Malpresentation (i.e. noncephalic presentation) complicates approximately 5% of pregnancies at term.¹ Diagnosis is typically made by ultrasound, preferably before the onset of labor. Although abdominal palpation or vaginal exam may suggest malpresentation, the diagnosis should be confirmed by ultrasound. The American College of Obstetricians and Gynecologists (ACOG) recommends documentation of fetal presentation starting at 36 weeks gestation.² If malpresentation is identified and no contraindications exist, the obstetrician should offer the patient ECV and counsel her on the risks and benefits of the procedure. In ECV, the obstetrician attempts to turn the fetus manually into a cephalic presentation. ACOG has recently published a Practice Bulletin that summarizes the major points and evidence with regard to ECV.²

Breech presentation occurs in 3% to 4% of labors.¹ It is more common earlier in gestation, with 25% of pregnancies <28 weeks and 7% of pregnancies at 32 weeks being complicated by breech presentation.¹ There are three types of breech presentation: frank, complete, and incomplete (also known as footling) (Fig. 63-1). Factors associated with breech presentation include such fetal malformations as trisomies, prematurity, müllerian anomalies, and fundal placentation.¹ As experience with breech vaginal deliveries (Chapter 59) is declining, most women with a breech fetus deliver by cesarean section (C-section) (Chapter 60). Alternatively, ECV may be employed to turn the fetus and permit a vaginal delivery. Of note, ECV also should be offered in cases of transverse and oblique lies, and it has a higher success rate in these circumstances than in breech presentation.²

All women with singleton fetuses in nonvertex presentations at term should be offered a trial of ECV unless contraindications exist. Box 63-1 lists the indications for ECV.

There is only limited data on contraindications to ECV.³ A number of absolute and relative contraindications are listed in Table 63-1.⁴ ACOG states that the appropriateness of ECV must be individualized.² Although there is evidence that ECV has a higher success rate earlier in gestation, this must be balanced against the risk of prematurity that could ensue after preterm labor or emergency C-section.⁵ ACOG recommends ECV starting only at 37 weeks.² Other contraindications include factors that increase the risk of the complications associated with ECV, including cord prolapse (ruptured membranes) and placental abruption (antepartum bleeding, gestational hypertension or preeclampsia). Factors that are associated with a high risk of failure with ECV, such as morbid obesity,⁶ uterine anomalies, and oligohydramnios, may tilt the balance unfavorably when comparing the risks and potential benefits of the procedure; therefore they are considered relative contraindications.