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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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Breech Births

In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby’s buttocks, feet, or both are positioned to come out first during birth. This happens in 3–4% of full-term births.

What are the different types of breech birth presentations?

Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

You have been pregnant before
In pregnancies of multiples
When there is a history of premature delivery
When the uterus has too much or too little amniotic fluid
When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy . The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC) is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

You are carrying more than one fetus
There are concerns about the health of the fetus
You have certain abnormalities of the reproductive system
The placenta is in the wrong place
The placenta has come away from the wall of the uterus ( placental abruption )

Complications of EVC include:

Prelabor rupture of membranes
Changes in the fetus’s heart rate
Placental abruption
Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor. The following conditions are considered necessary in order to attempt a vaginal birth:

The baby is full-term and in the frank breech presentation
The baby does not show signs of distress while its heart rate is closely monitored.
The process of labor is smooth and steady with the cervix widening as the baby descends.
The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse . In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

Creating Your Birth Plan
Labor & Birth Terms to Know
Cesarean Birth After Care

Compiled using information from the following sources:

ACOG: If Your Baby is Breech
William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

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

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

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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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What Causes Breech Presentation?

Learn more about the types, causes, and risks of breech presentation, along with how breech babies are typically delivered.

What Is Breech Presentation?

Types of breech presentation, what causes a breech baby, can you turn a breech baby, how are breech babies delivered.

FatCamera/Getty Images

Toward the end of pregnancy, your baby will start to get into position for delivery, with their head pointed down toward the vagina. This is otherwise known as vertex presentation. However, some babies turn inside the womb so that their feet or buttocks are poised to be delivered first, which is commonly referred to as breech presentation, or a breech baby.

As you near the end of your pregnancy journey, an OB-GYN or health care provider will check your baby's positioning. You might find yourself wondering: What causes breech presentation? Are there risks involved? And how are breech babies delivered? We turned to experts and research to answer some of the most common questions surrounding breech presentation, along with what causes this positioning in the first place.

During your pregnancy, your baby constantly moves around the uterus. Indeed, most babies do somersaults up until the 36th week of pregnancy , when they pick their final position in the womb, says Laura Riley , MD, an OB-GYN in New York City. Approximately 3-4% of babies end up “upside-down” in breech presentation, with their feet or buttocks near the cervix.

Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or they can conduct a vaginal exam if your cervix is open. A suspected breech presentation should ultimately be confirmed via an ultrasound, after which you and your provider would have a discussion about delivery options, potential issues, and risks.

There are three types of breech babies: frank, footling, and complete. Learn about the differences between these breech presentations.

Frank Breech

With frank breech presentation, your baby’s bottom faces the cervix and their legs are straight up. This is the most common type of breech presentation.

Footling Breech

Like its name suggests, a footling breech is when one (single footling) or both (double footling) of the baby's feet are in the birth canal, where they’re positioned to be delivered first .

Complete Breech

In a complete breech presentation, baby’s bottom faces the cervix. Their legs are bent at the knees, and their feet are near their bottom. A complete breech is the least common type of breech presentation.

Breech - series—Types of breech presentation

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There are three types of breech presentation: complete, incomplete, and frank.

Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth canal.

Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.

Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal.

There is also footling breech where one or both feet are presenting.

Review Date 11/21/2022

Updated by: LaQuita Martinez, MD, Department of Obstetrics and Gynecology, Emory Johns Creek Hospital, Alpharetta, GA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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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Published: 08 April 2024

Clinical analysis of complete uterine rupture during pregnancy

Jing Xie 1 , 2 ,
Xuefang Lu 3 &
Miao Liu 1 , 2

BMC Pregnancy and Childbirth volume 24 , Article number: 255 ( 2024 ) Cite this article

18 Accesses

Metrics details

Uterine rupture in pregnant women can lead to serious adverse outcomes. This study aimed to explore the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture.

Data from 33 cases of surgically confirmed complete uterine rupture at Chenzhou No.1 People’s Hospital between January 2015 and December 2022 were analyzed retrospectively.

In total, 31,555 pregnant women delivered in our hospital during the study period. Of these, approximately 1‰ ( n = 33) had complete uterine rupture. The average gestational age at complete uterine rupture was 31 +4 weeks (13 +1 –40 +3 weeks), and the average bleeding volume was 1896.97 ml (200–6000 ml). Twenty-six patients (78.79%) had undergone more than two deliveries. Twenty-five women (75.76%) experienced uterine rupture after a cesarean section, two (6.06%) after fallopian tube surgery, one (3.03%) after laparoscopic cervical cerclage, and one (3.03%) after wedge resection of the uterine horn, and Fifteen women (45.45%) presented with uterine rupture at the original cesarean section incision scar. Thirteen patients (39.39%) were transferred to our hospital after their initial diagnosis. Seven patients (21.21%) had no obvious symptoms, and only four patients (12.12%) had typical persistent lower abdominal pain. There were 13 cases (39.39%, including eight cases ≥ 28 weeks old) of fetal death in utero and two cases (6.06%, both full term) of severe neonatal asphyxia. The rates of postpartum hemorrhage, blood transfusion, hysterectomy were 66.67%, 63.64%, and 21.21%. Maternal death occurred in one case (3.03%).

Conclusions

The site of the uterine rupture was random, and was often located at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. Rapid recognition is key to the treatment of uterine rupture.

Peer Review reports

Uterine rupture(UR) is a serious complication that directly jeopardizes the life of the mother and the fetus [ 1 ]. It refers to the rupture of the uterine body or the lower uterine segment in late pregnancy or during labor [ 2 ], requiring a cesarean section to terminate the pregnancy as soon as the diagnosis is confirmed. The most common risk factors of UR are a history of previous cesarean section (CS), myomectomy, multiparity, malpresentation, breech extraction, and instrumental deliveries [ 3 ].

The incidence of uterine rupture in China has recently been reported to range from 0.1% to 0.55% [ 4 ]; although this incidence rate is low, UR is highly likely to lead to serious adverse outcomes.

Currently, there are no effective means for detecting or predicting the weakest points of the uterus. Therefore, in this study, we aimed to provide reference information and practical experience for the early recognition, management and emergency treatment of uterine rupture.

The Department of Obstetrics and Gynaecology of the First people’s Hospital of Chenzhou is a critical care center wherein treatment, consultation, referral, and technical guidance are proviede to pregnant women in Southern Hunan and the city with acute and critical illnesses. This was a retrospective study aimed at exploring the clinical characteristics, treatment, and prognosis of patients with complete uterine rupture between January 2015 and December 2022. The data (complete clinical data, medical history, and surgical records) of all patients with complete uterine rupture admitted to our hospital were retrospectively analyzed.

Diagnostic criteria

Complete uterine rupture was defined as rupture of the entire wall of the uterine myometrium, with the uterine cavity communicating with the abdominal cavity during late pregnancy or labor [ 1 ].

Postpartum hemorrhage (PPH) was defined as bleeding of ≥ 500 ml for vaginal delivery and ≥ 1000 ml for cesarean delivery within 24 h after delivery of the fetus [ 1 ].

Research methods

Basic maternal information (age, pregnancies, number of deliveries), previous pregnancy and surgery-related indicators (risk factor, causes and clinical manifestations, comorbidities, distance between periconceptional caesarean section scar and vesicovaginal fold), situation at the time of uterine rupture (gestational age, interval between the current pregnancy and previous cesarean section delivery, rupture site and length, bleeding volume and number of required blood transfusions, minimum hemoglobin level), mode of the current delivery (induced delivery, transvaginal delivery, or cesarean section), and outcomes of the mother and child (postpartum hemorrhage, hysterectomy, maternal death, perinatal deaths, severe neonatal asphyxia (Apgar scores are recorded at 1, 5, and 10 min after birth, with a score below or equal to 3 indicating severe asphxia) were cllected from the patients’ medical records. This study meticulously adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement guidelines.

General information

This was a retrospective study aimed at exploring the clinical characteristics, treatment, and prognosis of all patients with complete uterine rupture between January 2015 and December 2022. The data (complete clinical data, medical history, and surgical records) of all patients with uterine rupture admitted to our hospital were retrospectively analyzed. Thirty-three patients with surgically confirmed complete uterine rupture were included into the study.

Incidence of uterine rupture in our hospital

The total number of pregnant women who delivered in our hospital during the study was 31,555, with 33 cases of complete uterine rupture, accounting for approximately 0.1%(Table 1 ). The average gestational age at complete uterine rupture was 31 +4 weeks (13 +1 –40 +3 weeks), and the average bleeding volume was 1896.97 ml (200–6000 ml) (Table 2 ).

Causes of uterine rupture

The causes of uterine rupture are shown in Table 3 . Ten patients (30.3%) had a history of cesarean section and rupture at an incision site other than the original cesarean section. Patient 2 was involved in a car accident. Patient 11 underwent an elective cesarean section, and uterine rupture was found intraoperatively: the blood flow around the rupture was not rich, the bleeding was not much, and there were no obvious symptoms. Patient 14 had a history of laparoscopic right tubal surgery with poor symptomatology due to adhesion coverage. Patient 16 had a history of cesarean section and wedge resection of the right uterine horn (> 5 years prior), two artificial abortions (AA2), and one induction of labor in middle pregnancy (20 + weeks gestation, fetal anomaly, postpartum evacuation), with poor symptomatology due to adhesion coverage. Patient 27 has a cesarean section after transabdominal cerclage (intraoperative discovery of placental implantation), with uterine rupture in the cerclage line. Patient 33 had a history of two cesarean sections; this time, she was treated with ritodrine for fetal preservation and low molecular heparin in an outside hospital due to the presence of contractions, small vaginal bleeding, fast heart rhythm, and incomplete suppression of contractions, which were not taken seriously. She was transferred to our hospital for shock and stillbirth where she underwent an emergency cesarean section.

Six patients (18.18%) had a history of uterine operation. Patient 17 had a history of one AA and two vaginal births (VB). She was involved in coitus multiple times in the week prior to the delivery, and the night before delivery, resulting in premature rupture of the membranes; she did not notify the medical staff, and the labor did not come to term. The cervical canal did not open, HS-1 (the lowest point of the fetal skull is 1 cm below the sciatic ischiadica), and 10 min after using oxytocin, cervical dilatation was at 3 cm. Oxytocin was discontinued once abnormal fetal presentation was observed. A cesarean section was performed immediately fetal heart monitoring revealed a deceleration. Patient 20 underwent a breech vaginal trial of labor, with difficulty delivering the fetal head, vaginal rupture, and uterine rupture.

Clinical signs and symptoms of uterine rupture

The clinical signs and symptoms associated with complete uterine rupture are shown in Table 4 .

There were a few special cases. Patient 1 had an intellectual disability and was unable to express her discomfort accurately. Patient 25 had a metal ring at the breach site. Patient 10 had a cesarean scar pregnancy (CSP) with abdominal blood accumulation (mass) of approximately 3200 ml. Four (12.21%) placental implantation at the incision sites. Three patients presented with severe postpartum hemorrhage, and two of them underwent hysterectomies. The third patient had a repeat vaginal delivery after three VB, two cesarean sections (CS), and one vaginal birth after cesarean (VBAC), and was transferred to our hospital with hemorrhage after delivery; intraoperative rupture of the original cesarean section incision and placenta implantation at the rupture site were observed. Patient 21 had a post-VBAC.

Treatment of uterine rupture and maternal and fetal outcomes

The fetal outcomes and treatment of uterine rupture are shown in Table 5 . Postpartum hemorrhage did not occur in 11 patients (33.33%); six (18.18%) were found to have uterine rupture during full-term, elective surgery, with little blood flow around the rupture, and little bleeding with no obvious symptoms. Two patients (6.06%) had severe adhesions. One (Patient 21) was promptly delivered by cesarean section due to abnormal fetal heart rate monitoring; and two (Patients 28 and 29) had uterine tenderness after ethacridine administration and promptly underwent cesarean section.

Incidence of complete uterine rupture

Since the opening of the separate two-child policy in 2013, full liberalization of the two-child policy in 2016, and opening of the three-child policy in 2021, the cesarean section rate in China has increased from 34.9% (2014) to 41.1% (2016) [ 15 ]. Following this, the rate of scarred uterus has increased from 9.8% (2012) to 17.7% (2016) [ 16 ], which is far beyond the World Heallth Organizations ideal range.

The incidence of uterine rupture has been reported in several countries and regions; it is not consistent across countries and regions. This rate is related not only to the high-risk factors of the pregnant women themselves, but also to the economic level of each country, number of years of occurrence (which is related to the country's policy at that time), level of medical care, and transportation status (referral time). The reported incidence of uterine rupture: is 0.06% in Northern Europe [ 17 ], 0.67% in the University of Pakistan Teaching Hospital [ 18 ], 0.01% in the First Maternity and Infant Hospital of Shanghai [ 19 ], 0.2% in the Jiangxi Maternity and Child Healthcare Hospital [ 20 ], and 0.05% in the Women's Hospital of the Medical College of Zhejiang University [ 21 ]. Following the latest data [ 22 ], the total incidence of uterine rupture in China is 0.13%, consistent with 0.1% found in this study.

Analysis of the etiology and risk factors for complete uterine rupture

Due to the low cesarean section rate and the large number of patients with two or multiple deliveries between 1960 and 1990, uterine rupture was the predominantly primary. After 1990, with the implementation of family planning policies, the cesarean section rate increased, and subsequently, cesarean section scar rupture became the primary cause of uterine rupture [ 23 ]. Therefore, with the improvement in medical standards, doctors' awareness of uterine rupture, and repeated emergency drills, the main etiology has changed.

The known etiologies and risk factors for uterine rupture are as follows [ 1 , 23 ].

Previous uterine injury or history of abnormalities.

A history of myometrial surgery and short or long intervals between surgeries, which include cesarean section (incidence of uterine rupture was 0.071% [ 21 ], 0.095% for a history of one cesarean Sect [ 24 ]., and 1.92% for a history of two or more cesarean Sects [ 24 ].), history of repair of uterine rupture (33% [ 25 ]), myomectomy, wedge resection of the uterine horn (incidence of uterine rupture is up to 30% [ 26 ]), tubal surgery, hysteroscopic septum resection (incidence of uterine rupture is 1.0%–2.7% [ 27 , 28 ]), and separation of adhesions in the uterine cavity. Human Immunodeficiency Virus (HIV) infection may increase the incidence of cesarean delivery complications [ 29 ]. Current research suggests that the uterine wound healing takes 12 weeks [ 30 ], while myometrial incision healing and scar formation takes 6–12 months [ 31 ]; however, wound healing does not mean that it is able to withstand the pressure of pregnancy immediately. It also undergoes a process of tissue reconstruction, which further strengthens the elasticity of the uterine myometrial wall in the area of the scar. Therefore, less than 12–18 months is a high-risk factor for uterine rupture [ 32 ], and 2–3 years after cesarean section is the optimal period for uterine incision healing [ 33 ]. After > 5 years [ 6 ], the uterine scar’s degree of muscularization will gradually deteriorate and it will lose elasticity, making uterine rupture more likely during another pregnancy. The risk of uterine rupture for second pregnancies has been reported in the literature, even when tubal surgery does not involve the mesosalpinx or uterine horn, with a higher risk in the presence of electrocoagulation injuries, injury to or absence of part of the myometrial layer of the uterine horn, localized unsutures, and short intervals between pregnancies. The incidence of uterine rupture in our study was 0.79 per 1000 in those with a history of cesarean section, 0.057% in those with a history of one cesarean section, and 0.022% in those with a history of two or more cesarean sections. In our study, 11 patients (33.33%) had an interval of pregnancy out of 1.5 and 5 years, two (6.06%) had a history of tubal surgery, one (3.03%) had a history of wedge resection of the uterine horn, and one (3.03%) was a person living with HIV. It is important to note that in patients with a history of uterine rupture, the rupture was not at the same location. Uterine injuries include abortion, curettage, as well as sharp or blunt contusions such as car accidents, knives, and hidden uterine ruptures. In the present study, six (18.18%) patients had a history of intrauterine manipulation as a risk factor. Congenital abnormalities include uterine dysplasia, and connective tissue defects. In the present study, two patients (6.06%) had a double uterus. Furthermore, one patient (case 7) had a history of transabdominal cervical cerclage. During pregnancy, the cerclage line increases with the uterus, creating a chronic transverse cutting effect on the cervix, Uterine rupture occurs at the site of the cervical cut once there is significant uterine contraction.

Combined uterine injuries or abnormalities in this pregnancy

Postnatal etiologies include advanced age, muliple pregnancies and deliveries, spontaneous tonic uterine contractions, excessive contractions due to the use of oxytocin or prostaglandins and maternal sensitivity to drugs, prostaglandin or saline intra-amniotic infusion, sharp forceps contusion, external inversion, amniotic fluid overload, or multiple pregnancies. In this study, one patient (3.03%) was treated with uterotonics and three (9.09%) underwent induction of labor.

Intrapartum etiologies include any mechanism leading to obstruction of fetal descent, such as pelvic stenosis, cephalopelvic disproportion, obstruction of the soft birth canal, abnormal fetal position, and macrosomia; internal inversion; forceps delivery; emergency labor; breech traction; fetus destruction; excessive dilatation of the uterus in the lower part of the uterus caused by fetal anomalies; excessive pressure in the uterine cavity during delivery; implantation of the placenta or severe adhesion; and difficulty in manually stripping the placenta. One patient (case 20) in this study had uterine rupture due to breech traction during vaginal delivery and eight (24.24%) had placenta implantation.

Acquired etiologies include gestational trophoblastic disease, adenomyosis, posterior flexion uterine implantation, and uterine artery embolization surgery. One patient in this study had adenomyosis.

CSP involves a poorly healed uterine incision, wide scarring, and inflammation, leading to the development of microscopic fissures through which the fertilized ovum is deposited into the myometrium. Most cases have a poor prognosis [1]. Only one case of CSP was reported in this study.

Placental implantation: when it occurs at the site of the original cesarean section scar is caused by a structural defect in the endometrium [ 23 ] that allows the placenta to attach abnormally to the uterine myometrium. In our study, four patients (12.12%) had placental implantation, with three who had severe postpartum hemorrhage and two who underwent hysterectomies.

Trial of labor after cesarean (TOLAC), during a second pregnancy or request for a vaginal trial of labor; A meta-analysis showed that TOLAC results in a 0.27% higher risk of uterine rupture [ 9 ]. The management of TOLAC is a multifactorial. Factors [ 34 , 35 ] such as a previous vaginal delivery, use of epidural anesthesia, indication for previous cesarean section, pregnancy complications (such as preeclampsia, and placental anomalies), fetal weight above 4000 g, dose of oxytocin used, induction of labor with prostaglandins, women who delivered at > 41 +0 weeks of gestation, ethnicity, cervical length, head-perineum distance, maternal age (maybe), inter-delivery interval, body mass index (maybe), and prolonged second stage of labor (maybe) contribute to uterine rupture during TOLAC. However, there are no data or literature supporting whether to perform a TOLAC and assess the risk of uterine rupture in a second pregnancy after a history of two cesarean deliveries and after one VBAC.

Endometriosis causes tissue adhesions. Surgical separation of these adhesions results in localized myometrial destruction and thinning, affecting the healing, brittleness, and elasticity of the scar. Patient 6 had this clinical presentation. It has also been shown that the distance from the cesarean scar to the vesicovaginal fold (suggestive of the horizontal position of the uterine incision from the previous cesarean section) is significantly increased in patients with a gestational age > 22 weeks and antepartum uterine rupture, and may be predictive of uterine rupture [ 9 ].

Regardless of how the uterus is damaged, scarring occurs during the repair process, which constitutes non-normal muscle tissue (connective and scar tissue) [ 1 ]. This forms a weak site of the uterus during pregnancy. We obseerved that uterine rupture occurred at a random site, mainly at the weakest point of the uterus. There is no effective means for detecting or predicting the weakest point of the uterus. In addition, the uterus may have ruptured in more than one location (Patient 2 had three ruptures).

Clinical manifestations and early diagnosis of uterine rupture

In general, most uterine ruptures progress from uterine rupture precursors, with the main clinical manifestations being abdominal pain (especially during the intervals between contractions), uterine tenderness (reported in the literature to be approximately 36.0% [ 21 ]), fetal abnormalities, abnormal vaginal bleeding, pathological contractions, hematuria, disappearance of contractions, hemodynamic instability (tachycardia, hypotension, or shock), change of fetal position, signs of uterine rupture detected by ultrasound, and changes in abdominal contour [ 1 ]. Some symptoms are asymptomatic; however, typical symptoms are rare (less than 10% [ 36 ]). Currently, pregnancy relies on the co-monitoring of history, clinical presentation, signs, and ultrasonography or magnetic resonance imaging (MRI). It is very difficult to rely on pregnancy management to prevent uterine rupture, which may be due to the following: the timing of uterine rupture is random, the rupture may be unrelated to the original surgical site, most patients have multiple risk factors, and the weakest part of the uterus may change with gestational age and cannot be predicted in advance. The time window for uterine rupture is difficult to control. The time may be longer in patients with thick abdominal fat and varying pain tolerance. If referral is required (long travel time), the optimal time for resuscitation is easily delayed. Abdominal pain, fetal distress, and vaginal bleeding do not allow us to initially consider uncommon uterine ruptures. Clinicians have limitations in considering abdominal pain, which is prone to misdiagnosis as other acute abdominal conditions or labor precursors. Furthermore, multiple pregnancies, literacy levels, and family economic status may lead to irregularities during obstetrical tests. Uterine rupture most often occurs suddenly most ofter, with immediate surgery performed upon diagnosis, failure to achieve continuous fetal heart monitoring, or fetal death at the time of presentation. Other conditions that do not directly lead to uterine rupture but can interfere with early recognition, such as mental retardation, history of frequent coitus, history of abdominal trauma, unawareness of the condition by family members (inability to provide an accurate history when the patient is in shock), use of ritodrine (rapid heart rate) and vomiting during pregnancy, can mask the early signs of shock. Color ultrasonography and MRI can be affected by the level of the examiner, thickness of abdominal fat in the pregnant woman, measurement site, number of measurements, bladder filling, rupture site (posterior wall rupture is difficult to diagnose), fetal movement, dynamic monitoring or not, and clarity of the ultrasound machine. In addition, the presence of unknown previous surgery (inverted T-shaped incision, uterine monolayer suture, weak local myometrium, infection, poor healing of incision, cause of postpartum hemorrhage, and method used to stop bleeding), diverticulum of the uterine incision (occurs in approximately 60% of patients after a primary cesarean section and 100% after three cesarean Sects [ 37 ].), any perforation during uterine manipulation, artificial placental removal during previous delivery, and subsequent follow-ups can affect the diagnosis of uterine rupture. In particular, the healing of the original cesarean section scar is unknown; a study showed that the use of synthetic absorbable monofilament sutures for uterine closure was associated with increased residual myometrial thickness, with respect to synthetic absorbable multifilament sutures. A uterine segment thickness after cesarean section below 2.0 mm between 35 and 38 gestational weeks has been repetitively associated with a greater risk of uterine rupture or scar dehiscence [ 37 ]. Furthermore, when the breach is small and there are no blood vessels at the breach, there may be no obvious symptoms or imaging changes. Atypical symptoms, difficult diagnosis of intra-abdominal hemorrhage, and unsupportive ancillary tests plague surgical decision-making. There is limited data on some factors that may affect the healing of the uterine incision [ 23 ] (previous history of postpartum hemorrhage, gestational diabetes mellitus or diabeties as a comorbidity, embryo transplantation, hypertensive disorders of pregnancy, and hypoproteinemia), and factors that may provide local protection, such as the severity of the pelvic-abdominal adhesions (three patients in this study had little hematochezia or peritoneal hemorrhage). Therefore, the education of pregnant women and their families, as well as the rapid recognition of uterine rupture after it occurs, are key to early diagnosis.

Complications of complete uterine rupture

Uterine rupture can cause severe postpartum hemorrhage, shock, disseminated intravascular coagulation, impaired organ function (ischemia–reperfusion), bladder injury, massive blood transfusion, hysterectomy, maternal death, neonatal asphyxia, ischemic-hypoxic encephalopathy, perinatal death (fetal or neonatal death), and other serious adverse outcomes.

Good prenatal and pregnancy care (contraceptive promotion, previous surgical records, control of diet weight gain, etc.), graded management (all women need to be risk-graded, strict control of high-risk factors, and timely referral), and early hospitalization of patients with high-risk factors for uterine rupture are key to the early diagnosis and treatment of uterine rupture. For patients with reproductive requirements, strict control of surgical indications, strengthening of suturing skills, guidance on postoperative precautions, strict control of indications for uterotonics and close monitoring are important. Correct management of the labor process, mastery of the indications for obstetric surgically assisted delivery and operation norms, and strict inspection during surgery (e.g., abdominal cervical cerclage patients to check the integrity of the lower segment of the uterus in the posterior wall) are also required. Regardless of high-risk factors, vigilance for uterine rupture, early recognition, proactive management, and training of rapid response teams should be strengthened to achieve favorable maternal and fetal outcomes.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Abbreviations

Artificial Abortion

Caesarean Section

Caesarean Scar Pregnancy

Complete Placenta Previa

Caesarean Scar to Vesicovaginal Fold Distance

Chronic Hypertension

Chronic Hypertension with Superimposed Preeclampsia

Ectopic Pregnancy

Endometriosis

Gestational Diabetes Mellitus

Pregestational Diabetes Mellitus

Hypertensive Disorders of Pregnancy

Induce Childbirth

In Vitro Fertilization and Embryo Transfer

Low Molecular Weight Heparin

Marginal Placenta Previa

Placenta Accreta

Placenta Increta

Pernicious Placenta Previa

Postpartum Hemorrhage

Trial Of Labor After Cesarean

Uterine Myomectomy

Vaginal Birth

Vaginal Birth after Cesarean

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Acknowledgements

We would like to express my gratitude to all those who helped me during the writing of this thesis.

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The Chenzhou No.1 People’s Hospital, Chenzhou, 423000, China

Jing Xie & Miao Liu

The First Affiliated Hospital of Xiangnan University, Chenzhou, 423000, China

Department of Radiology, Renmin Hospital of Wuhan University, No. 238 Jiefang Road, Wuchang District, Wuhan, 430060, China

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JX performed the data analysis; ML performed the formal analysis; XFL performed the validation; JX wrote the manuscript. All authors read and approved the final manuscript.

Author’s information (Optional)

JX, female, 1989.06, resident physician, Master's Degree, Department of Obstetrics, the First People’s Hospital of Chenzhou/ the First Affiliated Hospital of Xiangnan University, Chenzhou 423000, China. Main research interest: Obstetric hemorrhage related diseases. XFL, female, 1988.10, attending physician, Master's Degree, Department of Radiology, Renmin Hospital of Wuhan University, Wuhan 430060, China. Main research interest: Radiodiagnosis. ML, female, 1975.11, head physician, Master's Degree, Department of Obstetrics, the First People’s Hospital of Chenzhou/ the First Affiliated Hospital of Xiangnan University, Chenzhou 423000, China. Main research interest: Obstetric hemorrhage related diseases.

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Correspondence to Xuefang Lu .

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The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This study was approved by the Ethics Committee of the First People’s Hospital of Chenzhou City (Approval No.论2024006). The informed consent requirement was waived by the Ethics Committee of the First People’s Hospital of Chenzhou City because of the retrospective study design.

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Xie, J., Lu, X. & Liu, M. Clinical analysis of complete uterine rupture during pregnancy. BMC Pregnancy Childbirth 24 , 255 (2024). https://doi.org/10.1186/s12884-024-06394-2

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Received : 16 September 2023

Accepted : 05 March 2024

Published : 08 April 2024

DOI : https://doi.org/10.1186/s12884-024-06394-2

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Complete uterine rupture
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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. 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 ...
Breech Baby: Causes, Complications, Turning & Delivery
A breech baby, or breech birth, is when your baby's feet or buttocks are positioned to come out of your vagina first. Your baby's head is up closest to your chest and its bottom is closest to your vagina. Most babies will naturally move so their head is positioned to come out of the vagina first during birth. Breech is common in early ...
Overview of breech presentation
Breech presentation, which occurs in approximately 3 percent of fetuses at term, describes the fetus whose presenting part is the buttocks and/or feet. Although most breech fetuses have normal anatomy, this presentation is associated with an increased risk for congenital malformations and mild deformations, torticollis, and developmental ...
Breech Presentation
Breech Births. In the last weeks of pregnancy, a baby usually moves so his or her head is positioned to come out of the vagina first during birth. This is called a vertex presentation. A breech presentation occurs when the baby's buttocks, feet, or both are positioned to come out first during birth. This happens in 3-4% of full-term births.
Fetal Presentation, Position, and Lie (Including Breech Presentation
Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.
Fetal Presentation, Position, and Lie (Including Breech Presentation
Presentation refers to the part of the fetus's body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.
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 management: A critical review of leading clinical
This pamphlet explains what a breech presentation is, the different types of breech presentation, discusses ECV and provides balanced information related to birth mode options along with visual representations of statistics comparing the perinatal mortality rate between cephalic vaginal birth, VBB and C/S. This pamphlet was also developed in ...
Breech Presentation: Types, Causes, Risks
Breech presentation is typically diagnosed during a visit to an OB-GYN, midwife, or health care provider. Your physician can feel the position of your baby's head through your abdominal wall—or ...
If Your Baby Is Breech
In a breech presentation, the body comes out first, leaving the baby's head to be delivered last. The baby's body may not stretch the cervix enough to allow room for the baby's head to come out easily. There is a risk that the baby's head or shoulders may become wedged against the bones of the mother's pelvis.
Breech Presentation: Overview, Vaginal Breech Delivery ...
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 births at term.
Management of Breech Presentation
Observational, usually retrospective, series have consistently favoured elective caesarean birth over vaginal breech delivery. A meta-analysis of 27 studies examining term breech birth, 5 which included 258 953 births between 1993 and 2014, suggested that elective caesarean section was associated with a two- to five-fold reduction in perinatal mortality when compared with vaginal breech ...
Breech Presentation
Breech presentation is a type of malpresentation and occurs when the fetal head lies over the uterine fundus and fetal buttocks or feet present over the maternal pelvis (instead of cephalic/head presentation). The incidence in the United Kingdom of breech presentation is 3-4% of all fetuses. 1.
Breech
Overview. There are three types of breech presentation: complete, incomplete, and frank. Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth canal. Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.
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 ...
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 ...
PDF Breech
Breech -Management of. Uncontrolled document when printed Published: 27/07/2020 Page 1 of 15. 1. Purpose. This document provides details of clinical management of women who have a diagnosis of breech presentation during pregnancy or intrapartum at the Women's. This procedure outlines the decision and management process required for: breech ...
Breech birth
Complete breech presentation is the next most favorable position, but these babies sometimes shift and become footling breeches during labour. Footling and kneeling breeches have a higher risk of cord prolapse and head entrapment. Parity - Parity refers to the number of times a woman has given birth before. If a woman has given birth ...
Management of term breech presentation
Undiagnosed term breech presentation can largely be prevented by routine third-trimester ultrasound. Research is needed to evaluate the efficacy of VBB simulation training in clinical practice. Learning objectives. To understand the evidence base around breech presentation at term, including ECV, VBB, caesarean section and adjunctive methods of ...
Clinical analysis of complete uterine rupture during pregnancy
One patient (case 20) in this study had uterine rupture due to breech traction during vaginal delivery and eight (24.24%) had placenta implantation. Acquired etiologies include gestational trophoblastic disease, adenomyosis, posterior flexion uterine implantation, and uterine artery embolization surgery. One patient in this study had adenomyosis.

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Clinical analysis of complete uterine rupture during pregnancy

Conclusions

Diagnostic criteria

Research methods

General information

Incidence of uterine rupture in our hospital

Causes of uterine rupture

Clinical signs and symptoms of uterine rupture

Treatment of uterine rupture and maternal and fetal outcomes

Incidence of complete uterine rupture

Analysis of the etiology and risk factors for complete uterine rupture

Clinical manifestations and early diagnosis of uterine rupture

Complications of complete uterine rupture

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