.

Bjerkreim I, Arseth PH. Congenital dislocation of the hip in Norway. Late diagnosis CDH in the years 1970 to 1974. Acta Paediatr Scand. 1978;67:329-32.

Haasbeek JF, Wright JG, Hedden DM. Is there a difference between the epidemiologic characteristics of hip dislocation diagnosed early and late?. Can J Surg. 1995;38:437-8.

Wynne–Davies R. Acetabular dysplasia and familial joint laxity: two etiological factors in congenital dislocation of the hip. A review of 589 patients and their families. J Bone Joint Surg Br. 1970;52:704-16.

Wilkinson JA. A post-natal survey for congenital displacement of the hip. J Bone Joint Surg Br. 1972;54:40-9.

Dunn PM. Perinatal observations on the etiology of congenital dislocation of the hip. Clin Orthop Relat Res. 1976;119:11-22.

Salter RB. Etiology, pathogenesis and possible prevention of congenital dislocation of the hip. Can Med Assoc J. 1968;98:933-45.

Skirving AP, Scadden WJ. The African neonatal hip and its immunity from congenital dislocation. J Bone Joint Surg Br. 1979;61–B:339-41.

Coleman SS. Congenital dysplasia of the hip in the Navajo infant. Clin Orthop Relat Res. 1968;56:179-93.

Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. American Academy of Pediatrics. Clinical practice guideline: early detection of developmental dysplasia of the hip. Pediatrics. 2000;105(4 pt 1):896-905.

Ortolani M. Congenital hip dysplasia in the light of early and very early diagnosis. Clin Orthop Relat Res. 1976;119:6-10.

Perry J. Pathologic gait. Instr Course Lect. 1990;39:325-31.

Graf R. New possibilities for the diagnosis of congenital hip joint dislocation by ultrasonography. J Pediatr Orthop. 1983;3:354-9.

Harcke HT, Grisson LE. Performing dynamic sonography of the infant hip. AJR Am J Roentgenol. 1990;155:837-44.

Harding MG, Harcke HT, Bowen JR, Guille JT, Glutting J. Management of dislocated hips with Pavlik harness treatment and ultrasound monitoring. J Pediatr Orthop. 1997;17:189-98.

Godward S, Dezateux C. Surgery for congenital dislocation of the hip in the UK as a measure of outcome screening. MRC Working Party on Congenital Dislocation of the Hip. Medical Research Council [Published correction appears in Lancet 1998;351:1664]. Lancet. 1998;351:1149-52.

U. S. Preventive Services Task Force. Screening for developmental dysplasia of the hip: recommendation statement. Pediatrics. 2006;117:898-902.

Suzuki S, Kashiwagi N, Kasahara Y, Seto Y, Futami T. Avascular necrosis and the Pavlik harness. The incidence of avascular necrosis in three types of congenital dislocation of the hip as classified by ultrasound. J Bone Joint Surg Br. 1996;78:631-5.

Mubarak S, Garfin S, Vance R, McKinnon B, Sutherland D. Pitfalls in the use of the Pavlik harness for treatment of congenital dysplasia, subluxation, and dislocation of the hip. J Bone Joint Surg Am. 1981;63:1239-48.

Grill F, Bensahel H, Canadell J, Dungl P, Matasovic T, Vizkelety T. The Pavlik harness in the treatment of congenital dislocating hip: report on a multicenter study of the European Paediatric Orthopaedic Society. J Pediatr Orthop. 1988;8:1-8.

Cashman JP, Round J, Taylor G, Clarke NM. The natural history of developmental dysplasia of the hip after early supervised treatment in the Pavlik harness. A prospective, longitudinal follow-up. J Bone Joint Surg Br. 2002;84:418-25.

Smith BG, Millis MB, Hey LA, Jaramillo D, Kasser JR. Postreduction computed tomography in developmental dislocation of the hip: part II: predictive value for outcome. J Pediatr Orthop. 1997;17:631-6.

McNally EG, Tasker A, Benson MK. MRI after operative reduction for developmental dysplasia of the hip. J Bone Joint Surg Br. 1997;79:724-6.

Vitale MG, Skaggs DL. Developmental dysplasia of the hip from six months to four years of age. J Am Acad Orthop Surg. 2001;9:401-11.

Weinstein SL, Mubarak SJ, Wenger DR. Developmental hip dysplasia and dislocation: part II. Instr Course Lect. 2004;53:531-42.

Powell EN, Gerratana FJ, Gage JR. Open reduction for congenital hip dislocation: the risk of avascular necrosis with three different approaches. J Pediatr Orthop. 1986;6:127-32.

Lalonde FD, Frick SL, Wenger DR. Surgical correction of residual hip dysplasia in two pediatric age-groups. J Bone Joint Surg Am. 2002;84–A:1148-56.

Hartofilakidis G, Karachalios T, Stamos KG. Epidemiology, demographics, natural history of congenital hip disease in adults. Orthopedics. 2000;23:823-7.

Klisic P, Jankovic L, Basara V. Long-term results of combined operative reduction of the hip in older children. J Pediatr Orthop. 1988;8:532-4.

Migaud H, Chantelot C, Giraud F, Fontaine C, Duquennoy A. Long-term survivorship of hip shelf arthroplasty and Chiari osteotomy in adults. Clin Orthop Relat Res. 2004;418:81-6.

Chougle A, Hammady MV, Hodgkinson JP. Long-term survival of the acetabular component after total hip arthroplasty with cement in patients with developmental dysplasia of the hip. J Bone Joint Surg Am. 2006;88:71-9.

Fujioka F, Terayama K, Sugimoto N, Tanikawa H. Long-term results of congenital dislocation of the hip treated with the Pavlik harness. J Pediatr Orthop. 1995;15:747-52.

Tucci JJ, Kumar SJ, Guille JT, Rubbo ER. Late acetabular dysplasia following early successful Pavlik harness treatment of congenital dislocation of the hip. J Pediatr Orthop. 1991;11:502-5.

Lindstrom JR, Ponseti IV, Wenger DR. Acetabular development after reduction in congenital dislocation of the hip. J Bone Joint Surg Am. 1979;61:112-8.

Weinstein SL. Natural history of congenital hip dislocation (CDH) and hip dysplasia. Clin Orthop Relat Res. 1987;225:62-76.

Albinana J, Dolan LA, Spratt KF, Morcuende J, Meyer MD, Weinstein SL. Acetabular dysplasia after treatment for developmental dysplasia of the hip. Implications for secondary procedures. J Bone Joint Surg Br. 2004;86:876-86.

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• Breech delivery
• 1 Background
• 2 Clinical Features
• 3.1 Emergent delivery and related complications
• 4 Evaluation
• 5 Management
• 6 Disposition
• 8 External Links
• 9 References

• 3-4% of term deliveries. [1] (Most common fetal malpresentation [2] )
• In breech delivery, body does not first maximally dilate cervix → higher risk of head entrapment, cord prolapse, and death.
• Breech presentations occur most commonly in preterm infants (25-30% of preterm deliveries <28 wks gestation).

Clinical Features

• Frank - Buttocks deliver first, hips flexed, knees extended (most common type)
• Complete - Buttocks deliver first, hips and knees flexed
• Incomplete - (aka "footling") One or both feet deliver first

Differential Diagnosis

Emergent delivery and related complications.

• Emergent delivery
• Umbilical cord prolapse
• Shoulder dystocia
• Perimortem cesarean delivery
• In ED precipitous delivery, this is a clinical diagnosis.
• If time allows, ultrasound can reveal position of fetus, but often not possible in ED deliveries.
• Zavanelli maneuver - pushing presenting fetal part back into vagina until C-Section can be performed [3] , though is associated with increased risk of soft tissue damage and sepsis [4]
• Place patient in lithotomy position
• Have assistant maintain fundal pressure throughout delivery
• Grab legs together with one hand if feet deliver spontaneously
• Head will need to be delivered with baby's face looking to mother's posterior
• If not sacral anterior, make it that way along delivery
• Place hand behind and parallel to fetal leg, then sweep laterally (away from midline) to deliver leg
• Repeat for opposite leg
• If around the neck, try to reduce it by pushing it over baby's head or just deliver baby through quickly
• If between the legs, this must be reduced around the foot as it will definitely avulse if delivery continues
• Allow delivery to proceed spontaneously until fetal umbilicus is at perineum
• Once torso begins to deliver, hold legs in one hand and hold bony pelvis with other (do not rupture spleen)
• Allow delivery to progress until axilla is visible
• If posterior arm and hand do not deliver spontaneously, grasp humerus and sweep downwards while still applying upward traction on fetal body.
• If anterior arm and hand do not deliver spontaneously, grasp humerus and sweet downwards over thorax while maintaining downward traction on fetal body.
• To deliver head, have assistant apply suprapubic pressure and rest fetal body on provider's forearm while reaching into vaginal canal to grasp fetal maxillae in order to flex head. (Mauriceau maneuver) - stabilize with other hand/forearm on fetal back and shoulders - avoid excessive angulation or traction of fetal body.
• Nitroglycerin (50 to 200 mcg IV) is an alternative.

Disposition

• Admit to L&D

External Links

• YouTube: Assisted Breech Delivery
• ↑ 1.0 1.1 1.2 Silver DW, Sabatino F. Precipitous and difficult deliveries. Emerg Med Clin North Am. 2012 Nov;30(4):961-75. doi: 10.1016/j.emc.2012.08.004.
• ↑ 2.0 2.1 Mercado J, Brea I, Mendez B, et al. Critical obstetric and gynecologic procedures in the emergency department. Emerg Med Clin North Am. 2013 Feb;31(1):207-36.
• ↑ Timothy F Kirn. To Handle Breech Births, Know Two Maneuvers. ACEP News May 2008. ACEP News Accessed 08/03/15.
• ↑ Gabbe, Steven G. Obstetrics : normal and problem pregnancies (6th ed.). Philadelphia: Elsevier/Saunders. p. 412
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• 1 Creighton University School of Medicine
• 2 Creighton University
• PMID: 28846227
• Bookshelf ID: NBK448063

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The 3 types of breech presentation are frank, complete, and incomplete. In a frank breech, the fetus has flexion of both hips, and the legs are straight with the feet near the fetal face, in a pike position. The complete breech has the fetus sitting with flexion of both hips and both legs in a tuck position. Finally, the incomplete breech can have any combination of 1 or both hips extended, also known as footling (one leg extended) or double footling breech (both legs extended).

Copyright © 2024, StatPearls Publishing LLC.

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Conflict of interest statement

Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.

• Continuing Education Activity
• Introduction
• Epidemiology
• Pathophysiology
• History and Physical
• Treatment / Management
• Differential Diagnosis
• Pearls and Other Issues
• Enhancing Healthcare Team Outcomes
• Review Questions

Similar articles

• [What effect does leg position in breech presentation have on mode of delivery and early neonatal morbidity?]. Krause M, Fischer T, Feige A. Krause M, et al. Z Geburtshilfe Neonatol. 1997 Jul-Aug;201(4):128-35. Z Geburtshilfe Neonatol. 1997. PMID: 9410517 German.
• The effect of intra-uterine breech position on postnatal motor functions of the lower limbs. Sival DA, Prechtl HF, Sonder GH, Touwen BC. Sival DA, et al. Early Hum Dev. 1993 Mar;32(2-3):161-76. doi: 10.1016/0378-3782(93)90009-j. Early Hum Dev. 1993. PMID: 8486118
• The influence of the fetal leg position on the outcome in vaginally intended deliveries out of breech presentation at term - A FRABAT prospective cohort study. Jennewein L, Allert R, Möllmann CJ, Paul B, Kielland-Kaisen U, Raimann FJ, Brüggmann D, Louwen F. Jennewein L, et al. PLoS One. 2019 Dec 2;14(12):e0225546. doi: 10.1371/journal.pone.0225546. eCollection 2019. PLoS One. 2019. PMID: 31790449 Free PMC article.
• Breech vaginal delivery at or near term. Tunde-Byass MO, Hannah ME. Tunde-Byass MO, et al. Semin Perinatol. 2003 Feb;27(1):34-45. doi: 10.1053/sper.2003.50003. Semin Perinatol. 2003. PMID: 12641301 Review.
• [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. Mattuizzi A. Mattuizzi A. Gynecol Obstet Fertil Senol. 2020 Jan;48(1):70-80. doi: 10.1016/j.gofs.2019.10.027. Epub 2019 Nov 1. Gynecol Obstet Fertil Senol. 2020. PMID: 31682966 Review. French.
• Hinnenberg P, Toijonen A, Gissler M, Heinonen S, Macharey G. Outcome of small for gestational age-fetuses in breech presentation at term according to mode of delivery: a nationwide, population-based record linkage study. Arch Gynecol Obstet. 2019 Apr;299(4):969-974. - PubMed
• Schlaeger JM, Stoffel CL, Bussell JL, Cai HY, Takayama M, Yajima H, Takakura N. Moxibustion for Cephalic Version of Breech Presentation. J Midwifery Womens Health. 2018 May;63(3):309-322. - PubMed
• Niles KM, Barrett JFR, Ladhani NNN. Comparison of cesarean versus vaginal delivery of extremely preterm gestations in breech presentation: retrospective cohort study. J Matern Fetal Neonatal Med. 2019 Apr;32(7):1142-1147. - PubMed
• Grabovac M, Karim JN, Isayama T, Liyanage SK, McDonald SD. What is the safest mode of birth for extremely preterm breech singleton infants who are actively resuscitated? A systematic review and meta-analyses. BJOG. 2018 May;125(6):652-663. - PubMed
• Andrews S, Leeman L, Yonke N. Finding the breech: Influence of breech presentation on mode of delivery based on timing of diagnosis, attempt at external cephalic version, and provider success with version. Birth. 2017 Sep;44(3):222-229. - PubMed

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Breech Presentation

Management of the breech presentation, 1. what every clinician should know.

The breech presentation refers to a longitudinal lie where the presenting part is the breech pole, which can be constituted by the fetal buttocks, the thighs and/or the feet. It must be differentiated from a transverse lie, when the feet of the fetus might be extended into the lower uterine segment and cervix. In those cases the fetal head and breech pole would not be found in the uterine fundus but on the maternal flanks.

The vaginal breech delivery has two significant differences relative to the delivery of the fetus in a cephalic presentation:

In the vaginal breech delivery the largest segment of dystocia is delivered last (relative to the hips and the shoulders), setting up the potential for mechanical dystocia (particularly soft tissues).

Unlike the delivery in a cephalic presentation, in which the cord is protected until the onset of spontaneous respirations, it has been theorized that in the vaginal breech the appearance of the umbilical cord signals the onset of compression of the cord by the fetal head at the level of the pelvic brim.

These characteristics may potentially result in variable delays in the delivery of the fetal head and therefore in the transition of the fetus to the extrauterine environment. In addition to a higher rate of fetal anomalies and potentially some intrinsic factors to the breech presentation, these differences have been associated with higher rates of neonatal morbidity and mortality when compared to individuals presenting cephalic at the end of their pregnancies.

Terminology

Depending on what portion of the fetus is presenting, breech presentations have been divided into 3 broad groups:

Complete: Buttocks and feet are presenting and usually palpable by vaginal exam of the presentation when the cervix is dilated. It is also recognizable by imaging techniques (X-rays, U/S, CT or MRI)

Incomplete: Includes a variety of possibilities involving various degrees of flexion or extension of one or both thighs and one or both lower legs. The most common incomplete breech is called “frank” breech, in which only the fetal buttocks are presenting (both thighs are flexed over the trunk and both lower legs are extended). This can be recognizable by the vaginal exam or imaging techniques.

Footling: Only the fetal feet are presenting. This can be recognized by the vaginal examination or imaging techniques. Care must be exerted in calling a footling presentation as the lower legs might be extended from a complete breech presentation.

The diagnostic and guiding point of the breech presentation is the fetal sacrum, palpable as a firm triangle, the base of which is continuous with the fetal spine. Its orientation in the pelvis is described with the guiding point and the corresponding location of the maternal pelvis.

(RSA stands for right sacrum anterior, referring to the location on the pelvis of the guiding point: the fetal sacrum.)

Predisposing factors

The factors contributing to breech presentation can be separated in three large groups, which may coexist:

Gestational age (prematurity)

Multiple gestations

Anomalies (CNS in particular)

Placenta previa

• Extraovular

Uterine anomalies

Polyhydramnios

2. Diagnosis and differential diagnosis

Diagnostic criteria.

In non-obese patients abdominal palpation may yield enough information regarding the fetal lie and presentation starting at approximately 30 weeks gestation.

On palpation of the lower uterine segment the breech pole is larger, softer and irregular when compared to the cephalic pole (smaller, harder and regular). The breech pole is usually not ballotable.

The digital exam reveals the absence of structures consistent with a fetal head (hard parietal bones, suture and fontanelles) and the presence of a softer ill-defined mass. The palpation of feet (if complete breech) facilitates the diagnosis. The palpation of a chin, nose and orbits will assist in the differentiation of this presentation from a face or brow presentation.

The intergluteal groove can rarely be confused with the sagittal suture. Clinically one of the edges of the intergluteal leads to the fetal gender and anus and finishes in a solid triangle (the fetal sacrum) which is continuous with the fetal spine. The absence of fontanelles and the palpation of the sacrum should alert to the fetal presentation being breech.

Particular care should be taken when palpating to avoid the fetal gender, as repeat examinations have been associated with edema, bruising and, exceptionally, testicular necrosis.

From an imaging standpoint it is important to determine the fetal size, the presence or absence of fetal anomalies, the location of the placenta, the possibility of uterine abnormalities and, if close to term, the flexion of the head. The identification of a loop of cord below the presentation (cord procubitus) is probably worth reporting.

Near term the plane of the fetal face and that of the cervical spine are compared by ultrasound. In the flexed fetus the plane of the face will be parallel to the cervical spine or at an acute angle inferiorly. In the stargazing fetus the plane of the fetal face will be at right angles with the angle of the cervical spine (the plane of the fetal face is perpendicular to the longitudinal axis of the patient).

The assessment of the flexion can also be performed by other imaging modalities (X-ray, CT, MRI) but they are rarely necessary.

Abdominal palpation: After 30 weeks in most patients the Leopold maneuvers would assist in the diagnosis of fetal lie (longitudinal; oblique or transverse) and fetal presentation (cephalic or breech). The cephalic pole is smaller, harder and more regular to palpation than the breech pole (softer, larger and irregular).

Vaginal examination: With some cervical dilatation the diagnosis of a breech presentation is made with the identification of the sacrum as the guiding and diagnostic point. The palpation of feet would make the difference between a frank breech (no feet palpable), a complete breech (feet and sacrum palpable) or a footling (feet but no sacrum palpable)

Paraclinical

Ultrasound and MRI

US and MRI allow for the evaluation of the fetal attitude (and therefore the different modalities of the breech), flexion of the fetal head and its dimensions, and the presence of anomalies potentially associated with the breech presentation.

• Differential diagnosis

Oblique or transverse lie. Some fetuses will present as footling breech presentations when the legs are extended in the low uterine segment and cervix. Abdominal palpation and a transabdominal sonogram would provide the correct diagnosis by locating the breech pole.

3. Management

Contraindications to labor include:

Funic (cord) presentation.

Fetal growth restriction or macrosomia (estimated fetal weight between 2500 and 4000 g).

Any presentation other than a frank or complete breech with a flexed or neutral fetal head attitude.

Fetal anomaly incompatible with a vaginal delivery.

Labor management

Factors regarded as unfavorable for vaginal breech birth include:

Other contraindications to vaginal birth (e.g. placenta previa, compromised fetal condition).

Clinically inadequate pelvis.

Footling or kneeling breech presentation.

Large baby (usually defined as larger than 3800 g).

Growth-restricted baby (usually defined as smaller than 2000 g).

Hyperextended fetal neck in labor (diagnosed with ultrasound or X-ray where ultrasound is not available).

Lack of presence of a clinician trained in vaginal breech delivery.

Previous caesarean section.

Decreasing the incidence

Considering the higher morbidity associated with the vaginal delivery of a breech baby, different strategies have been used to decrease the possibility of a breech presentation at delivery. The most important are:

External cephalic version (ECV)

Term pregnancy.

The manipulation of the presentation through the maternal abdomen can effectively change the fetal lie from transverse to longitudinal and from breech to cephalic. This is accomplished by one or two operators by identifying the existent lie and exerting gentle external manipulation to slide the fetus within the uterus to adopt a cephalic presentation.

Technique of ECV

The key steps of the procedure are:

The elevation of the presentation (to disengage the breech into the abdomen).

The compression of the lie (to reduce the size of the fetus and promote flexion of the head).

The version.

Much debate has been given whether to use forward or backward flips. Backward flips (towards the fetal spine) promote flexion but may be harder to do.

Contraindications to an ECV

Where CD delivery is required for other reasons.

Antepartum hemorrhage within the last 7 days.

Abnormal EFM tracing.

Major uterine anomaly.

Ruptured membranes.

Multiple pregnancies (except delivery of second twin).

Fetal anomalies.

Oligohydramnios. The AFI below which the success of ECV is decreased is approximately 10. The success of ECV is approximately 50-60% (40% for nulliparous, and 60% for multiparous women)

Small-for-gestational-age fetus with abnormal Doppler parameters.

Proteinuric pre-eclampsia.

Oligohydramnios.

Major fetal anomalies.

Scarred uterus. The available data on ECV after one cesarean section are reassuring but are insufficient to confidently conclude that the risk is not increased.

Potential complications include fetal bradycardia (usually transient) or abnormalities in the EFM (approximately 3%), rupture of membranes, abruption placentae, cesarean section for fetal bradycardia and uterine rupture. Rarely fetal fractures have been reported. The risk of undergoing an emergency C/S is approximately 0.5%. About 3% rate of fetuses will revert after a successful version and 3% of the failed ECV will turn spontaneously.

ECV should be performed where ultrasound to enable fetal heart rate visualization, cardiotocography and theatre facilities are available. Cardiotocography should be performed after the procedure. Kleihauer testing is unnecessary but anti-D immunoglobulin is normally offered to Rh(D) negative women. RCOG does not recommend fasting, anesthetic premedication or intravenous access before the versions.

The technique of ECV is facilitated by the use of tocolytics and maternal analgesia (including regional anesthesia). Lubrication of the maternal skin with powder or gel facilitates the external movements. A bedside sonogram can assist in the success of the interventions and to monitor the fetus during the procedure.

In a meta-analysis of the methods contributing to the success of ECV, tocolytics, in particular beta agonists, were effective in increasing cephalic presentations in labor (average risk ratio (RR) 1.38, 95% confidence interval (CI) 1.03-1.85, eight studies, 993 women) and in reducing the number of caesarean sections (average RR 0.82, 95% CI 0.71-0.94, eight studies, 1,177 women).

There were insufficient data comparing different groups of tocolytic drugs. Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone in terms of increasing successful versions (assessed by the rate of failed ECVs, average RR 0.67, 95% CI 0.51-0.89, six studies, 550 women) but there was no difference identified in cephalic presentation in labor (average RR 1.63, 95% CI 0.75-3.53, three studies, 279 women) nor in caesarean sections (average RR 0.74, 95% CI 0.40-1.37, three studies, 279 women).

Results of ECV

A meta-analysis including seven studies and 1,245 women concluded that the use of external cephalic version was associated with a statistically significant reduction in non-cephalic birth (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.31-0.66); and cesarean section (RR 0.63, 95% CI 0.44-0.90). This reduction is in spite of a two-fold increase in intrapartum caesarean sections for successfully turned babies when compared with babies that were not breech at term. This is independent of an increased induction rate: Both fetal and maternal indications for intervention are implicated. A small increase in instrumental delivery is also seen.

Comparing verted and non-verted infants there were no significant differences in the incidence of Apgar score ratings below seven at 1 minute (two trials, 108 women; RR 0.95, 95% CI 0.47-1.89) or 5 minutes (four trials, 368 women; RR 0.76, 95% CI 0.32-0.77), low umbilical artery pH levels (one trial, 52 women; RR 0.65, 95% CI 0.17-2.44), neonatal admission (one trial, 52 women; RR 0.36, 95% CI 0.04-3.24) or perinatal death (six trials, 1053 women; RR 0.34, 95% CI 0.05-2.12).

If an ECV fails a second attempt may lead to a small increase in overall success rates and tocolysis may increase the success rate of a second attempt if it has not been used first. Other methods employed to increase success rates include the application of fetal acoustic stimulation where the back is in the midline, and regional analgesia. For the latter, an increase in success rate is evident with epidural but not spinal analgesia.

Preterm pregnancy

ECV before 36 weeks of gestation is not associated with a significant reduction in noncephalic births or cesarean section. Performing ECV’s at 34-35 weeks versus 37 or more increases the likelihood of cephalic presentation at birth but does not reduce the rate of C/S and may increase the rate of preterm birth. ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women. The RCOG recommends performing ECVs from 36 weeks in nulliparous women and from 37 weeks in multiparous women.

Moxibustion and acupuncture

Moxibustion (a treatment method of traditional Chinese medicine) involves the burning of a herb (Artemisia vulgaris) close to the skin to induce a warming sensation. Anecdotal evidence suggests that moxibustion to a certain acupuncture point located at the tip of the fifth toe, may correct breech presentation. The mechanism of action has not yet been determined. Treatment regimens vary and there is no consensus on the best regimen, but moxibustion may be administered for 15-20 minutes, from one to 10 times daily, for up to 10 days. In a meta-analysis of eight trials involving 1,346 women and compared with no treatment, moxibustion was not found to reduce the number of non-cephalic presentations at birth (P = 0.45).

One trial on 226 women by Neri and colleagues evaluated the use of moxibustion plus acupuncture versus no treatment found a reduction of non-cephalic presentation at birth in the treatment group (RR 0.73, 95% CI 0.57-0.94). A meta-analysis of three trials on 470 women moxibustion plus postural technique found a reduction in the number of women with non-cephalic presentation at birth compared with postural technique alone (RR 0.26, 95% CI 0.12-0.56; random-effects analysis, T² = 0.32, I² = 68%).

The authors of these meta-analyses concluded that there is a need for well-designed randomized controlled trials to evaluate moxibustion for breech presentation which report on clinically relevant outcomes as well as the safety.

Postural management (“breech exercises”)

Many postural techniques have been used by midwives, doctors and traditional birth attendants to promote cephalic version. The rationale of these techniques is to promote the natural version of the fetus by relaxing the pelvis in an elevated position. In 1982 Elkins reported on the use of the knee-chest position (15 minutes every two hours of waking for five days). Chenia and colleagues (1987) modified Elkins’s procedure to be used three times a day for seven days with a full urinary bladder. In Bung’s report (1987) women were encouraged to lie down once or twice a day for 10-15 minutes in the supine, head-down position with the pelvis being supported by a wedge-shaped cushion.

In a meta-analysis of the published evidence by Hofmeyr, including 6 studies involving a total of 417 women, the rates for non-cephalic births and Cesarean section were similar between the intervention and control groups (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.84-1.15; RR 1.10; 95% CI 0.89-1.37. The authors concluded that there is insufficient evidence from well-controlled trials to support the use of postural management to decrease the rate of breech presentation at the time of delivery.

Vaginal versus cesarean delivery

Evidence for one route versus the other

A systematic review of randomized trials comparing a policy of intended cesarean delivery (CD) with a policy of intended vaginal birth included three trials with 2,396 participants. Caesarean delivery occurred in 1060/1169 (91%) of those women allocated to planned caesarean section and 550/1227 (45%) of those allocated to a vaginal delivery (VD) protocol. Perinatal or neonatal death (excluding fatal anomalies) or short-term neonatal morbidity was reduced with a policy of planned CD (RR 0.33, 95% CI 0.19-0.56) and perinatal or neonatal death alone (excluding fatal anomalies) was reduced with a policy of planned CD (RR 0.29, 95% CI 0.10-0.86). Most of the data for the review were contributed by the Term Breech Trial (TBT).

After excluding footling or uncertain type of breech presentation at delivery, labors that were induced or augmented with oxytocin or prostaglandins, deliveries associated with prolonged labor and those cases for whom there was no skilled or experienced clinician present at the birth, the risk of the combined outcome of perinatal mortality, neonatal mortality or serious neonatal morbidity with planned CD compared with planned VD was still lower: 16/1006 (1.6%) vs. 23/704 (3.3%) (RR 0.49; CI 0.26-0.91); P = 0.02).

Based on the existing evidence women should be informed that a planned CD carries a reduced composite outcome (perinatal mortality and early neonatal morbidity) for babies with a breech presentation at term compared with planned VB. The magnitude of those risks should be provided.

Mortality was not significantly different (3 of 511 or 0.6%) in the planned vaginal delivery group compared with zero in the planned caesarean group. One of these deaths, included in the intention to treat analysis, occurred before the onset of labor in a cephalic twin weighing 1150 g, highlighting concerns about the adequacy of case selection.

The impact of the trial’s results was due primarily to an excess of short term morbidity in the planned vaginal delivery group. In the TBT, the end point included perinatal mortality and various short term morbidities, including hypotonia, transient brachial plexus injury, and isolated low arterial cord pH or base excess, whose lasting significance is unclear. In countries with low perinatal mortality, this combined end point occurred in 5.7% of planned vaginal deliveries and 0.4% of women undergoing elective caesareans.

On the other hand, couples should also be informed that there is no evidence that the route of delivery influences the long term health of breech-presenting infants delivered at term.

A number of questions were raised following publication of the Term Breech Trial, largely about selection criteria and the conduct of labor.

At that time there was evidence available to indicate that different strategies would eliminate the benefits of planned caesarean section for the baby. Inconsistencies in the care of women in the Term Breech Trial have also been criticized; however, multiple subgroup analyses failed to identify any group for which the benefit of planned caesarean section was eliminated.

For complex phenomena, a large, randomized, multicenter trial does not overrule demonstrated safety. Since publication of the term breech trial, the onus has been placed on individual obstetrical units to retrospectively examine their experience with vaginal breech delivery and to show safety. Several have done so and continue to offer vaginal breech delivery. Safety in these specific centers is due to heterogeneity of human skill, not to statistical anomaly, and vaginal breech delivery in those units should be studied and emulated.

Selection criteria for a vaginal breech birth

Willing and cooperative mother.

Normal size fetus (2500-4000 g).

No congenital anomalies* (relative).

Adequate pelvis.

No obstetrical contraindications for vaginal delivery.

Appropriate setting to perform neonatal resuscitation and a cesarean delivery.

*The vaginal delivery of an anomalous fetus might be the alternative for delivery in cases where fetal survival is not expected (Potter syndrome for example).

• Management of a vaginal breech

During labor

Intravenous access is desirable. Oxytocin can be used for augmentation. Continuous electronic fetal monitoring is recommended as these fetuses may require a cesarean delivery for fetal indications. Meconium may appear in the active phase and is a sign of anal patency and compression of the fetal trunk in the birthing canal and not of fetal compromise.

The mother can be transferred to the Delivery Room (or Operating Room) once the presentation is distending the perineum.

Delivery technique

The delivery should ideally take place in the Operating Room with the availability of a Surgical Team, including an anesthesiologist and a surgical technician. A double setup is desirable. A conflict exists between the need to deliver the baby rapidly to avoid progressive acidosis and the need to avoid trauma due to a hasty delivery. It has been speculated that progressive acidosis during the period from exposure of the umbilical cord to delivery of the aftercoming head may be reduced by expediting the cord-to-head delivery time to occur during a single contraction. At this time there is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

The keys to a successful vaginal delivery of a fetus in breech presentation are:

Good maternal positioning in the delivery bed (enough clearance is needed in front of the perineum to effect downward traction of the presentation).*

Avoid pulling the presentation until the delivery of the cord insertion.

The creation of a loop of cord to facilitate the rest of the delivery (by gentle downward traction on the visible cord).

The appropriate obstetric manipulation of the fetal long bones (flexion or stabilization of joints as appropriate).

The appropriate placement of the hands for the manipulation of the fetal trunk (on the fetal iliac wings, not the fetal ribs or lumbar muscles).

The gentle downward traction of the fetal trunk between delivery of segments of dystocia (hips and shoulders and between shoulders and head) to promote head flexion.

The constant communication with the delivering mother (to provide feedback and direct pushing efforts when needed).

The availability of forceps for the possibility of assisting the delivery of the aftercoming head.

The availability of supporting personnel including a Pediatric/Neonatal Team proficient in resuscitation, should assistance in the neonatal transition be required.

Good documentation in the form of a predelivery note (including the assessment of the fetus, maternal pelvis and informed consent) and a delivery note describing the maneuvers employed.

*If delivery is occurring imminently on a labor or hospital bed, rather than attempting to move the patient to a delivery area, assisting turning the patient 90 degrees so that she is perpendicular to the bed might be the fastest way to prepare for the vaginal delivery of a breech.

Use of forceps

Piper forceps, Laufe forceps or Kielland forceps can be used to assist the delivery of the aftercoming head on a breech. Their presence in the delivery room is recommended. Most fetuses in breech presentation would be in the equivalent of an occipito anterior presentation. The forceps application is a direct anterior with the operator standing (or kneeling) under the presentation.

The utilization of forceps requires an assistant to hold the fetal trunk and limbs to allow the obstetrician to place forceps blades. During this maneuver attention needs to be made not to elevate the fetal body beyond the horizontal plane as this elevation could promote deflexion and make the forceps application and the fetal extraction more difficult.

After locking the blades the fetus can be laid on the forceps shanks to complete the delivery. The mechanism of delivery of the fetal head in a breech (unlike that of most cephalic presentations) is by flexion and the forceps needs to be elevated slightly.

Special situations

Preterm infant

The preterm infant offers additional difficulties for the vaginal breech delivery. These are related to the higher head to body ratio when compared to a term infant, which facilitates not only a descent of the presentation through a partially dilated cervix but also contributes to potential head entrapment.

Previous cesarean section

A breech presentation is not an absolute contraindication for a trial of labor and a vaginal birth after cesarean section. In this case the same conditions and precautions employed for the VBAC and for the breech presentation apply. An informed consent detailing both the risks of a trial of labor and a vaginal breech delivery is required.

Second twin

Non-cephalic presentation of the first twin (twin A), the second twin (twin B) or both twins occurs in about 60 % of all twin pregnancies.

The route of delivery of dichorionic diamniotic or monochorionic diamniotic is subject of controversy. According to the results of a Spanish study vaginal delivery is as safe as elective cesarean section in twin pregnancies when the first twin is in cephalic presentation and the intrapartum management should not vary due to chorionicity. One high-quality clinical trial (60 twin pairs) and 16 moderate/low-quality observational studies (3,167 twin pairs) showed no difference in neonatal outcome between vaginal and cesarean delivery in twin A and/or B. No final conclusion could be drawn by the authors of the meta-analysis due to the small sample sizes and statistic limitations of the included studies. Randomized studies with sufficient power are required to make a strong recommendation.

Increasing twin-to-twin delivery time does not seem to be associated with adverse fetal outcome. Expectant management of the second twin appears possible and elapsed time alone does not appear to be an indication for intervention.

4. Prognosis and outcome

Neonatal outcomes.

They include intracranial associated with tentorial tears, rupture of the liver or spleen, and fracture dislocation of the cervical spine. The manipulation of trunk and limbs in breech delivery may cause muscle damage, sometimes severe and associated with intramuscular coagulation, and there may also be evidence of the crush syndrome in other organs.

The incidence of minor childhood handicap following breech presentation has been found to be high (19.4%) and similar for those delivered following trial of labor and those following an elective caesarean section.

5. Training

Teaching vaginal breech delivery techniques to residents, fellows and other providers, including midwives and family physicians, should be an important educational task from academic institutions with simulation capabilities. For practitioners with active obstetrical practices encountering a breech presentation in labor is almost unavoidable.

The cognitive skills required to counsel woman, indicate and perform an ECV, manage labor, and deliver the fetus should be provided as a bundle of comprehensive breech presentation management.

• 6. What is the evidence for specific management and treatment recommendations

Hofmeyr, GJ, Kulier, R. “Cephalic version by postural management for breech presentation”. Cochrane Database of Systematic Reviews. 2012. pp. CD000051

Bung, P, Huch, R, Huch, A. “Is Indian version a successful method of lowering the frequency of breech presentations?”. Geburtshilfe und Frauenheilkunde. vol. 47. 1987. pp. 202-5.

Chenia, F, Crowther, CA. “Does advice to assume the knee-chest position reduce the incidence of breech presentation at delivery? A randomized clinical trial”. Birth. vol. 14. 1987. pp. 75-8.

Coyle, ME, Smith, CA, Peat, B. “Cephalic version by moxibustion for breech presentation”. Cochrane Database of Systematic Reviews. 2012. pp. CD003928

Neri, I, Airola, G, Contu, G, Allais, G, Facchinetti, F. “Acupuncture plus moxibustion to resolve breech presentation: a randomized controlled study”. Journal of Maternal-Fetal and Neonatal Medicine. vol. 15. 2004. pp. 247-52.

Hofmeyr, GJ, Kulier, R. “Expedited versus conservative approaches for vaginal delivery in breech presentation”. Cochrane Database of Systematic Reviews. 2012. pp. CD000082

Hofmeyr, GJ, Kulier, R. “External cephalic version for breech presentation at term”. Cochrane Database of Systematic Reviews. 2012. pp. CD000083

Cluver, C, Hofmeyr, GJ, Gyte, GML, Sinclair, M. “Interventions for helping to turn term breech babies to head first presentation when using external cephalic version”. Cochrane Database of Systematic Reviews. 2012. pp. CD000184

Collins, S, Ellaway, P, Harrington, D, Pandit, M, Impey, L. “The complications of external cephalic version: results from 805 consecutive attempts”. BJOG. vol. 114. 2007. pp. 636-8.

Nassar, N, Roberts, CL, Barratt, A, Bell, JC, Olive, EC. “Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term”. Paediatr Perinat Epidemiol. vol. 20. 2006. pp. 163-71.

Hutton, E, Hannah, M, Ross, S, Delisle, M, Carson, G. “for the 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. vol. 118. 2011. pp. 564-77.

Kayem, G, Goffinet, F, Clement, D, Hessabi, M, Cabrol, D. “Breech presentation at term: morbidity and mortality according to the type of delivery at Port Royal Maternity hospital from 1993 through 1999”. Eur J Obstet Gynecol ReprodBiol. vol. 102. 2002. pp. 137-42.

Giuliani, A, Schoell, W, Basver, A, Tamussino, K. “Mode of delivery and outcome of 699 term singleton breech deliveries at a single center”. Am J Obstet Gynecol. vol. 187. 2002. pp. 1694-8.

Alarab, M, Regan, C, O’Connell, MP, Keane, DP, O’Herlihy, C. “Singleton vaginal breech delivery at term: still a safe option”. Obstet Gynecol. vol. 103. 2004. pp. 407-12.

Copyright © 2017, 2013 Decision Support in Medicine, LLC. All rights reserved.

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Breech Presentation

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• Breech presentation : fetal head at uterine fundus, buttocks or feet over maternal pelvis; occurs in 3-4% of all fetuses in the UK.
• Aetiology : mostly idiopathic.
• Complete (flexed) breech : one or both knees flexed.
• Footling (incomplete) breech : one or both feet below fetal buttocks, hips and knees extended.
• Frank (extended) breech : hips flexed, knees extended; increased risk of developmental dysplasia of the hip.
• Maternal : multiparity, fibroids, previous breech, Mullerian duct abnormalities.
• Fetal : preterm, macrosomia, fetal abnormalities, multiple pregnancy.
• Placental : placenta praevia, polyhydramnios, oligohydramnios, amniotic bands.
• Breech common before 36 weeks, often asymptomatic, diagnosed incidentally.
• 20% breech at 28 weeks, 16% at 32 weeks, 3-4% at term.
• Longitudinal lie, head at fundus, irregular mass over pelvis, fetal heart auscultated higher, palpation of feet/sacrum at cervical os during vaginal examination.
• Investigations : ultrasound scan to confirm breech presentation and assess for abnormalities.
• External cephalic version (ECV) : manual rotation under ultrasound; success rate 40% in primiparous, 60% in multiparous; contraindications include antepartum haemorrhage, ruptured membranes, previous caesarean, major uterine abnormality, multiple pregnancy, abnormal CTG.
• Vaginal delivery : risks include head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse, trauma; contraindications include footling breech, macrosomia, growth restriction, other complications of vaginal birth, lack of trained staff, previous caesarean.
• Caesarean section : elective procedure at term, preferred for preterm babies, unsuccessful ECV, or maternal preference; fewer risks than vaginal delivery.
• Fetal complications : developmental dysplasia of the hip, cord prolapse, fetal head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality.
• ECV complications : transient fetal heart abnormalities, fetomaternal haemorrhage, placental abruption (rare).

Introduction

Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation).

The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses. 1

Breech presentation is most commonly idiopathic .

Types of breech presentation

The three types of breech presentation are:

• Complete (flexed) breech : one or both knees are flexed (Figure 1)
• Footling (incomplete) breech : one or both feet present below the fetal buttocks, with hips and knees extended (Figure 2)
• Frank (extended) breech : both hips flexed and both knees extended. Babies born in frank breech are more likely to have developmental dysplasia of the hip (Figure 3)

Risk factors

Risk factors for breech presentation can be divided into maternal , fetal and placental risk factors:

• Maternal : multiparity, fibroids, previous breech presentation, Mullerian duct abnormalities
• Fetal : preterm, macrosomia, fetal abnormalities (anencephaly, hydrocephalus, cystic hygroma), multiple pregnancy
• Placental : placenta praevia , polyhydramnios, oligohydramnios , amniotic bands

Clinical features

Before 36 weeks , breech presentation is not significant, as the fetus is likely to revert to a cephalic presentation. The mother will often be asymptomatic with the diagnosis being incidental.

The incidence of breech presentation is approximately 20% at 28 weeks gestation, 16% at 32 weeks gestation and 3-4% at term . Therefore, breech presentation is more common in preterm labour . Most fetuses with breech presentation in the early third trimester will turn spontaneously and be cephalic at term.

However, spontaneous version rates for nulliparous women with breech presentation at 36 weeks of gestation are less than 10% .

Clinical examination

Typical clinical findings of a breech presentation include:

• Longitudinal lie
• Head palpated at the fundus
• Irregular mass over pelvis (feet, legs and buttocks)
• Fetal heart auscultated higher on the maternal abdomen
• Palpation of feet or sacrum at the cervical os during vaginal examination

For more information, see the Geeky Medics guide to obstetric abdominal examination .

Positions in breech presentation

There are multiple fetal positions in breech presentation which are described according to the relation of the fetal sacrum to the maternal pelvis .

These are: direct sacroanterior, left sacroanterior, right sacroanterior, direct sacroposterior, right sacroposterior, left sacroposterior, left sacrotransverse and right sacrotranverse. 5

Investigations

An ultrasound scan is diagnostic for breech presentation. Growth, amniotic fluid volume and anatomy should be assessed to check for abnormalities.

There are three management options for breech presentation at term, with consideration of maternal choice: external cephalic version , vaginal delivery and Caesarean section .

External cephalic version

External cephalic version (ECV) involves manual rotation of the fetus into a cephalic presentation by applying pressure to the maternal abdomen under ultrasound guidance. Entonox and subcutaneous terbutaline are used to relax the uterus.

ECV has a 40% success rate in primiparous women and 60% in multiparous women . It should be offered to nulliparous women at 36 weeks and multiparous women at 37 weeks gestation. 

If ECV is unsuccessful, then delivery options include elective caesarean section or vaginal delivery. 

Contraindications for undertaking external cephalic version include:

• Antepartum haemorrhage
• Ruptured membranes
• Previous caesarean section
• Major uterine abnormality  
• Multiple pregnancy 
• Abnormal cardiotocography (CTG) 

Vaginal delivery

Vaginal delivery is an option but carries risks including head entrapment, birth asphyxia, intracranial haemorrhage, perinatal mortality, cord prolapse and fetal and/or maternal trauma.

The preference is to deliver the baby without traction and with an anterior sacrum during delivery to decrease the risk of fetal head entrapment .

The mother may be offered an epidural , as vaginal breech delivery can be very painful. 6

Contraindications for vaginal delivery in a breech presentation include:

• Footling breech: the baby’s head and trunk are more likely to be trapped if the feet pass through the dilated cervix too soon
• Macrosomia: usually defined as larger than 3800g
• Growth restricted baby: usually defined as smaller than 2000g
• Other complications of vaginal birth: for example, placenta praevia and fetal compromise
• Lack of clinical staff trained in vaginal breech delivery

Caesarean section

A caesarian section booked as an elective procedure at term is the most common management for breech presentation.

Caesarean section is preferred for preterm babies (due to an increased head to abdominal circumference ratio in preterm babies) and is used if the external cephalic version is unsuccessful or as a maternal preference. This option has fewer risks than a vaginal delivery. 

Complications

Fetal complications of breech presentation include:

• Developmental dysplasia of the hip (DDH)
• Cord prolapse
• Fetal head entrapment
• Birth asphyxia
• Intracranial haemorrhage
• Perinatal mortality

Complications of external cephalic version include:

• Transient fetal heart abnormalities (common)
• Fetomaternal haemorrhage
• Placental abruption (rare)

Miss Saba Al Juboori

Consultant in Obstetrics and Gynaecology

Miss Neeraja Kuruba

Dr chris jefferies.

• Oxford Handbook of Obstetrics and Gynaecology. Breech Presentation: Overview. Published in 2011.
• Jemimah Thomas. Image: Complete breech.
• Bonnie Urquhart Gruenberg. Footling breech. Licence: [ CC BY-SA ]
• Bonnie Urquhart Gruenberg. Frank breech . Licence: [ CC BY-SA ]
• A Comprehensive Textbook of Obstetrics and Gynaecology. Chapter 50: Malpresentation and Malposition: Breech Presentation. Published in 2011.
• Diana Hamilton Fairley. Lecture Notes: Obstetrics and Gynaecology, Malpresentation, Breech Presentation. Published in 2009.

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Developmental Dysplasia of the Hip (DDH): Etiology, Diagnosis, and Management

Khaled bakarman.

1 Pediatric Orthopaedics, King Saud University, Riyadh, SAU

Abdulmonem M Alsiddiky

2 Pediatric Orthopedics & Spinal Deformities, Research Chair of Spinal Deformities, King Saud University, Riyadh, SAU

Mohamed Zamzam

3 Pediatric Orthopedics, King Saud University, Riyadh, SAU

Kholoud O Alzain

4 Orthopedic Surgery, King Saud University, Riyadh, SAU

Fahad S Alhuzaimi

5 Orthopedics, King Saud University, Riyadh, SAU

Zulqurnain Rafiq

6 Orthopaedics, King Saud University, Riyadh, SAU

Developmental dysplasia of the hip (DDH) is a complex disorder that refers to different hip problems, ranging from neonatal instability to acetabular or femoral dysplasia, hip subluxation, and hip dislocation. It may result in structural modifications, which may lead to early coxarthrosis. Despite identifying the risk factors, the exact aetiology and pathophysiology are still unclear. Neonatal screening, along with physical examination and ultrasound, is critical for the early diagnosis of DDH to prevent the occurrence of early coxarthrosis. This review summarizes the currently practised strategies for the detection and treatment of DDH, focusing particularly on current practices for managing residual acetabular dysplasia (AD). AD may persist even after a successful hip reduction. Pelvic osteotomy is required in cases of persistent AD. It could also be undertaken simultaneously with an open hip reduction. Evaluation of the residual dysplasia (RD) of the hip and its management is still a highly active area of discussion. Recent research has opened the door to discussion on this issue and suggested treatment options for AD. But there is still room for more research to assist in managing AD.

Introduction and background

Developmental dysplasia of the hip (DDH) is a complex disorder that refers to different hip problems, including neonatal instability, acetabular, or femoral dysplasia, hip subluxation, and hip dislocation [ 1 - 3 ]. DDH has replaced the previous term 'congenital dislocation of the hip (CDH)' as several manifestations of DDH may not be detectable at the time of birth and may appear at a later stage [ 4 ]. Also, "congenital" has been replaced by "developmental" because the spectral range of the disease extended from acetabular dysplasia (AD) to complete dislocation [ 5 ].

Early detection and treatment are critical for improving pediatric quality of life. Delayed diagnosis and treatment at a later stage entail extensive surgery, which comes with greater difficulties and a worsened functional outcome [ 6 ]. Untreated dysplasia may lead to severe discomfort, pain, and osteoarthritis, requiring total hip arthroplasty [ 7 ]. Management is significantly influenced by the patient’s age and the severity of the dysplasia. The focus is on obtaining a concentric femoral head reduction and promoting acetabular and proximal femur development. A Pavlik harness or rigid abduction is used as the first step in early treatment for children. Patients who do not respond to brace treatment or present late require closed or open reduction (OR) and Spica casting. AD may persist even after a successful hip reduction. Pelvic osteotomy is required in cases of persistent AD. It could also be done simultaneously with an open hip reduction [ 2 , 5 ]. Evaluation of the residual dysplasia (RD) of the hip and its management is still a highly active area of debate. Recent research has provided insight into this issue and suggested treatment options for AD. But there is still room for further research to contribute to the better management of AD. This review describes the epidemiology, etiopathogenesis, and diagnosis of DDH and summarizes the current trends in managing recurrent AD.

The hip joint is made up of the acetabulum and proximal femur. The joint is comprised of the capsule, teres ligament, transverse ligament, and pulvinar. The acetabulum is a hemispherical complex structure in growing children formed by the pubis, ischium, and ilium. The acetabular outer surface is formed by horseshoe-shaped articular cartilage. The cartilage of the acetabulum continues medially as the triradiate cartilage, and together they form the acetabular cartilage complex [ 8 ]. The labrum is attached to the outer edge of the acetabulum, thereby increasing the acetabular depth and helping to keep the hip stable [ 9 ]. If the head of the femur is not directly connected to the acetabulum, the latter does not develop properly, becoming flat in its shape [ 10 ]. At birth, the proximal femur is entirely made up of cartilage. The cephalic nucleus begins to ossify at the age of six months, while the ossification of the trochanteric nucleus is initiated at the age of five to six years [ 11 ].

Dysplastic Changes in Hip

The growth changes affect all structures in the acetabulum, proximal femur, and soft components of the dysplastic hip. The aberrant pressure exerted on the labrum by a dislocated or subluxated femoral head promotes fibrocartilage hypertrophy and the formation of fibrous tissue. A labral inversion may be present in dislocated hips, which makes reduction difficult. The limbus, which could be everted or inverted, is the thickened labrum. In some cases, the hyaline cartilage in the acetabulum thickens in the posterosuperior region of the articular cartilage forming a crest, termed a neolimbus [ 12 ]. The neolimbus develops due to eccentric pressure exerted by the femur head, which is divided into two cavities: the primary acetabulum on the medial aspect and the secondary acetabulum present laterally. When the hip is reduced, the neolimbus disappears [ 13 ]. Several abnormalities are seen in the proximal femur, including a shortened femoral neck and a delay in the development of secondary ossification. The valgus and anteversion of the dysplastic femur are exaggerated. However, there is disagreement regarding femoral anteversion between the affected and unaffected sides [ 14 ].

Natural history

The term DDH may refer to one of four clinical patterns, including hip instability, AD, hip subluxation, and dislocation [ 3 ]. The Barlow and Ortolani maneuvers show that hip dysplasia produces instability in the first few months after birth. Hip instability is common in infants, with a prevalence of 1% to 1.5% and an incidence rate of 5 per 1,000 in boys and 13 per 1,000 among girls. A spontaneous improvement is observed in approximately 90% of children with mild instability during the first two months of life [ 15 ]. This spontaneous resolution is caused by a reduction in relaxin levels and an increase in muscle tone. Only 1.2% of neonatal hip instability occurrences necessitate surgical intervention [ 16 ]. Persistent DDH left untreated results in a sequence of anatomical alterations that alter the joint biomechanics by raising tension on a reduced-contact articular surface. The maintenance of increased articular pressures for lengthy periods promotes articular cartilage degradation and early coxarthrosis. However, there is a well-established link between AD and coxarthrosis [ 17 ]. On the other hand, in the case of subluxation coxarthrosis nearly always develops in the 30s and 40s for such patients [ 18 ]. In true dislocation, whether unilateral or bilateral, it depends on whether the femoral head articulates with the ilium or not. In the bilateral case, where the femur head has not articulated with the ilium, the individuals have pain-free, excellent range-of-motion, but they have a waddling gait, hyperlordosis, and back pain. If the femoral head articulates with the ilium at any point, these patients develop disabling degenerative joint disease and require arthroplasty very early in life. Patients with unilateral dislocation develop leg length discrepancy, an unsteady gait, valgus deformities of the knee, lateral compartment degenerative joint disease, and possibly secondary scoliosis.

Etiology and pathogenesis

The optimal growth of the hip joint depends upon two main factors: first, the concentric reduction of femoral head, and second, adequate balance of growth between acetabular and triradiate cartilages. Any imbalance in these, whether during fetal development or postnatal growth, will result in abnormal hip development. The dynamic femoral and acetabular interactions are crucial in the development of hip joint. The complex nature of this condition is due to a mix of genetic, environmental, and mechanical factors. Various etiological theories of DDH have been proposed in the literature, highlighting hormonal, mechanical, and genetic factors.

Risk Factors

The hormonal theory: The hormonal theory has a significant role in hip dysplasia development. It is based on an imbalanced ratio of estrogen to progesterone. A progesterone-rich environment can promote dislocation, whereas an estrogen-rich environment can inhibit it [ 15 ].

Fetal packaging deformity: The mechanical factors are usually related to restricted space in utero resulting in fetal packaging deformities. This could be seen in the first baby. The baby may be growing inside a horn of a bicornuate uterus where there is limited space. If the baby is relatively large, there may be a subsequent packaging deformity [ 12 ].

 Breech delivery: One of the most important mechanical factors that may be a risk for DDH is breech presentation at birth. A 25% risk of DDH exists for neonates born after being in the breech position. About 30 to 50% of patients with DDH have a history of breech delivery. During breech delivery, the hips and the knees are quite extended, and the subsequently increased flexion results in the contraction of the iliopsoas muscle, thereby further dislocating the joint [ 19 ].

Swaddling: In a newborn infant, the normal hip posture is flexion and abduction. The maintenance of acetabulo-femoral contact promotes hip growth. Although the majority of AD identified in neonatal hip ultrasound recovers spontaneously, swaddling may promote deformity in infants. DDH is more likely in situations where swaddling is a common practice [ 20 ]. Swaddling has gained popularity in several developed countries in recent years due to its benefits for improving newborn sleep. The traditional infant wrapping with the lower limbs extended and adducted among Saudi population has been proposed as a predisposition to hip dislocation and future progression to an unstable hip joint [ 21 ].

Familial predisposition: An inherited predisposition has been well-established in the literature. First-degree relatives have a 12 times greater risk of acquiring a DDH, but second-degree relationships have a relative risk of only 1.7 times. In cases of DDH familial aggregation, changes in genes such as CX3CR1 have been detected [ 22 ].

Hundt et al., in a meta-analysis, emphasized that only breech presentation, females, clicking hips during the examination, and being in a familial aggregation were found to increase the chance of developing DDH [ 23 ]. However, the majority of DDH patients and those who require treatment often do not exhibit any risk factors other than being female [ 24 ].

Clinical Examination

In newborns: All neonates, in particular those displaying the risk factors for DDH, should go through a thorough clinical assessment. The Ortolani test and the Barlow maneuver should both be included in routine screening, and each hip should be checked separately for instability [ 25 , 26 ]. For the physical examination, the infant should be laid down on a flat, warm surface in a quiet environment. In the Ortolani reduction test, the newborn should be placed in the supine position with hip flexion kept at 90 degrees (Figure ​ (Figure1A). 1A ). The examiner should then place his index and middle fingers on the lateral aspect of the baby's greater trochanter, while keeping his thumb medially at the groin crease. Thereafter, the stabilization of the pelvis is maintained by keeping the contralateral hip steady while the other hip is being evaluated. At the same time, an upward push is exerted through the greater trochanter laterally. Sensing a clunk is considered to be a positive result for the Ortolani test, indicating a dislocated and reducible hip. In the Barlow dislocation test, the first step is stabilizing the pelvis. The patient's position is maintained similarly to that for the Ortolani test, with the knee adducted. Then, a gentle downward force is exerted longitudinally along the femoral axis, identifying any possible posterior subluxation or dislocation by producing a palpable sensation (Figure ​ (Figure1B 1B ).

In older children: Examination of the extremities of infants and toddlers involves meticulous assessment of skin folds and/or discrepancies along the length of the legs that may occur in unilateral hip dislocation cases. Asymmetrical limitation abduction may also aid in the identification of children with hip dislocation. Hip dislocation can also be detected by a positive Galeazzi sign [ 27 ]. It is performed by laying the child in a supine position with the hips and knees flexed. An unequal height of the knees indicates a positive test. In neglected cases, when children reach walking age, they limp on the affected side, resulting in a positive Trendelenberg sign and hyperlordosis.

Ultrasonography: Because the head of the femur and acetabulum are predominantly composed of cartilage, standard radiographs have poor diagnostic value in neonates [ 28 ]. Ultrasonography is the investigation of choice for DDH in the first six months of life. It is more beneficial to evaluate subtle sub-types of the disorder when the clinical examination is inconclusive. Moreover, this is the only imaging mode that provides real-time 3D images of the hip joints of newborns. Other benefits include the avoidance of radiation, hip joint puncture, medium contrast, and sedation. It provides a detailed evaluation of the cartilaginous femoral head and demonstrates the relationship of the head to the bone as well as the cartilaginous acetabulum [ 28 ]. Graf et al. developed a strategy based on the morphological features of the hip, requiring the calculation of two angles: the alpha angle, between the ilium and the osseous acetabular wall, and the beta angle, between the ilium and the labral cartilage [ 29 ].

Radiography: The radiographic examination is a more useful method of evaluating hip development. Several classic lines on the X-ray of the immature pelvis guide the process of assessing DDH (Figure ​ (Figure2) 2 ) [ 30 ]. Hilgenreiner's line is a line joining both of the triradiate cartilages. The Perkins line extends along the lateral border of the acetabulum and is at right angles to the Hilgenreiner's line in a normal hip. The Shenton’s line contains a curvature that starts at the lesser trochanter, extends upwards towards the neck of the femur, and connects to a line along the inner margin of the pubis. In a normal hip, Shenton's line is smooth. This line is non-continuous when the affected hip is subluxated or dislocated. The angle formed at the intersection of Hilgenreiner’s line and the line drawn along the surface of the acetabulum is called the acetabular index. As the baby grows, this angle changes as well. It measures how much the roof of the acetabulum is inclined. This is the most frequently employed parameter in assessing the morphological features of the acetabulum. In normal newborns, this angle is 27.50 degrees, 23.50 degrees at six months, and progresses to 20 degrees at second birthday. Generally, 30 degrees is considered as normal upper limit and a notable increase in this value is considered a sign of AD [ 31 ].

However, it is important to consider the variations in normal indices among the various research papers. Moreover, the method used for the measurement of the acetabular index should be noted. Novais et al. and Tonnis both positioned the horizontal "Hilgrenreiner line" at the lower lateral iliac edge on the triradiate cartilage [ 28 , 32 ]. Novais et al. selected the lateral margin of the weight-bearing sourcil, whereas Tonnis used the lateral bony margin as shown in Figure ​ Figure3. 3 . However, disagreements on the landmark for the lateral margin persist.

The Wiberg centre-edge angle (CEA) is formed by the Perkin's line and the line from the centre of the femoral head to the lateral acetabulum. Due to the difficulty in locating the centre of the head of the femur, it exhibits significant variability in the initial three years of life. Among older children, it measures how much of the acetabulum covers the head of the femur. In children aged 3 to 17 years, an abnormal angle is one less than 15 degrees. On the other hand, angles greater than 25 degrees are categorized as normal among adults, while values under 20 degrees are regarded as abnormal [ 32 ]. Severin's classification evaluates the hip at maturity with a good correlation regarding long-term radiological, clinical, and functional hip results [ 33 ].

CT and MRI: CT is also among the imaging modalities used to assess reduction quality after closed or OR in a Spica cast [ 34 ]. CT contributes towards evaluating dysplasia in adolescents and young adults and allowing for better selection of the type of surgery required, such as pelvic or femoral osteotomies. A limited CT emits low ionizing radiation, although MRI is now successfully employed to eliminate radiation exposure [ 35 ]. MRI is considered as a predictor of AVN after closed reduction in DDH. In addition, MRI is also a useful tool in detection and assessment of labral abnormalities [ 35 ].

Arthrography: Arthrography is beneficial in the non-ossified skeleton because it facilitates the assessment of soft tissues and cartilages of the femoral head and acetabulum. As a result, it is frequently utilized as an intraoperative dynamic test to determine the quality of reduction and hip joint stability. It is critical in determining whether to use closed or OR [ 36 ].

Treatment of DDH

The aim of DDH treatment depends on the patient's age at the time of diagnosis and requires concentric reduction of the femoral head into the acetabulum (Figure ​ (Figure4) 4 ) [ 37 , 38 ].

DDH: Developmental dysplasia of the hip

Newborn to six months of age

Patients should ideally be diagnosed and managed during infancy. Hip subluxation, which is usually resolved spontaneously, can be observed for three weeks without any treatment. The commencement of treatment is recommended after three weeks if the evidence of subluxation on physical and ultrasonographic assessment is present [ 2 ]. When the hip joint is fully dislocated at the neonatal stage, it is advised to start treatment immediately. Hip reduction is easier, and the Pavlik harness is the most often used orthosis during this period. In most cases, hip reduction enables the acetabulum to normalize itself during this age. In the 1940s, Arnold Pavlik invented the "harness with stirrups" [ 38 , 39 ]. When the hip and knee are flexed with the hip in an abducted position while dynamic hip movements are enabled, the hip adduction contraction will relax and subsequently reduce spontaneously during abduction motions [ 2 , 38 ]. It is recommended to wear the Pavlik harness with the hips abducted between 30° and 60°. The major objective is to achieve spontaneous and painless realignment and to centralize the femoral head in children from neonatal age until the age of six to 10 months to achieve optimal structural and functional outcomes [ 2 ].

The Pavlik harness had a 95% success rate in cases of AD or hip subluxation and an 80% success rate in cases of hip dislocation [ 2 ]. The Pavlik harness is the most widely used approach in managing pediatric DDH from birth to six months, according to various publications, and it remains the standard treatment [ 27 , 36 , 38 ]. It is safe and extremely effective. Residual AD still poses a substantial challenge after the orthopaedic intervention. Another study reported that after successfully using closed reduction with the Pavlik harness, about 30% of patients had AD [ 38 , 40 ]. The harness is associated with a few complications that occur rarely if it is used appropriately. Avascular necrosis (AVN) of the femoral head is reported as the most serious complication and is associated with excessive abduction of the hip. Placing the harness such that the hips are flexed excessively may dislocate the joint in a downward direction or even result in femoral nerve palsy [ 2 ].

Persistent dysplasia or instability between six and 18 months

With increasing age, the hip reduction becomes more challenging and decreases the effectiveness of the Pavlik harness. If the hip reduction fails or the child is older than six months, then this is an indication for a closed or OR and Spica cast immobilization. Dynamic arthrography using fluoroscopy is recommended for evaluating the reduction quality to determine whether the reduction should be closed or open [ 2 , 5 , 9 ].

Closed Reduction

For children older than six months, a closed reduction and spica cast immobilization is indicated under general anaesthesia with the hips flexed at 90 to 100 degrees with well-controlled abduction. Immobilization should not be performed in an excessive hip abduction position. Serial radiographs are used to monitor hip development. It has been reported that the majority of patients who achieved successful closed reduction may require additional treatment after 18 months, as a sizable number of individuals had persistent AD, necessitating future acetabular osteotomies [ 41 ]. Forced close reduction in the presence of interposed structures leads to poor outcomes and an elevated risk for AVN [ 42 ].

Open Reduction

With age, the risk of OR increases. OR is recommended when closed reduction has failed to reduce the dislocated hip into a stable, concentric position. Although OR is challenging, concentric reduction promotes normalization in AD because of its growth potential [ 37 ]. Once OR is achieved, maintenance with a cast for three months facilitates hip stabilization.

Older than 18 months

When the hip dislocation is not detected early, secondary alterations take place in the soft tissues around the joint and subsequently in the proximal femur and the acetabulum. AD may still occur even if the reduction is carried out within the first few months of life. The potential of a dysplastic acetabulum to become normal diminishes with age [ 2 , 15 ]. Up to 19% of patients who had successful treatment with the Pavlik harness developed RD. Similar to this, persistent dysplasia may occur in 22% to 33% of patients who have had a closed or OR [ 43 , 44 ]. The age of the patient at the time of the surgery may have an impact on this variability [ 2 , 15 ]. With persistent hip dislocations, significant secondary adaptive alterations exacerbate the pathophysiology of hip dysplasia. Surgery is usually required to reconstruct the acetabulum and the femur, and the release of periarticular soft tissues is usually necessary for older children. When indicated, reconstruction measures may include a pelvic or femoral osteotomy [ 2 , 43 ].

Femoral osteotomies can facilitate reduction by shortening and reorienting the femoral head by derotation [ 45 ]. Osteotomy increases the varus of the hip joint to stabilize and stimulate acetabular growth and a reduction in the rate of osteonecrosis. These techniques are based on the controversial concepts of coxa valga and increased femoral anteversion. Subluxation of the hip is frequently believed to recur because of femoral anteversion, necessitating derotational osteotomy to maintain a stable hip reduction [ 40 ]. The indications for femoral derotational osteotomy are still unclear due to a lack of consensus. Although previous research suggests the common use of derotational osteotomy, studies done recently do not recommend this [ 46 ]. It has recently been recommended that, because of the inconsistency of femoral anteversion derotation osteotomy be performed on a case-by-case basis [ 46 ].

Pelvic osteotomy is recommended in cases where AD persists or is detected later in its development. Pelvic osteotomy facilitates the process by increasing the cover of the femoral head on the acetabular side. In recent years, there has been a trend to perform an acetabular intervention during primary treatment to optimize the chances of normal acetabular development [ 2 , 40 , 43 , 47 ]. Pelvic osteotomies can be organized into three subsets based on their intended effect on the acetabular morphology (Figure ​ (Figure5 5 ).

AD: Acetabular dysplasia

Redirectional Osteotomies 

Re-directional pelvic osteotomy shifts the position of the acetabulum while leaving its shape and volume unchanged [ 2 , 36 , 43 , 38 ]. Because these osteotomies are performed via complete cuts of the innominate bone, they are unstable and require stabilization with internal fixation. The three most commonly performed redirection osteotomies are the Salter, triple, and periacetabular osteotomies, commonly referred to as periacetabular osteotomy (PAO) (Figure ​ (Figure6 6 ).

(a) Salter’s osteotomy; (b) TIO; (c) periacetabular osteotomy; (d) evolution of the TIO, modification of ischial cuts, southerland (green dotted line); Carlioz (orange lines in pubic and ischial bones ); Steel’s (blue line); and Tonnis TIO (black lines) Bernes TIO (red line)

TIO: Triple innominate osteotomy

Reshaping Osteotomies

Reshaping osteotomies are ultimately aimed at achieving a congruently reduced femoral head and acetabulum [ 47 ]. These osteotomies are incomplete innominate osteotomies and are associated with high correction rates of AD as shown in Figure ​ Figure7. 7 . The objective of these osteotomies is to restore the acetabular morphology by changing the shape of a capacious and wandering acetabulum. The osteotomies consist of an incomplete opening wedge osteotomy in the peri-acetabular area held open with a bone graft that results in a change in the acetabular slope, shape, and volume. These are appropriately referred to as "acetabuloplasties" and are inherently stable; therefore, fixation is not necessary. The size, direction, and location of the opening wedge dictate the resulting change and acetabular coverage. These osteotomies rely on hinges through the triradiate cartilage and are therefore indicated only in skeletally immature patients. Three of the most commonly performed reshaping osteotomies are the Dega, San Diego, and Pemberton osteotomies. These osteotomies are quite similar in their approach and vary slightly concerning the extent to which the inner table is cut and how close the osteotomy is to the joint [ 43 , 48 ].

(a) Pemberton; (b) Dega; (c) San Diego osteotomies as viewed from the outer surfaces of the ilium

Salvage/Augmentation Procedures

Salvage osteotomies are utilized when concentric reduction may not be possible. The goal is to merely increase the weight-bearing surface of the hip. Numerous factors influence the choice of pelvic osteotomy in cases of DDH, including the surgeon's preference, the patient's age, and skeletal maturity, as well as the congruity, morphological features, and volume of the hip joint itself [ 2 , 47 ].

Salvage osteotomies are recommended in cases where the femoral head and the acetabulum may not be congruently reduced or where hyaline cartilage is insufficient for femoral head coverage. Such an osteotomy may also be appropriate in cases with a painful subluxated hip or previous failed surgical interventions [ 2 , 36 , 48 ]. These procedures aim to increase the weight-bearing surface area of the hip by causing metaplasia of hip capsular tissue into fibrocartilage. Two commonly utilized salvage procedures for the hip are the Chairi and Shelf osteotomies as depicted in Figure ​ Figure8 8 .

(a) a dysplastic acetabulum with deficient superior coverage; (b) the Chiari osteotomy; (c) shelf acetabuloplasty both improves superior coverage

Conclusions

Early diagnosis of DDH is critical for a favorable outcome. Newborns with DDH should be managed with a Pavlik harness until the age of six months. For children who have failed Pavlik harness treatment, a closed or OR is recommended. 18-month-old children should be treated by OR along with femoral or pelvic osteotomies where indicated. Post-surgical radiological follow-up is mandatory for residual AD, which is a frequently encountered complication of DDH treatment. Surgeons should highlight the importance of counselling parents about the possibility of RD and the requirements of additional surgeries following closed or OR. The decision to perform additional procedures depends on the patient's age, level of dysplasia, skeletal maturity, and acetabular deficiency.

The authors have declared that no competing interests exist.