External cephalic version
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|External cephalic version|
External cephalic version is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. External cephalic version (ECV) is a manual procedure that is advocated by national guidelines for breech presentation singleton pregnancy, in order to enable vaginal delivery.  It is usually performed after about 37 weeks. It is often reserved for late pregnancy because breech presentation greatly decreases with every week. ECV is endorsed by the American College of Obstetricians and Gynaecologists (ACOG) and Royal College of Obstetricians and Gynaecologists (RCOG), among others, as a mode to avoid the risks and morbidity associated with vaginal breech or cesarean delivery for singleton breech presentation. 
It can be contrasted with "internal cephalic version", which involves the hand inserted through the cervix.
In this procedure hands are placed on the mother's abdomen around the baby. The baby is moved up and away from the pelvis and gently turned in several steps from breech, to a sideways position, and finally to a head first presentation.
External cephalic version performed before term may decrease the rate of breech presentation compared to external cephalic version at term, but may increase the risk of preterm delivery. There is some evidence to support the use of tocolytic drugs in external cephalic version. Use of intravenous nitroglycerin has been proposed.
Success rates reported for ECV range from 35 to 86%. Various factors can alter the success rates of ECV, such as practitioner experience, maternal weight, obstetric factors such as uterine relaxation, a palpable foetal head, a non-engaged breech, non-anterior placenta, and an amniotic fluid index above 7-10cm, are all factors which can be associated with higher success rates. In addition ECV success rates are reportedly higher when performed under neuoraxial blockade.  Reports from a study carried out by the University Kebangsaan Malaysia Medical Centre, between 1 September 2008 and 30 September 2010, indicate that patients in the ECV group with pregnancies which went post dates (beyond 40 weeks), two-thirds had successful vaginal delivery while a third required caesarean section.  Within this study the success rate of ECV was 51.4% (73/142 cases) over the three-year period. 
Complications and risks
As with any procedure there can be complications most of which can be greatly decreased by having an experienced professional on the birth team. An ultrasound to estimate a sufficient amount of amniotic fluid and monitoring of the foetus immediately after the procedure can also help minimise risks.
Typical risks include umbilical cord entanglement, abruption of placenta, preterm labor, premature rupture of the membranes (PROM) and severe maternal discomfort. Overall complication rates have ranged from about 1 to 2 percent since 1979. While somewhat out of favour between 1970 and 1980, the procedure has seen an increase in use due to its relative safety.
Successful external cephalic version significantly decreases the rate of cesarean section, however women are still at an increased risk of instrumental delivery and cesarean section compared to women with spontaneous cephalic presentation.
Again referring to the study carried out by the University Kebangsaan Malaysia Medical Centre, (as reported above), amongst the 67 women within the study whom had successful ECV procedures, the most common complications occurring within 24 hours of ECV were spontaneous labour (6.0%) and transient CTG changes (4.5%). 
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