Hong?Kong?Med?J??Vol?13?No?1?# February?2007?# www.hkmj.org
Department of Obstetrics and
Gynaecology, Tuen Mun Hospital, Tuen
Mun, Hong Kong
SPY Yong, MB, BS, MRCOG
Correspondence to: Dr SPY Yong
Hong Kong Med J 2007;13:40-5
Stephen PY Yong
Breech presentation and, less commonly, oblique and transverse lie occur in 3 to 4% of
pregnancies at term.1-3 Planned caesarean section is safer for the baby than planned vaginal
breech delivery for term breech foetuses in extended or flexed presentations.4 Compared to
vaginal breech delivery, caesarean section reduced perinatal mortality, late neonatal mortality,
and serious neonatal morbidity by two thirds.4 Hence, caesarean section is the preferred and
more commonly used mode of delivery for otherwise uncomplicated breech presentations at
term. However, caesarean section is associated with higher maternal morbidity and mortality as
well as financial costs and long-term complications than vaginal delivery per se.5
term. A meta-analysis of six randomised controlled trials has found it effective in reducing the
number of vaginal breech deliveries by 87% and caesarean sections by 64%.2 No significant
increase in foetal or maternal mortality or morbidity following ECV has been found, though
numbers may have been too small to reliably detect changes in perinatal morbidity or mortality.6
The American College of Obstetricians and Gynecologists7 and Royal College of Obstetricians
External cephalic version (ECV) is another option for foetuses with breech presentation at
Objective To assess the outcome of external cephalic version for routine
management of malpresenting foetuses at term.
Design Prospective observational study.
Setting Tertiary teaching hospital, Malaysia.
Patients From September 2003 to June 2004, a study involving 41 pregnant
women with malpresentation at term was undertaken. An external
cephalic version protocol was implemented. Data were collected
for identifying characteristics associated with success or failure of
external cephalic version.
Main outcome measures Maternal and foetal outcome measures including success rate of external
cephalic version, maternal and foetal complications, and characteristics
associated with success or failure; engagement of presenting part,
placental location, direction of version, attempts at version, use of
intravenous tocolytic agent, eventual mode of delivery, Apgar scores,
birth weights, and maternal satisfaction with the procedure.
Results Data were available for 38 women. External cephalic version was
successful in 63% of patients; the majority (75%) of whom achieved
a vaginal delivery. Multiparity (odds ratio=34.0; 95% confidence
interval, 0.67-1730) and high amniotic fluid index (4.9; 1.3-
18.2) were associated with successful external cephalic version.
Engagement of presenting part (odds ratio=0.0001; 95% confidence
interval, 0.00001-0.001) and a need to resort to backward somersault
(0.02; 0.00001-0.916) were associated with poor success rates.
Emergency caesarean section rate for foetal distress directly resulting
from external cephalic version was 8%, but there was no perinatal
or maternal adverse outcome. The majority (74%) of women were
satisfied with external cephalic version.
Conclusions External cephalic version has acceptable success rates. Multiparity,
liquor volume, engagement of presenting part, and the need for
backward somersault were strong predictors of outcome. External
cephalic version is relatively safe, simple to learn and perform,
and associated with maternal satisfaction. Modern obstetric units
should routinely offer the procedure.
Introducing external cephalic version in a Malaysian
Breech presentation; Obstetric surgical
procedures; Patient satisfaction;
Pregnancy outcome; Version, fetal
? Hong?Kong?Med?J??Vol?13?No?1?# February?2007?# www.hkmj.org?
to all suitable malpresentations. We encountered only
three such patients, all of whom had successful ECV, but
no conclusions can be drawn regarding this issue owing
to the very small numbers.
External cephalic version was successfully introduced
in a Malaysian hospital; its efficacy was comparable to
that in other countries. Multiparity and high AFI were
strong predictors of a success, whereas engagement
of the presenting part and the need for backward
somersault were strong predictors of a failure. It is a
relatively safe procedure, simple to learn and perform,
and it is associated with a high maternal satisfaction rate.
All modern obstetric units should offer ECV to suitable
women at term with malpresentation.
I wish to thank the following doctors from Hospital Tenku
Ampuan Afzan for their assistance: Drs Suhaidin Che Ngah
(drafting ECV protocol), Jalilah (data collection), and Ahmad
Murad Zainuddin (comments). I am also grateful to the
following staff from Tuen Mun hospital: Ms Willy Sung
(statistical analyses) and Dr Kai-bun Cheung (comments). I
also wish to thank the referees and the Editors of this Journal
for their valuable comments and suggestions. This study
was funded by the Research Centre of the International
Islamic University of Malaysia (IIUM/504/022/3/C 31).
1. Royal College of Obstetricians and Gynaecologists. The
management of breech presentation. Greentop guideline
No. 20. London: RCOG press; 2001:1-8.
2. Thorpe-Beeston JG. Management of breech presentation at
term. In: Studd JW, editor. Progress in obstetrics and gynae-
cology. Vol 13. Edinburgh: Churchill Livingstone; 1999:87-100.
3. Johanson R. Malposition, malpresentation and cephalopelvic
disproportion. In: Edmonds DK, editor. Dewhurst’s textbook
of obstetrics and gynaecology for postgraduates. 6th ed.
London: Blackwell Science; 1999:277-90.
4. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal
S, Willan AR. Planned caesarean section versus planned
vaginal birth for breech presentation at term: a randomised
multicentre trial. Term Breech Trial Collaborative Group.
5. van Roosmalen J, Rosendaal F. There is still room for
disagreement about vaginal delivery of breech infants at
term. BJOG 2002;109:967-9.
6. Hofmeyr GJ. External cephalic version facilitation for breech
presentation at term (Cochrane Review). In: The Cochrane
Library, Issue 2. Oxford: Update Software; 2002.
7. ACOG practice patterns. External cephalic version. Number
4, July 1997. American College of Obstetricians and
Gynecologists. Int J Gynaecol Obstet 1997;59:73-80.
8. Caukwell S, Joels LA, Kyle PM, Mills MS. Women’s attitudes
towards management of breech presentation at term. J
Obstet Gynaecol 2002;22:486-8.
9. Raynes-Greenow CH, Roberts CL, Barratt A, Brodrick B, Peat
B. Pregnant women’s preferences and knowledge of term
breech management, in an Australian setting. Midwifery
10. Coltart T, Edmonds DK, al-Mufti R. External cephalic
version at term: a survey of consultant obstetric practice in
the United Kingdom and Republic of Ireland. Br J Obstet
11. Edmonds S. Management of breech deliveries [Letter]. The
Obstetrician Gynaecologist 2002;4:239-43.
12. Myerscough P. The practice of external cephalic version. Br
J Obstet Gynaecol 1998;105:1043-5.
13. Moore TR, Cayle JE. The amniotic fluid index in normal
human pregnancy. Am J Obstet Gynecol 1990;162:1168-73.
14. Burr RW, Johanson RB. Breech presentation: is external
cephalic version worthwhile? In: J Studd, editor. Progress
in obstetrics and gynaecology. Vol 12. Edinburgh: Churchill
15. Devendra K. Introducing routine external cephalic version
for the management of the malpresenting fetus near term.
Med J Malaysia 2002;57:454-9.
16. Lau TK, Lo KW, Rogers M. Pregnancy outcome after
successful external cephalic version for breech presentation
at term. Am J Obstet Gynecol 1997;176:218-23.
17. Nassar N, Roberts CL, Barratt A, Bell JC, Olive EC, Peat B.
Systematic review of adverse outcomes of external cephalic
version and persisting breech presentation at term. Paediatr
Perinat Epidemiol 2006;20:163-71.
18. Lau TK, Lo KW, Wan D, Rogers MS. Predictors of successful
external cephalic version at term: a prospective study. Br J
Obstet Gynaecol 1997;104:798-802.
19. Guyer CH, Heard MJ. A prospective audit of external
cephalic version at term: are ultrasound parameters
predictive of outcome? J Obstet Gynaecol 2001;21:580-2.
20. Nor Azlin HI, Haliza H, Mahdy ZA, Anson I, Fahya MN, Jamil
MA. Tocolysis in term breech external cephalic version. Int J
Gynaecol Obstet 2005;88:5-8.
21. Chan LY, Leung TY, Fok WY, Chan LW, Lau TK. High
incidence of obstetric interventions after successful external
cephalic version. BJOG 2002;109:627-31.
22. Collaris RJ, Oei SG. External cephalic version: a safe
procedure? A systematic review of version-related risks.
Acta Obstet Gynecol Scand 2004;83:511-8.
23. Leung TY, Lau TK, Lo KW, Rogers MS. A survey of pregnant
women’s attitude towards breech delivery and external
cephalic version. Aust N Z J Obstet Gynaecol 2000;40:253-9.
24. Fok WY, Chan LW, Leung TY, Lau TK. Maternal experience
of pain during external cephalic version at term. Acta Obstet
Gynecol Scand 2005;84:748-51.