External cephalic version (ECV) for breech presentation involves manual manipulation of the fetus from breech to cephalic presentation at or near term, in an attempt to avoid breech birth. This systematic review summarizes the literature on the effects of ECV at or near term on pregnancy outcomes in high-resource settings.

The MEDLINE, Embase, CINAHL, Cochrane Library, MIDIRS, and SweMED+ databases were searched for relevant articles published through April 2019, with no limitation on publication date. Clinical trials comparing the effects of ECV at ≥36 weeks, with or without tocolysis, with that of no ECV, conducted in northern, western, and central Europe, the USA, Canada, Australia, and New Zealand were eligible for inclusion.

Nine articles reporting on 184704 breech pregnancies were included. Pooled data showed that ECV attempts reduced the failure to achieve vaginal cephalic birth (risk ratio, RR=0.56; 95% CI: 0.45–0.71), caesarean section performance (RR=0.57; 95% CI: 0.50–0.64), and non-cephalic presentation at birth (RR=0.45; 95% CI: 0.29–0.68) compared with no ECV. ECV attempts also increased the incidence of Apgar score <7 at 5 minutes (RR=1.29; 95% CI: 1.10–1.52).

Women for whom ECV is attempted at or near term are at reduced risk of caesarean section, non-cephalic presentation at term, and failure to achieve vaginal cephalic birth. Compared with no ECV, attempted ECV was also associated with a slightly increased risk of a low Apgar score at 5 minutes. The evidence is limited by the scarcity of high-quality research and the presence of risks of bias.

The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported.
There was no source of funding for this research.
Not commissioned; externally peer reviewed.
Cammu H, Dony N, Martens G, Colman R. Common determinants of breech presentation at birth in singletons: a population-based study. Eur J Obstet Gynecol Reprod Biol. 2014;177:106-109. doi:10.1016/j.ejogrb.2014.04.008
Zsirai L, Csakany GM, Vargha P, Fulop V, Tabak AG. Breech presentation: its predictors and consequences. An analysis of the Hungarian Tauffer Obstetric Database (1996-2011). Acta Obstet Gynecol Scand. 2016;95(3):347-354. doi:10.1111/aogs.12834
Rayl J, Gibson PJ, Hickok DE. A population-based case-control study of risk factors for breech presentation. Am J Obstet Gynecol. 1996;174(1 Pt 1):28-32. doi:10.1016/s0002-9378(96)70368-x
Macharey G, Gissler M, Rahkonen L, et al. Breech presentation at term and associated obstetric risks factors-a nationwide population based cohort study. Arch Gynecol Obstet. 2017;295(4):833-838. doi:10.1007/s00404-016-4283-7
Grootscholten K, Kok M, Oei SG, Mol BW, van der Post JA. External cephalic version-related risks: a meta-analysis. Obstet Gynecol. 2008;112(5):1143-1151. doi:10.1097/AOG.0b013e31818b4ade
Velzel J, de Hundt M, Mulder FM, et al. Prediction models for successful external cephalic version: a systematic review. Eur J Obstet Gynecol Reprod Biol. 2015;195:160-167. doi:10.1016/j.ejogrb.2015.10.007
Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2012;10:CD000083. doi:10.1002/14651858.CD000083.pub2
Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Term Breech Presentation: Green-top Guideline No. 20a. BJOG. 2017;124(7):e178-e192. doi:10.1111/1471-0528.14466
The American College of Obstetricians and Gynecologists. Practice Bulletin No. 161: External Cephalic Version. Obstet Gynecol. 2016;127(2):e54-e61. doi:10.1097/AOG.0000000000001312
Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi:10.1186/2046-4053-4-1
United Nations Development Programme. Human Development Reports: 2019 Human Development Index Ranking. Accessed March 25, 2020.
Higgins JTP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ. Cochrane Handbook for Systematic Reviews of Interventions version 6.0 2019. 2nd ed. Chichester, UK: John Wiley & Sons, 2019.
Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi:10.1136/bmj.i4919
Balayla J, Dahdouh EM, Villeneuve S, et al. Obstetrical and neonatal outcomes following unsuccessful external cephalic version: a stratified analysis amongst failures, successes, and controls. J Matern Fetal Neonatal Med. 2015;28(5):605-610. doi:10.3109/14767058.2014.927429
Bewley S, Robson SC, Smith M, Glover A, Spencer JA. The introduction of external cephalic version at term into routine clinical practice. Eur J Obstet Gynecol Reprod Biol. 1993;52(2):89-93. doi:10.1016/0028-2243(93)90233-3
Dyson DC, Ferguson JE 2nd, Hensleigh P. Antepartum external cephalic version under tocolysis. Obstet Gynecol. 1986;67(1):63-68. PMID:3940340.
Goh JT, Johnson CM, Gregora MG. External cephalic version at term. Aust N Z J Obstet Gynaecol. 1993;33(4):364-366. doi:10.1111/j.1479-828x.1993.tb02110.x
Healey M, Porter R, Galimberti A. Introducing external cephalic version at 36 weeks or more in a district general hospital: a review and an audit. BJOG. 1997;104(9):1073-1079. doi:10.1111/j.1471-0528.1997.tb12070.x
Nassar N, Roberts CL, Cameron CA, Peat B. Outcomes of external cephalic version and breech presentation at term, an audit of deliveries at a Sydney tertiary obstetric hospital, 1997-2004. Acta Obstet Gynecol Scand. 2006;85(10):1231-1238. doi:10.1080/00016340600853651
Stine LE, Phelan JP, Wallace R, Eglinton GS, van Dorsten JP, Schifrin BS. Update on external cephalic version performed at term. Obstet Gynecol. 1985;65(5):642-646. PMID:3982742.
Brocks V, Philipsen T, Secher NJ. A randomized trial of external cephalic version with tocolysis in late pregnancy. BJOG. 1984;91(7):653-656. doi:10.1111/j.1471-0528.1984.tb04825.x
Van Dorsten JP, Schifrin BS, Wallace RL. Randomized control trial of external cephalic version with tocolysis in late pregnancy. Am J Obstet Gynecol. 1981;141(4):417-424. doi:10.1016/0002-9378(81)90604-9
Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits?. Am J Perinatol. 2012;29(1):7-18. doi:10.1055/s-0031-1285829