Breech Presentation and External Cephalic Version (ECV): A PLAB 2 Guide
- Ann Augustin
- 1 day ago
- 3 min read
Introduction
A breech presentation is when the baby’s buttocks or feet are the presenting part instead of the head.
Occurs in about 3–4% of pregnancies at term.
Important for PLAB 2: data gathering, explaining findings, counselling on ECV, and discussing delivery options.
Risk Factors for Breech
Maternal: uterine anomalies, fibroids, placenta praevia, multiparity, previous breech.
Fetal: prematurity, congenital anomalies, multiple pregnancy, short cord.
Pregnancy-related: oligohydramnios, polyhydramnios, abnormal placental location.
Clinical Examination
Abdominal exam (Leopold’s manoeuvres):
Head in fundus, soft breech in pelvis.
Fetal heart heard above the umbilicus.
Vaginal exam (if in labour): buttocks/feet, absence of sutures/fontanelles.
Confirmatory: Ultrasound scan.
Ultrasound Findings
Baby’s head in fundus, bottom in pelvis.
Identifies type of breech (frank, complete, footling).
Assesses placenta, amniotic fluid, fetal wellbeing, head flexion/extension.
Explaining to the Patient (Layman terms)
“Your baby is sitting bottom-first instead of head-down. The scan shows the baby is healthy, the fluid is normal, and the placenta is in a good position. This may make a normal vaginal birth more difficult, so we usually try to gently turn the baby.”
External Cephalic Version (ECV)
What it is
A procedure to turn the baby from breech to head-down by gently pressing on the abdomen.
How it’s performed
Done at 36 weeks (nulliparous), 37 weeks (multiparous).
In hospital, with continuous monitoring.
Tocolysis may be used to relax the uterus.
Anti-D given if mother is Rh-negative.
Success rates
~40% success in first pregnancy.
~50–60% in multiparous women.
Risks
Discomfort.
Temporary changes in baby’s heartbeat.
Rare: waters breaking, placental abruption, emergency caesarean (<1%).
Contraindications
Absolute: placenta praevia, multiple pregnancy, ruptured membranes, compromised fetus, previous classical CS.
Relative: oligohydramnios, polyhydramnios, IUGR, uterine scar, hypertension.
Investigations Before ECV
Ultrasound scan → confirm breech, placenta, fluid, growth.
CTG → assess fetal wellbeing.
Blood group & Rh status → Anti-D if Rh-negative.
Routine antenatal checks → vitals, history, rule out contraindications.
If Baby Doesn’t Turn
Planned Caesarean Section (ELCS):
Safer option, usually scheduled at 39 weeks.
Reduces risks to baby.
Planned Vaginal Breech Delivery:
Considered only if: frank/complete breech, normal fetal wellbeing, no hyperextended head, appropriate fetal size.
Requires experienced team and immediate access to emergency CS.
Higher risk to baby compared to ELCS.
PLAB 2 Data Gathering (to rule out contraindications)
Previous caesarean or uterine surgery?
Any bleeding during pregnancy?
Have the waters broken?
Told placenta is low-lying?
Any concerns about baby’s growth or fluid levels?
Single baby or twins?
History of high blood pressure or complications?
Sample Patient-friendly Script (for PLAB 2)
“Maya, your baby is currently sitting bottom-first, which we call breech. Most babies turn by now, but sometimes they don’t. We can try a safe procedure called ECV, where we gently turn the baby by pressing on your tummy. It works in about half of women, is done in hospital with monitoring, and has only small risks. If the baby doesn’t turn, we usually recommend a caesarean section at 39 weeks, although a vaginal breech birth can sometimes be considered if all safety conditions are met.”
Key Takeaway for PLAB 2
Always gather history to rule out contraindications.
Explain findings clearly: breech = bottom-first.
Counsel on ECV: what, how, success, risks, alternatives.
Discuss delivery options if ECV fails: ELCS vs vaginal breech.
Show empathy and reassurance throughout.
📌 References for further reading:
NICE Clinical Guideline [CG70] – Intrapartum care for healthy women and babies.
RCOG Green-top Guideline No. 20b – Management of Breech Presentation.
NHS website – Breech birth and ECV.
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