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In case of breech presentation after 35 weeks, health care providers often try to manually guide the fetus into the right position for birth or the head-down position.  This procedure of turning a breech baby into the head first position is known as external cephalic version (ECV).

ECV involves pushing on the maternal belly and guiding the baby’s head into the right position, all the while monitoring the presentation of the fetus on an ultrasound monitor. This procedure causes some discomfort to the mother though it is largely painless.

ECV is offered to most pregnant women with breech presentation after 36 weeks gestation. When performed by a skilled professional, the success rate of ECV is about 40% in first pregnancies (nulliparous) and about 60% in women who have given birth earlier or multiparous women.

In nulliparous women, ECV is offered after 36 weeks gestation and in multiparous women the procedure is offered after 37 weeks.

Studies have shown that ECV reduces the need for caesarean sections due to breech presentation at term. However, in 5% of cases, spontaneous reversion can occur after a successful ECV.

Contraindications to ECV

ECV must not be performed in the following conditions:

• Caesarean delivery is indicated for reasons other than breech presentation such as placenta previa, complicated C section in previous pregnancy
• Abnormal fetal heart rate (FHR)
• Contracted pelvis
• Ruptured membranes
• Fetal death
• Placental abruption

The ECV Procedure

Before starting ECV

• Counselling is provided to the woman about the benefits, risks and possible outcomes of the procedure.
• With the help of an ultrasound, fetal presentation, level of amniotic fluid, anomalies in the fetus or uterus and location of the placenta are examined a day before.
• Breech presentation is again confirmed prior to starting the procedure. Fetal heart rate (FHR) is also measured.
• Vital maternal parameters such as pulse, BP, and respiration are measured.
• Tocolysis is used to relax uterine muscles and then the maternal pulse, blood pressure (BP), and FHR are monitored every 10 minutes until the ECV commences.
• ECV procedure is started 30 min after tocolysis or when maternal pulse is >100bpm.

Turning the baby

• The maternal abdomen is lubricated to decrease friction and reduce discomfort.
• The breech is dislodged from maternal pelvis by placing hands between the breech and the pubic joint of the mother.
• The fetal head is guided toward the pelvis while the breech is guided towards the upper part of the uterus called the fundus.
• Anytime during the procedure, if any abnormality is noted in the FHR or pressure needs to be applied on the uterus for over 5 minutes, then the procedure is abandoned.

After ECV

Regardless of the outcome of the ECV, the following needs to be done:

• FHR, maternal pulse and BP are monitored and recorded for 30 to 40 min.
• In mothers with Rh negative blood group, a sample is obtained for blood group and antibody screening and a prophylactic anti-D administration is done.
• An hour after the procedure, the mother can be discharged, after ensuring that the vital maternal and fetal parameters are normal.
• Women should be advised to call the hospital in case of membrane rupture, vaginal bleeding, abnormal abdominal pain or decrease in fetal movements.
• An antenatal clinic appointment is fixed after a week of ECV to review and assess spontaneous reversion if any.

Risks Associated with ECV

Complications that can result following ECV include the following:

• Abnormal fetal parameters
• Major anomaly in the uterus
• Membrane rupture
• Pre-eclampsia
• Bleeding due to fetomaternal transfusion or abruption
• Complications of the umbilical cord such as cord around fetal neck
• Fetal death
• Fetal head hyperextension

References

• https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000623.htm
• https://www.sahealth.sa.gov.au/wps/wcm/connect/2277f4804ee1e4adae3aafd150ce4f37/Breech+presentation_June2014.pdf?MOD=AJPERES&CACHEID=2277f4804ee1e4adae3aafd150ce4f37
• http://www.kemh.health.wa.gov.au/development/manuals/O&G_guidelines/sectionb/2/b2.10.2.pdf

Further Reading

• All Childbirth Content
• Visitor Policies for Cesarean Sections
• Breeched Birth: Caesarean Section or Vaginal Delivery?
• Natural Childbirth
• What is a Transverse Baby?

Written by

Susha Cheriyedath

Susha has a Bachelor of Science (B.Sc.) degree in Chemistry and Master of Science (M.Sc) degree in Biochemistry from the University of Calicut, India. She always had a keen interest in medical and health science. As part of her masters degree, she specialized in Biochemistry, with an emphasis on Microbiology, Physiology, Biotechnology, and Nutrition. In her spare time, she loves to cook up a storm in the kitchen with her super-messy baking experiments.