What are the guidelines for a provider to recommend external cephalic version (ECV) to a pregnant woman with a breech presentation after 37 weeks of gestation?

External Cephalic Version (ECV): Essential Provider Knowledge

What is ECV and When to Offer It

External cephalic version should be offered to all pregnant women with breech presentation at or after 36-37 weeks of gestation, as it is a safe and effective intervention that reduces breech deliveries and cesarean sections. 1, 2

• ECV involves manually rotating the fetus from breech to cephalic presentation through the maternal abdomen 1
• The procedure is recommended in national guidelines as standard care for breech presentation 1
• Success rates range from 28-38% depending on patient factors 3, 4

Optimal Timing for ECV

Begin ECV attempts at 34-36 weeks of gestation rather than waiting until 37-38 weeks, as early ECV reduces the rate of non-cephalic presentation at birth. 2, 5

• Early ECV (34-35 weeks) reduces non-cephalic presentation at birth compared to term ECV (RR 0.81,95% CI 0.74-0.90) 2
• Early ECV decreases failure to achieve vaginal cephalic birth (RR 0.90,95% CI 0.83-0.97) 2
• Early ECV reduces vaginal breech delivery rates (RR 0.44,95% CI 0.25-0.78) 2

Important Caveat About Early ECV

• Early ECV increases risk of late preterm birth (6.6% vs 4.3%, RR 1.51,95% CI 1.03-2.21) 2
• Counsel women carefully about this increased preterm birth risk when discussing timing 2
• Repeat ECV attempts are allowed and should be offered if initial attempt fails 5

Absolute Contraindications to ECV

Limit contraindications to those with clear empirical evidence or pathophysiological relevance, as guidelines show poor consensus on eligibility criteria. 1

• Placental abruption 3
• Placenta previa 3
• Uterine malformations 3
• Regular contractions or active labor 3
• Premature rupture of membranes 3
• Non-reassuring fetal heart rate patterns 3
• Oligohydramnios (the only contraindication mentioned in all reviewed guidelines) 1

Critical Pitfall to Avoid

• Guidelines list 18 different contraindications with poor reproducibility between sources (ranging from 5-13 per guideline) 1
• Only six contraindications have actual evidence supporting them 1
• Do not unnecessarily restrict ECV eligibility based on unsubstantiated contraindications 1

Predictors of ECV Success

Multiparity, increased amniotic fluid, and higher estimated fetal weight significantly predict successful ECV. 3

• At least one prior vaginal delivery is the strongest maternal predictor (p = 0.002) 3
• Increased Amniotic Fluid Index (AFI) strongly predicts success (p < 0.001) 3
• Higher estimated fetal weight increases success rates (p = 0.045) 3
• Use these factors to counsel women on their individual likelihood of success 3

Pre-Procedure Requirements

• Perform extended ultrasound examination within 21 days of the procedure 3
• Ensure experienced practitioner performs the procedure 5
• Have tocolytics available as part of the protocol 5
• Consider epidural analgesia availability 5

Patient Counseling About the Procedure

Women should be informed that ECV is painful and stressful, but most would still recommend it or repeat it. 4

• Women rate pain at an average of 60/100 on visual analog scale 4
• 68% describe the procedure as severely painful to unbearable 4
• 70% find the procedure stressful 4
• Despite this, the majority would recommend ECV to friends or repeat it themselves 4
• Women desiring vaginal birth are more likely to accept ECV (52% vs 24.4%, p<0.001) 4

Safety Profile

• No deliveries should occur within 48 hours after ECV in uncomplicated cases 3
• Serious fetal complications are rare (approximately 7% with no significant difference between early and delayed ECV) 5
• Reversion to breech after successful ECV is low in both early and delayed groups 5

Impact on Delivery Outcomes

• ECV reduces cesarean section rates, though the effect may not reach statistical significance (RR 0.92,95% CI 0.85-1.00) 2
• Neonatal outcomes including Apgar scores and perinatal mortality show no significant differences between ECV and no ECV groups 2
• The procedure effectively reduces the need for cesarean delivery when successful 1