External cephalic version at 38 weeks’ gestation at a specialized German single center

Ann-Sophie Zielbauer; Frank Louwen; Lukas Jennewein

doi:10.1371/journal.pone.0252702

Peer Review History

Original SubmissionAugust 2, 2020
29 Sep 2020 Decision Letter - Salvatore Andrea Mastrolia, Editor PONE-D-20-24091 External cephalic version in 38 weeks’ gestation – demographics, prognostic factors and success rates: a prospective analysis from a German single center PLOS ONE Dear Authors, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 13 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Salvatore Andrea Mastrolia, M.D. Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating the following in the Competing Interests section: 'I have read the journal's policy and the authors of this manuscript have the following competing interests: F.L. is first vice president of the German Society for Gynaecology and Obstetrics (DGGG), council member of the European Board and College of Obstetrics and Gynaecology (EBCOG) and Executive Board Member und Committee chairman of the International Federation of Gynecology and Obstetrics (FIGO). F.L. and L.J. worked on the first German S3-Guideline for cesarean section published in 2020. A.Z. declares no relevant conflicts of interest.' a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). 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Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: No Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: title - too long keywords - too many introduction - ECV is mostly performed before 37 GA? LINE 67 - provide reference for most ecv performed before 37 line 68-70 - is redundant ECV not offered line79 - provide reference line 79-81 - more studies to be published??? numerous studies regarding predictors of success. the authors should replace outofdate reference (years 2000-2010) regarding success rate (ezra, ben meir) and replace with more updated reference (31312960, 30941816) a prospective analyses? is this trully prospective or retrospective? approval (Ref:176/18) means 2018? extremely low success rate of ECV -22% should be discussed and explained reults chapter is written badly - please rewrite. tables - ages with 2 decimals? what age does 33.13 represents?? parity and gravidity with decimals? table 2 looks like it was copied from the SPSS sowtware - please provide a better version of presentation of table what does constant mean? vaginal delivery rate of 62% is very low - should be discussed line 275-276 claiming novely - what about 31312960? overall i dont see novelty, maybe unfamiliarity with current literature, therefore a more thorough literature review should be performed in the introduction and discussion and old references (more than 10 years should be discuraged) limited new information, low success rate - thus limiting generalizability Reviewer #2: First of all, this is a very interesting manuscript about management of breech presentation at term. This Care Unit seems to be a very expertise Breech Unit, and provide care about counseling about all possible maneuvers such as ECV, cesarean and vaginal birth. Congratulations for that. However, it is commented on several occasions that this is the first article published about the safety of ECV in 38 weeks of gestation (lines 39, 49, 85, 275). The study fails to address how the findings relate to previous research in this area. The authors should return to publications such as that of Rodgers et al., 2017 (reference number 32 of the manuscript), where the mean gestational age of the ECV was 37 + 5, or in others such as Beuckens et al., 2015 (an observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwifes) where 60% were more than 36 weeks; or in other publications like Ainsworth et al. 2017, with ECV even in 40 weeks of gestation. All of these publications are about ECV complications. Also, the complication total rate is 17%. This is higher than 6% in the revision published by Kok et al (2008) or Rodgers et al. (2017) about 5% or 2,5% in Neatherlands by Beuckens et al. (2016). This manuscript can be very interesting and important, but the authors should rewrite their Introduction and Discussion to reference the related literature, because this is not the first publishing data about 38 gw ECVs. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0252702.r001
Revision 1
13 Nov 2020 Author Response 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at Journal requirements were double-checked. 2. Thank you for stating the following in the Competing Interests section: 'I have read the journal's policy and the authors of this manuscript have the following competing interests: F.L. is first vice president of the German Society for Gynaecology and Obstetrics (DGGG), council member of the European Board and College of Obstetrics and Gynaecology (EBCOG) and Executive Board Member und Committee chairman of the International Federation of Gynecology and Obstetrics (FIGO). F.L. and L.J. worked on the first German S3-Guideline for cesarean section published in 2020. A.Z. declares no relevant conflicts of interest.' a. Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. F.L. is first vice president of the German Society for Gynaecology and Obstetrics (DGGG), council member of the European Board and College of Obstetrics and Gynaecology (EBCOG) and Executive Board Member und Committee chairman of the International Federation of Gynecology and Obstetrics (FIGO). F.L. and L.J. worked on the first German S3-Guideline for cesarean section published in 2020. A.Z. declares no relevant conflicts of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials. b. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. We included the Update in our cover letter. 3. Review Comments to the Author Reviewer #1: title - too long Thank you for your profound comments. They were very helpful in improving our manuscript. The title was shortened. The new title is: “External cephalic version in 38 weeks’ gestation in a specialized German single center” keywords - too many Less important key words were deleted. introduction - ECV is mostly performed before 37 GA? The wording was infelicitous. Despite recommendations for performing ECV after 37 weeks of gestation, a lot of departments still offer ECV before 37 weeks in Germany. Citations were included in the revised manuscript. LINE 67 - provide reference for most ecv performed before 37 Citations were included in the revised manuscript. line 68-70 - is redundant The passage was shortened, we focused on more present literature. ECV not offered line 79 - provide reference Citations were included in the revised manuscript. Kohls et. al. carried out an anonymized online survey asking about preferred primary intervention for ECV in Germany in 2018. Although it seems that ECV is offered nationwide, only for 61% ECV is the preferred primary intervention, for 12.4% of the surveyed hospitals CS is still the preferred intervention. line 79-81 - more studies to be published??? numerous studies regarding predictors of success. the authors should replace outofdate reference (years 2000-2010) regarding success rate (ezra, ben meir) and replace with more updated reference (31312960, 30941816) Outdate reference was replaced by updated reference. Only four studies, we think are very important to the topic and were published before 2010 (Hannah et. al 2000, Hutton et. al. 2003, Kainer et. al. 2003, Grootscholten et. al. 2008) were kept in the manuscript. A prospective analyses? is this trully prospective or retrospective? approval (Ref:176/18) means 2018? Thank you for pointing out this unclarity. Our study is an interim analysis of an ongoing larger single center study at our department starting from 2004. Our study design is overall prospective, but additional data was collected in a retrospective approach. The additional retrospective data collection was approved by the local ethics committee in 2018. An explanation was added in the revised manuscript. extremely low success rate of ECV -22% should be discussed and explained Thank you for addressing this important topic. In the rewritten discussion, we clarified the background of our low success rate. reults chapter is written badly - please rewrite. Thank you for your remarks, the results chapter has been rewritten. We focused on improving the language and cut out the repetitive results. I hope your demands were met. tables - ages with 2 decimals? what age does 33.13 represents?? parity and gravidity with decimals? The differences between the two groups in cases of age, parity, gravidity etc. were only visible within the decimals despite being significant. We shortened the decimal digits to only one digit, so the difference is still visible. Without the digits the numbers would be the same, although there is a significant difference. table 2 looks like it was copied from the SPSS sowtware - please provide a better version of presentation of table Thank you for the remark. The regression was run using the program Bias. We diminished the reported variables to Odds ratio, standard deviation and Wald’s p. what does constant mean? The constant term in regression analysis is the value at which the regression line crosses the y-axis, also known as the y-intercept. It was deleted from the table, as it may cause incomprehension. vaginal delivery rate of 62% is very low - should be discussed Thank you for pointing out this unclarity. The vaginal delivery rate of 62% refers to overall vaginal delivery after ECV disregarding the success. To make it clearer, we changed the labeling of the table to: ‘all deliveries after ECV’. This number describes cephalic as well as breech vaginal delivery. The rate of cephalic vaginal delivery after successful ECV is 78%, which is higher than the nationwide average on cephalic birth. The rate of vaginal breech birth after unsuccessful ECV exceeds with 60% the nationwide average as well as rates described in previously published data. line 275-276 claiming novely - what about 31312960? Thank you for your remark. While Levin et. al. offers ECV as an alternative between CS and breech delivery, at our center we offer a combined approach discussing ECV, vaginal breech delivery and CS to reach a shared decision with the patient. overall i dont see novelty, maybe unfamiliarity with current literature, therefore a more thorough literature review should be performed in the introduction and discussion and old references (more than 10 years should be discuraged) The reference list was updated, the introduction and discussion were rewritten. We hope your demands were met in the revised manuscript. limited new information, low success rate - thus limiting generalizability We addressed this point more precise in the revised discussion. Reviewer #2: First of all, this is a very interesting manuscript about management of breech presentation at term. This Care Unit seems to be a very expertise Breech Unit, and provide care about counseling about all possible maneuvers such as ECV, cesarean and vaginal birth. Congratulations for that. However, it is commented on several occasions that this is the first article published about the safety of ECV in 38 weeks of gestation (lines 39, 49, 85, 275). The study fails to address how the findings relate to previous research in this area. The authors should return to publications such as that of Rodgers et al., 2017 (reference number 32 of the manuscript), where the mean gestational age of the ECV was 37 + 5, or in others such as Beuckens et al., 2015 (an observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwifes) where 60% were more than 36 weeks; or in other publications like Ainsworth et al. 2017, with ECV even in 40 weeks of gestation. All of these publications are about ECV complications. Thank you for your remarks, we followed your recommendation and discussed the articles mentioned above alike your suggestion. Also, the complication total rate is 17%. This is higher than 6% in the revision published by Kok et al (2008) or Rodgers et al. (2017) about 5% or 2,5% in Neatherlands by Beuckens et al. (2016). Thank you for addressing this important issue. Our “higher” complication rate compared to previously published data is the result of reporting on all minor bradycardia and CTG-alterations. Beuckens et. al. only reported on bradycardia lasting over 10 minutes, Kok et. al. recommended only to report on bradycardia leading to CS. We discussed the complication rate in the revised paper. This manuscript can be very interesting and important, but the authors should rewrite their Introduction and Discussion to reference the related literature, because this is not the first publishing data about 38 gw ECVs. Thank you for your remarks. We rewrote the Introduction and Discussion as recommended and revised the reference list with more present studies. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0252702.r002
28 Mar 2021 Decision Letter - Salvatore Andrea Mastrolia, Editor PONE-D-20-24091R1 External cephalic version in 38 weeks’ gestation in a specialized German single center PLOS ONE Dear Dr. Authors, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by 30th April. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Salvatore Andrea Mastrolia, M.D. Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: (No Response) Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: I Don't Know Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #3: No Reviewer #4: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #3: 38. Not clear what is meant by breech birth procedures? 39. There has been a paper published this year that demonstrated that ECV at 38 weeks has equal success rates to ECVs performed at 36, 37, 39 and 40 weeks and is equally safe. 48. ECV at 38 weeks. 49. False claim of first evidence. 131. No mention on the technique of ECV used, i.e., forward or backward flip? 154. fetuses. 160. Success rates appear to be skewed by the higher numbers of nulliparous women. 177. Definition of AFI measurements not mentioned, i.e., abundant is 20, 25, 30 cm? 289. The study published in 2021 reported higher success with higher EFW 290-293. Need to be re-written in a clearer way 318. A fetus cannot be referred to as children 327 – 329. No justification/hypothesis written on to why success was higher in larger fetuses. Reviewer #4: I read with great interest the Manuscript titled “External cephalic version in 38 weeks’ gestation in a specialized German single center ” The topic of this manuscript falls within the scope of PLOS One. I was particularly pleased to review this revised version of the manuscript. In my honest opinion, the past reviewers' concerns have been resolved by the Authors. Now its scientific soundness is interesting enough to attract the readers’ attention. The methodology is accurate, and conclusions are supported by the summarized evidence. However, I believe that the Discussions might benefit from a brief deeping of factors that might or might not improve the ECV successfulness, for example: - Neuraxial analgesia [ PMID 27131581] - Tocolysis [PMID 33421816] - Other prognostic factors [PMID 31369397] ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #3: No Reviewer #4: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0252702.r003
Revision 2
25 Apr 2021 Author Response Reviewer #3: Thank you for your profound comments. They were very helpful in improving our manuscript. 38. Not clear what is meant by breech birth procedures? Thanks for the remark, the corresponding part has been specified and alternatives for breech birth were described. 39. There has been a paper published this year that demonstrated that ECV at 38 weeks has equal success rates to ECVs performed at 36, 37, 39 and 40 weeks and is equally safe. Thank you for pointing out this recent paper. The paper was cited and addressed in the introduction and discussion of the revised manuscript. 48. ECV at 38 weeks. Thank you very much for your remarks regarding grammar and spelling. We undertook a profound correction. Additionally, the manuscript was proof-read by the suggested English language editing service. 49. False claim of first evidence. Thanks for this comment. This statement had been adjusted to the current evidence in the revised manuscript. 131. No mention on the technique of ECV used, i.e., forward or backward flip? Again, thank you for the helpful remark. The explanation below was added in the revised manuscript. “The baby was moved upwards with one hand and pushed to perform a forward or backward roll, preferably in the direction with less resistance. In cases of unsuccessful ECV (NECV), both directions were attempted. The direction (backwards or forwards) of successful ECV (SECV) has not been documented. 154. fetuses. Thanks, we corrected the typo. 160. Success rates appear to be skewed by the higher numbers of nulliparous women. Thank you very much for pointing out this important issue. The range of nulliparous women in our population is indeed higher compared to previously published data. We discussed the lower range in the revised manuscript. 177. Definition of AFI measurements not mentioned, i.e., abundant is 20, 25, 30 cm? As suggested, we explained the cutoff for an abundant AFI score at our center. 289. The study published in 2021 reported higher success with higher EFW. Thank you for the recommendation. We discussed this recent evidence in our submitted revision. 290-293. Need to be re-written in a clearer way This part has been extended for more clarity. The whole manuscript has been double-checked for infelicitous wording. 318. A fetus cannot be referred to as children. Thank you for pointing this out. We corrected this context. 327 – 329. No justification/hypothesis written on to why success was higher in larger fetuses. Thanks again for the helpful comment. We discussed possible hypothesis for the observed higher success rate in larger fetuses. Reviewer #4: I read with great interest the Manuscript titled “External cephalic version in 38 weeks’ gestation in a specialized German single center ” The topic of this manuscript falls within the scope of PLOS One. I was particularly pleased to review this revised version of the manuscript. In my honest opinion, the past reviewers' concerns have been resolved by the Authors. Now its scientific soundness is interesting enough to attract the readers’ attention. The methodology is accurate, and conclusions are supported by the summarized evidence. However, I believe that the Discussions might benefit from a brief deeping of factors that might or might not improve the ECV successfulness, for example: - Neuraxial analgesia [ PMID 27131581] - Tocolysis [PMID 33421816] - Other prognostic factors [PMID 31369397] Thank you very much for your profound comments and remarks. The suggested studies are very interesting and highly relevant. We discussed these articles alike your suggestions. We hope your demands were met in the revised manuscript. The language within the manuscript was also improved with the help of an editing service. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0252702.r004
21 May 2021 Decision Letter - Salvatore Andrea Mastrolia, Editor External cephalic version at 38 weeks’ gestation in a specialized German single center PONE-D-20-24091R2 Dear Authors, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Salvatore Andrea Mastrolia, M.D. Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0252702.r005
Formally Accepted
11 Aug 2021 Acceptance Letter - Salvatore Andrea Mastrolia, Editor PONE-D-20-24091R2 External cephalic version at 38 weeks’ gestation at a specialized German single center Dear Dr. Zielbauer: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Salvatore Andrea Mastrolia Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0252702.r006

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