OB Guideline 20: Management of Breech Presentations

External Cephalic Version

External cephalic version should be discussed with all birthing people who are carrying a breech presenting singleton fetus as early as the clinician feels is suitable. The discussion and its conclusion should be documented in the prenatal record.

1. Patient Selection
   External cephalic version is precluded in anyone with a contraindication to vaginal delivery or evidence of fetal compromise.
2. Education/Consent
   A discussion with the patient should precede the performance of the procedure and include:
   • Pregnancy management after a successful or unsuccessful version
   • Success rate of attempted version
   • Risks and benefits of the procedure
   • When to call following the procedure

   See Appendix E for a sample consent form for this procedure. This, or a reasonable facsimile, should be reviewed with and signed by the patient prior to the procedure.

3. Prior to the Procedure
   • Arrange a location in close proximity to the delivery unit
   • Confirm that an immediate pre-procedure non-stress test is reactive
   • Perform an immediate pre-procedure sonogram to confirm presentation and that there is normal amniotic fluid volume
   • Perform a formal fetal anatomy survey (if one has not been performed previously), to evaluate the possibility of significant congenital anomalies
   • Consider a tocolytic agent (tocolytics are relatively contraindicated in patients with heart disease)
   • Consider regional anesthesia if the procedure is to be performed in the operating room
4. During the Procedure
   Monitor the fetal heart rate, at minimum, every 30 seconds during the procedure.
5. Following the Procedure
   • Observe the patient for at least one hour
   • Continuously monitor the fetal heart rate and pattern via electronic fetal monitor apparatus for a minimum of one hour
   • Confirm a Category I fetal heart rate tracing post-procedure, prior to discharge
   • Administer RhoGAM if indicated
   • Instruct the patient about follow-up plans, and advise whom to call in the event of any issues
   • Give the patient a written discharge instruction sheet
6. Documentation of the Procedure
   The details on the procedure should be recorded in the patient’s medical record, including:
   • Gestational age
   • Rh blood type
   • Results of pre-procedure testing
   • Medication administered
   • Details on the version attempt, whether it was successful or unsuccessful
   • Post-procedure testing
   • Future plans

Delivery Options: Breech Singleton

Cesarean delivery is the most usual method for delivery of a breech singleton living fetus without any significant congenital anomalies. Assessment of the fetal presentation should be performed immediately prior to a scheduled cesarean.

Planned vaginal delivery of a term singleton breech may be reasonable under hospital-specific protocol for both eligibility and management of labor (including use of oxytocin).^1,2 If the patient opts for a vaginal breech delivery, a detailed written informed consent shall be obtained and placed in the medical record. Patients should be informed that the risk of perinatal or neonatal mortality or short-term serious morbidity may be higher than for cesarean delivery.

In this circumstance:

• The obstetrician must be skilled in vaginal breech delivery or have adequate back-up consultants available
• The adequacy of the pelvis must be assessed; the estimated fetal weight, type of breech, and fetal attitude shall be determined
• Labor dysfunction of any type warrants delivery by cesarean
• Breech delivery should be permitted to occur spontaneously, or by assisted breech delivery maneuvers as indicated

1. ACOG Committee Opinion No. 745: Mode of Term Singleton Breech Delivery. Obstet Gynecol. 2018;132(2):e60-e63. Reaffirmed 2023. doi:10.1097/AOG.0000000000002755
2. External Cephalic Version: ACOG Practice Bulletin, Number 221. Obstet Gynecol. 2020;135(5):e203-e212. Reaffirmed 2023. doi:10.1097/AOG.0000000000003837