External Cephalic Version: Clinical Recommendations and Factors for Success
Breech occurs in approximately 3 to 4% of term pregnancies. The goal of External Cephalic Version (ECV) is to increase the proportion of vertex presentation at term and to decrease the risk of cesarean delivery secondary to breech presentation. Between 20 to 30% of eligible women are not offered this procedure
Fetal presentation should be assessed beginning at 36w0d
Preterm ECV has been linked with higher rates of initial success, but increased risk of preterm birth and higher rates of reversion
If spontaneous version is going to occur it is likely to have occurred by then
Risk of spontaneous reversion is decreased
ECV during delivery admission vs breech presentation has a 65% success rate and is associated with
Lower cesarean delivery rate
Lower likelihood of hospital stay >7 days
Limited information in women with preexisting uterine scar or during early stages of labor
ECV is contraindicated when vaginal delivery is not clinically appropriate
There are no absolute or relative contraindications
Evaluate each case individually
Fewer cesarean deliveries
Lower odds of
Endometritis | Sepsis | Hospital stay > 7 days
Lower hospital charges
No differences for
Low Apgar | Low umbilical vein pH | Neonatal death
Risks and Adverse effects
Most common risk is fetal heart rate changes
Typically, heart rate stabilizes when procedure is discontinued
Overall serious adverse effects are very low with rates
Professional Recommendations: Delivery of Breech Presentation at Term
ACOG guidance addresses the trend in the United States to deliver term singleton fetuses in breech presentation by cesarean section and the concomitant decrease in the number of practitioners with the skills and experience to perform vaginal breech deliveries. In 2001, the ACOG committee on Obstetric Practice recommended that planned vaginal delivery of a singleton breech was no longer appropriate but due to additional publications since that time, the recommendations have been updated.
Vaginal delivery of a term singleton breech fetus
Planning a vaginal deliver for term singleton breech fetus may be a reasonable option under hospital-specific protocol guidelines that address eligibility and labor management
Consider patient’s wishes and the experience of the health care provider
Criteria based on retrospective studies have resulted in “excellent” neonatal outcomes, using protocols similar to the following
> 37 weeks gestational age
Frank or complete breech presentation
No fetal anomalies on ultrasound examination
Adequate maternal pelvis
EFW between 2,500 g and 4,000 g
One study also included
Fetal head flexion
AFV ≥3 cm vertical pocket
No oxytocin induction or augmentation
Strict criteria for normal labor progress
If vaginal breech delivery is planned, a detailed informed consent should be documented that include risks and benefits
Short term risk/benefit
Term Breech Trial (2000) demonstrated that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower in the planned cesarean delivery group (1.6%) vs planned vaginal delivery group (5%) with no difference in maternal morbidity or mortality
Follow-up at 3 months: Risk of urinary incontinence was lower for women in the planned cesarean delivery group but no difference at 2 years
Long term risk/benefit (2 years)
No differences for risk of death or neurodevelopmental delay, although there may be multiple reasons to explain this discrepancy, described in the ACOG Committee Opinion (see ‘Learn More – Primary Sources’ below)
No difference for most maternal parameters, such as breastfeeding, pain, depression, or upsetting memories of the birth experience in 79.1% of women
ACOG states that
Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear.
The SOGC guidelines (2019; see ‘Learn More – Primary Sources’ below) address both oxytocin augmentation and induction as follows
Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong recommendation; moderate quality evidence)
Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak recommendation; low quality evidence)
RCOG recommendations (2017; see Learn More – Primary Sources’ below) also address augmentation and induction and advises caution (D Grade Recommendation)
Women should be informed that induction of labour is not usually recommended.
Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia.
External cephalic version
Offer as an alternative to planned cesarean delivery if the patient desires planned vaginal delivery of a vertex-presenting fetus and has no contraindications
Only attempt external cephalic version in a setting where cesarean delivery services are readily available
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
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presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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