cephalic presentation at 33 weeks pregnant

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What to know if your baby is breech

Find out what breech position means, how to turn a breech baby, and what having a breech baby means for your labor and delivery.

What does it mean when a baby is breech?

Signs of a breech baby, why are some babies breech, how to turn a breech baby: is it possible, will i need a c-section if my baby is breech, how to turn a breech baby naturally.

Breech is a term used to describe your baby's position in the womb. Breech position means your baby is bottom-down instead of head-down.

Babies are often active in early pregnancy, moving into different positions. But by around 8 months, there's not much room in the uterus. Most babies maximize their cramped quarters by settling in head down, in what's known as a cephalic or vertex presentation. But if you have a breech baby, it means they're poised to come out buttocks and/or feet first. At 28 weeks or less, about a quarter of babies are breech, and at 32 weeks, 7 percent are breech. By the end of pregnancy, only 3 to 4 percent of babies are in breech position. At term, a baby in breech position is unlikely to turn on their own.

There are several types of breech presentations:

• Frank breech (bottom first with feet up near the head)
• Complete breech (bottom first with legs crossed)
• Incomplete or footling breech (one or both feet are poised to come out first)

(In rare cases, a baby will be sideways in the uterus with their shoulder, back, or arm presenting first – this is called a transverse lie.)

See what these breech presentations look like .

If your baby is in breech position, you may feel them kicking in your lower belly. Or you may feel pressure under your ribcage, from their head.

By the beginning of your third trimester , your practitioner may be able to tell what position your baby is in by feeling your abdomen and locating the baby's head, back, and bottom.

If your baby's position isn't clear during an abdominal exam at 36 weeks, your caregiver may do an internal exam to try to feel what part of the baby is in your pelvis. In some cases, they may use ultrasound to confirm the baby's position.

We don't usually know why some babies are breech – in most cases it seems to be chance. While sometimes a baby with certain birth defects may not turn to a head-down position, most babies in breech position are perfectly fine. Here are some things that might increase the risk of a breech presentation:

• You're carrying multiples
• You've been pregnant before
• You've had a breech presentation before
• There's too much amniotic fluid or not enough amniotic fluid
• You have placenta previa (the placenta is covering all of part of the opening of the uterus)
• Your baby is preterm
• Your uterus is shaped abnormally or has growths, such as fibroids
• The umbilical cord is short
• You were a breech delivery, or your sibling or parent was a breech delivery
• Advanced maternal age (especially age 45 and older)
• Your baby is a low weight at delivery
• You're having a girl

There is a procedure for turning a breech baby. It's called an external cephalic version (ECV). An ob/gyn turns your baby by applying pressure to your abdomen and manually manipulating the baby into a head-down position. Some women find it very uncomfortable or even painful.

An EVC has about a 58 percent success rate, and it's more likely to work if this isn't your first baby. It's not for everyone – you can't have the procedure if you're carrying multiples or if you have too little amniotic fluid or placental abruption , for example. Your provider also won't attempt to turn your breech baby if your baby has any health problems.

The procedure is done after 36 weeks and in the hospital, where your baby can be monitored and where you'll be near a delivery room should any complications arise.

It depends, and it's something you'll want to talk with your caregiver about ahead of time. Discuss your preferences, the advantages and risks of each option ( vaginal and cesarean delivery of a breech presentation), and their experience. The biggest risk of a breech delivery is when the body delivers but the head stays entrapped within the cervix.

In the United States, most breech babies are delivered via cesarean. You may wind up having a vaginal breech delivery if your labor is so rapid that you arrive at the hospital just about to deliver. Another scenario is if you have a twin pregnancy where the first baby is in the head-first position and the second baby is not. A baby who delivers head-first will make room for the breech baby.

However, the vast majority of babies who remain breech arrive by c-section. If a c-section is planned, it will usually be scheduled at 39 weeks. To make sure your baby hasn't changed position in the meantime, you'll have an ultrasound at the hospital to confirm their position just before the surgery.

If you go into labor or your water will break s before your planned c-section, be sure to call your provider right away and head for the hospital.

In rare circumstances, if you're at low risk of complications and your caregiver is experienced delivering breech babies vaginally, you may choose to have what is called a "trial of vaginal birth." This means that you can attempt to deliver vaginally but should be prepared to have a cesarean delivery if labor isn't progressing well. You and your baby will be closely monitored during labor.

In addition to ECV, there are some alternative, natural ways to try to turn your baby. There's no proof that any of them work – or that all of them are safe. Consult your practitioner before trying them.

There's no conclusive proof that the mother's position has any effect on the baby's position, but the idea is to employ gravity to help your baby somersault into a head-down position. A few tips:

• Get into one of the following positions twice a day, starting at around 32 weeks.
• Be sure to do these moves on an empty stomach, lest your lunch comes back up.
• Make sure there's someone around to help you get up if you start feeling lightheaded.
• If you find these positions uncomfortable, stop doing them.

Position 1: Lie flat on your back and raise your pelvis so that it's 9 to 12 inches off the floor. Support your hips with a pillow and stay in this position for five to 15 minutes. Position 2: Kneel down, with your forearms on the floor in front of you, so that your bottom sticks up in the air. Stay in this position for five to 15 minutes. Sleeping position

Many women wonder if there are sleeping positions to turn a breech baby. But the positions you use to try to coax your baby head down for a short time shouldn't be used while you're sleeping. (It's not safe to sleep flat on your back in late pregnancy, for example, because the weight of your baby may compress the blood vessels that provide oxygen and nutrients to them.)

The best position for sleeping during pregnancy is on your side. Placing a pillow between your legs in this position may help open your pelvis, giving your baby room to move more easily. Support your back with plenty of pillows, too. Again, there's no proof that this works, but since it's the best sleeping position for you and your baby, you may as well give it a try.

Moxibustion

This ancient Chinese technique burns herbs to stimulate key acupressure points. To help turn a breech baby, an acupuncturist or other practitioner burns mugwort near the acupressure point of your pinky toes. According to Chinese medicine, this should stimulate your baby's activity enough that they may change position on their own. Some studies show that moxibustion in combination with acupuncture and/or positioning methods may be of some benefit. Others show moxibustion to provide no help in coaxing a baby into cephalic position. If you've discussed it with your caregiver and want to give it a try, contact your state acupuncture or Chinese medicine association and ask for the names of licensed practitioners.

One small study found that women who are regularly hypnotized into a state of deep relaxation at 37 to 40 weeks are more likely to have their baby turn than other women. If you're willing to try this technique, look for a licensed hypnotherapist with experience working with pregnant women.

Chiropractic care

There's a technique – called The Webster Breech Technique – that aims to reduce stress on the pelvis by relaxing the uterus and surrounding ligaments. The idea is that a breech baby can turn more naturally in a relaxed uterus, but research is limited as to the risks and benefits of this technique. If you're interested, talk with your provider about working with a chiropractor who's experienced with the technique.

This is a safe – and again, unproven – method based on the fact that your baby can hear sounds outside the womb. Simply play music close to the lower part of your abdomen (some women use headphones) to encourage your baby to move in the direction of the sound.

Learn more:

• C-section recovery
• Third trimester pregnancy guide and checklist
• Hospital bag checklist

Was this article helpful?

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C-section recovery: Timeline, aftercare tips, and expectations

BabyCenter's editorial team is committed to providing the most helpful and trustworthy pregnancy and parenting information in the world. When creating and updating content, we rely on credible sources: respected health organizations, professional groups of doctors and other experts, and published studies in peer-reviewed journals. We believe you should always know the source of the information you're seeing. Learn more about our editorial and medical review policies .

ACOG. 2019. If your baby is breech. FAQ. The American College of Obstetricians and Gynecologists. https://www.acog.org/womens-health/faqs/if-your-baby-is-breech Opens a new window [Accessed November 2021]

ACOG. 2018. Mode of term singleton breech delivery. Committee opinion number 745. The American College of Obstetricians and Gynecologists. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/08/mode-of-term-singleton-breech-delivery Opens a new window [Accessed November 2021]

Brici P et al. 2019. Turning foetal breech presentation at 32-35 weeks of gestational age by acupuncture and moxibustion. Evidence-based Complementary and Alternative Medicine https://www.hindawi.com/journals/ecam/2019/8950924/ Opens a new window [Accessed November 2021]

Ekeus C et al. 2019. Vaginal breech delivery at term and neonatal morbidity and mortality — a population-based cohort study in Sweden. Journal of Maternal Fetal Neonatal Medicine 32(2):265. https://pubmed.ncbi.nlm.nih.gov/28889774/ Opens a new window [Accessed November 2021]

Fruscalzo A et al 2014. New and old predictive factors for breech presentation: our experience in 14433 singleton pregnancies and a literature review. Journal of Maternal Fetal Neonatal Medicine 27(2): 167-72. https://pubmed.ncbi.nlm.nih.gov/23688372/ Opens a new window [Accessed November 2021]

Garcia MM et al. 2019 Effectiveness and safety of acupuncture and moxibustion in pregnant women with noncephalic presentation: An overview of systematic reviews. Evidence Based Complementary Alternative Medicine 7036914. https://pubmed.ncbi.nlm.nih.gov/31885661/ Opens a new window [Accessed November 2021]

Gray C. 2021. Breech presentation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK448063/ Opens a new window [Accessed November 2021]

Meaghan M et al. 2021. External cephalic version. NCBI StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK482475/ Opens a new window [Accessed November 2021]

MedlinePlus. 2020. Breech - series - Types of breech presentation. https://medlineplus.gov/ency/presentations/100193_3.htm Opens a new window [Accessed November 2020]

Noli SA et al. 2019. Preterm birth, low gestational age, low birth weight, parity, and other determinants of breech presentation: Results from a large retrospective population-based study. Biomed Research International https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766171/ Opens a new window [Accessed November 2021]

Pistolese RA. 2002. The Webster Technique: A chiropractic technique with obstetric implications. Journal of Manipulative and Physiological Therapeutics 25(6): E1-9. https://pubmed.ncbi.nlm.nih.gov/12183701/ Opens a new window [Accessed November 2021]

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What Is Cephalic Position?

The ideal fetal position for labor and delivery

• Why It's Best

Risks of Other Positions

• Determining Position
• Turning a Fetus

The cephalic position is when a fetus is head down when it is ready to enter the birth canal. This is one of a few variations of how a fetus can rest in the womb and is considered the ideal one for labor and delivery.

About 96% of babies are born in the cephalic position. Most settle into it between the 32nd and 36th weeks of pregnancy . Your healthcare provider will monitor the fetus's position during the last weeks of gestation to ensure this has happened by week 36.

If the fetus is not in the cephalic position at that point, the provider may try to turn it. If this doesn't work, some—but not all—practitioners will attempt to deliver vaginally, while others will recommend a Cesarean (C-section).

Getty Images

Why Is the Cephalic Position Best?

During labor, contractions dilate the cervix so the fetus has adequate room to come through the birth canal. The cephalic position is the easiest and safest way for the baby to pass through the birth canal.

If the fetus is in a noncephalic position, delivery becomes more challenging. Different fetal positions have a range of difficulties and varying risks.

A small percentage of babies present in noncephalic positions. This can pose risks both to the fetus and the mother, and make labor and delivery more challenging. It can also influence the way in which someone can deliver.

A fetus may actually find itself in any of these positions throughout pregnancy, as the move about the uterus. But as they grow, there will be less room to tumble around and they will settle into a final position.

It is at this point that noncephalic positions can pose significant risks.

Cephalic Posterior

A fetus may also present in an occiput or cephalic posterior position. This means they are positioned head down, but they are facing the abdomen instead of the back.

This position is also nicknamed "sunny-side up."

Presenting this way increases the chance of a painful and prolonged delivery.

There are three different types of breech fetal positioning:

• Frank breech: The legs are up with the feet near the head.
• Footling breech: One or both legs is lowered over the cervix.
• Complete breech: The fetus is bottom-first with knees bent.

A vaginal delivery is most times a safe way to deliver. But with breech positions, a vaginal delivery can be complicated.

When a baby is born in the breech position, the largest part—its head—is delivered last. This can result in them getting stuck in the birth canal (entrapped). This can cause injury or death.

The umbilical cord may also be damaged or slide down into the mouth of the womb, which can reduce or cut off the baby's oxygen supply.

Some providers are still comfortable performing a vaginal birth as long as the fetus is doing well. But breech is always a riskier delivery position compared with the cephalic position, and most cases require a C-section.

Likelihood of a Breech Baby

You are more likely to have a breech baby if you:

• Go into early labor before you're full term
• Have an abnormally shaped uterus, fibroids , or too much amniotic fluid
• Are pregnant with multiples
• Have placenta previa (when the placenta covers the cervix)

Transverse Lie

In transverse lie position, the fetus is presenting sideways across the uterus rather than vertically. They may be:

• Down, with the back facing the birth canal
• With one shoulder pointing toward the birth canal
• Up, with the hands and feet facing the birth canal

If a transverse lie is not corrected before labor, a C-section will be required. This is typically the case.

Determining Fetal Position

Your healthcare provider can determine if your baby is in cephalic presentation by performing a physical exam and ultrasound.

In the final weeks of pregnancy, your healthcare provider will feel your lower abdomen with their hands to assess the positioning of the baby. This includes where the head, back, and buttocks lie

If your healthcare provider senses that the fetus is in a breech position, they can use ultrasound to confirm their suspicion.

Turning a Fetus So They Are in Cephalic Position

External cephalic version (ECV) is a common, noninvasive procedure to turn a breech baby into cephalic position while it's still in the uterus.

This is only considered if a healthcare provider monitors presentation progress in the last trimester and notices that a fetus is maintaining a noncephalic position as your delivery date approaches.

External Cephalic Version (ECV)

ECV involves the healthcare provider applying pressure to your stomach to turn the fetus from the outside. They will attempt to rotate the head forward or backward and lift the buttocks in an upward position. Sometimes, they use ultrasound to help guide the process.

The best time to perform ECV is about 37 weeks of pregnancy. Afterward, the fetal heart rate will be monitored to make sure it’s within normal levels. You should be able to go home after having ECV done.

ECV has a 50% to 60% success rate. However, even if it does work, there is still a chance the fetus will return to the breech position before birth.

Natural Methods For Turning a Fetus

There are also natural methods that can help turn a fetus into cephalic position. There is no medical research that confirms their efficacy, however.

• Changing your position: Sometimes a fetus will move when you get into certain positions. Two specific movements that your provider may recommend include: Getting on your hands and knees and gently rocking back and forth. Another you could try is pushing your hips up in the air while laying on your back with your knees bent and feet flat on the floor (bridge pose).
• Playing stimulating sounds: Fetuses gravitate to sound. You may be successful at luring a fetus out of breech position by playing music or a recording of your voice near your lower abdomen.
• Chiropractic care: A chiropractor can try the Webster technique. This is a specific chiropractic analysis and adjustment which enables chiropractors to establish balance in the pregnant person's pelvis and reduce undue stress to the uterus and supporting ligaments.
• Acupuncture: This is a considerably safe way someone can try to turn a fetus. Some practitioners incorporate moxibustion—the burning of dried mugwort on certain areas of the body—because they believe it will enhance the chances of success.

A Word From Verywell

While most babies are born in cephalic position at delivery, this is not always the case. And while some fetuses can be turned, others may be more stubborn.

This may affect your labor and delivery wishes. Try to remember that having a healthy baby, and staying well yourself, are your ultimate priorities. That may mean diverting from your best laid plans.

Speaking to your healthcare provider about turning options and the safest route of delivery may help you adjust to this twist and feel better about how you will move ahead.

Glezerman M. Planned vaginal breech delivery: current status and the need to reconsider . Expert Rev Obstet Gynecol. 2012;7(2):159-166. doi:10.1586/eog.12.2

Cleveland Clinic. Fetal positions for birth .

MedlinePlus. Breech birth .

UT Southwestern Medical Center. Can you turn a breech baby around?

The American College of Obstetricians and Gynecologists. If your baby is breech .

Roecker CB. Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios .  Journal of Chiropractic Medicine . 2013;12(2):74-78. doi:10.1016/j.jcm.2013.06.003

By Cherie Berkley, MS Berkley is a journalist with a certification in global health from Johns Hopkins University and a master's degree in journalism.

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• Pregnancy week by week
• Fetal presentation before birth

The way a baby is positioned in the uterus just before birth can have a big effect on labor and delivery. This positioning is called fetal presentation.

Babies twist, stretch and tumble quite a bit during pregnancy. Before labor starts, however, they usually come to rest in a way that allows them to be delivered through the birth canal headfirst. This position is called cephalic presentation. But there are other ways a baby may settle just before labor begins.

Following are some of the possible ways a baby may be positioned at the end of pregnancy.

Head down, face down

When a baby is head down, face down, the medical term for it is the cephalic occiput anterior position. This the most common position for a baby to be born in. With the face down and turned slightly to the side, the smallest part of the baby's head leads the way through the birth canal. It is the easiest way for a baby to be born.

Head down, face up

When a baby is head down, face up, the medical term for it is the cephalic occiput posterior position. In this position, it might be harder for a baby's head to go under the pubic bone during delivery. That can make labor take longer.

Most babies who begin labor in this position eventually turn to be face down. If that doesn't happen, and the second stage of labor is taking a long time, a member of the health care team may reach through the vagina to help the baby turn. This is called manual rotation.

In some cases, a baby can be born in the head-down, face-up position. Use of forceps or a vacuum device to help with delivery is more common when a baby is in this position than in the head-down, face-down position. In some cases, a C-section delivery may be needed.

Frank breech

When a baby's feet or buttocks are in place to come out first during birth, it's called a breech presentation. This happens in about 3% to 4% of babies close to the time of birth. The baby shown below is in a frank breech presentation. That's when the knees aren't bent, and the feet are close to the baby's head. This is the most common type of breech presentation.

If you are more than 36 weeks into your pregnancy and your baby is in a frank breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Most babies in a frank breech position are born by planned C-section.

Complete and incomplete breech

A complete breech presentation, as shown below, is when the baby has both knees bent and both legs pulled close to the body. In an incomplete breech, one or both of the legs are not pulled close to the body, and one or both of the feet or knees are below the baby's buttocks. If a baby is in either of these positions, you might feel kicking in the lower part of your belly.

If you are more than 36 weeks into your pregnancy and your baby is in a complete or incomplete breech presentation, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. It involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a breech position, talk with a member of your health care team about the choices you have for delivery. Many babies in a complete or incomplete breech position are born by planned C-section.

When a baby is sideways — lying horizontal across the uterus, rather than vertical — it's called a transverse lie. In this position, the baby's back might be:

• Down, with the back facing the birth canal.
• Sideways, with one shoulder pointing toward the birth canal.
• Up, with the hands and feet facing the birth canal.

Although many babies are sideways early in pregnancy, few stay this way when labor begins.

If your baby is in a transverse lie during week 37 of your pregnancy, your health care professional may try to move the baby into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of your health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

If the procedure isn't successful, or if the baby moves back into a transverse lie, talk with a member of your health care team about the choices you have for delivery. Many babies who are in a transverse lie are born by C-section.

If you're pregnant with twins and only the twin that's lower in the uterus is head down, as shown below, your health care provider may first deliver that baby vaginally.

Then, in some cases, your health care team may suggest delivering the second twin in the breech position. Or they may try to move the second twin into a head-down position. This is done using a procedure called external cephalic version. External cephalic version involves one or two members of the health care team putting pressure on your belly with their hands to get the baby to roll into a head-down position.

Your health care team may suggest delivery by C-section for the second twin if:

• An attempt to deliver the baby in the breech position is not successful.
• You do not want to try to have the baby delivered vaginally in the breech position.
• An attempt to move the baby into a head-down position is not successful.
• You do not want to try to move the baby to a head-down position.

In some cases, your health care team may advise that you have both twins delivered by C-section. That might happen if the lower twin is not head down, the second twin has low or high birth weight as compared to the first twin, or if preterm labor starts.

• Landon MB, et al., eds. Normal labor and delivery. In: Gabbe's Obstetrics: Normal and Problem Pregnancies. 8th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed May 19, 2023.
• Holcroft Argani C, et al. Occiput posterior position. https://www.updtodate.com/contents/search. Accessed May 19, 2023.
• Frequently asked questions: If your baby is breech. American College of Obstetricians and Gynecologists https://www.acog.org/womens-health/faqs/if-your-baby-is-breech. Accessed May 22, 2023.
• Hofmeyr GJ. Overview of breech presentation. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Strauss RA, et al. Transverse fetal lie. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Chasen ST, et al. Twin pregnancy: Labor and delivery. https://www.updtodate.com/contents/search. Accessed May 22, 2023.
• Cohen R, et al. Is vaginal delivery of a breech second twin safe? A comparison between delivery of vertex and non-vertex second twins. The Journal of Maternal-Fetal & Neonatal Medicine. 2021; doi:10.1080/14767058.2021.2005569.
• Marnach ML (expert opinion). Mayo Clinic. May 31, 2023.

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Why Is Cephalic Presentation Ideal For Childbirth?

5   Dec   2017 | 8 min Read

During labour, contractions stretch your birth canal so that your baby has adequate room to come through during birth. The cephalic presentation is the safest and easiest way for your baby to pass through the birth canal.

If your baby is in a non-cephalic position, delivery can become more challenging. Different fetal positions pose a range of difficulties and varying risks and may not be considered ideal birthing positions.

Two Kinds of Cephalic Positions

There are two kinds of cephalic positions:

• Cephalic occiput anterior , where your baby’s head is down and is facing toward your back.
• Cephalic occiput posterior , where your baby is positioned head down, but they are facing your abdomen instead of your back. This position is also nicknamed ‘sunny-side-up’ and can increase the chances of prolonged and painful delivery. 

How to Know if Your Baby is In a Cephalic Position?

You can feel your baby’s position by rubbing your hand on your belly. If you feel your little one’s stomach in the upper stomach, then your baby is in a cephalic position. But if you feel their kicks in the lower stomach, then it could mean that your baby is in a breech position.

You can also determine whether your baby is in the anterior or posterior cephalic position. If your baby is in the anterior position, you may feel their movement underneath your ribs and your belly button could also pop out. If your baby is in the posterior position, then you may feel their kicks in their abdomen, and your stomach may appear rounded up instead of flat. 

You can also determine your baby’s position through an ultrasound scan or a physical examination at your healthcare provider’s office. 

Benefits of Cephalic Presentation in Pregnancy

Cephalic presentation is one of the most ideal birth positions, and has the following benefits:

• It is the safest way to give birth as your baby’s position is head-down and prevents the risk of any injuries.
• It can help your baby move through the delivery canal as safely and easily as possible.
• It increases the chances of smooth labour and delivery.

Are There Any Risks Involved in Cephalic Position?

Conditions like a cephalic posterior position in addition to a narrow pelvis of the mother can increase the risk of pregnancy complications during delivery. Some babies in the head-first cephalic presentation might have their heads tilted backward. This may, in some rare cases, cause preterm delivery.

What are the Risks Associated with Other Birth Positions?

A small percentage of babies may settle into a non-cephalic position before their birth. This can pose risks to both your and your baby’s health, and also influence the way in which you deliver. 

In the next section, we have discussed a few positions that your baby can settle in throughout pregnancy, as they move around the uterus. But as they grow old, there will be less space for them to tumble around, and they will settle into their final position. This is when non-cephalic positions can pose a risk.  

Breech Position

There are three types of breech fetal positioning:

• Frank breech : Your baby’s legs stick straight up along with their feet near their head.
• Footling breech: One or both of your baby’s legs are lowered over your cervix.
• Complete breech: Your baby is positioned bottom-first with their knees bent.

If your baby is in a breech position , vaginal delivery is considered complicated. When a baby is born in breech position, the largest part of their body, that is, their head is delivered last. This can lead to injury or even fetal distress. Moreover, the umbilical cord may also get damaged or get wrapped around your baby’s neck, cutting off their oxygen supply.  

If your baby is in a breech position, your healthcare provider may recommend a c-section, or they may try ways to flip your baby’s position in a cephalic presentation.

Transverse Lie

In this position, your baby settles in sideways across the uterus rather than being in a vertical position. They may be:

• Head-down, with their back facing the birth canal
• One shoulder pointing toward the birth canal
• Up with their hands and feet facing the birth canal

If your baby settles in this position, then your healthcare provider may suggest a c-section to reduce the risk of distress in your baby and other pregnancy complications.

Turning Your Baby Into A Cephalic Position

External cephalic version (ECV) is a common, and non-invasive procedure that helps turn your baby into a cephalic position while they are in the womb. However, your healthcare provider may only consider this procedure if they consider you have a stable health condition in the last trimester, and if your baby hasn’t changed their position by the 36th week.

You can also try some natural remedies to change your baby’s position, such as:

• Lying in a bridge position: Movements like bridge position can sometimes help move your baby into a more suitable position. Lie on your back with your feet flat on the ground and your legs bent. Raise your pelvis and hips into a bridge position and hold for 5-10 minutes. Repeat several times daily.
• Chiropractic care: A chiropractor can help with the adjustment of your baby’s position and also reduce stress in them.
• Acupuncture: After your doctor’s go-ahead, you can also consider acupuncture to get your baby to settle into an ideal birthing position.

While most babies settle in a cephalic presentation by the 36th week of pregnancy, some may lie in a breech or transverse position before birth. Since the cephalic position is considered the safest, your doctor may recommend certain procedures to flip your baby’s position to make your labour and delivery smooth. You may also try the natural methods that we discussed above to get your baby into a safe birthing position and prevent risks or other pregnancy complications. 

When Should A Baby Be In A Cephalic Position?

Your baby would likely naturally drop into a cephalic position between weeks 37 to 40 of your pregnancy .

Is Cephalic Position Safe?

Research shows that 95% of babies take the cephalic position a few weeks or days before their due date. It is considered to be the safest position. It ensures a smooth birthing process.

While most of the babies are in cephalic position at delivery, this is not always the case. If you have a breech baby, you can discuss the available options for delivery with your doctor.

Does cephalic presentation mean labour is near?

Head-down is the ideal position for your baby within your uterus during birth. This is known as the cephalic position. This posture allows your baby to pass through the delivery canal more easily and safely.

Can babies change from cephalic to breech?

The external cephalic version (ECV) is the most frequent procedure used for turning a breech infant.

How can I keep my baby in a cephalic position?

While your baby naturally gets into this position, you can try some exercises to ensure that they settle in cephalic presentation. Exercises such as breech tilt, forward-leaning position (spinning babies program), cat and camel pose can help.

Stitches after a normal delivery : How many stitches do you need after a vaginal delivery? Tap this post to know.

Vaginal birth after caesarean delivery : Learn all about the precautions to consider before having a vaginal delivery after a c-section procedure. 

How many c-sections can you have : Tap this post to know the total number of c-sections that you can safely have.

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Week 33 of Your Pregnancy

Find out how your body is changing—and how your baby is developing—in week 33 of your pregnancy.

Design By Alice Morgan / Illustration by Tara Anand

It's week 33 of your pregnancy and, with just a few weeks left until your due date, you may be getting anxious about labor and delivery . You may also be wondering about what comes next, i.e. what does life with a newborn look like. But for now, let’s focus on the moment. Let’s learn all about the changes you and your unborn baby are undergoing at 33 weeks pregnant. Oh, and learn the difference between “practice” contractions and real contractions—so you’re ready to go, when the time comes.

Pregnancy Week 33 Quick Facts

• At 33 weeks, you are 8 months pregnant
• You have 7 weeks until your due date
• You're in the third trimester

Your Unborn Baby's Size at 33 Weeks 

Your unborn baby is about the size of a pineapple . The fetus weighs between 4.23 pounds and is about 17.20 inches long.

Pregnancy Symptoms Week 33 

During week 33, your pregnancy symptoms will be similar to week 32 (and earlier weeks). However, the intensity of said symptoms may increase this week. You may experieince:

• Braxton Hicks contractions
• Frequent urination
• Breathlessness

"Braxton Hicks contractions are a normal and common occurrence during pregnancy. These contractions, also known as ‘practice contractions,’ are the body's way of preparing for labor. It is important to note that, if you experience frequent or painful contractions, it is best to contact your health care provider to ensure that there are no underlying issues or complications," says Stanislaw Miaskowski, M.D., OB-GYN with the Orlando Health Winnie Palmer Hospital for Women and Babies in Orlando, Florida. 

Braxton Hicks are characterized by the tightening of the uterine muscles. "The contraction can last anywhere from 30 seconds to 2 minutes and can occur sporadically or in a regular pattern,” says Dr. Miaskowski. “True labor contractions [on the other hand] will typically maintain in a regular pattern, with contractions occurring every two to five minutes and lasting for 30 to 60 seconds for at least an hour. Additionally, the contractions will increase in intensity over time.”

That said, Braxton Hicks can be disruptive—and can catch you off guard. So how can you best manage Braxton Hicks contractions? Dr. Miaskowski suggests changing positions, resting, hydrating, and practicing breathing techniques such as slow, deep breathing or belly breathing to help relax the body and reduce the intensity of Braxton Hicks contractions. Massaging the abdomen can also reduce the discomfort caused by Braxton Hicks contractions.

It is important to note that if you experience frequent or painful contractions, it is best to contact your health care provider to ensure there are no underlying issues or complications.

You may have already been experiencing frequent urination for some time, but in week 33 (and beyond) some pregnant individuals find they need to rush to the bathroom all of the time. "Frequent urination is due to additional pressure on the bladder from the growing uterus and the increased circulating fluid volume in pregnancy," says Teresa Tan, M.D., OB-GYN at Altos Medical Group with Stanford Medicine Children's Health in Mountain View, California. 

In most cases, this is normal, but pregnant individuals should be concerned and seek out medical guidance if there is corresponding pain and/or burning with urination, increased urgency, and/or fever and chills.

Experts recommend pregnant individuals do their best when it comes to breathlessness. Again, it may not be a new symptom, but by week 33—and beyond—symptoms may start to increase. According to Dr. Tan, this is due to the pressure the pregnancy is placing on the diaphragm.

For pregnant people who have a chronic respiratory condition, breathlessness may make things harder. So, if you have pre-existing respiratory issues like asthma, it's important to keep your rescue medication nearby at all times. 

And whether you have a history of respiratory issues or not, Dr. Tan says she would be very concerned if a pregnant individual has severe symptoms, including "difficulty talking, chest pain, swelling in the face or throat, or any other concerning issues relating to breathlessness." Simply put, if you feel you are having a respiratory emergency, head to your closest emergency room or medical facility, or dial 911. 

Remember, if you have questions about any symptoms—big or small—don't hesitate to call your health care provider.

Design by Alice Morgan

Developmental Milestones 

Developmentally, big changes are happening to the fetus during week 33. Your unborn baby is practicing their breathing movements as their lungs continue to develop and get stronger. They now have their very own immune system. In fact, antibodies can now be passed from you to your fetus as they continue to grow. Once the unborn baby is delivered and outside the womb, its immune system will help fight against germs.

Your unborn baby's brain and nervous system are now fully developed and their bones will continue to harden with one exception: the skull. A fetus' skull bones stay soft and separated until after the birth to make the journey through the birth canal easier.

Prenatal Tests and Doctor's Appointments 

The majority of pregnant people will have this week off, having had a visit last week and a visit scheduled next week. However, if there were scheduling conflicts or if you are high-risk, you may have a 33-week appointment. 

As is the case with most prenatal visits, there are a number of routine tests and procedures: you will probably be weighed, have your blood pressure taken, and have your urine tested. During the standard 32 to 34 prenatal visit, your provider will monitor your unborn baby's fetal heart rate, and notice any changes with your unborn baby's fetal growth measurements. 

Many providers will also check on the position of the unborn baby. The most common fetal position is cephalic and occiput anterior, meaning the unborn baby's head enters the pelvis facing your back and is considered to be the least risky position for a vaginal birth. The  breech position  is when the unborn baby is lying bottom or feet first. Transverse position is when the unborn baby is positioned horizontally across the uterus rather than vertically. 

If you do not want to know your weight, let the staff know as soon as you're called into the exam room. It's important to advocate for yourself during your prenatal check-ups. That said, it is worth noting that weight checks are an important part of many prenatal visits, i.e. they help your care team catch significant losses and/or gains. So while self advocacy is important, it can and should be done through the lens of informed consent. You can also just ask your doctor, midwife, or health care provider to keep your numbers a secret. They do not have to disclose the results to you.

Common Questions at This Pregnancy Stage

What can I do about frequent urination?

While frequent urination is not dangerous, it can be an unpleasant (and disruptive) pregnancy symptom. But what can you do about it? According to Dr. Tan, the best way is to plan accordingly: "Frequent urination can be helped with planned/timed voiding to avoid sudden urges and emergencies. Pelvic floor strengthening exercises can also be useful." Is my unborn baby in the right position?

When it comes to labor and delivery, you want your baby to be positioned head-down, facing your back, with their chin tucked to their chest. This is called cephalic presentation. Most babies settle into this position between the 32nd and 36th week of pregnancy, but some babies may move into this position sooner—or later. If you are concerned about babies positioning, speak to your doctor, midwife , or health care provider. Should I be meal prepping?

While you still have several weeks left in pregnancy, it is never too early to start meal prepping—especially crock pot-style meals which can be frozen in Tupperware containers or Ziploc bags. Kimberly Zapata, an associate editor at Parents, started the process in her eighth month. Not sure where to begin? Think casseroles, stews, soups, and other meals which are easy to prep, freeze, and reheat.

Things You Might Consider This Week 

At 33 weeks pregnant, now is a great time to check out breastfeeding classes—if you are considering breastfeeding and want more information. La Leche League has free online resources and their meetings (both online and in-person) are often very welcoming to pregnant individuals and first-time parents. Don't think you have to wait until after you've given birth to join a breastfeeding support group community.

You may also want to consider packing your hospital bag during week 33 of your pregnancy. While you still have time, it’s never too early to get things in order—especially when you consider that you could give birth before your due date. But what do you need to pack in your hospital bag? I mean, where do you begin? Check out this handy checklist to ensure you have everything in order. 

Support You May Need This Week

You may have a lot of energy this week, specifically organizational energy. Commonly referred to as nesting , this instinctual reaction is one of the ways expectant parents unconsciously prepare for birth. But while you may want to do all the things all at once—like meal prep, paint, build furniture, and babyproof your home —it’s important you don’t overextend yourself. Instead, ask for help. No task is too silly (or small) and every little bit helps.   

Head over to week 34 of pregnancy

What Week 33 of Your Pregnancy Is Really Like

Related articles.

You and your baby at 32 weeks pregnant

Your baby at 32 weeks.

By about 32 weeks, the baby is usually lying with their head pointing downwards, ready for birth. This is known as cephalic presentation.

If your baby is not lying head down at this stage, it's not a cause for concern – there's still time for them to turn.

The amount of amniotic fluid in your uterus is increasing, and your baby is still swallowing fluid and passing it out as urine.

You at 32 weeks

Being active and fit during pregnancy will help you adapt to your changing shape and weight gain. It can also help you cope with labour and get back into shape after the birth.

Find out about exercise in pregnancy .

You may develop pelvic pain in pregnancy. This is not harmful to your baby, but it can cause severe pain and make it difficult for you to get around.

Find out about ways to tackle pelvic pain in pregnancy .

Read about the benefits of breastfeeding for you and your baby. It's never too early to start thinking about how you're going to feed your baby, and you do not have to make up your mind until your baby is born.

Things to think about

• how you might feel after the birth

Start4Life has more about you and your baby at 32 weeks pregnant .

You can sign up for Start4Life's weekly emails for expert advice, videos and tips on pregnancy, birth and beyond.

Page last reviewed: 13 October 2021 Next review due: 13 October 2024

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• Prenatal Care

Fetal Cephalic Presentation During Pregnancy

What Is Cephalic Position?

Types of cephalic position, benefits of cephalic presentation, risks of cephalic position, what are some other positions and their associated risks, when does a foetus get into the cephalic position, how do you know if baby is in cephalic position, how to turn a breech baby into cephalic position, natural ways to turn a baby into cephalic position.

If your baby is moving around in the womb, it’s a good sign as it tells you that your baby is developing just fine. A baby starts moving around in the belly at around 14 weeks. And their first movements are usually called ‘ quickening’ or ‘fluttering’.

A baby can settle into many different positions throughout the pregnancy, and it’s alright. But it is only when you have reached your third and final trimester that the position of your baby in your womb will matter the most. The position that your baby takes at the end of the gestation period will most likely be how your baby will make its appearance in the world. Out of all the different positions that your baby can settle into, the cephalic position at 36 weeks is considered the best position. Read on to learn more about fetal cephalic presentation.

When it comes to cephalic presentation meaning, the following can be considered. A baby is in the cephalic position when he is in a head-down position. This is the best position for them to come out in. In case of a ‘cephalic presentation’, the chances of a smooth delivery are higher. This position is where your baby’s head has positioned itself close to the birth canal, and the feet and bottom are up. This is the best position for your baby to be in for safe and healthy delivery.

Your doctor will begin to keep an eye on the position of your baby at around 34 weeks to 36 weeks . The closer you get to your due date, the more important it is that your baby takes the cephalic position. If your baby is not in this position, your doctor will try gentle nudges to get your baby in the right position.

Though it is pretty straightforward, the cephalic position actually has two types, which are explained below:

1. Cephalic Occiput Anterior

Most babies settle in this position. Out of all the babies who settle in the cephalic position, 95% of them will settle this way. This is when a baby is in the head-down position but is facing the mother’s back. This is the preferred position as the baby is able to slide out more easily than in any other position.

2. Cephalic Occiput Posterior

In this position, the baby is in the head-down position but the baby’s face is turned towards the mother’s belly. This type of cephalic presentation is not the best position for delivery as the baby’s head could get stuck owing to its wide position. Almost 5% of the babies in cephalic presentation settle into this position. Babies who come out in this position are said to come out ‘sunny side up’.

Cephalic presentation, where the baby’s head is positioned down towards the birth canal, is the most common and optimal fetal presentation for childbirth. This positioning facilitates a smoother delivery process for both the mother and the baby. Here are several benefits associated with cephalic presentation:

1. Reduced risk of complications

Cephalic presentation decreases the likelihood of complications during labor and delivery , such as umbilical cord prolapse or shoulder dystocia, which can occur with other presentations.

2. Easier vaginal delivery

With the baby’s head positioned first, vaginal delivery is generally easier and less complicated compared to other presentations, resulting in a smoother labor process for the mother.

3. Lower risk of birth injuries

Cephalic presentation reduces the risk of birth injuries to the baby, such as head trauma or brachial plexus injuries, which may occur with other presentations, particularly breech or transverse positions.

4. Faster progression of labor

Babies in cephalic presentation often help to stimulate labor progression more effectively through their positioning, potentially shortening the duration of labor and reducing the need for medical interventions.

5. Better fetal oxygenation

Cephalic presentation typically allows for optimal positioning of the baby’s head, which facilitates adequate blood flow and oxygenation, contributing to the baby’s well-being during labor and delivery.

Factors such as the cephalic posterior position of the baby and a narrow maternal pelvis can increase the likelihood of complications during childbirth. Occasionally, infants in the cephalic presentation may exhibit a backward tilt of their heads, potentially leading to preterm delivery in rare instances.

In addition to cephalic presentation, there are several other fetal positions that can occur during pregnancy and childbirth, each with its own associated risks. These positions can impact the delivery process and may require different management strategies. Here are two common fetal positions and their associated risks:

1. Breech Presentation

• Babies in breech presentation, where the buttocks or feet are positioned to enter the birth canal first, are at higher risk of birth injuries such as hip dysplasia or brachial plexus injuries.
• Breech presentation can lead to complications during labor and delivery, including umbilical cord prolapse, entrapment of the head, or difficulty delivering the shoulders, necessitating interventions such as cesarean section.

2. Transverse Lie Presentation

• Transverse lie , where the baby is positioned sideways across the uterus, often leads to prolonged labor and increases the likelihood of cesarean section due to difficulties in the baby’s descent through the birth canal.
• The transverse position of the baby may result in compression of the umbilical cord during labor, leading to decreased oxygen supply and potential fetal distress. This situation requires careful monitoring and intervention to ensure the baby’s well-being.

When a foetus is moving into the cephalic position, it is known as ‘head engagement’. The baby stars getting into this position in the third trimester, between the 32nd and the 36th weeks, to be precise. When the head engagement begins, the foetus starts moving down into the pelvic canal. At this stage, very little of the baby is felt in the abdomen, but more is felt moving downward into the pelvic canal in preparation for birth.

You may think that in order to find out if your baby has a cephalic presentation, an ultrasound is your only option. This is not always the case. You can actually find out the position of your baby just by touching and feeling their movements.

By rubbing your hand on your belly, you might be able to feel their position. If your baby is in the cephalic position, you might feel their kicks in the upper stomach. Whereas, if the baby is in the breech position, you might feel their kicks in the lower stomach.

Even in the cephalic position, it may be possible to tell if your baby is in the anterior position or in the posterior position. When your baby is in the anterior position, they may be facing your back. You may be able to feel your baby move underneath your ribs. It is likely that your belly button will also pop out.

When your baby is in the posterior position, you will usually feel your baby start to kick you in your stomach. When your baby has its back pressed up against your back, your stomach may not look rounded out, but flat instead.

Mothers whose placentas have attached in the front, something known as anterior placenta , you may not be able to feel the movements of your baby as well as you might like to.

Breech babies can make things complicated. Both the mother and the baby will face some problems. A breech baby is positioned head-up and bottom down. In order to deliver the baby, the birth canal needs to open a lot wider than it has to in the cephalic position. Besides this, your baby can get an arm or leg entangled while coming out.

If your baby is in the breech position, there are some things that you can do to encourage the baby to get into the cephalic position. There are a few exercises that could help such as pelvic tilts , swimming , spending a bit of time upside down, and belly dancing are a few ways you can try yourself to get your baby into the head-down position .

If this is not working either, your doctor will try an ECV (External Cephalic Version) . Here, your doctor will be hands-on, applying some gentle, but firm pressure to your tummy. In order to reach a cephalic position, the baby will need to be rolled into a bottom’s up position. This technique is successful around 50% of the time. When this happens, you will be able to have a normal vaginal delivery.

Though it sounds simple enough to get the fetal presentation into cephalic, there are some risks involved with ECV. If your doctor notices your baby’s heart rate starts to become problematic, the doctor will stop the procedure right away.

Encouraging a baby to move into the cephalic position, where the head is down towards the birth canal, is often desirable for smoother labor and delivery. While medical interventions may be necessary in some cases, there are natural methods that pregnant individuals can try to help facilitate this positioning. Here are several techniques that may help turn a baby into the cephalic position:

1. Optimal Maternal Positioning

Maintaining positions such as kneeling, hands and knees, or pelvic tilts may encourage the baby to move into the cephalic position by utilizing gravity and reducing pressure on the pelvis.

2. Spinning Babies Techniques

Specific exercises and positions recommended by the Spinning Babies organization, such as Forward-Leaning Inversion or the Sidelying Release, aim to promote optimal fetal positioning and may help encourage the baby to turn cephalic.

3. Chiropractic Care or Acupuncture

Some individuals find that chiropractic adjustments or acupuncture sessions with qualified practitioners can help address pelvic misalignment or relax tight muscles, potentially creating more space for the baby to maneuver into the cephalic position.

4. Prenatal Yoga and Swimming

Engaging in gentle exercises like prenatal yoga or swimming may help promote relaxation, reduce stress on the uterine ligaments, and encourage the baby to move into the cephalic position naturally. These activities also support overall physical and mental well-being during pregnancy.

1. What factors influence whether my baby will be in cephalic presentation?

Several factors can influence your baby’s position during pregnancy, including the shape and size of your uterus, the strength of your abdominal muscles, the amount of amniotic fluid, and the position of the placenta . Additionally, your baby’s own movements and preferences play a role.

2. Is it necessary for my baby to be in cephalic presentation for a vaginal delivery?

While cephalic presentation is considered the optimal position for vaginal delivery, some babies born in non-cephalic presentations can still be safely delivered vaginally with the guidance of a skilled healthcare provider. However, certain non-cephalic presentations may increase the likelihood of needing a cesarean section.

3. What can I do to encourage my baby to stay in the cephalic presentation?

Maintaining good posture, avoiding positions that encourage the baby to settle into a breech or transverse lie, staying active with gentle exercises, and avoiding excessive reclining can all help encourage your baby to remain in the cephalic presentation. Additionally, discussing any concerns with your healthcare provider and following their recommendations can be beneficial.

This was all about fetus with cephalic presentation. Most babies get into the cephalic position on their own. This is the most ideal situation as there will be little to no complications during normal vaginal labour. There are different cephalic positions, but these should not cause a lot of issues. If your baby is in any position other than cephalic in pregnancy, you may need C-Section . Keep yourself updated on the smallest of progress during your pregnancy so that you are aware of everything that is going on. Go for regular check-ups as your doctor will be able to help you if a complication arises during acephalic presentation at 20, 28 and 30 weeks.

References/Resources:

1. Glezerman. M; Planned vaginal breech delivery: current status and the need to reconsider (Expert Review of Obstetrics & Gynecology); Taylor & Francis Online; https://www.tandfonline.com/doi/full/10.1586/eog.12.2 ; January 2014

2. Feeling your baby move during pregnancy; UT Southwestern Medical Center; https://utswmed.org/medblog/fetal-movements/

3. Fetal presentation before birth; Mayo Clinic; https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/fetal-positions/art-20546850

4. Fetal Positions; Cleveland Clinic; https://my.clevelandclinic.org/health/articles/9677-fetal-positions-for-birth

5. FAQs: If Your Baby Is Breech; American College of Obstetricians and Gynecologists; https://www.acog.org/womens-health/faqs/if-your-baby-is-breech

6. Roecker. C; Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios (Journal of Chiropractic Medicine); Science Direct; https://www.sciencedirect.com/science/article/abs/pii/S1556370713000588 ; June 2013

7. Presentation and position of baby through pregnancy and at birth; Pregnancy, Birth & Baby; https://www.pregnancybirthbaby.org.au/presentation-and-position-of-baby-through-pregnancy-and-at-birth

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External Cephalic Version—A Chance for Vaginal Delivery at Breech Presentation

Ionut marcel cobec.

1 Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Diakoniestrasse 10, 74523 Schwäbisch Hall, Germany

Vlad Bogdan Varzaru

Tamas kövendy, lorant kuban, anca-elena eftenoiu.

2 Clinic of Internal Medicine, Hohenloher Krankenhaus Öhringen, 74613 Öhringen, Germany

Aurica Elisabeta Moatar

Andreas rempen.

Background and Objectives : In recent years, the rate of caesarean section (CS) has increased constantly. Although vaginal breech delivery has a long history, breech presentation has become the third most common indication for CS. This study aims to identify factors associated with the success of external cephalic version (ECV), underline the success rate of ECV for breech presentation and highlight the high rate of vaginal delivery after successful ECV. Material and Methods : This retrospective observational study included 113 patients with singleton fetuses in breech presentation, who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakonieklinikum Schwäbisch Hall, Germany. Maternal and fetal parameters and data related to procedure and delivery were collected. Possible predictors of successful ECV were evaluated. Results : The success rate of ECV was 54.9%. The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The vaginal birth rate after successful ECV was 80.6%. Overall, 79.0% of women with successful ECV delivered spontaneously without complications, 19.4% delivered through CS performed during labor by medical necessity, and 1.6% delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS. Gravidity, parity, maternal age, gestational age, fetal weight, and amniotic fluid index (AFI) were significantly correlated with the outcome of ECV. Conclusions : ECV for breech presentation is a safe procedure with a good success rate, thus increasing the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV.

1. Introduction

In recent years, the rate of caesarean section (CS) has increased constantly in Germany [ 1 ]. In singleton pregnancies, an important indication of CS has been fetal malpresentation. In clinical practice, breech presentation (praesentation caudae) is the most common abnormal fetal presentation, which refers to fetuses lying bottom- or feet/knee-first rather than head-first [ 2 ]. Breech presentation is defined as a longitudinal positioning of the fetus with the buttocks or feet closest to the cervix. In Germany, fetal breech presentation at term occurs in about 3% of singleton pregnancies. The rate of breech presentation decreases with gestational age. This rate is about 9% between 33 and 36 pregnancy weeks, 18% between 28 and 32 weeks, and about 30% before the 28th pregnancy week [ 3 ].

The predisposing factors for breech presentation are uterine anomalies (e.g., uterus arcuatus, uterus bicornis, uterus duplex), uterus myomatosus, pelvic tumor, advanced multiparity, history of cesarean delivery or breech delivery, gestational diabetes, multiple gestation, congenital anomalies of the fetus (neural tube defects, fetal hydrocephalus or anencephaly), neuromuscular diseases, cephalo-pelvic disproportion, prematurity, low fetal birth weight, oligohydramnios, short umbilical cord, polar placentation, and placenta praevia [ 4 , 5 ]. However, in about 75% of cases, no specific cause of term breech presentation could be identified [ 4 , 6 ]. The main types of breech presentation are frank (≈60–70%), complete (≈4–10%), and incomplete breech (≈20–36%) [ 7 , 8 ].

Vaginal breech delivery has a long history. Studies have shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were higher in the planned vaginal delivery than in the planned cesarean delivery at breech presentation [ 9 ]. These findings significantly lead to CS being accepted by obstetricians as the safer option for breech delivery [ 9 ].

In the United States, there has been an increase in the frequency of CS in the past 20 years. One in three women giving birth in the USA will undergo a CS [ 10 ]. In many other developed and developing countries, this rate is the same. For example, in Korea, the frequency of CS was about 36.9% in 2012, CS being the usual method of delivery for term breech presentation [ 11 ]. Breech presentation became the third most common indication for CS, after previous CS and labor dystocia [ 12 ].

The maternal morbidity of CS is approximately three times higher than that of vaginal delivery [ 13 ]. The maternal risks of CS compared to vaginal delivery are well known. These include greater blood loss, thrombotic events, unplanned hysterectomy, operative damage to other organs, mortality, longer hospital stay with higher costs, and more readmissions than patients undergoing vaginal delivery [ 14 ]. Additional maternal complications of CS include scarring, chronic pain, and intestinal obstruction caused by adhesive disease. Moreover, in the following pregnancies, a previous cesarean delivery may cause a higher rate of placental abnormalities, unexplained stillbirth, as well as repeated surgical delivery in many cases [ 14 ]. However, vaginal delivery could also have maternal complications compared to CS, such as postpartum urinary incontinence and pelvic organ prolapse [ 15 ].

In case of fetal breech position, the external cephalic version (ECV) could be an option for reducing the number of CSs and vaginal breech deliveries [ 9 ]. ECV is a technique used to convert the fetal breech presentation into a cephalic position with targeted manual pressure on the mother’s abdominal wall at-term or near-term pregnancies in order to increase the chance of a vaginal cephalic birth [ 9 , 16 , 17 ]. ECV can be carried out with or without analgesics and with or without tocolytic therapy [ 18 ].

Factors favoring the success of ECV could be multiparous women, non-anterior placental location, palpability of the fetal skull, lower maternal body mass index, the type of breech presentation (for example, the frank breech presentation is associated with lower rates of success) and, of course, the experience of the physician in performing ECV [ 10 , 18 , 19 ]. Placental abruption, vaginal bleeding, fetal injury (including fractures and brachial plexus injuries), and pathological cardiotocography (CTG) findings, such as fetal bradycardia, may represent complications of the method [ 20 ].

The aim of this study is to identify factors associated with the success of ECV, highlight the relevance and success rate of ECV for breech presentation, and underline the high rate of vaginal deliveries in patients with successful ECV for breech presentation.

2. Material and Methods

This study represents a retrospective and anonymized data analysis over a period of 5 years. We reviewed the records of 113 women who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakoneo Diak Klinikum Schwäbisch Hall, Germany. In our study, we included all patients with singleton fetuses in breech presentation who agreed to the maneuver. The ECV was performed by different senior consultants. Prior to ECV, an ultrasound control was performed, and the possible risks of the maneuver were discussed. Each patient signed the ECV informed consent. ECV was not performed if the patient rejected ECV or if there were absolute contraindications of ECV.

For 30 min before and during the ECV, the patient received an infusion with tocolysis with fenoterol. Before and after the ECV, a CTG control was performed. The ECV was attempted under ultrasound control of the fetal heartbeat. Fetal biometric parameters were obtained sonographically. The patient was placed in a comfortable lying position with knees slightly elevated. The patient was allowed to end the maneuver at any point in time.

Maternal age, number of pregnancies, number of childbirths, history of CS, ultrasonographic findings (type of breech presentation, placental location, amniotic fluid index), characteristics of ECV (gestational age at ECV, fetal weight at ECV, success of ECV, direction in which successful ECV was performed, complications during and after ECV), and birth-related characteristics (planned and real type of delivery, gestational age at birth, fetal weight at birth) were collected from our database. Data were analyzed using IBM SPSS Statistics 20. Grouping by the dichotomous outcome of ECV, we used either χ 2 analysis or Fisher’s exact test for categorical variables and independent samples t -test for continuous variables. Multiple binary logistic regression was used to identify possible predictors of the outcome of ECV. We used the significance threshold of α = 0.05 corresponding to the 95% confidence interval.

In the observed five years, we registered 6619 singleton deliveries out of a total of 6825 deliveries and a general CS rate of 24.9%. Overall, 11.0% were elective CSs and 13.9% CSs were performed during labor by medical necessity. In total, 4.8% of all registered deliveries in our clinic in the observed period were CSs with breech presentation. In our sample of 113 women, the mean maternal age was 31.69 years ( SD = 4.44)—the youngest patient was 18 years old and the oldest patient was 43 years old. In total, 53.1% of the women were primigravida and 61.9% were nullipara. Four (3.5%) women had a history of CS.

Before ECV was performed, the fetal back faced the maternal left in 60 (53.1%) cases and the maternal right in 53 (46.9%) cases. In 56 (49.6%) cases, the placenta was located on the posterior wall, in 47 (41.6%) on the anterior wall, in 6 (5.3%) in the fundus, and in 4 (3.6%) on the left or right wall. The mean amniotic fluid index (AFI) at ECV was 14.88 ( SD = 3.58), ranging from 8 to 25. The mean gestational age at ECV was 261.82 days ( SD = 4.98). The minimum gestational age at ECV in our cohort was 35 + 2 weeks of pregnancy and the latest performed ECV was at 40 + 0 weeks of pregnancy. In 12 cases (10.6%), ECV was performed under 37 weeks of gestation because of medical necessity and with informed patient consent. The mean fetal weight at ECV was 2966.02 g ( SD = 391.06), ranging from 2158 g to 4123 g.

The success rate of ECV was 54.9%. ECV succeeded backwards in 39 (62.9%) cases and forwards in 23 (37.1%) cases. Overall, 101 (89.4%) of the ECVs were performed without any complications during the maneuver. In total, 12 (10.6%) cases encountered complications during the attempt of ECV. The complications were represented by fetal bradycardia with quick recovery in 7 cases, maternal intolerable abdominal pain in 2 cases, vena cava compression with quick recovery in 1 case, low maternal tocolysis tolerance in 1 case, and maternal nausea and emesis in 1 case. A single patient (0.9%) developed contractions during post-ECV monitoring, while 112 patients (99.1%) had no complications post-ECV.

The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The successful ECV group was planned for spontaneous delivery. The vaginal birth rate of the successful ECV group was 80.6%. Out of 62 patients, 49 (79.0%) delivered spontaneously without complications, 12 (19.4%) delivered through CS performed during labor by medical necessity, and 1 (1.6%) delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS; three delivered through CS and one delivered vaginally. The unsuccessful ECV group delivered through CS.

For gestational age and fetal weight at birth, eight observations were excluded from the analysis due to missing values. Five patients were planned for CS and decided to deliver in another clinic, while three patients were planned for spontaneous delivery and decided upon home birth. The mean gestational age at birth was 275.41 days ( SD = 8.96), the earliest delivery was at 37 + 0 weeks of pregnancy and the latest was at 42 + 0 weeks of pregnancy. The mean fetal weight at birth was 3350.43 ( SD = 470.69), ranging from 2180 g to 4470 g.

We analyzed the relationship between the outcome of ECV and the following categorical variables: gravidity, parity, history of CS, fetal back position before ECV and placental location ( Table 1 ). Multigravidity, defined as having been pregnant more than once, and a parity ≥ 1 were significantly associated with a successful ECV.

Association between outcome ECV and gravidity, parity, history of CS, fetal back position before ECV and placental location.

We compared maternal age, gestational age, fetal weight and AFI at ECV for successful and unsuccessful ECV using an independent samples t -test and found significant differences ( Table 2 ). For gestational age, we conducted a Welch’s t -test since equal variances could not be assumed. The other continuous variables were compared using Student’s t -test.

Comparison between maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV for successful and unsuccessful ECV using independent samples t -test.

Multiple logistic regression analysis was used to construct a prediction model for the outcome of ECV and covariates parity, maternal age, gestational age at ECV, fetal weight at ECV and AFI at ECV ( Table 3 ). A parity ≥ 1 and a higher maternal age were found to be favorable predictors of successful ECV in our prediction model.

Results of multiple logistic regression analysis for predictors of successful ECV.

4. Discussions

This study was performed in a clinic where the CS rate is lower than the reported CS rate for Germany, which is about 31.8% according to the official statistics [ 3 ]. In 2000, a large international multicenter randomized clinical trial, called the Term Breech Trial, compared vaginal deliveries with planned cesarean deliveries [ 21 ]. It was shown that perinatal and neonatal mortality rates, as well as serious neonatal morbidity rates, were significantly higher in the planned vaginal delivery group than in the planned cesarean delivery group (16% vs. 5%) at breech presentation. These findings significantly led to obstetricians choosing CS as the safer option for breech delivery in the 2000s [ 9 ]. For this reason, more than 12% of the CSs in Germany are performed in case of breech presentation. For example, in the west-central part of Germany, in the State of Hessen, about 90% of breech fetuses at term are delivered via CS [ 3 ]. In our clinic, CS at breech presentation represented 4.8% of all registered deliveries from 2016 to 2020.

In case of fetal breech position, ECV could be a successful and safe option to reduce the number of CSs [ 22 , 23 ]. The routine use of ECV could lower the rate of surgical delivery in case of breech presentation by approximately two-thirds in term pregnancies [ 9 ]. In most cases, fenoterol is used as tocolytic therapy, mainly as a continuous tocolysis. The improvement of the monitoring during the ECV with sonography and CTG and the use of tocolytic therapy made this method safer, thus reducing the complication rate associated with ECV [ 18 ].

By performing ECV, we aim to increase the proportion of vaginal cephalic delivery and thereby decrease the rate of CSs. For these reasons, ECV can be considered the first-line management in dealing with uncomplicated breech presentation at term. The method is recommended by Cochrane and the American and Royal Colleges of Obstetrics and Gynecologists, as well as by the German Society for Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe) [ 3 , 24 , 25 ].

ECV would be generally recommended after 37 weeks of gestation [ 9 , 16 ]. It is performed as an elective procedure in non-laboring women, aiming to improve the chance of vaginal cephalic birth. Attempting ECV before term, between 34th and 36th pregnancy weeks, can be associated with an increase in late preterm birth [ 17 ]. According to the German guidelines, ECV should be offered to all women with uncomplicated breech presentation by singleton pregnancies in hospitals where facilities for an emergency CS are present [ 3 , 20 ]. In a study performed by Weiniger et al., the CS rate among women with successful ECV was 20.2%, whereas among women with persistent breech presentation at delivery it was 94.9% [ 26 ]. We registered a CS rate for successful ECV of 19.4%, while the unsuccessful ECV patients delivered through CS.

Furthermore, women who underwent vaginal delivery after a successful ECV had lower odds of developing endometriosis and sepsis and shorter hospitalization, therefore lower hospital charges [ 26 ]. In contrast, these women could have a higher risk of chorioamnionitis. Attempted ECV may be also associated with an increased risk of a low APGAR score at 5 min [ 6 ]. According to the literature, the absolute risk of all complications of ECV is approximately 1% in fetuses at term [ 14 ]. We noticed in our study that the registered complications were minimal and insignificant compared to the high rate of successful ECV, followed by a high rate of vaginal deliveries.

Women with singleton pregnancy and breech presented fetus without the following pathologies are potentially eligible for ECV near term (≥36 weeks). These pathologies include multiple gestation, onset of active labor, rupture of membranes, oligohydramnios, antepartum hemorrhage or history with placental abruption, pelvic abnormalities, severe preeclampsia or eclampsia, pathological Doppler or CTG, placenta praevia, placenta accreta, and infant with major congenital anomalies or growth restrictions [ 2 ].A point system, such as Kainer score, can be helpful to estimate the success rate of ECV, which includes parameters, such as AFI, placental location, fetal position, nuchal cord, estimated fetal weight, parity, fetal engagement, and uterine tone [ 27 , 28 ]. We noticed positive results even though we did not apply this score.

Multiparous women are known to have higher ECV success rates [ 9 ]. Our study shows that multigravidity and a parity ≥ 1 are associated with successful ECV. The absence of nulliparity was also identified as an important predictor of successful ECV, which supports the findings of previous studies.

According to the literature, ECV is considered safe in women with a history of CS and some studies showed that the success rate of ECV is comparable to that of women with no previous CS [ 29 , 30 , 31 , 32 ]. Although rare, we registered four cases with a history of CS. ECV was successful in three of them, but only one delivered vaginally. In our sample, the fetal back faced either the maternal left or right. We found no statistically significant relationship between the fetal position and the outcome of the maneuver.

The anterior placental location has been reported as being associated with a lower rate of success, probably due to the anterior location of the placenta making it difficult to perform ECV [ 9 ]. In the present study, we included patients with anterior, posterior, lateral, and fundal placental location. We noticed that the relationship between placental location and ECV outcome was not significant.

Our study included women between 18 and 43 years old. The group with successful ECV had a higher mean maternal age than the group with unsuccessful ECV, therefore we included maternal age in our logistic regression analysis. In our prediction model, higher maternal age was found to be a predictor for successful ECV, therefore the success rate increases with maternal age. Other studies did report similar results [ 33 , 34 ]. It is important to note that there may be other related variables affecting this relationship, for example, BMI, which we did not take into account. According to the literature, high BMI values are associated with a low success rate of ECV and a decrease in the rate of vaginal delivery after successful ECV [ 35 ].

The relationship between estimated fetal weight at ECV and ECV outcome is controversial [ 9 , 34 ]. We found an association between the success of the maneuver and higher fetal weight, as well as higher gestational age at ECV. An explanation could be that a larger fetus, which corresponds to a higher gestational age, is more palpable [ 27 , 36 ].

It has been reported that a higher AFI is associated with successful ECV [ 18 , 37 , 38 ]. In the present study, the group with successful ECV had a higher mean AFI than the group with unsuccessful ECV. It is important to note that the minimum AFI score registered was eight.

The safety, efficacy, and cost-effectiveness of ECV for breech presentation followed by vaginal delivery are underlined in our study through good clinical practice and are sustained by other performed studies [ 2 ].

5. Conclusions

ECV for breech presentation is a safe procedure with a good success rate which increases the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV. Multigravidity, absence of nulliparity, higher maternal age, higher gestational age, higher fetal weight, and higher AFI are all associated with successful ECV.

Funding Statement

This research received no external funding.

Author Contributions

I.M.C. and A.R. conceived and planned in detail the present study. I.M.C., V.B.V. and T.K. extracted and analyzed the entire patient data. A.-E.E. performed the computations and interpreted the patient data together with I.M.C., L.K., V.B.V. and A.E.M., I.M.C. took the lead in writing the manuscript with input from T.K., V.B.V., A.-E.E. and A.E.M., in consultation with A.R., I.M.C. and A.R. supervised this study. All authors discussed the results and commented on the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

This study used pre-existing, anonymized and irreversibly de-identified data. Approval from the ethics committee was not required.

Informed Consent Statement

This retrospective study used pre-existing, anonymized and irreversibly de-identified data.

Conflicts of Interest

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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