Knowledge, attitude and practice of obstetricians towards external cephalic version

Aisha Moon, Saima Shabbir


Background: Breech presentation is found in 3-5% of pregnant women at term. The cause for this fetal presentation may vary from fetal to maternal. Management option for breech presentation includes assisted vaginal breech birth, caesarean section and external cephalic version. External cephalic version is a maneuver performed to avoid breech presentation at term labor and helping the obstetricians to avoid complications of cesarean section. The success rate of ECV is 50%. Considering a high success rate and low risks it can be concluded that ECV can help reduce cesarean section rate of any region. The objective of this study is to determine the knowledge, attitude and practice of healthcare practitioners towards external cephalic version.

Methods: This is an observational cross-sectional study conducted by the postgraduate trainee of Kulsumbai Valika social security SITE hospital, Karachi, Pakistan. By purposive sampling selection, there were 50 consultant obstetricians that have been well informed and were willing to complete KAP study questionnaires were enrolled to participate.

Results: A total of 50 participants were included, 70% had clinical experience of more than 10 years. 80% considered ECV a safe procedure.75% believe that effective knowledge and practice of ECV can bring down cesarean section rate. If encountered by client with breech presentation 69% will manage with elective LSCS (lower segment caesarean section), 26% with ECV and only 5% will manage with assisted breech vaginal birth.

Conclusions: For uncomplicated singleton breech at term, both ACOG and RCOG recommend external cephalic version. In Pakistan the current trend involves performing cesarean section for breech presentation. Effective knowledge, Proper training, and adequate practice can improve ECV uptake in our country.



Breech presentation, External cephalic version, Assisted breech vaginal delivery, Elective LSCS

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Impey LW, Murphy DJ, Griffiths M, Penna LK. GM. Management of Breech Presentation: Green-top Guideline No. 20b. BJOG An Int J Obstet Gynaecol. 2017;124:e151-77.

Hickok DE, Gordon DC, Milberg JA, Williams MA, Daling JR. The frequency of breech presentation by gestational age at birth: a large population-based study. Am J Obstetr Gynecol. 1992;166(3):851-2.

Lyons J, Pressey T, Bartholomew S, Liu S, Liston RM, Joseph KS. Delivery of breech presentation at term gestation in Canada, 2003–2011. Obstetrics & Gynecology. 2015;125(5):1153-61.

Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Drake P. Birth: final data for 2016. Natl Vital Stat Rep. 2018;67:1–55.

External cephalic version and reducing the incidence of term breech presentation: Green-Top Guideline No. 20a. BJOG 2017;124:e178–92.

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. The Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD000083. Available at: 10.1002/14651858.CD000083.pub3. Accessed on 17 July 2021.

Melo P, Georgiou EX, Hedditch A, Ellaway P, Impey L. External cephalic version at term: a cohort study of 18 years’ experience. BJOG: An International Journal of Obstetrics & Gynaecology. 2019;126(4):493-9.

Grootscholten K, Kok M, Oei SG, Mol BWJ, van der Post JA. External cephalic version-related risks: a meta-analysis. Obstet Gynecol. 2008;112:1143–51.

Rodgers R, Beik N, Nassar N, Brito I, de Vries B. Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney. BJOG: An International Journal of Obstetrics & Gynaecology. 2017;124(5):767-72.

Thissen D, Swinkels P, Dullemond RC, van der Steeg JW. Introduction of a dedicated team increases the success rate of external cephalic version: A prospective cohort study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2019;236:193-7.

World Health Organization. WHO statement on caesarean section rates. Geneva: WHO; 2015.

Gabay M, Wolfe SM. Unnecessary cesarean sections: curing a national epidemic; 2020.

World Health Organization. Maternal deaths data by country. 2015; Available at: data/view.main.GSWCAH01v. Accessed on 17 July 2021.

Pakistan Demographic. Health survey 2012–13. islamabad and calverton, ma: National institute of population studies and icf international; 2013: 2015.

Kanji Z, Simonovich SD, Najmi N, Bishop-Royse J. Examining clinical indications for cesarean section in a university hospital in Karachi, Pakistan. Journal of Asian Midwives (JAM). 2019;6(1):14-25.

Sánchez-Romero J, García-Soria V, Araico-Rodríguez F, Herrera-Giménez J, Blanco-Carnero JE, Nieto-Díaz A, Sánchez-Ferrer ML. External Cephalic Version: Is it an Effective and Safe Procedure. JoVE. 2020;6(160):e60636.

Bin YS, Roberts CL, Nicholl MC, Ford JB. Uptake of external cephalic version for term breech presentation: an Australian population study, 2002–2012. BMC pregnancy and childbirth. 2017;17(1):1-7.

Kim GJ. Reviving external cephalic version: a review of its efficacy, safety, and technical aspects. Obstetrics & Gynecology Science. 2019 Oct 8;62(6):371-81.

Hakem E, Lindow SW, O’Connell MP, von Bünau G. External cephalic version-A 10-year review of practice. European Journal of Obstetrics & Gynecology and Reproductive Biology; 2021.

Levin G, Rottenstreich A, Weill Y, Pollack RN. External cephalic version at term: A 6‐year single‐operator experience. Birth. 2019;46(4):616-22.