External cephalic version RCOG, 2006

Aboubakr Elnashar Prof . Obs Gyn

Benha University Hospital

Reduction of incidence of breech presentation

have become more important

1. Breech: 3–4% of all term deliveries

2. CS for breech increased markedly in the last 20 ys

safer for the fetus & of similar safety to the mother

(The term breech trial).

Impact of ECV on the incidence of breech

presentation at delivery ECV reduces the chance of breech presentation at

delivery.

Spontaneous version: 8%

Spontaneous version after unsuccessful ECV: 5%

Success rates of ECV: 30–80%.

Spontaneous reversion to breech after successful ECV:

5%.

Effect of ECV on CS rate ECV lowers CS rate

Labour with a cephalic presentation following ECV is

associated with a higher rate of obstetric intervention

than when ECV has not been required.

Risk difference: 17%

NNT: 6

Success rate of ECV 50%

30%-80%

Nulliparous: 40%

multiparous 60%

Factors affecting success 1. Race

2. Parity

3. uterine tone

4. liquor volume,

5. engagement of the breech

6. whether the head is palpable

7. use of tocolysis

The highest success rates 1. Multiparous

2. non-white women

3. Relaxed uterus

4. breech is not engaged

5. head is easily palpable.

6. increasing liquor volume. N.B. very high liquor

volume may be associated with spontaneous

reversion.

Less important factors: 1. Maternal weight

2. placental position

3. Gestation

4. fetal size

5. position of the legs

Tocolysis either routinely or if an initial attempt has failed.

beta-sympathomimetics increase the success rate:

ritodrine, salbutamol, terbutaline

slow IV or SC bolus

Not

glyceryl trinitrate

nifedipine.

Methods to increase the success rate

of ECV 1. Second attempt: particularly with a second operator or where the back

has been in the midline

2. Tocolysis

3. Fetal acoustic stimulation: where the back is in the midline

4. Regional analgesia: success rate is evident with epidural but not spinal

As maternal pain might indicate a complication,

concerns regarding safety

Timing of ECV Nulliparous: 36 w

Multiparous: 37 w

{ECV before 36 w is not associated with a significant

reduction in noncephalic births or CS}.

No upper time limit on the appropriate gestation for

ECV.

Successes has been reported at 42 w

can be performed in early labour provided that the

membranes are intact.

Complications Rare

1. placental abruption

2. uterine rupture

3. fetomaternal haemorrhage.

4. immediate emergency CS: 0.5%

5. Transient alterations in fetal parameters:

5. Transient alterations in fetal parameters:

Fetal bradycardia

Nonreactive CTG

Alterations in umbilical artery and middle cerebral artery

waveforms

increase in AFV.

The significance of these is unknown.

No increase in neonatal morbidity and mortality

Labour

Prerequisites 1. Facilities for monitoring

US: FHR visualisation

CTG: before & after procedure

2. Facilities for immediate delivery

3. Anti-D immunoglobulin to rhesus-negative

Not necessary 1. Kleihauer testing

2. Preoperative preparations for CS

Starvation

anaesthetic premedication

intravenous access

ECV & pain can be painful

No discomfort: few women

High pain scores: 5%: stop

Pain is greater where the procedure fails.

Contraindications Absolute ● where CS is required

● antepartum haemorrhage within the last 7 days

● abnormal CTG

● major uterine anomaly

● ruptured membranes

● multiple pregnancy (except delivery of second

twin).

Relative ● small-for-gestational-age fetus with abnormal Doppler

parameters

● proteinuric pre-eclampsia

● oligohydramnios

● major fetal anomalies

● scarred uterus: The available data on ECV after one caesarean section are reassuring, but are insufficient to confidently conclude that the risk is not increased.

● unstable lie: ECV is only logical in the context of a stabilising induction. There are few available data on this procedure, which should only be performed for a valid indication and may be associated with a significant intrapartum complication rate.

Increasing the uptake of ECV Local policies should be implemented to actively

increase the number of women offered and

undergoing ECV.

Obstetricians and midwives should be able to

discuss the benefits and risks of ECV

Alternatives to ECV 1. Postural management: insufficient evidence

2. Moxibustion: should not be recommended

burnt at the tip of the fifth toe (acupuncture point

BL67)

Developing an ECV service 1. An ECV service should be available to all women

with a breech presentation at term.

2. ECV is not difficult and skills should be developed,

if necessary, by visiting other hospitals. ECV can be

performed by suitably trained midwives; experience

with ultrasound is essential.

3. All women undergoing ECV should be offered

detailed information (preferably written) concerning

the risks and benefits of the procedure.

4. Consent may also be appropriate.

1-2: 0%

9-10: 100%

2 1 0

>2 1 0 Parity

Lat, fun post ant Placenta

0 1-2 >3 Dilatation

>3.5 2.5-3.5 <2.5 EFW

-3 -2 -1 Station

Head palpable.

Breech unengagement

Symphysisfundal height

Uterine relaxation

Procedure

Prepare for the possibility of CS

U/S: confirm breech

check growth

AFV

F anomalies

NST

ECV can be performed with 2 operators.

Mg. sulfate: 4 amp 10 ml,10% IV within 20 m.

ECV is accomplished by judicious manipulation of the

fetal head toward the pelvis while the breech is

brought up toward the fundus..

Judicious manipulation

of the fetal head

toward the pelvis while

the breech is brought

up toward the fundus

Following an ECV attempt, repeat NST

Administer Rh-immune globulin to women who

are Rh negative.

Be prepared for an unsuccessful ECV.

Some physicians induce labors following

successful ECV