is cephalic presentation at 28 weeks normal

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• Fetal presentation before birth

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.

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

• Variations in Fetal Position and Presentation |

During pregnancy, the fetus can be positioned in many different ways inside the mother's uterus. The fetus may be head up or down or facing the mother's back or front. At first, the fetus can move around easily or shift position as the mother moves. Toward the end of the pregnancy the fetus is larger, has less room to move, and stays in one position. How the fetus is positioned has an important effect on delivery and, for certain positions, a cesarean delivery is necessary. There are medical terms that describe precisely how the fetus is positioned, and identifying the fetal position helps doctors to anticipate potential difficulties during labor and delivery.

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 uterus is abnormally shaped or contains growths such as fibroids .

The fetus has a birth defect .

There is more than one fetus (multiple gestation).

Position and Presentation of the Fetus

Variations in fetal position and presentation.

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).

When a fetus faces up, the neck is often straightened rather than bent,which requires more room for the head to pass through the birth canal. Delivery assisted by a vacuum device or forceps or cesarean delivery may be necessary.

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.

In a first delivery, these problems may occur more frequently because a woman’s tissues have not been stretched by previous deliveries. Because of risk of injury or even death to the baby, cesarean delivery is preferred when the fetus is in breech presentation, unless the doctor is very experienced with and skilled at delivering breech babies or there is not an adequate facility or equipment to safely perform a cesarean delivery.

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

Labor starts too soon (preterm labor).

The uterus is abnormally shaped or contains abnormal growths such as fibroids .

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

• Key Points |

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 , or cesarean delivery .

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

Uterine abnormalities

Fetal anomalies

If delivery is vaginal, breech presentation may increase risk of

Umbilical cord prolapse

Birth trauma

Perinatal death

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 or cesarean delivery 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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INTRODUCTION

Diagnosis and management of face and brow presentations will be reviewed here. Other cephalic malpresentations are discussed separately. (See "Occiput posterior position" and "Occiput transverse position" .)

Prevalence  —  Face and brow presentation are uncommon. Their prevalences compared with other types of malpresentations are shown below [ 1-9 ]:

● Occiput posterior – 1/19 deliveries

● Breech – 1/33 deliveries

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Breech, posterior, transverse lie: What position is my baby in?

Fetal presentation, or how your baby is situated in your womb at birth, is determined by the body part that's positioned to come out first, and it can affect the way you deliver. At the time of delivery, 97 percent of babies are head-down (cephalic presentation). But there are several other possibilities, including feet or bottom first (breech) as well as sideways (transverse lie) and diagonal (oblique lie).

Fetal presentation and position

During the last trimester of your pregnancy, your provider will check your baby's presentation by feeling your belly to locate the head, bottom, and back. If it's unclear, your provider may do an ultrasound or an internal exam to feel what part of the baby is in your pelvis.

Fetal position refers to whether the baby is facing your spine (anterior position) or facing your belly (posterior position). Fetal position can change often: Your baby may be face up at the beginning of labor and face down at delivery.

Here are the many possibilities for fetal presentation and position in the womb.

Medical illustrations by Jonathan Dimes

Head down, facing down (anterior position)

A baby who is head down and facing your spine is in the anterior position. This is the most common fetal presentation and the easiest position for a vaginal delivery.

This position is also known as "occiput anterior" because the back of your baby's skull (occipital bone) is in the front (anterior) of your pelvis.

Head down, facing up (posterior position)

In the posterior position , your baby is head down and facing your belly. You may also hear it called "sunny-side up" because babies who stay in this position are born facing up. But many babies who are facing up during labor rotate to the easier face down (anterior) position before birth.

Posterior position is formally known as "occiput posterior" because the back of your baby's skull (occipital bone) is in the back (posterior) of your pelvis.

Frank breech

In the frank breech presentation, both the baby's legs are extended so that the feet are up near the face. This is the most common type of breech presentation. Breech babies are difficult to deliver vaginally, so most arrive by c-section .

Some providers will attempt to turn your baby manually to the head down position by applying pressure to your belly. This is called an external cephalic version , and it has a 58 percent success rate for turning breech babies. For more information, see our article on breech birth .

Complete breech

A complete breech is when your baby is bottom down with hips and knees bent in a tuck or cross-legged position. If your baby is in a complete breech, you may feel kicking in your lower abdomen.

Incomplete breech

In an incomplete breech, one of the baby's knees is bent so that the foot is tucked next to the bottom with the other leg extended, positioning that foot closer to the face.

Single footling breech

In the single footling breech presentation, one of the baby's feet is pointed toward your cervix.

Double footling breech

In the double footling breech presentation, both of the baby's feet are pointed toward your cervix.

Transverse lie

In a transverse lie, the baby is lying horizontally in your uterus and may be facing up toward your head or down toward your feet. Babies settle this way less than 1 percent of the time, but it happens more commonly if you're carrying multiples or deliver before your due date.

If your baby stays in a transverse lie until the end of your pregnancy, it can be dangerous for delivery. Your provider will likely schedule a c-section or attempt an external cephalic version , which is highly successful for turning babies in this position.

Oblique lie

In rare cases, your baby may lie diagonally in your uterus, with his rump facing the side of your body at an angle.

Like the transverse lie, this position is more common earlier in pregnancy, and it's likely your provider will intervene if your baby is still in the oblique lie at the end of your third trimester.

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Ahmad A et al. 2014. Association of fetal position at onset of labor and mode of delivery: A prospective cohort study. Ultrasound in obstetrics & gynecology 43(2):176-182. https://www.ncbi.nlm.nih.gov/pubmed/23929533 Opens a new window [Accessed September 2021]

Gray CJ and Shanahan MM. 2019. Breech presentation. StatPearls.  https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed September 2021]

Hankins GD. 1990. Transverse lie. American Journal of Perinatology 7(1):66-70.  https://www.ncbi.nlm.nih.gov/pubmed/2131781 Opens a new window [Accessed September 2021]

Medline Plus. 2020. Your baby in the birth canal. U.S. National Library of Medicine. https://medlineplus.gov/ency/article/002060.htm Opens a new window [Accessed September 2021]

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• v.62(6); 2019 Nov

Reviving external cephalic version: a review of its efficacy, safety, and technical aspects

Gwang jun kim.

Department of Obstetrics and Gynecology, Chung-Ang University Hospital, Seoul, Korea.

Currently, the rate of cesarean sections being performed in Korea is approximately 40%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries. Breech presentation at term is an important indication for cesarean section among other factors, including medicolegal concerns and pregnancies in women of advanced maternal age. Term breech presentation is associated with a higher fetal mortality rate than that associated with a cephalic presentation. Therefore, in Korea, most of these women deliver by cesarean section to avoid the complications of vaginal breech delivery. However, cesarean section is itself associated with considerable obstetric morbidity and sometimes, mortality. External cephalic version (ECV) is a useful method to reduce the cesarean section rate in women with breech presentation and therefore to reduce the incidence of breech presentation at delivery. Studies have shown that routine use of ECV reduces the cesarean section rate by approximately two-thirds in term pregnancies with breech presentation. ECV is accepted as a safe, efficacious, and cost-effective method and is recommended by both the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists in all pregnancies with term breech presentation, if not contraindicated. In Korea, although most clinicians are aware of the option of ECV, their relative lack of experience in performing the procedure and fear of complications render them hesitant to perform ECV. This review is aimed at guiding obstetricians by describing the efficacy, safety concerns, and technical aspects of this procedure.

Introduction

Non-cephalic presentations are common in preterm pregnancies and their rate gradually decreases with increasing gestational age. Breech presentation, which is the most common non-cephalic presentation, occurs in 25% of fetuses before 28 weeks of gestation, and this rate decreases to 7% by 32 weeks of gestation and further to 3–4% at term [ 1 ].

Vaginal breech delivery has a long history and was a common practice over the past 2 decades. In 2000, the Term Breech Trial, a large, international multicenter randomized clinical trial comparing planned vaginal deliveries with planned cesarean deliveries showed that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates were significantly higher in the planned vaginal delivery group than in the planned cesarean delivery group (16% vs. 5%) [ 2 ]. These findings of the Term Breech Trial significantly affected the attitude of obstetricians toward breech deliveries and since 2000, cesarean sections are being accepted as the safer option for breech delivery.

In the United States, the rate of cesarean deliveries among women in labor with breech presentation increased to 86.9% after the Term Breech Trial [ 3 ]. Currently, in most countries including Korea, cesarean section is the usual mode of delivery for term breech presentation. This is one of the prime reasons for the current cesarean section rate in Korea being as high as 38%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries [ 4 ]. Notably, other reasons include medicolegal concerns and a high percentage of pregnancies in women of advanced maternal age. This is cause for concern because at the population level, the ideal rate for cesarean sections ranges from 10% to 15%, with rates >10% not associated with reduced maternal and newborn mortality [ 5 ].

Breech presentation is the 3rd most common indication for cesarean section, after previous cesarean section and labor dystocia [ 6 ]. Approximately 12% of cesarean sections in the United States were performed in women secondary to breech presentation [ 7 ]. Although regarded as a safer mode of breech delivery by most pregnant women and clinicians alike, cesarean section is one of the most significant contributing factors to post-partum maternal morbidity rates in developed countries and is known to cause significant complications, which can sometimes result in permanent health impairment.

Thus, the rapid increase in cesarean section rates has become a global concern. With respect to breech presentation, the only option to avoid cesarean section is attempting external cephalic version (ECV), a procedure that involves rotation of the fetus from a non-cephalic to cephalic presentation by manipulating the pregnant woman's abdomen, thereby reducing the incidence of breech presentation at delivery. The routine use of this procedure has been reported to reduce the rate of cesarean sections by approximately two-thirds in term pregnancies with breech presentation [ 8 ]. The overall success rate of ECV has been reported to be 58%, of which 80% women can deliver vaginally [ 9 ]. Moreover, a Cochrane systematic review reported that the use of ECV at term was associated with a clinically and statistically significant reduction in breech presentation, as well as cesarean section without significant adverse perinatal outcomes (based on Apgar scores, infant mortality, and neonatal admission rates) [ 1 ]. Furthermore, Tan et al. [ 8 ] evaluated the cost-effectiveness of ECV for term breech presentation and reported that an ECV trial was cost-effective when the probability of its success was over 32% [ 10 ].

The current recommendation by the Cochrane Foundation is to offer ECV to women with normal pregnancies and breech presentation at term (level A recommendation) [ 1 ]. Moreover, both the American College of Obstetricians and Gynecologists (ACOG) and the Royal College of Obstetricians and Gynecologists (RCOG) recommend the use of ECV as first-line management of breech presentation at term [ 11 , 12 ].

In Korea, the birth rate is declining, with only 357,800 neonates born in 2017; however, the percentage of pregnancies among women of advanced maternal age has shown an increasing trend over the years. This perhaps explains the increasing percentage of breech presentation at term in recent times because the risk of breech presentation is known to increase in a linear manner in association with maternal age [ 13 ].

Considering an incidence rate of 5%, approximately 18,000 pregnancies in Korea were associated with breech presentation at term (5% of 357,800) in 2018. Presumably, most of these women underwent cesarean section. If an ECV trial were to be attempted in even 50% of these term breech pregnancies, it is possible that 4,500 cesarean sections could have been avoided, assuming a modest success rate of 50% (considering a cesarean section rate of 20% associated with successful ECV). This is in significant contrast to countries such as the Netherlands, where it has been reported that approximately 70% of eligible women are offered an ECV trial [ 14 ].

In Korea, low-intervention birth experience (typically referred to as “natural birth”) is gaining popularity among educated pregnant women of advanced age. Thus, this is an optimal time to revive the practice of ECV. Although most clinicians are aware of ECV as a useful option, their relative lack of experience with the procedure renders them hesitant to perform ECV. Additionally, concerns over the safety of ECV exist among both clinicians as well as pregnant women [ 15 ]. Furthermore, there is a relative lack of studies and reviews regarding this topic in Korea. This review aims to encourage the revival of ECV by describing the efficacy, safety concerns, and technical aspects of this procedure.

A brief history of external cephalic version

The practice of ECV has a long history and dates back to the times of Hippocrates (460–377 BC). Aristotle (384–322 BC) is known to have described ECV, advocating that physicians advise midwives to perform this procedure [ 16 ]. Around 100 AD, Soranus described ECV as a method to reduce complications associated with vaginal breech birth [ 8 ], and in the 17th century, the French obstetrician Francois Mauriceau described this procedure as being “a little more difficult than turning an omelette in a frying pan” [ 16 ]. Over the last century, the practice of ECV gradually gained popularity, and by the mid-1970s, it was an integral component of routine obstetric practice owing to its obvious and immediate effectiveness. However, after this period, its popularity declined owing to concerns regarding its effectiveness and safety, with reports describing considerable perinatal mortality associated with the procedure [ 17 ]. Consequently, ECV became relatively obsolete by the mid-1980s. However, after 1980, following the increasing popularity of ultrasonography and electronic fetal monitoring (EFM), the 2 ground-breaking technologies introduced in obstetrics at the time, ECV was re-established as a safe procedure [ 16 ] with an overall success rate of 65%.

Timing of external cephalic version

In nulliparous women, ECV may be performed beginning at 36.0 weeks of gestation [ 18 ]. A randomized multicenter trial reported that although ECV performed at 34–36 weeks (in contrast to 37–38 weeks) decreased the rate of breech presentation at birth by 19%, it was associated with an increased incidence of late preterm delivery [ 19 ]. Therefore, it is preferable to wait until 36.0 weeks to perform ECV to avoid preterm delivery. By consensus, in multipara, ECV is performed at term beginning at 37.0 weeks of gestation [ 11 ].

Contraindications to external cephalic version

ECV may not be beneficial or may in fact be harmful in a few fetal and maternal conditions. Notably, contraindications to vaginal delivery, such as placenta previa, serious fetal compromise, or major congenital anomalies serve as contraindications for ECV. Fetal well-being should be confirmed using ultrasonography and EFM prior to performing ECV.

Other contraindications for ECV are as follows:

• • Onset of active labor: Uterine contractions caused by active labor make it difficult to perform an ECV trial. However, ECV can be attempted during the time interval between uterine contractions. Two studies that described intrapartum ECV reported promising results with success rates of 73% (11 of 15 attempts) [ 20 ] and 92.3% (12 of 13 attempts) [ 21 ]. Therefore, onset of active labor is not an absolute contraindication for ECV.
• • Rupture of membranes: Most clinicians regard rupture of membranes as a relative contraindication for ECV because decreased amniotic fluid volume itself hinders the trial [ 15 ]. However, ECV trials may be successfully performed in multiparous women with some amount of amniotic fluid. Thus, rupture of membranes is not an absolute contraindication for ECV.
• • Vaginal bleeding: It is preferable to delay ECV or completely avoid the procedure in a woman with recent vaginal bleeding of unknown origin or bleeding secondary to placental detachment [ 15 ].
• • Severe preeclampsia or eclampsia: Fetuses of women with this condition commonly develop heart rate deceleration after ECV. A previous study reported that nearly 50% of the fetuses evaluated in that study showed abnormal heart rate tracings during or immediately after the procedure [ 22 ], which suggests that although transient, ECV is a stressful event for the fetus [ 15 ].
• • Multiple gestation: Twin fetuses are known to easily return to breech presentation after successful ECV. Furthermore, an ECV trial in such cases can cause rupture of the intertwin membrane, which can progress to serious complications such as amniotic band or cord entanglement. Therefore, most clinicians do not attempt ECV in women with multiple pregnancies.
• • Major fetal anomalies: It is preferable to avoid ECV in women in whom prenatal ultrasonography reveals major fetal anomalies such as complex cardiac defects, significant brain malformation, and anomalies affecting the fetal pulmonary system. However, an ECV trial is not contraindicated in women in whom minor fetal anomalies are detected.
• • Abnormal cardiotocography before external cephalic version: Most authors agree that ECV should not be performed in cases of abnormal EFM before the trial because the procedure may aggravate the situation.
• • Growth restriction associated with an abnormal umbilical artery Doppler index: Fetuses with this condition commonly show abnormal heart rates after the ECV trial [ 15 ]. Therefore, it is safe to avoid the procedure in these cases.
• • Previous cesarean section: An ECV trial can be attempted in women who wish to trial vaginal birth after previous cesarean section. This practice is based on the recommendations of a study in which ECV was performed on 42 women with term breech presentation with a history of previous cesarean section, with a success rate of 74.0% without significant fetal or maternal complications [ 23 ]. Similarly, another prospective, comparative cohort study reported 74 ECV trials performed on women with a history of cesarean section with a 67.1% success rate, without significant complications [ 24 ].
• • Nuchal cord: No guidelines or definitive data are available regarding the risk of ECV in women with ultrasonographic evidence of nuchal cord. Based on the author's personal experience of performing >1,000 consecutive ECV trials (unpublished data), a single nuchal cord does not increase the risk; however, >2 tight nuchal cords tend to decrease the success rate of ECV.

In conclusion, as reported by a systematic review, to date, there is lack of consensus regarding the indications of ECV in pregnant women [ 25 ].

Factors associated with successful external cephalic version

The reported success rates associated with ECV vary considerably across studies ranging from 28% to 74% [ 26 , 27 , 28 , 29 , 30 ]. A meta-analysis showed that the success rate of ECV ranged from 16% to 100%, with a pooled rate of 58% [ 12 ]. Prognostic parameters associated with the success of ECV include the following:

• • Parity: Multiparous women tend to show a higher ECV success rate (72.3%) than nulliparous women (between 40% and 64%) [ 26 , 28 , 30 , 31 ].
• • Amniotic fluid: It has been reported that an amniotic fluid index (AFI) >7 cm is associated with a successful ECV trial [ 26 , 30 , 31 , 32 ]; however, a study reported significantly higher success rates with AFI >10 (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.5–2.1) [ 33 ]. Furthermore, a systematic review described a low ECV success rate with low amniotic fluid volume, although it was not possible to define the AFI threshold associated with an unsuccessful ECV trial [ 34 ].
• • Non-anterior placental location: ECV trials were more successful in women with the placenta located on the posterior uterine wall (OR, 1.9; 95% CI, 1.5–2.4) [ 33 ], and an anteriorly located placenta decreased the success rate of the ECV [ 33 , 34 ]. This was probably because an anterior placenta hinders palpation of the fetal head, and most clinicians do not exert full pressure when turning the fetus to avoid the risk of abruption of an anteriorly placed placenta.
• • Type of breech presentation: Frank breech presentation is associated with a lower rate of success [ 30 ] than a complete breech presentation (OR, 2.3; 95% CI, 1.9–2.8) [ 33 ], possibly because in cases of frank breech presentation, the fetal buttocks are often engaged deeply and are firmly secured within the maternal pelvis; thus, lifting the buttocks is more difficult compared to other types of breech presentations.
• • Estimated fetal weight before external cephalic version: The effect of estimated fetal weight on the success rates of ECV is controversial in that a few authors have reported greater success rates with high estimated fetal weight [ 26 , 31 ], whereas a few others have reported no such association [ 35 ].
• • Maternal body mass index (BMI): A cross-sectional analysis of 51,002 ECV trials in the United States showed lower success rates with high maternal BMI ( P <0.01). The success rate was 58.5% in women with BMI ≥40 kg/m 2 and 65% in women with normal BMI [ 36 ].

A systematic review reported that the predictive variables for successful ECV included parity, placental location, breech engagement, and a palpable fetal head [ 36 ].

Spontaneous version after external cephalic version

In women with term gestation, reversion after successful ECV occurred in 2.2–7.5% of cases [ 34 , 37 ], and spontaneous version after failed ECV occurred in 4.3% of cases and was more common in multipara [ 28 ].

Cesarean section after successful external cephalic version

Following a successful and uncomplicated ECV trial, the mean cesarean section rate ranged from 14.7% to as high as 21% [ 38 , 39 ]. Although the pregnancy progresses beyond 40 weeks in women who undergo successful ECV, these women are known to require labor induction with a higher rate of cesarean section [ 40 ], mainly necessitated by labor dystocia (OR, 2.2; 95% CI, 1.6–3.0) and fetal distress (OR, 2.2; 95% CI, 1.6–2.9) [ 39 ].

Parity, BMI, and amniotic fluid volume are known to affect the cesarean section rate after successful ECV [ 27 , 28 , 39 , 41 , 42 ]. Nulliparity increased the risk of cesarean section (OR, 2.7; 95% CI, 1.2–6.1) [ 41 ], with only 50% of nulliparae undergoing a vaginal vertex delivery following successful ECV, whereas the corresponding figure in multipara was as high as 88.5% [ 27 ]. A Dutch study that included 301 women reported that of all the variables evaluated, only parity could predict the risk of cesarean section [ 41 ]. Notably, only 59.5% of women with BMI ≥40 kg/m 2 delivered vaginally following successful ECV; however, the corresponding figure was much higher (81.0%) in women with normal BMI [ 37 ]. Moreover, women with AFI ≥13 were significantly more likely to deliver vaginally after successful ECV [ 41 ].

Induction of labor, high BMI, and previous cesarean section were associated with an increased risk of cesarean section after successful ECV [ 39 ]. However, the time interval between ECV and delivery failed to predict spontaneous vaginal delivery after successful ECV [ 42 ]. The other variables, such as maternal age, gestational age, estimated fetal birth weight, and neonatal sex were not observed to predict cesarean section after successful ECV [ 42 ].

Complications

Although the history of ECV spanning several decades provides proof of its safety profile, this procedure continues to remain controversial. Complications of ECV are as follows:

• • Transient abnormal cardiotocography patterns: With an incidence rate of 5.7–9.6%, a transient abnormal cardiotocography pattern is the most commonly reported complication of ECV [ 43 ]. Temporary baseline bradycardia is relatively common (9–9.6%) [ 44 , 45 ]; however, a report from Japan has described an exceptionally high incidence of fetal bradycardia during or immediately after ECV (48.5%, 189 of 390 cases) that lasted for <1 minute in 43.3%, <5 minutes in 88.9%, and <10 minutes in 98.4% of cases [ 22 ]. Bradycardia lasting >10 minutes occurred in 3 of 390 cases (0.7%), and low Apgar scores at 5 minutes, with an umbilical cord arterial pH <7.1 were observed in 2 of these cases [ 22 ].
• • Fetal heart rate deceleration: Although the incidence of a persistent pathological cardiotocographic pattern was between 0.2% (2 of 980 trials) [ 44 ] and 0.37% [ 43 ] after ECV, it was not significantly associated with the AFI [ 32 ].
• • Umbilical cord accidents: Success or failure of ECV was not associated with an increased risk of umbilical cord accidents [ 45 ].
• • Placental abruption: A recent systematic review of 7,377 ECV trials reported a placental abruption incidence rate of 0.12% [ 43 ]; however, an earlier systematic review of 2,503 ECV trials published in 2006 identified no reports of placental abruption associated with ECV [ 46 ].
• • Vaginal bleeding: Vaginal spotting or bleeding occurred in 0.47% of women after the procedure [ 43 ]. Although the cause of vaginal bleeding is unclear, it can infrequently be associated with placental abruption. Therefore, in the event of vaginal spotting, the ECV trial should be promptly discontinued, and close monitoring for further spotting and cardiotocography should be performed.
• • Premature rupture of the membranes: A previous study has reported that immediate delivery occurred in 1.3% of women following ECV secondary to premature rupture of membranes [ 47 ]; however, a systematic review of 2,503 ECV trials reported no such findings [ 46 ].
• • Fetomaternal hemorrhage: The rate of detectable fetomaternal hemorrhage during ECV was reported to be 2.4% [ 48 ]. Moreover, estimated fetomaternal hemorrhage >30 mL occurred in just 1 case (0.08%) reported among the 1,311 ECV trials; therefore, it was recommended that Rh immunoglobulin in addition to the routine dose of 300 microgram dose need not be administered at 28 weeks of gestation and postpartum [ 48 ].
• • Uterine rupture: Uterine rupture during an ECV trial is one of the most catastrophic complications. However, fortunately, this is rare, and no cases included in a systematic review of 2,503 ECV trials have reported this complication [ 46 ].
• • Emergency cesarean section: The risk of emergency cesarean deliveries during and after ECV reportedly ranges between 0.2% and 0.7% [ 15 , 22 , 43 , 44 , 49 ], with the most common indication being an abnormal fetal heart rate pattern detected on EFM.
• • Fetal death: A previous study reported no increase in the risk of antepartum fetal death associated with ECV [ 46 ], whereas another study reported that although no intrauterine death occurred within 24 hours of performing ECV, intrauterine death occurred in 1 case (0.09%) at 4 weeks following an uncomplicated ECV [ 50 ]. Furthermore, a recent cohort study spanning over 18 years reported a corrected post-ECV perinatal mortality rate of 0.12% [ 28 ], whereas a systematic review of 7,377 women reported a slightly higher perinatal mortality rate of 0.16% [ 43 ]. Another Cochrane systematic review published in 2015 reported that perinatal mortality occurred in 2 of 644 neonates in the ECV group and in 6 of 661 neonates in the control group [ 1 ].

A meta-analysis has reported a pooled ECV complication rate of 6.1% (0.24% for serious complications) [ 49 ]. Compared to findings in women who did not undergo ECV, ECV failure was associated with an increased risk of premature rupture of membranes (adjusted OR [aOR], 1.75; 95% CI, 1.60–1.90), abnormal fetal heart rate tracing (aOR, 1.78; 95% CI, 1.50–2.11), assisted ventilation at birth (aOR, 1.50; 95% CI, 1.27–1.78), and 5-min Apgar scores < 7 (aOR, 1.35; 95% CI, 1.20–1.51) [ 51 ]. A large study that included 4,117 women reported that compared to expectant management, an ECV trial at term was not associated with increased prenatal morbidity or mortality [ 52 ].

Therefore, the latest guideline issued by the RCOG with respect to ECV does not recommend standard preoperative preparations for cesarean section for women undergoing ECV [ 18 ].

Procedure of external cephalic version

1. before performing the external cephalic version, 1) obtaining pre-procedural informed consent.

Informed consent should be documented and must include the following important points:

• a. Successful ECV can reduce the rate of cesarean sections (success rate approximately 60–70%).
• b. Possible use of tocolytics.
• c. The procedure may be uncomfortable and occasionally painful.
• d. Risks and benefits of the procedure should be explained to women/their family prior to the ECV.

2) Electronic fetal monitoring

EFM tracings should be normal before the procedure. The monitoring should continue during, as well as after the procedure.

3) Ultrasonography

Ultrasonography should be performed before ECV to confirm the fetal position and size, the type of breech, position of the fetal spine, location of the placenta, amniotic fluid volume, cord around the neck, and descent of the breech fetus [ 53 , 54 ].

4) Intravenous access

Intravenous access must be established for the administration of tocolytics, as well as for use during emergencies.

2. Technique of external cephalic version

After lubricating the maternal abdomen with ultrasound gel to reduce friction, real-time ultrasonography is performed intermittently during the ECV procedure to check fetal progress and to detect changes in the fetal heart rate pattern. Usually, at the first ECV attempt, the direction of rotation is a forward roll (motion in the direction of the fetal face) ( Fig. 1 ). If this maneuver is unsuccessful, a back flip (motion in the direction of the fetal occiput) can be tried. An ECV procedure includes the following steps:

Maneuver showing dislodgement of the fetal buttocks from the maternal pelvis.

• a. Dislodge the fetal buttocks from the pelvis pushing upwards and subsequently laterally with 1 hand (usually the dominant one) ( Fig. 1 ).
• b. Gently grasp the fetal head and direct it downwards with the other hand ( Fig. 1 ).

Maneuver showing the operator pushing the fetal buttocks upward and guiding the fetal head.

Maneuver showing the operator directing the fetal head into the maternal pelvis.

• e. If the forward roll fails, a backward flip can be tried in the opposite direction of the fetal occiput descending first.
• f. The ECV procedure can be performed either by a single operator or with the help of an assistant (to help with pushing the buttocks upward or with performing ultrasonography during the procedure).
• g. Discontinue the procedure if the woman complains of significant discomfort or if the fetal heart rate is atypical or abnormal.
• h. If the fetal heart rate does not recover within 3 minutes of emergency measures (maternal lateral position, bolus fluid infusion, and/or oxygen mask placement, among other such measures), it is necessary to prepare for an emergency cesarean section. If the fetal heart rate does not recover within 5 minutes, an emergency cesarean section is performed. Delivery should be completed within 10 minutes after the onset of bradycardia [ 22 ].

3. Interventions and medications to increase the success rate of external cephalic version

Various interventions have been used including the administration of tocolytics [ 55 ], neuraxial analgesia (epidural, spinal) [ 56 ], opioids, hypnosis, amnioinfusion, and the use of lubricants to increase the success rate of ECV. Recently, a Cochrane review of 28 studies reported that tocolytics (beta-agonists) were significantly effective (relative risk, 1.68; 95% CI, 1.14–2.48) in facilitating successful ECV [ 57 ], and the effectiveness increased when these were used in combination with regional analgesia.

However, the result of adding regional analgesia was underpowered secondary to lack of cost-effectiveness. Notably, no difference was observed in cephalic presentation in labor [ 57 ].

Individual studies have reported a significantly higher success rate of ECV associated with the use of epidural anesthesia. However, these studies may have been biased by low overall ECV success rates or physician preferences [ 12 ]. Although routine use of regional analgesia or neuraxial blockade is not recommended for ECV, these may be considered during a repeat attempt or in women unable to tolerate ECV without analgesia [ 55 ]. Presently, other methods including the use of vibroacoustic stimulation, amnioinfusion, systemic administration of opioids, and hypnosis are not recommended owing to lack of evidence. In the author's hospital, only a beta-agonist (ritodrine) is used during ECV, and no analgesia or anesthesia is used.

4. After external cephalic version

Transient bradycardia is common (9–9.6%) and occurs during or immediately following ECV [ 43 , 45 ], possibly secondary to the vagal reflex when pressure is exerted on the fetal head. EFM commonly shows decreased baseline variability and baseline heart rate, which represent the fetal stress response caused by decreased uteroplacental blood flow during the procedure [ 45 ]. It is recommended that EFM be continued for a minimum of 20 minutes after ECV, regardless of the success of the procedure.

1) Warning for possible complications

A woman undergoing ECV should be instructed to return promptly if she develops abdominal pain, symptoms of labor, bleeding, fluid leakage, fever, or decreased fetal movements.

Management after external cephalic version

1. after successful external cephalic version.

Labor induction is not necessary after successful ECV, and maintaining the usual schedule of prenatal visits is recommended. Spontaneous reversion to breech presentation is not common and occurs in approximately 3% of cases [ 15 ].

2. After external cephalic version failure

The option of scheduling the next ECV trial (on another day) or a cesarean delivery can be discussed based on the woman's choice and fetal condition. The woman is also informed that 3–7% of term breech fetuses spontaneously turn to a cephalic presentation [ 58 ].

3. Rh immunoglobulin injection

Most authors recommend that 300 µg of Rh immunoglobulin be injected in unsensitized Rh-negative women after an ECV trial. However, routine Rh immunoglobulin injection and performing a Kleihauer-Betke test are challenged by other authors because usually ECV-induced blood loss >30 mL occurs only in 0.08% of women undergoing the procedure [ 48 ].

Currently, both the RCOG and ACOG recommend that all women with an uncomplicated singleton breech presentation at term should be offered an ECV trial [ 11 , 12 ]. It is known that ECV is a relatively simple and safe maneuver, which effectively reduces the risk of breech presentation at term. In Korea, the current trend involves performing a cesarean section in women with term breech presentation. If the situation is to change, it is important to overcome the main barrier to performing ECV among obstetricians–the lack of knowledge to educate and counsel pregnant women regarding ECV [ 14 ]. This review is a step in this direction and is aimed at providing obstetricians with the requisite knowledge to enable them to offer the benefit of this procedure to eligible women, to reduce the alarming increase in the rate of cesarean sections performed in Korea.

Conflict of interest: No potential conflict of interest relevant to this article was reported.

Ethical approval: No ethical approval was required for this study, which presents a literature-based review.

Patient consent: This being a review article, obtaining patient consent was not necessary.

Is cephalic presentation normal at 21 weeks?

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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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You and your baby at 32 weeks pregnant

Your baby at 32 weeks.

By about 32 weeks, the baby is usually lying with their head pointing downwards, ready for birth. This is known as cephalic presentation.

If your baby is not lying head down at this stage, it's not a cause for concern – there's still time for them to turn.

The amount of amniotic fluid in your uterus is increasing, and your baby is still swallowing fluid and passing it out as urine.

You at 32 weeks

Being active and fit during pregnancy will help you adapt to your changing shape and weight gain. It can also help you cope with labour and get back into shape after the birth.

Find out about exercise in pregnancy .

You may develop pelvic pain in pregnancy. This is not harmful to your baby, but it can cause severe pain and make it difficult for you to get around.

Find out about ways to tackle pelvic pain in pregnancy .

Read about the benefits of breastfeeding for you and your baby. It's never too early to start thinking about how you're going to feed your baby, and you do not have to make up your mind until your baby is born.

Things to think about

• how you might feel after the birth

Start4Life has more about you and your baby at 32 weeks pregnant .

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Page last reviewed: 13 October 2021 Next review due: 13 October 2024