The influence of prenatal breech presentation on neonatal leg posture
Introduction
Movement restriction in the human foetus can cause abnormal development of bones and joints. Persistent and most severe forms are caused by congenital disorders like the foetal hypokinesia–akinesia disorder sequence [1]. In pregnancies complicated by oligohydramnios transient effects have been found on the quality of foetal and neonatal movements until 5 weeks after birth [2]. Even in physiological circumstances, like in uncomplicated foetal breech presentation, movement restriction of the foetal hips seems to have an influence, demonstrated by the known association between breech presentation and congenital hip dysplasia [3], [4].
Also, Sival et al. [5] have demonstrated long term effects of foetal breech presentation on postnatal motor functions of the lower limbs, namely leg posture, reflexes and posture while walking until the age of 12–18 months. In a comparison between breech-born and cephalic-born infants Bartlett et al. [6] found minor transient differences; more open popliteal angles at birth (Dubowitz assessment) and significantly lower motor scores at 6 weeks (Alberta Infant Motor Scale) in the breech infants. Both studies lack extensive longitudinal and repeated foetal postural assessment to relate to the postnatal data.
The aim of our study was to examine the effect of prenatal breech presentation on postnatal movements of the lower limbs in children of whom we know that they have been in breech presentation for at least 6 weeks before birth. In weekly observations of prenatal posture from 33 weeks gestational age onwards, we demonstrated significantly more knee extension in the breech foetuses and significantly less crossing of the lower part of the legs in this group when compared to cephalic foetuses in the same gestational age period [7]. We studied leg crossing prenatally as a means of getting an indirect impression of foetal hip motility, as with 2-D ultrasound it is impossible to get a direct view of the hip joint. For the same study groups, we reported earlier on the influence of breech presentation on foetal arm posture and head position preference [8], [9]. Now we are able to correlate foetal postural aspects with postnatal development of the lower extremities up to 18 weeks. In this paper we will focus on three aspects. Firstly, what is the development of leg posture during general movements in the first 18 weeks after birth in children born after breech and cephalic presentation and is there a difference in this development between these groups? With our prenatal data in mind, we would expect more knee extension and less hip extension in the breech group, especially in the first weeks after birth. Secondly, what is the influence of a change in gravity on the leg posture development in both groups? By positioning the children first in supine and thereafter in vertical position we studied the influence of a physiological change in postnatal environment, namely an increase in gravitational forces. Our hypothesis here is that severity of prenatal movement restriction would be inversely related to the impact of an increase in gravitational forces. And finally, can continuity in leg posture be found when going from prenatal to postnatal life for both groups? Our expectation is that for the breech babies postnatal leg posture would show more continuity with prenatal findings because of the prenatal movement restriction experienced by this group.
Section snippets
Methods
Twelve children after uncomplicated breech presentation and nine children after cephalic presentation participated in the present study. The study was approved by the Medical Ethics Committee of the VU University Medical Centre and all parents of the participating infants gave their informed consent.
This study is part of a longitudinal follow-up study on the influences of breech presentation on pre- and postnatal development of posture and motility, in both groups of children.
At the postnatal
Results
Table 1 shows the clinical data for both groups. All babies in both groups had birth weights > 10th centile according to Kloosterman [12]. However, the birth weights in the breech group were significantly lower than those in the cephalic group (mean 3271 g vs. 3682 g; p = 0.031). This is probably because the breech infants were born earlier than the cephalic infants (mean 38 weeks vs. 39 weeks). The amount of amniotic fluid was within the normal ranges with the exception of one breech foetus,
Discussion
This longitudinal study shows differences between breech-born and cephalic-born infants in neonatal leg posture during spontaneous movements.
When considering our first focus point, regarding the development of leg posture in both groups, we found for the breech babies in supine position a significant decrease in hip flexion and a significant increase in hip extension during the first 4 to 6 weeks after birth. The cephalic group showed a significant decrease in hip flexion between 12 and
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