External Cephalic Version: Clinical Recommendations and Factors for Success

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

Professional Recommendations: Delivery of Breech Presentation at Term

SUMMARY:

ACOG guidance addresses the trend in the United States to deliver term singleton fetuses in breech presentation by cesarean section and the concomitant decrease in the number of practitioners with the skills and experience to perform vaginal breech deliveries. In 2001, the ACOG committee on Obstetric Practice recommended that planned vaginal delivery of a singleton breech was no longer appropriate but due to additional publications since that time, the recommendations have been updated.

KEY POINTS:

Vaginal delivery of a term singleton breech fetus

  • Planning a vaginal deliver for term singleton breech fetus may be a reasonable option under hospital-specific protocol guidelines that address eligibility and labor management  
  • Decision making  
    • Consider patient’s wishes and the experience of the health care provider  
  • Criteria based on retrospective studies have resulted in “excellent” neonatal outcomes, using protocols similar to the following
    • > 37 weeks gestational age 
    • Frank or complete breech presentation 
    • No fetal anomalies on ultrasound examination 
    • Adequate maternal pelvis 
    • EFW between 2,500 g and 4,000 g 
    • One study also included  
      • Fetal head flexion 
      • AFV ≥3 cm vertical pocket  
      • No oxytocin induction or augmentation  
      • Strict criteria for normal labor progress 

Informed Consent 

If vaginal breech delivery is planned, a detailed informed consent should be documented that include risks and benefits  

  • Short term risk/benefit 
    • Term Breech Trial (2000) demonstrated that perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower in the planned cesarean delivery group (1.6%) vs planned vaginal delivery group (5%) with no difference in maternal morbidity or mortality 
    • Follow-up at 3 months: Risk of urinary incontinence was lower for women in the planned cesarean delivery group but no difference at 2 years 
  • Long term risk/benefit (2 years)  
    • No differences for risk of death or neurodevelopmental delay, although there may be multiple reasons to explain this discrepancy, described in the ACOG Committee Opinion (see ‘Learn More – Primary Sources’ below) 
    • No difference for most maternal parameters, such as breastfeeding, pain, depression, or upsetting memories of the birth experience in 79.1% of women  
  • ACOG states that  

Current evidence demonstrates short-term benefits in neonatal and maternal morbidity and mortality from planned cesarean delivery of the term fetus with a breech presentation. Long-term benefits of planned cesarean delivery for these infants and women are less clear.

The SOGC guidelines (2019; see ‘Learn More – Primary Sources’ below) address both oxytocin augmentation and induction as follows

Oxytocin augmentation is acceptable to correct weak uterine contractions. If progress in labour is poor despite adequate contractions, Caesarean section is recommended (strong recommendation; moderate quality evidence)

Although data are limited, induction of labour with breech presentation does not appear to be associated with poorer outcomes than spontaneous labour (weak recommendation; low quality evidence)

RCOG recommendations (2017; see Learn More – Primary Sources’ below) also address augmentation and induction and advises caution (D Grade Recommendation)

Women should be informed that induction of labour is not usually recommended.

Augmentation of slow progress with oxytocin should only be considered if the contraction frequency is low in the presence of epidural analgesia.

External cephalic version 

  • Offer as an alternative to planned cesarean delivery if the patient desires planned vaginal delivery of a vertex-presenting fetus and has no contraindications  
  • Only attempt external cephalic version in a setting where cesarean delivery services are readily available

Learn More – Primary Sources:  

ACOG Committee Opinion 745: Mode of Term Singleton Breech Delivery

Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group

SOGC Guideline 384: Management of Breech Presentation at Term

RCOG Green Top Guideline 20b: Management of Breech Presentation