What is the recommended management for a pregnant individual with a breech presentation at or near term using external cephalic version (ECV)?

External Cephalic Version for Breech Presentation

External cephalic version (ECV) should be attempted for all pregnant individuals with a breech presentation at term to decrease breech presentation at birth and reduce cesarean section rates. 1

Timing of ECV

• Optimal timing: ECV should be performed from 36 weeks' gestation (Professional consensus) 1
• Early ECV (34-36 weeks) compared to delayed ECV (37-38 weeks):
  • Reduces risk of non-cephalic presentation at birth (RR 0.81,95% CI 0.74-0.90) 2
  • Reduces failure to achieve vaginal cephalic birth (RR 0.90,95% CI 0.83-0.97) 2
  • Reduces vaginal breech delivery (RR 0.44,95% CI 0.25-0.78) 2
  • May slightly increase risk of preterm labor (6.6% vs 4.3%, RR 1.51,95% CI 1.03-2.21) 2

Procedure Requirements

• ECV should be performed with immediate access to an operating room for emergency cesarean (Professional consensus) 1
• Cardiotocography should be performed prior to and for 30 minutes after the procedure 1
• Parenteral tocolysis (β-mimetic or atosiban) is recommended to increase success rate (Grade B) 1

Success Factors

• Main factors associated with successful ECV:
  • Multiparity (higher success rates) 1, 3
  • Non-obese maternal status 1
  • Flexed type of breech 3

Safety Considerations

• ECV is associated with a low risk of complications:
  • Transient fetal heart rate abnormalities may occur 1
  • Risk of significant fetomaternal hemorrhage is low (<0.1%) 1
  • For Rh-negative women, Rh prophylaxis should be administered (Professional consensus) 1

Contraindications

• There is no general consensus on contraindications for ECV 4
• Only oligohydramnios is consistently mentioned as a contraindication across guidelines 4
• Contraindications should be limited to those with clear empirical evidence or pathophysiological relevance 4

Alternative Methods

• Acupuncture, moxibustion, and postural methods are not effective in reducing breech presentation at birth (Level of Evidence 2) and are not recommended (Grade B) 1

Outcomes

• ECV is associated with:
  • Decreased rate of breech presentation at birth (Level of Evidence 2) 1
  • Potentially lower rate of cesarean section (Level of Evidence 3) 1
  • No increase in severe maternal morbidity (Level of Evidence 3) 1
  • No increase in perinatal morbidity (Level of Evidence 3) 1

Management After Failed ECV

• Options after failed ECV include:
  • Repeat ECV attempt
  • Planned cesarean delivery
  • Trial of vaginal breech delivery (in selected cases with appropriate expertise)

Patient Counseling

• All eligible women with breech presentation at term should be informed about the benefits and risks of ECV
• Success rates of approximately 80% have been reported in selected populations 3
• The cesarean section rate following successful ECV is significantly lower (12.5%) compared to persistent breech presentation 3

ECV represents an important intervention to reduce breech presentation at birth and subsequent cesarean deliveries. The procedure should be offered to all eligible pregnant individuals with breech presentation at term, with careful consideration of timing and appropriate use of tocolysis to maximize success rates.