What should a pregnant woman in her third trimester with a breech fetus and no prior uterine surgeries know about external cephalic version (ECV)?

External Cephalic Version (ECV): What You Should Know

If your baby is breech in the third trimester and you have no prior uterine surgeries, you should strongly consider external cephalic version (ECV) at 37 weeks, as it successfully turns 62-82% of breech babies to head-down position and significantly reduces your need for cesarean section, with serious complications occurring in only 1-3% of cases. 1, 2, 3

What is ECV?

• ECV is a procedure where your doctor manually turns your baby from breech (bottom-down) to cephalic (head-down) position by applying pressure on your abdomen 4
• The technique involves grasping the baby through your abdominal wall and rotating them into the correct position 4

Why ECV Matters for You

• Breech vaginal delivery carries 5% risk of serious complications or death for your baby, compared to 1.6% with planned cesarean section 5
• However, cesarean section also carries risks for you, including hemorrhage, bladder injuries, and complications in future pregnancies 6
• ECV allows you to avoid both the risks of breech vaginal birth AND the risks of cesarean section by enabling normal head-down vaginal delivery 4, 1

Success Rates You Can Expect

• Overall success rate ranges from 62-82%, meaning most women who try ECV will have their baby successfully turned 2, 3
• If you've had a vaginal delivery before, your success rate is 3 times higher than first-time mothers 2
• If your BMI is over 40 kg/m², your success rate drops to only 9% compared to women with BMI under 25 2

Optimal Timing

• ECV should be performed at 37 weeks of pregnancy, which offers the best balance of success rate and safety 1, 3
• Performing ECV before 37 weeks increases your chance of achieving head-down position at birth but carries a small increased risk of moderate prematurity 1
• The best results occur at exactly 37 weeks, with 81% success rate followed by 77% vaginal delivery rate 3

What Happens During the Procedure

• You will receive tocolysis medication (either beta-mimetic or atosiban) to relax your uterus, which significantly increases success rates 1
• Your baby's heart rate will be monitored with cardiotocography before and for 30 minutes after the procedure 1
• The procedure must be performed where emergency cesarean section is immediately available 1
• If you are Rh-negative, you will receive RhoGAM prophylaxis, but routine Kleihauer testing is not necessary as significant bleeding occurs in less than 0.1% of cases 1

Risks and Complications

• Serious complications requiring emergency cesarean occur in only 1-3% of attempts 5, 2
• Specific complications include:
  • Fetal bradycardia (slow heart rate): 2.8% 2
  • Vaginal bleeding: 2.5% 2
  • Preterm rupture of membranes: 0.3% 2
  • Cord prolapse: 0.3% 2
• The risk of fetal death after ECV is extremely rare at 0.0001% (1 in 1 million) 5
• Transient fetal heart rate abnormalities are common but usually resolve without intervention 1

What Happens After Successful ECV

• If ECV is successful, your cesarean rate drops to 22%, compared to nearly 100% if breech presentation persists 2
• Your chance of normal vaginal delivery is 52% 2
• Your chance of needing forceps or vacuum assistance is 26%, which is about 6% higher than the general population 2
• There is no difference in cesarean rates between women who had successful ECV and the general pregnant population 2

If ECV Fails or Baby Turns Back to Breech

• You will need to choose between planned cesarean section or vaginal breech delivery 6
• Cesarean section is currently the most common and safest approach for persistent breech presentation 6
• Vaginal breech delivery can only be considered if your provider has specific expertise in this technique, you have no contraindications, and emergency cesarean facilities are immediately available 6

Alternatives That DON'T Work

• Acupuncture, moxibustion, and postural methods (like lying in specific positions) are NOT effective at turning breech babies and are not recommended 1

Critical Factors That Affect Your Success

• Previous vaginal delivery is the strongest predictor of success (3-fold increase) 2
• Maternal obesity significantly reduces success, particularly if BMI exceeds 40 kg/m² 2
• Multiparity (having had previous pregnancies) increases success 1

When ECV Should NOT Be Attempted

• Multiple pregnancy (twins or more) 5
• Significant third-trimester bleeding 5
• Placental insufficiency or intrauterine growth restriction 5
• Low amniotic fluid (oligohydramnios) 5
• Ruptured membranes 5
• Preeclampsia or pregnancy-induced hypertension 5
• Non-reassuring fetal heart rate patterns 5
• Any contraindication to vaginal birth 5

Bottom Line for Your Decision

ECV at 37 weeks offers you the best chance to avoid cesarean section while maintaining safety for you and your baby, with success rates of 62-82% and serious complication rates of only 1-3%. 1, 2, 3 The procedure is particularly effective if you've delivered vaginally before and have normal BMI. Given that only 1-1.5% of women with breech presentation actually undergo ECV despite clear evidence of benefit, you should specifically request this procedure from your provider. 5