Vaginal birth can occur in breech presentation, but it still commonly leads to cesarean delivery.1 Breech presentation, where the foetus lies bottom- or feet/knee-first is the most common abnormal foetal presentation at term, affecting approximately 3-4% of singleton pregnancies.2,3 Historically, the management of breech presentations shifted significantly after the 2000 Term Breech Trial, which reported higher perinatal and neonatal morbidity in planned vaginal breech deliveries compared to planned caesarean sections (CS).4 This led to a global increase in CS for breech presentation, making it the third most common indication for CS.5 However, CS is associated with considerable maternal morbidity, including increased blood loss, thrombotic events, longer hospital stays, and risks in subsequent pregnancies. These rising CS rates also place a greater economic burden on healthcare systems.6

Malpresentation, specifically breech presentation, may arise as a consequence of pre-existing maternal or fetal conditions, or may be attributed to abnormalities in placental implantation, such as placenta praevia or cornual implantation. In some instances, it may also occur without an identifiable underlying cause. Regardless of the etiology, breech presentation is associated with a heightened risk of adverse perinatal outcomes. These include the potential for a complicated vaginal delivery, which carries significant perinatal morbidity and mortality, as well as the increased likelihood of requiring a caesarean section, a procedure that itself is linked to greater risks of both maternal and fetal complications.8

In response to the increased CS rates and associated risks, External Cephalic Version (ECV) has regained prominence as a valuable intervention.8 ECV is a technique involving targeted manual pressure on the maternal abdominal wall to convert a foetal breech presentation into a cephalic position, typically performed at or near term.5,8 The primary goal of ECV is to increase the likelihood of a vaginal cephalic birth, thereby reducing the need for CS and its associated maternal and neonatal morbidities. Recommended by major obstetrics societies as a first-line management for uncomplicated term breech presentations, ECV is broadly considered a safe procedure with a good success rate, although it has been noted as underused despite its benefits.7,9

Only a limited number of studies have investigated the success rates of external cephalic version (ECV) in term singleton breech pregnancies. Therefore, the primary objective of the present study was to evaluate the success rate of this often-overlooked procedure, external cephalic version in pregnant women presenting with a singleton breech presentation at 37 to 38 weeks of gestation. Additionally, the study aimed to compare ECV outcomes between primigravida and multigravida women, and to observe the various complications encountered during the procedure.

This retrospective observational study was conducted in the Department of Obstetrics & Gynaecology, at a tertiary care hospital, Mandya. Institutional ethics committee approval was obtained prior to data collection.

At our institution, during routine antenatal visits after 36 weeks’ gestation, women found to have a non cephalic presentation are counselled regarding external cephalic version (ECV) to increase the likelihood of vaginal delivery. Once deemed eligible, the risks and benefits of ECV are explained, and those who provide informed consent will be proceeded to the procedure. An experienced obstetrician performs the version using either the forward roll or backward flip technique, with continuous ultrasonographic monitoring of the fetal heart rate immediately before, during, and after the manoeuvre. Following ECV, patients are observed for bradycardia, non reassuring fetal heart patterns, membrane rupture, the onset of labor, or decreased fetal movements. If no complications arise, they are discharged with detailed follow up instructions. Emergency caesarean section is reserved for any subsequent obstetric indications.

A register was maintained for all women undergoing deliveries and what type of procedures were done at our institution. From that records, women who underwent external cephalic version (ECV) between March 2024 and February 2025 for singleton pregnancies in breech presentation at term (37 + 0 to 38 + 6 weeks gestation) were identified and reviewed. A total of 26 case records were identified. There were no specific exclusion criteria, ensuring comprehensive inclusion of all eligible cases. From the records, a detailed history related to key demographic and obstetric characteristics, mode of delivery, procedure outcomes, and complications were extracted.

Statistical analysis:

The collected data was subjected to statistical analysis using the SPSS software package. Descriptive statistics included calculation of proportions and frequencies to summarize the sample characteristics and primary outcomes.

A total of 26 cases was retrieved from the registry who were documented as having ECV got done in their term pregnancy with singleton breech presentation during March 2024 and February 2025.

The majority of participants (65.4%) from the case records were relatively young, aged between 20 and 25 years old followed by 30.8% in 26-30 years and 3.8% in 31-35 years old age category. With respect to gravida status, 42.3% of them belonged to primi whereas, 57.7% belonged to multigravidas. Out of total 26 cases who underwent ECV, majority 19 cases (73.1%) had vaginal delivery while 26.9% of deliveries were conducted by caesarean sections. [Table 1]

Table 1: Distribution of baseline characteristics

Table 2 exclusively focussed on participants who underwent successful ECVs (19 cases). Among those who obtained successful ECVs, majority 63.1% were multigravidas followed by 36.8% primigravidas. Nearly half (47.4%) of the babies weighed between 2.5 kg and 3 kg followed by <2.5 kg (15.8%), 3-3.5 kg (31.6%), and only 5.3% weighed over 3.5 kg. A normal amount of fluid was present in just over half (52.6%) of successful ECV cases. A significant proportion (42.1%) had "Polyhydramnios" (excessive fluid), while only a small percentage (5.3%) had "Oligohydramnios" (low fluid).

Table 2: Distribution of parameters among successful ECVs [n=19]:

-Majority of ECV procedures (76.9%) had no complications. This suggests that ECV is generally a safe procedure in terms of immediate complications. Among complications observed, majority experienced PROM (Premature Rupture of Membranes) 11.6%, fetal distress 7.7% and PPH (Postpartum Haemorrhage) 3.8%. [Table 3]

Table 3: Distribution based on complications occurred during ECV procedure:

Nearly a third (31.6%, or 6 babies) required admission to the NICU in our study. For the 6 babies who were admitted to the NICU, the majority of NICU admissions (66.7%, or 4 out of 6 babies) were from vaginal deliveries, while 33.3% (2 out of 6 babies) were from Cesarean deliveries. Most babies admitted to NICU (83.3%, or 5 out of 6 babies) were born to mothers experiencing their first pregnancy ("Primi"), whereas only 16.7% (1 out of 6 babies) were born to mothers who had multiple pregnancies ("Multi").

Our study mainly aimed to revive the forgotten art named external cephalic version which was performed to term pregnancies (i.e., beyond 37 weeks of gestation) who had non-cephalic presentations. Mainly, the success rate of ECV was observed and additionally complications related to the ECV procedure was also observed. The majority of participants in this study were young (65.4% aged 20–25 years). These findings were consistent to the study done by Marcus et al7., who reported 90.7% of their cohort with 20–35yrs age range, and Mishra et al10., where 80% of women were 20–30 years old, emphasizing a trend of ECV attempts predominantly in younger, reproductive-age women.

The success rate of ECV in our study was 73.1% who delivered vaginally. Similar trends were observed with studies by Marcus et al.’s rate of 80.5% vaginal delivery after ECV, Mishra et al.’s10 75.6%, and Nalam et al.’s9 75% after successful ECV. Londero et al.11 also supported these findings in a much larger cohort (71.6% spontaneous vaginal delivery with successful ECV).

In our study, 63.1% of successful ECVs occurred in multigravida women, a similar trend supported by Mishra et al,10 who reported an 83% success rate among multiparous women compared to only 77% in primiparous women demonstrating that parity significantly increases the likelihood of success. Londero et al.11 identified nulliparity as a strong predictor of ECV failure, a finding likely related to anatomical and tissue compliance differences between these groups. The implication is that uterine laxity and abdominal wall compliance, more common in multigravida, facilitate fetal manipulation. Amniotic fluid volume and fetal weight also play important roles in ECV outcomes. Our study found normal liquor in 52.6% of successful cases, polyhydramnios in 42.1%, and oligohydramnios in 5.3%. Fetal birth weights between 2.5–3.5 kg were associated with higher success rates. However, increased fetal weight can negatively impact success, as noted by Mishra et al10 in their study. In contrast, Londero et al.11 observed that fetuses with low weight percentiles were at increased risk of ECV failure.

ECV in our study cohort was largely safe, with no complications in 76.9% of cases. PROM, fetal distress, and postpartum hemorrhage were noted in 11.6%, 7.7%, and 3.8%, respectively. In a study done by Marcus et al7, no major adverse events was observed in their 2-year study, reflecting practice safety in well-monitored hospital settings which is in similar line with our study. Han et al.12 in their retrospective analysis, reported PROM in 7.1% and fetal distress in 4.8%, findings comparable to our study. McLaren et al.13 also described low rates of adverse outcomes, emphasizing the general safety of the ECV procedure.

In this study, 31.6% of neonates required NICU admission. The majority (83.3%) were primigravidae, and most (66.7%) were from vaginal deliveries. Borgmeier et al14, found a NICU admission rate of only 3.28% for vaginal births after ECV and 3.92% for elective caesarean sections, with no statistically significant difference in short-term neonatal outcomes. Marcus et al. and Cobec et al.5 both reported low neonatal morbidity, with most neonates having normal APGAR scores and no increased need for intensive care.

Limitations:

The moderate sample size (n=26) limits the generalizability of findings, especially for rare outcomes such as serious complications. Since our study was done in single institution, results may reflect unique patient populations and institutional protocols.

Conclusion: ECV for singleton term breech pregnancy is safe which increases the likelihood of vaginal delivery, and is associated with low rates of significant complications. The procedure’s success is higher in multigravida and in women with normal or increased amniotic fluid volume. Though, NICU admission rate was higher than typically reported, international studies overwhelmingly demonstrate equivalent perinatal and neonatal outcomes to caesarean deliveries. Larger, multicentric, and prospective studies are needed to fully clarify variations in neonatal outcomes.

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