The external cephalic version (ECV) is a manual procedure performed to rotate the fetus from a breech to a cephalic presentation through external manipulation of the maternal abdomen. Although recommended by major guidelines and proven to reduce cesarean delivery rates [1,2], routine adoption of ECV remains limited, with few institutions reporting high trial rates [3]. Previous studies have addressed the success factors and safety of ECV [4-6], but practical guidance on the technique and perioperative management remains insufficient. In this article, we outline the indications, contraindications, preparation, and detailed step-by-step approach to ECV based on our institutional protocol, with the aim of providing a clinically applicable guide for safe and effective practice.

ECV is generally indicated for singleton breech presentations at or beyond 37 weeks of gestation with no contraindications to vaginal birth. The reason for performing ECV after 37 weeks is that there may be a need for delivery owing to nonreassuring fetal status on cardiotocography while performing ECV. Performing this procedure before 37 weeks may lead to preterm delivery, although the incidence of fetal heart rate abnormalities requiring delivery is less than 1% [1]. Contraindications include placenta previa, active labor, uterine rupture risk (e.g., classical cesarean scarring), significant fetal anomalies, and abnormal fetal heart rate patterns [7]. Premature rupture of membranes is considered a relative contraindication because of the potential risk of cord prolapse [8]. In cases of oligohydramnios, low-lying placenta, uterine anomalies, or hypertensive disorders, ECV is not strictly contraindicated [9,10]; however, these conditions may be associated with a higher likelihood of subsequent cesarean delivery compared with uncomplicated pregnancies, and ECV should therefore be performed with caution. Although fetal weight alone is not an absolute determinant of ECV, extremely low or high estimated fetal weights may be clinically relevant. Underlying fetal, placental, or umbilical cord abnormalities may be present in cases of suspected fetal growth restriction. These conditions could predispose the fetus to a nonreassuring fetal status during ECV or subsequent labor, potentially resulting in a higher likelihood of cesarean delivery. Conversely, in cases of suspected macrosomia, the technical difficulty of achieving successful rotation may increase. Even after successful ECV, these pregnancies may carry a higher risk of cephalopelvic disproportion, labor dystocia, prolonged labor, or shoulder dystocia, which may also reduce the likelihood of successful vaginal birth. Therefore, the estimated fetal weight should be interpreted cautiously and considered as part of individualized decision-making rather than as an absolute contraindication [11]. Each case should be assessed individually based on fetal and maternal conditions.

As ECV is an elective rather than a medically urgent procedure, obtaining informed consent is essential. Guidelines from the American College of Obstetricians and Gynecologists and Royal College of Obstetricians and Gynaecologists recommend offering ECV to all eligible patients with breech presentation at term [1,2]. However, patient autonomy must be respected, and declining ECV remains a valid and acceptable choice.

Preprocedural counseling should provide a balanced overview of the potential benefits of avoiding cesarean delivery and risks, such as transient fetal heart rate abnormalities that resolve without intervention (5-10%), emergent cesarean delivery (<1%), placental abruption, a very rare complication (typically reported around 0.1%), and rupture of membranes [4,7,12,13]. Complications such as placental abruption and rupture of membranes occur at rates similar to the background risks in late pregnancy and systematic reviews support the overall safety of ECV [4]. To avoid excessive anxiety, it is important to emphasize neonatal safety during counseling. Available evidence indicates that successful ECV does not increase adverse neonatal outcomes, including low Apgar scores or neonatal intensive care unit admission, compared with spontaneous cephalic presentations. The use of ritodrine hydrochloride and neuraxial anesthesia may improve the success rate of ECV by promoting uterine relaxation and reducing maternal pain and discomfort [1,14-16]. It is also necessary to explain potential maternal side effects, such as palpitations caused by ritodrine hydrochloride, nausea and vomiting associated with neuraxial anesthesia-induced hypotension, and discomfort during the procedure; however, these symptoms are usually mild and self-limiting. The discussion should also include realistic expectations regarding the outcomes of ECV, including success rates, possible reversion to breech presentation, and associated delivery modes. Success rates range from 50% to 65% globally [4] and can increase to 80-90% with neuraxial analgesia [3,15-18]. Reversion to breech presentation occurs in 2-5% of cases [9]. Although some studies have reported a slightly higher cesarean delivery rate during a trial of labor after successful ECV compared with spontaneous cephalic deliveries [3,19], others have found comparable rates when compared with spontaneous cephalic presentations [20] or in cases in which breech presentations converted spontaneously to cephalic [21]. Therefore, shared decision-making should encourage open dialogue tailored to patients’ values and concerns. Patients should feel empowered to actively participate in the decision and change their minds at any point prior to the procedure.

All procedures were performed in an operating room with immediate access for cesarean delivery. Continuous monitoring of fetal heart rate and maternal vital signs was initiated before the procedure. Ultrasound was used to assess fetal position, amniotic fluid volume, placental location, and cord position. Although findings such as oligohydramnios or nuchal cord may influence the likelihood of success, they are not strictly contraindicated.

Intravenous access with continuous infusion rather than bolus ritodrine hydrochloride is preferred to minimize cardiovascular side effects and optimize uterine relaxation. In our practice, neuraxial analgesia is provided most commonly via combined spinal epidural anesthesia to reduce maternal discomfort and abdominal wall resistance [3]. During the preparation and performance of the ECV, the operating table was tilted approximately 15° to the left to achieve left uterine displacement and prevent supine hypotensive syndrome due to aortocaval compression.

A supplementary video demonstrating the complete ECV procedure at our institution is available online (Supplementary Video 1).

The critical step in the ECV is lifting the fetal buttocks upward from the maternal pelvis. Adequate elevation of the fetal buttocks has been identified as a key technical factor associated with ECV success [22]. Therefore, the operator usually stands on the maternal right side and uses the dominant right hand to elevate the buttocks; if the dominant hand is the left, it is preferable to stand on the maternal left side. Successful elevation can be confirmed by placing a transabdominal ultrasound probe just above the pubic symphysis to ensure that the fetal buttocks and legs are not caudal to the operator’s lifting hand. It is essential that the lifting hand maintain upward traction throughout the maneuver and not relax because releasing tension allows the rotational force of the other hand to be directed caudally, causing the buttocks to re-engage in the pelvis and prevent further rotation. In the breech presentation with the left sacrum (first breech position), the other hand rotates the fetal head counterclockwise to achieve a forward somersault, whereas in the breech presentation with the right sacrum (second breech position), the maneuver is performed clockwise. The rotating hand should apply a steady and continuous force because intermittent pressure may impose unnecessary stress on the fetus. Rotation is more effective when performed in a wide arc, utilizing the full uterine space, rather than a narrow range of motion, which facilitates a smoother forward somersault. As the fetal head gradually rotates toward the lateral position, the spontaneous upward movement of the buttocks may be palpable, and subtle counterclockwise adjustments of the lifting hand’s vector can facilitate the completion of the rotation. When the fetal head nearly reaches the 6 o’clock position, further rotation may be impeded by lifting the buttocks. In this situation, the hand should be released and repositioned to the buttocks or trunk to provide upward traction in the 12 o’clock direction, which assists the head in moving to the 6 o’clock position. At times, the fetal head may be obstructed by the maternal ilium, and in such cases, gentle elevation of the fetal head from the maternal dorsal side in the ventral direction can help it pass beyond the osseous structures.

Once the fetal head reaches the 6 o’clock position, it must be engaged with the pelvis to prevent reversion. Engagement was achieved by applying a slight dorsal pressure on the head to guide it beneath the pubic symphysis, followed by gentle fundal pressure. A digital vaginal examination was performed to confirm the station of the fetal head, while ultrasonography was used to verify the absence of the limbs or umbilical cord below the presenting part. If a cord or limb presentation is detected, the head should be elevated again and rotated further past the 6 o’clock position before attempting re-engagement. When performed appropriately, the maneuver is usually completed within 1-2 minutes.

In most cases of failure, the fetal buttocks cannot be adequately elevated or fail to follow despite head rotation. Continuing an attempt under these circumstances may stress the fetus and increase the risk of adverse events. Moreover, both the mother and the operator often share a strong desire for success, which may bias the operator toward persisting with the maneuver beyond an appropriate limit. Defining what constitutes a single ECV attempt can be challenging, particularly when attempts are driven by a strong desire for success, which may introduce an operator-related bias. As counting the number of rotational cycles is inherently subjective, we did not impose a limit on the number of maneuvers. Instead, a time-based approach is adopted as a more objective indicator. Therefore, appointing a third-party timekeeper is advisable to ensure timely decision-making. Establishing an appropriate limit for ECV attempts is essential to minimize fetal stress and avoid unnecessary operator-driven persistence, which is associated with increased fetal heart rate abnormalities [4,11]. Clear criteria and time awareness support safer decision-making and reduce the risk of adverse events. In cases of failed ECV, cesarean delivery is performed immediately, especially when the fetal status is nonreassuring.

Left uterine displacement and continuous fetal monitoring are maintained until the effect of neuraxial anesthesia diminishes, reducing aortocaval compression and enabling early detection of fetal heart rate abnormalities. The epidural catheter was kept in place for a certain time after the procedure, considering the possibility of cesarean delivery if fetal heart rate abnormalities occurred. At our institution, patients are generally observed overnight and discharged the day after confirming the absence of fetal heart rate abnormalities. Transvaginal ultrasound verifies that the fetus is in cephalic presentation without the umbilical cord or a limb descending ahead of the head.

This article presents a practical and stepwise approach for ECV based on our institutional protocol, focusing on safety, success factors, and perioperative management. While ECV is underutilized in many facilities despite its proven benefits, we hope that this detailed technical guide, accompanied by a supplementary procedural video, will help promote its wider adoption by providing clinicians with the knowledge and confidence to perform the procedure safely.