is it normal to have cephalic presentation at 29 weeks

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The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

• Down, with the back facing the birth canal
• With one shoulder pointing toward the birth canal
• Up, with the hands and feet facing the birth canal

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Cherie Berkley is an award-winning journalist and multimedia storyteller covering health features for Verywell.

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INTRODUCTION

Diagnosis and management of face and brow presentations will be reviewed here. Other cephalic malpresentations are discussed separately. (See "Occiput posterior position" and "Occiput transverse position" .)

Prevalence  —  Face and brow presentation are uncommon. Their prevalences compared with other types of malpresentations are shown below [ 1-9 ]:

● Occiput posterior – 1/19 deliveries

● Breech – 1/33 deliveries

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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Is cephalic presentation normal at 21 weeks?

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In this Article

The ABCs of Cephalic Presentation: A Comprehensive Guide for Moms-to-Be

Updated on 24 November 2023

As expectant mothers eagerly anticipate the arrival of their little ones, understanding the intricacies of pregnancy becomes crucial. One term that frequently arises in discussions about childbirth is "cephalic presentation." In this article, we will understand its meaning, types, benefits associated with it, the likelihood of normal delivery and address common concerns expectant mothers might have.

What is the meaning of cephalic presentation in pregnancy?

Cephalic presentation means the baby's head is positioned down towards the birth canal, which is the ideal fetal position for childbirth. This position is considered optimal for a smoother and safer delivery. In medical terms, a baby in cephalic presentation is said to be in a "vertex" position.

The majority of babies naturally assume a cephalic presentation before birth. Other presentations, such as breech presentation (where the baby's buttocks or feet are positioned to enter the birth canal first) or transverse presentation (where the baby is lying sideways), may complicate the delivery process and may require medical intervention.

Cephalic presentation types

There are different types of cephalic presentation, each influencing the birthing process. The primary types include:

1. Vertex Presentation

The most common type where the baby's head is down, facing the mother's spine.

2. Brow Presentation

The baby's head is slightly extended, and the forehead presents first.

3. Face Presentation

The baby is positioned headfirst, but the face is the presenting part instead of the crown of the head.

Understanding these variations is essential for expectant mothers and healthcare providers to navigate potential challenges during labor.

You may also like: How to Get Baby in Right Position for Birth?

What are the benefits of cephalic presentation?

In order to understand whether cephalic presentation is good or bad, let’s take a look at its key advantages:

1. Easier Engagement

This presentation facilitates the baby's engagement in the pelvis, aiding in a smoother descent during labor.

2. Reduced Risk of Complications

Babies in head-first position typically experience fewer complications during delivery compared to other presentations.

3. Faster Labor Progression

This position is associated with quicker labor progression, leading to a potentially shorter and less stressful birthing process.

4. Lower Cesarean Section Rates

The chances of a cesarean section are significantly reduced when the baby is in cephalic presentation in pregnancy.

5. Optimal Fetal Oxygenation

The head-first position allows for optimal oxygenation of the baby as the head can easily pass through the birth canal, promoting a healthy start to life.

What are the chances of normal delivery in cephalic presentation?

The chances of a normal delivery are significantly higher when the baby is in cephalic or head-first presentation. Vaginal births are the natural outcome when the baby's head leads the way, aligning with the natural mechanics of childbirth.

While this presentation increases the chances of a normal delivery, it's important to note that individual factors, such as the mother's pelvic shape, the size of the baby, and the progress of labor, can also influence the delivery process. Sometimes complications may arise during labor and medical interventions or a cesarean section may be necessary.

You may also like: Normal Delivery Tips: An Expecting Mother's Guide to a Smooth Childbirth Experience

How to achieve cephalic presentation in pregnancy?

While fetal positioning is largely influenced by genetic and environmental factors, there are strategies to encourage head-first fetal position:

1. Regular Exercise

Engaging in exercises such as pelvic tilts and knee-chest exercises may help promote optimal fetal positioning.

2. Correct Posture

Maintaining good posture, particularly during the third trimester , can influence fetal positioning.

3. Hands and Knees Position

Spend some time on your hands and knees. This position may help the baby settle into the pelvis with the head down.

4. Forward-leaning Inversion

Under the guidance of a qualified professional, some women try forward-leaning inversions to encourage the baby to move into a head-down position. This involves positioning the body with the hips higher than the head.

5. Prenatal Yoga

Prenatal yoga focuses on strengthening the pelvic floor and promoting flexibility, potentially aiding in cephalic presentation.

6. Professional Guidance

Seeking guidance from a healthcare provider or a certified doula can provide personalized advice tailored to individual needs.

1. Cephalic presentation is good or bad?

Cephalic position is generally considered good as it aligns with the natural process of childbirth. It reduces the likelihood of complications and increases the chances of a successful vaginal delivery . However, it's essential to note that the overall health of both the mother and baby determines its appropriateness.

2. How to increase the chances of normal delivery in cephalic presentation?

Increasing the chances of normal delivery in cephalic presentation involves adopting healthy practices during pregnancy, such as maintaining good posture, engaging in appropriate exercises, and seeking professional guidance. However, individual circumstances vary, and consultation with a healthcare provider is paramount.

Final Thoughts

Navigating the journey of pregnancy involves understanding various aspects, and cephalic presentation plays a crucial role in determining the birthing experience. The benefits of a head-first position, coupled with strategies to encourage it, empower expectant mothers to actively participate in promoting optimal fetal positioning. As always, consulting with healthcare professionals ensures personalized care and guidance, fostering a positive and informed approach towards childbirth.

1. Makajeva J, Ashraf M. Delivery, Face and Brow Presentation. (2023). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing

2. Boos R, Hendrik HJ, Schmidt W. (1987). Das fetale Lageverhalten in der zweiten Schwangerschaftshälfte bei Geburten aus Beckenendlage und Schädellage [Behavior of fetal position in the 2d half of pregnancy in labor with breech and vertex presentations]. Geburtshilfe Frauenheilkd

Anupama Chadha

Anupama Chadha, born and raised in Delhi is a content writer who has written extensively for industries such as HR, Healthcare, Finance, Retail and Tech.

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

, MD, Children's Hospital of Philadelphia

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Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

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.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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External cephalic version at 38 weeks’ gestation at a specialized German single center

Ann-Sophie Zielbauer

Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Frankfurt, Germany

Frank Louwen

Lukas jennewein, associated data.

The minimal data set is within the paper. Additional data may be available upon request.

Introduction

Cesarean section (CS) rates are increasing worldwide. One constant indication is the breech presentation at term. By offering external cephalic version (ECV) and vaginal breech delivery CS rates can be further reduced.

This study aimed to analyze the ECV at 38 weeks of gestation with the associate uptake rate, predicting factors, success rate, and complications at a tertiary healthcare provider in Germany specializing in vaginal breech delivery.

We conducted a prospective cohort study with retrospective data acquisition. All women with a singleton fetus in breech presentation presenting after 34 weeks of gestation for counseling between 2013 and 2017 were included. ECV impact factors were analyzed using logistic regression.

A total of 1,598 women presented for breech birth planning. ECV was performed on 353 patients. The overall success rate was 22.4%. A later week of gestation (odds ratio [OR] 1.69), an abundant amniotic fluid index (AFI score) (OR 5.74), fundal (OR 3.78) and anterior (OR 0.39) placental location, and an oblique lie (OR 9.08) were significantly associated with successful ECV in our population. No major complications were observed. The overall vaginal delivery rates could be increased to approximately 14% with ECV.

The demand for alternative birth modes other than CS for breech birth is high in the area of Frankfurt, Germany. Our study offers evidence of the safety of ECV at 38 weeks. Centers with expertise in vaginal breech delivery and ECV can reduce CS-rates. To further establish vaginal breech delivery and ECV as alternate options, the required knowledge and skill should be implemented in the revised curricula.

The cesarean section (CS) rate is increasing worldwide, and surpassing 50% of all births in some countries [ 1 ]. Since CS is associated with severe complications, increasing CS rates contribute to a rise in maternal mortality worldwide, with a mortality rate of 8/1,000 for procedures in low- and middle-income countries and 16/100,000 per birth in more developed countries [ 1 – 3 ]. In Germany, 30.5% of all babies are born through CS [ 4 ]. The fetal breech presentation is among the most critically discussed indications for a CS. In Germany, 65.7% of pregnant women with breech presentation receive planned CS at term [ 5 ]. The CS rate is over 90% in some countries [ 6 ].

Vaginal breech births are a possible alternative. Unfortunately, the expertise for vaginal breech delivery has rapidly declined over the last two decades, according to the study by Hannah et al. [ 7 ]. In nationwide guidelines and committee opinions, it is (1) proposed to be a safe option to deliver vaginally and (2) recommended to offer external cephalic version (ECV) to patients with breech presentation [ 8 , 9 ]. Previous studies have shown that vaginal breech delivery at term is not accompanied by increased maternal or infant morbidity, even with a high fetal weight [ 10 ].

The aim of ECV is to rotate the fetus, resulting in a vertex position, by manipulation through the maternal abdomen. Even though ECV is recommended based on current gynaecologic guidelines, it is not always offered in Germany or is refused by pregnant women [ 11 , 12 ]. Little information is available regarding the demographics and implementation rates in Germany. In a recently published multicenter observational study in Germany, hospitals were questioned about breech birth and the ECV approach. Unfortunately, the response rate was low (37.2%) [ 12 ].

The ideal week of gestation for ECV has been investigated in multiple studies. The current data situation was heterogeneous. Most studies comparing an early attempt at 36–37 weeks of gestation with a late attempt at 37–38 weeks of gestation, showed a higher success rate for ECV at 36–37 weeks, accompanied by a higher risk for preterm birth [ 13 – 17 ]. In contrast, a recently published large cohort study demonstrated equal success and preterm birth rates regardless of the week of gestation [ 18 ]. The American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists guidelines recommend that ECV should be performed beginning at 37+0 weeks to decrease the rate of reversion and increase the rate of spontaneous version [ 8 , 19 ]. To the best of our knowledge, many obstetrics departments in Germany offer ECV before 37 weeks of gestation [ 12 , 20 ].

The Frankfurt University Hospital offers vaginal breech delivery to all women presenting for breech consultation and has the highest number of ECVs and vaginal breech delivery in the federal state. With the offer of breech delivery in an upright position, we were able to further decrease CS rates by 32% [ 21 ].

We aimed to evaluate whether the routine offer of ECV at 38 weeks of gestation can further reduce CS rates at a center specializing in vaginal breech birth. Therefore, this study primarily aimed to analyze the ECV success rate and delivery outcomes at a tertiary obstetrics center in Germany. Our secondary aim was to analyze the prognostic factors of ECV, our patient characteristics, and birth modalities along with complications and perinatal outcomes.

Materials and methods

We conducted a prospective analysis of all women presenting for counseling with a singleton fetus in breech presentation after 34 weeks of gestation at a tertiary healthcare center for obstetrics between January 2013 and December 2017. Patients with multiple pregnancies were excluded from the study. A study period of 5 years was chosen in order to arrive at a representative sample size. The ethics committee of the Goethe University Hospital Frankfurt, approved the study protocol (ref: 176/18). Patient consent was waived because we analyzed routinely collected medical data. All data were retrospectively gathered after patient discharge.

At our department, women with a fetus in breech presentation were recommended to present themselves after 34 weeks of gestation for birth counseling. ECV is offered to all patients with a singleton breech pregnancy in the absence of contraindications. Contraindications include intrauterine growth restriction, fetal malformations, uterine myomatosus, and placental or uterine abnormalities. Ultrasound examination was performed, and fetal weight, type of breech, placental location, and amount of amniotic fluid were documented within the standard counseling procedure.

Two doctors performed ECV together monitoring of fetal heart rate using ultrasonography. Fenoterol was used as an intravenous uterine relaxant starting 30 min prior to the procedure and was continuously applied until completion of the procedure. The baby was moved upwards with one hand and pushed to perform a forward or backward roll, preferably in the direction with less resistance. In cases of unsuccessful ECV (NECV), both directions were attempted. The direction (backwards or forwards) of successful ECV (SECV) has not been documented.

Patients presenting for breech birth planning were registered and abstracted for ECV eligibility and birth mode. Women giving birth at another center were lost to follow-up. All patients who underwent ECV at our center were included in the analysis. For these patients, maternal patient history (age, height, weight, underlying diseases, number of pregnancies, and childbirth) and fetal biometrics (type of breech, placental location, and amount of amniotic fluid) were extracted and compared. Fetal weight was estimated sonographically (by Hadlock), and the amniotic fluid index was measured according to Phelan et al. [ 22 , 23 ]. An AFI ≤7 was defined as a scarce amount of amniotic fluid, and an AFI ≥20, an abundant amount. All data regarding the ECV procedure were documented. For further analysis, births after SECV and NECV were examined separately. In women giving birth at our clinic after ECV, the birth mode and outcome parameters of the mother and neonates were additionally analyzed. Routine patient history documentation was used to select and extract the data.

Statistical analysis was performed using Excel, BiAS v11.08, and IBM SPSS Statistics 22. For descriptive analysis, means, medians, and percentages were calculated using variance and standard deviation. Confidence intervals were calculated at 95%, and p-values were calculated bilaterally, with statistical significance set at p < 0.05. As missing data occurred without pattern, a complete case analysis was performed for all variables.

We used the binary outcome (success or failure) of the ECV as a grouping variable and tested all variables for significance using the chi-square test for nominal variables, the Mann–Whitney U test for ordinal variables, and an independent samples t-test for all continuous variables. Then, a Bonferroni correction was applied, and a logistic regression with backward elimination was carried out for all significant variables to confirm the findings.

Within the observation period, a total of 1,598 patients with breech presentation visited the consultation center for birth planning. We observed an average yearly increase in consultations of 9.0% over the 5-year period, resulting in a total increase from 265 patients in 2013 to 366 in 2017.

The catchment area for outpatient consultation is shown by postal code in Fig 1 . The highest incidence of consultation was observed in close proximity to the department. The catchment area exceeds Frankfurt by up to 200 km despite neighboring obstetric departments in Darmstadt, Wiesbaden, and Mainz. Forty percent of our patients presenting for breech birth planning have a residence exceeding a 30-km radius.

Hospital catchment area for outpatient consultations for birth planning with breech presentation. Patients from areas outside of the depicted map were excluded. The number of consultations over 5 years is depicted for each zip code. Color was chosen at equal intervals. The map was created using CARTO and OpenStreetMaps. Reprinted from https://carto.com under a CC BY license, with permission from CARTO Legal, original copyright 2021.

Of the consulting patients, 1,398 (87.5%) women made follow-up appointments and completed the preceding diagnostics for ECV and breech delivery. A total of 61.5% would have been suitable for ECV. Twelve children were born premature prior to the ECV appointment. A total of 381 women presented with ECV at our department, and ECV was attempted in 353 women. Moreover, 28 fetuses had spontaneously turned into cephalic presentation prior to the procedure.

A flowchart of outpatient consultations for birth planning with breech presentation is shown in Fig 2 .

Of the 353 women undergoing ECV, the median gestational age at ECV was 37+5 weeks, and the majority were nulliparous (70.8%). Most fetuses were in frank breech presentation, mostly with a posterior placental location. The median estimated birth weight at the ECV was 3,260 g. The overall success rate for ECV was 22.4%. Maternal and fetal characteristics for SECV and NECV are compared in Table 1 .

Maternal characteristics of all women undergoing ECV and fetal characteristics prior to ECV. All ratios in the first column are listed as a percentage of the total fetal number, in the second column as a percentage of all successful ECVs and in the third column as percentage of all not successful ECVs. All metric parameters are presented as means and standard deviations. T-test of the mean difference between SECV and NECV.

The outcomes differed significantly between SECV and NECV in terms of parity, gestational age, estimated fetal weight, breech type, amniotic fluid index, and placental location.

In nulliparous women, the success rates were 18.4% and 32.0% in women with multiple pregnancies. The amniotic fluid index was significantly higher among patients with SECV. The amniotic fluid index ranged from 3.3 cm to 23 cm.

For the SECV group, the fetal birth weight was higher (2,959 g) compared to that in the NECV group (2,860 g, p = 0.028), as well as the biparietal diameter (BPD) (94.3 mm vs. 92.9 mm, p = 0.35). Gestational age was higher for SECV.

In cases of placental location, SECV was associated with a fundal placental position, whereas the prevalence of an anterior location was significantly higher in NECV. For the type of breech, SECV was significantly associated with an oblique lie, whereas NECV was significantly associated with frank breech presentation.

After logistic regression with stepwise backward elimination, the AFI score, placental location, and type of breech remained significant in the final model.

The oblique lie had a significant and tenfold chance for SECV than any other breech presentation (p = 0.003); an abundant AFI score increased the chances of SECV by almost six times (p = 0.037). The only variable with a significant negative impact on SECV was the anterior placental location (odds ratio [OR] 0.39; p = 0.003). The estimated birth weight, frank breech presentation and multiparity were not significant. The adjusted ORs with confidence intervals are shown in Table 2 .

The variables remaining in the final model after backward selection are presented. All variables significantly associated with SECV were included in the logistic regression analysis.

Within the first 24 h after ECV, complications were noted in 60 (17.0%) patients. Most complications were nonpermanent. Complications were divided into minor and major complications, as shown in Table 3 . Minor complications, such as cardiotocography (CTG) alterations, had no clinical significance. Major complications were defined as complications leading to a measurable impact on the mother or fetus. We reported the most severe complication in six patients with multiple complications ( Table 3 ). The most frequent fetal complications were CTG alterations, especially bradycardia. Most CTG alterations (85.7%) under ECV were nonpermanent and terminated when the procedure was stopped. In five cases, tocolytics had to be administered to end fetal bradycardia. Clinical significant pain or maternal circulatory problems leading to an early termination of ECV are rare, accounting for 1.4% of all ECVs. Five procedures were stopped upon patient demand or difficulties due to obesity.

Complications were divided into minor and major complications. Minor complications are nonpersistent and do not lead to the onset of labor, whereas major complications lead to the onset of birth within 24 h. Major complications leading to emergency CS are presented separately.

a One case of temporal loss of vaginal fluid by drop.

Labor began within 24 h after ECV in 4.8% of cases. In 41.2% of cases, the child could be delivered vaginally. Emergency CS was performed twice, once due to placental abruption immediately after ECV, and once due to therapy-resistant bradycardia of the fetus. Three children were admitted to the newborn ICU because of respiratory adaption disorder or newborn infection. At discharge from the hospital, all infants were healthy and clinically stable.

A total of 252 (71%) patients attending ECV also delivered in our department. Patients were more likely to deliver elsewhere after SECV (59.5%), while the majority of patients after NECV (80.3%) were delivered at our center. Successful vaginal delivery after ECV was achieved in 62.3% of all women delivered to our clinic. After SECV, only one fetus had turned into an oblique lie, and all the others were born out of cephalic presentation. A total of 78.13% of all women with SECV delivered vaginally. After the unsuccessful version, the chances for a spontaneous version were low (2%). Two fetuses had turned spontaneously into cephalic presentation, and three were in oblique lie. Vaginal delivery was attempted in 82.6% of all women with NECV delivery at our center. Further, 59% of these successfully delivered vaginally out of breech presentation. In 23.6% of cases, a CS under labor had to be performed due to obstructed labor or pathological CTGs. A total of 13.2% in the NECV group decided to undergo elective CS.

Fetal outcomes did not differ significantly between the two groups (APGAR < 5; 0% vs. 0.5%, p = 0.072; base excess < -12; 3.1% vs. 5.5%, p = 0.57 or pH of the umbilical artery < 7; 0% vs. 2.27%, p = 0.39). There was no significant difference in the rate of admission to a neonatal intensive care unit (NICU) or the difference in discharge dates between mothers and children. There were 19 children transferred to a NICU. The most common reason was newborn infection. Six children had congenital abnormalities, such as congenital heart disease. In 4.8% of the discharge dates, the mother and child differed by a maximum of 13 days. The delivery information and child outcomes are shown in Table 4 .

The characteristics of birth of all women who delivered in our clinic after ECV. All ratios in the first column are listed as a percentage of the total number, in the second column as a percentage of all successful ECVs and in the third column as a percentage of all NECVs. All metric parameters are presented as means and standard deviations.

A total of 845 women who decided against ECV still delivered in our center. Of these, 7.0% had spontaneously turned into cephalic presentation before birth. A total of 573 women underwent a vaginal breech delivery. The birth mode without prior ECV is shown in Fig 3 . We achieved a total vaginal delivery rate of 50.9% of all patients presenting for breech birth planning and delivered in our center disregarded ECV.

Main findings

Over the 5-year period, we observed a low uptake rate for ECV at 22.1% and a high rate for breech vaginal delivery with and without prior ECV of over 50%. The overall success rate for ECV at 38 weeks (37+0 to 38+0) was 22.4%. A significant correlation between SECV and the gestational age, an abundant AFI score, fundal placental location, and an oblique lie can be seen. Conversely, an anterior placental location was significantly associated with NECV. No major complications related to ECV resulting in maternal or fetal morbidity or mortality were observed over the 5-year period.

Strength and limitations

Our study is the first to analyze the impact of an ECV in a highly experienced center for vaginal breech birth. In many centers, vaginal breech delivery is not as equally offered as an ECV [ 12 ]. ECV then constitutes the only possibility for vaginal delivery and decreases the likelihood of CS. At our center, we offer vaginal breech delivery as an equal alternative to breech management. Our consultation for breech birth planning follows a standardized procedure, in which all possible procedures such as ECV, vaginal breech birth, and CS were discussed, to reach a participatory decision with the patient. Observing for five years, we included a large number of patients who consulted for breech birth planning.

The major limitation of this study is the low number of SECVs, which resulted from the relatively low uptake and success rates. These rates resemble our highly specialized center for vaginal breech delivery. In contrast, we reported a high number of breech deliveries. We were able to show that a SECV is not the only option for vaginal birth. Our data differ from those of previous studies especially because of the high rate of breech delivery.

Therefore, our findings might not be transferable to other hospitals or countries with different levels of knowledge and experience in ECV and vaginal breech delivery.

By performing ECV at 38 weeks risks such as preterm birth were reduced, and security of the procedure can be provided, which is crucial for our consultation offering the safest options for mothers and children.

Another limitation is the lack of information on women giving birth in other hospitals. The loss to follow-up was especially high in women with SECV. Conversely, one aim of ECV is the opportunity for women to have a cephalic birth close to their home.

Interpretation

A few international studies have reported ECV uptake rates ranging from approximately 20% to 70% in the Netherlands [ 11 , 20 , 24 , 25 ]. Compared with other centers, we encountered a low uptake rate for ECV and a high uptake rate for vaginal breech delivery. Most women eligible for ECV waived the offer and decided for vaginal breech delivery, resulting in a relatively low uptake rate for ECV. Other hospitals in the catchment area offer ECV but do not routinely offer vaginal delivery out of the breech presentation. Pregnant women who wish to deliver vaginally when their baby is in breech presentation tend to consult in our center. Women preferring a CS from the beginning as the mode of delivery out of the breech presentation are probably more likely to choose other obstetrical departments for consultation, ECV, or cesarean delivery leading to lower ECV uptake rates at our center.

Furthermore, women in Germany are still reluctant to use ECV as a procedure. The fear of pain or discomfort is the main reason for choosing ECV [ 11 , 26 ]. If the resident gynecologist has already advised against ECV and vaginal breech birth, and advocated for CS, pregnant women may not reconsider this option. These recommendations by resident doctors against ECV and vaginal breech birth may still be based on the breech term trial and based on false risk assumptions [ 7 ].

However, the routine use of ECV resulted in an increase in vaginal delivery. Compared to the international literature, we observed a higher rate of vaginal delivery after NECV (15.5% described by Trobo et al. vs. 66.8% in our population) [ 27 ]. Our total rate of vaginal delivery exceeds the German average of 6.75% vaginal delivery from breech presentation by far [ 5 ]. ECV and vaginal breech delivery should be offered to all applicable patients, as already manifested in many obstetrician guidelines [ 28 ].

Our overall success rate is within the lower end of the internationally reported range [ 29 , 30 ]. As recommended in international and national guidelines, ECV has been performed at our center at 38 weeks of gestation in the past decade. Previous multicenter studies have compared ECVs prior to term and at term. These studies indicated that ECV success rates might be higher when ECV is performed before 36 weeks of gestation, but may also increase the risk of preterm birth [ 14 , 15 ]. To decrease the risk of preterm birth, we accept a lower success rate for ECV by offering ECV at 38 weeks of gestation. Another reason for the lower success rate might be that ECV attempts in women considering vaginal breech delivery could be less intense carried out compared to that in women who wish to deliver vaginally out of cephalic presentation.

Obstetricians in our center also attempt ECV despite little chance for success due to the patient’s wishes, for example in cases of a scarce AFI-score, which has already been described to be correlated with a NECV [ 17 , 20 ]. Nulliparity has been associated with a lower ECV success rate [ 31 ]. The proportion of nulliparous women was lower in our population than in most studies, with approximately 55% nulliparity [ 27 , 32 , 33 ]. This could partially explain the lower success rates at our center. If ECV was only performed in patients with preferential prognostic conditions, the success rate might have been higher. However, stricter exclusion criteria would further decrease the total amount of ECVs.

Drug interventions that improve the ECV success rate include neuraxial analgesia and tocolytics. The impact of beta-stimulant tocolytics, calcium channel blockers and oxytocin antagonists on the success rate of ECV has already been studied. All drugs have been shown to be safe with only few side effects, but beta-stimulants significantly improved the success rate compared to other tocolytics [ 27 , 34 – 36 ]. In our clinic, fenoterol is a standard tocolytic drug for ECV. The use of a different tocolytic drugs might not improve the ECV success rates in our population.

A systematic review by Magro-Malosso et al. showed a significant increase in the success rate of ECV by administering neuraxial analgesia in addition to tocolytics [ 37 ]. Whether women with low success rates, such as nulliparous women, would benefit more from neuraxial analgesia than multiparous women, where success rates are already higher, should be the subject of further research.

Factors such as multiparity, posterior placental location, and a high AFI score have been previously described to increase the success rate of ECV in most studies. In contrast, nulliparity, anterior placental location, and oligohydramnion were described to reduce the chances of success [ 20 , 27 , 31 – 33 , 38 , 39 ]. Within our population we were able to confirm the negative impact of an anterior placental location, as well as the positive impact of a high AFI score. For multiparity, we were able to show a positive impact on the success rate, but we were not able to statistically confirm this parameter. For posterior placental location or scarce amniotic fluid index, no statistical impact on the success rate could be confirmed within our population.

Other parameters such as breech presentation, maternal body mass index (BMI), and gestational age are described to influence ECV as well, but the data situation is heterogeneous [ 20 , 33 , 38 ]. Within our population, oblique lie was significantly associated with SECV, which was previously described by Salzer et al. [ 40 ]. For maternal height and weight, we found no significant effect on the success rate. The influence of these parameters might be of minor importance or may be correlated with other maternal or fetal factors.

In Germany, a commonly used score for the evaluation of success is the score by Kainer et al. [ 12 , 41 ]. It was established for ECV at 36 weeks of gestation with prognostic factors such as an AFI score ≥7, posterior placental location, multiparity, and a lower estimated fetal weight. We were able to confirm these parameters for 38 weeks of gestation, except for fetal weight. In our population, we were surprisingly able to show an inverse effect on gestational age with a supporting tendency for higher birth weight. In a recently published paper success rates were significantly higher in children born with a birth weight of 3.5 kg or above [ 18 ]. Hakem et al. assumed that a larger fetus is less engaged in the pelvis and is therefore easier to rotate. Another possible reason might be that the larger fetus is more palpable, leading to a greater power transmission, which results in a higher mobility of the fetus.

When ECV is performed at 38 weeks of gestation, it might be recommended to attempt ECV at the end of 38 weeks. With this modification, the score is applicable for ECV at 38 weeks.

ECV has been described as a safe procedure [ 42 ]. We were able to confirm that ECV at 38 weeks of gestation was not associated with higher risks for the mother or child. Most of the observed complications were non-severe. All complications defined as minor, such as short bradycardias or other CTG alterations were not clinically significant, but led to a higher number of complications in total than reported in previous studies [ 32 , 43 , 44 ]. Grootscholten et al. recommended only considering cardiotocographic abnormalities leading to CS as a complication of the ECV. [ 43 ] Beuckens et al. only reported on more severe complications when an obstetrician was consulted, for example, bradycardia lasting over 10 min [ 32 ]. Our complication rate might seem higher at first sight, but comparing serous events such as preterm birth or placental abruption, our complication rate is comparable to those described by Grootscholten et al. or Beuckens et al. [ 32 , 43 ]. We observed no of the other major complications as described by Rodgers et al., such as bone fracture, cord prolapse or fetal death [ 44 ].

Considering our large catchment area for breech consultation, there is a high demand for alternatives to planned CS when breech presentation is apparent in Germany. In a recently published multicenter study, Kohls et al. described the majority of hospitals offering ECV in Germany as university or maximum care hospitals [ 12 ]. One reason might be that our expired German guideline for breech presentation only comments on ECV in an annex stating that it may be carried out [ 45 ]. This might change in the near future because the recently published German guideline on CS provides a stronger recommendation on ECV [ 46 ].

The rate of elective CS for women presenting with a breech presentation at term at our center is lower than the nationwide average (23.8% vs . 65.7%) [ 5 ]. This underlines the necessity of offering an ECV. However, a significant number of CSs were performed on patient demand. Two out of three women with planned CS had no contraindications for vaginal breech delivery. Independent information and early evidence-based counseling may further decrease CS numbers.

By offering both ECV and vaginal breech delivery, we were able to give women with breech pregnancy one more possibility for breech delivery. In our cohort, the vaginal birth approach in breech presentation was often preferred in pregnant women seeking consultation in both women with and without prior ECV. Despite our low success rates for ECV, a SECV was effective at increasing the rate of vaginal birth. Obstetricians should always discuss ECV as a first-step approach to breech presentation. In particular, by offering ECV at 38 weeks, a thorough risk-benefit analysis has yielded positive results. It is desirable that ECV and vaginal breech deliveries are further implemented in the clinical routine of obstetricians in Germany and spread methods and clinical competence through practical guided training so that more centers are able to offer further consultation and clinical management. Especially in the primary care center, thorough patient education on ECV and vaginal breech delivery can further decrease barriers to the procedure and help patients during the decision-making process on their optimal form of delivery.

We were able to confirm the previously described prognostic factors and the safety of ECV. For future consultations, it might be useful to further implement these in the consultation process and recommend women with unfavourable chances of ECV a vaginal breech birth.

Acknowledgments

We thank all involved team members at our university hospital (midwives, nurses, doctors, and other hospital employees). We are grateful to all participating patients.

Funding Statement

The authors received no specific funding for this work.

Data Availability

• PLoS One. 2021; 16(8): e0252702.

Decision Letter 0

29 Sep 2020

PONE-D-20-24091

External cephalic version in 38 weeks’ gestation – demographics, prognostic factors and success rates: a prospective analysis from a German single center

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F.L. is first vice president of the German Society for Gynaecology and Obstetrics (DGGG), council member of the European Board and College of Obstetrics and Gynaecology (EBCOG) and Executive Board Member und Committee chairman of the International Federation of Gynecology and Obstetrics (FIGO).

F.L. and L.J. worked on the first German S3-Guideline for cesarean section published in 2020.

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Reviewer #1: Partly

Reviewer #2: Partly

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: title - too long

keywords - too many

introduction - ECV is mostly performed before 37 GA?

LINE 67 - provide reference for most ecv performed before 37

line 68-70 - is redundant

ECV not offered line79 - provide reference

line 79-81 - more studies to be published??? numerous studies regarding predictors of success. the authors should replace outofdate reference (years 2000-2010) regarding success rate (ezra, ben meir) and replace with more updated reference (31312960, 30941816)

a prospective analyses? is this trully prospective or retrospective? approval (Ref:176/18) means 2018?

extremely low success rate of ECV -22% should be discussed and explained

reults chapter is written badly - please rewrite.

tables - ages with 2 decimals? what age does 33.13 represents?? parity and gravidity with decimals?

table 2 looks like it was copied from the SPSS sowtware - please provide a better version of presentation of table

what does constant mean?

vaginal delivery rate of 62% is very low - should be discussed

line 275-276 claiming novely - what about 31312960?

overall i dont see novelty, maybe unfamiliarity with current literature, therefore a more thorough literature review should be performed in the introduction and discussion and old references (more than 10 years should be discuraged)

limited new information, low success rate - thus limiting generalizability

Reviewer #2: First of all, this is a very interesting manuscript about management of breech presentation at term. This Care Unit seems to be a very expertise Breech Unit, and provide care about counseling about all possible maneuvers such as ECV, cesarean and vaginal birth. Congratulations for that.

However, it is commented on several occasions that this is the first article published about the safety of ECV in 38 weeks of gestation (lines 39, 49, 85, 275). The study fails to address how the findings relate to previous research in this area. The authors should return to publications such as that of Rodgers et al., 2017 (reference number 32 of the manuscript), where the mean gestational age of the ECV was 37 + 5, or in others such as Beuckens et al., 2015 (an observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwifes) where 60% were more than 36 weeks; or in other publications like Ainsworth et al. 2017, with ECV even in 40 weeks of gestation. All of these publications are about ECV complications.

Also, the complication total rate is 17%. This is higher than 6% in the revision published by Kok et al (2008) or Rodgers et al. (2017) about 5% or 2,5% in Neatherlands by Beuckens et al. (2016).

This manuscript can be very interesting and important, but the authors should rewrite their Introduction and Discussion to reference the related literature, because this is not the first publishing data about 38 gw ECVs.

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Reviewer #2: No

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Author response to Decision Letter 0

13 Nov 2020

Journal requirements were double-checked.

a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests ). If there are restrictions on sharing of data and/or materials, please state these.

A.Z. declares no relevant conflicts of interest.

This does not alter our adherence to PLOS ONE policies on sharing data and materials.

We included the Update in our cover letter.

3. Review Comments to the Author

Reviewer #1: title - too long

Thank you for your profound comments. They were very helpful in improving our manuscript.

The title was shortened. The new title is: “External cephalic version in 38 weeks’ gestation in a specialized German single center”

Less important key words were deleted.

The wording was infelicitous. Despite recommendations for performing ECV after 37 weeks of gestation, a lot of departments still offer ECV before 37 weeks in Germany. Citations were included in the revised manuscript.

Citations were included in the revised manuscript.

The passage was shortened, we focused on more present literature.

ECV not offered line 79 - provide reference

Citations were included in the revised manuscript. Kohls et. al. carried out an anonymized online survey asking about preferred primary intervention for ECV in Germany in 2018. Although it seems that ECV is offered nationwide, only for 61% ECV is the preferred primary intervention, for 12.4% of the surveyed hospitals CS is still the preferred intervention.

Outdate reference was replaced by updated reference. Only four studies, we think are very important to the topic and were published before 2010 (Hannah et. al 2000, Hutton et. al. 2003, Kainer et. al. 2003, Grootscholten et. al. 2008) were kept in the manuscript.

A prospective analyses? is this trully prospective or retrospective? approval (Ref:176/18) means 2018?

Thank you for pointing out this unclarity. Our study is an interim analysis of an ongoing larger single center study at our department starting from 2004. Our study design is overall prospective, but additional data was collected in a retrospective approach. The additional retrospective data collection was approved by the local ethics committee in 2018. An explanation was added in the revised manuscript.

Thank you for addressing this important topic. In the rewritten discussion, we clarified the background of our low success rate.

Thank you for your remarks, the results chapter has been rewritten. We focused on improving the language and cut out the repetitive results. I hope your demands were met.

The differences between the two groups in cases of age, parity, gravidity etc. were only visible within the decimals despite being significant. We shortened the decimal digits to only one digit, so the difference is still visible. Without the digits the numbers would be the same, although there is a significant difference.

Thank you for the remark. The regression was run using the program Bias. We diminished the reported variables to Odds ratio, standard deviation and Wald’s p.

The constant term in regression analysis is the value at which the regression line crosses the y-axis, also known as the y-intercept. It was deleted from the table, as it may cause incomprehension.

Thank you for pointing out this unclarity. The vaginal delivery rate of 62% refers to overall vaginal delivery after ECV disregarding the success. To make it clearer, we changed the labeling of the table to: ‘all deliveries after ECV’.

This number describes cephalic as well as breech vaginal delivery. The rate of cephalic vaginal delivery after successful ECV is 78%, which is higher than the nationwide average on cephalic birth. The rate of vaginal breech birth after unsuccessful ECV exceeds with 60% the nationwide average as well as rates described in previously published data.

Thank you for your remark. While Levin et. al. offers ECV as an alternative between CS and breech delivery, at our center we offer a combined approach discussing ECV, vaginal breech delivery and CS to reach a shared decision with the patient.

The reference list was updated, the introduction and discussion were rewritten. We hope your demands were met in the revised manuscript.

We addressed this point more precise in the revised discussion.

Reviewer #2: First of all, this is a very interesting manuscript about management of breech presentation at term. This Care Unit seems to be a very expertise Breech Unit, and provide care about counseling about all possible maneuvers such as ECV, cesarean and vaginal birth. Congratulations for that.

Thank you for your remarks, we followed your recommendation and discussed the articles mentioned above alike your suggestion.

Thank you for addressing this important issue. Our “higher” complication rate compared to previously published data is the result of reporting on all minor bradycardia and CTG-alterations. Beuckens et. al. only reported on bradycardia lasting over 10 minutes, Kok et. al. recommended only to report on bradycardia leading to CS. We discussed the complication rate in the revised paper.

Thank you for your remarks. We rewrote the Introduction and Discussion as recommended and revised the reference list with more present studies.

Submitted filename: Response to Reviewers.docx

Decision Letter 1

28 Mar 2021

PONE-D-20-24091R1

External cephalic version in 38 weeks’ gestation in a specialized German single center

Dear Dr. Authors,

Please submit your revised manuscript by 30th April. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: Yes

Reviewer #4: Yes

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: I Don't Know

4. Have the authors made all data underlying the findings in their manuscript fully available?

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #3: No

6. Review Comments to the Author

Reviewer #3: 38. Not clear what is meant by breech birth procedures?

39. There has been a paper published this year that demonstrated that ECV at 38 weeks has equal success rates to ECVs performed at 36, 37, 39 and 40 weeks and is equally safe.

48. ECV at 38 weeks.

49. False claim of first evidence.

131. No mention on the technique of ECV used, i.e., forward or backward flip?

154. fetuses.

160. Success rates appear to be skewed by the higher numbers of nulliparous women.

177. Definition of AFI measurements not mentioned, i.e., abundant is 20, 25, 30 cm?

289. The study published in 2021 reported higher success with higher EFW

290-293. Need to be re-written in a clearer way

318. A fetus cannot be referred to as children

327 – 329. No justification/hypothesis written on to why success was higher in larger fetuses.

Reviewer #4: I read with great interest the Manuscript titled “External cephalic version in 38 weeks’ gestation in a specialized German single center ”

The topic of this manuscript falls within the scope of PLOS One.

I was particularly pleased to review this revised version of the manuscript. In my honest opinion, the past reviewers' concerns have been resolved by the Authors. Now its scientific soundness is interesting enough to attract the readers’ attention. The methodology is accurate, and conclusions are supported by the summarized evidence.

However, I believe that the Discussions might benefit from a brief deeping of factors that might or might not improve the ECV successfulness, for example:

- Neuraxial analgesia [ PMID 27131581]

- Tocolysis [PMID 33421816]

- Other prognostic factors [PMID 31369397]

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #4: No

Author response to Decision Letter 1

25 Apr 2021

Reviewer #3:

38. Not clear what is meant by breech birth procedures?

Thanks for the remark, the corresponding part has been specified and alternatives for breech birth were described.

Thank you for pointing out this recent paper. The paper was cited and addressed in the introduction and discussion of the revised manuscript.

Thank you very much for your remarks regarding grammar and spelling. We undertook a profound correction. Additionally, the manuscript was proof-read by the suggested English language editing service.

Thanks for this comment. This statement had been adjusted to the current evidence in the revised manuscript.

Again, thank you for the helpful remark. The explanation below was added in the revised manuscript.

“The baby was moved upwards with one hand and pushed to perform a forward or backward roll, preferably in the direction with less resistance. In cases of unsuccessful ECV (NECV), both directions were attempted. The direction (backwards or forwards) of successful ECV (SECV) has not been documented.

Thanks, we corrected the typo.

Thank you very much for pointing out this important issue. The range of nulliparous women in our population is indeed higher compared to previously published data. We discussed the lower range in the revised manuscript.

As suggested, we explained the cutoff for an abundant AFI score at our center.

289. The study published in 2021 reported higher success with higher EFW.

Thank you for the recommendation. We discussed this recent evidence in our submitted revision.

This part has been extended for more clarity. The whole manuscript has been double-checked for infelicitous wording.

318. A fetus cannot be referred to as children.

Thank you for pointing this out. We corrected this context.

Thanks again for the helpful comment. We discussed possible hypothesis for the observed higher success rate in larger fetuses.

Reviewer #4:

I read with great interest the Manuscript titled “External cephalic version in 38 weeks’ gestation in a specialized German single center ”

Thank you very much for your profound comments and remarks. The suggested studies are very interesting and highly relevant. We discussed these articles alike your suggestions. We hope your demands were met in the revised manuscript. The language within the manuscript was also improved with the help of an editing service.

Decision Letter 2

21 May 2021

External cephalic version at 38 weeks’ gestation in a specialized German single center

PONE-D-20-24091R2

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Acceptance letter

11 Aug 2021

Dear Dr. Zielbauer:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact gro.solp@sserpeno .

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Dr. Salvatore Andrea Mastrolia

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cephalic position at 22 weeks normal?

• b BabyCenter__member Posted 05-09-15 Please consult your doctor to clear off the doubt. ... if the overall scan report is good then there shouldn't be anything to worry about. . do not wait. .consult immediately for the symptoms. ..

• l lovely1233 Posted 05-09-15 I asked the same question to the doctor few days back she said baby keeps moving so any position is ok 

• s sfk4 Original Poster Posted 10-09-15 BabyCenter__member said: Hi sfk... today only I visited my doctor and asked whether cepha… Thnks for the concern soma_b....I also went for a checkup and nd my gynec said its all normal but adviced me to rest for my lower abdominal pain :)