Journal of Perinatology (2014) 34, 1115

& 2014 Nature America, Inc. All rights reserved 0743-8346/14

www.nature.com/jp

ORIGINAL ARTICLE

Breech presentation at delivery: a marker for congenital anomaly?

D Mostello1, JJ Chang2, F Bai2, J Wang3, C Guild4, K Stamps2 and TL Leet2,{
OBJECTIVE: To determine whether congenital anomalies are associated with breech presentation at the time of birth.
STUDY DESIGN: A population-based, retrospective cohort study was conducted among 460 147 women with singleton live births
using the Missouri Birth Defects Registry, which includes all defects diagnosed during the rst year of life. Maternal and obstetric
characteristics and outcomes between breech and cephalic presentation groups were compared using w2-square statistic and
Students t-test. Multivariable binary logistic regression analysis was used to estimate adjusted odds ratios (aORs) and 95%
condence intervals (CIs).
RESULT: At least one congenital anomaly was more likely present among infants breech at birth (11.7%) than in those with cephalic
presentation (5.1%), whether full-term (9.4 vs 4.6%) or preterm (20.1 vs 11.6%). The relationship between breech presentation and
congenital anomaly was stronger among full-term births (aOR 2.09, CI 1.96, 2.23, term vs 1.40, CI 1.26, 1.55, preterm), but not in all
categories of anomalies.
CONCLUSION: Breech presentation at delivery is a marker for the presence of congenital anomaly. Infants delivered breech deserve
special scrutiny for the presence of malformation.
Journal of Perinatology (2014) 34, 1115; doi:10.1038/jp.2013.132; published online 24 October 2013
Keywords: congenital abnormalities; labor presentation; pregnancy outcome; registries

INTRODUCTION
In about 4% of pregnancies, the fetus is in breech presentation at
the time of delivery.1 Although the immediate impact of this
nding for the obstetrician is typically on mode of delivery, the
reason why the fetus failed to assume the cephalic presentation
warrants consideration. Unfortunately, the mechanism controlling
fetal alignment for delivery is not clear. Hypotheses to explain why
the fetus fails to assume the cephalic presentation include primary
fetal disorders, such as fetal neuromuscular dysfunction or
neurologic decits2,3 or spatial considerations, such as uterine
anomalies,1 site of placental implantation4 or amount of amniotic
uid,5,6 which may interfere with the process of achieving cephalic
presentation. These theories revolve around primarily mechanical
factors due to the lack of proper fetal movement or tone,7 a bulky
hydrocephalic head or lack of proper uterine architecture due to
over-distention or a lax maternal abdominal wall.
Although these explanations seem logical, existing data do not
support these hypotheses. For example, although breech presentation occurs in almost one-third of infants with dysautonomia, no
greater hypotonia is noted in those who present breech vs cephalic.8
In addition, when controlled for gestational age at birth, breech
presentation was not associated with polyhydramnios or placenta
previa in a large population-based study.7 Indeed, recognition of a
potential mechanical factor to explain presentation is found in only
15% of breech deliveries systematically assessed for them.6
Braun et al.2 proposed the concept that breech presentation
may constitute an important indicator of a deeper underlying
problem in fetal morphogenesis and/or function of which the
breech presentation is only one manifestation. Although it has

been an obstetric maxim that congenital anomalies are associated

with breech presentation,5 the data supporting this assertion are
from studies limited by their small sample sizes2,5,6,911 (especially
problematic when reporting rates of uncommon anomalies), lack
of stated method of ascertainment of anomalies,5,11 incomplete
statistical analysis,2,10 ndings limited to those reported on birth
certicates,7 and experience reported from a single institution.5
If breech presentation is indeed a marker for underlying
abnormality, the presence of breech presentation near the time
of delivery becomes an important trigger for the obstetrician and
pediatrician to think beyond scheduling the Cesarean section and
checking for hip clicks to an enhanced scrutiny of the fetal/
newborn anatomy and function.
We sought to address the question of whether congenital
anomaly in the newborn is associated with breech presentation at
the time of live birth, using population-based data with a reliable
source of anomaly ascertainment, and multivariable analysis to
identify and control for relevant confounding factors.
METHODS
The Missouri Birth Defects Registry is a passive data collection system that
identies live-born infants diagnosed with birth defects during the rst
year of life. This registry receives information from multiple sources,
including birth and death certicates, abstracts of medical records of
newborn and pediatric patients from both inpatient and outpatient
encounters, and a special healthcare needs database.
Using this resource, a population-based, retrospective cohort study was
conducted among women who gave birth at 24 weeks gestation or greater
in Missouri between January 1, 1993 and December 31, 1999, and the

1
Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Womens Health, School of Medicine, Saint Louis University, St Louis, MO, USA; 2Department of
Epidemiology, School of Public Health, Saint Louis University, St Louis, MO, USA; 3Department of Biostatistics, School of Public Health, Saint Louis University, St Louis, MO, USA
and 4Department of Pediatrics and the Center for Outcomes Research, School of Medicine, Saint Louis University, St Louis, MO, USA. Correspondence: Dr D Mostello, Division of
Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Womens Health, School of Medicine, Saint Louis University, 6420 Clayton Road, St Louis, MO 63117, USA.
E-mail: mostello@slu.edu
Presented at the 32nd Annual Meeting of the Society for Maternal-Fetal Medicine, February 611, 2012, Dallas, TX, USA.
{
Dr Leet is deceased.
Received 1 May 2013; revised 1 September 2013; accepted 13 September 2013; published online 24 October 2013

Breech presentation and congenital anomaly

D Mostello et al

12
Table 1.

Demographic, obstetric and medical characteristics by fetal presentation at delivery stratified by term status

Characteristics

Cephalic
n 415 273 (%)

Breech
n 11 939 (%)

26.3 (5.9)
9
49.2
34.7
7.1

27.3 (6.0)
7.5
43.8
38.9
9.8

Maternal race
Non-Hispanic whites
Non-Hispanic blacks
Others

82
14.7
3.4

89
7.7
3.3

Maternal education
High school diploma or lower
Some college or higher

53.7
46.3

48.9
51.1

Maternal low SES

47.6

40.8

Maternal age (years), Mean (s.d.)

1218
1927
2835
435

Parity
0
1
X2
Smoking usage
Alcohol usage
Hydramnios/oligohydramnios
Diabetes
Renal disease
Hypertension, preeclampsia
Cardiac disease
Late or no prenatal care
Female child
Childs birth weight (g), Mean (s.d.)
Gestational age (weeks), Mean (s.d.)
SGA

o37 weeks

P-value

X37 weeks

o0.0001
o0.0001

P-value

Cephalic
n 30 063 (%)

Breech
n 2872 (%)

25.8 (6.3)
12.7
49.3
30.5
7.6

26.7 (6.5)
9.5
46.9
33
10.7

o0.0001

o0.0001
71.3
25.6
3.1

81
16.3
2.7

62.3
37.7

58.2
41.8

57.3

51.5

o0.0001

o0.0001

40.8
33.6
25.6

54.5
27.3
18.1

19.5
1.3
1.5
2.4
0.24
4.5
0.63
14.5
54.7
3442 (476)
39.4 (1.1)
9.5

21.2
1.5
3.2
3.2
0.22
4.6
0.75
12
48.8
3334 (505)
39.0 (1.1)
13.8

o0.0001
0.12
o0.0001
o0.0001
0.70
0.72
0.12
o0.0001
o0.0001
o0.0001
o0.0001
o0.0001

o0.0001
o0.0001

o0.0001

o0.0001
45.7
27.9
26.4

49.4
28.4
22.2

25.7
2.4
4.4
4.3
0.77
14.8
0.83
20.9
50.0
2446 (652)
34.4 (2.3)
15.9

27.5
2.1
10.7
4.8
0.9
15.1
0.87
16.7
46.9
2083 (749)
32.7 (3.3)
20.2

o0.0001
o0.0001

0.04
0.3
o0.0001
0.23
0.43
0.64
0.80
o0.0001
0.002
o0.0001
o0.0001
o0.0001

Abbreviations: SES, socioeconomic status; SGA, small for gestational age.

Data are percent of n unless specified as mean /  standard deviation (s.d.).

resulting offspring from these births. The study population consisted of all
Missouri residents who delivered singleton pregnancies. Eligible women
were identied by using birth certicate and birth defects registry data.
Only singleton live births were included to avoid the confounding effects
of multiple gestation on breech presentation and other adverse outcomes,
such as shorter pregnancy duration and low birth weight. We excluded
pregnancies complicated by placenta previa as a possible confounder for
breech presentation.1,4 The study cohort included women with a fetus in
either breech or cephalic presentation at the time of delivery. Other
presentations were excluded.
Breech presentation was considered present at the time of delivery if it was
checked on the birth certicate. Congenital anomalies were identied through
the Missouri Birth Defects Registry. Congenital anomalies were analyzed in
toto as well as in specic systems, including chromosomal anomalies, central
nervous system anomalies, cardiovascular anomalies, oral clefts, gastrointestinal anomalies, urogenital anomalies and musculoskeletal anomalies. We
also created a category for multi-system anomalies, dened as anomalies
identied in more than one system, as a proxy for complex anomalies and
congenital syndromes that may involve multiple organ systems.
Maternal and fetal factors previously found to be associated with either
breech presentation or congenital anomalies were evaluated as potential
confounders (listed in Table 1): Maternal demographic, lifestyle and
pregnancy characteristics included maternal age, race, low socioeconomic
status, education, cigarette smoking, alcohol consumption, parity and late
or no prenatal care. Obstetric and maternal medical risk factors included
hydramnios or oligohydramnios, diabetes of any type, renal disease,
chronic hypertension or preeclampsia, and cardiovascular disease. Infant
characteristics, such as birth weight, gender, and gestational age were also
assessed in the analysis. Some risk factors and potential confounders are
not available elds in the database, including maternal congenital
anomalies, maternal uterine anomalies, and the performance of an
external cephalic version prior to delivery. Maternal age was analyzed as
Journal of Perinatology (2014), 11 15

a categorical variable to account for a potential nonlinear relationship and

categorized as less than 18 years, 19 to 27 years, 28 to 35 years, and 36
years or older. Race was categorized as non-Hispanic white, non-Hispanic
black and other. Low socioeconomic status was dened as enrollment in
any of the programs including Medicaid, Women, Infants and Children, or
the Food Stamp Program. Education was divided into two groups: lower
than or equal to a high school degree and some college or more. Cigarette
smoking and alcohol consumption were treated as dichotomous variables.
Parity was dened as prior live births and categorized into three groups, 0,
1 and X2. Prenatal care was categorized as care beginning during the rst
trimester, and care beginning after the rst trimester (late) or no care
through the pregnancy. Small for gestational age was also used as an
indicator of relative infant birth weight, which was dened as birth weight
below the tenth percentile for the clinical estimate of gestational age
based on a national standard.12
In the descriptive analysis, the w2-square statistic was used for
categorical data and Students t-test for continuous variables to study
and compare the characteristics between breech and cephalic presentation groups. Because the rate of breech presentation at birth is inversely
proportional to gestational age,13 we stratied our bivariable and
multivariable analyses by term status categorized as preterm birth (o37
weeks) or full-term birth (X37 weeks). The descriptive analysis, therefore,
also was stratied to allow for easier reference and comparison. We
conducted bivariable analysis between outcomes of interest and
presentation using the w2-square statistic. Multivariable binary logistic
regression analysis was used to estimate odds ratios and 95% condence
intervals (CIs). Potential confounders were evaluated using the 10%
change-in-point-estimate rule in the multivariable analysis.14 Primary
outcomes were congenital anomaly of any kind, congenital anomaly
affecting specic organ systems, or multi-system anomalies. All statistical
analyses were conducted using SAS, version 9.1 software (Cary, NC, USA).
All tests were two-tailed, and Po0.05 was considered signicant.
& 2014 Nature America, Inc.

Breech presentation and congenital anomaly

D Mostello et al

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Table 2.

Anomalies according to presentation at birth, stratified by term status

Congenital anomaly

Breech
n 11 939 n (%)
Any anomalies
Central nervous system
Cardiovascular
Oral clefts
Gastrointestinal
Urogenital
Musculoskeletal
Chromosomal
Multi-system

1126
77
226
33
83
200
587
56
137

(9.4)
(0.6)
(1.9)
(0.3)
(0.7)
(1.7)
(4.9)
(0.5)
(1.2)

Cephalic
n 415 273 n (%)
19234
915
5219
707
2308
4968
4463
677
1591

(4.6)
(0.2)
(1.3)
(0.2)
(0.6)
(1.2)
(1.1)
(0.2)
(0.4)

This study was considered by Saint Louis University Institutional Review

Board as non-human subject research, owing to the use of de-identied
data, and no further oversight was needed.

RESULTS
A total of 519 504 births in Missouri occurred over the study
period, among which 475 551 met the inclusion criteria. In total,
460 147 subjects were included in the nal analysis, as 15 404
women had at least one missing value for the outcome or other
variables included in the analysis. The study group included
14 811 (3.2%) women with breech presentation and 445 336
(96.8%) women with cephalic presentation. There were 32 935
(7.2%) preterm births among all subjects in the study population.
The incidence of breech presentation was 2.8% among full-term
births, and 9.5% among preterm births.
Sample characteristics by fetal presentation, stratied by term
status, are shown in Table 1. The preterm birth group and full-term
birth group shared similar distributions of most characteristics,
although many were statistically different. Women giving birth
with breech presentation were signicantly older, more likely to
have higher levels of education and socioeconomic status, to be
non-Hispanic white and nulliparous. They also were more likely to
have an abnormality of amniotic uid volume. Infants born breech
were more likely to be small for gestational age. In those women
delivering at term, diabetes was more prevalent in those with
breech presentation. Of those women who delivered preterm,
those whose infants were in breech presentation had infants of
lower gestational age and birth weight.
At least one congenital anomaly was more likely to be present in
infants in the breech presentation (11.7%) than those in cephalic
presentation (5.1%) at birth. Table 2 shows the rates of congenital
anomaly for breech vs cephalic presentation for both preterm
(20.1% vs 11.6%) and term deliveries (9.4% vs 4.6%). The pattern
was similar for chromosomal anomalies and in specic organ
systems including central nervous, cardiovascular, oral clefts,
urogenital, gastrointestinal and musculoskeletal. Those who delivered preterm were more likely to have congenital anomalies
regardless of presentation. Among the systems we analyzed,
cardiovascular, musculoskeletal and urogenital anomalies were
the most common for both term and preterm groups. Multi-system
anomalies were more likely in infants born from the breech
presentation than in cephalic-presenting infants in both term (1.2%
vs 0.4%) and preterm groups (4.3% vs 2%). We detected a
signicant interaction effect between breech presentation and term
status for anomalies in the following systems: central nervous
(Po0.01), cardiovascular (Po0.02) and musculoskeletal (Po0.0001).
This conrmed our decision, based on clinical observation, to
stratify by term status. Within each stratum, gestational age was an
important confounder for the association of congenital anomalies
& 2014 Nature America, Inc.

o37 weeks

P-value

X37 weeks

Breech
n 2872 n (%)
o0.0001
o0.0001
o0.0001
0.006
0.04
o0.0001
o0.0001
0.0001
o0.0001

600
83
238
20
64
100
161
38
123

(20.1)
(2.9)
(8.3)
(0.7)
(2.2)
(3.5)
(5.6)
(1.3)
(4.3)

P-value

Cephalic
n 30 063 n (%)
3474
462
1363
84
484
600
718
205
592

(11.6)
(1.5)
(4.5)
(0.3)
(1.6)
(2)
(2.4)
(0.7)
(2)

o0.0001
o0.0001
o0.0001
0.0001
0.01
o0.0001
o0.0001
0.0001
o0.0001

with breech presentation; therefore, we controlled for gestational

age (by week) in the multivariable analyses.
Owing to the signicantly different distributions of risk by fetal
presentation, we evaluated maternal age, race, education, socioeconomic status, parity, smoking, alcohol usage, amniotic uid
abnormalities, maternal medical conditions during pregnancy,
insufcient prenatal care and infants small for gestational age
status, sex, as well as gestational age as potential confounding
variables. Of these covariates, only gestational age (by week)
changed the point estimates by 10% or more. After adjustment for
gestational age and some other clinically relevant variables,
having at least one congenital anomaly occurred with greater
likelihood in infants delivered with breech presentation than in
those with cephalic presentation (for full-term birth: aOR (adjusted
odds ratio) 2.09, 95% CI: 1.96, 2.23, and for preterm birth:
aOR 1.40, 95% CI: 1.26, 1.55, Table 3). The odds of having a
congenital anomaly in a specic organ system when born breech
compared with cephalic are shown in Table 3 for both preterm
and term births. Though infants born preterm were more likely to
have a congenital anomaly, a stronger association between
congenital anomaly and breech presentation was seen for fullterm birth, and specically for central nervous system, musculoskeletal system, and chromosomal anomalies. Oral clefts showed
a stronger relationship with breech presentation in preterm rather
than full-term births.
DISCUSSION
Our nding of a greater likelihood of congenital anomaly in
infants with breech presentation supports the concept of an
underlying problem in fetal morphogenesis or function2 of which
the breech presentation is only one sign. Although in no way do
we consider the presence of breech presentation in the causal
pathway of most congenital disorders, breech presentation is an
easily identiable factor at the time of birth that may signal the
presence of an underlying abnormality. The association is present
for many categories of anomalies and not limited only to
chromosomal and central nervous system defects. The high
percentage of births affected by congenital anomalies in our study
is about twice the rates reported in other studies5,7,11,15 some of
which used only birth certicate data or other short-term
ascertainment of cases. Our overall rates are in a similar range
as those referred to by Cruikshank1 in his review of breech
presentation and by Kauppila16 in his comprehensive assessment
of perinatal mortality in breech deliveries, but categories of
anomalies were not specied in these reports.
Despite the common practice of a midtrimester, sonographic
anomaly screen, prenatal detection of abnormalities was estimated at 64% in the best of hands and at 13% in non-tertiary
centers.17 The largest study addressing prenatal detection rates18
Journal of Perinatology (2014), 11 15

Breech presentation and congenital anomaly

D Mostello et al

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Table 3. Multivariable analyses: odds of having a congenital anomaly with breech compared to cephalic presentation at delivery, stratified by
term status

cOR (95% CI)

Any anomalies
Central nervous
Cardiovascular
Oral clefts
Gastrointestinal
Urogenital
Musculoskeletal
Chromosomal
Multi-system

o37 weeks (n 32 935)

X37 weeks (n 427 212)

Congenital anomalies

2.15
2.94
1.52
1.63
1.26
1.41
4.76
2.89
3.15

(2.01,
(2.33,
(1.33,
(1.15,
(1.01,
(1.22,
(4.36,
(2.20,
(2.64,

2.29)
3.71)
1.73)
2.31)
1.57)
1.62)
5.20)
3.79)
3.76)

aOR (95% CI)a

2.09
2.61
1.40
1.51
1.21
1.46
4.47
1.91
2.18

(1.96,
(2.06,
(1.22,
(1.06,
(0.97,
(1.26,
(4.08,
(1.44,
(2.05,

2.23)
3.30)
1.60)
2.14)
1.50)
1.69)
4.89)
2.54)
2.33)

cOR (95% CI)

2.02
1.91
1.90
2.50
1.39
1.77
2.43
1.95
2.39

(1.84,
(1.51,
(1.65,
(1.54,
(1.07,
(1.43,
(2.04,
(1.38,
(1.96,

2.23)
2.41)
2.20)
4.08)
1.81)
2.20)
2.89)
2.77)
2.92)

aOR (95% CI)a

1.40
1.14
1.24
1.91
1.04
1.43
2.00
1.52
1.40

(1.26,
(0.89,
(1.04,
(1.13,
(0.79,
(1.14,
(1.66,
(1.05,
(1.26,

1.55)
1.46)
1.48)
3.21)
1.36)
1.79)
2.40)
2.21)
1.56)

Abbreviations: aOR, adjusted odds ratio; CI, confidence interval; cOR, crude odds ratio.
a
Adjusted for maternal age, race, education, low socioeconomic status, smoking, alcohol usage, diabetes, hydramnios/ oligohydramnios, childs sex, small for
gestational age and gestational age (by week).

used infant status at birth and at 6 days as the standard for the
presence of anomalies, and only calculated detection rates based
on sonographically detectable abnormalities, so the percentage of
abnormalities identied prenatally is likely lower than reported.
Therefore, the presence of breech presentation at birth can be an
important marker to raise the index of suspicion in evaluating
newborns for the presence of anomalies. Although ultrasound
technology has improved over time, making it possible that a
greater number of anomalies would be detected prenatally now
when compared with when these studies were done, the increase
in maternal obesity and continued limited access to high-quality
ultrasound services may counteract the advances in technology.
In the Collaborative Project, infants who were delivered breech
fared worse on individual components of the neurological
examination at 1 year compared with children of cephalic
deliveries.10 This greater neurologic morbidity in those delivered
breech has been attributed to the mode of delivery,10 but the
presumption of birth trauma in vaginal breech deliveries may
have precluded detection of an association between neurologic
function and the presentation itself. Braun et al.2 was prescient in
proposing that the decient function may be of prenatal onset
and the reason behind the breech presentation as well.
Our ndings conrm those from other studies which show
congenital anomalies are signicantly associated with breech
presentation.2,5,11 Brenner et al.5 also found overall rates for
congenital abnormalities of every organ system were higher in
breech deliveries, but owing to smaller numbers, found signicant
differences in only a few systems after correction for confounding
factors. Of the congenital anomalies (116 in total) found by Mazor
et al.11 among breech deliveries at a single institution in Israel, the
organ system most involved was musculoskeletal, with dislocation
of the hip accounting for 83% of the cases. In our study,
congenital dislocation of the hip was present in about 25% of
breech infants with anomalies at term and about 6% of breech
infants with anomalies born preterm (data not shown). Braun
et al.2 reported on specic genetic disorders of infants and
associations with breech presentation at delivery. Unfortunately,
our database did not specify diagnoses to the same level of detail.
Term status modies the association between risk of congenital
anomaly and presentation at birth. The stronger association of
congenital anomaly with breech presentation at term compared
with preterm is not surprising. As the rate of breech presentation
at birth is inversely proportional to gestational age,12 some of the
breech presentations in the premature cohort may be explained
by early gestational age alone, with labor or other reason
for delivery occurring before the fetus would have converted
to a cephalic presentation on her own. Similarly, factors that
predispose to preterm labor may also predispose to breech
Journal of Perinatology (2014), 11 15

presentation,1 so the cohort of preterm births in which breech

presentation is associated with anomaly may be diluted by breech
presentation due to other factors. Brenner et al.5 found that most
of the infants with congenital abnormalities were delivered after
35 weeks gestation and Mazor et al.11 reported that 90% of all
congenital anomalies occurred in neonates weighing 2000 g or
more at birth. Indeed, our ndings show that 80% of infants with
anomalies are delivered at term.
Our ndings substantiate birth certicate7 and Collaborative
Project10 ndings of association of breech presentation with
older maternal age,7,10 primiparity,7 low birth weight,7,10 shorter
duration of gestation,6,7,10 maternal diabetes, smoking and
Caucasian race. No explanations for these associations have been
established to date. High parity is considered a risk factor for breech
presentation, but an association of breech presentation with a
parity of two or more was not evident in our study. The association
observed in prior studies seems to apply only at parity X510 or 6,3
and sample size for that degree of parity is small in our database.
The major strengths of our study include the large numbers of
subjects from the population-based design and the comprehensive ascertainment of anomalies through the rst year of life by
the Birth Defects Registry. Not all birth defects are obvious at birth.
Indeed, ascertainment limited to defects observed at birth or
shortly thereafter would likely capture most neural tube defects,
for example, but would miss a signicant percentage of heart and
other defects.17,19,20 When assessed over a longer period, about
19% of cases of birth defects are diagnosed prenatally, 48%
between birth and one month of age, and 12% between one
month and a year of age.20 Another 12% are found later in
childhood.20 Registries of birth defects, such as the one we used,
have improved case ascertainment with inclusion of data from
infant death certicates21 and hospital discharges.22 They capture
89% of the birth defects ascertained by a more intensive
surveillance system.23
Our large sample size provided sufcient statistical power to
evaluate for the presence of congenital anomaly overall as well as
by various organ systems and to stratify by term status. The nature
of our population-based data, however, does impose some
limitations: Some women in the cohort may have delivered more
than once in the period selected; the data was de-identied and
not maternally linked, so we are unable to control for that
possibility. In addition, the reliance on birth certicate data for
some of the demographic data may introduce misclassication
errors with regard to gestational age, the presence of breech
presentation as well as medical risk factors.24 However, the
misclassication of some measurements is likely non-differential,
which would bias our point estimates toward the null value. In a
comparison with information from hospital records, birth
& 2014 Nature America, Inc.

Breech presentation and congenital anomaly

D Mostello et al

15
certicates correctly reported breech presentation 91% to 99% of
the time.24,25 Residual confounding may be present from potentially relevant variables not available in our dataset. Factors which
may be associated with breech presentation, such as maternal
uterine anomalies and uterine leiomyomas, were not available,
hence, were not controlled for in the analysis. In addition, we may
have underestimated the association between breech presentation and anomalies by failing to account for infants born from
the cephalic presentation after a successful external cephalic
version from breech prior to delivery. Another possible limitation
is diagnostic bias. Some clinicians may be already armed with a
belief that infants delivered from the breech presentation are
more likely to have anomalies, and therefore these infants receive
more detailed evaluation in the rst year of life, resulting in
greater reporting of anomalies in this group.
According to our ndings, the presence of breech presentation
at the time of delivery, especially at term, is a marker for the
presence of a congenital anomaly. As a signicant risk factor for an
anomaly, the breech presentation at delivery should be noted and
conveyed, as any risk factor, in documentation beyond the
delivery summary. Finding breech presentation close to term
prenatally, especially in someone previously unevaluated or
incompletely evaluated sonographically, may warrant targeted
ultrasound evaluation.11 Careful evaluation in the nursery for
anomalies as well as genetic evaluation may be indicated for those
delivered from the breech presentation. Screening, such as with
pulse oximetry for critical congenital heart disease, if not done
universally, may be appropriately targeted to infants born breech.
Because the breech presentation may only be a marker for some
underlying disorder, appreciation of the association may spur
earlier recognition of problems in the weeks to years following
discharge from the nursery. Further research using genetic
microarray and follow-up of neurologic development may help
in determining the nature of the underlying disorders.
CONFLICT OF INTEREST
The authors declare no conict of interest.

ACKNOWLEDGEMENTS
Many thanks go to Gilad Gross, MD for his helpful advice on improving this
manuscript. The authors also acknowledge the Missouri Department of Health and
Senior Services, Section of Epidemiology for Public Health Practice as the original
source of the data. The analysis, interpretations and conclusions in the present study
are those of the authors and not the Missouri Department of Health and Senior
Services, Section of Epidemiology for Public Health Practice.

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