cephalic presentation 21 weeks

Is cephalic presentation normal at 21 weeks?

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The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

• Down, with the back facing the birth canal
• With one shoulder pointing toward the birth canal
• Up, with the hands and feet facing the birth canal

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

When Will Your Baby Turn Head Down?

During pregnancy, your baby’s position can change frequently. One of the most important changes occurs when the baby turns to a headfirst, head-down position in the uterus, which often happens toward the end of your pregnancy. Wondering when “should” your baby be head down, or how to tell if your baby is head down? Get these answers as well as more information on the baby’s head-down position, the symptoms of a baby turning head down, and the optimal baby position for birth.

Why Does a Baby Turn to a Head-Down Position for Birth?

So, what does it mean when a baby is head down? Babies generally turn head down toward the birth canal as a part of their natural instinct to get into the best possible position for birth. This is known as the vertex or cephalic presentation . A baby may settle into the optimal position, which is head down and facing the mother's back ( occiput anterior position ), but occasionally they may position themselves head down and face forward ( occiput posterior position ). The face-forward position may cause more discomfort during delivery.

Remember, each pregnancy is unique. If you have any concerns about your baby's position, it's always best to consult your healthcare provider.

When Does a Baby Turn Head Down?

Curious about when a baby “should” be head down? It’s important to remember that the exact timing of when a baby turns head down can vary from pregnancy to pregnancy. Generally, babies turn head down during the third trimester (which ranges from 28 to 40 weeks), a few weeks before birth.

How to Tell if Your Baby Is Head Down

To determine your baby’s position, your healthcare provider will usually perform a physical exam during the final few weeks of your pregnancy, feeling your abdomen to locate your baby’s head. They may also perform an ultrasound to confirm the position, especially if your baby is suspected of being in breech presentation, meaning your baby’s feet or buttocks are positioned downward, lower than the head.

So, how to tell if your baby is head down without an ultrasound? And can you feel when your baby turns head down? You may notice signs and symptoms indicating your baby is turning head down. These could include:

Pressure on your bladder, which may cause frequent urination

Pressure in your pelvis and hips

A reduction of pressure against your diaphragm and lungs, making it easier to breathe

The area where you feel kicks when your baby is head down. You may feel kicks higher in your belly or under your ribs when your baby is head down, whereas in the breech position, you may feel kicks lower in your belly.

These symptoms may be more evident when your baby “drops” lower into your pelvis in preparation for labor. This process is known as lightening .

Remember, every pregnancy is different, and you may not experience any sensation or signs that your baby is head down.

If you're unsure if your baby is head down, your healthcare provider can confirm the position during a prenatal checkup.

What if Your Baby Doesn’t Move Head Down?

When a baby is not head down, they might be in what's known as a breech position or a sideways transverse lie position . In a breech position, the baby's buttocks or feet are positioned to descend down the birth canal first, instead of the head. This position can pose certain risks during vaginal birth , as the baby's head is the last part to emerge. Three main types of breech positions include frank breech, complete breech, and footling breech.

If you're getting closer to your due date and your baby is still not head down, there are a few options that your healthcare provider may consider:

External cephalic version (ECV), a procedure in which a healthcare provider gently manipulates the baby's position from outside the belly. This procedure is usually performed if your baby isn’t in the head-down position after 36 weeks of pregnancy.

A planned cesarean birth ( cesarean section or c-section ) , if the baby's position cannot be changed or poses risks during vaginal delivery.

It's important to discuss these options with your healthcare provider to determine the best course of action for you and your baby. In some cases, your little one may continue to move around and switch positions in the weeks before birth. Again, keep in mind that every pregnancy and birth is unique and your healthcare team will work with you to ensure a safe delivery for both you and your little one.

Can You Help Your Baby Move to a Head-Down Position?

If your baby is not yet in a head-down position and your due date is approaching, you may be wondering how to “get” your baby to turn head down. While you can’t actually make your little one do something, there are some gentle things you can try to encourage them to move, after checking with your healthcare provider. It's important to note that these methods are not guaranteed to work. They include:

Spending time on all fours and rocking back and forth gently

Doing pelvic tilts or rotating your hips in a circular motion

Swimming or walking in water, which can provide buoyancy and help the baby move into a head-down position

Talking to your baby and using gentle and stimulating sounds, such as music, may also encourage them to turn.

Remember to always consult your provider before attempting any exercises or techniques to help your baby move.

The Bottom Line

In the final weeks of pregnancy, you could be concerned about your baby's positioning and wondering “When do babies turn head down?” if your little one hasn't settled into this position yet. But rest assured, your baby still has time to turn head down, and even if they don't do this, there are safe delivery options available. Remember to stay in close communication with your healthcare provider and reach out if you have any questions or concerns. You're doing a great job—keep up the good work!

How We Wrote This Article The information in this article is based on the expert advice found in trusted medical and government sources, such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. You can find a full list of sources used for this article below. The content on this page should not replace professional medical advice. Always consult medical professionals for full diagnosis and treatment.

• American College of Obstetricians and Gynecologists, Your Pregnancy and Childbirth: Month to Month, 7th ed. (Washington, DC: American College of Obstetricians and Gynecologists, 2021).
• ACOG. “If Your Baby is Breech.”
• Cleveland Clinic. “Breech Baby.”
• Cleveland Clinic. “Fetal Positions for Birth.”
• Cleveland Clinic. “Vertex Presentation.”
• Mayo Clinic. “Fetal Presentation Before Birth.”

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

, MD, Children's Hospital of Philadelphia

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Abnormal fetal lie or presentation may occur due to fetal size, fetal anomalies, uterine structural abnormalities, multiple gestation, or other factors. Diagnosis is by examination or ultrasonography. Management is with physical maneuvers to reposition the fetus, operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more , or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more .

Terms that describe the fetus in relation to the uterus, cervix, and maternal pelvis are

Fetal presentation: Fetal part that overlies the maternal pelvic inlet; vertex (cephalic), face, brow, breech, shoulder, funic (umbilical cord), or compound (more than one part, eg, shoulder and hand)

Fetal position: Relation of the presenting part to an anatomic axis; for transverse presentation, occiput anterior, occiput posterior, occiput transverse

Fetal lie: Relation of the fetus to the long axis of the uterus; longitudinal, oblique, or transverse

Normal fetal lie is longitudinal, normal presentation is vertex, and occiput anterior is the most common position.

Abnormal fetal lie, presentation, or position may occur with

Fetopelvic disproportion (fetus too large for the pelvic inlet)

Fetal congenital anomalies

Uterine structural abnormalities (eg, fibroids, synechiae)

Multiple gestation

Several common types of abnormal lie or presentation are discussed here.

Transverse lie

Fetal position is transverse, with the fetal long axis oblique or perpendicular rather than parallel to the maternal long axis. Transverse lie is often accompanied by shoulder presentation, which requires cesarean delivery.

Breech presentation

There are several types of breech presentation.

Frank breech: The fetal hips are flexed, and the knees extended (pike position).

Complete breech: The fetus seems to be sitting with hips and knees flexed.

Single or double footling presentation: One or both legs are completely extended and present before the buttocks.

Types of breech presentations

Breech presentation makes delivery difficult ,primarily because the presenting part is a poor dilating wedge. Having a poor dilating wedge can lead to incomplete cervical dilation, because the presenting part is narrower than the head that follows. The head, which is the part with the largest diameter, can then be trapped during delivery.

Additionally, the trapped fetal head can compress the umbilical cord if the fetal umbilicus is visible at the introitus, particularly in primiparas whose pelvic tissues have not been dilated by previous deliveries. Umbilical cord compression may cause fetal hypoxemia.

Predisposing factors for breech presentation include

Preterm labor Preterm Labor Labor (regular uterine contractions resulting in cervical change) that begins before 37 weeks gestation is considered preterm. Risk factors include prelabor rupture of membranes, uterine abnormalities... read more

Multiple gestation Multifetal Pregnancy Multifetal pregnancy is presence of > 1 fetus in the uterus. Multifetal (multiple) pregnancy occurs in up to 1 of 30 deliveries. Risk factors for multiple pregnancy include Ovarian stimulation... read more

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Perinatal death

It is best to detect abnormal fetal lie or presentation before delivery. During routine prenatal care, clinicians assess fetal lie and presentation with physical examination in the late third trimester. Ultrasonography can also be done. If breech presentation is detected, external cephalic version can sometimes move the fetus to vertex presentation before labor, usually at 37 or 38 weeks. This technique involves gently pressing on the maternal abdomen to reposition the fetus. A dose of a short-acting tocolytic ( terbutaline 0.25 mg subcutaneously) may help. The success rate is about 50 to 75%. For persistent abnormal lie or presentation, cesarean delivery is usually done at 39 weeks or when the woman presents in labor.

Face or brow presentation

In face presentation, the head is hyperextended, and position is designated by the position of the chin (mentum). When the chin is posterior, the head is less likely to rotate and less likely to deliver vaginally, necessitating cesarean delivery.

Brow presentation usually converts spontaneously to vertex or face presentation.

Occiput posterior position

The most common abnormal position is occiput posterior.

The fetal neck is usually somewhat deflexed; thus, a larger diameter of the head must pass through the pelvis.

Progress may arrest in the second phase of labor. Operative vaginal delivery Operative Vaginal Delivery Operative vaginal delivery involves application of forceps or a vacuum extractor to the fetal head to assist during the second stage of labor and facilitate delivery. Indications for forceps... read more or cesarean delivery Cesarean Delivery Cesarean delivery is surgical delivery by incision into the uterus. The rate of cesarean delivery was 32% in the United States in 2021 (see March of Dimes: Delivery Method). The rate has fluctuated... read more is often required.

Position and Presentation of the Fetus

If a fetus is in the occiput posterior position, operative vaginal delivery or cesarean delivery is often required.

In breech presentation, the presenting part is a poor dilating wedge, which can cause the head to be trapped during delivery, often compressing the umbilical cord.

For breech presentation, usually do cesarean delivery at 39 weeks or during labor, but external cephalic version is sometimes successful before labor, usually at 37 or 38 weeks.

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ACOG Guidelines at a Glance: External Cephalic Version

Expert commentary on Practice Bulletin No. 161: External Cephalic Version

COMMITTEE ON PRACTICE BULLETINS-OBSTETRICS Practice Bulletin #161: External Cephalic Version.

American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e54-61. Full text of Practice Bulletin #161 is available to ACOG members at http://www.acog.org/Resources%20And%20Publications/Practice%20Bulletsin/Committee%20on%20Practice%20Bulletins%20Obstetrics/External%20Cephalic%20Version.aspx

EXTERNAL CEPHALIC VERSION In the United States, there is a widespread belief that the overall cesarean delivery rate is higher than necessary. Eff orts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean delivery, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Used with permission. Copyright the American College of Obstetricians and Gynecologists.

ECV: A tool to prevent the first cesarean

by Stephen F Thung, MD, MSCI

Dr Thung is Associate Professor of Maternal Fetal Medicine, Clinical Chief of Obstetrics and Medical Director of Patient Flow Management, The Ohio State University, Columbus, Ohio

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Meaghan M. Shanahan ; Daniel J. Martingano ; Caron J. Gray .

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Last Update: December 13, 2023 .

• Continuing Education Activity

In carefully selected patients, an external cephalic version (ECV) may be an alternative to cesarean delivery for fetal malpresentation at term. ECV is a noninvasive procedure that manipulates fetal position through the abdominal wall of the gravida. With the global cesarean section rate reaching 34%, fetal malpresentation ranks as the third most common indication for cesarean delivery, accounting for nearly 17% of cases. Studies suggest a 60% mean success rate for ECV, emphasizing its cost-effectiveness and potential to decrease cesarean delivery rates significantly. While particularly crucial in resource-limited settings where access to medical services during labor is constrained or cesarean delivery is unavailable or unsafe, ECV presents a viable option to improve rates of vaginal delivery in singleton gestations in all settings. 

This activity reviews the indications, contraindications, necessary equipment, preferred personnel, procedural technique, risks, and benefits of ECV and highlights the role of the interprofessional team in caring for patients who may benefit from this procedure.

• Select suitable candidates for an external cephalic version based on their clinical history and presentation.
• Screen patients effectively regarding the risks and benefits of an external cephalic version.
• Apply best practices when performing an external cephalic version.
• Develop and implement effective interpersonal team strategies to improve outcomes for patients undergoing external cephalic version.
• Introduction

The global cesarean section rate has increased from approximately 23% to 34% in the past decade. Fetal malpresentation is now the third-most common indication for cesarean delivery, encompassing nearly 17% of cases. Almost one-fourth of all fetuses are in a breech presentation at 28 weeks gestational age; this number decreases to between 3% and 4% at term. In current clinical practice, most pregnancies with a breech fetus are delivered by cesarean section.

Individual and institutional efforts are increasing to reduce the overall cesarean delivery rate, particularly for nulliparous patients with term, singleton, and vertex gestations. [1] [2]  An alternative to cesarean delivery for fetal malpresentation at term is an external cephalic version (ECV), a procedure to correct fetal malpresentation. ECV may be indicated when the fetus is breech or in an oblique or transverse lie after 37 0/7 weeks gestation. [3]  The overall success rate for ECV approaches 60%, is cost-effective, and can lead to decreased cesarean delivery rates. [4]  ECV is of particular importance in resource-poor environments, where patients may have limited access to medical services during labor and delivery or where cesarean delivery is unavailable or unsafe.

• Anatomy and Physiology

ECV can be attempted when managing breech presentations or fetuses with a transverse or oblique lie. Three types of breech presentation are established concerning fetal attitude: complete, frank, and incomplete, which is sometimes referred to as footling breech. In complete breech, the fetal pelvis engages with the maternal pelvic inlet, and the fetal hips and knees are flexed. In frank breech, the fetal pelvis engages with the maternal pelvic inlet, the fetal hips are flexed, the knees are extended, and the feet are near the head. In incomplete or footling breech, one (single footling) or both (double footling) feet are extended below the level of the fetal pelvis.

A fetus with a transverse lie is positioned with their long axis, defined as the spine, at a right angle to the long axis of the gravida. The fetal head may be to the right or left side of the maternal spine. The fetus may be facing up or down. The long axis of the fetus characterizes an oblique lie at any angle to the maternal long axis that is not 90°. An oblique fetus is usually positioned with their head in the right or left lower quadrants, although this is not universal.

• Indications

ECV may be indicated in carefully selected patients. The fetus must be at or beyond 36 0/7 weeks of gestation with malpresentation, and there must be no absolute contraindications to vaginal delivery, such as placenta previa, vasa previa, or a history of classical cesarean delivery. Fetal status must be reassuring, and preprocedural nonstress testing is recommended. While ECV may be performed as early as 36 0/7 weeks gestation, many practitioners will delay ECV until 37 0/7 weeks gestation to ensure delivery of a term fetus.

ECV is more successful in multigravidas, those with a complete breech or transverse or oblique presentation, an unengaged presenting part, adequate amniotic fluid, and a posterior placenta. Nulliparous patients and those with an anterior, lateral, or cornual placenta have lower success rates. Patients with advanced cervical dilatation, obesity, oligohydramnios, or ruptured membranes also have lower success rates. Additionally, if the fetus weighs less than 2500 g, is at a low station with an engaged presenting part, is frank breech, or the spine is posterior, the success of ECV is decreased. [5]  

Evidence supports the use of parenteral tocolysis, most often with the beta-2-agonist medication terbutaline, to improve the success of ECV; most studies evaluating the various aspects of ECV aspects include using a tocolytic agent. [6] [7] [8] [9]  Data regarding the improved success of ECV incorporating regional anesthesia is inconsistent. 

• Contraindications

Any contraindication to vaginal delivery would also be a contraindication to ECV. These contraindications include but are not limited to placenta previa, vasa previa, active genital herpes outbreak, or a history of classical cesarean delivery. A history of low transverse cesarean delivery is not an absolute contraindication to ECV. [10]  The overall success rate of ECV in patients with a previous cesarean birth ranges from 50% to 84%; no cases of uterine rupture during ECV were reported in the four trials evaluating this outcome in patients with a prior cesarean delivery. [11] [12] [13] [14]

Antepartum ECV is contraindicated in multiple gestations, although it can be utilized for twin gestations that would otherwise be suitable candidates for breech extraction. [15] [16]

Patients with severe oligohydramnios, nonreassuring fetal monitoring, a hyperextended fetal head, significant fetal or uterine anomaly, fetal growth restriction, and maternal hypertension carry a low likelihood of successful ECV and a significantly increased risk of poor fetal outcomes; ECV in such situations requires careful consideration.

If a gravida who is otherwise a suitable candidate for ECV presents in early labor with fetal malpresentation, ECV may be a reasonable option if the presenting part is unengaged, the amniotic fluid index is within the normal range, and there are no contraindications to ECV or vaginal delivery. Data from the Nationwide Inpatient Sample from 1998 to 2011 noted a success rate of 65% for ECV performed in carefully selected patients during the admission for delivery. [17]  ECV performed in this circumstance resulted in a significantly lower cesarean birth rate and hospital stay of greater than 7 days compared to patients with a persistent breech presentation at the time of delivery. [17]

External cephalic versions should be attempted only in settings where cesarean delivery services are readily available. Therefore, the required equipment for ECV includes all such requirements for cesarean delivery, including anesthesia services. Access to tocolytic agents, bedside ultrasonography, and external fetal heart rate monitoring equipment is also required. Following ECV, fetal status must be assessed; nonstress testing is preferred. If nonstress testing is unavailable, Doppler indices of the umbilical artery, middle cerebral artery, and ductus venosus may be performed. [18]

The personnel typically required to perform an ECV include:

• Obstetrician
• Labor and delivery nurse.

ECV may only be performed in a setting where cesarean delivery services are readily available. Personnel typically required for cesarean delivery include:

• Surgical first assistant
• Anesthesia personnel
• Surgical technician or operating room nurse
• Circulating or operating room nurse
• Pediatric personnel
• Note: for cesarean delivery, labor and delivery nurses may serve as surgical technicians, circulating, or operating room roles.
• Preparation

Before attempting ECV, informed consent must be obtained; this should include tocolysis and neuraxial analgesia if those procedures will be performed. Some clinicians will obtain consent from the patient for potential emergency cesarean delivery at this time, although this practice is not universal. Additionally, an ultrasound examination should be performed to verify fetal presentation, exclude fetal and uterine anomalies, locate the placental position, and evaluate the amniotic fluid index. Many clinicians will evaluate preprocedural fetal status with a nonstress test. 

The current evidence supports the administration of terbutaline 0.25mg subcutaneously 15 to 30 minutes before the ECV but does not support using calcium channel blockers or nitroglycerin for preprocedural tocolysis. [19]  While multiple studies report the increased success of ECV in patients who are administered epidural or spinal neuraxial anesthesia, overall data is insufficient to warrant a universal recommendation; neuraxial anesthesia may improve success rates for ECV in situations where tocolysis alone was unsuccessful. [20]

• Technique or Treatment

The gravida should be supine with a leftward tilt using a wedge support to relieve pressure on the great vessels. ECV is best performed using a 2-handed approach.

If the fetal presentation is breech, lift the breech out of the pelvis with one hand and apply downward pressure to the posterior fetal head to attempt a forward roll. If a forward roll is unsuccessful, a backward roll can be attempted. If the fetus is in either a transverse or oblique presentation, similar manipulation of the fetus is used to try to move the fetal head to the pelvis. [21]

Fetal well-being should be evaluated intermittently with Doppler or real-time ultrasonography during ECV. ECV should be abandoned if there is significant fetal bradycardia, patient discomfort, or if a version is not achieved easily. After a successful or unsuccessful ECV, external fetal heart rate monitoring should be performed for 30 to 60 minutes. If the gravida is Rh negative, anti-D immune globulin should be administered.

Immediate induction of labor to minimize reversion is not recommended. If the initial attempt at ECV is unsuccessful, additional attempts can be made during the same admission or at a later date.

• Complications

Complications of ECV are rare and occur in only 1% to 2% of attempts. The most common complication associated with ECV is fetal heart rate abnormalities, particularly bradycardia, occurring at a rate of 4.7% to 20%; these abnormalities usually are transient and improve upon completion or abandonment of the procedure.

More severe complications of ECV occur at a rate of less than 1% and include premature rupture of membranes, cord prolapse, vaginal bleeding, placental abruption, fetomaternal hemorrhage, emergent cesarean delivery, and stillbirth. Many of these rare complications require emergent cesarean delivery; some clinicians choose to perform ECV in the operating room, although this is neither necessary nor universal. [22]   

ECV is associated with changes in Doppler indices that may reflect decreased placental perfusion. It appears these changes are short-lived and have no detrimental effects on the outcomes of uncomplicated pregnancies. A recent prospective study investigating the effects of ECV on fetal circulation in the antepartum period noted no differences in the Doppler evaluation of the middle cerebral artery or ductus venosus; all studied patients remained stable and were discharged home after the procedure. [18]  

• Clinical Significance

Some data indicate that only 20% to 30% of eligible candidates are offered ECV. [23]  Patients who undergo a successful ECV procedure have a lower cesarean delivery rate than patients who do not but are still at a higher risk of cesarean delivery than patients with cephalic fetuses who do not require ECV. ECV is cost-effective if the probability of a successful ECV exceeds 32%. Overall, ECV is successful in 58% of attempts, reduces the risk for CS by two-thirds, and enables 80% of these patients to deliver vaginally. [24]

• Enhancing Healthcare Team Outcomes

ECV is not a benign procedure and is most successful when performed under the care of an interprofessional team. Labor and delivery nurses play an integral role in the success of ECV as they frequently assist in the procedure, prepare the patient for ECV, and implement external fetal monitoring before, during, and after the procedure. Additionally, the support of emergent operating room staff promotes the safe delivery of a healthy fetus should complications arise during the ECV procedure. Clear and concise anticipatory interprofessional communication improves safety and outcomes for the gravida and the fetus should complications occur.

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Disclosure: Meaghan Shanahan declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Martingano declares no relevant financial relationships with ineligible companies.

Disclosure: Caron Gray declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Shanahan MM, Martingano DJ, Gray CJ. External Cephalic Version. [Updated 2023 Dec 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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• Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation. [Ultrasound Obstet Gynecol. 2020] Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation. De Castro H, Ciobanu A, Formuso C, Akolekar R, Nicolaides KH. Ultrasound Obstet Gynecol. 2020 Feb; 55(2):248-256.
• External cephalic version at 38 weeks' gestation at a specialized German single center. [PLoS One. 2021] External cephalic version at 38 weeks' gestation at a specialized German single center. Zielbauer AS, Louwen F, Jennewein L. PLoS One. 2021; 16(8):e0252702. Epub 2021 Aug 30.
• External cephalic version in singleton pregnancies at term: a retrospective analysis. [Gynecol Obstet Invest. 2008] External cephalic version in singleton pregnancies at term: a retrospective analysis. Zeck W, Walcher W, Lang U. Gynecol Obstet Invest. 2008; 66(1):18-21. Epub 2008 Jan 30.
• Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - External Cephalic Version and other Interventions to turn Breech Babies to Cephalic Presentation]. [Gynecol Obstet Fertil Senol. 2...] Review [Breech Presentation: CNGOF Guidelines for Clinical Practice - External Cephalic Version and other Interventions to turn Breech Babies to Cephalic Presentation]. Ducarme G. Gynecol Obstet Fertil Senol. 2020 Jan; 48(1):81-94. Epub 2019 Oct 31.
• Review Association between hospitals' cesarean delivery rates for breech presentation and their success rates for external cephalic version. [Eur J Obstet Gynecol Reprod Bi...] Review Association between hospitals' cesarean delivery rates for breech presentation and their success rates for external cephalic version. Athiel Y, Girault A, Le Ray C, Goffinet F. Eur J Obstet Gynecol Reprod Biol. 2022 Mar; 270:156-163. Epub 2022 Jan 13.

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Fetal Presentation, Position, and Lie (Including Breech Presentation)

, MD, Children's Hospital of Philadelphia

Variations in Fetal Position and Presentation

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Presentation refers to the part of the fetus’s body that leads the way out through the birth canal (called the presenting part). Usually, the head leads the way, but sometimes the buttocks (breech presentation), shoulder, or face leads the way.

Position refers to whether the fetus is facing backward (occiput anterior) or forward (occiput posterior). The occiput is a bone at the back of the baby's head. Therefore, facing backward is called occiput anterior (facing the mother’s back and facing down when the mother lies on her back). Facing forward is called occiput posterior (facing toward the mother's pubic bone and facing up when the mother lies on her back).

Lie refers to the angle of the fetus in relation to the mother and the uterus. Up-and-down (with the baby's spine parallel to mother's spine, called longitudinal) is normal, but sometimes the lie is sideways (transverse) or at an angle (oblique).

For these aspects of fetal positioning, the combination that is the most common, safest, and easiest for the mother to deliver is the following:

Head first (called vertex or cephalic presentation)

Facing backward (occiput anterior position)

Spine parallel to mother's spine (longitudinal lie)

Neck bent forward with chin tucked

Arms folded across the chest

If the fetus is in a different position, lie, or presentation, labor may be more difficult, and a normal vaginal delivery may not be possible.

Variations in fetal presentation, position, or lie may occur when

The fetus is too large for the mother's pelvis (fetopelvic disproportion).

The fetus has a birth defect Overview of Birth Defects Birth defects, also called congenital anomalies, are physical abnormalities that occur before a baby is born. They are usually obvious within the first year of life. The cause of many birth... read more .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Some variations in position and presentation that make delivery difficult occur frequently.

Occiput posterior position

In occiput posterior position (sometimes called sunny-side up), the fetus is head first (vertex presentation) but is facing forward (toward the mother's pubic bone—that is, facing up when the mother lies on her back). This is a very common position that is not abnormal, but it makes delivery more difficult than when the fetus is in the occiput anterior position (facing toward the mother's spine—that is facing down when the mother lies on her back).

Breech presentation

In breech presentation, the baby's buttocks or sometimes the feet are positioned to deliver first (before the head).

When delivered vaginally, babies that present buttocks first are more at risk of injury or even death than those that present head first.

The reason for the risks to babies in breech presentation is that the baby's hips and buttocks are not as wide as the head. Therefore, when the hips and buttocks pass through the cervix first, the passageway may not be wide enough for the head to pass through. In addition, when the head follows the buttocks, the neck may be bent slightly backwards. The neck being bent backward increases the width required for delivery as compared to when the head is angled forward with the chin tucked, which is the position that is easiest for delivery. Thus, the baby’s body may be delivered and then the head may get caught and not be able to pass through the birth canal. When the baby’s head is caught, this puts pressure on the umbilical cord in the birth canal, so that very little oxygen can reach the baby. Brain damage due to lack of oxygen is more common among breech babies than among those presenting head first.

Breech presentation is more likely to occur in the following circumstances:

Labor starts too soon (preterm labor).

Sometimes the doctor can turn the fetus to be head first before labor begins by doing a procedure that involves pressing on the pregnant woman’s abdomen and trying to turn the baby around. Trying to turn the baby is called an external cephalic version and is usually done at 37 or 38 weeks of pregnancy. Sometimes women are given a medication (such as terbutaline ) during the procedure to prevent contractions.

Other presentations

In face presentation, the baby's neck arches back so that the face presents first rather than the top of the head.

In brow presentation, the neck is moderately arched so that the brow presents first.

Usually, fetuses do not stay in a face or brow presentation. These presentations often change to a vertex (top of the head) presentation before or during labor. If they do not, a cesarean delivery is usually recommended.

In transverse lie, the fetus lies horizontally across the birth canal and presents shoulder first. A cesarean delivery is done, unless the fetus is the second in a set of twins. In such a case, the fetus may be turned to be delivered through the vagina.

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Chapter 15:  Abnormal Cephalic Presentations

Jessica Dy; Darine El-Chaar

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Malpresentations.

• TRANSVERSE POSITIONS OF THE OCCIPUT
• POSTERIOR POSITIONS OF THE OCCIPUT
• BROW PRESENTATIONS
• MEDIAN VERTEX PRESENTATIONS: MILITARY ATTITUDE
• FACE PRESENTATION
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The fetus enters the pelvis in a cephalic presentation approximately 95 percent to 96 percent of the time. In these cephalic presentations, the occiput may be in the persistent transverse or posterior positions. In about 3 percent to 4 percent of pregnancies, there is a breech-presenting fetus (see Chapter 25 ). In the remaining 1 percent, the fetus may be either in a transverse or oblique lie (see Chapter 26 ), or the head may be extended with the face or brow presenting.

Predisposing Factors

Maternal and uterine factors.

Contracted pelvis: This is the most common and important factor

Pendulous maternal abdomen: If the uterus and fetus are allowed to fall forward, there may be difficulty in engagement

Neoplasms: Uterine fibromyomas or ovarian cysts can block the entry to the pelvis

Uterine anomalies: In a bicornuate uterus, the nonpregnant horn may obstruct labor in the pregnant one

Abnormalities of placental size or location: Conditions such as placenta previa are associated with unfavorable positions of the fetus

High parity

Fetal Factors

Errors in fetal polarity, such as breech presentation and transverse lie

Abnormal internal rotation: The occiput rotates posteriorly or fails to rotate at all

Fetal attitude: Extension in place of normal flexion

Multiple pregnancy

Fetal anomalies, including hydrocephaly and anencephaly

Polyhydramnios: An excessive amount of amniotic fluid allows the baby freedom of activity, and he or she may assume abnormal positions

Prematurity

Placenta and Membranes

Placenta previa

Cornual implantation

Premature rupture of membranes

Effects of Malpresentations

Effects on labor.

The less symmetrical adaptation of the presenting part to the cervix and to the pelvis plays a part in reducing the efficiency of labor.

The incidence of fetopelvic disproportion is higher

Inefficient uterine action is common. The contractions tend to be weak and irregular

Prolonged labor is seen frequently

Pathologic retraction rings can develop, and rupture of the lower uterine segment may be the end result

The cervix often dilates slowly and incompletely

The presenting part stays high

Premature rupture of the membranes occurs often

The need for operative delivery is increased

Effects on the Mother

Because greater uterine and intraabdominal muscular effort is required and because labor is often prolonged, maternal exhaustion is common

There is more stretching of the perineum and soft parts, and there are more lacerations

Tears of the uterus, cervix, and vagina

Uterine atony from prolonged labor

Early rupture of the membranes

Excessive blood loss

Tissue damage

Frequent rectal and vaginal examinations

Prolonged labor

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How your twins’ fetal positions affect labor and delivery

Twin fetal presentation – also known as the position of your babies in the womb – dictates whether you'll have a vaginal or c-section birth. Toward the end of pregnancy, most twins will move in the head-down position (vertex), but there's a risk that the second twin will change position after the first twin is born. While there are options to change the second twin's position, this can increase the risk of c-section and other health issues. Learn about the six possible twin fetal presentations: vertex-vertex, vertex-breech, breech-breech, vertex-transverse, breech-transverse, and transverse-transverse – and how they'll impact your delivery and risks for complications.

What is fetal presentation and what does it mean for your twins?

As your due date approaches, you might be wondering how your twins are currently positioned in the womb, also known as the fetal presentation, and what that means for your delivery. Throughout your pregnancy, your twin babies will move in the uterus, but sometime during the third trimester – usually between 32 and 36 weeks – their fetal presentation changes as they prepare to go down the birth canal.

The good news is that at most twin births, both babies are head-down (vertex), which means you can have a vaginal delivery. In fact, nearly 40 percent of twins are delivered vaginally.

But if one baby has feet or bottom first (breech) or is sideways (transverse), your doctor might deliver the lower twin vaginally and then try to rotate the other twin so that they face head-down (also called external cephalic version or internal podalic version) and can be delivered vaginally. But if that doesn't work, there's still a chance that your doctor will be able to deliver the second twin feet first vaginally via breech extraction (delivering the breech baby feet or butt first through the vagina).

That said, a breech extraction depends on a variety of factors – including how experienced your doctor is in the procedure and how much the second twin weighs. Studies show that the higher rate of vaginal births among nonvertex second twins is associated with labor induction and more experienced doctors, suggesting that proper delivery planning may increase your chances of a vaginal birth .

That said, you shouldn't totally rule out a Cesarean delivery with twins . If the first twin is breech or neither of the twins are head-down, then you'll most likely have a Cesarean delivery.

Research also shows that twin babies who are born at less than 34 weeks and have moms with multiple children are associated with intrapartum presentation change (when the fetal presentation of the second twin changes from head-down to feet first after the delivery of the first twin) of the second twin. Women who have intrapartum presentation change are more likely to undergo a Cesarean delivery for their second twin.

Here's a breakdown of the different fetal presentations for twin births and how they will affect your delivery.

Head down, head down (vertex, vertex)

This fetal presentation is the most promising for a vaginal delivery because both twins are head-down. Twins can change positions, but if they're head-down at 28 weeks, they're likely to stay that way.

When delivering twins vaginally, there is a risk that the second twin will change position after the delivery of the first. Research shows that second twins change positions in 20 percent of planned vaginal deliveries. If this happens, your doctor may try to rotate the second twin so it faces head-down or consider a breech extraction. But if neither of these work or are an option, then a Cesarean delivery is likely.

In vertex-vertex pairs, the rate of Cesarean delivery for the second twin after a vaginal delivery of the first one is 16.9 percent.

Like all vaginal deliveries, there's also a chance you'll have an assisted birth, where forceps or a vacuum are needed to help deliver your twins.

Head down, bottom down (vertex, breech)

When the first twin's (the lower one) head is down, but the second twin isn't, your doctor may attempt a vaginal delivery by changing the baby's position or doing breech extraction, which isn't possible if the second twin weighs much more than the first twin.

The rates of emergency C-section deliveries for the second twin after a vaginal delivery of the first twin are higher in second twins who have a very low birth weight. Small babies may not tolerate labor as well.

Head down, sideways (vertex, transverse)

If one twin is lying sideways or diagonally (oblique), there's a chance the baby may shift position as your labor progresses, or your doctor may try to turn the baby head-down via external cephalic version or internal podalic version (changing position in the uterus), which means you may be able to deliver both vaginally.

Bottom down, bottom down (breech, breech)

When both twins are breech, a planned C-section is recommended because your doctor isn't able to turn the fetuses. Studies also show that there are fewer negative neonatal outcomes for planned C-sections than planned vaginal births in breech babies.

As with any C-section, the risks for a planned one with twins include infection, loss of blood, blood clots, injury to the bowel or bladder, a weak uterine wall, placenta abnormalities in future pregnancies and fetal injury.

Bottom down, sideways (breech, transverse)

When the twin lowest in your uterus is breech or transverse (which happens in 25 percent of cases), you'll need to have a c-section.

Sideways, sideways (transverse, transverse)

This fetal presentation is rare with less than 1 percent of cases. If both babies are lying horizontally, you'll almost definitely have a C-section.

Learn more:

• Twin fetal development month by month
• Your likelihood of having twins or more
• When and how to find out if you’re carrying twins or more

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24 weeks pregnant with twins

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Cleveland Clinic. Fetal Positions for Birth: https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth Opens a new window [Accessed July 2021]

Mayo Clinic. Fetal Presentation Before Birth: https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/multimedia/fetal-positions/sls-20076615?s=7 Opens a new window [Accessed July 2021]

NHS. Giving Birth to Twins or More: https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

Science Direct. Breech Extraction: https://www.sciencedirect.com/topics/medicine-and-dentistry/breech-extraction Opens a new window [Accessed July 2021]

Obstetrics & Gynecology. Clinical Factors Associated With Presentation Change of the Second Twin After Vaginal Delivery of the First Twin https://pubmed.ncbi.nlm.nih.gov/29016498/ Opens a new window [Accessed July 2021]

American Journal of Obstetrics and Gynecology. Fetal presentation and successful twin vaginal delivery: https://www.ajog.org/article/S0002-9378(04)00482-X/fulltext [Accessed July 2021]

The Journal of Maternal-Fetal & Neonatal Medicine. Changes in fetal presentation in twin pregnancies https://www.tandfonline.com/doi/abs/10.1080/14767050400028592 Opens a new window [Accessed July 2021]

Reviews in Obstetrics & Gynecology. An Evidence-Based Approach to Determining Route of Delivery for Twin Gestations https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3252881/ Opens a new window [Accessed July 2021]

Nature. Neonatal mortality and morbidity in vertex–vertex second twins according to mode of delivery and birth weight: https://www.nature.com/articles/7211408 Opens a new window [Accessed July 2021]

Cochrane. Planned cesarean for a twin pregnancy: https://www.cochrane.org/CD006553/PREG_planned-caesarean-section-twin-pregnancy Opens a new window [Accessed July 2021]

Kids Health. What Is the Apgar Score?: https://www.kidshealth.org/Nemours/en/parents/apgar0.html Opens a new window [Accessed July 2021]

American Journal of Obstetrics & Gynecology. Neonatal mortality in second twin according to cause of death, gestational age, and mode of delivery https://pubmed.ncbi.nlm.nih.gov/15467540/ Opens a new window [Accessed July 2021]

Lancet. Planned cesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group https://pubmed.ncbi.nlm.nih.gov/11052579/ Opens a new window [Accessed July 2021]

Cleveland Clinic. Cesarean Birth (C-Section): https://my.clevelandclinic.org/health/treatments/7246-cesarean-birth-c-section Opens a new window [Accessed July 2021]

St. Jude Medical Staff. Delivery of Twin Gestation: http://www.sjmedstaff.org/documents/Delivery-of-twins.pdf Opens a new window [Accessed July 2021]

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