breech presentation green top guideline

Europe PMC requires Javascript to function effectively.

Either your web browser doesn't support Javascript or it is currently turned off. In the latter case, please turn on Javascript support in your web browser and reload this page.

Search life-sciences literature (43,947,359 articles, preprints and more)

• Full text links
• Citations & impact
• Similar Articles

Management of Breech Presentation: Green-top Guideline No. 20b.

BJOG : an International Journal of Obstetrics and Gynaecology , 16 Mar 2017 , 124(7): e151-e177 https://doi.org/10.1111/1471-0528.14465   PMID: 28299904 

Abstract 

Full text links .

Read article at publisher's site: https://doi.org/10.1111/1471-0528.14465

References 

Articles referenced by this article (76)

Title not supplied

New and old predictive factors for breech presentation: our experience in 14 433 singleton pregnancies and a literature review..

Fruscalzo A , Londero AP , Salvador S , Bertozzi S , Biasioli A , Della Martina M , Driul L , Marchesoni D

J Matern Fetal Neonatal Med, (2):167-172 2013

MED: 23688372

Long-term outcome by method of delivery of fetuses in breech presentation at term: population based follow up.

Danielian PJ , Wang J , Hall MH

BMJ, (7044):1451-1453 1996

MED: 8664622

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.

Hannah ME , Hannah WJ , Hewson SA , Hodnett ED , Saigal S , Willan AR

Lancet, (9239):1375-1383 2000

MED: 11052579

The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies.

Berhan Y , Haileamlak A

BJOG, (1):49-57 2015

MED: 26234485

Time trend in the risk of delivery-related perinatal and neonatal death associated with breech presentation at term.

Pasupathy D , Wood AM , Pell JP , Fleming M , Smith GC

Int J Epidemiol, (2):490-498 2008

MED: 18977783

Planned caesarean section for term breech delivery

Cochrane Database Syst Rev, (7):CD000166- 2015

Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial.

Whyte H, Hannah ME, Saigal S, Hannah WJ, Hewson S, Amankwah K, Cheng M, Gafni A, Guselle P, Helewa M, Hodnett ED, Hutton E, Kung R, McKay D, Ross S, Willan A ; Term Breech Trial Collaborative Group

Am J Obstet Gynecol, (3):864-871 2004

MED: 15467555

The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35,453 term breech infants.

Rietberg CC , Elferink-Stinkens PM , Visser GH

BJOG, (2):205-209 2005

MED: 15663585

Five years to the term breech trial: the rise and fall of a randomized controlled trial.

Glezerman M

Am J Obstet Gynecol, (1):20-25 2006

MED: 16389006

Citations & impact 

Impact metrics, citations of article over time, alternative metrics.

Smart citations by scite.ai Smart citations by scite.ai include citation statements extracted from the full text of the citing article. The number of the statements may be higher than the number of citations provided by EuropePMC if one paper cites another multiple times or lower if scite has not yet processed some of the citing articles. Explore citation contexts and check if this article has been supported or disputed. https://scite.ai/reports/10.1111/1471-0528.14465

Article citations, applying the modified ten-group robson classification in a spanish tertiary hospital..

Gutiérrez-Martínez S , Fernández-Martínez MN , Adánez-García JM , Fernández-Fernández C , Pérez-Prieto B , García-Gallego A , Gómez-Salgado J , Medina-Díaz M , Fernández-García D

J Clin Med , 13(1):252, 31 Dec 2023

Cited by: 0 articles | PMID: 38202259 | PMCID: PMC10780088

OptiBreech collaborative care versus standard care for women with a breech-presenting fetus at term: A pilot parallel group randomised trial to evaluate the feasibility of a randomised trial nested within a cohort.

Walker S , Spillane E , Stringer K , Trepte L , Davies SM , Bresson J , Sandall J , Shennan A , OptiBreech Collaborative

PLoS One , 18(11):e0294139, 15 Nov 2023

Cited by: 0 articles | PMID: 37967120 | PMCID: PMC10650999

Evaluating the effectiveness of lateral postural management for breech presentation: study protocol for a randomized controlled trial (BRLT study).

Shinmura H , Matsushima T , Watanabe A , Shi H , Nagashima A , Takizawa A , Yamada M , Harigane E , Tsunoda Y , Kurashina R , Ichikawa G , Suzuki S

Trials , 24(1):360, 27 May 2023

Cited by: 0 articles | PMID: 37245031 | PMCID: PMC10225078

Incidence of obstetric anal sphincter injuries following breech compared to cephalic vaginal births.

Leborne P , de Tayrac R , Zemmache Z , Serrand C , Fabbro-Peray P , Allegre L , Vintejoux E

BMC Pregnancy Childbirth , 23(1):317, 04 May 2023

Cited by: 0 articles | PMID: 37142944 | PMCID: PMC10161470

Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study.

Jennewein L , Heemann R , Hoock SC , Hentrich AE , Eichbaum C , Feidicker S , Louwen F

Arch Gynecol Obstet , 309(4):1333-1340, 24 Mar 2023

Cited by: 0 articles | PMID: 36961567 | PMCID: PMC10894138

Similar Articles 

To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation.

Vaginal delivery of breech presentation.

Kotaska A , Menticoglou S , Gagnon R , MATERNAL FETAL MEDICINE COMMITTEE

J Obstet Gynaecol Can , 31(6):557-566, 01 Jun 2009

Cited by: 35 articles | PMID: 19646324

External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a.

BJOG , 124(7):e178-e192, 16 Mar 2017

Cited by: 17 articles | PMID: 28299867

Survey of external cephalic version services in the East of England region: comparison of services in 2007 and 2012.

Koh LM , Mumdzjans A , Pradhan A

J Obstet Gynaecol , 34(8):659-661, 09 Jun 2014

Cited by: 0 articles | PMID: 24911163

Vaginal breech birth: can we move beyond the Term Breech Trial?

J Midwifery Womens Health , 59(3):320-327, 24 Apr 2014

Cited by: 5 articles | PMID: 24762034

Moxibustion for breech presentation.

Complement Ther Nurs Midwifery , 6(4):176-179, 01 Nov 2000

Cited by: 11 articles | PMID: 11858300

Europe PMC is part of the ELIXIR infrastructure

Breech presentation: diagnosis and management

Key messages.

• All women with a breech presentation should be offered an external cephalic version (ECV) from 37 weeks, if there are no contraindications.
• Elective caesarean section (ELCS) for a singleton breech at term has been shown to reduce perinatal and neonatal mortality rates.
• Planning for vaginal breech birth requires careful assessment of suitability criteria, contraindications and the ability of the service to provide experienced personnel.

In June 2023, we commenced a project to review and update the Maternity and Neonatal eHandbook guidelines, with a view to targeting completion in 2024. Please be aware that pending this review, some of the current guidelines may be out of date. In the meantime, we recommend that you also refer to more contemporaneous evidence.

Breech and external cephalic version

Breech presentation is when the fetus is lying longitudinally and its buttocks, foot or feet are presenting instead of its head.

Figure 1. Breech presentations

• Breech presentation occurs in three to four per cent of term deliveries and is more common in nulliparous women.
• External cephalic version (ECV) from 37 weeks has been shown to decrease the incidence of breech presentation at term and the subsequent elective caesarean section (ELCS) rate.
• Vaginal breech birth increases the risk of low Apgar scores and more serious short-term complications, but evidence has not shown an increase in long-term morbidity.
• Emergency caesarean section (EMCS) is needed in approximately 40 per cent of women planning a vaginal breech birth.
• 0.5/1000 with ELCS for breech >39 weeks gestation
• 2.0/1000 planned vaginal breech birth >39/40
• 1.0/1000 with planned cephalic birth.
• A reduction in planned vaginal breech birth followed publication of the Term Breech Trial (TBT) in 2001.
• Acquisition of skills necessary to manage breech presentation (for example, ECV) is important to optimise outcomes.

Clinical suspicion of breech presentation

• Abdominal palpation: if the presenting part is irregular and not ballotable or if the fetal head is ballotable at the fundus
• Pelvic examination: head not felt in the pelvis
• Cord prolapse
• Very thick meconium after rupture of membranes
• Fetal heart heard higher in the abdomen

In cases of extended breech, the breech may not be ballotable and the fetal heart may be heard in the same location as expected for a cephalic presentation.

If breech presentation is suspected, an ultrasound examination will confirm diagnosis.

Cord prolapse is an obstetric emergency. Urgent delivery is indicated after confirming gestation and fetal viability.

Diagnosis: preterm ≤36+6 weeks

• Breech presentation is a normal finding in preterm pregnancy.
• If diagnosed at the 35-36 week antenatal visit, refer the woman for ultrasound scan to enable assessment prior to ECV.
• Mode of birth in a breech preterm delivery depends on the clinical circumstances.

Diagnosis: ≥37+0 weeks

• determine type of breech presentation
• determine extension/flexion of fetal head
• locate position of placenta and exclude placenta praevia
• exclude fetal congenital abnormality
• calculate amniotic fluid index
• estimate fetal weight.

Practice points

• Offer ECV if there are no contraindications.
• If ECV is declined or unsuccessful, provide counselling on risks and benefits of a planned vaginal birth versus an ELCS.
• Inform the woman that there are fewer maternal complications with a successful vaginal birth, however the risk to the woman increases significantly if there is a need for an EMCS.
• Inform the woman that caesarean section increases the risk of complication in future pregnancies, including the risk of a repeat caesarean section and the risk of invasive placentation.
• If the woman chooses an ELCS, document consent and organise booking for 39 weeks gestation.

Information and decision making

Women with a breech presentation should have the opportunity to make informed decisions about their care and treatment, in partnership with the clinicians providing care.

Planning for birth requires careful assessment for risk of poor outcomes relating to planned vaginal breech birth. If any risk factors are identified, inform the woman that an ELCS is recommended due to increased perinatal risk.

Good communication between clinicians and women is essential. Treatment, care and information provided should:

• take into account women's individual needs and preferences
• be supported by evidence-based, written information tailored to the needs of the individual woman
• be culturally appropriate
• be accessible to women, their partners, support people and families
• take into account any specific needs, such as physical or cognitive disabilities or limitations to their ability to understand spoken or written English.

Documentation

The following should be documented in the woman's hospital medical record and (where applicable) in her hand-held medical record:

• discussion of risks and benefits of vaginal breech birth and ELCS
• discussion of the woman's questions about planned vaginal breech birth and ELCS
• discussion of ECV, if applicable
• consultation, referral and escalation

External cephalic version (ECV)

• ECV can be offered from 37 weeks gestation
• The woman must provide written consent prior to the procedure
• The success rate of ECV is 40-60 per cent
• Approximately one in 200 ECV attempts will lead to EMCS
• ECV should only be performed by a suitably trained, experienced clinician
• continuous electronic fetal monitoring (EFM)
• capability to perform an EMCS.

Contraindications

Table 1. Contraindications to ECV

Precautions

• Hypertension
• Oligohydramnios
• Nuchal cord

Escalate care to a consultant obstetrician if considering ECV in these circumstances.

• Perform a CTG prior to the procedure - continue until  RANZCOG criteria  for a normal antenatal CTG are met.
• 250 microg s/c, 30 minutes prior to the procedure.
• Administer Anti-D immunoglobulin if the woman is rhesus negative.
• Do not make more than four attempts at ECV, for a suggested maximum time of ten minutes in total.
• Undertake CTG monitoring post-procedure until  RANZCOG criteria  for a normal antenatal CTG are met.

Emergency management

Urgent delivery is indicated in the event of the following complications:

• abnormal CTG
• vaginal bleeding
• unexplained pain.

Initiate emergency response as per local guidelines.

Alternatives to ECV

There is a lack of evidence to support the use of moxibustion, acupuncture or postural techniques to achieve a vertex presentation after 35 weeks gestation.

Criteria for a planned vaginal breech birth

• Documented evidence of counselling regarding mode of birth
• Documentation of informed consent, including written consent from the woman
• Estimated fetal weight of 2500-4000g
• Flexed fetal head
• Emergency theatre facilities available on site
• Availability of suitably skilled healthcare professional
• Frank or complete breech presentation
• No previous caesarean section.
• Cord presentation
• Fetal growth restriction or macrosomia
• Any presentation other than a frank or complete breech
• Extension of the fetal head
• Fetal anomaly incompatible with vaginal delivery
• Clinically inadequate maternal pelvis
• Previous caesarean section
• Inability of the service to provide experienced personnel.

If an ELCS is booked

• Confirm presentation by ultrasound scan when a woman presents for ELCS.
• If fetal presentation is cephalic on admission for ELCS, plan ongoing management with the woman.

Intrapartum management

Fetal monitoring.

• Advise the woman that continuous EFM may lead to improved neonatal outcomes.
• Where continuous EFM is declined, perform intermittent EFM or intermittent auscultation, with conversion to EFM if an abnormality is detected.
• A fetal scalp electrode can be applied to the breech.

Position of the woman

• The optimal maternal position for birth is upright.
• Lithotomy may be appropriate, depending on the accoucheur's training and experience.

Pain relief

• Epidural analgesia may increase the risk of intervention with a vaginal breech birth.
• Epidural analgesia may impact on the woman's ability to push spontaneously in the second stage of labour.

Induction of labour (IOL)

See the  IOL eHandbook page  for more detail.

• IOL may be offered if clinical circumstances are favourable and the woman wishes to have a vaginal birth.
• Augmentation (in the absence of an epidural) should be avoided as adequate progress in the absence of augmentation may be the best indicator of feto-pelvic proportions.

The capacity to offer IOL will depend on clinician experience and availability and service capability.

First stage

• Manage with the same principles as a cephalic presentation.
• Labour should be expected to progress as for a cephalic presentation.
• If progress in the first stage is slow, consider a caesarean section.
• If an epidural is in situ and contractions are less than 4:10, consult with a senior obstetrician.
• Avoid routine amniotomy to avoid the risk of cord prolapse or cord compression.

Second stage

• Allow passive descent of the breech to the perineum prior to active pushing.
• If breech is not visible within one hour of passive descent, a caesarean section is normally recommended.
• Active second stage should be ½ hour for a multigravida and one hour for a primipara.
• All midwives and obstetricians should be familiar with the techniques and manoeuvres required to assist a vaginal breech birth.
• Ensure a consultant obstetrician is present for birth.
• Ensure a senior paediatric clinician is present for birth.

VIDEO:  Maternity Training International - Vaginal Breech Birth

• Encouragement of maternal pushing (if at all) should not begin until the presenting part is visible.
• A hands-off approach is recommended.
• Significant cord compression is common once buttocks have passed the perineum.
• Timely intervention is recommended if there is slow progress once the umbilicus has delivered.
• Allow spontaneous birth of the trunk and limbs by maternal effort as breech extraction can cause extension of the arms and head.
• Grasp the fetus around the bony pelvic girdle, not soft tissue, to avoid trauma.
• Assist birth if there is a delay of more than five minutes from delivery of the buttocks to the head, or of more than three minutes from the umbilicus to the head.
• Signs that delivery should be expedited also include lack of tone or colour or sign of poor fetal condition.
• Ensure fetal back remains in the anterior position.
• Routine episiotomy not recommended.
• Lovset's manoeuvre for extended arms.
• Reverse Lovset's manoeuvre may be used to reduce nuchal arms.
• Supra-pubic pressure may aide flexion of the fetal head.
• Maricueau-Smellie-Veit manoeuvre or forceps may be used to deliver the after coming head.

Undiagnosed breech in labour

• This occurs in approximately 25 per cent of breech presentations.
• Management depends on the stage of labour when presenting.
• Assessment is required around increased complications, informed consent and suitability of skilled expertise.
• Do not routinely offer caesarean section to women in active second stage.
• If there is no senior obstetrician skilled in breech delivery, an EMCS is the preferred option.
• If time permits, a detailed ultrasound scan to estimate position of fetal neck and legs and estimated fetal weight should be made and the woman counselled.

Entrapment of the fetal head

This is an extreme emergency

This complication is often due to poor selection for vaginal breech birth.

• A vaginal examination (VE) should be performed to ensure that the cervix is fully dilated.
• If a lip of cervix is still evident try to push the cervix over the fetal head.
• If the fetal head has entered the pelvis, perform the Mauriceau-Smellie-Veit manoeuvre combined with suprapubic pressure from a second attendant in a direction that maintains flexion and descent of the fetal head.
• Rotate fetal body to a lateral position and apply suprapubic pressure to flex the fetal head; if unsuccessful consider alternative manoeuvres.
• Reassess cervical dilatation; if not fully dilated consider Duhrssen incision at 2, 10 and 6 o'clock.
• A caesarean section may be performed if the baby is still alive.

Neonatal management

• Paediatric review.
• Routine observations as per your local guidelines, recorded on a track and trigger chart.
• Observe for signs of jaundice.
• Observe for signs of tissue or nerve damage.
• Hip ultrasound scan to be performed at 6-12 weeks post birth to monitor for developmental dysplasia of the hip (DDH). See Neonatal eHandbook -  Developmental dysplasia of the hip .

More information

Audit and performance improvement.

All maternity services should have processes in place for:

• auditing clinical practice and outcomes
• providing feedback to clinicians on audit results
• addressing risks, if identified
• implementing change, if indicated.

Potential auditable standards are:

• number of women with a breech presentation offered ECV
• success rate of ECV
• ECV complications
• rate of planned vaginal breech birth
• breech birth outcomes for vaginal and caesarean birth.

For more information or assistance with auditing, please contact us via  [email protected]

• Bue and Lauszus 2016, Moxibustion did not have an effect in a randomised clinical trial for version of breech position.  Danish Medical Journal  63(2), A599
• Coulon et.al. 2014,  Version of breech fetuses by moxibustion with acupuncture.  Obstetrics and Gynecology  124(1), 32-39. DOI: 10.1097/AOG.0000000000000303
• Coyle ME, Smith CA, Peat B 2012, Cephalic version by moxibustion for breech presentation.  Cochrane Database of Systematic Reviews  2012, Issue 5. Art. No.: CD003928. DOI: 10.1002/14651858.CD003928.pub3
• Evans J 2012,  Essentially MIDIRS Understanding Physiological Breech Birth  Volume 3. Number 2. February 2012
• Hoffmann J, Thomassen K, Stumpp P, Grothoff M, Engel C, Kahn T, et al. 2016, New MRI Criteria for Successful Vaginal Breech Delivery in Primiparae.  PLoS ONE  11(8): e0161028. doi:10.1371/journal.pone.0161028
• Hofmeyr GJ, Kulier R 2012, Cephalic version by postural management for breech presentation.  Cochrane Database of Systematic Reviews  2012, Issue 10. Art. No.: CD000051. DOI: 10.1002/14651858.CD000051.pub2
• New South Wales Department of Health 2013,  Maternity: Management of Breech Presentation  HNELHD CG 13_01, NSW Government; 2013
• Royal College of Obstetricians and Gynaecologists 2017, External Cephalic Version and Reducing the Incidence of Term Breech Presentation.  Green-top Guideline No. 20a . London: RCOG; 2017
• The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) 2016,  Management of breech presentation at term , July 2016 C-Obs-11:
• The Royal Women's Hospital 2015,  Management of Breech - Clinical Guideline
• Women's and Newborn Health Service, King Edward Memorial Hospital 2015, Complications of Pregnancy Breech Presentation

Abbreviations

Get in touch, version history.

First published:  November 2018 Due for review:  November 2021

Uncontrolled when downloaded

Related links.

External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a

• PMID: 28299867
• DOI: 10.1111/1471-0528.14466

Umbilical Cord Prolapse (Green-top Guideline No. 50)

• Access the PDF version of the guideline

Cord prolapse has been defined as the descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation is the presence of the umbilical cord between the fetal presenting part and the cervix, with or without membrane rupture. The overall incidence of cord prolapse ranges from 0.1% to 0.6%. In the case of breech presentation, the incidence is slightly higher than 1%. It has been reported that male fetuses appear to be predisposed to cord prolapse. The incidence is influenced by population characteristics and is higher where there is a large percentage of multiple gestations.

Cases of cord prolapse appear consistently in perinatal mortality enquiries, and one large study found a perinatal mortality rate of 91/1000. Prematurity and congenital malformations account for the majority of adverse outcomes associated with cord prolapse in hospital settings but birth asphyxia is also associated with cord prolapse. Perinatal death has been described with normally formed term babies, particularly with planned home birth. Delay in transfer to hospital appears to be an important contributing factor.

Asphyxia may also result in hypoxic–ischaemic encephalopathy and cerebral palsy. The principal causes of asphyxia in this context are thought to be cord compression and umbilical arterial vasospasm preventing venous and arterial blood flow to and from the fetus. There is a paucity of long-term follow-up data of babies born alive after cord prolapse in both hospital and community settings.

The management of prolapsed cord is one of the labour ward guidelines mandated by the Clinical Negligence Scheme for Trusts (CNST), Welsh Pool Risk and Clinical Negligence and Other Risks Scheme (CNORIS) maternity standards in England, Wales and Scotland, respectively.

The purpose of this guideline is to describe modalities to prevent, diagnose and manage cord prolapse. It addresses those pregnant women at high risk of or with a diagnosis of cord prolapse in hospital and community settings. Pregnancies complicated by fetal malformation or with cord prolapse before 22 completed weeks of gestation ate not covered by this guideline. All later gestations are included.

COVID disclaimer

This guideline was developed as part of the regular programme of Green-top Guidelines, as outlined in our document  Developing a Green-top Guideline: Guidance for developers (PDF) , and prior to the emergence of COVID-19.

Version history

This is the second edition of this guideline.

Please note that the RCOG Guidelines Committee regularly assesses the need to update the information provided in this publication. Further information on this review is available on request.

Developer declaration of interests

Available on request.

This page was last reviewed 05 November 2014.

• Long Course for Part 3 MRCOG
• Crash Course
• Circuit course
• EBCOG part 2 Examinatin
• FSRH Guidelines
• Green top guidelines
• Nice Guidelines (Gynaecology)
• NICE Guidelines (Obstetrics)
• BASHH & BHIVA Guidelines
• Colposcopy Guidelines and Leaflets
• Anomaly Patient Leaflets
• Nice Obstetric Leaflets
• Nice Gynaecological leaflets
• BASHH & BHIVA Leaflets
• Uro Gynae leaflets
• ORIENTATION About MRCOG part 3 exam
• Good Practice
• Consent & Clinical Goverance Advise
• Important Notes
• Testimonials
• Nice Abortion care and Ectopic
• Recurrent miscarriage
• Hyperemesis gravidarum & NVP GTG 69
• Infertility - Nice Guidelines
• Part 3 stations - Class on 24-09-2023
• POP Q - class and part 3 station - 05-08-2023
• Class on 1st Jan 2023
• Class on 28th June 2020
• Class on 6th October 2019
• Class on 2nd August 2019
• Colposcopy Updated Feb 2020
• Carcinoma Cervix
• Cancer of Vulva
• MRCOG 2 & 3, online class on Endometrial Cancer
• Epithelial carcinoma BGCS guideline - Dr. Priyata Lal
• MRCOG 2 Online class on Breast Cancer
• Non-Epithelial Germ cell tumors
• Hydatidiform mole
• Urodynamics
• Urinary Incontinence
• Uterine Prolapse
• Class 1 - Combined Hormonal Contraception
• Class 2 - Progesterone only Contraception
• Class 3 - Emergency Contraception
• Class 4 Sterilization and Post-Natal Contraception
• Small For Gestatoinal Age (GTG - 31)
• Operative Delivery Tutorial
• Fetal Monitoring
• Intrapartum Nice Guidelines & Labour Module questions
• NICE CS NG192 - GTG 45 VBAC
• Pre-term Labour PPROM
• Assisted Breech & ECV
• Antepartum Hemorrhage
• Consent and Ethics
• Menopause & POI
• Vulval Disorders
• Thrombo-prophylaxis in gynaecology
• WHO Labour Care guide
• Twin Tutorial
• Cervical Cerclage GTG 75
• Sickle cell anaemia
• Red cell antibodies and anti - D tutorial
• Maternal Collapse
• Diabetes In Pregnancy
• Inherited Bleeding Disorders (GTG - 71)
• Hypertension in Pregnancy - Diagnosis and management
• Intrahepatic Cholestasis
• Heart Diseases in Pregnancy
• VTE in Pregnancy
• MEOWS and NEWS
• EOGBS - GTG 36
• Covid 19 in Pregnancy
• BHIVA Guidelines HIV in Pregnancy
• STD - BASHH Guidelines 2018 & 2019
• Fetal Infections

Green top Guidelines -

• The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)
• Recurrent Miscarriage - Guideline number 17
• Intrahepatic cholestasis of pregnancy - Green-top Guideline No. 43 June 2022
• Antenatal corticosteroids to reduce neonatal morbidity and mortality - Green-top Guideline No. 74 July 2022
• Cervical Cerclage - Green-top Guideline No. 75 June 2022
• Amniocentesis and chorionic villus sampling - Green-top Guideline No. 8 October 2021
• Management of sickle cell disease in pregnancy. A British Society for Haematology Guideline-2021
• Assisted Vaginal Birth - Green-top Guideline No. 26, April 2020
• Management of Gestational Trophoblastic Disease - Green-top Guideline No. 38, September 2020
• Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation - Thomson AJ, on behalf of the Royal College of Obstetricians and Gynaecologists. BJOG 2019 .
• Care of Women Presenting with Suspected Preterm Prelabour Rupture of Membranes from 24+0 Weeks of Gestation - Green-top Guideline No. 73, June 2019
• Maternal Collapse in Pregnancy and the Puerperium - Green-top Guideline No. 56, December 2019
• GTG_OBESITY_IN_PREGANANCY_NO_72 - Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, Diamond A, on behalf of theRoyal College of Obstetricians and Gynaecologists. Care of Women with Obesity in Pregnancy.Green-top Guideline No. 72. BJOG 2018.
• Placenta Praevia and Placenta Accreta:Green-top Guideline No. 27a (September 2018) - Jauniaux ERM, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D, Kayem G, Kingdom J, Silver R, Sentilhes L on behalf of the Royal College of Obstetricians and Gynaecologists. Placenta Praevia and Placenta Accreta: Diagnosis and Management. Green-top Guideline No. 27a. BJOG 2018
• Vasa Praevia: Diagnosis and Management - Jauniaux ERM, Alfirevic Z, Bhide AG, Burton GJ, Collins SL, Silver R on behalf of the Royal College of Obstetricians and Gynaecologists. Vasa praevia: diagnosis and management. Green-top Guideline No. 27b.BJOG 2018.
• Prevention of Early-onset Neonatal Group B Streptococcal Disease, Green-top Guideline No. 36, (September 2017) - Hughes RG, Brocklehurst P, Steer PJ, Heath P, Stenson BM on behalf of the Royal College of Obstetricians and Gynaecologists. Prevention of early-onset neonatal group B streptococcal disease. Green-top Guideline-No. 36. BJOG 2017;124:e280–e305.
• External Cephalic Version and Reducing the Incidence of Term Breech Presentation, Green-top Guideline No. 20a (March 2017) - Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Term Breech Presentation. BJOG 2017; 124: e178–e192.
• Management of Breech Presentation, Green-top Guideline No. 20b (March 2017), Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. BJOG 2017; 124: e151–e177.
• Management of Inherited Bleeding Disorders in Pregnancy, Green-top Guideline No. 71 (joint with UKHCDO) (April 2017) Pavord S, Rayment R, Madan B, Cumming T, Lester W, Chalmers E, Myers B, Maybury H, Tower C, Kadir R on behalf of the Royal College of Obstetricians and Gynaecologists. Management of Inherited Bleeding Disorders in Pregnancy. Green-top Guideline No. 71. BJOG 2017; 124:e193–e263.
• Management of Premenstrual Syndrome, Green-top Guideline No. 48 (February 2017) Green LJ, O’Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. BJOG 2017;124:e73–e105.
•   The Management of Ovarian Hyperstimulation Syndrome, Green-top Guideline No. 5 (February 2016)
• The Management of Ovarian Cysts in Postmenopausal Women, Green-top Guideline No. 34 (July 2016)
• Management of Endometrial Hyperplasia, Green-top Guideline No. 67 RCOG/BSGE Joint Guideline (February 2016)
• Epilepsy in Pregnancy, Green-top Guideline No. 68 (June 2016)
• The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum, Green-top Guideline No. 69 (June 2016)
• Management of Bladder Pain Syndrome, Green-top Guideline No. 70 RCOG/BSUG Joint Guideline (December 2016)
• Prevention and Management of Postpartum Haemorrhage, Green-top Guideline No. 52 (December 2016)
• Chickenpox in Pregnancy, Green-top Guideline No. 13 (January 2015)
• The Management of Third- and Fourth-Degree Perineal Tears, Green-top Guideline No. 29 (June 2015)
• Reducing the Risk of Venous Thromboembolism during Pregnancy and the Puerperium, Green-top Guideline No. 37a (April 2015)
• Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management, Green-top Guideline No. 37b (April 2015)
• Birth After Previous Caesarean Birth, Green-top Guideline No. 45 (October 2015)
• Post-Hysterectomy Vaginal Vault Prolapse, Green-top Guideline No. 46 RCOG/BSUG Joint Guideline (July 2015)
• Blood Transfusion in Obstetrics, Green-top Guideline No. 47 (May 2015)
• Female Genital Mutilation and its Management, Green-top Guideline No. 53 (July 2015)
• Long-term Consequences of Polycystic Ovary Syndrome, Green-top Guideline No. 33 (November 2014)
• Umbilical Cord Prolapse, Green-top Guideline No. 50 (November 2014)
• Management of Beta Thalassaemia in Pregnancy, Green-top Guideline No. 66 (March 2014)
• The Management of Women with Red Cell Antibodies during Pregnancy, Green-top Guideline No. 65 (May 2014)
• The Investigation and Management of the Small–for–Gestational–Age Fetus, Green–top Guideline No. 31 2nd Edition (February 2013 | Minor revisions – January 2014)
• The Initial Management of Chronic Pelvic Pain Green-top Guideline No. 41 May 2012
• Shoulder Dystocia Green–top Guideline No. 42 2nd Edition I March 2012
• Pregnancy and Breast Cancer Green–top Guideline No. 12 March 2011
• The Investigation and Treatment of Couples with Recurrent First trimester and Second-trimester Miscarriage Green-top Guideline No. 17 April 2011
• Reduced Fetal Movements Green-top Guideline No. 57 February 2011
• Management of Sickle Cell Disease in Pregnancy Green–top Guideline No. 61 July 2011
• Management of Suspected Ovarian Masses in Premenopausal Women Green–top Guideline No. 62 RCOG/BSGE Joint Guideline I November 2011
• Antepartum Haemorrhage Green–top Guideline No. 63 November 2011
• Best Practice in Outpatient Hysteroscopy RCOG/BSGE Green-top Guideline No. 59 March 2011

Mission MRCOG is the online platform for the training of the candidates for MRCOG 2 and MRCOG 3 examinations held by Royal College of Obstetrics and Gynaecology, London.

Follow us on

Copyright © 2019 missionmrcog.com All rights reserved.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Medicina (Kaunas)

External Cephalic Version—A Chance for Vaginal Delivery at Breech Presentation

Ionut marcel cobec.

1 Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Diakoniestrasse 10, 74523 Schwäbisch Hall, Germany

Vlad Bogdan Varzaru

Tamas kövendy, lorant kuban, anca-elena eftenoiu.

2 Clinic of Internal Medicine, Hohenloher Krankenhaus Öhringen, 74613 Öhringen, Germany

Aurica Elisabeta Moatar

Andreas rempen.

Background and Objectives : In recent years, the rate of caesarean section (CS) has increased constantly. Although vaginal breech delivery has a long history, breech presentation has become the third most common indication for CS. This study aims to identify factors associated with the success of external cephalic version (ECV), underline the success rate of ECV for breech presentation and highlight the high rate of vaginal delivery after successful ECV. Material and Methods : This retrospective observational study included 113 patients with singleton fetuses in breech presentation, who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakonieklinikum Schwäbisch Hall, Germany. Maternal and fetal parameters and data related to procedure and delivery were collected. Possible predictors of successful ECV were evaluated. Results : The success rate of ECV was 54.9%. The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The vaginal birth rate after successful ECV was 80.6%. Overall, 79.0% of women with successful ECV delivered spontaneously without complications, 19.4% delivered through CS performed during labor by medical necessity, and 1.6% delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS. Gravidity, parity, maternal age, gestational age, fetal weight, and amniotic fluid index (AFI) were significantly correlated with the outcome of ECV. Conclusions : ECV for breech presentation is a safe procedure with a good success rate, thus increasing the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV.

1. Introduction

In recent years, the rate of caesarean section (CS) has increased constantly in Germany [ 1 ]. In singleton pregnancies, an important indication of CS has been fetal malpresentation. In clinical practice, breech presentation (praesentation caudae) is the most common abnormal fetal presentation, which refers to fetuses lying bottom- or feet/knee-first rather than head-first [ 2 ]. Breech presentation is defined as a longitudinal positioning of the fetus with the buttocks or feet closest to the cervix. In Germany, fetal breech presentation at term occurs in about 3% of singleton pregnancies. The rate of breech presentation decreases with gestational age. This rate is about 9% between 33 and 36 pregnancy weeks, 18% between 28 and 32 weeks, and about 30% before the 28th pregnancy week [ 3 ].

The predisposing factors for breech presentation are uterine anomalies (e.g., uterus arcuatus, uterus bicornis, uterus duplex), uterus myomatosus, pelvic tumor, advanced multiparity, history of cesarean delivery or breech delivery, gestational diabetes, multiple gestation, congenital anomalies of the fetus (neural tube defects, fetal hydrocephalus or anencephaly), neuromuscular diseases, cephalo-pelvic disproportion, prematurity, low fetal birth weight, oligohydramnios, short umbilical cord, polar placentation, and placenta praevia [ 4 , 5 ]. However, in about 75% of cases, no specific cause of term breech presentation could be identified [ 4 , 6 ]. The main types of breech presentation are frank (≈60–70%), complete (≈4–10%), and incomplete breech (≈20–36%) [ 7 , 8 ].

Vaginal breech delivery has a long history. Studies have shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were higher in the planned vaginal delivery than in the planned cesarean delivery at breech presentation [ 9 ]. These findings significantly lead to CS being accepted by obstetricians as the safer option for breech delivery [ 9 ].

In the United States, there has been an increase in the frequency of CS in the past 20 years. One in three women giving birth in the USA will undergo a CS [ 10 ]. In many other developed and developing countries, this rate is the same. For example, in Korea, the frequency of CS was about 36.9% in 2012, CS being the usual method of delivery for term breech presentation [ 11 ]. Breech presentation became the third most common indication for CS, after previous CS and labor dystocia [ 12 ].

The maternal morbidity of CS is approximately three times higher than that of vaginal delivery [ 13 ]. The maternal risks of CS compared to vaginal delivery are well known. These include greater blood loss, thrombotic events, unplanned hysterectomy, operative damage to other organs, mortality, longer hospital stay with higher costs, and more readmissions than patients undergoing vaginal delivery [ 14 ]. Additional maternal complications of CS include scarring, chronic pain, and intestinal obstruction caused by adhesive disease. Moreover, in the following pregnancies, a previous cesarean delivery may cause a higher rate of placental abnormalities, unexplained stillbirth, as well as repeated surgical delivery in many cases [ 14 ]. However, vaginal delivery could also have maternal complications compared to CS, such as postpartum urinary incontinence and pelvic organ prolapse [ 15 ].

In case of fetal breech position, the external cephalic version (ECV) could be an option for reducing the number of CSs and vaginal breech deliveries [ 9 ]. ECV is a technique used to convert the fetal breech presentation into a cephalic position with targeted manual pressure on the mother’s abdominal wall at-term or near-term pregnancies in order to increase the chance of a vaginal cephalic birth [ 9 , 16 , 17 ]. ECV can be carried out with or without analgesics and with or without tocolytic therapy [ 18 ].

Factors favoring the success of ECV could be multiparous women, non-anterior placental location, palpability of the fetal skull, lower maternal body mass index, the type of breech presentation (for example, the frank breech presentation is associated with lower rates of success) and, of course, the experience of the physician in performing ECV [ 10 , 18 , 19 ]. Placental abruption, vaginal bleeding, fetal injury (including fractures and brachial plexus injuries), and pathological cardiotocography (CTG) findings, such as fetal bradycardia, may represent complications of the method [ 20 ].

The aim of this study is to identify factors associated with the success of ECV, highlight the relevance and success rate of ECV for breech presentation, and underline the high rate of vaginal deliveries in patients with successful ECV for breech presentation.

2. Material and Methods

This study represents a retrospective and anonymized data analysis over a period of 5 years. We reviewed the records of 113 women who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Germany. In our study, we included all patients with singleton fetuses in breech presentation who agreed to the maneuver. The ECV was performed by different senior consultants. Prior to ECV, an ultrasound control was performed, and the possible risks of the maneuver were discussed. Each patient signed the ECV informed consent. ECV was not performed if the patient rejected ECV or if there were absolute contraindications of ECV.

For 30 min before and during the ECV, the patient received an infusion with tocolysis with fenoterol. Before and after the ECV, a CTG control was performed. The ECV was attempted under ultrasound control of the fetal heartbeat. Fetal biometric parameters were obtained sonographically. The patient was placed in a comfortable lying position with knees slightly elevated. The patient was allowed to end the maneuver at any point in time.

Maternal age, number of pregnancies, number of childbirths, history of CS, ultrasonographic findings (type of breech presentation, placental location, amniotic fluid index), characteristics of ECV (gestational age at ECV, fetal weight at ECV, success of ECV, direction in which successful ECV was performed, complications during and after ECV), and birth-related characteristics (planned and real type of delivery, gestational age at birth, fetal weight at birth) were collected from our database. Data were analyzed using IBM SPSS Statistics 20. Grouping by the dichotomous outcome of ECV, we used either χ 2 analysis or Fisher’s exact test for categorical variables and independent samples t -test for continuous variables. Multiple binary logistic regression was used to identify possible predictors of the outcome of ECV. We used the significance threshold of α = 0.05 corresponding to the 95% confidence interval.

In the observed five years, we registered 6619 singleton deliveries out of a total of 6825 deliveries and a general CS rate of 24.9%. Overall, 11.0% were elective CSs and 13.9% CSs were performed during labor by medical necessity. In total, 4.8% of all registered deliveries in our clinic in the observed period were CSs with breech presentation. In our sample of 113 women, the mean maternal age was 31.69 years ( SD = 4.44)—the youngest patient was 18 years old and the oldest patient was 43 years old. In total, 53.1% of the women were primigravida and 61.9% were nullipara. Four (3.5%) women had a history of CS.

Before ECV was performed, the fetal back faced the maternal left in 60 (53.1%) cases and the maternal right in 53 (46.9%) cases. In 56 (49.6%) cases, the placenta was located on the posterior wall, in 47 (41.6%) on the anterior wall, in 6 (5.3%) in the fundus, and in 4 (3.6%) on the left or right wall. The mean amniotic fluid index (AFI) at ECV was 14.88 ( SD = 3.58), ranging from 8 to 25. The mean gestational age at ECV was 261.82 days ( SD = 4.98). The minimum gestational age at ECV in our cohort was 35 + 2 weeks of pregnancy and the latest performed ECV was at 40 + 0 weeks of pregnancy. In 12 cases (10.6%), ECV was performed under 37 weeks of gestation because of medical necessity and with informed patient consent. The mean fetal weight at ECV was 2966.02 g ( SD = 391.06), ranging from 2158 g to 4123 g.

The success rate of ECV was 54.9%. ECV succeeded backwards in 39 (62.9%) cases and forwards in 23 (37.1%) cases. Overall, 101 (89.4%) of the ECVs were performed without any complications during the maneuver. In total, 12 (10.6%) cases encountered complications during the attempt of ECV. The complications were represented by fetal bradycardia with quick recovery in 7 cases, maternal intolerable abdominal pain in 2 cases, vena cava compression with quick recovery in 1 case, low maternal tocolysis tolerance in 1 case, and maternal nausea and emesis in 1 case. A single patient (0.9%) developed contractions during post-ECV monitoring, while 112 patients (99.1%) had no complications post-ECV.

The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The successful ECV group was planned for spontaneous delivery. The vaginal birth rate of the successful ECV group was 80.6%. Out of 62 patients, 49 (79.0%) delivered spontaneously without complications, 12 (19.4%) delivered through CS performed during labor by medical necessity, and 1 (1.6%) delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS; three delivered through CS and one delivered vaginally. The unsuccessful ECV group delivered through CS.

For gestational age and fetal weight at birth, eight observations were excluded from the analysis due to missing values. Five patients were planned for CS and decided to deliver in another clinic, while three patients were planned for spontaneous delivery and decided upon home birth. The mean gestational age at birth was 275.41 days ( SD = 8.96), the earliest delivery was at 37 + 0 weeks of pregnancy and the latest was at 42 + 0 weeks of pregnancy. The mean fetal weight at birth was 3350.43 ( SD = 470.69), ranging from 2180 g to 4470 g.

We analyzed the relationship between the outcome of ECV and the following categorical variables: gravidity, parity, history of CS, fetal back position before ECV and placental location ( Table 1 ). Multigravidity, defined as having been pregnant more than once, and a parity ≥ 1 were significantly associated with a successful ECV.

Association between outcome ECV and gravidity, parity, history of CS, fetal back position before ECV and placental location.

We compared maternal age, gestational age, fetal weight and AFI at ECV for successful and unsuccessful ECV using an independent samples t -test and found significant differences ( Table 2 ). For gestational age, we conducted a Welch’s t -test since equal variances could not be assumed. The other continuous variables were compared using Student’s t -test.

Comparison between maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV for successful and unsuccessful ECV using independent samples t -test.

Multiple logistic regression analysis was used to construct a prediction model for the outcome of ECV and covariates parity, maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV ( Table 3 ). A parity ≥ 1 and a higher maternal age were found to be favorable predictors of successful ECV in our prediction model.

Results of multiple logistic regression analysis for predictors of successful ECV.

4. Discussions

This study was performed in a clinic where the CS rate is lower than the reported CS rate for Germany, which is about 31.8% according to the official statistics [ 3 ]. In 2000, a large international multicenter randomized clinical trial, called the Term Breech Trial, compared vaginal deliveries with planned cesarean deliveries [ 21 ]. It was shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were significantly higher in the planned vaginal delivery group than in the planned cesarean delivery group (16% vs. 5%) at breech presentation. These findings significantly led to obstetricians choosing CS as the safer option for breech delivery in the 2000s [ 9 ]. For this reason, more than 12% of the CSs in Germany are performed in case of breech presentation. For example, in the west-central part of Germany, in the State of Hessen, about 90% of breech fetuses at term are delivered via CS [ 3 ]. In our clinic, CS at breech presentation represented 4.8% of all registered deliveries from 2016 to 2020.

In case of fetal breech position, ECV could be a successful and safe option to reduce the number of CSs [ 22 , 23 ]. The routine use of ECV could lower the rate of surgical delivery in case of breech presentation by approximately two-thirds in term pregnancies [ 9 ]. In most cases, fenoterol is used as tocolytic therapy, mainly as a continuous tocolysis. The improvement of the monitoring during the ECV with sonography and CTG and the use of tocolytic therapy made this method safer, thus reducing the complication rate associated with ECV [ 18 ].

By performing ECV, we aim to increase the proportion of vaginal cephalic delivery and thereby decrease the rate of CSs. For these reasons, ECV can be considered the first-line management in dealing with uncomplicated breech presentation at term. The method is recommended by Cochrane and the American and Royal Colleges of Obstetrics and Gynecologists, as well as by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe) [ 3 , 24 , 25 ].

ECV would be generally recommended after 37 weeks of gestation [ 9 , 16 ]. It is performed as an elective procedure in non-laboring women, aiming to improve the chance of vaginal cephalic birth. Attempting ECV before term, between 34th and 36th pregnancy weeks, can be associated with an increase in late preterm birth [ 17 ]. According to the German guidelines, ECV should be offered to all women with uncomplicated breech presentation by singleton pregnancies in hospitals where facilities for an emergency CS are present [ 3 , 20 ]. In a study performed by Weiniger et al., the CS rate among women with successful ECV was 20.2%, whereas among women with persistent breech presentation at delivery it was 94.9% [ 26 ]. We registered a CS rate for successful ECV of 19.4%, while the unsuccessful ECV patients delivered through CS.

Furthermore, women who underwent vaginal delivery after a successful ECV had lower odds of developing endometriosis and sepsis and shorter hospitalization, therefore lower hospital charges [ 26 ]. In contrast, these women could have a higher risk of chorioamnionitis. Attempted ECV may be also associated with an increased risk of a low APGAR score at 5 min [ 6 ]. According to the literature, the absolute risk of all complications of ECV is approximately 1% in fetuses at term [ 14 ]. We noticed in our study that the registered complications were minimal and insignificant compared to the high rate of successful ECV, followed by a high rate of vaginal deliveries.

Women with singleton pregnancy and breech presented fetus without the following pathologies are potentially eligible for ECV near term (≥36 weeks). These pathologies include multiple gestation, onset of active labor, rupture of membranes, oligohydramnios, antepartum hemorrhage or history with placental abruption, pelvic abnormalities, severe preeclampsia or eclampsia, pathological Doppler or CTG, placenta praevia, placenta accreta, and infant with major congenital anomalies or growth restrictions [ 2 ].A point system, such as Kainer score, can be helpful to estimate the success rate of ECV, which includes parameters, such as AFI, placental location, fetal position, nuchal cord, estimated fetal weight, parity, fetal engagement, and uterine tone [ 27 , 28 ]. We noticed positive results even though we did not apply this score.

Multiparous women are known to have higher ECV success rates [ 9 ]. Our study shows that multigravidity and a parity ≥ 1 are associated with successful ECV. The absence of nulliparity was also identified as an important predictor of successful ECV, which supports the findings of previous studies.

According to the literature, ECV is considered safe in women with a history of CS and some studies showed that the success rate of ECV is comparable to that of women with no previous CS [ 29 , 30 , 31 , 32 ]. Although rare, we registered four cases with a history of CS. ECV was successful in three of them, but only one delivered vaginally. In our sample, the fetal back faced either the maternal left or right. We found no statistically significant relationship between the fetal position and the outcome of the maneuver.

The anterior placental location has been reported as being associated with a lower rate of success, probably due to the anterior location of the placenta making it difficult to perform ECV [ 9 ]. In the present study, we included patients with anterior, posterior, lateral, and fundal placental location. We noticed that the relationship between placental location and ECV outcome was not significant.

Our study included women between 18 and 43 years old. The group with successful ECV had a higher mean maternal age than the group with unsuccessful ECV, therefore we included maternal age in our logistic regression analysis. In our prediction model, higher maternal age was found to be a predictor for successful ECV, therefore the success rate increases with maternal age. Other studies did report similar results [ 33 , 34 ]. It is important to note that there may be other related variables affecting this relationship, for example, BMI, which we did not take into account. According to the literature, high BMI values are associated with a low success rate of ECV and a decrease in the rate of vaginal delivery after successful ECV [ 35 ].

The relationship between estimated fetal weight at ECV and ECV outcome is controversial [ 9 , 34 ]. We found an association between the success of the maneuver and higher fetal weight, as well as higher gestational age at ECV. An explanation could be that a larger fetus, which corresponds to a higher gestational age, is more palpable [ 27 , 36 ].

It has been reported that a higher AFI is associated with successful ECV [ 18 , 37 , 38 ]. In the present study, the group with successful ECV had a higher mean AFI than the group with unsuccessful ECV. It is important to note that the minimum AFI score registered was eight.

The safety, efficacy, and cost-effectiveness of ECV for breech presentation followed by vaginal delivery are underlined in our study through good clinical practice and are sustained by other performed studies [ 2 ].

5. Conclusions

ECV for breech presentation is a safe procedure with a good success rate which increases the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV. Multigravidity, absence of nulliparity, higher maternal age, higher gestational age, higher fetal weight, and higher AFI are all associated with successful ECV.

Funding Statement

This research received no external funding.

Author Contributions

I.M.C. and A.R. conceived and planned in detail the present study. I.M.C., V.B.V. and T.K. extracted and analyzed the entire patient data. A.-E.E. performed the computations and interpreted the patient data together with I.M.C., L.K., V.B.V. and A.E.M., I.M.C. took the lead in writing the manuscript with input from T.K., V.B.V., A.-E.E. and A.E.M., in consultation with A.R., I.M.C. and A.R. supervised this study. All authors discussed the results and commented on the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study used pre-existing, anonymized and irreversibly de-identified data. Approval from the ethics committee was not required.

Informed Consent Statement

This retrospective study used pre-existing, anonymized and irreversibly de-identified data.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.