cephalic presentation at 11 weeks

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• Fetal presentation before birth

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

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

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

Head down, face down

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

Head down, face up

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

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

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

Frank breech

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

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

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

Complete and incomplete breech

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

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

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

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

Getty Images

Why Is the Cephalic Position Best?

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

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

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

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

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

Cephalic Posterior

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

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

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

There are three different types of breech fetal positioning:

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

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

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

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

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

Likelihood of a Breech Baby

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

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

Transverse Lie

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

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

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

Determining Fetal Position

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

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

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

Turning a Fetus So They Are in Cephalic Position

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

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

External Cephalic Version (ECV)

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

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

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

Natural Methods For Turning a Fetus

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

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

A Word From Verywell

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

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

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

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

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

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

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

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

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

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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

Call Pregnancy, Birth and Baby to speak to a maternal child health nurse on 1800 882 436 or video call . Available 7am to midnight (AET), 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

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. Sometimes it’s possible to move the baby, but a caesarean maybe 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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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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Management of Labour and Delivery – Questions

Rekha Wuntakal, Madhavi Kalidindi, Tony Hollingworth in Get Through , 2014

For each clinical scenario below, choose the single most appropriate stage of labour from the above list of options. Each option may be used once, more than once or not at all. A 30-year-old para 3 woman was admitted at term with regular uterine activity at 5 cm cervical dilatation and 4 hours later she delivered a female neonate with APGARs 9, 10, 10 at 1, 5 and 10 minutes. Syntometrine injection was given immediately after delivery and placenta with membranes was delivered completely 20 minutes after the delivery of the baby by continuous cord traction.A 23-year-old para 3 woman was admitted after spontaneous rupture of membranes at 39 weeks’ gestation. She is contracting 4 in 10 minutes and pushing involuntarily. On vaginal examination the cervix was fully dilated, vertex was 2 cm below the spines in direct occipito-anterior position with minimal caput and moulding.A 30-year-old nulliparous woman was admitted at term with uterine contractions once in every 5 minutes. On examination, the fetus is in cephalic presentation with two fifths palpable per abdomen. The cervix is central, soft, fully effaced and 2 cm dilated with intact membranes.

Biometric Measurements and Normal Growth Parameters in a Child

Nirmal Raj Gopinathan in Clinical Orthopedic Examination of a Child , 2021

In cephalic presentation, the intra-uterine fetal position is of universal flexion, which is carried by the child to the immediate post-partum period. The hips and knees are flexed. The lower legs are internally rotated. The feet are further internally rotated with respect to the lower legs. At times there is an external rotational contracture of the hip that tends to mask the true femoral rotational profile. The anatomy of the lower limbs changes significantly as the child grows. This is primarily in response to the development of motor abilities and the ability of the child to crawl, cruise, stand, walk, and finally run. These changes are seen right from the hip joints, the femoral neck, knees, and tibia to the feet.

DRCOG MCQs for Circuit A Questions

Una F. Coales in DRCOG: Practice MCQs and OSCEs: How to Pass First Time three Complete MCQ Practice Exams (180 MCQs) Three Complete OSCE Practice Papers (60 Questions) Detailed Answers and Tips , 2020

External cephalic version: Used to convert a breech presentation to cephalic presentation.Not contraindicated if there is a prior Caesarean section scar.Can cause premature labour.Contraindicated in hypertension.Can be performed after 33 weeks' gestation in a rhesus-negative mother.

Complex maternal congenital anomalies – a rare presentation and delivery through a supra-umbilical abdominal incision

Published in Journal of Obstetrics and Gynaecology , 2018

Samantha Bonner, Yara Mohammed

She had a spontaneous conception and booked at 9 weeks of gestation under consultant-led care. A scan confirmed the pregnancy was in the right uterus. She had no other significant medical history but did suffer from recurrent urinary tract infections and hence was on low-dose antibiotic prophylaxis. There was no sonographic evidence of hydronephrosis. Her body mass index (BMI) was 18 at the time of booking. Combined screening was low risk and she had a normal 20 week anomaly scan. She had serial growth scans which demonstrated a normal growth trajectory on a customised chart. The baby was consistently a cephalic presentation. She had multidisciplinary antenatal care, including specialist urologists, general surgeons, obstetricians and anaesthetists. An antenatal MRI scan had shown extensive adhesions over the lower segment of the uterus. She was extensively counselled regarding the mode of delivery and this was scheduled at 37 weeks of gestation to avoid the potential of spontaneous labour and an emergency Caesarean section.

Utilization of epidural volume extension technique for external cephalic version

Published in Baylor University Medical Center Proceedings , 2021

Hanna Hussey, James Damron, Mark F. Powell, Michelle Tubinis

Repeat ultrasound demonstrated breech presentation, normal amniotic fluid volume, and fetal head toward the maternal left abdomen. After 0.25 mg of intramuscular terbutaline injection, a forward roll was initiated by applying pressure from behind the fetal head toward the maternal left. Continuous progress was made and bedside ultrasound showed cephalic presentation. Immediately after successful ECV, the fetal heart rate was 70 beats/min but returned to baseline with conservative measures. Motor blockade regressed after approximately 1.5 hours. After 4 hours of fetal heart rate monitoring and tocometry, the patient was deemed stable for discharge. Follow-up discussion with the patient via phone call on postprocedure day 1 confirmed that she was not experiencing pain or concerning symptoms for neuraxial complications. She returned to the labor and delivery unit at 40 weeks’ gestation for elective induction of labor and had a successful vaginal delivery.

Antenatal scoring system in predicting the success of planned vaginal birth following one previous caesarean section

Aida Kalok, Shahril A. Zabil, Muhammad Abdul Jamil, Pei Shan Lim, Mohamad Nasir Shafiee, Nirmala Kampan, Shamsul Azhar Shah, Nor Azlin Mohamed Ismail

The inclusion criteria were pregnant women at 36 weeks of gestation or more with singleton foetus in cephalic presentation, who agreed for trial of vaginal delivery after one lower segment caesarean section. We excluded women with contraindication for vaginal birth, or who declined trial of vaginal delivery from this study. Previous antenatal history was noted and recorded during the 36-week assessment, including year and indication for previous caesarean section. Recurrent indications involved were cephalopelvic disproportion and obstructed labour. While non-recurrent indications were foetal distress and malpresentation. Past operative notes were checked for any operative complications such as extended uterine tear, organ injury and post-partum haemorrhage. Information regarding current pregnancy including pre-existing medical disorder was recorded. Estimated foetal weight based on ultrasound scan at 36 weeks of gestation was used in this study.

Related Knowledge Centers

• Breech Birth
• Occipital Bone
• Pelvic Cavity
• Presentation
• Shoulder Presentation

Current Research

• Clinical Trials (United States)
• Clinical Trials (Europe)
• Clinical Trials (Australia/New Zealand)
• Clinical Trials (India)

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• Vishal's account
• Prenatal Care

Fetal Cephalic Presentation During Pregnancy

What Is Cephalic Position?

Types of cephalic position, benefits of cephalic presentation, risks of cephalic position, what are some other positions and their associated risks, when does a foetus get into the cephalic position, how do you know if baby is in cephalic position, how to turn a breech baby into cephalic position, natural ways to turn a baby into cephalic position.

If your baby is moving around in the womb, it’s a good sign as it tells you that your baby is developing just fine. A baby starts moving around in the belly at around 14 weeks. And their first movements are usually called ‘ quickening’ or ‘fluttering’.

A baby can settle into many different positions throughout the pregnancy, and it’s alright. But it is only when you have reached your third and final trimester that the position of your baby in your womb will matter the most. The position that your baby takes at the end of the gestation period will most likely be how your baby will make its appearance in the world. Out of all the different positions that your baby can settle into, the cephalic position at 36 weeks is considered the best position. Read on to learn more about fetal cephalic presentation.

When it comes to cephalic presentation meaning, the following can be considered. A baby is in the cephalic position when he is in a head-down position. This is the best position for them to come out in. In case of a ‘cephalic presentation’, the chances of a smooth delivery are higher. This position is where your baby’s head has positioned itself close to the birth canal, and the feet and bottom are up. This is the best position for your baby to be in for safe and healthy delivery.

Your doctor will begin to keep an eye on the position of your baby at around 34 weeks to 36 weeks . The closer you get to your due date, the more important it is that your baby takes the cephalic position. If your baby is not in this position, your doctor will try gentle nudges to get your baby in the right position.

Though it is pretty straightforward, the cephalic position actually has two types, which are explained below:

1. Cephalic Occiput Anterior

Most babies settle in this position. Out of all the babies who settle in the cephalic position, 95% of them will settle this way. This is when a baby is in the head-down position but is facing the mother’s back. This is the preferred position as the baby is able to slide out more easily than in any other position.

2. Cephalic Occiput Posterior

In this position, the baby is in the head-down position but the baby’s face is turned towards the mother’s belly. This type of cephalic presentation is not the best position for delivery as the baby’s head could get stuck owing to its wide position. Almost 5% of the babies in cephalic presentation settle into this position. Babies who come out in this position are said to come out ‘sunny side up’.

Cephalic presentation, where the baby’s head is positioned down towards the birth canal, is the most common and optimal fetal presentation for childbirth. This positioning facilitates a smoother delivery process for both the mother and the baby. Here are several benefits associated with cephalic presentation:

1. Reduced risk of complications

Cephalic presentation decreases the likelihood of complications during labor and delivery , such as umbilical cord prolapse or shoulder dystocia, which can occur with other presentations.

2. Easier vaginal delivery

With the baby’s head positioned first, vaginal delivery is generally easier and less complicated compared to other presentations, resulting in a smoother labor process for the mother.

3. Lower risk of birth injuries

Cephalic presentation reduces the risk of birth injuries to the baby, such as head trauma or brachial plexus injuries, which may occur with other presentations, particularly breech or transverse positions.

4. Faster progression of labor

Babies in cephalic presentation often help to stimulate labor progression more effectively through their positioning, potentially shortening the duration of labor and reducing the need for medical interventions.

5. Better fetal oxygenation

Cephalic presentation typically allows for optimal positioning of the baby’s head, which facilitates adequate blood flow and oxygenation, contributing to the baby’s well-being during labor and delivery.

Factors such as the cephalic posterior position of the baby and a narrow maternal pelvis can increase the likelihood of complications during childbirth. Occasionally, infants in the cephalic presentation may exhibit a backward tilt of their heads, potentially leading to preterm delivery in rare instances.

In addition to cephalic presentation, there are several other fetal positions that can occur during pregnancy and childbirth, each with its own associated risks. These positions can impact the delivery process and may require different management strategies. Here are two common fetal positions and their associated risks:

1. Breech Presentation

• Babies in breech presentation, where the buttocks or feet are positioned to enter the birth canal first, are at higher risk of birth injuries such as hip dysplasia or brachial plexus injuries.
• Breech presentation can lead to complications during labor and delivery, including umbilical cord prolapse, entrapment of the head, or difficulty delivering the shoulders, necessitating interventions such as cesarean section.

2. Transverse Lie Presentation

• Transverse lie , where the baby is positioned sideways across the uterus, often leads to prolonged labor and increases the likelihood of cesarean section due to difficulties in the baby’s descent through the birth canal.
• The transverse position of the baby may result in compression of the umbilical cord during labor, leading to decreased oxygen supply and potential fetal distress. This situation requires careful monitoring and intervention to ensure the baby’s well-being.

When a foetus is moving into the cephalic position, it is known as ‘head engagement’. The baby stars getting into this position in the third trimester, between the 32nd and the 36th weeks, to be precise. When the head engagement begins, the foetus starts moving down into the pelvic canal. At this stage, very little of the baby is felt in the abdomen, but more is felt moving downward into the pelvic canal in preparation for birth.

You may think that in order to find out if your baby has a cephalic presentation, an ultrasound is your only option. This is not always the case. You can actually find out the position of your baby just by touching and feeling their movements.

By rubbing your hand on your belly, you might be able to feel their position. If your baby is in the cephalic position, you might feel their kicks in the upper stomach. Whereas, if the baby is in the breech position, you might feel their kicks in the lower stomach.

Even in the cephalic position, it may be possible to tell if your baby is in the anterior position or in the posterior position. When your baby is in the anterior position, they may be facing your back. You may be able to feel your baby move underneath your ribs. It is likely that your belly button will also pop out.

When your baby is in the posterior position, you will usually feel your baby start to kick you in your stomach. When your baby has its back pressed up against your back, your stomach may not look rounded out, but flat instead.

Mothers whose placentas have attached in the front, something known as anterior placenta , you may not be able to feel the movements of your baby as well as you might like to.

Breech babies can make things complicated. Both the mother and the baby will face some problems. A breech baby is positioned head-up and bottom down. In order to deliver the baby, the birth canal needs to open a lot wider than it has to in the cephalic position. Besides this, your baby can get an arm or leg entangled while coming out.

If your baby is in the breech position, there are some things that you can do to encourage the baby to get into the cephalic position. There are a few exercises that could help such as pelvic tilts , swimming , spending a bit of time upside down, and belly dancing are a few ways you can try yourself to get your baby into the head-down position .

If this is not working either, your doctor will try an ECV (External Cephalic Version) . Here, your doctor will be hands-on, applying some gentle, but firm pressure to your tummy. In order to reach a cephalic position, the baby will need to be rolled into a bottom’s up position. This technique is successful around 50% of the time. When this happens, you will be able to have a normal vaginal delivery.

Though it sounds simple enough to get the fetal presentation into cephalic, there are some risks involved with ECV. If your doctor notices your baby’s heart rate starts to become problematic, the doctor will stop the procedure right away.

Encouraging a baby to move into the cephalic position, where the head is down towards the birth canal, is often desirable for smoother labor and delivery. While medical interventions may be necessary in some cases, there are natural methods that pregnant individuals can try to help facilitate this positioning. Here are several techniques that may help turn a baby into the cephalic position:

1. Optimal Maternal Positioning

Maintaining positions such as kneeling, hands and knees, or pelvic tilts may encourage the baby to move into the cephalic position by utilizing gravity and reducing pressure on the pelvis.

2. Spinning Babies Techniques

Specific exercises and positions recommended by the Spinning Babies organization, such as Forward-Leaning Inversion or the Sidelying Release, aim to promote optimal fetal positioning and may help encourage the baby to turn cephalic.

3. Chiropractic Care or Acupuncture

Some individuals find that chiropractic adjustments or acupuncture sessions with qualified practitioners can help address pelvic misalignment or relax tight muscles, potentially creating more space for the baby to maneuver into the cephalic position.

4. Prenatal Yoga and Swimming

Engaging in gentle exercises like prenatal yoga or swimming may help promote relaxation, reduce stress on the uterine ligaments, and encourage the baby to move into the cephalic position naturally. These activities also support overall physical and mental well-being during pregnancy.

1. What factors influence whether my baby will be in cephalic presentation?

Several factors can influence your baby’s position during pregnancy, including the shape and size of your uterus, the strength of your abdominal muscles, the amount of amniotic fluid, and the position of the placenta . Additionally, your baby’s own movements and preferences play a role.

2. Is it necessary for my baby to be in cephalic presentation for a vaginal delivery?

While cephalic presentation is considered the optimal position for vaginal delivery, some babies born in non-cephalic presentations can still be safely delivered vaginally with the guidance of a skilled healthcare provider. However, certain non-cephalic presentations may increase the likelihood of needing a cesarean section.

3. What can I do to encourage my baby to stay in the cephalic presentation?

Maintaining good posture, avoiding positions that encourage the baby to settle into a breech or transverse lie, staying active with gentle exercises, and avoiding excessive reclining can all help encourage your baby to remain in the cephalic presentation. Additionally, discussing any concerns with your healthcare provider and following their recommendations can be beneficial.

This was all about fetus with cephalic presentation. Most babies get into the cephalic position on their own. This is the most ideal situation as there will be little to no complications during normal vaginal labour. There are different cephalic positions, but these should not cause a lot of issues. If your baby is in any position other than cephalic in pregnancy, you may need C-Section . Keep yourself updated on the smallest of progress during your pregnancy so that you are aware of everything that is going on. Go for regular check-ups as your doctor will be able to help you if a complication arises during acephalic presentation at 20, 28 and 30 weeks.

References/Resources:

1. Glezerman. M; Planned vaginal breech delivery: current status and the need to reconsider (Expert Review of Obstetrics & Gynecology); Taylor & Francis Online; https://www.tandfonline.com/doi/full/10.1586/eog.12.2 ; January 2014

2. Feeling your baby move during pregnancy; UT Southwestern Medical Center; https://utswmed.org/medblog/fetal-movements/

3. Fetal presentation before birth; Mayo Clinic; https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/fetal-positions/art-20546850

4. Fetal Positions; Cleveland Clinic; https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth

5. FAQs: If Your Baby Is Breech; American College of Obstetricians and Gynecologists; https://www.acog.org/womens-health/faqs/if-your-baby-is-breech

6. Roecker. C; Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios (Journal of Chiropractic Medicine); Science Direct; https://www.sciencedirect.com/science/article/abs/pii/S1556370713000588 ; June 2013

7. Presentation and position of baby through pregnancy and at birth; Pregnancy, Birth & Baby; https://www.pregnancybirthbaby.org.au/presentation-and-position-of-baby-through-pregnancy-and-at-birth

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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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Sullivan JT, Grobman WA, Bauchat JR, Scavone BM, Grouper S, McCarthy RJ, et al. A randomized controlled trial of the effect of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation. Int J Obstetric Anesthesia . 2009. 18:328-334.

Carlan SJ, Dent JM, Huckaby T, Whittington EC, Shaefer D. The effect of epidural anesthesia on safety and success of external cephalic version at term. Anesth Analg . 1994 Sep. 79(3):525-8. [QxMD MEDLINE Link] .

Schorr SJ, Speights SE, Ross EL, Bofill JA, Rust OA, Norman PF. A randomized trial of epidural anesthesia to improve external cephalic version success. Am J Obstet Gynecol . 1997 Nov. 177(5):1133-7. [QxMD MEDLINE Link] .

Mancuso KM, Yancey MK, Murphy JA, Markenson GR. Epidural analgesia for cephalic version: a randomized trial. Obstet Gynecol . 2000 May. 95(5):648-51. [QxMD MEDLINE Link] .

Yoshida M, Matsuda H, Kawakami Y, et al. Effectiveness of epidural anesthesia for external cephalic version (ECV). J Perinatol . 2010 Sep. 30(9):580-3. [QxMD MEDLINE Link] .

Macarthur AJ, Gagnon S, Tureanu LM, Downey KN. Anesthesia facilitation of external cephalic version: a meta-analysis. Am J Obstet Gynecol . 2004 Oct. 191(4):1219-24. [QxMD MEDLINE Link] .

Bolaji I, Alabi-Isama L. Central neuraxial blockade-assisted external cephalic version in reducing caesarean section rate: systematic review and meta-analysis. Obstet Gynecol Int . 2009. 718981. [QxMD MEDLINE Link] . [Full Text] .

Goetzinger KR, Harper LM, Tuuli MG, Macones GA, Colditz GA. Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol . 2011 Nov. 118(5):1137-44. [QxMD MEDLINE Link] . [Full Text] .

Chalifoux LA, Bauchat JR, Higgins N, Toledo P, Peralta FM, Farrer J, et al. Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial. Anesthesiology . 2017 Oct. 127 (4):625-632. [QxMD MEDLINE Link] .

Robertson AW, Kopelman JN, Read JA, Duff P, Magelssen DJ, Dashow EE. External cephalic version at term: is a tocolytic necessary?. Obstet Gynecol . 1987 Dec. 70(6):896-9. [QxMD MEDLINE Link] .

Tan GW, Jen SW, Tan SL, Salmon YM. A prospective randomised controlled trial of external cephalic version comparing two methods of uterine tocolysis with a non-tocolysis group. Singapore Med J . 1989 Apr. 30(2):155-8. [QxMD MEDLINE Link] .

Yanny H, Johanson R, Balwin KJ, Lucking L, Fitzpatrick R, Jones P. Double-blind randomised controlled trial of glyceryl trinitrate spray for external cephalic version. BJOG . 2000 Apr. 107(4):562-4. [QxMD MEDLINE Link] .

Bujold E, Marquette GP, Ferreira E, Gauthier RJ, Boucher M. Sublingual nitroglycerin versus intravenous ritodrine as tocolytic for external cephalic version: a double-blinded randomized trial. Am J Obstet Gynecol . 2003 Jun. 188(6):1454-7; discussion 1457-9. [QxMD MEDLINE Link] .

Fernandez CO, Bloom SL, Smulian JC, Ananth CV, Wendel GD Jr. A randomized placebo-controlled evaluation of terbutaline for external cephalic version. Obstet Gynecol . 1997 Nov. 90(5):775-9. [QxMD MEDLINE Link] .

El-Sayed YY, Pullen K, Riley ET, Lyell D, Druzin ML, Cohen SE. Randomized comparison of intravenous nitroglycerin and subcutaneous terbutaline for external cephalic version under tocolysis. Am J Obstet Gynecol . 2004 Dec. 191(6):2051-5. [QxMD MEDLINE Link] .

Mohamed Ismail NA, Ibrahim M, Mohd Naim N, Mahdy ZA, Jamil MA, Mohd Razi ZR. Nifedipine versus terbutaline for tocolysis in external cephalic version. Int J Gynaecol Obstet . 2008 Sep. 102(3):263-6. [QxMD MEDLINE Link] .

Collaris R, Tan PC. Oral nifepidine versus subcutaneous terbutaline tocolysis for external cephalic version: a double-blind randomised trial. BJOG . 2009 Jan. 116(1):74-80; discussion 80-1. [QxMD MEDLINE Link] .

Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand . 2004 Jun. 83(6):511-8. [QxMD MEDLINE Link] .

• 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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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

External cephalic version.

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

Affiliations

Last Update: December 13, 2023 .

• Continuing Education Activity

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

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

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

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

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

• Anatomy and Physiology

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

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

• Indications

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

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

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

• Contraindications

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

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

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

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

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

The personnel typically required to perform an ECV include:

• Obstetrician
• Labor and delivery nurse.

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

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

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

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

• Technique or Treatment

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

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

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

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

• Complications

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

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

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

• Clinical Significance

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

• Enhancing Healthcare Team Outcomes

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

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

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

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

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

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

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

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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

You and your baby at 32 weeks pregnant

Your baby at 32 weeks.

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

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

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

You at 32 weeks

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

Find out about exercise in pregnancy .

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

Find out about ways to tackle pelvic pain in pregnancy .

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

Things to think about

• how you might feel after the birth

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

You can sign up for Start4Life's weekly emails for expert advice, videos and tips on pregnancy, birth and beyond.

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