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Born Breech: What to Look for in the First Months (and Why a Caesarean Is Not Enough)

Team Ri-Hub16 min lettura

Revisione clinica: Daniele Carretto, Fisioterapista (Albo 2019) · Pubblicato il 27 luglio 2026

Piccola bambina carina nel passeggino che tiene un giocattolo lavorato a maglia. Momento felice dell'infanzia.
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On the discharge sheet it says breech presentation. On the ward you were told about a hip ultrasound to do “in a month or so”, and you went home with a perfect baby and the feeling of something left hanging, without anyone explaining why. Especially if the birth ended in a caesarean and it seems to you that the problem was, in the end, avoided.

Here is the answer straight away: being born breech is one of the strongest risk factors for hip dysplasia, and the way the birth ended does not remove it. Not the caesarean, not a successful external version, not a birth check that went well. The ultrasound should be done anyway, between two and six weeks.

Why breech weighs so heavily

A newborn's hip is not a finished joint: the socket of the acetabulum takes shape only if the head of the femur sits inside it and is well centred. The position held in the last months of pregnancy determines how regular that pressure was, and breech presentation, with the bottom down, legs bent against the trunk and often little room, shifts it more than any other.

Three independent meta-analyses quantify this:

Study Babies included Risk linked to breech
JAMA Network Open, 2025 64,543 (20 studies, dysplasia confirmed on ultrasound before 3 months) odds ratio 4.15 (95% CI: 2.62-6.57)
Orthopaedics & Traumatology, 2024 979,757 (11 cohort studies) odds ratio 4.14 (3.09-5.54)
European Journal of Obstetrics & Gynecology, 2012 1,494,387 (30 studies) odds ratio 5.7 (4.4-7.4)

Three groups, three periods, three methods: the estimate moves between four and six times the baseline risk. That is why breech presentation triggers an ultrasound everywhere in the world. One limit straight away: in the 2025 meta-analysis the heterogeneity between studies was high (I² above 70%) for almost all the factors, a sign that they were not measuring the same thing in the same way. Take it as an order of magnitude.

The absolute measure comes from the 2024 meta-analysis: in babies with risk factors the incidence of dysplasia is about 48 cases per thousand, against 3 per thousand in the general population. For breech-born babies alone, the figure comes from a review of nine cohort studies on 35,139 babies, which you will read about shortly: dysplasia in about 6-7% of cases. And that is the other half of the answer, the one you need tonight: more than nine breech-born babies out of ten will have no dysplasia. It is a probability that rises, not a diagnosis.

What resolves by itself and what needs treating is covered in Hip dysplasia in newborns: what heals on its own and what does not.

A caesarean cancels nothing

It is the most widespread and the most understandable belief: if the baby did not pass through there, the risk should have passed with it. But the risk factor is not the birth, it is the months before.

In the 2025 meta-analysis of 64,543 babies, caesarean delivery is not associated with the risk of dysplasia, neither up nor down. In the 2024 one, on nearly a million babies, the odds ratio is 1.11 (95% CI: 1.01-1.21): statistically different from 1 by a very small margin, and in any case in the opposite direction to the one you hope for. In neither does the caesarean protect.

There is a review that seems to say the opposite, and it is worth reading in full. In 2012 nine cohort studies and 35,139 babies compared, among breech-born babies only, vaginal delivery and caesarean: with caesarean the risk was 13.5% lower, 5.95% against 6.88% (relative risk 0.87, 95% CI: 0.78-0.97). Look at them the way a parent would rather than a statistician: among breech babies dysplasia was found in about 6-7% of cases in both groups. The reduction is real, and it is irrelevant to the decision you face, which is whether to have an ultrasound or not. The authors hypothesise that the critical factor is the mode of birth rather than the presentation itself, but they present it as a hypothesis, and the more recent meta-analyses, which are much larger, point in the opposite direction.

Incantevole immagine in scala di grigi di un bambino felice in casa con giocattoli, che mostra innocenza e gioia.

And external version?

Same story: it reduces, it does not reduce to zero. A Dutch cohort study of 498 babies whose mothers had attempted an external cephalic version found 40 diagnoses of dysplasia (8%), 35 of which needed treatment. A successful version was associated with a lower risk, odds ratio 0.29, but with a confidence interval from 0.09 to 0.95: it holds by a whisker, on a few hundred babies. The authors close by calling for the very same screening policy reserved for breech-born babies.

If your baby was breech and was turned, the ultrasound is still done.

The ultrasound: why it matters even if the check went well

The paediatrician opened and closed the legs and said everything was fine. The point of another test is one line in the 2016 document of the American Academy of Pediatrics: clinical instability of the hip is found in 1-2% of term babies, but up to 15% have an instability or immaturity that is seen only on imaging. And dysplasia is clinically silent throughout the first year of life: it does not hurt, does not make a baby cry, does not stop anything. That is why screening exists.

The window for a high-risk baby with a normal clinical examination is between 2 and 6 weeks of age, according to the guidelines of the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons. In practice many centres schedule it around six weeks: in the 2026 study you will read below the ultrasound was recommended at six weeks and was done on average at 7.1. Earlier, many immaturities are physiological and resolve on their own; much later, time is lost.

A normal ultrasound does not close the file

A 2026 study followed 367 babies born breech: 280 had the ultrasound at about seven weeks, and 87% (243) were normal. Of those 243, 139 came back for a pelvic X-ray at six months, and 9% (13 babies) had developed dysplasia in the meantime: 11 of the acetabulum and 2 dislocations.

The limits are substantial: a single centre, a level III study, and above all only 57% of babies with a normal ultrasound came back for follow-up, and those who return to an optional appointment are never a neutral sample. The authors themselves write that the result does not extend to all babies undergoing screening. In the same study, the presence of congenital torticollis was not associated with late dysplasia (OR 3, 95% CI: 0.9-10.0, p = 0.06): not significant, not “nearly significant”.

The intrauterine constraint sequence

There is a little-known concept that links three things that seem unconnected: hips, neck and head. If the space in the womb was small or uncomfortable (breech, little amniotic fluid, first child), the baby spent weeks bent in the same way, and the consequences do not arrive one at a time.

The most elegant evidence is a Korean study of 67 babies with congenital torticollis under three months, in which fibrosis of the sternocleidomastoid was classified on ultrasound. 34% had a history of breech presentation and, of those, 91.3% had been born by elective caesarean: no possibility of birth trauma. Compared with a normal pregnancy, breech presentation showed a 6.7 times higher probability of severe fibrosis, and oligohydramnios 7.5 times. The sample is small, but the reasoning is hard to dismantle: if the muscle is already fibrotic in a baby born by planned caesarean, it shortened before.

Alongside this there is a prospective study of 510 babies with a swelling of the neck muscle: a strong correlation with breech presentation, but also with assisted delivery, which needs saying because it pulls in the opposite direction, and, in the subgroups defined by limited neck rotation, an incidence of hip dysplasia that reached up to 11.6%.

How often do they coexist? The estimates vary: in an ultrasound study of 47 babies with torticollis, coexistence was 17%, falling to 8.5% when counting only hips that needed treatment; in a series of 292 babies, 16 had dysplasia, and coexistence with dysplasia that needed treatment was 4.5%, much less than the 20% you read around the internet. Neither figure justifies panic; both justify one more look.

How it is recognised, and why timing matters enormously, is covered in Infant torticollis: why timing matters more than anything.

And flat head?

Here the news is good and counterintuitive: plagiocephaly, in the great majority of cases, does not come from the belly. It is built afterwards.

In a Dutch prospective cohort of 380 term babies measured at birth and at 7 weeks, of the 23 babies with plagiocephaly at birth only 9 still had it at the check, while 75 new babies had developed it in the meantime: the shape at birth does not predict the shape at seven weeks. The factors associated with it at seven weeks are almost all habits: preference for turning the head in sleep, head always on the same side on the changing mat, bottle always on the same side, tummy time while awake less than three times a day, slow motor milestones. And no significant relationship emerged between sleeping on the back and plagiocephaly.

The five-year follow-up of the same cohort, on 248 children, closes the loop: plagiocephaly was within the normal range in 80%, mild in 19% and moderate or severe in only 1%. The same authors add a limit that also applies to us: paediatric physiotherapy does not change the long-term outcome, it lowers the severity sooner.

The full picture, helmets included, is in Flat head in newborns: what the studies really say about helmets.

What to look at at home in the first months

You do not need to play paediatrician. Four things need observing well, always the same ones, while you change the baby.

How the legs open. This is the sign that matters most. With the baby on his back and his knees bent, let the legs open by themselves towards the changing mat: they should open in the same way on both sides.

Asymmetric folds: look at them, but do not fixate on them. In 584 babies aged 4 to 12 months referred to the specialist after a suspicious screening, 78.4% (458) had been sent only for asymmetric thigh folds, and none of them had dysplasia; among those referred for other reasons, the diagnosis came in 18.3% of cases. Together with limited abduction, however, they count: in 968 babies who had routine ultrasound, the two signs assessed together gave sensitivity 83.8%, specificity 70.2%, negative predictive value 96.9% and positive predictive value 27.8%. When there is nothing, there is almost certainly nothing; when there is a sign, three times out of four it is a false alarm that only ultrasound can close.

The head. Notice whether he turns it with the same ease to both sides, whether he always keeps it tilted to the same side when awake, and whether in the first weeks you feel a hard lump along the neck muscle. In the study of 510 babies the average age at which the problem was noticed was day 24 of life: it shows up early, if you look.

How you wrap him and carry him. This is the only variable really in your hands. A randomised trial of 80 newborns with hips already immature compared traditional Mongolian swaddling, legs straight and close together, with no swaddling: abnormal hips at follow-up in 40% of the swaddled group against 7.5% of the free group, with 8 cases of dysplasia on one side and none on the other. The limit matters, those babies already started with immature hips; the practical rule remains one: the legs must be able to stay bent and open, in a frog position. For baby carriers there is a direct measurement on just 13 babies: the one with a wide base, which supports the thigh down to the knee, kept the hips like a Pavlik harness, while with a narrow base the alpha angle was 6.9° lower and the femoral head coverage 10-12% lower.

When to call the paediatrician, without waiting

  • the baby was born breech and at six to eight weeks has not yet had the hip ultrasound: this is the most important item on this list;
  • one hip opens clearly less than the other, or you feel a click when opening the legs;
  • the legs look different in length: with the baby lying on his back, hips and knees bent and feet resting, one knee is lower than the other;
  • he keeps his head always turned or tilted to the same side and does not bring it to the centre, or you feel a hard lump along the neck;
  • he cries or stiffens every time you open his legs to change him;
  • later on: he does not crawl symmetrically, or limps when he starts to walk.

Outside this list, a breech-born baby who moves, feeds and grows does not need watching all day: he needs the ultrasound at the right time and a check around six months.

What is NOT true

  • "With a caesarean the risk is gone." In the most recent meta-analysis the caesarean is not associated with any reduction in risk.
  • "They turned him, so we're fine." It reduces the risk, it does not eliminate it: the authors recommend the same screening as for babies born breech.
  • "The check went well, the ultrasound is not needed." Imaging finds up to 15% against 1-2% for the check, and for a year there are no symptoms.
  • "The six-week ultrasound was normal, that's it." Among breech babies re-checked at six months, 9% had dysplasia.

What a physiotherapist can do, and what not

Let us say it plainly: hip dysplasia is not treated with physiotherapy. If the ultrasound finds something to treat, the treatment is orthopaedic (a harness, followed by whoever prescribes it), and anyone who promises to resolve it with their hands is selling you something. Nor do we replace the ultrasound: the paediatrician prescribes it and reads it.

What we can do comes before and around it. Congenital torticollis is our territory, and the 2018 APTA paediatric physiotherapy guideline is explicit: babies with torticollis should be referred to a physiotherapist as soon as the problem is identified. The reason is in a prospective study of 821 babies followed on average for four and a half years: controlled manual stretching is safe and effective in babies seen within the first year, and the age at presentation predicts both the duration of treatment and the final result. Surgery was needed in 8% of babies with a muscle swelling, 3% of those with only a tight muscle, and none of those with postural torticollis. And then there is the rest of the day: how you wrap him, how you carry him, which side you put him down on, how you spread out tummy time.

With Ri-Hub Junior you start with a free twenty-minute introductory consultation by video call with a physiotherapist on the Italian professional register who works with children and teenagers: you show us how he moves, how you hold him and how you change him, and we tell you what is worth correcting and what is not. For children up to 10 years old, sessions last 50 minutes and cost 59,90 €.

Two limits, stated before rather than after. If the signs in the list above appear, the right place is the paediatrician, straight away, and the ultrasound comes before anything else. And if behind it there is a complex neurological or neuromuscular condition, those pathways require in-person assessment and specialised centres: we do not follow them online.

In three lines

Being born breech multiplies the risk of hip dysplasia by four or five, and nothing that happened at the birth cancels it. What turns it from a risk into a closed matter is an ultrasound done between two and six weeks, plus a check around six months. In the meantime you watch how the legs open and which way the head turns, you wrap him leaving his hips free and you carry him with his thighs supported: these are the only levers you have, and they are enough.

Sources

Last source check: September 2026.

Domande frequenti

My baby was born breech but by caesarean: is the hips' risk the same anyway?

Yes, and this is the point that almost nobody explains on the ward. The risk factor is having been breech, not having passed through the birth canal: it is the months in which the hips were kept bent and tight in the womb that count. The most recent meta-analysis, published in JAMA Network Open in 2025 on 20 studies and 64,543 babies, with dysplasia confirmed on ultrasound, finds breech presentation associated with an odds ratio of 4.15 (95% CI: 2.62-6.57) and caesarean delivery associated with no increase and no reduction in risk. A second meta-analysis from 2024 on 979,757 babies gives an odds ratio of 1.11 for caesarean (1.01-1.21): statistically different from 1 by a whisker, and in any case in the opposite direction to the one you hope for. The caesarean protects the birth, not the hips.

When should a breech-born baby have a hip ultrasound?

Between 2 and 6 weeks of age, even if the birth check was perfectly normal. It is the window indicated by the guidelines of the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons for babies with a normal clinical examination but high risk, a category into which breech presentation squarely falls. The reason a clinical check is not enough is in the Academy's 2016 document: clinical instability is found in 1-2% of term babies, but up to 15% have an unstable or immature hip visible only on imaging, and dysplasia is clinically silent throughout the first year. If your baby was born breech and at six to eight weeks has not yet had a hip ultrasound, that phone call to the paediatrician is the most useful thing you can do today.

Does a successful external cephalic version remove the risk factor?

It reduces it, it does not cancel it, and those who have studied it still recommend the same screening. A Dutch cohort study published in BJOG in 2013 followed 498 babies whose mothers had attempted an external cephalic version: 40 (8%) received a diagnosis of dysplasia and 35 needed treatment. In the multivariate analysis, a successful version was associated with an odds ratio of 0.29, but with a confidence interval from 0.09 to 0.95 that just touches 1. The authors' conclusion is plain: a still high proportion of babies born after a successful version have dysplasia, so until larger studies are available they recommend the same screening policy as for babies born breech.

Is the six-week ultrasound normal: can I close the matter?

Not entirely, and there is a 2026 study that measures this. In Clinical Orthopaedics and Related Research, a group followed 367 babies born breech: 280 had the ultrasound at around seven weeks and 87% (243) were normal. Of these 243, 139 returned for a pelvic X-ray at about six months, and 9% (13 babies) had developed dysplasia in the meantime: 11 acetabular dysplasias and 2 dislocations. Girls had higher odds (OR 5, 95% CI: 1.2-48.0), with a huge interval that tells you how few cases there were. It is a single-centre, level III study, and only 57% of babies with a normal ultrasound came back for the follow-up: those who come back are never a neutral sample. But the direction is clear, and the authors turn it into a simple request: an imaging check at around six months even after a normal ultrasound.

What does torticollis have to do with a breech birth?

It has to do with it because often it is not the birth that caused it, but the months before. A Korean study of 67 babies with congenital torticollis under three months classified fibrosis of the sternocleidomastoid muscle on ultrasound: 34% had a history of breech presentation and, of those, 91.3% had been born by elective caesarean, so with no possibility of birth trauma. Compared with a normal pregnancy, breech presentation showed a 6.7 times higher probability of severe fibrosis, and oligohydramnios 7.5 times. The small sample (67 babies) is the limit, but the reasoning holds: if the muscle is already fibrotic in a baby born by planned caesarean, the cause is the space it had before, not the passage.

Do asymmetric thigh folds mean dysplasia?

On their own, almost never, and this is one of the few things you can stop worrying about. A study of 584 babies aged 4 to 12 months referred to the specialist after a suspicious screening found that 78.4% (458 babies) had been sent only for asymmetric folds, and none of them had dysplasia; among those referred for other reasons, by contrast, the diagnosis came in 18.3% of cases. The sign that really matters is another one: the hip that opens less. In a series of 968 babies who had routine ultrasound, limited abduction and asymmetric folds assessed together gave a sensitivity of 83.8%, a specificity of 70.2% and a negative predictive value of 96.9%, but a positive predictive value of 27.8%. In plain terms: if there is nothing, there is almost certainly nothing; if there is something, three times out of four it is a false alarm that only ultrasound can close.

Does being born breech mean a flat head?

No, and this is the part where you have more room to act than you think. In a Dutch prospective cohort of 380 term babies, of the 23 who had plagiocephaly at birth only 9 still had it at seven weeks, while 75 new babies had developed it in the meantime: a flat head, in the great majority of cases, is not carried over from the belly, it is built afterwards. The factors associated with it at seven weeks were largely daily habits: preference for turning the head in sleep, head always on the same side on the changing mat, bottle feeding always from the same side, tummy time while awake less than three times a day, motor milestones reached slowly. And the five-year follow-up of the same cohort is reassuring: of 248 children, plagiocephaly was within the normal range in 80%, mild in 19% and moderate or severe in only 1%.

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