Breech presentation and external cephalic version — Rapid

Synopsis

Recognise persistent breech presentation, assess suitability for external cephalic version and explain safe birth options when the baby remains bottom or feet first.

Breech presentation is common earlier in pregnancy, but only about 3–4% of babies remain breech near term.
Confirm suspected breech by ultrasound and assess presentation subtype, fetal growth, head attitude, fluid and placental position.
Discuss external cephalic version, planned caesarean birth and appropriately selected vaginal breech birth as relevant options.
NICE offers ECV after 36+0 weeks for uncomplicated singleton breech; RCOG usually offers it from 37 weeks, or from 36 weeks in nulliparous women.
ECV succeeds in around half of attempts and should take place where fetal monitoring and emergency caesarean birth are available.
Assess the fetal heart before and after ECV and offer indicated anti-D with fetomaternal haemorrhage testing after the procedure.
A previous single caesarean is not by itself an absolute contraindication to ECV, although birth planning still requires scar assessment.

Key red flags

Persistent bradycardia after an ECV attempt may require emergency caesarean birth; do not discharge before fetal wellbeing has been reassessed.

Fresh significant bleeding, sustained abdominal pain, contractions or reduced movements after ECV require prompt maternity assessment.

Ruptured membranes with a high or footling presenting part increases cord prolapse risk and warrants urgent assessment if fetal abnormalities occur.

An unexpected breech with advanced labour requires immediate experienced help and a decision based on how imminent birth is.

Investigation priorities

Ultrasound before ECVFirst step

Confirm current presentation and identify factors influencing the procedure's safety and success.

Management branches

Antenatal assessmentConfirm breech and discuss the available choices

A fetus remains or is suspected to be breech around 36 weeks of pregnancy.

Arrange ultrasound confirmation and review the current pregnancy, previous surgery, fetal wellbeing and any independent reason for caesarean birth.
Discuss ECV with its approximate 50% success rate, discomfort, chance of failure and uncommon complications, alongside the alternatives if breech persists.
Arrange an appropriate appointment: NICE offers ECV after 36+0 weeks, while RCOG specifies from 37+0 weeks with the option from 36+0 weeks in nulliparous women.
Record the person's preference and an interim plan for labour, bleeding, ruptured membranes or reduced movements before the appointment.

Key medicines

Terbutaline for ECV tocolysisRCOG describes terbutaline 250 micrograms subcutaneously as a pragmatic single-dose regimen before ECV, with maternal assessment and monitoring according to the maternity protocol.Betamimetics should not be used with significant cardiac disease or hypertension and may be ineffective during beta-blocker treatment. Explain transient tachycardia, palpitations, flushing and tremor; this supervised ECV use is distinct from prolonged treatment for preterm labour.

Anti-D immunoglobulin after ECVFor D-Gam after a sensitising event beyond 20 weeks, give at least 500 IU intramuscularly as soon as possible and within 72 hours, with FMH testing and additional dosing advised by the transfusion laboratory.Confirm RhD and antibody status and the exact supplied product; D-Gam is intramuscular, whereas other anti-D products have different doses and routes. Seek product-specific advice when intramuscular injection is unsuitable. Prophylaxis does not treat established immune anti-D sensitisation.

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