4 types of cephalic presentation

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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.

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Presentation and position of baby through pregnancy and at birth

9-minute read

If you are concerned about your baby’s movements, contact your doctor or midwife for advice immediately.

• If you baby is in a breech presentation, your doctor may recommend trying a technique called an external cephalic version to try and move your baby while they are still in the uterus for an easier birth.

What does presentation and position mean?

Presentation refers to the part of your baby’s body that is facing downwards in the direction of the birth canal.

Position refers to where your baby’s occiput (the bottom part of the back of their head) is in relation to your body.

If your baby is in a breech presentation , then position refers to where your baby’s sacrum (lower back) is in relation to your body.

People — including medical professionals — sometimes use these terms incorrectly. Sometimes when speaking about babies in breech presentation, the word ‘position’ will be used to refer to their presentation. For example, you may read information or hear people say ‘breech position’ instead of ‘breech presentation’.

What are the different types of presentation my baby could be in during pregnancy and birth?

Most babies present headfirst, also known as cephalic presentation. Most babies that are headfirst will be vertex presentation. This means that the crown of their head sits at the opening of your birth canal.

In rare cases, your baby can be headfirst but in face or brow presentation, which may not be suitable for vaginal birth.

If your baby is in a breech presentation, their feet or bottom will be closest to your birth canal. The 3 most common types of breech presentation are:

• frank or extended breech — where your baby’s legs are straight up in front of their body, with their feet up near their face
• complete or flexed breech — where your baby is in a sitting position with their legs crossed in front of their body and their feet near their bottom
• footling breech — where one or both of your baby’s feet are hanging below their bottom, so the foot or feet are coming first

Read more on breech presentation .

What are the different positions my baby could be in during pregnancy and birth?

If your baby is headfirst, the 3 main types of presentation are:

• anterior – when the back of your baby’s head is at the front of your belly
• lateral – when the back of your baby’s head is facing your side
• posterior – when the back of your baby’s head is towards your back

How will I know what presentation and position my baby is in?

Your doctor or midwife can usually work out your baby’s presentation by feeling your abdomen. They may also double check it with a portable ultrasound. Your baby’s presentation is usually checked around 36 weeks .

Your doctor or midwife will also confirm your baby’s head position in labour by examining your belly and using an ultrasound , and they may also do a vaginal examination . During the vaginal examination they are feeling for certain ridges on your baby’s head called sutures and fontanelles that help them work out which way your baby is positioned.

What is the ideal presentation and position for baby to be in for a vaginal birth?

For a vaginal birth, your baby will ideally be headfirst with the back of their head at the front of your belly, also known as being in the anterior position. This position is best for labour and birth since it means that the smallest part of your baby’s head goes down the birth canal first.

When does a baby usually get in the ideal presentation and position for birth?

Your baby will usually be in a headfirst position by 37 weeks of pregnancy. Around 3 in every 100 babies will be in breech presentation after 37 weeks.

Your baby’s position can change with your contractions during labour as they move down the birth canal, so their exact position can change during labour.

What are my options if baby isn't in the ideal presentation or position for a vaginal birth?

If your baby is in a breech presentation, your doctor may recommend a technique called an external cephalic version (ECV) to try and move your baby while they are still in the uterus . An ECV involves your doctor using their hands to apply pressure on your belly and help turn your baby to a headfirst position. It has a 1 in 2 chance of success and is a safe option in most pregnancies.

There is no evidence to show that alternative therapies, such as exercises, acupuncture or chiropractic treatments, help your baby change from a breech presentation to headfirst.

If your baby remains breech, your doctor may discuss having a breech vaginal birth. Not all doctors and hospitals offer this option. They may also suggest you birth your baby with a planned caesarean section .

If your baby’s presentation is headfirst but the position of your baby’s head is not ideal for labour, it can lead to a longer labour, and potential complications . The position of your baby’s head will often change as your labour progresses. If it doesn’t, sometimes you can still give birth without assistance, or you may need your doctor to help turn your baby’s head or help your birth with a vacuum or forceps .

Any procedure or decision for a type of birth will only go ahead with your consent . You will be able to discuss all the options with your doctor, and based on your preferences for yourself and your baby’s safety, make a decision together .

Resources and support

The Royal Australian and New Zealand College of Obstetrics and Gynaecology has a factsheet about the options available to you if your baby is in a breech presentation at the end of your pregnancy .

Mercy Perinatal has information on external cephalic version (ECV) safety and benefits if your baby is in a breech presentation at the end of your pregnancy.

The Women’s Hospital has information about the different presentations and positions your baby could be in, and how it can affect your birthing experience.

Speak to a maternal child health nurse

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Last reviewed: October 2023

Related pages

External cephalic version (ecv), malpresentation, breech pregnancy, search our site for.

• Foetal Version
• Breech Presentation

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Breech presentation and turning the baby

In preparation for a safe birth, your health team will need to turn your baby if it is in a bottom first ‘breech’ position.

Read more on WA Health website

Breech Presentation at the End of your Pregnancy

Breech presentation occurs when your baby is lying bottom first or feet first in the uterus (womb) rather than the usual head first position. In early pregnancy, a breech position is very common.

Read more on RANZCOG - Royal Australian and New Zealand College of Obstetricians and Gynaecologists website

External Cephalic Version for Breech Presentation - Pregnancy and the first five years

This information brochure provides information about an External Cephalic Version (ECV) for breech presentation

Read more on NSW Health website

When a baby is positioned bottom-down late in pregnancy, this is called the breech position. Find out about 3 main types and safe birthing options.

Read more on Pregnancy, Birth & Baby website

Malpresentation is when your baby is in an unusual position as the birth approaches. It may be possible to move the baby, but a caesarean may be safer.

Labour complications

Even if you’re healthy and well prepared for childbirth, there’s always a chance of unexpected problems. Learn more about labour complications.

ECV is a procedure to try to move your baby from a breech position to a head-down position. This is performed by a trained doctor.

Having a baby

The articles in this section relate to having a baby – what to consider before becoming pregnant, pregnancy and birth, and after your baby is born.

Anatomy of pregnancy and birth - pelvis

Your pelvis helps to carry your growing baby and is tailored for vaginal births. Learn more about the structure and function of the female pelvis.

Planned or elective caesarean

There are important things to consider if you are having a planned or elective caesarean such as what happens during and after the procedure.

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Cephalic presentation

October 14, 2016

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation where the occiput is the leading part (the part that first enters the birth canal). All other presentations are abnormal (malpresentations) which are either more difficult to deliver or not deliverable by natural means.

The movement of the fetus to cephalic presentation is called head engagement. It occurs in the third trimester. In head engagement, the fetal head descends into the pelvic cavity so that only a small part (or none) of it can be felt abdominally. The perineum and cervix are further flattened and the head may be felt vaginally. Head engagement is known colloquially as the baby drop, and in natural medicine as the lightening because of the release of pressure on the upper abdomen and renewed ease in breathing. However, it severely reduces bladder capacity, increases pressure on the pelvic floor and the rectum, and the mother may experience the perpetual sensation that the fetus will “fall out” at any moment.

The vertex is the area of the vault bounded anteriorly by the anterior fontanelle and the coronal suture, posteriorly by the posterior fontanelle and the lambdoid suture and laterally by 2 lines passing through the parietal eminences.

In the vertex presentation the occiput typically is anterior and thus in an optimal position to negotiate the pelvic curve by extending the head. In an occiput posterior position, labor becomes prolonged and more operative interventions are deemed necessary. The prevalence of the persistent occiput posterior is given as 4.7 %

The vertex presentations are further classified according to the position of the occiput, it being right, left, or transverse, and anterior or posterior:

Left Occipito-Anterior (LOA), Left Occipito-Posterior (LOP), Left Occipito-Transverse (LOT); Right Occipito-Anterior (ROA), Right Occipito-Posterior (ROP), Right Occipito-Transverse (ROT);

By Mikael Häggström – Own work, Public Domain  

Cephalic presentation. (2016, September 17). In Wikipedia, The Free Encyclopedia . Retrieved 05:18, September 17, 2016, from https://en.wikipedia.org/w/index.php?title=Cephalic_presentation&oldid=739815165

• Learn   /  

Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

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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 vertex 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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Obstetric and Newborn Care I

10.02 key terms related to fetal positions.

a. “Lie” of an Infant.

Lie refers to the position of the spinal column of the fetus in relation to the spinal column of the mother. There are two types of lie, longitudinal and transverse. Longitudinal indicates that the baby is lying lengthwise in the uterus, with its head or buttocks down. Transverse indicates that the baby is lying crosswise in the uterus.

b. Presentation/Presenting Part.

Presentation refers to that part of the fetus that is coming through (or attempting to come through) the pelvis first.

(1) Types of presentations (see figure 10-1). The vertex or cephalic (head), breech, and shoulder are the three types of presentations. In vertex or cephalic, the head comes down first. In breech, the feet or buttocks comes down first, and last–in shoulder, the arm or shoulder comes down first. This is usually referred to as a transverse lie.

(2) Percentages of presentations.

(a) Head first is the most common-96 percent.

(b) Breech is the next most common-3.5 percent.

(c) Shoulder or arm is the least common-5 percent.

(3) Specific presentation may be evaluated by several ways.

(a) Abdominal palpation-this is not always accurate.

(b) Vaginal exam–this may give a good indication but not infallible.

(c) Ultrasound–this confirms assumptions made by previous methods.

(d) X-ray–this confirms the presentation, but is used only as a last resort due to possible harm to the fetus as a result of exposure to radiation.

c. Attitude.

This is the degree of flexion of the fetus body parts (body, head, and extremities) to each other. Flexion is resistance to the descent of the fetus down the birth canal, which causes the head to flex or bend so that the chin approaches the chest.

(1) Types of attitude (see figure 10-2).

(a) Complete flexion. This is normal attitude in cephalic presentation. With cephalic, there is complete flexion at the head when the fetus “chin is on his chest.” This allows the smallest cephalic diameter to enter the pelvis, which gives the fewest mechanical problems with descent and delivery.

(b) Moderate flexion or military attitude. In cephalic presentation, the fetus head is only partially flexed or not flexed. It gives the appearance of a military person at attention. A larger diameter of the head would be coming through the passageway.

(c) Poor flexion or marked extension. In reference to the fetus head, it is extended or bent backwards. This would be called a brow presentation. It is difficult to deliver because the widest diameter of the head enters the pelvis first. This type of cephalic presentation may require a C/Section if the attitude cannot be changed.

(d) Hyperextended. In reference to the cephalic position, the fetus head is extended all the way back. This allows a face or chin to present first in the pelvis. If there is adequate room in the pelvis, the fetus may be delivered vaginally.

(2) Areas to look at for flexion.

(a) Head-discussed in previous paragraph, 10-2c(1).

(b) Thighs-flexed on the abdomen.

(c) Knees-flexed at the knee joints.

(d) Arches of the feet-rested on the anterior surface of the legs.

(e) Arms-crossed over the thorax.

(3) Attitude of general flexion. This is when all of the above areas are flexed appropriately as described.

d. Station.

This refers to the depth that the presenting part has descended into the pelvis in relation to the ischial spines of the mother’s pelvis. Measurement of the station is as follows:

(1) The degree of advancement of the presenting part through the pelvis is measured in centimeters.

(2) The ischial spines is the dividing line between plus and minus stations.

(3) Above the ischial spines is referred to as -1 to -5, the numbers going higher as the presenting part gets higher in the pelvis (see figure10-3).

(4) The ischial spines is zero (0) station.

(5) Below the ischial spines is referred to +1 to +5, indicating the lower the presenting part advances.

e. Engagement.

This refers to the entrance of the presenting part of the fetus into the true pelvis or the largest diameter of the presenting part into the true pelvis. In relation to the head, the fetus is said to be engaged when it reaches the midpelvis or at a zero (0) station. Once the fetus is engaged, it (fetus) does not go back up. Prior to engagement occurring, the fetus is said to be “floating” or ballottable.

f. Position.

This is the relationship between a predetermined point of reference or direction on the presenting part of the fetus to the pelvis of the mother.

(1) The maternal pelvis is divided into quadrants.

(a) Right and left side, viewed as the mother would.

(b) Anterior and posterior. This is a line cutting the pelvis in the middle from side to side. The top half is anterior and the bottom half is posterior.

(c) The quadrants never change, but sometimes it is confusing because the student or physician’s viewpoint changes.

NOTE: Remember that when you are describing the quadrants, view them as the mother would.

(2) Specific points on the fetus.

(a) Cephalic or head presentation.

1 Occiput (O). This refers to the Y sutures on the top of the head.

2 Brow or fronto (F). This refers to the diamond sutures or anterior fontanel on the head.

3 Face or chin presentation (M). This refers to the mentum or chin.

(b) Breech or butt presentation.

1 Sacrum or coccyx (S). This is the point of reference.

2 Breech birth is associated with a higher perinatal mortality.

(c) Shoulder presentation.

1 This would be seen with a transverse lie.

2. Scapula (Sc) or its upper tip, the acromion (A) would be used for the point of reference.

(3) Coding of positions.

(a) Coding simplifies explaining the various positions.

1 The first letter of the code tells which side of the pelvis the fetus reference point is on (R for right, L for left).

2 The second letter tells what reference point on the fetus is being used (Occiput-O, Fronto-F, Mentum-M, Breech-S, Shoulder-Sc or A).

3 The last letter tells which half of the pelvis the reference point is in (anterior-A, posterior-P, transverse or in the middle-T).

(b) Each presenting part has the possibility of six positions. They are normally recognized for each position–using “occiput” as the reference point.

1 Left occiput anterior (LOA).

2 Left occiput posterior (LOP).

3 Left occiput transverse (LOT).

4 Right occiput anterior (ROA).

5. Right occiput posterior (ROP).

6 Right occiput transverse (ROT).

(c) A transverse position does not use a first letter and is not the same as a transverse lie or presentation.

1 Occiput at sacrum (O.S.) or occiput at posterior (O.P.).

2 Occiput at pubis (O.P.) or occiput at anterior (O.A.).

(4) Types of breech presentations (see figure10-4).

(a) Complete or full breech. This involves flexion of the fetus legs. It looks like the fetus is sitting in a tailor fashion. The buttocks and feet appear at the vaginal opening almost simultaneously.

A–Complete. B–Frank. C–Incomplete.

(b) Frank and single breech. The fetus thighs are flexed on his abdomen. His legs are against his trunk and feet are in his face (foot-in-mouth posture). This is the most common and easiest breech presentation to deliver.

(c) Incomplete breech. The fetus feet or knees will appear first. His feet are labeled single or double footing, depending on whether 1 or 2 feet appear first.

(5) Observations about positions (see figure 10-5).

(a) LOA and ROA positions are the most common and permit relatively easy delivery.

(b) LOP and ROP positions usually indicate labor may be longer and harder, and the mother will experience severe backache.

(c) Knowing positions will help you to identify where to look for FHT’s.

1 Breech. This will be upper R or L quad, above the umbilicus.

2 Vertex. This will be lower R or L quad, below the umbilicus.

(d) An occiput in the posterior quadrant means that you will feel lumpy fetal parts, arms and legs (see figure 10-5 A). If delivered in that position, the infant will come out looking up.

(e) An occiput in the anterior quadrant means that you will feel a more smooth back (see figure 10-5 B). If delivered in that position, the infant will come out looking down at the floor.

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Your baby in the birth canal

During labor and delivery, your baby must pass through your pelvic bones to reach the vaginal opening. The goal is to find the easiest way out. Certain body positions give the baby a smaller shape, which makes it easier for your baby to get through this tight passage.

The best position for the baby to pass through the pelvis is with the head down and the body facing toward the mother's back. This position is called occiput anterior.

Information

Certain terms are used to describe your baby's position and movement through the birth canal.

FETAL STATION

Fetal station refers to where the presenting part is in your pelvis.

• The presenting part. The presenting part is the part of the baby that leads the way through the birth canal. Most often, it is the baby's head, but it can be a shoulder, the buttocks, or the feet.
• Ischial spines. These are bone points on the mother's pelvis. Normally the ischial spines are the narrowest part of the pelvis.
• 0 station. This is when the baby's head is even with the ischial spines. The baby is said to be "engaged" when the largest part of the head has entered the pelvis.
• If the presenting part lies above the ischial spines, the station is reported as a negative number from -1 to -5.

In first-time moms, the baby's head may engage by 36 weeks into the pregnancy. However, engagement may happen later in the pregnancy, or even during labor.

This refers to how the baby's spine lines up with the mother's spine. Your baby's spine is between their head and tailbone.

Your baby will most often settle into a position in the pelvis before labor begins.

• If your baby's spine runs in the same direction (parallel) as your spine, the baby is said to be in a longitudinal lie. Nearly all babies are in a longitudinal lie.
• If the baby is sideways (at a 90-degree angle to your spine), the baby is said to be in a transverse lie.

FETAL ATTITUDE

The fetal attitude describes the position of the parts of your baby's body.

The normal fetal attitude is commonly called the fetal position.

• The head is tucked down to the chest.
• The arms and legs are drawn in towards the center of the chest.

Abnormal fetal attitudes include a head that is tilted back, so the brow or the face presents first. Other body parts may be positioned behind the back. When this happens, the presenting part will be larger as it passes through the pelvis. This makes delivery more difficult.

DELIVERY PRESENTATION

Delivery presentation describes the way the baby is positioned to come down the birth canal for delivery.

The best position for your baby inside your uterus at the time of delivery is head down. This is called cephalic presentation.

• This position makes it easier and safer for your baby to pass through the birth canal. Cephalic presentation occurs in about 97% of deliveries.
• There are different types of cephalic presentation, which depend on the position of the baby's limbs and head (fetal attitude).

If your baby is in any position other than head down, your doctor may recommend a cesarean delivery.

Breech presentation is when the baby's bottom is down. Breech presentation occurs about 3% of the time. There are a few types of breech:

• A complete breech is when the buttocks present first and both the hips and knees are flexed.
• A frank breech is when the hips are flexed so the legs are straight and completely drawn up toward the chest.
• Other breech positions occur when either the feet or knees present first.

The shoulder, arm, or trunk may present first if the fetus is in a transverse lie. This type of presentation occurs less than 1% of the time. Transverse lie is more common when you deliver before your due date, or have twins or triplets.

CARDINAL MOVEMENTS OF LABOR

As your baby passes through the birth canal, the baby's head will change positions. These changes are needed for your baby to fit and move through your pelvis. These movements of your baby's head are called cardinal movements of labor.

• This is when the widest part of your baby's head has entered the pelvis.
• Engagement tells your health care provider that your pelvis is large enough to allow the baby's head to move down (descend).
• This is when your baby's head moves down (descends) further through your pelvis.
• Most often, descent occurs during labor, either as the cervix dilates or after you begin pushing.
• During descent, the baby's head is flexed down so that the chin touches the chest.
• With the chin tucked, it is easier for the baby's head to pass through the pelvis.

Internal Rotation

• As your baby's head descends further, the head will most often rotate so the back of the head is just below your pubic bone. This helps the head fit the shape of your pelvis.
• Usually, the baby will be face down toward your spine.
• Sometimes, the baby will rotate so it faces up toward the pubic bone.
• As your baby's head rotates, extends, or flexes during labor, the body will stay in position with one shoulder down toward your spine and one shoulder up toward your belly.
• As your baby reaches the opening of the vagina, usually the back of the head is in contact with your pubic bone.
• At this point, the birth canal curves upward, and the baby's head must extend back. It rotates under and around the pubic bone.

External Rotation

• As the baby's head is delivered, it will rotate a quarter turn to be in line with the body.
• After the head is delivered, the top shoulder is delivered under the pubic bone.
• After the shoulder, the rest of the body is usually delivered without a problem.

Alternative Names

Shoulder presentation; Malpresentations; Breech birth; Cephalic presentation; Fetal lie; Fetal attitude; Fetal descent; Fetal station; Cardinal movements; Labor-birth canal; Delivery-birth canal

Barth WH. Malpresentations and malposition. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 17.

Kilpatrick SJ, Garrison E, Fairbrother E. Normal labor and delivery. In: Landon MB, Galan HL, Jauniaux ERM, et al, eds. Gabbe's Obstetrics: Normal and Problem Pregnancies . 8th ed. Philadelphia, PA: Elsevier; 2021:chap 11.

Review Date 11/10/2022

Updated by: John D. Jacobson, MD, Department of Obstetrics and Gynecology, Loma Linda University School of Medicine, Loma Linda, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

Related MedlinePlus Health Topics

• Childbirth Problems

Cephalic Presentation

In subject area: Medicine and Dentistry

Malposition refers to the fetus in cephalic presentation, not positioned as a flexed vertex.

From: Obstetrics, Gynaecology & Reproductive Medicine , 2023

Chapters and Articles

You might find these chapters and articles relevant to this topic.

Obstetric Anesthesia

Stephanie Lim MD , Jennifer Lucero MD , in Anesthesiology Clinics , 2017

Breech presentation is the most common abnormal fetal presentation and complicates approximately 3% to 4% of all pregnancies. External cephalic version (ECV) should be recommended to women with a breech singleton pregnancy, if there is no maternal or fetal contraindication. ECV increases the chance of cephalic presentation at the onset of labor and decreases the rate of cesarean delivery by almost 40%. The success rate of ECV is approximately 60%. Review of the risks and benefits for performing an ECV and for both the timing of ECV and the number of attempts should be should be discussed with the patient.

Mechanisms and management of normal labour

Jennifer M Thornton , ... Meenakshi Ramphul , in Obstetrics, Gynaecology & Reproductive Medicine , 2020

Presentation

Presentation refers to the fetal part that engages with the maternal pelvis. This has important mechanical implications in the second stage of labour (see Table 2 ).

Table 2 . Diameter of presenting part and important landmarks of the fetal skull

Cephalic: Vertex/Occiput, Face, Sinciput, Brow

Breech: This is much less common than cephalic presentation , comprising only 3–4% of term deliveries. Whilst vaginal breech delivery is beyond the scope of this article, and indeed is much less common currently, presentation may be further described as frank, complete or footling.

Pregnancy: Third Trimester

Aviva Romm , ... Christopher Hobbs , in Botanical Medicine for Women's Health , 2010

CONVENTIONAL TREATMENT OPTIONS FOR TURNING A BREECH PRESENTATION: EXTERNAL CEPHALIC VERSION

The primary method used to turn a breech baby to a cephalic presentation is external cephalic version (ECV). ECV is the manual transabdominal rotation of the fetus into a cephalic presentation. The practice was popular in the 1960s and 1970s but fell out of favor because of fetal deaths associated with the procedure. However, the practice was revived in the 1980s and is now considered a safe and effective means for avoiding cesarean section caused by breech presentation. 135–138 135 136 137 138 ACOG recommends ECV as a standard procedure for turning a breech to avoid cesarean section when the maternal–fetal dyad meets eligibility criteria. 129 , 139 CV is performed in the hospital with a surgical room set up should emergency cesarean be necessitated as a result of complications, which occasionally occur as a result of the procedure, including cord entanglement, fetal hypoxia, premature rupture of the membranes, separation of the placenta, and even fetal death. 140 The procedure may be performed with or without tocolysis (medications to relax the uterus) or anesthetic administered to the mother. Use of tocolysis or anesthetic may facilitate the procedure and reduces pain to the mother. 141 , 142 RhoGAM should be given to RH-negative mothers prior to attempting a version. The average success rate for the procedure is 58%. Efficacy is greater when the procedure is performed between 34 and 37 weeks, as compared with later in pregnancy, although the fetus may revert to its previous position, thus requiring that the procedure be repeated.

Updates in Obstetric and Gynecologic Emergencies

Samantha A. King MD , ... Sarah Sommerkamp MD , in Emergency Medicine Clinics of North America , 2023

Fetal Presentation

In a patient who is presenting with signs of labor, it is important to identify the fetal presentation. To evaluate for fetal presentation, the curvilinear transducer is placed transversely over the suprapubic region with the marker towards the patient’s right. 46 In a cephalic presentation , the fetal skull will be visualized in the pelvis ( Fig. 10 C). In the term, laboring patient, any fetal part other than the head within the maternal pelvis indicates a breech presentation.

Usefulness of atosiban for tocolysis during external cephalic version: Systematic review and meta-analysis

Gaetano Riemma , ... Maddalena Morlando , in European Journal of Obstetrics & Gynecology and Reproductive Biology , 2021

Introduction

Breech/transverse presentation is responsible for about 30–50 % of cesarean sections in the world. Cesarean section carries a five-fold greater morbidity than vaginal delivery, deeply impacting on women’s health. External Cephalic Version (ECV) is an external manipulation used to convert a non-cephalic to a cephalic presentation . The use of tocolysis might facilitate this procedure; however, it is still controversial which drug should be considered as first choice.

To assess the effectiveness of tocolysis with atosiban, a competitive oxytocin receptor antagonist, in order to increase the rate of successful ECV.

Study design

Nine databases (including MEDLINE, CINAHL, LILACS, EMBASE, Scopus, ClinicalTrials.gov, Scielo, PROSPERO, Cochrane at CENTRAL) were searched from the inception to August 2020 using a combination of MeSH terms and keywords regarding “atosiban” and “external cephalic version”. We included trials of women with a singleton pregnancy who reached at least 36 weeks of gestation and were scheduled to ECV and tocolysis with atosiban (intervention group) compared to beta-agonists or other drugs (control group). The primary outcome was the incidence of successful ECV. Summary measures were reported as relative risk (RR) with 95 % confidence interval (CI).

Data collection and analysis

Four studies (1534 women) were eligible for analysis. ECV success rate was significantly lower in women randomized to atosiban (36.7 % vs 45.3 %; RR 0.78 [95 % CI 0.6 to 0.98]). Cesarean section and vaginal delivery rates did not differ between intervention and control group ((59.8 % vs 52.6 %; RR 1.17 [0.98–1.38] and (38.6 % vs 45.0 %; RR 0.83 [95 % CI 0.69–1.01] respectively). Cephalic (36.9 % vs 44.6 %; RR 0.81 [95 % CI 0.65 to 1.01], or breech/transverse presentation at labor (63.4 % vs 55.1 %; RR 1.18 [95 % CI 0.99–1.40]), APGAR score less than 7 at 5 min (1.6 % vs 2.0 %; RR 1.14 [95 % CI 0.27–4.73], NICU admissions (44.2 % vs 48.1 %; RR 0.92 [95 % CI 0.58–1.46] and Umbilical cord pH were similar in both groups. Drug-related side effects were lower in women randomized to atosiban, compared with control group (16.0 % vs 42.9 %; RR 0.38 [95 % CI 0.31 to 0.47].

The use of atosiban for tocolysis does not improve the rate of successful ECVs when compared to beta-agonists. However, atosiban was associated with a significantly lower incidence of side effects and comparable cesarean section rates.

BREECH PRESENTATION AND VERSION

Breech presentation is when the fetus presents with the buttocks, knees, or feet rather than the head, toward the vaginal canal during pregnancy. It is common in early pregnancy when the fetus has ample room to move around. As the pregnancy progresses, the baby has less space to move around. The fetal head will tend to gravitate toward the pelvis and the baby will assume a position it often maintains until labor. By 32 weeks pregnancy, the prevalence of breech presentation is reduced to 16% and by term it is 3% to 4%. The likelihood that a baby in the breech position at 36 weeks will remain so until the time of birth is 25%; however, spontaneous version to a cephalic (head first) presentation may occur at any time. Preterm babies are more likely to present breech than those born at full term.

There are three classifications of breech presentation:

Frank breech, which is when the fetus has both hips flexed and both knees extended so its feet are near its head ( Fig. 15-4 ). This occurs in 50% to 70% of breech presentations.

Footling or incomplete breech, in which the fetus has one or both hips or one or both knees not flexed. As a result, one or both feet present before the buttocks ( Fig. 15-5 ). This occurs in 10% to 40% of breech presentations.

Complete breech refers to a fetus with both hips and both knees flexed. The feet are opposite the fetal trunk rather than the head, but do not present in advance of the buttocks ( Fig. 15-6 ). This occurs in 5% to 10% of breech presentations.

REASONS FOR BREECH PRESENTATION

In most cases a persistent breech position is nonpathologic in origin, being a random occurrence, or a combination of the dynamics between the maternal pelvic and fetal head shapes. Breech presentation itself presents little risk to the fetus. In some cases, however, persistent breech position is the result of a maternal, fetal, or placental problem. Maternal factors that may contribute to breech presentation include uterine abnormalities that change the normal shape of the uterus, for example, bicornate uterus or uterine fibroids; multiparity that leads to uterine and abdominal wall laxity, changing the shape of the uterus; and a deformed or contracted maternal pelvis. Placental abnormalities, for example, placenta previa, which prevent the fetal head from properly entering the pelvis can contribute to breech position, as can amniotic fluid volume abnormalities (polyhydramnios, oligohydramnios). Any factors that alter either the normal fetal shape or normal fetal mobility can contribute to breech presentation, and include fetal anomalies (e.g., anencephaly, hydrocephaly), multiple pregnancy (i.e., twins), short umbilical cord, and fetal demise. Previous breech birth is considered a risk factor for breech presentation in subsequent pregnancies.

RISKS OF BREECH PRESENTATION AND BREECH BIRTH

Breech presentation itself presents little risk to the fetus. Risk occurs when there are predisposing maternal, fetal, or placental factors that cause the baby to present breech. Breech birth does appear to increase the risk to the fetus. 128 The exact extent to which this is so is uncertain, as are the reasons. Prior to the 1950s, vaginal delivery was the preferred method for breech presentation in the United States. In 1970, cesarean rates for breech were 12%. By 2002, this rate had risen to 86.9%. 129 The American College of Obstetricians and Gynecologists Committee on Obstetric Practice currently recommends use of external cephalic version and planned cesarean delivery for persistent singleton breech presentation at term. This recommendation was amended to allow vaginal delivery of a term singleton breech if there is detailed patient informed consent, under hospital specific protocol guidelines for eligibility and labor management, and by a health care provider experienced in vaginal breech delivery. 129

There is significant controversy regarding whether cesarean section is necessary or improves outcome, and just how great a risk there is with vaginal breech birth. 130 Several studies demonstrate decreased morbidity and mortality to the fetus with elective cesarean; however, this is accompanied by increased maternal morbidity. It has been suggested that the risk of breech birth is more attributable to the fact that most obstetricians are inexperienced in breech birth management because of the high use of cesarean delivery, than to inherent risks in the breech birth process, and that with skilled management, breech birth is a safe option in the absence of complicating factors. 131–134 131 132 133 134 The American College of Obstetricians and Gynecologists states

The number of practitioners with the skills and experience to perform vaginal breech delivery has decreased. Even in academic medical centers where faculty support for teaching vaginal breech delivery to residents remains high, there may be insufficient volume of vaginal breech deliveries to adequately teach this procedure. 129

To avoid the need for unnecessary cesarean section, obstetric and midwifery care providers recommended that attempts be made to turn the baby to a cephalic presentation prior to the onset of labor. This chapter focuses on the use of external cephalic version and moxibustion as two techniques that may be attempted with potential for success. Although this chapter addresses breech presentation as something to be changed, the author wishes to emphasize that breech presentation is most often a variation of normal rather than a pathologic condition, and that a discussion on changing the breech to a cephalic presentation is in no way meant to disparage vaginal breech birth.

SIGNS, SYMPTOMS, AND DIAGNOSIS OF BREECH PRESENTATION

With breech presentation, the mother is likely to report more upper abdominal discomfort, indigestion, and greater fetal movement in the upper, rather than lower, abdomen. The care provider may identity the breech presentation upon abdominal palpation. Ultrasound visualization is used as confirmation. Breech presentation is sometimes first diagnosed upon vaginal examination in labor.

BOTANICAL TREATMENT OPTIONS FOR TURNING A BREECH PRESENTATION

Moxibustion for breech presentation.

Moxibustion is a traditional Chinese medicine technique that involves the use of a cigar-shaped stick of compressed Artemisia herb, lit and indirectly applied as a heat source over the acupuncture point Bladder 67 (zhi yin) on the outer edge of the fifth (pinky) toenail, on each foot (the moxa is not applied directly to the skin). (see Fig. 15-7 ). The technique is repeated twice daily for 15 minutes on each foot for 7 to 10 days, and is discontinued when the fetus has felt to have turned. Fetal activity is observed to increase during the treatment period, followed by movement of the baby into a cephalic presentation . In a study by Cardini et al. published in JAMA in 1998, the authors reported that of 130 women with breech babies who received moxibustion beginning at 33 weeks gestation, 75.4% of babies were cephalic by 35 weeks gestation vs. 47.7% in the control group. Because no studies had previously been carried out on Western populations, pregnant Italian women at 33 to 35 weeks gestational age carrying a fetus in breech presentation were enrolled in a randomized controlled trial involving BL67 point stimulation and an observation group. A total of 240 were randomized to receive active treatment (acupuncture plus moxibustion) or be assigned to the observation group. Bilateral acupuncture plus moxibustion was applied at the BL67 acupoint (zhi yin). The primary outcome of the study was fetal presentation at delivery. Fourteen cases dropped out. The final analysis thus was made on 226 cases, 114 randomized to observation and 112 to acupuncture plus moxibustion. At delivery, the proportion of cephalic version was lower in the observation group (36.7%) than in the active-treatment group (53.6%). Hence, the proportion of cesarean sections indicated for breech presentation was significantly lower in the treatment group than in the observation group (52.3% vs. 66.7%). 143 Ewies and Olah report that moxa is a safe, painless, inexpensive, and easily administered option, but emphasize the small sample sizes of most studies, with lack of randomization. 144 The Cochrane Review reports no side effects associated with use of moxibustion in pregnancy. 145 Patients should be advised that the smell of burning moxibustion is similar to the smell of marijuana. This author has had several patients who had house guests or business associates who thought they were smoking cannabis. It may be suggested that clients use moxa outside or away from an area of business. One funny anecdote with moxa use is of a real estate agent who told a patient that if she wanted to sell her house, which was on the market during the time the patient was using moxibustion for breech version, she might want to smoke her marijuana somewhere else. The patient explained and demonstrated the moxa use to the realtor, and afterward completed her treatments outside, in spite of it being late autumn! She had a cesarean for a breech baby with her first pregnancy, and was delighted when, after 4 days of treatment at 37 weeks gestation, her baby changed to a cephalic presentation and she gave birth vaginally at 39 weeks, to a vertex baby.

Although from a Western medical perspective, the mechanism of action is entirely unknown, the treatment appears to be entirely safe, is inexpensive, and is applied externally only. It is certainly a preferable alternative to external cephalic version or cesarean section for the management of persistent breech presentation. Because it is advised to be done from 34 weeks onward, treatment does not preclude the decision to perform external version or surgical delivery.

ADDITIONAL TECHNIQUES

Postural management of breech presentation.

Five studies involving a total of 392 women were included in a Cochrane review on the efficacy of postural management for changing a breech to a cephalic presentation . Postural management includes the use of slant boards upon which the mother lies on her back, at a 45-degree angle with her head down, and other similar techniques that are thought to coax the baby to change position. The authors of the review concluded that there is insufficient evidence from well-controlled trials to support the use of postural management for breech presentation. The numbers of women studied to date, however, remains relatively small. 146

In a study by Mehl, 100 women with breech presentation between 37 weeks and term were compared with a similarly matched control group and achieved a version rate of 81% compared with 48% in the nonintervention group. It is thought that because psychophysiologic factors may influence breech presentation, relaxing the mother's abdominal musculature, or preparing her mentally and emotionally for delivery through the use of hypnotism or other techniques may assist in achieving cephalic version. 140 There are no studies in the literature on the use of hypnosis for breech version. 140

Small non-randomized, noncontrolled studies and case reports suggest that there may be some small benefit to a variety of techniques for changing breech position. These include yoga, chiropractic, and homeopathic methods, as well as the use of ginger paste applied in place of moxibustion to stimulate heat to BL67. 140 One of these methods has been systemically evaluated. Use of music applied to the mother's abdomen, a popular technique promoted on the Internet, has only been minimally studied in conjunction with the use of ECV with tocolytic drugs, making it difficult to evaluate the usefulness of the studies. 140

Cytomegalovirus

In Diagnostic Imaging: Obstetrics (Third Edition) , 2016

Imaging Recommendations

If cephalic presentation , use transvaginal ultrasound for highest resolution brain images

MR imaging higher sensitivity than ultrasound in detecting brain anomalies (92% vs. 38%) and in predicting symptomatic infection (83% vs. 33%)

Ultrasound and MR appear to be complementary; they are not mutually exclusive in high-risk fetuses

Structural reflex zone therapy for pregnancy

Denise Tiran MSc, PGCEA, RM, RGN, ADM , ... Maggie Evans RM, RN, HV Cert, MSc (Complementary Therapies) , in Reflexology in Pregnancy and Childbirth , 2010

BREECH PRESENTATION

Structural physiology and aetiology.

When the fetal breech is the presenting part this can cause problems for delivery. Although fetal presentation and position change frequently during pregnancy, it is expected that most will settle into a cephalic presentation from about 34 weeks’ gestation. Thus, although difficulties are not normally encountered until labour, any management or attempt to encourage the fetus to alter position needs to be undertaken in late pregnancy.

There are many reasons why a fetus may adopt a breech presentation: the maternal pelvis may be an abnormal shape, size or in an abnormal position; there may be an obstruction within the uterine cavity, for example placenta praevia, fibroids or another fetus; the fetus/fetal head may be too large. Alternatively, or additionally, there may be loss of muscle tone in either the mother or fetus, as a result of an impaired immune system. This prevents maintenance of a cephalic presentation, since increases in stress hormones such as cortisol, which occur in immunological compromise, impact on prostaglandin production, thereby adversely affecting muscle tone of the maternal uterus and of the fetus (Choi et al 2004).

Conventional management usually consists of offering the mother an external cephalic version (ECV), which is an attempt to turn the fetus by use of external abdominal massage, or a Caesarean section. Vaginal breech birth is rarely offered as obstetricians consider it too risky for mother or baby, although this is debatable.

In structural terms, a misaligned pelvis and spine can alter the angle of inclination of the pelvic brim, making it difficult for the fetal head to enter the pelvis. This may be due to any musculoskeletal trauma, injury or congenital deviation from the normal shape or position of the pelvis or spinal column. Chiropractors acknowledge this misalignment and use a specific manipulation, the Webster technique (Pistolese 2002).

Relevant reflexology treatment

Contrary to the claims of numerous reflexologists (personal communications), reflexology does not directly convert a breech presentation to cephalic, as there is no specific “zone” for the fetal position. It would be inappropriate to massage the reflex zone for the uterus in an attempt to encourage the fetus to turn, as this could, theoretically, trigger haemorrhage, placental separation and entanglement of the fetus in the cord. On the other hand, RZT may indirectly help to turn the breech to cephalic, simply by relaxing the mother, aiding homeostasis, stimulating immunological function and improving muscle tone in both the maternal uterus and the fetus. Manipulation of reflex zones for the entire muscusloskeletal system may assist in realigning any deviations which may be contributing to an altered angle of inclination of the pelvic brim, facilitating a change of presentation. This should specifically focus on manipulation and release of tension in the neck and head, bimanual torsion of the rib cage zones and the thoracic spine, toning of the lumbar and sacral spine zones, and treating any discomforts in the system, such as sacroiliac joint, hip or symphysis pubis pain.

Some complementary therapists perform stimulation of a point on the little toes which is often successful in turning the fetus to cephalic. However, this is not a reflexology point, but an acupressure point on the feet, the Bladder 67 point, usually stimulated with moxibustion (a heat source used in Chinese medicine). There is considerable literature and research on this increasingly popular technique which is purported to be at least 66% successful (see Tiran 2004a, 2009, van den Berg et al 2008), and is normally performed from 34 weeks’ gestation. It is permissible for midwives and reflexologists who fully understand the individual mother's case history to incorporate Bladder 67 acupressure stimulation in an RZT treatment. The fetal presentation must be confirmed by abdominal palpation or by ultrasound scan immediately prior to commencing the course of treatment, the fetal heart should be auscultated before and after the session, and the mother's notes must specify the precise nature of the treatment and any relevant after care (see Chapter 5 and Fig. 5.2 for precise location of the Bladder 67 acupoint).

On no account should stimulation of the Bladder 67 acupoint be performed in women with a history of a previous Caesarean section or other uterine surgery, as treatment may over-stress the scar tissue. Similarly, women with major medical problems such as hypertension, epilepsy, cardiac disease or unstable diabetes should not be treated, nor should those with obstetric complications including multiple pregnancy, placenta praevia, antepartum haemorrhage, or any mother who is due to have a planned Caesarean section for a specific medical reason. Any mother who has been informed by her obstetrician or midwife that an ECV is not appropriate for her personal medical condition should not be treated with Bladder 67 stimulation.

Breech presentation: Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF)

Loïc Sentilhes , ... Eric Verspyck , in European Journal of Obstetrics & Gynecology and Reproductive Biology , 2020

Epidemiology, associated factors, and complications [ 4 ]

There are three categories of breech presentation, depending on the position of the fetus's lower limbs: frank in two thirds of cases, complete in one third, and, much more rarely, kneeling or footling (LE3). In France, around 5% of women give birth to fetuses in breech presentation (LE3). Because the frequency of this presentation diminishes as gestational age increases, its incidence is lower after 37 weeks; these presentations account for no more than 3% of births at term (LE3). Among these 3%, around 5% are referred to as "unexpected breech" (LE4), that is, breech presentations discovered only during labor.

The principal factors associated with breech presentation in the literature are the presence of a congenital malformation or myomas (LE3), oligohydramnios (LE3), preterm delivery (LE3), some specific fetal congenital malformations (LE3), and smallness-for-gestational-age (LE3).

In France, a trial of labor is performed for a third of the women with a fetus in breech presentation at term (LE3), and its success rate is 70% (LE3). Perinatal morbidity and mortality after 37 weeks for infants in breech presentation appear higher than in those in cephalic presentation , for all modes of delivery combined (LE3). The risk of traumatic injuries during all breech births is estimated at less than 1% (LE3). The most frequent injuries involve clavicle fractures, hematomas or contusions, brachial plexus injuries (LE3), and perineal hematomas. Breech presentation is associated with a higher risk of hip dysplasia (LE3), and cesarean delivery does not appear to protect against it (LE3). After exclusion of fetuses with congenital malformations, breech, compared with cephalic, presentation does not appear to be associated with a higher risk of cerebral palsy (LE3).

Management of First and Second Stages of Labor

Michael L. Stitely MD , Robert B. Gherman MD , in Obstetrics and Gynecology Clinics of North America , 2005

Abnormal presentation and position are encountered infrequently during labor. Breech and transverse presentations should be converted to cephalic presentations by external cephalic version or delivered by cesarean section. Face, brow, and compound presentations are usually managed expectantly. Persistent occiput transverse positions are managed by rotation to anterior positions and delivered as such. Occiput posterior positions can be delivered as such or rotated to occiput anterior positions. As with any position or presentation, an obstetrician should not hesitate to abandon any rotational or operative vaginal procedure and proceed to cesarean delivery if rotation or descent does not occur with relative ease.

Related terms:

• Vaginal Delivery
• Vaginal Birth after Cesarean
• Cesarean Section
• External Cephalic Version
• Breech Presentation
• Intrapartum

External Cephalic Version

• Author: Stacey Ehrenberg-Buchner, MD; Chief Editor: Carl V Smith, MD  more...
• Sections External Cephalic Version
• Periprocedural Care

External cephalic version (ECV) is a procedure that externally rotates the fetus from a breech presentation to a cephalic presentation. Successful version of a breech into cephalic presentation allows women to avoid cesarean delivery , which is currently the largest contributing factor to the incidence of postpartum maternal morbidity. [ 1 , 2 ]

Breech presentation occurs in 3-4% of all term pregnancies. [ 3 , 4 ] Breech presentation ranks as the third most frequent indication for cesarean section, following previous cesarean section and labor dystocia. More than 90% of breech fetuses are delivered by planned cesarean section. [ 5 , 6 ] Approximately 12% of cesarean deliveries in the United States are performed for breech presentation, not including repeat cesarean sections secondary to a history of a prior cesarean indicated for breech presentation.

Since the results of the Term Breech Trial [ 7 ] recommended cesarean section for breech fetuses at term, ECV has resurfaced as a valuable maneuver. [ 8 ] ECV enjoyed great popularity in the 1970s, although its use decreased after reports of increased perinatal mortality associated with the procedure. These cases may have been caused by undue force being applied to the maternal abdomen, as well as the concomitant perception of planned cesarean section as a safer alternative to ECV or breech vaginal delivery . [ 3 , 4 ]

ECV has been clearly shown to decrease the incidence of breech presentation at term, thereby reducing the cesarean section rate. [ 3 ] The safety of ECV, described later in this article, has been well-studied and confirmed. In accordance with the recommendations of the American College of Obstetricians and Gynecologists (ACOG), Royal College of Obstetricians and Gynaecologists, the Dutch Society for Obstetrics and Gynaecology, and Royal Dutch Organization for Midwives, ECV should be available and offered to all women near term with breech presentation who do not have any contraindications to the procedure. [ 3 , 4 , 9 , 10 , 11 , 12 , 13 ] In the properly selected patient, ECV is considered to be a safe and effective procedure to convert babies from breech to vertex presentation. [ 14 ]

Cesarean section is considered the largest contributing factor to maternal morbidity after childbirth [ 8 ] and routine use of ECV could potentially reduce the rate of cesarean delivery by about two thirds. [ 6 ] The use of tocolytics and regional anesthesia should be offered to all women who desire an external cephalic version.

Indications

Barring contraindications, ECV is recommended by several national organizations for all women with an uncomplicated singleton fetus in breech presentation at term to improve their chances of having a cephalic vaginal birth, [ 15 ] including ACOG, the Royal College of Obstetricians and Gynaecologists, the Dutch Society for Obstetrics and Gynaecology, and Royal Dutch Organization for Midwives. ECV should be available and offered to all women near term with breech presentation who do not have any contraindications to the procedure. [ 3 , 4 , 9 , 10 , 11 , 12 , 13 ]

Breech fetal presentation occurs when the fetal vertex is in the fundus of the uterus with the buttocks, legs, or feet presenting. There are four types of breech presentations:

Frank breech occurs when the fetus’s legs are extended up to its head and the buttocks only are the presenting fetal part

Complete breech occurs when the fetus’s hips and knees are flexed but the feet do not extend below the fetal buttocks

Incomplete breech occurs when one or both hips are extended resulting in one or both feet or knees falling below the breech, so that the knee or foot is the presenting part

Footling breech occurs when one or both legs are extended below the fetus’s buttocks

While the etiology of a breech presentation is not always clear, there are both fetal and maternal factors that can be causative. If there is more relative room for the fetus to move around, then there is a greater chance of malpresentation. Prematurity is the most common factor associated with malpresentation due to a smaller fetus and a relatively larger volume of amniotic fluid. As pregnancy continues and the volume of amniotic fluid diminishes in relationship to fetal size, the fetus is usually found in a presentation that allows the least constriction, that is, a longitudinal orientation with the buttocks and flexed thighs in the uterine fundus.

Similarly, polyhydramnios is associated with a higher rate of malpresentation. High parity is also a risk factor for breech presentation of the fetus due to a more spacious and lax uterine cavity. Conversely, if there is too little room for a fetus to move or the fetus is unable to move adequately, then a fetus in breech presentation may not be able to rotate into a cephalic presentation prior to delivery.

Examples of anatomical restraints that may restrict fetal movement into the vertex presentation include extended fetal legs, placental implantation (cornual or previa), contracted maternal pelvis, mullerian duct anomalies , leiomyomata, tumors, certain fetal anomalies (hydrocephaly, sacrococcygeal teratoma), and multiple gestation. [ 16 , 17 , 18 , 19 , 20 ]

A fetus that has altered mobility, such as with fetal neurologic impairments, myotonic dystrophy, or short umbilical cord, is less likely to move into the vertex presentation. [ 21 , 22 ]

Contraindications

Contraindications to ECV exist either when the procedure may put the fetus in jeopardy or when the procedure is very unlikely to succeed. Clearly, if cesarean delivery is indicated for reasons other than breech presentation, ECV is contraindicated. [ 23 ] Placenta previa or abruptio placentae , nonreassuring fetal status, intrauterine growth restriction in association with abnormal umbilical artery Doppler index, isoimmunization, severe preeclampsia , recent vaginal bleeding, and significant fetal or uterine anomalies are also contraindications for ECV.

Other contraindications to ECV include ruptured membranes, fetus with a hyperextended head, and multiple gestations, although ECV may be considered for a second twin after delivery of the first.

Relative contraindications include maternal obesity, small for gestational age fetus (less than 10%), and oligohydramnios because they make successful ECV less likely. [ 24 ] Previous uterine scar from cesarean delivery or myomectomy may also be a relative contraindication for ECV.

Technical Considerations

Best Practices

We recommend that all ECV attempts be performed on the labor and delivery unit, with an operating room available if an emergency cesarean becomes necessary. In addition, labor and delivery provides easy access to fetal monitoring, anesthesia, and phlebotomy for maternal Rh status and blood count.

Procedure Planning

Prior to the procedure, fetal testing with a nonstress test or biophysical profile should be completed and reassuring fetal status should be documented. A bedside ultrasound should assess fetal position, amniotic fluid level, placenta location, and uterine cavity shape to help determine if the procedure should be performed and the likelihood of success. After the ultrasound assessment and fetal testing, informed consent should be obtained, taking in to account the information gathered from the fetal testing and ultrasound.

Breech presentation is associated with fetal abnormalities and, in and of itself, can be a marker for poor perinatal outcome. The incidence of childhood handicap following breech presentation has been found to be as high as 16% regardless of mode of delivery. It is unknown whether vaginal delivery of the breech fetus or abnormalities innate to the breech fetus are responsible for the perinatal outcome. [ 3 ]

Successful ECV is defined as conversion from malpresentation to cephalic presentation at the time of the procedure. The reported success rate of ECV ranges from 35 to 86%, with a commonly quoted figure of 50%. [ 3 , 9 , 10 , 11 , 12 , 13 ]

Despite the low success rate, women who underwent ECV had a significant reduction in both noncephalic births and cesarean delivery compared to women who did not undergo ECV. [ 3 ] Barring contraindications, both ACOG and the Royal College of Obstetricians and Gynaecologists recommend offering ECV as an intervention for breech presentation at term.

Even with this recommendation, the percentage of women who are appropriate candidates for ECV who are not offered an attempt ranges from 4-33%. [ 9 , 10 ] Moreover, of those who are offered ECV, reported rates of maternal refusal range from 18% to 76%. [ 10 , 11 , 12 , 13 ]

With a 50% chance of successful ECV, 72.3% in multiparous women and 46.1% in nulliparous women, uncertainty about the success of attempted ECV likely explains the hesitancy of providers to offer the maneuver as well as maternal declination of this procedure. [ 25 ] In order to better counsel patients and providers on the likelihood of successful ECV, several factors such as parity, placental location, amniotic fluid index, and type of breech presentation have been studied. [ 26 ]

Factors that predict the outcome of ECV in breech pregnancies at term can be divided into clinical prognosticators, those that can be elicited from a history and physical examination, and ultrasound prognosticators.

Clinical prognosticators predictive of successful ECV include the following: [ 24 ]

Multiparity

Nonengagement of the presenting fetal part into the maternal pelvis

Relaxed uterus

Palpable fetal head

Maternal weight less than 65 kg

All of these prognostic features lend to increased mobility of the fetus and better access to the fetus for the physician performing the procedure.

Ultrasonographic factors associated with successful ECV include the following [ 27 , 28 ] :

Amniotic fluid index greater than 10 cm

Posterior placenta

Lateral fetal spine position (facilitating operator’s ability to flex the fetal head and thereby form a more compact fetal mass)

Complete breech fetal presentation

Kok et al proposed a prediction model that discriminated between women with poor chance of successful ECV (less than 20%) and good chance of success (greater than 60%) in breech pregnancies after 36 weeks gestational age. While this model has yet to be validated externally, it demonstrated that the prognosticators of multiparity, increasing maternal age, increasing estimated fetal weight until 3000 g, lateral placenta location, nonfrank breech presentation, and normal amniotic fluid (amniotic fluid index greater than 10 cm) were significantly associated with successful ECV. [ 26 ]

A prospective study conducted in Germany by Zielbauer et al demonstrated an overall success rate of 22.4% for ECV among 353 patients with a singleton fetus in breech presentation. ECV was performed at 38 weeks of gestation. Factors found to increase the likelihood of success were a later week of gestation, abundant amniotic fluid, fundal and anterior placental location, and an oblique lie. [ 29 ]

Factors associated with reduced success of ECV include the following:

Nulliparity

Firm maternal abdominal muscles

Tense or contracting uterus

Anterior or cornual placenta

Decreased amniotic fluid volume (amniotic fluid index less than 10 cm)

Ruptured membranes

Low birth weight

Presenting fetal part engaged into the maternal pelvis

Maternal obesity

Nonpalpable fetal head

Posteriorly located fetal spine

Fetal abdominal circumference below the fifth percentile

These factors decrease the likelihood of a successful ECV because they either make it more difficult for the physician to manipulate the fetus (maternal obesity and small fetus) or they decrease mobility of the fetus.

Successful ECV is significantly less likely in nulliparous women. This is explained by the increased abdominal wall musculature and uterine tone when compared to parous women. It is hypothesized that increased tone in the uterus and abdominal wall in nulliparous women could predispose to extended fetal legs and therefore frank breech presentation, an independent factor that lessens the chance of successful version. Ferguson et al noted that even when tocolytics were used routinely with attempted ECV, uterine relaxation in nulliparous women was rarely as complete as that achieved in parous women. [ 27 ]

Placental position may alter the intrauterine shape, lessening the space available for the traditional "forward roll" or "backward flip" used to rotate the fetus into cephalic presentation. Thus, cornual placentation is also associated with a lower rate of successful ECV. [ 16 , 17 , 18 , 19 , 20 ]

There are two additional procedural factors that are associated with decreased success rates. Higher levels of pain with ECV attempts are more likely to occur when greater force is applied, which is thought to indicate that the presenting fetal part is engaged and not turning readily. [ 3 ] In addition, ECV is abandoned earlier when pain is reported. [ 27 , 30 ] Similarly, ECV is less successful when multiple attempts are made to turn the fetus. Again, the number of unsuccessful attempts at turning a fetus is frequently related to a fetus being more engaged in the maternal pelvis or other factors that decrease mobility of the fetus. [ 3 ]

ECV after Prior Cesarean Section

Although no large studies have evaluated the safety of ECV following cesarean delivery, several smaller case series have supported its use. [ 31 , 32 , 33 , 34 , 35 , 36 , 37 ] The controversy over ECV after cesarean is twofold. First, it is unknown what effect the abdominal manipulations of ECV have on a uterine scar. Second, although the current ACOG recommendation supports vaginal birth after cesarean, a physiologic risk to uterine integrity similar to ECV, many practitioners remain uncomfortable with this practice. [ 3 ]

In their prospective cohort study and review of the literature, Abenhaim et al found an overall success rate of ECV in women with a previous cesarean to be 50% from their data, and an overall success rate from the pooled literature of 71%. Given rates of success similar to women without a previous cesarean section, they concluded that concern over the success and safety of ECV in women with prior cesarean section is unwarranted and should not deter an attempt at ECV. Adverse outcomes were not addressed in this study. [ 14 ]

Flamm et al reported a 92% success rate among 56 patients with a previous cesarean section who attempted ECV without serious maternal or neonatal complications. [ 32 ] Schachter et al. reported success in all 11 ECV attempts after cesarean section when ritodrine was used to promote uterine relaxation. The only reported abnormality in that study was a fetal heart rate tracing with transient tachycardia in one fetus after the procedure that resolved after 30 minutes. All uterine scars, when examined either at surgery or by postpartum manual uterine exploration, showed no signs of dehiscence. [ 37 ]

In their case report of 38 women, Meeus et al reported a 65.8% success rate and no uterine ruptures in those women with previous cesarean who attempted ECV. There was one episode of vaginal bleeding after ECV, but after elective repeat cesarean, no placental abruption was noted and there were no adverse outcomes to mother or baby. All women who delivered vaginally after successful version (76%) underwent immediate postpartum examination to evaluate the uterine scar and no uterine ruptures were noted, but one uterine scar dehiscence was noted at the time of elective cesarean section performed 24 hrs after failed ECV. The study concluded that, after fetal weight assessment by clinical examination and ultrasonography, clinical examination of the pelvis and well-documented indications for prior cesarean delivery, ECV is acceptable and effective in women with a prior low transverse uterine scar. [ 38 ]

Ultimately, larger randomized trials are needed before definitive conclusions can be made.

Approach Considerations

An algorithm for patient management with external cephalic version is shown in the image below.

During ECV, practitioners place their hands on the maternal abdomen to gently turn the fetus from breech to cephalic presentation.

When the patient has been deemed an appropriate candidate for ECV and she has signed the consent form, a tocolytic agent plus or minus a spinal or epidural anesthesia should been given.

An ultrasound or other means of assessing the fetal heart rate should be immediately available during the entire procedure. It is helpful to put ultrasound gel on the maternal abdomen to allow the practitioner’s hands to slide easily.

When the uterus is relaxed, the breech or feet should be elevated out of the maternal pelvis.

If one practitioner is performing the ECV, one hand is placed on the fetal head and the other is on the fetal buttocks.

If two practitioners are performing the ECV, one controls the fetal head while the other controls the fetal buttocks.

Usually a forward roll is attempted first.

A backward roll can follow if the forward roll is unsuccessful.

The fetal heart rate should be checked every few minutes and all maneuvers halted if the fetal heart rate is not reassuring. If the heart rate is repeatedly abnormal, the procedure should stop. The procedure should also be aborted for maternal discomfort not tolerated by the patient.

Although there are no large studies evaluating the number of ECV attempts, most studies attempt ECV no more than 3 or 4 times. If ECV is unsuccessful after 3 to 4 attempts, the fetus is unlikely to turn and the procedure should end.

After the ECV, the fetus should be monitored until a reassuring tracing is obtained.

Alternative Approaches

Expectant Management

Expectant management is always an alternative to any procedure or treatment. The likelihood of spontaneous conversion to cephalic presentation from breech presentation at term is quoted as 3%. [ 15 ]

In one study, the overall rate of spontaneous cephalic version following a failed ECV attempt was as high as 6.6%, with 2.3% rate in nulliparous women and 12.5% in multiparous women. [ 39 ]

Delivery by Cesarean

Another option is either planned or unscheduled cesarean delivery .

Trial of Labor

Trial of labor of a persistently breech fetus is theoretically an option. However, since the Term Breech Trial [ 7 ] was published supporting cesarean delivery over breech vaginal delivery to minimize perinatal morbidity and mortality, many providers will not offer vaginal delivery of a breech fetus as the standard of care.

In carefully chosen patients such as a multiparous female with a proven pelvis, a term infant, and achievement of complete cervical dilation, trial of labor may be an option as long as the patient is aware of the risks, benefits, and alternatives.

Version During Labor

Although sparse literature exits, ECV after the onset of labor with intact membranes for breech presentation is considered safe. Tocolytics have been used for uterine relaxation during labor to facilitate ECV in two small case studies. [ 32 , 40 ]

Advantages of this strategy include allowing maximum time for fetal growth and development before the intervention, allowing ample opportunity for spontaneous version to cephalic presentation, continuous monitoring of the fetus until delivery, readily available cesarean delivery if needed, and administration of Rho(D) immune globulin may be delayed until fetal blood type is known after delivery.

Potential disadvantages of this approach include a tense uterus, advanced gestational age (and therefore larger fetal size and relatively lower amniotic fluid index), and the possibility that the opportunity for ECV will be lost from rupture of membranes or rapid progression of labor.

Postural Maneuvers

Postural maneuvers to convert a fetus from breech to cephalic presentation are another alternative to ECV. These maneuvers include pelvic elevation either in the hands-and-knees position or supine with a wedge supporting the pelvis. There is no high-quality evidence to support the efficacy of such maneuvers.

A systemic review involving 392 women found that, when compared with no intervention, there was no significant effect of postural maneuvers on the rate of breech births. [ 41 , 42 ] The benefit of these maneuvers is that they can be done by the patient at home with very little risk to the mother or fetus.

Moxibustion and Acupuncture

Moxibustion is a practice in which a Chinese herb is burnt close to an acupuncture point on the skin. For version of the breech fetus, this is acupuncture point bladder 67 (BL67), at the tip of the fifth toe. This procedure is performed 20-60 minutes once or twice a day, either daily or twice weekly for 1-2 weeks. [ 43 ]

Several systemic reviews have supported moxibustion as a safe and effective tool for facilitating version. One study reported a higher rate of successful version in the moxibustion group as compared to observation or postural maneuvers (72.5% vs. 53.2%). [ 43 ] Similarly, a Cochrane review found that moxibustion reduced the need for ECV. [ 44 ]

However, these results are clouded by significant heterogeneity among the trials reviewed, significant patient crossover, lack of sham moxibustion control, and small number of women who pursued moxibustion alone as an intervention for version. Thus at this time, there is insufficient information to recommend for or against the use of moxibustion for version of the breech fetus. [ 43 , 44 , 45 ]

Patient Education & Consent

Informed consent should discuss the reason for the ECV, how the procedure will be done, the medications that will be used and their potential side effects, the benefits and risks of the procedure, the likelihood of success (taking in to account the results of the fetal testing and bedside ultrasound), and the management plan if the procedure is successful or unsuccessful. Only when the patient understands everything that was discussed and agrees to the procedure should the procedure commence.

Pre-Procedure Planning

The appropriate timing of performing ECV is currently under debate. Some posit that ECV may be more successful prior to 36 weeks gestation as the average fetus is smaller, not yet engaged into the maternal pelvis, and has proportionately more amniotic fluid. Others argue that patients who have completed 36 weeks of gestation are preferred candidates for ECV given high rates of spontaneous version (25% of fetuses are breech at 28 weeks while only 3-4% are breech at term), high risk of spontaneous reversion after successful version of a preterm fetus (due to smaller fetus, lack of engagement, and greater amniotic fluid index), and the improved outcome of emergency delivery of a term infant should complications arise during attempted version. [ 46 , 47 , 48 , 49 , 50 ]

The Early External Cephalic Version Trial, a prospective trial, randomized patients with a singleton breech fetus to ECV at 34-36 weeks of gestation (early ECV group) or to ECV at 37-38 weeks of gestation (delayed ECV group). [ 15 ] The practitioners were permitted by the protocol to repeat an ECV if the fetus reverted to a noncephalic presentation prior to delivery. While the early ECV group had a lower rate of malpresentation at delivery than the late ECV group (57% vs 66%), the result was not statistically significant. On the other hand, more fetuses reverted to breech presentation in the early ECV group than the delayed ECV group (12% vs 6%). The cesarean section rate was not statistically different between the two groups, with 64.7% of patients in the early ECV group and 71.6% of patients in the delayed ECV group requiring a cesarean section. As there were only 233 women included in the study, comparing complication rates between the groups was not possible.

Similarly, a randomized trial by Kasule et al studying ECV attempts between 33 and 36 weeks gestation found no significant difference between the cesarean delivery rates of patients with an ECV attempt and controls who did not undergo ECV. [ 51 ] Furthermore, in a Cochrane review of the literature, Hutton et al found that compared with no ECV attempt, ECV attempted before term reduces noncephalic births. [ 52 ]

Hutton et al reinvestigated early versus delayed attempt at ECV in their Early External Cephalic Version 2 Trial in 2011. Although their trial did not find higher risks of adverse outcomes for infants in the early attempt group, their results suggested that early ECV attempt may be associated with higher risk of preterm birth. This could be explained by preterm labor brought on by manipulation of the uterus. Overall, they concluded that ECV initiated at 34–35 weeks of gestation compared with 37 or more weeks of gestation increases the probability of vertex presentation at birth, but does not significantly reduce the rate of caesarean delivery and may increase the rate of preterm birth. [ 53 ]

While it seems tempting to perform an early ECV due to the increased rate of success, there are two major disadvantages. One, since the fetus is more likely to spontaneously revert to breech presentation after an early ECV, the patient may have to undergo additional ECV attempts, incurring the risks again of the procedure and medications as well as the discomfort. Two, if complications arise during the procedure between 34-36 weeks that necessitate an emergent delivery, the fetus is at significantly higher risk for having complications related to prematurity than a fetus born after 36-37 weeks of gestation.

In addition, the end result which the physician is trying to prevent, a cesarean section, is identical whether an ECV is performed prior to 36 weeks or after 36 weeks of gestation. Thus, we recommend a first attempt at ECV after 36 weeks gestation, as it provides a high rate of success (approximately 58%) with a significantly lower rate of complications due to prematurity should the fetus have to be delivered at the time of the procedure. If unsuccessful, it is reasonable to attempt retrial of version using tocolytics and/or regional anesthesia during a repeat attempt.

Further trials are needed to confirm this finding and to rule out increased rates of preterm birth, reversion to breech, or other adverse perinatal outcomes. ACOG guidelines issued in 2020 recommend that ECV should be performed starting at 37+0 weeks, in order to reduce the likelihood of reversion and to increase the rate of spontaneous version. [ 54 ]

Patient Preparation

Controversy exists in the literature over whether or not regional anesthesia during an ECV can improve the success rate, resulting in a decrease in cesarean section rate, without increasing the complication rate. Proponents of regional anesthesia claim that patients are more comfortable and the abdominal wall is more relaxed, leading to higher success rates. [ 55 ] Others believe that regional anesthesia allows the practitioners to use excessive force, thus increasing the risk of placental abruption, uterine rupture, and fetal compromise or death. General anesthesia has been completely abandoned due to a fetal mortality rate of 1%. [ 56 ]

There are five studies that compare the use of spinal anesthesia to no anesthesia for ECV. All of the studies used a tocolytic agent for all patients in both the control and intervention groups, and all of the studies performed ECV at or beyond 36 weeks of gestation. In 102 patients, 50 who received spinal anesthesia and 52 without anesthesia, Dugoff et al found no difference between the two groups. There was an ECV success rate of 44% in the spinal group and 42% in the control group. The only adverse event was transient fetal tachycardia in 17 patients. [ 57 ] Similarly, studies by Delise and Holland did not find a statistically significant difference in rate of successful ECV when using spinal anesthesia, 41.4% versus 30.4% and 52.9% vs 52.6%, respectively. [ 58 , 59 ]

There were two trials performed by Weiniger, one evaluating the use of spinal anesthesia for ECV in nulliparous women and the other evaluating the use in multiparous women. Both were randomized control trials. In nulliparous women, the ECV success rate was 66.7% in the spinal group and 32.4% in the control group. [ 60 ] This revealed a fourfold higher odds of success if spinal anesthesia was used. In 15 patients in the control group who had an unsuccessful ECVs due to pain, subsequent spinal anesthesia was offered and 11 of those patients went on to have a successful ECV. Of note, the study began using ritodrine as a tocolytic and concluded using nifedipine and found no difference in ECV success rates between these two tocolytic agents.

In Weiniger’s trial evaluating spinal anesthesia for ECV in multiparous women, there were 64 patients, of whom 31 received spinal anesthesia and 33 patients had no anesthesia. The success rate was 87.1% with spinal anesthesia and 57.5% in the control group. [ 61 ] In both the nulliparous and multiparous trials, there were no adverse fetal outcomes. There was a statistically significant difference in maternal hypotension due to spinal anesthesia, but again this did not result in any adverse fetal outcomes or increase in cesarean section rate due to nonreassuring fetal status. There were two nulliparous patients in the spinal anesthesia group that developed a spinal headache. One received a blood patch. Thus, there still remains conflicting evidence as to whether or not spinal anesthesia increases the rate of successful ECV. It does not, however, seem to increase the risk of adverse fetal outcomes.

A trial by Cherayil et al offered a spinal or epidural to women who had an unsuccessful ECV attempt without anesthesia. Of those who agreed to participate in the trial, 4 of 5 nulliparous women had a successful second ECV attempt using spinal anesthesia, and 1 of 1 had a second ECV attempt using epidural anesthesia. In multiparous women, 100% had a successful second ECV attempt using a spinal or epidural anesthesia. [ 62 ] Although the numbers are small, it seems that, from this trial and the trial by Weiniger et al, utilization of regional anesthesia following a failed ECV attempt without anesthesia significantly improves success rates.

One trial evaluated the use of a combined spinal and epidural for ECV. Sullivan et al performed a randomized control trial with 95 patients, 47 patients who were randomized to the combined spinal and epidural group and 48 patients who received intravenous fentanyl. There was no significant difference in ECV success rate between the two groups, with 47% in the combined spinal and epidural group versus 31% in the fentanyl group. [ 63 ]

At least five trials compare epidural anesthesia in addition to a tocolytic for ECV at or beyond 36 weeks of gestation. A retrospective study by Carlan et al found that the overall success rate of ECV was 59% with an epidural and 24% without an epidural. [ 64 ] In the epidural group, only 46% of the patients had a cesarean section, whereas 89% of the patients without an epidural had a cesarean section. There was no significant difference between the two groups in the rates of bradycardia, placental abruption, Apgar scores, or umbilical artery pH.

Schorr et al performed a prospective randomized control trial comparing 35 women who had an epidural for ECV to 34 women who had no anesthesia for ECV. Successful ECV was completed in 69% of the women with an epidural but only 32% of those without an epidural. [ 65 ] Schorr et al found that 34% of the patient in the epidural group underwent a cesarean section compared to 79% in the control group. There was no difference in fetal or maternal adverse outcomes between the two groups.

Mancuso et al also performed a larger prospective randomized control trial evaluating epidural anesthesia versus no anesthesia for ECV at term. There were 54 patients in each group and neither had any maternal or fetal adverse outcomes. The success rate for ECV with an epidural was 59% versus 33% without an epidural. Fifty-four percent of the epidural group had a vaginal delivery versus 24% in the control group. [ 66 ]

Yoshida et al looked at their group’s ECV success rate before they began offering regional anesthesia to the success rate after regional anesthesia was offered. Their overall ECV success rates rose from 56% to 79% after regional anesthesia was offered. The cesarean section rate dropped from 50% to 33% in the term breech population. [ 67 ]

Two meta-analyses have been able to put all of this information together since none of these trials have large sample sizes. MacArthur et al included all trials that used any type of general or regional anesthesia for ECV. The primary outcome was immediate success of ECV attempt. Four studies met their criteria with a total of 480 patients, of whom 238 received central axial anesthesia and 242 did not receive any anesthesia. The anesthesia group had a 50% success rate while the control group had a 34% ECV success rate. Thus, when using regional anesthesia, a woman is 1.5 times more likely to have a successful ECV. [ 68 ]

Bolaji et al [ 69 ] found similar results in their meta-analysis that included seven randomized control trials. In 681 women, 339 women received either epidural or spinal anesthesia, 47 women received intravenous fentanyl, and 295 women had no anesthetic. The ECV success rate with regional anesthesia was 51.3% in contrast to 34.9% in those without anesthesia. More women had success with ECV with regional anesthesia with a corresponding reduction in the cesarean section rate.

The meta-analysis by Bolaji et al also found that ECV was 1.5 times more likely to succeed in the regional anesthesia group compared to the control group. In addition, Bolaji et al found a 30% reduction in cost using epidural anesthesia due to the decrease in cesarean section and resultant complication rate. [ 69 ]

A systematic review of randomized controlled trials found regional anesthesia (spinal and epidural) was associated with a higher external cephalic version success rate compared with intravenous or no analgesia; 59.7% compared with 37.6%, respectively. [ 70 ]

Thus, it seems that regional anesthesia increases the rate of successful ECV, with a resultant decrease in cesarean rate without increasing maternal or fetal morbidity and mortality. Therefore, we recommend that regional anesthesia be offered to all women at term who choose to have an ECV. Larger randomized controlled trials are needed before this should become a standard practice.

A study by Chalifoux et al reported that higher doses of intrathecal bupivacaine (≥ 2.5 mg) do not lead to an increase in procedural success. [ 71 ]

Tocolytic Use

While the use of tocolytics during ECV is common practice, their impact on success rates is questionable. Historically, numerous tocolytic agents were used to relax the uterus during ECV. Ritodrine, salbutamol, and nitroglycerin were all used without increasing success rates over the control group. [ 72 , 73 , 74 , 75 ] Betamimetic tocolytics were then used to relax the uterus during an ECV with good success. Fernandez et al found an ECV success rate of 52% when 0.25 mg of terbutaline was given subcutaneously prior to the procedure compared to a 27% success rate in those given a placebo. [ 76 ] Thus, terbutaline became the tocolytic of choice for ECV.

As nifedipine gained popularity as a tocolytic for preterm labor due to its efficacy and favorable side effect profile, many researchers looked at nifedipine as an alternative to terbutaline for tocolysis during ECV. Two different randomized trials revealed increased success rates when using terbutaline over nifedipine. [ 77 , 78 ] A double-blind randomized trial by Collaris and Tan compared 10 mg of oral nifedipine plus subcutaneous saline to an oral placebo plus subcutaneous terbutaline. The terbutaline group had a high ECV success rate compared to the nifedipine group (52% versus 34%). In addition, there was a decrease cesarean section rate in the terbutaline group compared to the nifedipine group (56.5% versus 77.3%). [ 79 ]

Because there is an increase in successful ECV while using terbutaline with a significant side effect profile limited to transient maternal tachycardia, we recommend that ECV be performed approximately 5-20 minutes after subcutaneous administration of terbutaline.

Complications

Despite the universal recommendation that women be offered ECV for breech presentation, many practitioners have been hesitant to routinely offer this service, not only because of questions of efficacy but also because of fears about the safety of this procedure.

In a series of 805 consecutive ECV attempts in nulliparous women at or beyond 36 weeks gestation and multiparous women at or beyond 37 weeks, the overall perinatal mortality was only 0.1%—a result not clearly associated with the procedure itself. The rate of suspected placental abruption was 0.1%. [ 15 ]

In the same study, emergency cesarean section was performed for 4 patients at the time of the attempted version (0.5%). Two had abnormal fetal heart rate tracings for more than 20 minutes after the procedure; one of these neonates was subsequently diagnosed with trisomy 21. A third woman experienced vaginal bleeding with a normal fetal heart rate tracing after a failed ECV. At the time of cesarean section, there was no definitive evidence of placental abruption. The fourth cesarean section was due to rupture of membranes during a failed ECV attempt. All three congenitally normal babies were born with normal Apgar scores and cord pH levels. Uterine rupture and fetal trauma were not experienced. The authors concluded that women should be counseled that ECV is extremely safe but has a 0.5% risk of emergency cesarean section at the time of the procedure. [ 15 ]

In another study by Collaris and Oei, the overall perinatal mortality was 0.16%. The most frequently reported complications were transient fetal heart rate changes (5.7%), persistent fetal heart rate changes (0.37%), and vaginal bleeding (0.4%). Fetomaternal hemorrhage occurred 3.7% of the time. The reported incidence of placental abruption was 0.12% and the rate of emergency cesarean was 0.43%. [ 80 ] There was also a 3% risk of spontaneous reversion to breech presentation after successful ECV at or beyond 36 weeks gestation. [ 15 ]

We recommend counseling patients of a 0.5% risk of emergency cesarean section, perinatal mortality of < 0.1%, persistent fetal heart rate changes of 0.37%, spontaneous reversion to breech of 3%, and placental abruption of 0.1%. [ 15 , 80 , 38 ] The overall failure rate of ECV is approximately 50%, with a success rate of 72.3% in multiparous women and 46.1% in nulliparous women. [ 25 ]

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• Algorithm for patient management of external cephalic version.

Contributor Information and Disclosures

Stacey Ehrenberg-Buchner, MD Fellow in Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System Stacey Ehrenberg-Buchner, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , Society for Maternal-Fetal Medicine Disclosure: Nothing to disclose.

Jamie M Bishop, MD Resident Physician, Department of Obstetrics and Gynecology, University of Michigan Medical School Jamie M Bishop, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Medical Association , American Medical Women's Association Disclosure: Nothing to disclose.

Cosmas JM Van De Ven, MD J Robert Willson Collegiate Professor of Obstetrics, Department of Obstetrics and Gynecology, University of Michigan Medical School; Director, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Hospitals and Health Centers Cosmas JM Van De Ven, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , North American Society for the Study of Hypertension in Pregnancy , Norman F Miller Gynecologic Society , International Society for the Study of Hypertension in Pregnancy Disclosure: Nothing to disclose.

Carl V Smith, MD The Distinguished Chris J and Marie A Olson Chair of Obstetrics and Gynecology, Professor, Department of Obstetrics and Gynecology, Senior Associate Dean for Clinical Affairs, University of Nebraska Medical Center Carl V Smith, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists , American Institute of Ultrasound in Medicine , Association of Professors of Gynecology and Obstetrics , Central Association of Obstetricians and Gynecologists , Society for Maternal-Fetal Medicine , Council of University Chairs of Obstetrics and Gynecology , Nebraska Medical Association Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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