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Chapter 52: External Cephalic Version

Lior Levy

BACKGROUND

Approximately 3% to 4% of term fetuses present breech. Vaginal breech delivery is associated with excess risk of neonatal near miss and perinatal morbidity and mortality, compared with vaginal cephalic delivery. External cephalic version (ECV) is the manual rotation of the fetus’ head to a cephalic presentation to achieve cephalic vaginal delivery and decrease cesarean delivery (CD) rates. ECV is successful about 58% of the time (40% for nulliparous and 64% for multiparous). A successful version decreases the risk of CD by about 40% in this patient population. Table 52-1 lists factors that influence success of ECV.

TABLE 52-1Factors That Influence Success of ECV
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TABLE 52-1 Factors That Influence Success of ECV

Factors That Increase Success of ECV

Factors That Reduce Success of ECV

  • Prior vaginal delivery

  • Use of neuraxial anesthesia

  • Unengaged presenting part

  • Transverse lie

  • Earlier gestational age

  • Experienced obstetrician

  • Use of terbutaline

  • Black race

  • Nulliparity

  • Strong abdominal muscles

  • Descent of buttocks/feet into pelvis

  • Anterior or lateral placenta

  • Posterior position of fetal back

  • Decreased amniotic fluid volume

  • Low fetal weight

  • Ruptured membranes

  • Obesity

TIMING OF ECV

  • Timing is controversial, typically between 37 and 39 weeks in the United States.

  • Better success rate at 34 to 36 weeks but does not seem to lead to lower CD rates. This is likely due to the increased risk of reversion to breech. Furthermore, if an emergency CD is necessary, the baby will be preterm.

  • ECV can be done in laboring patients, yet rarely successful and is discouraged once membranes are ruptured, or cervix is in advanced dilation.

COMPLICATIONS OF ECV

Overall, ECV has a very low complication rate (about 1%) and is considered safe.

A systematic review involving 12,995 patients shows the following complications1:

  • Transient (6.1%) and persistent (0.2%) fetal heart rate abnormalities

  • Emergency CD (0.33%)

  • Vaginal bleeding (0.3%)

  • Stillbirth (0.19%)

  • Placental abruption (0.08%)

  • Ruptured membranes and cord prolapse (0.2%)

  • Fetomaternal hemorrhage (0.9%) during a version; consider giving Rhogam to the Rh-negative patients

CONTRAINDICATIONS FOR ECV

  • Need for a CD regardless of fetal presentation (i.e., placenta previa)

  • Antepartum bleeding within 7 days

  • Placental abruption

  • Abnormal fetal heart rate tracing

  • Major uterine abnormality

  • Multiple gestations (except delivery of the second twin)

  • Severe oligohydramnios

INFLUENCE OF NEURAXIAL ANESTHESIA ON ECV

Influence of Neuraxial Anesthesia on ECV2

  • ECV can be painful.

  • Initial concerns were that providing anesthesia for ECV would encourage excessive force. Evidence shows spinal anesthesia decreases the force required for a successful version.

  • Multiple studies show that the use of neuraxial significantly increases the success rate of ECV (58.4% vs. 43.1%) and lowers the rate of CD (46.0% vs. 55.3%).

  • No studies have shown that anesthesia increases ...

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