Intended for healthcare professionals


Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study

BMJ 2006; 333 doi: (Published 14 September 2006) Cite this as: BMJ 2006;333:578

Use of ECV should be a maternity service quality indicator

EDITOR – The recent study by Nasser et al (1) reported in the BMJ
highlights the long known clinical failure to diagnose all breech
presentations at term, especially in the obese.

However, there is little point in improving clinical detection unless
it makes a difference to mothers or babies. The point of detecting a
breech is to offer external cephalic version (ECV) and to discuss mode of
delivery if persistent. If ECV is successful, this avoids the hazards both
of vaginal breech delivery (2) and caesarean section (CS) (3).
Disturbingly, the National Sentinel Caesarean Section Audit (4) showed
that only 33% of women in the UK having caesarean section for breech had
been offered an ECV, and less than half of these had undergone the
procedure. A recent systematic review (5) confirmed the high success rates
(>60% in some studies) and the extremely low risks of ECV. Set against
the well-documented risks of caesarean section, those obstetricians and
gynaecologists who do not offer ECV, offer it timidly, or find many so-
called ‘exclusion criteria’ are failing their patients.

Along with the principles of ‘non-maleficence’ and ‘informed
consent’, the NHS should be providing excellent evidence-based care with
minimum risks to patients. Those maternity units that are not offering and
carrying out ECVs, as well as training juniors to be proficient, must be
considered sub-standard. Women (and their GPs) need to know that urgent
referrals at term for ECV can be made and that elective caesarean section
should not be the first resort. External quality indicators of maternity
services must include not only % of term breechs diagnosed, but also the %
offered ECV and % turning success rates.

Stephanie Kuku, Senior SHO

Susan Bewley, Consultant Obstetrician

Womens’ Health Directorate,
St Thomas’ Hospital,
Lambeth Palace Road,


(1) Nasser N, Roberts CL, Cameron CA, Olive. Diagnostic accuracy of
clinical examination for detection of non-cephalic presentation in late
pregnancy: cross sectional analytic study. BMJ 2006 333: 578 - 580

(2) Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR,
for the Term Breech Trial Collaborative Group. Planned caesarean section
versus planned vaginal birth for breech presentation at term: a randomised
multicentre trial. Lancet 2000; 356: 1375-1383

(3) Hofmeyr GJ. External cephalic version facilitation for breech
presentation at term. Cochrane Database Syst Rev 2000;2:CD000184.

(4) Thomas J, Paranjothy S. National Sentinal Caesarean Section Audit
Report. RCOG Clinical Effectiveness Support Unit. RCOG press, London

(5) Nasser et al. Systematic review of adverse outcomes of external
cephalic version and persisting breech presentation at term. Paed. Perinat
Epidem 2006 March (2); 163-71

Competing interests:
None declared

Competing interests: No competing interests

18 September 2006
Stephanie Y Kuku
Senior SHO
Susan Bewley
St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH