Breech and external cephalic version (ECV) – turning a breech baby in the uterus

What does an ECV involve?

An ECV involves applying gentle but firm pressure on your abdomen to help your baby turn in the uterus to lie head first.

Relaxing the muscle of your uterus with medication has been shown to improve the chances of turning your baby. This medication is given by injection in your arm before the ECV and is safe for both you and your baby. It may make you feel flushed and you may become aware of your heart beating faster than usual but this will only be for a short time.

• You will need to come in for your appointment fasted, which means you must not eat for six to eight hours before your appointment time
  • During this time, you may drink water only and take any regular medication you may need
  • You may eat and drink normally after the procedure, so you may wish to bring something food with you
• This ECV appointment takes approximately two hours. You are welcome to bring someone with you
• Before the ECV you will have an ultrasound scan to confirm your baby is breech
• We will take a set of observations, such as blood pressure and pulse
• You will then have cardiotocography (CTG) monitoring to ensure that baby is well and there is no uterine activity (i.e. no contractions)
• During your ECV, we will use ultrasound scanning to see where baby is and to check baby’s position, and to confirm if the baby has changed position
• After the ECV, you will have another CTG scan to monitor baby’s well-being and heart rate
• An ECV can be uncomfortable, and occasionally painful, but your doctor will stop if you are experiencing pain, and the procedure will only last for a few minutes
• If your Doctor is unsuccessful after their first attempt in turning your baby, they may, with your consent, try again on another day
• If your blood type is rhesus D negative, you will be advised to have an anti D injection after the ECV and to have a blood test

Why turn my baby head first?

If your ECV is successful and your baby is turned into the head-first position, you are more likely to have a vaginal birth. Successful ECV lowers your chances of requiring a caesarean section and its associated risks.

Is ECV safe for me and my baby?

ECV is generally safe, with a very low complication rate. We carry out many ECVs, and our doctors are very highly trained in the procedure. Overall, there does not appear to be an increased risk to your baby from having ECV. After ECV has been performed, you will normally be able to go home on the same day.

When you do go into labour, your chances of needing an emergency caesarean section, forceps or ventouse (vacuum cup) birth is slightly higher than if your baby had always been in a head-down position.

Immediately after ECV, there is a 1 in 200 chance of you needing an emergency caesarean section because of bleeding from the placenta and/or changes in your baby’s heartbeat.

Your ECV will be carried out in a hospital where you can have an emergency caesarean section if needed. Therefore, the procedure will be done at Good Hope or Heartlands hospitals.

When should ECV not be carried out?

ECV should not be carried out if:

• you need a caesarean section for other reasons such as placenta location concerns
• if you have had recent vaginal bleeding
• your baby's heart beat tracing (also known as a CTG) is abnormal
• your waters have broken
• you are pregnant with more than one baby

Is ECV always successful?

• ECV is successful for approximately 50% of women
• It is more likely to work if you have had a vaginal birth before
• Your Doctor should give you information about the chances of your baby turning based on their assessment of your pregnancy

If your baby does not turn, your doctor will discuss your options for birth. However, it's possible to have another attempt on a different day.

If ECV is successful, there is still a small chance that your baby will turn back to the breech position. However, this happens to fewer than 5 in 100 (5%) women who have had a successful ECV.

Is there anything I can do to help my baby to turn?

There is no scientific evidence that lying down or sitting in a particular position can help your baby to turn.

What are my options for birth if my baby remains breech?

We want you to feel empowered about your birth choices. Depending on your situation your choices are:

• planned caesarean section
• planned vaginal breech birth

There are benefits and risks associated with both caesarean section and vaginal breech birth. We will discuss these risks with you, so you can choose what is best for you and your baby.

Caesarean section

If your baby remains breech towards the end of pregnancy, you should be given the option of a caesarean section. Research has shown that planned caesarean section is safer for your baby than a vaginal breech birth. Caesarean section carries slightly more risk for you than a vaginal birth.

Caesarean section can increase your chances of problems in future pregnancies. These may include placental problems, difficulty with repeat caesarean section surgery and a small increase in stillbirth in subsequent pregnancies.

Vaginal breech birth

After discussion with your doctor about you and your baby’s suitability for a breech delivery, you may choose to have a vaginal breech birth.

If you choose this option, you will need to be cared for by a team trained in helping women to have breech babies vaginally. (We can provide this service at UHB.) You should plan a hospital birth where you can have an emergency caesarean section if needed, as 4 in 10 (40%) women planning a vaginal breech birth do need a caesarean section. Induction of labour is not usually recommended.

While a successful vaginal birth carries the fewest risks for you, it carries a small increased risk of your baby dying around the time of delivery. A vaginal breech birth may also cause serious short-term complications for your baby. However, these complications do not seem to have any long-term effects.

Your doctor will discuss your individual risks with you.

Your doctor may advise against a vaginal birth if:

• your baby is a footling breech (one or both of the baby’s feet are below its bottom)
• your baby is larger or smaller than average
• your baby is in a certain position, for example its neck is very tilted back (hyper extended)
• you have a low-lying placenta or other placenta concerns
• you have pre-eclampsia or other pregnancy concerns

What can I expect in labour with a breech baby?

With a breech baby you can have the same choices for pain relief at UHB as with a baby who is in the head-first position.

If you choose to have an epidural, there is an increased risk of caesarean section. However, whatever you choose, we will always provide a calm atmosphere, with continuous support.

If you have a vaginal breech birth, we will usually monitor your baby’s heart rate continuously, as this has been shown to improve your baby’s chance of a good outcome.

In some circumstances, for example, if there are concerns about your baby’s heart rate or if your labour is not progressing, you may need an emergency caesarean section during labour. A paediatrician (a doctor who specialises in the care of babies and children) will attend the birth to check your baby is doing well.

What if I go into labour early?

If you go into labour before 37 weeks of pregnancy, the balance of the benefits and risks of having a caesarean section or vaginal birth changes. We will discuss this with you. You must attend the Pregnancy Assessment Emergency Room (PAER) at Heartlands Hospital or Delivery Suite at Good Hope Hospital.

What if I am having more than one baby and one of them is breech?

If you are having twins and the first baby is breech, your doctor will usually recommend a planned caesarean section.

If, however, the first baby is head-first, the position of the second baby is less important. This is because after the birth of the first baby, the second baby has lots more room to move. It may turn naturally into a head-first position or a doctor may be able to help the baby turn.

Making a choice

We would like to empower you in your choices, by giving you the information and time to discuss things with your partner, loved ones and family, and anyone else who may be supporting you.

If you are asked to make a choice, you may have lots of questions. This is perfectly normal. It might be helpful to write a list of questions and bring it to your appointment.

You might not know where to start, so here are some examples of questions you may want to ask.