Everything You Need To Know About External Cephalic Version (ECV)

As you near the end of your pregnancy, the people caring for you will begin to monitor you and your baby quite closely. If you’ve already made a birth plan and planned on having a vaginal delivery, it can be upsetting to find — typically at your 36 week prenatal visit — that your baby is breech. About 4% of pregnancies are breech at term, explains Dr. Latoya Patterson, MD, MPH, obstetrician and gynecologist at Duke Women’s Health Associates, and vaginal deliveries are considered very risky for breech babies, she explains. If having a vaginal birth is a really high priority to you and you’d like to try everything you can to encourage your baby to turn, you’ll probably begin to learn about external cephalic version (ECV), a procedure that your OB can perform to help try to turn your baby so that they’re in a head-down position.

What is external cephalic version?

“External cephalic version is when we're trying to externally convert or turn the baby to head down,” Patterson says. The procedure is usually performed around 37 weeks, and in the simplest terms, during an ECV, you will get an epidural and two OBs will manually try to maneuver your baby by pressing on your belly. If the procedure is a success, then they will wait for you to go into spontaneous labor. If they can’t flip the baby — “Babies are babies. They're going to do what they want,” says Patterson — then you would be scheduled for a C-section at around 39 weeks.

The conversation about whether or not to have an ECV may be an on-going one, but go-getters and birth plan devotees may want to educate themselves before your 36 week appointment just in case the issue arises so you know what you want to do. When midwife Michele Megregian, Ph.D, CNM, FACNM, an Assistant Professor at the Oregon Health & Science University School of Nursing, talks with patients about it, she considers it very much to be a “shared decision-making conversation.” While ECV is considered to be generally quite safe, Megregian says, there is a risk that the fetus may not tolerate the turning. “If we have signs that perhaps the baby may not tolerate turning, or may not tolerate a vaginal delivery, then we need to listen to that,” she explains. “We listen to the pregnant person's instinct about their own bodies, too. Some people who go into this with the attitude that the baby is breech for a reason, and so we explore that pregnant person's feelings around that framework and we support them.”

Why is my baby breech?

It’s really tricky to say why a baby is breech at term, Patterson explains. However, she urges pregnant people who have been told that their baby is breech to rest assured that it’s nothing that they did. “Sometimes patients feel like there's something that they have done that’s caused their baby to be breech, but there's not anything that you have done,” she says. There are many reasons babies are breech, she says, but none are within your control. Common reasons she says babies are breech include:

• You’re having twins
• You have a narrow pelvis
• You have a heart-shaped uterus

How painful is an ECV?

An ECV shouldn’t be very painful, Patterson says, because many practitioners will give you an epidural before they begin so that you are numb from the top of your abdomen down. However, she adds that the procedure “can be uncomfortable because you're applying pressure on the abdomen.” So, it’s likely that — in terms of pain — the worst part of it will be getting the epidural at the beginning. And after it’s done, she adds that most people don't feel a lot of discomfort. By the time the epidural wears off — which takes about an hour — you should be feeling pretty normal again.

Is ECV worth it? Risks to consider

Overall, both Patterson and Megregian agree that ECV is quite low-risk, but “any procedure that we do has risk,” Patterson says. With an ECV, the greatest risks are:

• Baby’s heart rate decreases
• Placental abruption, which is when the placenta starts to separate from the uterus
• Your water breaks and you go into labor
• You need an emergency c-section (if Baby hasn’t turned)

However, all of these risks combined are less than 1% chance of happening. “There's actually more risk to mom with having a C-section,” Patterson adds. The risk of going in to labor or needing an emergency C-section — something they would do if, say, the baby’s heart rate drops and doesn’t recover — is one of the reasons Patterson says they give pregnant people an epidural before beginning the ECV. Not only does it make you more comfortable, but it also ensures that the doctors can work very quickly if a risk becomes a reality.

What to expect during an ECV procedure

Your ECV will be an outpatient procedure, meaning you’ll come to the hospital, have the procedure, and head home that same day. Most OBs will give you an epidural to begin, and Patterson says that many use a medication — either an injection or oral medication — to relax the uterine muscle as well. “By having the uterus relax, it allows you a little bit more flexibility when trying to turn baby.”

As the greatest risk of ECV is that Baby will not tolerate it — again, a very low risk — your baby will be closely monitored during the whole procedure. Once you’re numb from the epidural, the providers will begin trying to turn the baby. Two providers will work together “literally just try to maneuver the baby from the outside of the belly,” Patterson says. “Usually, one person is pushing Baby out of the pelvis, and then the other person is in the upper part. You're either flipping forward, or flipping back.” Your OB and their partner will likely make two or three attempts at most to flip your baby.

After the procedure, care takers will make sure that your epidural has worn off, and then monitor the baby after the procedure for a bit as well. “We put baby on the monitor just to ensure that baby's heart rate is normal and everything looks good.”

How long does ECV last?

Overall, even if your doctor makes three attempts to get your baby to turn, ECV doesn't last that long just because each attempt is not very long, about 30 minutes max for the entire procedure, explains Patterson. “So that's you coming in, getting your anesthesia, we give you the medication to relax the uterus, and the procedure itself.” They will spend about 15 minutes at the most trying to get the baby to flip, she adds. “You usually can tell after two or three attempts if you're going to be successful or not.”

And speaking of success, just how likely is ECV to be successful?

“I usually tell patients that it's about 50%,” Patterson says. However, she adds a caveat: “It is provider dependent. And some providers have a higher success rate than others.” She sites a wide range of success rates that ECV studies have shown as anywhere from “16% to 100% success rate.” In light of that, it may be worthwhile to find out your own provider’s success rate. And if your ECV is successful, will your baby stay put? Thankfully, most likely yes. “Usually, once they're flipped, they pretty much stay,” Patterson adds. “But there's always a small chance that baby could flip back.”

The bottom line? Do what feels right to you

“There’s risk to everything and you have to weigh in what's most important to you,” Patterson says simply. “I think that's how people decide. I usually talk to every patient who has a breech baby the same way, but everyone thinks about what they value differently.” Megregian agrees that every patient is going to weigh their options, risks and ultimate value a bit differently, and sees her job as presenting all of the options available to a person with a breech baby and supporting them however she can. She often begins by suggesting alternatives to ECV — things like acupuncture and moxibustion and changing position — just in case a less hands-on approach succeeds in turning the baby, saying she thinks they’re worth doing (and Patterson agrees that most of those alternatives are at least not harmful for people having normal, healthy pregnancies). “It's a very safe procedure, but the idea is that we do these alternatives before trying the external cephalic version, since that is a little bit more intervention,” Megregian explains. “Then if you still need an ECV, then it's worth doing that as well if the goal is to have a vaginal delivery.”

Ultimately though, both agree that it comes down to having a deep conversation between the pregnant person, their support people, and their provider(s) to create an individualized plan of care. Most of all, Megregian adds, “we know that we need to listen to the baby and we need to listen to the pregnant person.” Don’t be afraid to ask questions, seek good support, and do what feels right to you.

Experts:

Dr. Latoya Patterson, MD, MPH, obstetrician and gynecologist at Duke Women’s Health Associates

Michele Megregian, Ph.D, CNM, FACNM, Assistant Professor, at the Oregon Health & Science University School of Nursing