In 2018, five of my clients carried frank breech babies (butt down) and three were successfully turned to vertex (head down) with a procedure known as External Cephalic Version, or ECV. If you find out that your baby is positioned breech, rather than vertex, it does not mean you automatically have to be scheduled for a cesarean section. ECV is performed by either an obstetrician or a maternal fetal medicine physician around 37 weeks gestation. They utilize ultrasound surveillance with the goal to turn a breech or transverse (laying sideways,) singleton fetus to a head down position for vaginal birth.
There are three variations of breech: 1. Frank breech (50-70%) the baby’s hips are flexed, knees extended (pike position) 2. Complete breech (5-10%) - baby’s hips and knees are flexed (cannonball position) 3. Footling or incomplete (10-30%) - One or both hips are extended, and one or two feet presenting. As described in the American Journal of Obstetrics & Gynecology, as a woman’s pregnancy advances, the breech fetus has a greater chance of turning head down on its own. Prior to 28 weeks, 22-25% of babies are breech and at 32 weeks 7-15% are breech. At 37 weeks and beyond, 96-97% of all baby’s are head down. That means 3-4% of babies remain breech to term.
David S. Cole, MD, Maternal-Fetal Medicine Specialist, Mt. Sinai West, has an ECV success rate of around 60+%. “I am a proponent of ECV because if it is successful, the patient can possibly avoid a cesarean delivery. I try on most patients and do not preselect who gets the procedure or not. Patients with the best chance of success have a normal amniotic fluid level, a posterior placenta, and a normal sized fetus. The fetus with the least likely chance to be turned would be in a patient with oligohydramnios (low fluid).”
ECV should be done in a hospital as per ACOG, where an immediate cesarean section can take place if the procedure creates a challenge for either the baby or the mother. While all of my client’s ECVs were done without an epidural, one may be requested.
My client Ashley M: “There’s no denying that the procedure was a bit unnerving at first, since a doctor was pressing down on my abdomen with my precious boy inside! However, the sensation was not pain. There was a significant amount of pressure. For instance, I’ve had massages that were way more painful than the version. My experience was exceedingly positive and I encourage women to consider it if they are a candidate.”
According to Cole,“The right candidate for ECV is a patient who is motivated to undergo the procedure. The most important objective piece of data is having enough amniotic fluid (usually an AFI (Amniotic Fluid Index) of at least 8 cm)." I have been told by many women who had a c section for a breech, that they were not offered ECV, or even told about it. I wondered if all OB/GYN’s were familiar with ECV and Cole said ECV is usually taught in OB/GYN residency or a maternal fetal medicine fellowship program. "Some women have conditions where an ECV might not be offered such as a twin gestation, oligohydramnios, or a uterine anomaly,” he added. Intrauterine conditions preventing ECV include fibroids, low lying placenta (placenta previa), or mom’s pelvic structure. A short umbilical cord can also contribute to a fetus remaining breech. Other conditions that could predispose babies to being breech include prematurity, polyhydramnios (increased amniotic fluid levels,) and fetal abnormalities (ie. CNS malformations, neck masses, aneuploidy).
My client Marika had a successful ECV at 37 weeks and 3 days,” I am so thankful that my midwife Risa Klein introduced the version and the right team to give me this option. During the actual physical experience, I felt pushed hard on and sometimes breathless but it was very short. I also believe sending positive energy to my baby in advance and during the version helped me connect to my baby and made the procedure less difficult for the doctor.” Another client pregnant with her fifth, (this was her first breech,) had a successful ECV. To keep her baby head down, I asked her to wear an abdominal binder for the remainder of her pregnancy. Two of my clients who transferred to me in their third trimester did not have the same ECV success - both babies were deeply engaged in the pelvis due to low amniotic fluid levels between five and seven centimeters.
If you are without risk factors, here are proactive tips to improve ECV success, along with some measures to help prevent your fetus from turning breech:
1. Maintain good nutrition and an adequate weight gain. Increase your hydration and salt food to taste - all helps grow a healthy baby and avoid premature labor and a premature baby.
2. Lifestyle: Slow down if you are continuously busy, over exercise, or stand on your feet the majority of the day. Conversely if you sit most of the day, or lead a sedentary lifestyle, discuss a pregnancy exercise, yoga, swimming, or other activity schedule with your provider.
3. Sleep: Make sure you are getting at least 8 hours a night. Lack of sleep due to stress or emotional fears can be tiring and can negatively impact your nutrition which can zap your amniotic fluid or trigger premature labor. Take naps during the day.
4. Counseling: Feeling topsy-turvy? Have fears of labor or parenting? Seek counseling. 5. Circulation: If your baby seems ‘stuck’ on one side, it could mean low amniotic fluid levels. If baby has constant movement, it could mean high fluid levels. Both conditions may not allow for a successful ECV. Lie down daily for one to two hours in a left side lying running position to increase and maximize blood flow to baby. Discuss with your provider.
6. Alignment: Avoid wearing heavy backpacks, pocketbooks and bags. They create unnecessary pressures on the spine and baby’s ability to turn. See my Blog The Trouble with Backpacks when Pregnant.
7. Sonogram: Dr. Cole: “If the ECV is not successful, I tell the patient that the fetus could still turn to vertex on its own. Some fetuses even turn in labor.” With that said, have a sonogram to check your baby's position prior to your c section.
I hope you found this useful. Have you had an External Cephalic Version?