External cephalic version (ECV) refers to a procedure in which the fetus is rotated from the breech to the cephalic presentation by manipulation through the mother's abdomen (figure 1). ECV is typically performed in nonlaboring women at or near term to improve their chances of having a vaginal cephalic birth.
Several national organizations recommend ECV. For example, the Royal College of Obstetricians and Gynaecologists (RCOG) states that a skilled service for ECV should be available and offered to women with breech presentation at term . Likewise, the American College of Obstetricians and Gynecologists (ACOG) states that all women near term with breech presentation should be offered an attempt at version . ECV is also recommended by clinical guidelines of the Royal Dutch Organization for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG) .
Women who are well-informed, encouraged to undergo the procedure, believe in its safety, and desire a vaginal delivery are more likely to opt for ECV . Women may choose not to undergo ECV because of fear of the procedure, the preference for scheduled cesarean delivery, incomplete information, and concerns related to birth complications among friends and family. This topic will discuss the procedure for ECV. The causes, diagnosis, management, and outcome of breech presentation are reviewed separately. (See "Overview of breech presentation".)
The effectiveness of ECV is based on its ability to increase the proportion of fetuses in cephalic presentation at the onset of labor and decrease the frequency of cesarean delivery. The effectiveness of ECV was illustrated by a systematic review of seven randomized trials of ECV at term . Compared with women with breech fetuses who had no attempt at ECV, women who attempted ECV had a significant reduction in both noncephalic births (relative risk [RR] 0.46, 95% confidence interval [CI] 0.31-0.66) and cesarean delivery (RR 0.63, 95% CI 0.44-0.90) . Although ECV decreased the frequency of cesarean delivery compared with no ECV, studies have shown that the cesarean delivery rate after successful ECV remains higher than in the general obstetrical population:
A 2014 meta-analysis reported that women with successful ECV had a cesarean delivery rate of 21 percent, which was significantly higher than the 11 percent rate in women with cephalic-presenting fetuses and no ECV (RR 2.19, 95% CI 1.73-2.76) . The excess risk of cesarean delivery was due to both dystocia and nonreassuring fetal heart rate patterns.