SUMMARY:

Breech occurs in approximately 3 to 4% of term pregnancies. The goal of External Cephalic Version (ECV) is to increase the proportion of vertex presentation at term and to decrease the risk of cesarean delivery secondary to breech presentation. Between 20 to 30% of eligible women are not offered this procedure

Timing

• Fetal presentation should be assessed beginning at 36w0d
• Preterm ECV has been linked with higher rates of initial success, but increased risk of preterm birth and higher rates of reversion
• At 37w0d
  • If spontaneous version is going to occur it is likely to have occurred by then
  • Risk of spontaneous reversion is decreased
• ECV during delivery admission vs breech presentation has a 65% success rate and is associated with
  • Lower cesarean delivery rate
  • Lower likelihood of hospital stay >7 days
• Limited information in women with preexisting uterine scar or during early stages of labor

Contraindications

• ECV is contraindicated when vaginal delivery is not clinically appropriate
• There are no absolute or relative contraindications
  • Evaluate each case individually

Benefits

• Fewer cesarean deliveries
• Lower odds of
  • Endometritis | Sepsis | Hospital stay > 7 days
• Lower hospital charges
• No differences for
  • Low Apgar | Low umbilical vein pH | Neonatal death

Risks and Adverse effects

• Most common risk is fetal heart rate changes
  • Typically, heart rate stabilizes when procedure is discontinued
• Overall serious adverse effects are very low with rates <1%
  • Abruptio placentae | Umbilical cord prolapse | Rupture of membranes | Stillbirth | Fetomaternal hemorrhage
• Although chance of complications are low, cesarean delivery services should still be readily available
  • Rate of cesarean deliveries due to ECV is low

Factors affecting success

• Overall success rate approximately 58%
• Positive association between parity and successful version
• Transverse or oblique presentation associated with higher immediate success rate
• Lower success rates at hospitals with higher cesarean rates
• Factors that might predict success
  • Amniotic fluid volume | Location of placenta | Maternal weight
• Factors associated with failure
  • Nulliparity | Advanced dilation | Fetal weight < 2500 g | Anterior placenta | Low station

Tocolytic agents

• Parenteral β stimulants
  • Terbutaline has doubled the rate of ECV success
  • Effective in achieving cephalic presentation
  • Lower rate of failure
  • Data insufficient to analyze adverse effects
• Nitric oxide
  • Use is discouraged
• Calcium channel blockers
  • Insufficient data for a recommendation

Analgesia

• Neuraxial analgesia with tocolysis has a higher incidence of
  • Successful ECV | Cephalic presentation | Vaginal delivery
  • Insufficient data of neuraxial analgesia without tocolysis to make a recommendation
• Epidural may be considered for women with previous failed ECV attempt

Procedure Considerations

Before ECV

• Perform ultrasound to confirm malpresentation and rule out abnormalities that would complicate vaginal delivery
• Inform the patient about benefit and risks of the procedure, tocolysis and analgesia
• Assess fetal well-being by NST or BPP before and after ECV
• Cesarean services should be readily available

Performing ECV

• May be performed by one or two people
• Lifting the breech upward from the pelvis with one hand and providing pressure on the head with the other hand to produce a forward roll
  • If the forward roll fails, a backward roll may be attempted
• Intermittent use of ultrasonography during procedure allows evaluation of FHR and position of fetus
• Abandon attempt if
  • Prolonged fetal bradycardia
  • Patient discomfort
  • Cannot be completed easily

After ECV

• Repeat fetal evaluation
• Monitor patient for 30 minutes
• Administer Anti-D immune globulin to Rh- patients if delivery is not anticipated in the next 72 hours
• No evidence for routine immediate induction to minimize reversion

KEY POINTS:

• Fetal presentation should be evaluated beginning at 36w0d
• All women near term with breech presentation should be offered an ECV attempt if there are no contraindications
• Evidence supports use of neuraxial analgesia plus tocolysis to increase success
• Fetal well-being should be assessed before and after ECV and cesarean services should be available

Learn More – Primary Sources:

ACOG Practice Bulletin: External Cephalic Version

Related ObG Topics:

Meta-analysis: External Cephalic Version Following Previous Cesarean

External Cephalic Version – 18 Years Experience

Professional Recommendations: Delivery of Breech Presentation at Term

How Does External Cephalic Version Compare to Expectant Management