breech presentation findings

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Breech presentation.

Caron J. Gray ; Meaghan M. Shanahan .

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Last Update: November 6, 2022 .

Continuing Education Activity

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. 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. This activity reviews the cause and pathophysiology of breech presentation and highlights the role of the interprofessional team in its management.

Describe the pathophysiology of breech presentation.
Review the physical exam of a patient with a breech presentation.
Summarize the treatment options for breech presentation.
Explain the importance of improving care coordination among interprofessional team members to improve outcomes for patients affected by breech presentation.
Introduction

Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. 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 one or both hips extended, also known as footling (one leg extended) breech, or double footling breech (both legs extended). [1] [2] [3]

Clinical conditions associated with breech presentation include those that 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 at term 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 28 weeks or less, 25% are breech.

Specifically, following one breech delivery, the recurrence rate for the second pregnancy was nearly 10%, and for a subsequent third pregnancy, it was 27%. Prior cesarean delivery has also been described by some to increase the incidence of breech presentation two-fold.

Pathophysiology

As mentioned previously, the most common clinical conditions or disease processes that result in the breech presentation are those that 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 is occupying the inferior portion of the uterine cavity. Therefore, the presenting part cannot engage
Uterine leiomyoma: Mainly larger myomas located in the lower uterine segment, often intramural or submucosal, that 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: Fetus is often in unstable lie, unable to engage
Oligohydramnios: Fetus is unable to turn to vertex due to lack of fluid
Laxity of the maternal abdominal wall: Uterus falls forward, the fetus is unable to 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%, while 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 ultrasound should be performed.

Diagnosis of a breech presentation can be accomplished through abdominal exam using the Leopold maneuvers in combination with the cervical exam. Ultrasound should confirm the diagnosis.

On ultrasound, the fetal lie and presenting part should be visualized and documented. If 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, there was no significant difference in maternal morbidity or mortality between the two groups. 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 two 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]

Since the TBT, many authors since have argued that there are still some specific situations that vaginal breech delivery is a potential, safe alternative to planned cesarean. Many smaller retrospective studies have reported no difference in neonatal morbidity or mortality using these specific 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 one 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 external cephalic version (ECV) to those patients that meet criteria, and for those whom are not candidates or decline external cephalic version, a planned cesarean section for delivery sometime after 39 weeks.

Regarding the premature breech, gestational age will determine the mode of delivery. Before 26 weeks, there is a lack of quality clinical evidence to guide 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, due to lack of recruitment, no prospective clinical trials are examining this issue.

Differential Diagnosis
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 and delivery nurse, anesthesiologist and a neonatologist. The ultimate decison rests on the obstetrician. To prevent complications, today cesarean sections are performed and experienced 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]

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

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

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Gray CJ, Shanahan MM. Breech Presentation. [Updated 2022 Nov 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Introduction

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

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

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

FUNDED: No external funding.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

World Health Organization Criteria for Screening for Health Problems

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

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

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

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

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

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

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

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

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

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

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

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

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

Positive family history

History of previous clinical instability

Parental concern

History of improper swaddling

Suspicious or inconclusive physical examination

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

American Academy of Orthopaedic Surgeons

American Academy of Pediatrics

avascular necrosis

developmental dysplasia of the hip

Pediatric Orthopaedic Society of North America

US Preventive Services Task Force

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

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

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

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

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

Brian A. Shaw, MD, FAAOS, FAAP

Lee S. Segal, MD, FAAP

Norman Y. Otsuka, MD, FAAP, Chairperson

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

Theodore John Ganley, MD, FAAP

Martin Joseph Herman, MD, FAAP

Joshua E. Hyman, MD, FAAP

Brian G. Smith, MD, FAAP

Niccole Alexander, MPP

Competing Interests

Re: breech presentation in preterm infants.

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

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

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

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

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

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

References:

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

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

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Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Lionel Carbillon ORCID: orcid.org/0000-0001-6367-4828 1 , 2 ,
Amelie Benbara 2 ,
Ahmed Tigaizin 2 ,
Rouba Murtada 2 ,
Marion Fermaut 2 ,
Fatma Belmaghni 2 ,
Alexandre Bricou 2 &
Jeremy Boujenah 2

BMC Pregnancy and Childbirth volume 20 , Article number: 263 ( 2020 ) Cite this article

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The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Peer Review reports

The ideal management of women with term breech presentation remains a matter of intense debate. The rate of vaginal delivery has steadily declined in the last decades of the last century [ 1 ]. In 2000, the Term Breech Trial (TBT) Collaborative Group concluded that a composite variable combining perinatal and neonatal mortality or serious neonatal morbidity was significantly lower in the planned caesarean section (CS) group than in the planned vaginal birth group [ 2 ], which marked an apparent turning point in this controversy. Based on the short-term outcomes presented in the TBT study, the Royal College of Obstetricians and Gynaecologists (RCOG) [ 3 ] and the American College of Obstetricians and Gynecologists (ACOG) [ 4 ] recommended over the next few years that all women with persistent singleton breech presentation at term should undergo a planned CS delivery. An important and almost immediate impact on the practice was also observed in some countries that previously had a high proportion of vaginal breech deliveries [ 5 ]. TBT was the largest randomized trial ever published on the term breech mode of delivery. However, despite its undeniable strengths, a number of weaknesses have been identified. Specifically, there was a lack of adherence to strict criteria for vaginal birth in an important proportion of the included patients and nonoptimal methods of labour management as recognized by the TBT group itself [ 6 , 7 , 8 ]. In addition, when the TBT Collaborative Group published the 2-year analysis of paediatric outcomes, despite a large (greater than 50%) post-randomization loss to follow-up [ 9 ], these researchers found no reduction in the risk of death or neurodevelopmental delay in children at 2 years of age, thus raising questions regarding the real lessons to be drawn from this trial. Using multiple logistic regression analyses, the TBT group also reported [ 10 ] that the risk of maternal morbidity was lowest following vaginal birth (odds ratio [OR] 1.0) and highest following CS after active labour (36.1% in the TBT) (OR 3.33; 95% CI 1.75–6.33, P < 0.001), particularly after a short second stage < 30 min (OR 0.25; 95% CI 0.11–0.57, P < 0.001) [ 9 ].

Later, population-based retrospective studies helped refine the consequences of applying recommendations of systematically planned CS for women with term breech presentation at the population level. Hartnack Tharin et al. [ 11 ] found that the rate of CS for term breech deliveries increased from 79.6 to 94.2% between 1997 and 2008 in Denmark, while intrapartum or early neonatal mortality decreased from 0.13 to 0.05% [relative risk (RR) 0.38 (95% CI 0.15–0.98)], which was a significant but lower reduction than the difference reported in the TBT. Using the Dutch National Perinatal Registry from 1999 to 2007, Vlemmix et al. [ 12 ] stated that after publication of the TBT, the elective CS rate increased from 24 to 60%, and overall perinatal mortality and short-term morbidity decreased. In contrast, these outcomes remained stable in the planned vaginal birth group. However, the authors estimated that 338 CS deliveries would need to be performed to prevent one perinatal death, and Schutte et al. [ 13 ] estimated the perinatal case fatality rate for elective CS for breech presentation in 2000–2002 at 0.47/1000 operations. At the same time, in the Netherlands the incidence of severe maternal morbidity (SMM) was estimated at 6.4/1000 during an elective CS compared with 3.9/1000 during an attempted vaginal delivery (OR 1.7; 95% CI 1.4–2.0), with an increased risk for SMM in the next pregnancy (OR 3.0; 95% CI 2.7–3.3) [ 14 ], despite the numerous facilities and adequate resources allocated to perinatal care in such a high-income country.

On the other hand, new guidelines were published in 2009 by the Society of Obstetricians and Gynaecologists of Canada (SOGC) stating that “planned vaginal delivery is reasonable in selected women with a term singleton breech foetus”. Afterwards, a study [ 15 ] including 52,671 breech deliveries in Canada (2003–2011) reported in 2011 that vaginal deliveries increased from 2.7% in 2003 to 3.9%. In this study, a concomitant increase in composite neonatal mortality and morbidity rates was observed with an adjusted rate ratio of 3.60 (95% CI 2.50–5.15), compared with CS without labour [ 15 ]. Moreover, CS with labour also increased from 8.7 to 9.8%, highlighting the particular difficulty in returning to previous practices after the clinical skills required to conduct a vaginal breech delivery have declined [ 15 , 16 ].

Some authors recently considered that “the TBT recommendations should be withdrawn” [ 6 ], while others still consider that the “results (of the TBT) are generalizable” [ 16 , 17 ]. Nevertheless, national guideline bodies have partially reversed their recommendations based on these discussions [ 18 , 19 , 20 ]. However, as rightly noted by Joseph et al. [ 16 ], the availability of clinical skills has declined in some of these countries, raising concerns from a pedagogic resident education and training standpoint [ 16 ]. In this regard, a meaningful role could be given to the possibility of training by simulation in building and maintaining specific skills and competencies for vaginal breech delivery.

A new meta-analysis [ 21 ] and several large-scale epidemiologic datasets from medical birth registries [ 22 , 23 , 24 ] recently evaluated risk factors associated with adverse perinatal outcomes in planned vaginal breech labours at term. These investigations were conducted in countries that have not abruptly modified their policies and that have continuously applied similar strict criteria over the last several decades for individual decision-making in cases of term breech presentation. We believe that the time has come to go beyond the sole question of delivery mode in the management of these situations.

Term breech presentation: are we asking the right questions?

It now appears time to expand our thinking and, considering recent important data that help elucidate the underlying significance of persistent breech presentation at term, to offer more dynamic and multidisciplinary insight into the management of these cases.

Indeed, similar to some older studies [ 25 , 26 , 27 ], several recent population-based studies [ 22 , 23 ] strongly suggest that the increased risk observed in foetuses that remain in the breech presentation at term is closely linked to antenatal or underlying disorders that may be associated with the breech presentation and is not solely due to the mode of delivery. Because adverse outcomes can be caused by underlying or gestational disorders, any discussion that is limited to delivery mode seems too restrictive and does not address the whole issue.

Most recent large-scale data

Deterministic or accidental breech presentation.

In a recent Finnish population-based case-control study including all singleton deliveries from 1 January 2005 to 31 December 2014 and excluding preterm deliveries, antepartum-diagnosed stillbirths, placenta previa and infants with congenital malformations (499,206 foetuses at term), Macharey et al. [ 22 ] evaluated the antenatal risk factors associated with adverse perinatal outcomes in planned vaginal breech labour at term. They found that the stillbirth rate was significantly higher in cases of planned vaginal breech labour than in cases of cephalic presentation (0.2 vs 0.1%, respectively), which was correlated with foetal growth restriction, oligohydramnios, gestational diabetes mellitus (GDM) and a history of CS. Furthermore, in another recent survey based on the same cohort of mother-neonate dyads that also excluded congenital malformations, placenta previa and prelabour stillbirths [ 23 ], this same group showed that breech presentation at term was significantly associated with antenatal stillbirth and a number of individual obstetric risk factors for adverse perinatal outcomes, including oligohydramnios, foetal growth restriction, gestational diabetes, history of CS section and congenital anomalies. Among all planned singleton vaginal deliveries with the foetus in the breech presentation at term, a composite adverse perinatal outcome defined as umbilical arterial pH < 7.00, 5-min Apgar score below 7 and/or neonatal mortality during the first 6 days of life (excluding stillbirth) was associated with foetal growth restriction (aOR 2.94 [1.30–6.67]), oligohydramnios (adjusted OR 2.94 [1.15–7.81]), gestational diabetes (aOR 2.89[1.54–5.40]), and a history of CS (aOR 2.94 [1.28–6.77]).

In another recent population-based study based on perinatal data of all (650,968) children born in Norway from 1999 to 2009 [ 24 ], the authors recognized the limitations of most registry-based studies, as the selection of women with breech presentation and planned vaginal delivery was based on criteria that might have identified pregnancies with a lower risk of adverse outcomes compared with those selected for CS delivery. Moreover, in this study [ 24 ], the intrapartum conversion of some of the planned vaginal deliveries to an emergency CS delivery may have increased the risk for adverse outcome in the CS group. However, Bjellmo et al. [ 24 ] conducted an innovative analysis comparing breech deliveries to vaginal cephalic births. Thus, they showed that singleton children born at term without congenital malformations had a higher risk for stillbirth and neonatal mortality if they were born in the breech presentation “regardless of whether they were born vaginally or by CS delivery” (0.9 per 1000 in those actually delivered vaginally and 0.8 per 1000 in those actually born by CS delivery) compared with those born by vaginal cephalic delivery (0.3 per 1000). Of note, among those children born in the breech rather than in the cephalic presentation, these authors [ 24 ] found that a higher proportion of infants were born small for gestational age (SGA). However, these authors [ 23 ] did not distinguish foetal growth restriction among SGA neonates. In their interpretation, Bjellmo et al. [ 23 ] considered that “the overall higher risk for stillbirth and the higher proportion of infants born SGA among children born in the breech than in the cephalic presentation may suggest that foetuses with antenatal acquired risk factors for adverse outcomes are more likely to present in the breech than in the cephalic presentation at birth.” According to these authors, the findings were most likely explained by a combination of antenatal acquired risk factors for neonatal death with increased vulnerability to the birth process. Of note, in the TBT group, birth weights of less than 2.8 kg were also associated with adverse perinatal outcomes ( P = 0.003) [ 10 ]. In fact, a limitation in the Norwegian study [ 24 ] was that, unlike Macharey et al., the authors did not distinguish foetal growth restriction among these SGA neonates. Indeed, in a large cohort study conducted with the National Health Service region in England through a multivariable analysis of 92,218 normally formed singletons delivered during 2009–2011 from 24 weeks of gestation, including 389 stillbirths, Gardosi et al. [ 25 ] showed that foetal growth restriction had the largest population attributable risk for stillbirth which was fivefold greater if it was not detected antenatally than when it was (32.0% v 6.2%). The above data suggest that some antenatal features associated with term breech presentation, notably foetal growth restriction, and some gestational disorders (such as uncontrolled gestational diabetes mellitus) could affect the prognosis in term breech cases. Previous data also support this conclusion; Luterkort M et al. [ 26 ] had previously reported in a prospective follow-up of 228 pregnancies with the foetus in the breech presentation in the 33rd gestational week that the 96 foetuses (42%) who remained in the breech presentation at delivery weighed 4.9% less than their vertex controls after adjustments were made for gestational age and had an increased frequency of oligohydramnios. Krebs et al. [ 27 ] later confirmed this association between breech presentation and foetal growth restriction from a register-based, case-control cohort of infants with cerebral palsy born between 1979 and 1986 in East Denmark.

In fact, as reported by Fox and Chapman [ 28 ], up to 21% of all foetuses adopt a noncephalic presentation at 28–29 weeks of gestation, and this proportion progressively decreases to 5% from 37 to 38 weeks [ 28 ]. Certain conditions, such as uterine malformation, can disturb both this continuous process of spontaneous cephalic version and normal foetal growth, thereby leading to increased term breech presentation rates in these cases [ 29 ]. This point highlights the importance of estimating foetal weight and well-being in cases of persistent breech presentation at term. Furthermore, even some cases of controlled GDM may be associated with excess foetal weight during the last weeks of pregnancy, leading to possible dystocia due to this overgrowth, or with other GDM-related complications, such as preeclampsia; thus, foetal weight estimates should be monitored closely beginning in the 37th week of gestation, with regular reassessment as long as the patient has not delivered.

The impact of strict criteria on the selection of vaginal delivery

From a broad perspective, in the most recent meta-analysis investigating the risks of planned vaginal breech delivery versus planned CS for term breech birth [ 21 ], the overall heterogeneity (I 2 = 36%) was informative. The variability of neonatal mortality among 14 studies accounting for 74,094 breech vaginal deliveries was low (ranging from 0.08 to 0.37%). On the other hand, neonatal mortality was markedly higher in only 2 studies authored by Singh et al. [ 30 ] and Hannah et al. [ 2 ] (the TBT). These two studies [ 2 , 30 ] accounted for 1099 breech vaginal deliveries (1.5% of births) and had perinatal mortality rates as high as 21 and 1.3%, respectively, for planned vaginal births (25.6% of perinatal deaths). The same was true for neurological morbidity, which was 3.4 and 1%, respectively, in the studies by Singh et al. [ 30 ] and TBT [ 2 ], while it ranged from 0.07 to 0.2% in the 14 other studies encompassing 74,094 breech vaginal deliveries conducted with the implementation of more stringent exclusion criteria for vaginal breech delivery.

In these 14 studies accounting for 74,094 breech vaginal deliveries, the retrospective observational cohort study from the Finnish Medical Birth Register [ 31 ] and the prospective observational study PREMODA [ 32 ] (as well as the more recent Norwegian Medical Birth Registry study) applied similar pre-established exclusion criteria for planned vaginal birth. In the PREMODA study, an increased absolute rate of perinatal death or serious neonatal morbidity was observed in both the planned vaginal group (1.60, 95% CI 1.14–2.17) and planned CS delivery group (1.45 [1.16–1.81]) with breech presentation among the total population of 264,105 births, but the planned vaginal group and the planned CS delivery group with breech presentation did not differ significantly for the combined outcome of foetal/neonatal mortality or serious morbidity (odds ratio [OR] = 1.10, 95% CI [0.75–1.61]). The Royal College of Obstetricians and Gynaecologists proposes comparable pre-established criteria for the management of term breech presentation, recommending that “women should be informed that a higher risk of planned vaginal breech birth is expected where there are independent indications for CS section and in circumstances such as a hyperextended neck on ultrasound, high estimated foetal weight (more than 3,800 g), low estimated weight (less than tenth centile), footling presentation, [and] evidence of antenatal foetal compromise” but considers that “the role of pelvimetry is unclear” [ 20 ]. Of note concerning this last point, Van Loon et al. showed in a randomized controlled trial [ 33 ] that the adequacy of pelvis size, as assessed by pelvimetry, improved the selection of delivery route. In line with them, two recent studies support this view [ 34 , 35 ]. Other authors also included criteria for the adequate management and continuous monitoring of foetal heart rate during labour (which is common in maternity wards of most high-income countries but could be monitored intermittently in the TBT). Indeed, decreased variability and late decelerations are more prevalent during breech deliveries than vertex deliveries [ 36 ], and good labour progress is a predictor of better neonatal outcomes [ 37 ]. In the Finnish Medical Birth Register [ 31 ], 1270 women (43.6%) were selected as candidates for vaginal breech delivery, and the selection quality was confirmed by the low conversion rate of vaginal to CS breech delivery (11.4%). This rate was higher (36.1%) in the TBT [ 30 ].

As noted by methodologists [ 38 ], real-world prenatal patient care is subject to decision-making based on the continuous evaluation of risk factors, medical history, comorbidities, behavioural aspects, and other factors that indeed cannot be strictly reproduced in randomized controlled trials. For example, in the TBT [ 2 ], an upper limit of 4000–4500 g was given for estimated foetal weight. However, as the duration between randomization and delivery inevitably lengthened in the planned vaginal delivery group, a significantly higher number of macrosomic neonates were born in the planned vaginal delivery group ( P = 0.002). In actuality, an informed woman who opts for vaginal delivery at 36 or 37 weeks of gestation usually changes her mind if she has not delivered several weeks later and if the clinician tells her that the birthweight will probably exceed 3800–4000 g, with an associated increased risk of adverse perinatal outcomes. Thus, in cases of even minor glycaemic disorder, special attention should be paid in the 37th week of gestation to foetal weight estimates and the possible occurrence of preeclampsia or associated gestational disorders; moreover, cases of SGA foetuses with possible foetal growth restriction should be closely followed, regardless of the delivery mode chosen by the patient [ 26 , 39 ].

How might we maximize patient benefit from a safe external cephalic version attempt?

With the restrictive practice of breech vaginal delivery in the last 15 years, national colleges of obstetricians (RCOG, ACOG, SOGC and RANZCOG) and FIGO updated their guidelines and recommended external cephalic version (ECV) at term to limit the increase in elective CS rate for cases of term breech presentation. However, recent data urge us to develop a broader perspective and an accurate assessment of the real impact of various ECV policies.

Indeed, the true impact of ECV may first be limited by the timely detection of breech presentation. In a retrospective cohort study of 394 consecutive cases of breech presentation at term, Hemelaar et al. [ 40 ] found that over two periods separated by 10 years (1998–1999 and 2008–2009), the proportion of breech presentations not diagnosed antenatally increased from 23.2 to 32.5% ( P = 0.04), causing 52.8% of women who were eligible for ECV to miss an attempt in 2008–2009. The authors also reported that the proportion of women who declined ECV during the same period decreased significantly from 19.1 to 9.0%.

Eligibility is a second limitation. In Australia, a large-scale survey [ 41 ] showed that 22.3% of 32,321 singleton breech pregnancies were considered ineligible (due to oligohydramnios, antepartum haemorrhage or abruption, previous CS or pelvic abnormality, placenta previa, placenta accreta, or an infant with major congenital anomalies). In this survey [ 41 ], only 10.5% of the singleton breech pregnancies had an ECV. In a systematic review, Rosman et al. [ 42 ] identified 60 studies that reported 39 different contraindications and five guidelines with 18 contraindications (varying from five to 13 contraindications per guideline), with oligohydramnios being the only contraindication that was consistently mentioned in all guidelines. Thus, there was no general consensus on the eligibility of patients for ECV, but contraindications generally include all conditions in which this procedure may be associated with a particular risk for the foetus or mother. These conditions include the following: severe intrauterine growth restriction, abnormal umbilical artery Doppler index and/or nonreassuring foetal heart rate, which may require an emergency CS birth; foetuses with a hyperextended head and significant foetal or uterine malformations, which may carry a particular foetal risk; rhesus alloimmunization, which might be reactivated by the procedure; and recent vaginal bleeding or ruptured membranes, which were associated with cord prolapse in 33% of reported cases after ECV attempt [ 43 ].

If CS or rapid delivery is indicated for another obstetric condition, ECV is also contraindicated, notably in cases of placenta previa, severe preeclampsia, and increased risk of placental abruption. Other situations, such as maternal obesity, nonsevere SGA foetuses, and nonsevere oligohydramnios, merely decrease the likelihood of ECV success. In contexts such as severe oligohydramnios or multiple gestations, ECV is simply impracticable, except for a second twin after delivery of the first. Furthermore, previous uterine surgery (CS delivery, myomectomy, or hysteroplasty) is considered a relative contraindication for ECV by some but not all authors [ 44 ]. On the other hand, in patients with gestational diabetes mellitus, incomplete or uncontrolled glucose levels are associated with an increased risk of foetal macrosomia in late pregnancy, and even if the estimated foetal weight seems compatible with a planned vaginal delivery when the mode of delivery is discussed, rapid foetal growth during the last weeks may lead to major difficulties during delivery. Therefore, in such a context, we believe there is potential for a particular benefit from successful ECV at 36 weeks.

Predictors of successful ECV

Pinard previously observed that unengaged breech presentation is an important predictor of successful ECV [ 45 ]; the same observation was made by Lau et al. [ 46 ], Aisenbrey et al. [ 47 ], and Hutton et al. [ 48 ]. In the large series of 1776 ECVs published by Hutton et al. [ 48 ], descent and impaction of the breech foetus were the most discriminating factors for predicting successful ECV, regardless of parity. Other predictors of success include parity [ 45 , 47 , 49 , 50 ], abundant amniotic fluid [ 49 , 50 , 51 ], nonfrank breech presentation [ 47 ], gestational age under 38 weeks [ 43 ], and posterior placenta [ 50 ]. In contrast, nulliparity and tense uterus are associated with a lower likelihood of success [ 44 , 48 , 52 ].

Velzel et al. [ 53 ] recently reviewed prediction models, most of which were developed without any external validation, and found that the most reliable predictors of successful ECV were nonimpacted breech presentation, parity and uterine softness (which usually go hand in hand), normal amniotic fluid index, posterior placental location, and, as noted by Pinard [ 45 ], foetal head in a palpable situation. These criteria might be used to support patient counselling and decision-making about ECV and to reduce the proportion of women declining ECV, particularly in the most favourable situations for ECV.

Obstetric outcomes after an ECV attempt

De Hundt et al. [ 54 ] conducted a systematic review and meta-analysis and showed that women who have had a successful ECV for breech presentation are at increased risk for CS delivery (OR 2.2; 95% CI 1.6–3.0) and instrumental vaginal delivery (OR 1.4; 95% CI 1.1–1.7) compared with women with spontaneous cephalic presentation. Interestingly, stratification by time delay between successful ECV and delivery revealed a trend for increased risk of CS during the first week after ECV [ 55 ]. Furthermore, in a cohort of 301 women with successful ECV, De Hundt et al. [ 56 ] found that nulliparity was the only of seven factors that predicted the risk of CS and instrumental vaginal delivery (OR 2.7; 95% CI 1.2–6.1). Based on a retrospective, population-based cohort study using the CDC’s birth data files from the US in 2006, Balayla et al. [ 57 ] also showed that relative to breech controls without an ECV attempt, cases of ECV failure with persistent breech presentation and labour attempts were associated with increased odds of CS delivery (adjusted OR 1.38; 95% CI 1.21–1.57), assisted ventilation at birth (aOR 1.50; 95% CI 1.27–1.78), 5-min Apgar score < 7 (aOR 1.35; 95% CI 1.20–1.51), and neonatal intensive care unit admission (aOR 1.48; 95% CI 1.20–1.82).

This information should also be considered in the dialog with women regarding the way in which late pregnancy and delivery should be managed based on existing data, their own situations and their wishes.

The true benefit of an active and systematic ECV policy is widely appreciated [ 58 , 59 ], and such evaluation may be subject to bias. Burgos et al. [ 58 ] found that their policy decreased the rate of breech presentation at delivery by 39.0% and decreased the CS rate for cases of breech presentation at term from 59 to 44%. On the other hand, Coppola et al. [ 59 ] reported that their CS rate was not significantly reduced in the planned ECV group, even after adjustments were made for age, parity and previous CS delivery. Thus, each perinatal centre should implement an appropriate and coherent policy in accordance with the prevalence of pathologies in the population.

Towards a consensus for a global shared vision and management of term breech presentation that could include the following

A policy of breech presentation screening at 36 weeks of gestation is efficient and cost effective [ 60 ].

Such screening should allow timely ECV and a careful evaluation of potential underlying antenatal risks, considering obstetric history, estimated foetal weight/growth and potential gestational disorders [ 23 , 24 , 25 , 26 , 27 , 29 ].

Foetal weight estimates based on clinical and ultrasound examinations are essential, despite the large confidence interval of all available algorithms for producing such estimates. Vaginal birth may be excluded when the estimated foetal weight approximates the upper limit used for selection in most national guidelines (3800 g) [ 18 , 19 , 20 ], particularly in the absence of previous successful vaginal delivery.

Before vaginal delivery is considered, clinical pelvic examination is universally recommended to rule out pathological pelvic contraction. Radiologic or magnetic resonance imaging (MRI) pelvimetry is not universally conducted [ 20 , 23 , 24 , 31 , 32 ]. However, Van Loon et al. [ 33 ] demonstrated in a randomized controlled trial that the use of MRI pelvimetry in breech presentation at term allowed better selection of delivery route, with a significantly lower emergency CS rate. More specifically, several recent studies [ 34 , 35 ] have evaluated the contribution of pelvimetry and found that MRI pelvimetry provided useful criteria for the preselection and counselling of women with breech presentation and the desire for vaginal delivery. Therefore, pelvimetry is diversely used in Europe for the preselection and counselling of women (particularly nulliparous women) with breech presentation and is specifically used in regions where vaginal delivery is still considered an option [ 35 ].

In cases of failed ECV with persistent breech presentation, this policy should allow customized care tailored to each situation in the last weeks of pregnancy.

A discussion with the informed patient is essential. One must thoroughly consider the experience of the health care team/the availability of clinical skills required for conducting a vaginal breech delivery and carefully select women who are eligible for planned vaginal delivery (considering obstetric history and the criteria described above for the choice between planned vaginal and CS deliveries) [ 20 , 23 , 24 , 26 , 28 ].

Regardless of the planned mode of delivery [ 22 ], adequate follow-up during the last weeks of pregnancy is mandatory, with particular consideration of possible associated underlying disorders (particularly foetal growth restriction or excessive foetal weight in cases of gestational diabetes mellitus) [ 24 , 25 , 26 ]. Thus, the foetal weight estimation should be carefully considered in the 37th week of gestation, even in cases of minor glycaemic disorder, with regular reassessments and a plan for CS delivery if the patient remains pregnant for many more weeks and if foetal weight estimates reach approximately 3600–3800 g.

If vaginal delivery is planned, careful labour management by a skilled team is needed, accompanied by continuous foetal heart rate monitoring [ 36 ] and a particular focus on the rate of progress in the second delivery stage [ 37 ]. When such conditions are not or cannot be fulfilled, a planned CS may be the best choice.

When a CS has been planned, adequate follow-up during the last weeks of pregnancy and careful calculation of the delivery date are needed, taking into account possible comorbidities and gestational disorders.

Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36–37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech presentation; and three, consider the obstetric history and pelvic size/conformation. The management plan, including ECV and follow-up during the last weeks, should then be organized taking into account antenatal risk factors on a case-by-case basis by a skilled team after informing the woman, discussing her personal situation and criteria and helping her make a rational decision. Foetal overgrowth or growth restriction and/or oligohydramnios may necessitate timely CS, and the mode of delivery should be re-evaluated as necessary according to obstetric conditions (e.g., estimated foetal weight and Bishop score).

Availability of data and materials

Not applicable.

Abbreviations

American College of Obstetricians and Gynecologists

Caesarean section

External cephalic version

International Federation of Gynecology and Obstetrics

Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Royal College of Obstetricians and Gynaecologists

Severe maternal morbidity

Society of Obstetricians and Gynaecologists of Canada

Term breech trial

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Study conception and design: LC, AB, JB, AT, FB, AB. Analysis and interpretation of data: LC, JB. Drafting of manuscript: LC. Critical revision: LC, JB, RM, MF. The authors read and approved the final manuscript.

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Carbillon, L., Benbara, A., Tigaizin, A. et al. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 20 , 263 (2020). https://doi.org/10.1186/s12884-020-2831-4

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Term breech delivery
Small-for-gestational-age
Foetal growth restriction
Oligohydramnios
Delivery route
Perinatal mortality
Perinatal morbidity

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Breech presentation: diagnosis and management

Key messages.

All women with a breech presentation should be offered an external cephalic version (ECV) from 37 weeks, if there are no contraindications.
Elective caesarean section (ELCS) for a singleton breech at term has been shown to reduce perinatal and neonatal mortality rates.
Planning for vaginal breech birth requires careful assessment of suitability criteria, contraindications and the ability of the service to provide experienced personnel.

In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines, with a view to targeting completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

Breech and external cephalic version

Breech presentation is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head.

Figure 1. Breech presentations

Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women.
External cephalic version (ECV) from 37 weeks has been shown to decrease the incidence of breech presentation at term and the subsequent elective caesarean section (ELCS) rate.
Vaginal breech birth increases the risk of low Apgar scores and more serious short-term complications, but evidence has not shown an increase in long-term morbidity.
Emergency caesarean section (EMCS) is needed in approximately 40 per cent of women planning a vaginal breech birth.
0.5/1000 with ELCS for breech >39 weeks gestation
2.0/1000 planned vaginal breech birth >39/40
1.0/1000 with planned cephalic birth.
A reduction in planned vaginal breech birth followed publication of the Term Breech Trial (TBT) in 2001.
Acquisition of skills necessary to manage breech presentation (for example, ECV) is important to optimise outcomes.

Clinical suspicion of breech presentation

Abdominal palpation: if the presenting part is irregular and not ballotable or if the fetal head is ballotable at the fundus
Pelvic examination: head not felt in the pelvis
Cord prolapse
Very thick meconium after rupture of membranes
Fetal heart heard higher in the abdomen

In cases of extended breech, the breech may not be ballotable and the fetal heart may be heard in the same location as expected for a cephalic presentation.

If breech presentation is suspected, an ultrasound examination will confirm diagnosis.

Cord prolapse is an obstetric emergency. Urgent delivery is indicated after confirming gestation and fetal viability.

Diagnosis: preterm ≤36+6 weeks

Breech presentation is a normal finding in preterm pregnancy.
If diagnosed at the 35-36 week antenatal visit, refer the woman for ultrasound scan to enable assessment prior to ECV.
Mode of birth in a breech preterm delivery depends on the clinical circumstances.

Diagnosis: ≥37+0 weeks

determine type of breech presentation
determine extension/flexion of fetal head
locate position of placenta and exclude placenta praevia
exclude fetal congenital abnormality
calculate amniotic fluid index
estimate fetal weight.

Practice points

Offer ECV if there are no contraindications.
If ECV is declined or unsuccessful, provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
Inform the woman that there are fewer maternal complications with a successful vaginal birth, however the risk to the woman increases significantly if there is a need for an EMCS.
Inform the woman that caesarean section increases the risk of complication in future pregnancies, including the risk of a repeat caesarean section and the risk of invasive placentation.
If the woman chooses an ELCS, document consent and organise booking for 39 weeks gestation.

Information and decision making

Women with a breech presentation should have the opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing care.

Planning for birth requires careful assessment for risk of poor outcomes relating to planned vaginal breech birth. If any risk factors are identified, inform the woman that an ELCS is recommended due to increased perinatal risk.

Good communication between clinicians and women is essential. Treatment, care and information provided should:

take into account women's individual needs and preferences
be supported by evidence-based, written information tailored to the needs of the individual woman
be culturally appropriate
be accessible to women, their partners, support people and families
take into account any specific needs, such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

Documentation

The following should be documented in the woman's hospital medical record and (where applicable) in her hand-held medical record:

discussion of risks and benefits of vaginal breech birth and ELCS
discussion of the woman's questions about planned vaginal breech birth and ELCS
discussion of ECV, if applicable
consultation, referral and escalation

External cephalic version (ECV)

ECV can be offered from 37 weeks gestation
The woman must provide written consent prior to the procedure
The success rate of ECV is 40-60 per cent
Approximately one in 200 ECV attempts will lead to EMCS
ECV should only be performed by a suitably trained, experienced clinician
continuous electronic fetal monitoring (EFM)
capability to perform an EMCS.

Contraindications

Table 1. Contraindications to ECV

Precautions

Hypertension
Oligohydramnios
Nuchal cord

Escalate care to a consultant obstetrician if considering ECV in these circumstances.

Perform a CTG prior to the procedure - continue until RANZCOG criteria for a normal antenatal CTG are met.
250 microg s/c, 30 minutes prior to the procedure.
Administer Anti-D immunoglobulin if the woman is rhesus negative.
Do not make more than four attempts at ECV, for a suggested maximum time of ten minutes in total.
Undertake CTG monitoring post-procedure until RANZCOG criteria for a normal antenatal CTG are met.

Emergency management

Urgent delivery is indicated in the event of the following complications:

abnormal CTG
vaginal bleeding
unexplained pain.

Initiate emergency response as per local guidelines.

Alternatives to ECV

There is a lack of evidence to support the use of moxibustion, acupuncture or postural techniques to achieve a vertex presentation after 35 weeks gestation.

Criteria for a planned vaginal breech birth

Documented evidence of counselling regarding mode of birth
Documentation of informed consent, including written consent from the woman
Estimated fetal weight of 2500-4000g
Flexed fetal head
Emergency theatre facilities available on site
Availability of suitably skilled healthcare professional
Frank or complete breech presentation
No previous caesarean section.
Cord presentation
Fetal growth restriction or macrosomia
Any presentation other than a frank or complete breech
Extension of the fetal head
Fetal anomaly incompatible with vaginal delivery
Clinically inadequate maternal pelvis
Previous caesarean section
Inability of the service to provide experienced personnel.

If an ELCS is booked

Confirm presentation by ultrasound scan when a woman presents for ELCS.
If fetal presentation is cephalic on admission for ELCS, plan ongoing management with the woman.

Intrapartum management

Fetal monitoring.

Advise the woman that continuous EFM may lead to improved neonatal outcomes.
Where continuous EFM is declined, perform intermittent EFM or intermittent auscultation, with conversion to EFM if an abnormality is detected.
A fetal scalp electrode can be applied to the breech.

Position of the woman

The optimal maternal position for birth is upright.
Lithotomy may be appropriate, depending on the accoucheur's training and experience.

Pain relief

Epidural analgesia may increase the risk of intervention with a vaginal breech birth.
Epidural analgesia may impact on the woman's ability to push spontaneously in the second stage of labour.

Induction of labour (IOL)

See the IOL eHandbook page for more detail.

IOL may be offered if clinical circumstances are favourable and the woman wishes to have a vaginal birth.
Augmentation (in the absence of an epidural) should be avoided as adequate progress in the absence of augmentation may be the best indicator of feto-pelvic proportions.

The capacity to offer IOL will depend on clinician experience and availability and service capability.

First stage

Manage with the same principles as a cephalic presentation.
Labour should be expected to progress as for a cephalic presentation.
If progress in the first stage is slow, consider a caesarean section.
If an epidural is in situ and contractions are less than 4:10, consult with a senior obstetrician.
Avoid routine amniotomy to avoid the risk of cord prolapse or cord compression.

Second stage

Allow passive descent of the breech to the perineum prior to active pushing.
If breech is not visible within one hour of passive descent, a caesarean section is normally recommended.
Active second stage should be ½ hour for a multigravida and one hour for a primipara.
All midwives and obstetricians should be familiar with the techniques and manoeuvres required to assist a vaginal breech birth.
Ensure a consultant obstetrician is present for birth.
Ensure a senior paediatric clinician is present for birth.

VIDEO: Maternity Training International - Vaginal Breech Birth

Encouragement of maternal pushing (if at all) should not begin until the presenting part is visible.
A hands-off approach is recommended.
Significant cord compression is common once buttocks have passed the perineum.
Timely intervention is recommended if there is slow progress once the umbilicus has delivered.
Allow spontaneous birth of the trunk and limbs by maternal effort as breech extraction can cause extension of the arms and head.
Grasp the fetus around the bony pelvic girdle, not soft tissue, to avoid trauma.
Assist birth if there is a delay of more than five minutes from delivery of the buttocks to the head, or of more than three minutes from the umbilicus to the head.
Signs that delivery should be expedited also include lack of tone or colour or sign of poor fetal condition.
Ensure fetal back remains in the anterior position.
Routine episiotomy not recommended.
Lovset's manoeuvre for extended arms.
Reverse Lovset's manoeuvre may be used to reduce nuchal arms.
Supra-pubic pressure may aide flexion of the fetal head.
Maricueau-Smellie-Veit manoeuvre or forceps may be used to deliver the after coming head.

Undiagnosed breech in labour

This occurs in approximately 25 per cent of breech presentations.
Management depends on the stage of labour when presenting.
Assessment is required around increased complications, informed consent and suitability of skilled expertise.
Do not routinely offer caesarean section to women in active second stage.
If there is no senior obstetrician skilled in breech delivery, an EMCS is the preferred option.
If time permits, a detailed ultrasound scan to estimate position of fetal neck and legs and estimated fetal weight should be made and the woman counselled.

Entrapment of the fetal head

This is an extreme emergency

This complication is often due to poor selection for vaginal breech birth.

A vaginal examination (VE) should be performed to ensure that the cervix is fully dilated.
If a lip of cervix is still evident try to push the cervix over the fetal head.
If the fetal head has entered the pelvis, perform the Mauriceau-Smellie-Veit manoeuvre combined with suprapubic pressure from a second attendant in a direction that maintains flexion and descent of the fetal head.
Rotate fetal body to a lateral position and apply suprapubic pressure to flex the fetal head; if unsuccessful consider alternative manoeuvres.
Reassess cervical dilatation; if not fully dilated consider Duhrssen incision at 2, 10 and 6 o'clock.
A caesarean section may be performed if the baby is still alive.

Neonatal management

Paediatric review.
Routine observations as per your local guidelines, recorded on a track and trigger chart.
Observe for signs of jaundice.
Observe for signs of tissue or nerve damage.
Hip ultrasound scan to be performed at 6-12 weeks post birth to monitor for developmental dysplasia of the hip (DDH). See Neonatal eHandbook - Developmental dysplasia of the hip .

More information

Audit and performance improvement.

All maternity services should have processes in place for:

auditing clinical practice and outcomes
providing feedback to clinicians on audit results
addressing risks, if identified
implementing change, if indicated.

Potential auditable standards are:

number of women with a breech presentation offered ECV
success rate of ECV
ECV complications
rate of planned vaginal breech birth
breech birth outcomes for vaginal and caesarean birth.

For more information or assistance with auditing, please contact us via [email protected]

Bue and Lauszus 2016, Moxibustion did not have an effect in a randomised clinical trial for version of breech position. Danish Medical Journal 63(2), A599
Coulon et.al. 2014, Version of breech fetuses by moxibustion with acupuncture. Obstetrics and Gynecology 124(1), 32-39. DOI: 10.1097/AOG.0000000000000303
Coyle ME, Smith CA, Peat B 2012, Cephalic version by moxibustion for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub3
Evans J 2012, Essentially MIDIRS Understanding Physiological Breech Birth Volume 3. Number 2. February 2012
Hoffmann J, Thomassen K, Stumpp P, Grothoff M, Engel C, Kahn T, et al. 2016, New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae. PLoS ONE 11(8): e0161028. doi:10.1371/journal.pone.0161028
Hofmeyr GJ, Kulier R 2012, Cephalic version by postural management for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD000051. DOI: 10.1002/14651858.CD000051.pub2
New South Wales Department of Health 2013, Maternity: Management of Breech Presentation HNELHD CG 13_01, NSW Government; 2013
Royal College of Obstetricians and Gynaecologists 2017, External Cephalic Version and Reducing the Incidence of Term Breech Presentation. Green-top Guideline No. 20a . London: RCOG; 2017
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016, Management of breech presentation at term , July 2016 C-Obs-11:
The Royal Women's Hospital 2015, Management of Breech - Clinical Guideline
Women's and Newborn Health Service, King Edward Memorial Hospital 2015, Complications of Pregnancy Breech Presentation

Abbreviations

Get in touch, version history.

First published: November 2018 Due for review: November 2021

Uncontrolled when downloaded

What Is Breech?

When a fetus is delivered buttocks or feet first

Types of Presentation

Risk Factors

Complications.

Breech concerns the position of the fetus before labor . Typically, the fetus comes out headfirst, but in a breech delivery, the buttocks or feet come out first. This type of delivery is risky for both the pregnant person and the fetus.

This article discusses the different types of breech presentations, risk factors that might make a breech presentation more likely, treatment options, and complications associated with a breech delivery.

Verywell / Jessica Olah

Types of Breech Presentation

During the last few weeks of pregnancy, a fetus usually rotates so that the head is positioned downward to come out of the vagina first. This is called the vertex position.

In a breech presentation, the fetus does not turn to lie in the correct position. Instead, the fetus’s buttocks or feet are positioned to come out of the vagina first.

At 28 weeks of gestation, approximately 20% of fetuses are in a breech position. However, the majority of these rotate to the proper vertex position. At full term, around 3%–4% of births are breech.

The different types of breech presentations include:

Complete : The fetus’s knees are bent, and the buttocks are presenting first.
Frank : The fetus’s legs are stretched upward toward the head, and the buttocks are presenting first.
Footling : The fetus’s foot is showing first.

Signs of Breech

There are no specific symptoms associated with a breech presentation.

Diagnosing breech before the last few weeks of pregnancy is not helpful, since the fetus is likely to turn to the proper vertex position before 35 weeks gestation.

A healthcare provider may be able to tell which direction the fetus is facing by touching a pregnant person’s abdomen. However, an ultrasound examination is the best way to determine how the fetus is lying in the uterus.

Most breech presentations are not related to any specific risk factor. However, certain circumstances can increase the risk for breech presentation.

These can include:

Previous pregnancies
Multiple fetuses in the uterus
An abnormally shaped uterus
Uterine fibroids , which are noncancerous growths of the uterus that usually appear during the childbearing years
Placenta previa, a condition in which the placenta covers the opening to the uterus
Preterm labor or prematurity of the fetus
Too much or too little amniotic fluid (the liquid that surrounds the fetus during pregnancy)
Fetal congenital abnormalities

Most fetuses that are breech are born by cesarean delivery (cesarean section or C-section), a surgical procedure in which the baby is born through an incision in the pregnant person’s abdomen.

In rare instances, a healthcare provider may plan a vaginal birth of a breech fetus. However, there are more risks associated with this type of delivery than there are with cesarean delivery.

Before cesarean delivery, a healthcare provider might utilize the external cephalic version (ECV) procedure to turn the fetus so that the head is down and in the vertex position. This procedure involves pushing on the pregnant person’s belly to turn the fetus while viewing the maneuvers on an ultrasound. This can be an uncomfortable procedure, and it is usually done around 37 weeks gestation.

ECV reduces the risks associated with having a cesarean delivery. It is successful approximately 40%–60% of the time. The procedure cannot be done once a pregnant person is in active labor.

Complications related to ECV are low and include the placenta tearing away from the uterine lining, changes in the fetus’s heart rate, and preterm labor.

ECV is usually not recommended if the:

Pregnant person is carrying more than one fetus
Placenta is in the wrong place
Healthcare provider has concerns about the health of the fetus
Pregnant person has specific abnormalities of the reproductive system

Recommendations for Previous C-Sections

The American College of Obstetricians and Gynecologists (ACOG) says that ECV can be considered if a person has had a previous cesarean delivery.

During a breech delivery, the umbilical cord might come out first and be pinched by the exiting fetus. This is called cord prolapse and puts the fetus at risk for decreased oxygen and blood flow. There’s also a risk that the fetus’s head or shoulders will get stuck inside the mother’s pelvis, leading to suffocation.

Complications associated with cesarean delivery include infection, bleeding, injury to other internal organs, and problems with future pregnancies.

A healthcare provider needs to weigh the risks and benefits of ECV, delivering a breech fetus vaginally, and cesarean delivery.

In a breech delivery, the fetus comes out buttocks or feet first rather than headfirst (vertex), the preferred and usual method. This type of delivery can be more dangerous than a vertex delivery and lead to complications. If your baby is in breech, your healthcare provider will likely recommend a C-section.

A Word From Verywell

Knowing that your baby is in the wrong position and that you may be facing a breech delivery can be extremely stressful. However, most fetuses turn to have their head down before a person goes into labor. It is not a cause for concern if your fetus is breech before 36 weeks. It is common for the fetus to move around in many different positions before that time.

At the end of your pregnancy, if your fetus is in a breech position, your healthcare provider can perform maneuvers to turn the fetus around. If these maneuvers are unsuccessful or not appropriate for your situation, cesarean delivery is most often recommended. Discussing all of these options in advance can help you feel prepared should you be faced with a breech delivery.

American College of Obstetricians and Gynecologists. If your baby is breech .

TeachMeObGyn. Breech presentation .

MedlinePlus. Breech birth .

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term . Cochrane Database Syst Rev . 2015 Apr 1;2015(4):CD000083. doi:10.1002/14651858.CD000083.pub3

By Christine Zink, MD Dr. Zink is a board-certified emergency medicine physician with expertise in the wilderness and global medicine.

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Open Access

Peer-reviewed

Research Article

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis

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

* E-mail: [email protected]

Affiliations Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom, The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom

Roles Formal analysis, Writing – review & editing

Affiliation Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom

Roles Conceptualization, Investigation, Writing – original draft

Roles Formal analysis, Methodology, Writing – review & editing

Affiliations Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom, Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom

Roles Conceptualization, Methodology, Writing – review & editing

David Wastlund,
Alexandros A. Moraitis,
Alison Dacey,
Ulla Sovio,
Edward C. F. Wilson,
Gordon C. S. Smith

Published: April 16, 2019
https://doi.org/10.1371/journal.pmed.1002778
Reader Comments

Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women.

Methods and findings

The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity.

Conclusions

According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman.

Author summary

Why was this study done.

Risks of complications at delivery are higher for babies that are in a breech position, but sometimes breech presentation is not discovered until the time of birth.
Ultrasound screening could be used to detect breech presentation before birth and lower the risk of complications but would be associated with additional costs.
It is uncertain if offering ultrasound screening to every pregnancy is cost effective.

What did the researchers do and find?

This study recorded the birth outcomes of pregnancies that were all screened using ultrasound.
Economic modelling and simulation was used to compare these outcomes with those if ultrasound screening had not been used.
Modelling demonstrated that ultrasound screening would lower the risk of breech delivery and, as a result, reduce emergency cesarean sections and the baby’s risk of death.

What do these findings mean?

Offering ultrasound screening to every pregnancy would improve the health of mothers and babies nationwide.
Whether the health improvements are enough to justify the increased cost of ultrasound screening is still uncertain, mainly because the cost of ultrasound screening for presentation alone is unknown.
If ultrasound screening could be provided sufficiently inexpensively, for example, by being used during standard midwife appointments, routinely offering ultrasound screening would be worthwhile.

Citation: Wastlund D, Moraitis AA, Dacey A, Sovio U, Wilson ECF, Smith GCS (2019) Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis. PLoS Med 16(4): e1002778. https://doi.org/10.1371/journal.pmed.1002778

Academic Editor: Jenny E. Myers, University of Manchester, UNITED KINGDOM

Received: August 30, 2018; Accepted: March 11, 2019; Published: April 16, 2019

Copyright: © 2019 Wastlund et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The terms of the ethical permission for the POP study do not allow publication of individual patient level data. Requests for access to patient level data will usually require a Data Transfer Agreement, and should be made to Mrs Sheree Green-Molloy at the Department of Obstetrics and Gynaecology, Cambridge University, UK ( [email protected] ).

Funding: This study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme, grant number 15/105/01. EW is part funded by the NIHR Cambridge Biomedical Research Centre. US is funded by the NIHR Cambridge Comprehensive Biomedical Research Centre. The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health ( https://www.nihr.ac.uk/ ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: GS reports grants from the National Institute for Health Research (NIHR), Stillbirth and Neonatal Death Society, and MRC and reports other from GE and NIHR Cambridge Clinical Research Facility, during the study; reports personal fees and other from GlaxoSmithKline and Roche, and reports other from Chiesi, outside of the study. GS is an Academic Editor on PLOS Medicine's editorial board. DW, AM, AD, US, and EW declare no competing interests.

Abbreviations: AFI, amniotic fluid index; AGA, appropriate for gestational age; CrI, credibility interval; ECV, external cephalic version; ELCS, elective cesarean section; EMCS, emergency cesarean section; FTE, full-time education; HCHS, Hospital and Community Health Services; ICER, incremental cost effectiveness ratio; IMD, Index of Multiple Deprivation; LGA, large for gestational age; MOD, mode of delivery; NHS, National Health Service; NICE, National Institute for Health and Care Excellence; POP, Pregnancy Outcome Prediction; PSA, probabilistic sensitivity analysis; QALY, quality-adjusted life-year; SGA, small for gestational age; wkGA, weeks of gestational age; RCOG, Royal College of Obstetricians and Gynaecologists; SRC, spontaneous reversion to cephalic; STROBE, Strengthening the Reporting of Observational Studies in Epidemiology

Introduction

Undiagnosed breech presentation in labour increases the risk of perinatal morbidity and mortality and represents a challenge for obstetric management. The incidence of breech presentation at term is around 3%–4% [ 1 – 3 ], and fewer than 10% of foetuses who are breech at term revert spontaneously to a vertex presentation [ 4 ]. Although breech presentation is easy to detect through ultrasound screening, many women go into labour with an undetected breech presentation [ 5 ]. The majority of these women will deliver through emergency cesarean section (EMCS), which has high costs and increased risk of morbidity and mortality for both mother and child.

In current practice, foetal presentation is routinely assessed by palpation of the maternal abdomen by a midwife, obstetrician, or general practitioner. The sensitivity of abdominal palpation varies between studies (range: 57%–70%) and depends on the skill and experience of the practitioner [ 6 , 7 ]. There is currently no guidance on what is considered an acceptable false negative rate when screening for breech presentation using abdominal palpation. In contrast, ultrasound examination provides a quick and safe method of accurately identifying foetal presentation.

Effective interventions exist for the care of women who have breech presentation diagnosed near term. The Royal College of Obstetricians and Gynaecologists recommends ‘that all women with an uncomplicated breech presentation at term should be offered external cephalic version (ECV)’ [ 2 ]. The rationale for this is to reduce the incidence of breech presentation at term and avoid the risks of vaginal breech birth or cesarean section. The success rate of ECV is considered to be approximately 50% [ 2 , 8 , 9 ], but it differs greatly between nulliparous and parous women (34% and 66%, respectively) [ 9 ]. ECV is overall safe, with less than 1% risk to the foetus and even smaller risk to the mother [ 10 ]; despite this, a significant number of women decline ECV for various reasons [ 11 ]. Should ECV be declined or fail, generally women are offered delivery by planned (elective) cesarean section, as there is level 1 evidence of reduced risk of perinatal death and severe morbidity compared with attempting vaginal breech birth, and it is also associated with lower costs [ 3 , 12 , 13 ]. However, some women may still opt for an attempt at vaginal breech birth if they prioritise nonintervention over managing the relatively small absolute risks of a severe adverse event [ 1 , 14 ].

We sought to assess the cost effectiveness of universal late-pregnancy ultrasound presentation scans for nulliparous women. We used data from the Pregnancy Outcome Prediction (POP) study, a prospective cohort study of >4,000 nulliparous women, which included an ultrasound scan at 36 weeks of gestational age (wkGA) [ 15 ]. Here, we report the outcomes for pregnant nulliparous women with breech presentation in the study and use these data to perform a cost effectiveness analysis of universal ultrasound as a screening test for breech presentation.

Study design

The POP study was a prospective cohort study of nulliparous women conducted at the Rosie Hospital, Cambridge (United Kingdom) between January 14, 2008 and July 31, 2012, and the study has been described in detail elsewhere [ 15 – 17 ]. Ethical approval for the study was obtained from the Cambridgeshire 2 Research Ethics Committee (reference 07/H0308/163), and all participants provided informed consent in writing. Participation in the POP study involved serial phlebotomy and ultrasound at approximately 12 wkGA, 20 wkGA, 28 wkGA, and 36 wkGA [ 16 ]. The outcome of pregnancy was obtained by individual review of all case records by research midwives and by linkage to the hospital’s electronic databases of ultrasonography, biochemical testing, delivery data, and neonatal care data. The research ultrasound at 36 wkGA was performed by sonographers and included presentation, biometry, uteroplacental Doppler, and placental location. The ultrasound findings were blinded except in cases of breech presentation, low lying placenta, or foetal concerns such as newly diagnosed foetal anomaly and an amniotic fluid index (AFI) < 5 cm. This study was not prospectively defined in the POP study protocol paper [ 16 ] but required no further data collection.

If the foetus was in a breech presentation at 36 wkGA, women were counselled by a member of the medical team. In line with guidelines from the National Institute for Health and Care Excellence (NICE), ECV was routinely offered unless there was a clinical indication that contraindicated the procedure, e.g., reduced AFI (<5 cm) [ 18 ]. ECV was performed by 1 of 5 obstetric consultants in the unit between 36–38 wkGA, patients were scanned before the procedure to confirm presentation, and it was performed with ultrasound assessment; 0.25 mg terbutaline SC was given prior to the procedure at the discretion of the clinician. If women refused ECV or the procedure failed, the options of vaginal breech delivery and elective cesarean section (ELCS) were discussed and documented. The local guideline for management of breech presentation, including selection criteria for vaginal breech delivery, was based upon recommendations from the Royal College of Obstetricians and Gynaecologists (RCOG) [ 1 ]. We extracted information about ECV from case records that were individually reviewed by research midwives. Finally, we obtained delivery-related information from our hospital electronic database (Protos; iSoft, Banbury, UK).

Foetal outcomes included mode of delivery (MOD), birth weight, and gestational age at delivery. We used the UK population reference for birthweight, with the 10th and 90th percentile cut-offs for small and large for gestational age, respectively; the centiles were adjusted for sex and gestational age [ 19 ]. Maternal age was defined as age at recruitment. Smoking status, racial ancestry, alcohol consumption, and BMI were taken from data recorded at the booking assessment by the community midwife. Socioeconomic status was quantified using the Index of Multiple Deprivation (IMD) 2007, which is based on census data from the area in the mother’s postcode [ 20 ]. Ethical approval for the study was obtained from the Cambridgeshire 2 Research Ethics Committee (reference 07/H0308/163), and all participants provided informed consent in writing.

This study is reported as per the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guideline.

Statistical analysis

Data are presented as median (interquartile range) or n (%), as appropriate. P values are reported for the difference between groups calculated using the two-sample Wilcox rank-sum (Mann–Whitney) test for continuous variables and the Pearson Chi-square test for categorical variables, with trend tests when appropriate. Comparisons were performed using Stata (version 15.1). Missing values were included in the presentation of patient characteristics and outcomes but were excluded from the economic analysis and estimation of parameters.

Economic model and analysis

To evaluate the cost effectiveness of routinely offering late-pregnancy presentation scans, a decision-tree simulation model was constructed using R (version 3.4.1) [ 21 – 24 ]. The time horizon of the economic analysis was from the ultrasound scan (36 wkGA) to infant lifetime, and costs were from the perspective of the English National Health Service (NHS). Costs for modes of delivery were obtained from NHS reference costs [ 25 ]; since these do not list a separate cost for vaginal breech delivery, we assumed that the cost ratio between vaginal breech and ELCS deliveries was the same as in another study (see Supporting information , S1 Text ) [ 12 ].

The population of interest is unselected nulliparous women. The model compares the outcomes at birth for two strategies: ‘universal ultrasound’ and ‘selective ultrasound’ ( Fig 1 ). For universal ultrasound, we assumed that all breech presentations at the time of scanning would be detected (i.e., assumed 100% sensitivity and specificity for the test). For selective ultrasound, the breech presentation was diagnosed either clinically (by abdominal palpation followed by ultrasound for confirmation) or as an incidental finding during a scan for a different indication. These assumptions were based upon current practice and derived from the POP study.

PPT PowerPoint slide
PNG larger image
TIFF original image

Structure of economic simulation model. ‘Universal ultrasound’ strategy starts in Model A, and patients with breech presentation enter Model C. ‘Selective ultrasound’, i.e., no routine ultrasound, starts in Model B, and only those with a detected breech presentation enter Model C. The letter–number codes for each node are equivalent to the codes in Table 1 . ELCS, elective cesarean section; EMCS, emergency cesarean section.

https://doi.org/10.1371/journal.pmed.1002778.g001

Compared to a standard antenatal ultrasound for which, typically, multiple measurements are made, an ultrasound scan for foetal presentation alone is technically simple. We theorised that such a scan could be provided by an attending midwife in conjunction with a standard antenatal visit in primary care, using basic ultrasound equipment. Since a specific unit cost for a scan for foetal presentation alone is not included in the national schedule of reference costs [ 25 ], we estimated the cost of ultrasound to include the midwife’s time, the cost of equipment, and room. More details are presented in the Supporting information, S1 Text . The cost of ECV was obtained from James and colleagues [ 26 ] and converted to the 2017 price level using the Hospital and Community Health Services (HCHS) index [ 27 ]. The probability of ECV uptake and success rate as well as MOD were obtained from the POP study. All model inputs are presented in Table 1 and S1 Table , and the calculation of cost inputs is shown in Supporting information, S1 Text .

https://doi.org/10.1371/journal.pmed.1002778.t001

The end state of the decision tree was the MOD, which was either vaginal, ELCS, or EMCS. Delivery could be either cephalic or breech. EMCS could be either due to previously undiagnosed breech presentation or for other reasons. All cases of breech could spontaneously revert to cephalic presentation. However, we assumed the probability of this to be lower if ECV had been attempted and failed [ 28 ]. If ECV was successful, a reversion back to breech presentation was possible. It is currently unclear whether the probability of MOD varies depending on whether cephalic presentation is the result of successful ECV or spontaneous reversion [ 2 , 10 , 29 – 31 ], but we assumed that the probabilities differed.

Long-term health outcomes were modelled based upon the mortality risk associated with each MOD. The risk of neonatal mortality was taken from the RCOG guidelines. For breech presentation, these risks were 0.05% for delivery through ELCS and 0.20% for vaginal delivery. The risk of neonatal mortality for cephalic presentation with vaginal delivery was 0.10% [ 1 ]. There were no randomised clinical trials that allowed us to compare the outcomes of ELCS versus vaginal delivery for uncomplicated pregnancies with cephalic presentation; however, most observational studies found no significant difference in neonatal mortality and serious morbidity between the two modes [ 32 – 34 ]. For this reason, we assumed the mortality risk for cephalic vaginal and ELCS deliveries to be identical. We also assumed that EMCS would have the same mortality rate as ELCS, both for cephalic and breech deliveries. Studies have found that the MOD for breech presentation affects the risk of serious neonatal morbidity in the short term but not in the long term [ 1 , 3 , 35 ]. For this reason, we focused the economic analysis on the effect from mortality only. The average lifetime quality-adjusted life-years (QALYs) per member of the UK population was estimated using data on quality of life from Euroqol, weighted by longevity indexes from the Office for National Statistics (ONS) [ 36 , 37 ]. Using the annual discount rate of 3.5%, as recommended by NICE, the net present value for the average lifetime QALYs at birth was 24.3 [ 38 ].

The model was probabilistic, capturing how uncertainty in the input parameters affected the outputs by allowing each parameter to vary according to its distribution. Binary and multivariable outcomes were modelled using the beta and the Dirichlet distributions, respectively [ 39 ]. Probabilities of events were calculated from the POP study and presented in Table 1 . On top of the probabilistic sensitivity analysis (PSA), the sensitivity of individual parameters was also explored through one-way sensitivity analyses modifying probabilities by +/− 1 percentage point and costs by +/− £10 to see which parameters had the greatest impact on cost effectiveness estimates.

Total costs depended on the distribution of MOD, the number of expected mortalities, and the cost of ultrasound scanning and ECV. Nationwide costs for each screening strategy were calculated for 585,489 deliveries, i.e., the number of births in England from 2016–2017, assuming 92% occur after 36 wkGA [ 15 , 40 ]. Model parameters were sampled from their respective distributions in a PSA of 100,000 simulations for each strategy. To determine cost effectiveness, we used two different willingness-to-pay thresholds: £20,000 and £30,000 [ 38 ]. A copy of the model code is available from the corresponding author (EW) upon request.

Recruitment to the POP study cohort is shown in Fig 2 and has been previously described [ 17 ]. Information about presentation at the 36-week scan was available for 3,879 women who delivered at the Rosie Hospital, Cambridge, UK; 179 of these had a breech presentation.

Schedule of patient recruitment in the POP study shown by foetal presentation. POP, Pregnancy Outcome Prediction.

https://doi.org/10.1371/journal.pmed.1002778.g002

We compared maternal and foetal characteristics of the 179 women with breech presentation at 36 weeks to the women with a cephalic presentation ( Table 2 ). Women diagnosed with breech presentation were, on average, a year older than women with a cephalic presentation, but other maternal characteristics did not differ. The babies of women diagnosed breech were smaller and born earlier, but their birth weight centile and the proportions of small for gestational age (SGA) or large for gestational age (LGA) were not markedly different. There were no differences in maternal BMI between the groups. As expected, women with breech presentation were more likely to deliver by ELCS or EMCS.

https://doi.org/10.1371/journal.pmed.1002778.t002

Breech presentation was suspected before the 36-wkGA scan for 79 (44.1%) of the women with breech presentation through abdominal palpation by the midwife or doctor; out of these, 27 had a clinically indicated scan between 32–36 weeks in which the presentation was reported. For 96 women, the breech presentation was unsuspected before the 36-week scan. Information on suspected breech position was missing for 4 women. There were no differences in BMI between the 79 women with suspected breech and the 96 women misdiagnosed as cephalic prior to the scan (median BMI was 24 in both groups, Wilcoxon rank-sum test P = 0.31).

MOD by ECV status is shown in Table 3 . ECV was performed for 84 women, declined by 45 women, and unsuitable for 23; contraindications included low AFI at screening (18 women), uterine abnormalities (2), and other reasons (3). For 25 women, an ECV was never performed despite consent; 17 babies turned spontaneously, 6 had reduced AFI on the day of the ECV, and 2 went into labour before ECV. When performed, ECV was successful for 12 women; in one case, the baby later reverted to breech presentation before delivery. Information on ECV uptake was missing for 2 women. Foetal presentation and ECV status in the structure of the economic model is shown in Supporting information, S1 Fig .

https://doi.org/10.1371/journal.pmed.1002778.t003

The results from the economic analysis are presented in Table 4 . On average, universal ultrasound resulted in an absolute decrease in breech deliveries by 0.39%. It also led to fewer vaginal breech deliveries (absolute decrease by 1.04%) and overall EMCS deliveries (0.72%) than selective ultrasound but increased overall deliveries through ELCS (1.51%). Resulting from the more favourable distribution of MOD, the average risk of mortality fell by 0.0013%. On average, 40 women had to be scanned to identify one previously unsuspected breech presentation (95% Credibility Interval [CrI]: 33 to 49); across England, this would mean that 14,826 (95% CrI: 12,048–17,883) unidentified breech presentations could be avoided annually.

https://doi.org/10.1371/journal.pmed.1002778.t004

The expected per person cost of universal ultrasound was £2,957 (95% CrI: £2,922–£2,991), compared to £2,949 (95% CrI: £2,915–£2,984) from selective ultrasound, a cost increase of £7.29 (95% CrI: 2.41–11.61). Across England, this means that universal ultrasound would cost £4.27 million more annually than current practice. The increase stems from higher costs of ultrasound scan (£20.3 per person) and ECV (£3.6 per person) but is partly offset by the lower delivery costs (−£16.5 per person). The distribution of differences in costs between the two strategies is shown as Supporting information, S2 Fig . The simulation shows that universal ultrasound would, on average, increase the number of total ELCS deliveries by 8,858 (95% CrI: 7,662–10,068) but decrease the number of EMCS and vaginal breech deliveries by 4,196 (95% CrI: 2,779–5,603) and 6,061 (95% CrI: 6,617–8,670) per year, respectively.

The long-term health outcomes are presented in Table 4 . Nationwide, universal ultrasound would be expected to lower mortality by 7.89 cases annually (95% CrI: 3.71, 12.7). After discounting, this means that universal ultrasound would be expected to yield 192 QALYs annually (95% CrI: 90,308). The cost effectiveness of universal ultrasound depends on the value assigned to these QALYs. The incremental cost effectiveness ratio (ICER) was £23,611 (95% CrI: 8,184, 44,851), which is of borderline cost effectiveness (given NICE’s willingness to pay of £20,000 to £30,000) [ 38 ]. The number needed to scan per prevented mortality was 74,204 (95% CrI: 46,124–157,642).

One-way sensitivity analysis showed that the probability parameter with the greatest impact upon the cost effectiveness of universal ultrasound was the prevalence of breech: increasing this parameter by 1 percentage point was associated with a relative reduction of costs for universal ultrasound by £3.07. The results were less sensitive to the ECV success rate; an increase by 1 percentage point led to a relative reduction in the cost of universal ultrasound by £0.12. The most important cost parameter was the unit cost of ultrasound scan; an increase in this parameter by £10 led to a relative increase for universal ultrasound by £9.79 (see Supporting information , S3 Fig ). Keeping all other parameters equal, universal ultrasound would be cost effective if ultrasound scanning could be provided for less than £19.80 or £23.10 per mother, for a willingness-to-pay threshold of £20,000 or £30,000, respectively. For universal ultrasound to be cost saving, scans would need to cost less than £12.90 per mother.

In a prospective cohort study of >3,800 women having first pregnancies, a presentation scan at approximately 36 wkGA identified the 4.6% of women who had a foetus presenting by the breech, and for more than half of these, breech presentation had not previously been clinically suspected. The majority of these women were ultimately delivered by planned cesarean section, some experienced labour before their scheduled date and were delivered by EMCS, and a small proportion had a cephalic vaginal delivery following either spontaneous cephalic version or ECV. No woman in the cohort had a vaginal breech delivery or experienced an intrapartum cesarean for undiagnosed breech. The low uptake of vaginal breech birth is likely to reflect the fact that this is a nulliparous population, and it is generally accepted that the risks associated with vaginal breech delivery are lower in women who have had a previous normal birth.

Our economic analysis suggests that a universal late-pregnancy presentation scan would decrease the number of foetal mortalities associated with breech presentation and that this is of borderline cost effectiveness, costing an estimated £23,611 per QALY gained. The key driver of cost effectiveness is the cost of the scan itself. In the absence of a specific national unit cost, we have identified the maximum cost at which it would be cost effective. This is £19.80 per scan to yield an ICER of £20,000 per QALY and £23.10 at £30,000. These unit costs may be possible if assessment of presentation could be performed as part of a routine antenatal visit. Portable ultrasound systems adequate for presentation scans are available at low cost, and a presentation scan is technically quite simple, so the required level of skill could be acquired by a large cadre of midwives. This would result in a small fraction of the costs associated with a trained ultrasonographer performing a scan in a dedicated space using a high-specification machine. If universal ultrasound could be provided for less than £12.90 per scan, the policy would also be cost saving.

Our sensitivity analysis shows that the unit cost of ultrasound scans and the prevalence of breech presentation were by far the biggest determinants of the cost and cost effectiveness of universal ultrasound. The detection rate with abdominal palpation (i.e., for selective ultrasound) is the most important parameter aside from these. By contrast, the costs, attempt, and success rates for ECV have modest impact upon the choice of scanning strategy. It appears that the main short-term cost benefit from late-pregnancy screening lies in the possibility of scheduling ELCSs when breech presentation is detected, rather than turning the baby into a cephalic position.

This analysis may have underestimated the health benefits of universal late-pregnancy ultrasound. In the absence of suitable data on long-term outcomes by MOD and foetal presentation, we made the simplifying assumption that mortality rates were equal for ELCSs and EMCSs. Relaxing this assumption would likely favour universal ultrasound, as this strategy would reduce EMCSs, and these are associated with higher risks of adverse outcomes than ELCSs [ 41 – 44 ]; on top of health benefits, this may also reduce long-term NHS costs. It is also possible that an EMCS for a known breech presentation is less expensive and has better health outcomes than one for which breech is detected intrapartum, although lack of separate data for these two scenarios prevented us from pursuing this analysis further.

Our analysis shows that universal late-pregnancy ultrasound screening would increase total number of cesarean sections. Evidence suggests that cesarean delivery may have long-term consequences on the health of the child (increased risk of asthma and obesity), the mother (reduced risk of pelvic organ prolapse and increased risk of subfertility), and future pregnancies (increased risk of placenta previa and stillbirth) [ 45 , 46 ]. There is no evidence that these are related to the type of the cesarean section (elective versus emergency) [ 45 , 46 ]. Our economic modelling has not been able to capture these complex effects due to the model’s endpoints and the focus on the current pregnancy only. However, accounting for these effects, it seems plausible that universal late-pregnancy ultrasound would be more favourable for mothers than children or future pregnancies.

Our results are also driven by vaginal delivery yielding worse long-term health outcomes than ELCS for breech presentation [ 1 ]. However, even though the rate of vaginal breech birth declined after the Term Breech Study, in many cases, the outcomes are not inferior to that of ELCS, and the RCOG guidelines state that vaginal breech delivery may be attempted following careful selection and counselling [ 1 , 3 , 47 ]. It is hard to assess how an increase in vaginal breech delivery would affect the cost effectiveness of universal ultrasound; while decreased mortality risk from vaginal breech delivery would decrease the importance of knowing the foetal presentation, universal screening would facilitate selection for attempted vaginal breech delivery.

One limitation of this study is that foetal presentation was revealed to all women in the POP study. Consequently, this study cannot say what would have happened without routine screening. However, we felt that it was appropriate to reveal the presentation at the time of the 36-wkGA scan, as there is level 1 evidence that planned cesarean delivery reduces the risk of perinatal morbidity and mortality in the context of breech presentation at term [ 44 ]. Another weakness was that the study was being undertaken in a single centre only and that the sample size was too small to avoid substantial parameter uncertainty for rare events. Moreover, less than half of all breech presentations in the POP study were detected by abdominal palpation. It is unclear whether the detection rates were affected by midwives knowing that the women were part of the POP study and, hence, would receive an ultrasound scan at 36 wkGA.

The prevalence of breech presentation in this study (4.6%) appears higher than the 3%–4% that is often reported in literature [ 1 ]. However, this study is unique in that it reports the prevalence at the time of ultrasound scanning, approximately 36 wkGA. Taking into account the number of spontaneous reversions to cephalic and that some cases of successful ECV may have turned spontaneously without intervention, our finding is consistent with the literature. The ECV success rate in the POP study was considerably lower than reported elsewhere in the literature; it was even lower than the 32% success rate that has been reported as the threshold level for when ECV is preferred over no intervention at all [ 48 ]. This might partly reflect the participants in the POP study; they were older and more likely to be obese than in many previous studies, and the cohort consisted of nulliparous women, who have higher rates of ECV failure than parous women [ 9 , 49 , 50 ]. It is also possible that the real-world ECV success rate is lower than in the literature due to publication bias. However, sensitivity analysis indicates that the impact from an increased ECV success rate would be modest (an increase in ECV success rate by 10 percentage points lowers the incremental cost of universal ultrasound by £0.91 per patient).

The findings from this study cannot easily be transferred to another health system due to the differences in healthcare costs and antenatal screening routines. Some countries, e.g., France and Germany, already offer a third-trimester routine ultrasound scan. However, these scans are offered prior to 36 wkGA, and as many preterm breech presentations revert spontaneously, it would have limited predictive value for breech at term [ 51 ]. Whether screening for breech presentation in lower-income settings is likely to be cost effective largely depends on the coverage of the healthcare system; while screening may be relatively more costly, the benefits from avoiding undiagnosed breech presentation may also be relatively larger.

Whether the findings of this study could be extrapolated beyond nulliparous women is hard to assess. The absence of comparable data on screening sensitivity without universal ultrasound for parous women is an important limitation. The risks associated with breech birth also differ between nulliparous and parous women [ 52 , 53 ]. Compared to nulliparous women, parous women have higher success rates for ECV but also higher risk of spontaneous reversion to breech after 36 wkGA [ 9 , 28 ]. Also, the risks associated with vaginal breech delivery are lower in women who have had a previous vaginal birth [ 30 ].

Breech presentation is not the only complication that could be detected through late-pregnancy ultrasound screening. The same ultrasound session could also be used to screen for other indicators of foetal health, such as biometry and signs of growth restriction. Whether also scanning for other complications could increase the benefits from universal ultrasound has been and currently is subject to research [ 54 , 55 ]. Exploring the consequences from such joint screening strategies goes beyond the scope of this paper but has important implications for policy-makers and should therefore be subject to further research.

This study shows that implementation of universal late-pregnancy ultrasound to assess foetal presentation would virtually eliminate undiagnosed intrapartum breech presentation in nulliparous women. If this procedure could be implemented into routine care, for example, by midwives conducting a routine 36-wkGA appointment and using a portable ultrasound system, it is likely to be cost effective. Such a programme would be expected to reduce the consequences to the child of undiagnosed breech presentation, including morbidity and mortality.

Supporting information

S1 strobe checklist. strobe, strengthening the reporting of observational studies in epidemiology..

https://doi.org/10.1371/journal.pmed.1002778.s001

S1 Text. Cost input estimation.

https://doi.org/10.1371/journal.pmed.1002778.s002

S1 Table. Input costs and probabilities for the economic model, detailed.

https://doi.org/10.1371/journal.pmed.1002778.s003

S1 Fig. Foetal presentation and ECV status in the POP breech study.

ECV, external cephalic version; POPs, Pregnancy Outcome Prediction.

https://doi.org/10.1371/journal.pmed.1002778.s004

S2 Fig. PSA of cost differences between universal ultrasound and selective ultrasound.

PSA, Probabilistic Sensitivity Analysis.

https://doi.org/10.1371/journal.pmed.1002778.s005

S3 Fig. One-way sensitivity analysis of the difference in costs between universal ultrasound and selective ultrasound.

https://doi.org/10.1371/journal.pmed.1002778.s006

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Detection of breech presentation: Abdominal palpation and hand-held scanning by midwives

Joanna Keable

Clinical midwifery manager, James Paget University Hospital

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Kenda Crozier

Professor of midwifery; Associate Dean for postgraduate research; lead midwife for education, School of Health Sciences, University of East Anglia

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The NHS Litigation Authority's ‘sign up to safety’ campaign aims to prevent undiagnosed breech birth and possible poor birth outcomes. An audit was completed following the introduction of hand-held scanning ultrasound examination.

The hand-held ultrasound was used by midwives for all women in labour and before induction of labour to confirm presentation.

A criterion-based retrospective audit, conducted over 6 months in 2016, with a sample of 2737 women.

The audit demonstrated that 22 breech presentations were detected when using the hand-held ultrasound before induction of labour or in labour. The audit standard of 100% of women receiving an ultrasound scan was not met, and potential reasons are explored.

Conclusions

The results support the use of hand-held ultrasound, as it did detect breech presentation before induction of labour or spontaneous labour and birth. Further work includes the audit of the reasons that hand-held ultrasound scanning was not used, to ensure that a targeted action plan can be created. Future research into midwifery values, cultural attitudes and the effectiveness of abdominal palpation is also needed, to develop the knowledge base on which scanning can be framed.

The ‘sign up to safety’ initiative ( NHS Litigation Authority, 2016 ) was introduced in 2016 to support improvements in care, and to reduce the number of stillbirths, as part of the Royal College of Obstetricians and Gynaecologists (RCOG) ‘Each Baby Counts’ programme ( RCOG, 2016 ).

The RCOG green top guideline ( Impey et al, 2017 ) cites the risk of perinatal mortality as 0.5/1000 for an elective breech caesarean section at 39 weeks gestation, 2/1000 for a planned vaginal breech birth, and 1/1000 for a planned cephalic birth. A planned vaginal breech birth therefore has twice the risk of a planned cephalic birth and one-and-a-half times the risk of the caesarean section. However, the guideline also states that planned vaginal breech birth is nearly as safe as the cephalic birth with skilled birth attendants. It also states that there is an increased risk of maternal complications with emergency caesarean section as well as the long-term reproductive complications. The risks associated with breech diagnosed late in pregnancy or during labour include the highest rates of emergency caesarean section (64%), cord prolapse (1.4%) and the poorest infant outcomes ( Gallagher et al, 2009 ). Planning the breech birth appears to be key, and the use of hand-held ultrasound scanning in midwifery could also support unbiased counselling.

The RCOG campaign was the stimulus for the introduction of hand-held ultrasound examination at Norfolk and Norwich University Hospital NHS Foundation Trust, which primarily aimed to identify breech presentation to improve outcomes. A risk-benefit analysis was completed by the Clinical Director and the Head of Legal Services, which led to midwives using hand-held scanners to confirm breech presentation.

Literature review

A literature search was carried out both in relation to the aim of the study and for the implications in midwifery practice. Literature relevant to improving outcomes found that 3-4% of pregnant women carried a breech baby to term and that 10% of those were not detected until labour ( RCOG, 2016 ; Impey et al, 2017 ).

Webb et al (2011) found that abdominal palpation, as a means to correctly identify the left occiput anterior fetal position (cephalic or ‘head down’ position), at labour onset was poor. They suggested that ultrasound scanning may be valuable to complement abdominal palpation at the onset of labour. The researchers discussed the notion that a reliance on ultrasound had reduced midwifery skill, suggesting that community midwives were more accurate with abdominal palpation, which they relied on out of necessity. They concluded that the routine use of ultrasound on labour wards might become necessary. The researchers considered the impact of bias based on maternal and midwifery characteristics, sample size and delay on verification of fetal position, which may, if completed at the time of palpation, have shown the same fetal position.

Edvardsson et al (2015) researched the views of midwives in Australia on the use of ultrasound during pregnancy. They found that ultrasound scanning was seen as having advantages, but was also perceived to contribute to increased medicalisation of pregnancy. The authors found that ultrasound was normalised and unquestioned in healthcare and that, while midwives prioritised maternal health, pregnant women put fetal interests ahead of their own. The authors also found that ultrasound had the potential to undermine the normal pregnancy and childbirth process, and was said to be trusted over clinical skills, partly due to the ‘evidence’ that could be provided. The midwives in the study described feeling that it was increasingly necessary to use medical skills to confirm midwifery skills, which they interpreted as negative. Midwives also felt unable to take full advantage of their skills to provide a nurturing atmosphere to support normal birth.

Increased technology could lead the mother and/or the midwife to rely more on a birth environment dependent on technology in order to support decision-making. Huang et al (2012) found that, in rural China, greater use of ultrasound scanning was associated with higher caesarean section rates (54.8%), although they failed to identify choice of birth at booking and so had to rely on women's recall. Harris et al (2015) did document place of birth at booking, and found that ultrasound was not associated with the decision, although their sampling and methodology led to results and conclusions that neither supported nor disproved the notion of ultrasound leading to increased medicalisation. These articles assumed that medicalisation was a negative construct, when in fact, it appeared to depend on whether the respondent was a midwife, woman or obstetrician.

Audit setting and objectives

Norfolk and Norwich University Hospital NHS Foundation Trust is a large teaching hospital with approximately 6000 births per year, and approximately 200 midwives working across the hospital and the community. In a 9-month period in 2015, six women with an unknown breech presentation were induced and eight had an undiagnosed vaginal breech birth. Hand-held ultrasound devices were introduced as routine care for all women presenting in labour at term in the midwife-led birthing unit (MLBU) and in the labour ward, and when admitted for induction of labour to the antenatal ward. The devices were funded by the ‘sign up to safety’ initiative. All midwifery staff who were working on antenatal ward, labour ward and MLBU were trained in their use and documentation. Information for service users on the use of ultrasound scanning was provided on admission to the hospital. Following the introduction of hand-held ultrasound, a criteria-based, restrospective audit was conducted to establish:

That all women who attended in labour had a hand-held ultrasound scan of presentation
That there was documentation to show that a presentation scan had been performed
That induction of labour did not occur with a term breech fetus.

Approvals for audit

Ethical approval was obtained from the Faculty of Medicine and Health Sciences Ethics Committee at the University of East Anglia. The project was supported by the Head of Midwifery, Clinical Director and Departmental Manager of Women and Children at the Trust. The audit was registered with the local Trust audit board. The audit was designed, from the beginning, to protect patient confidentiality: once data were collected, they were immediately anonymised by assigning an audit number. The number of staff aware of the patient-identifiable data was limited to two, and the data set was analysed and stored on Trust information technology systems. Identifiable data was not included in the final report. Patient consent was not sought as this was a retrospective audit and patient care was not being affected by inclusion.

The retrospective audit began in April 2016 and lasted for 6 months. Quantitative data were sourced from computer records, namely a database system in which the admitting and/or delivering midwife enters the woman's care episode. Paper records were also used if further information was required to clarify ambiguity.

Inclusion criteria for women in this study were:

Term pregnancy (37-42 weeks)
Singleton pregnancy
Induction of labour
Consented to ultrasound by a midwife.

The sample numbered 2737 women, who were divided into spontaneous labour ( n =1510) and induction of labour ( n =1227). Women were excluded from the audit if there was a multiple pregnancy, if they did not consent to ultrasound or if they presented in preterm labour (less than 37 weeks' gestation). During the course of the audit, women discussed birth choices with the senior registrar, and the results demonstrated that all women presenting for induction of labour chose an elective caesarean section if breech presentation was detected. The maternity department also had a midwife-led clinic, where midwives saw women to diagnose breech presentation late in pregnancy and offer external cephalic version. These data were not part of the audit. Women who wished to opt for a vaginal breech birth were also seen at the clinic by the consultant obstetrician.

Over the 6-month audit period, 585 women of 1510 (38.7%) presenting in spontaneous labour received ultrasound scanning ( Table 1 ). There were a total of 7 breech presentations detected during this time. The outcomes for those women who had a breech detected by hand-held ultrasound scanning were 2 vaginal breech births (Apgars were normal and the babies were not admitted to neonatal intensive care), 3 elective lower segment caesarean sections and 2 emergency lower segment caesarean sections.

An important outcome of this audit was the identification of breech presentation where women were attending for induction of labour. Table 2 shows that, of the hand-held ultrasound scans performed, 15 breech presentations were identified (all women in this group went on to have an elective lower segment caesarean section). Only 68% of women were scanned overall, but this percentage increased from April to September. Comparison of spontaneous labour scanning to induction of labour scanning ( Tables 1 and 2 ) shows that a higher proportion of women attending for induction of labour received hand-held ultrasound scanning than women who attended in spontaneous labour. As induction of labour primarily occurs on the antenatal ward, this suggests that hand-held ultrasound was used there more than the labour ward or the MLBU. From the existing data collection, it was not possible to analyse where the hand-held ultrasound scanner was most in use, between the MLBU or the labour ward.

A total of 2453 women received abdominal palaption between April and September 2016 ( Table 3 ). Of these, 1164 (47%) had hand-held ultrasound performed for presentation. The target of 100% of women having ultrasound by handheld device was not met. Following hand-held ultrasound, 28 women (2.4%) were identified as having a breech presentation, in comparison to 45 (1.8%) who had already received this diagnosis using abdominal palpation. This seems to indicate that abdominal palpation is less accurate than hand-held ultrasound. The data in Table 3 also included women who were scanned at term for other reasons, most commonly pre-labour rupture of membranes and decreased fetal movements. These data were included to analyse the effectiveness of hand-held scanning in relation to abdominal palpation.

Table 4 shows that 1504 (61%) women had a normal vaginal birth during 6 months of 2016, and 2409 women (65%) over 9 months in 2015. The combined totals for spontaneous vaginal breech birth and emergency caesarean section for breech represented less than 1% of all births in 2016. This was also the case in 2015, meaning that there was no change between spontaneous and emergency lower segment caesarean section rates for breech presentation since the use of the hand-held scanner was introduced. Emergency caesarean section (cephalic presentation) was 9.4% in 2015 and 13% in 2016, representing a small increase of 3.6%. Instrumental cephalic births were 12% in 2015 and 2016, and caesarean section 13% in both years, representing a stable rate. Combining the elective and emergency caesarean section percentages gives a figure of 22.4% in 2015 and 26% in 2016. This is comparable to the national average of 26.2% ( Winter, 2015 ); however, it represents an increase for this particular maternity unit.

The audit results support the use of the hand-held ultrasound by midwives, as it detected breech presentation in labour and before induction of labour, although the audit target for scanning was not achieved. The reasons for not using hand-held ultrasound were not captured, and having this information would have identified the local barriers to the use of hand-held ultrasound to form a targeted action plan to improve the rate of scanning.

The Trust continues to support the use of hand-held ultrasound scanning, and an action plan was drawn up to increase use following an exploration of the reasons for non-compliance among midwives. The plan includes more detailed information for women on the use of hand-held ultrasound devices. If women know to request this method of assessment when they attend hospital, use among midwives is likely to increase.

Future research must involve all stakeholders from the beginning. Funding for the project has now ended; therefore, a re-audit will need to be planned with consideration for the barriers of clinical workload. Further improvements would include separating the clinical areas to evaluate if there is any difference between the MLBU and the labour ward.

Recommendations include auditing the use of both hand-held ultrasound and abdominal palpation. This audit also raises the question of the usefulness of abdominal palpation as a screening tool, although there are benefits of the skill, such as improving the quality of the communication between the midwife and the woman.

Both the literature and the results of this audit raise the need for further research into the midwife's role in scanning technology. The existing system is fragmented, resulting in women attending multiple appointments with a range of medical and allied health professionals, which may lead to variation in decision-making and potential confusion and anxiety for the woman. If the midwifery role encompasses scanning, the service could be made more efficient, effective and safe. The Nursing and Midwifery Council (NMC) Code ( NMC, 2015 ) places a duty to accurately assess and to refer in a timely way to a suitably qualified practitioner (in this case, the midwife), who could be trained to assess breech presentation using hand-held ultrasound. The challenge is to be ‘with woman’ in the environment of her choice, while being able to use available technology competently.

Wider implications include the effect of scanning or hand-held ultrasound on the midwifery role, including the impact on resources in terms of training, funding and maintenance. NHS England (2016) and the Perinatal Institute (2017) aim to prevent stillbirth and promote safety by using ultarsound, among other strategies, to detect at-risk babies. These strategies also require funding and resourcing, an ethical dilemma for healthcare economics.

Audit was the best method of investigating hand-held ultrasound after it had been implemented as routine practice. Its measurement of outcomes was reliable and did not require randomisation. Although this was not research, a high standard of data collection and analysis was carried out, leading to improvements in care. Future research to support the recommendation includes exploring midwifery values and cultural attitudes so that hand-held ultrasound scanning can be effectively taught and introduced into clinical practice. Research into the effectiveness of abdominal palpation is limited, so it would be an improvement to increase this knowledge base on which scanning can be developed.

The audit of hand-held ultrasound demonstrated that it was effective at confirming breech presentation
The skill of using a hand-held ultrasound can be learned by midwives and used to support the practise of abdominal palpation
The use of the hand-held ultrasound by midwives was variable depending on place of work (antenatal ward, labour ward or midwife led birthing unit)
Further research is required into the midwife's role in relation to scanning, the effectiveness of abdominal palpation and the woman's perception

CPD reflective questions

Technology is an accepted part of everyday life and yet abdominal palpation continues to be the traditional benchmark for assessing presentation, do you think there is a disparity between what women and families value compared to midwifery values?
In the current financial climate within the NHS against the backdrop of Saving Babies Lives and other government initiatives how might the handheld ultrasound be introduced?
This audit focused on identifying breech presentation, can you think of other ways the hand-held ultrasound can be used in practice by midwives to enhance care, improve outcomes and the woman's experience?

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The public can learn about the latest findings directly from the person heading up the study, Dr. Ben Jellen, at a special Copperheads at Powder Valley Study Update virtual presentation, Friday, May 10, from 7 - 8:30 p.m.

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IMAGES

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Breech Presentation
Breech Definition
types of breech presentation ultrasound
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Breech Presentation and Turning a Breech Baby in the Womb (External

VIDEO

(BREECH PRESENTATION) by Ms Varnish Kumar (MTCN Kumhari)
Breech Presentation in C-Section #trending #breechbaby #adorable #jiyatanwar05
breech presentation
breech presentation #cow#calf#viral
Breech Delivery story #bestgynecologist #drkshilpireddy #breechbaby #breechdelivery #normaldelivery
Malpresentation

COMMENTS

Breech Presentation
Breech presentation refers to the fetus in the longitudinal lie with the buttocks or lower extremity entering the pelvis first. The three types of breech presentation include frank breech, complete breech, and incomplete breech. ... During a cervical exam, findings may include the lack of a palpable presenting part, palpation of a lower ...
Evaluation and Referral for Developmental Dysplasia of the Hip in
Breech presentation may be the most important single risk factor, with DDH reported in 2% to 27% of boys and girls presenting in the breech position. 6, 8, 9 Frank breech presentation in a girl (sacral presentation with hips flexed and knees extended) appears to have the highest risk. 1 Most evidence supports the breech position toward the end ...
Overview of breech presentation
The main types of breech presentation are: Frank breech - Both hips are flexed and both knees are extended so that the feet are adjacent to the head ( figure 1 ); accounts for 50 to 70 percent of breech fetuses at term. Complete breech - Both hips and both knees are flexed ( figure 2 ); accounts for 5 to 10 percent of breech fetuses at term.
Breech presentation management: A critical review of leading clinical
Breech presentation: clinical practice guideline from the French College of Gynaecologists and Obstetricians [2020] French College of Gynaecologists and Obstetricians (CNGOF) ... of VBB or the rate of C/S for breech presentation and the differences in the counselling recommendations were the main findings of this review. For example, the only ...
Management of Breech Presentation
Women who have a breech presentation at term following an unsuccessful or declined offer of ECV should be counselled on the risks and benefits of planned vaginal breech delivery versus planned caesarean section. ... 95% CI 0.52-2.30). This renders the morbidity, but not mortality, findings (and therefore the 'intention to treat' analysis ...
PDF Management of breech presentation
For women with suspected breech presentation in late third trimester, ultrasound imaging should be performed to confirm the examination findings. If breech presentation is confirmed, a detailed obstetric ultrasound should be performed to determine whether any fetal or maternal finding predisposing to malpresentation is present (such as a
Revisiting the management of term breech presentation: a proposal for
Term breech presentation is a condition for which personalized obstetrical care is particularly needed. The best way is likely to be as follows: first, efficiently screen for breech presentation at 36-37 weeks of gestation; second, thoroughly evaluate the maternal/foetal condition, foetal weight and growth potential, and the type (frank, complete, or footling) and mobility of breech ...
Breech presentation management: A critical review of leading clinical
1. Background. The management of breech presentation continues to cause academic and clinical contention globally [[1], [2], [3]].In recent years, research has shown that if certain criteria are met, and appropriately experienced and skilled clinicians are available, Vaginal Breech Birth (VBB) is a safe option [[4], [5], [6]].However, with Caesarean Section (C/S) rates for breech presentation ...
Breech Presentation: Overview, Vaginal Breech Delivery ...
Overview. Breech presentation is defined as a fetus in a longitudinal lie with the buttocks or feet closest to the cervix. This occurs in 3-4% of all deliveries. The percentage of breech deliveries decreases with advancing gestational age from 22-25% of births prior to 28 weeks' gestation to 7-15% of births at 32 weeks' gestation to 3-4% of ...
Breech presentation: diagnosis and management
Breech and external cephalic version. Breech presentation is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head. Figure 1. Breech presentations. Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women.
Breech Presentation
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
Term breech presentation—Intended cesarean section versus intended
These findings underline the importance of taking wish for future pregnancies into account when considering a CS. ... As breech presentation is uncommon and severe perinatal morbidity and mortality are rare, very large sample sizes are required to perform randomized trials. Future RCTs are highly unlikely to be conducted also due to ethical ...
PDF Breech Presentation Fact Sheet
dysfunctions for vaginally or CS delivered breech babies. - Denmark 15.3%.17 Findings: Higher rates of puerperal fever and pelvic infections for CS breech delivery. - California 4.9%.18 Findings: Neonatal ... Other Research on Breech Presentation Outcomes by Delivery Method - Meta analysis 1: 24 studies published between 1966-199220 ...
Breech: Types, Risk Factors, Treatment, Complications
At full term, around 3%-4% of births are breech. The different types of breech presentations include: Complete: The fetus's knees are bent, and the buttocks are presenting first. Frank: The fetus's legs are stretched upward toward the head, and the buttocks are presenting first. Footling: The fetus's foot is showing first.
Breech presentation: its predictors and consequences. An analysis of
These findings suggest that breech presentation is a marker of a pathological pregnancy and not just a normal variant. The 3.3% prevalence of breech presentation in term pregnancies observed in the present study is similar to those reported by other authors 3, 14.
Breech Delivery Clinical Presentation
Breech presentation occurs when the fetus presents to the birth canal with buttocks or feet first. This presentation creates a mechanical problem in delivery of the fetus. ... Physical findings may include the following: Leopold maneuvers: With the first maneuver, the hard fetal head can be palpated at the uterine fundus. ...
Screening for breech presentation using universal late-pregnancy ...
In their cohort study, David Wastlund and colleagues find that universal ultrasound scanning for breech presentation near term is associated with reduced undiagnosed breech presentation and improved pregnancy outcomes, ... Methods and findings. The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 ...
British Journal Of Midwifery
Findings. The audit demonstrated that 22 breech presentations were detected when using the hand-held ultrasound before induction of labour or in labour. The audit standard of 100% of women receiving an ultrasound scan was not met, and potential reasons are explored. Conclusions.
MDC virtual program reveals latest findings of cutting-edge copperhead
The public can learn about the latest findings directly from the person heading up the study, Dr. Ben Jellen, at a special Copperheads at Powder Valley Study Update virtual presentation, Friday, May 10, from 7 - 8:30 p.m.

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BMC Pregnancy and Childbirth

Breech presentation: diagnosis and management

Breech and external cephalic version

Clinical suspicion of breech presentation

Diagnosis: preterm ≤36+6 weeks

Diagnosis: ≥37+0 weeks

Practice points

Information and decision making

Documentation

External cephalic version (ECV)

Contraindications

Precautions

Emergency management

Alternatives to ECV

Criteria for a planned vaginal breech birth

If an ELCS is booked

Intrapartum management

Position of the woman

Pain relief

Induction of labour (IOL)

First stage

Second stage

Undiagnosed breech in labour

Entrapment of the fetal head

Neonatal management

More information

Abbreviations

Uncontrolled when downloaded

What Is Breech?

Risk Factors

Types of Breech Presentation

Signs of Breech

Recommendations for Previous C-Sections

A Word From Verywell

Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis

Methods and findings

Conclusions

Author summary

What did the researchers do and find?

What do these findings mean?

Introduction

Study design

Statistical analysis

Economic model and analysis

Supporting information

S1 Text. Cost input estimation.

S1 Table. Input costs and probabilities for the economic model, detailed.