External cephalic version

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External cephalic version
As tabula IX and Child presenting feet Wellcome L0009819.jpg
Child presenting head first (top) and feet first (bottom) [1]
Specialty Obstetrics
ICD-9-CM 73.91

External cephalic version (ECV) is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It is a manual procedure that is recommended by national guidelines for breech presentation of a pregnancy with a single baby, in order to enable vaginal delivery. [2] [3] It is usually performed late in pregnancy, that is, after 36 gestational weeks, [4] preferably 37 weeks, [5] and can even be performed in the early stages of childbirth. [4]

Contents

ECV is endorsed by the American College of Obstetricians and Gynecologists (ACOG) and Royal College of Obstetricians and Gynaecologists (RCOG) as a mode to avoid the risks associated with a vaginal breech or cesarean delivery for singleton breech presentation. [2] [6]

ECV can be contrasted with "internal cephalic version", which involves a hand inserted through the cervix. [7]

Medical use

ECV is one option of intervention should a breech position of a baby be found after 36 weeks gestation. Other options include a planned caesarian section or planned vaginal delivery. [4]

Success rates

ECV has an average success rate of around 58%, [3] between 40 and 64% depending on whether it is the mother's first child or not. (40% for first-time mothers and closer to 60% for women who have had previous children.[ citation needed ]

Various factors can alter the success rates of ECV. Practitioner experience, maternal weight, obstetric factors such as uterine relaxation, a palpable fetal head, a non-engaged breech, non-anterior placenta, and an amniotic fluid index above 7–10 cm, are all factors which can be associated with higher success rates. In addition, the effect of neuraxial blockade on ECV success rates have been conflicting, although ECV appears easier to perform under epidural block. [2] [8]

Following successful ECV, with the baby turned to head first, there is a less than 5% chance of the baby turning spontaneously to breech again. [9]

Contra-indications

Some situations exist where ECV is not indicated or may cause harm. These include recent antepartum haemorrhage, placenta praevia, abnormal fetal monitoring, ruptured membranes, multiple pregnancy, pre-eclampsia, reduced amniotic fluid and some other abnormalities of the uterus or baby. [9]

Risks

As with any procedure there can be complications most of which can be greatly decreased by having an experienced professional on the birth team. An ultrasound to estimate a sufficient amount of amniotic fluid and monitoring of the fetus immediately after the procedure can also help minimize risks. [10]

Evidence of complications of ECV from clinical trials is limited, but ECV does reduce the chance of breech presentation at birth and caesarian section. The 2015 Cochrane review concluded that "large observational studies suggest that complications are rare". [9] [11]

Typical risks include umbilical cord entanglement, abruption of placenta, preterm labor, premature rupture of the membranes (PROM) and severe maternal discomfort. Overall complication rates have ranged from about 1 to 2 percent since 1979. While somewhat out of favour between 1970 and 1980, the procedure has seen an increase in use due to its relative safety. [12]

Successful ECV significantly decreases the rate of cesarean section, however, women are still at an increased risk of instrumental delivery (ventouse and forceps delivery) and cesarean section compared to women with spontaneous cephalic presentation (head first). [4] [13]

Technique

The procedure is undertaken by either one or two physicians and where emergency facilities to undertake instrumental delivery and caesarian section are at hand. Blood is also taken for cross-matching should a complication arise. [12] Prior to performing ECV, an ultrasound of the abdomen is performed to confirm the breech position and the mother's blood pressure and pulse are taken. A cardiotocography (CTG) is also performed to monitor the baby's heart. [4] [14]

The procedure usually lasts a few minutes and is monitored intermittently with CTG. [6] With a covering of ultrasonic gel on the abdomen to reduce friction, [12] the physician's hands are placed on the mother's abdomen around the baby. Then, by applying firm pressure to manoeuvre the baby up and away from the pelvis and to gently turn in several steps from breech, to a sideways position, the final manipulation results in a head first presentation. [4] [15] The procedure is discontinued if maternal distress, repeated failure or fetal compromise on monitoring occurs. [12]

ECV performed before term may decrease the rate of breech presentation compared to ECV at term, but may increase the risk of preterm delivery. [16] There is some evidence to support the use of tocolytic drugs in ECV. [17] Given by injection, tocolytics relax the uterus muscle and may improve the chance of turning the baby successfully. This is considered safe for the mother and baby, but can cause the mother to experience facial flushing and a feeling of a fast heart rate. [4] Use of intravenous nitroglycerin has been proposed. [18]

Following the procedure, a repeat CTG is performed and a repeat ultrasound will confirm a successful turn. [4] Should this first attempt fail, a second attempt on another day can be considered. [9]

In addition, to prevent Rh disease after the procedure, all rhesus D negative pregnant women are offered an intramuscular injection of anti-Rh antibodies (Rho(D) immune globulin). [4]

History

ECV has existed since 384–322 B.C., the time of Aristotle. [12] Around 100 A.D., Soranus of Ephesus included guidance on ECV as a way to reduce complications of vaginal breech birth. 17th century French obstetrician, François Mauriceau, is alleged to have described ECV as "a little more difficult than turning an omelette in a frying pan". [19] Justus Heinrich Wigand published an account of ECV in 1807 and the procedure was increasingly accepted following Adolphe Pinard's demonstration of it in France. In 1901, British obstetrician, Herbert R. Spencer, advocated ECV in his publication on breech birth. In 1927, obstetrician George Frederick Gibberd, reviewed 9,000 consecutive births around Guy's Hospital, London. Following his study, he recommended ECV, even if it failed and needed to be repeated and even if it required anaesthesia. [19]

ECV's safety has continued to be a longstanding controversy. Following a protocol developed in Berlin, ECV did increase in popularity in the United States in the 1980s. [12] The procedure has been increasingly considered as low risk of complications and its improvement in safety as a result of the routine use of electronic fetal monitoring, waiting until closer to term and the replacement of anaesthesia by tocolysis, [19] has seen a recent resurgence. [6]

Related Research Articles

<span class="mw-page-title-main">Caesarean section</span> Surgical procedure in which a baby is delivered through an incision in the mothers abdomen

Caesarean section, also known as C-section or caesarean delivery, is the surgical procedure by which one or more babies are delivered through an incision in the mother's abdomen. It is often performed because vaginal delivery would put the mother or fetus at risk. Reasons for the operation include obstructed labor, twin pregnancy, high blood pressure in the mother, breech birth, shoulder presentation, and problems with the placenta or umbilical cord. A caesarean delivery may be performed based upon the shape of the mother's pelvis or history of a previous C-section. A trial of vaginal birth after C-section may be possible. The World Health Organization recommends that caesarean section be performed only when medically necessary.

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Breech birth</span> Birth of a baby bottom first

A breech birth is when a baby is born bottom first instead of head first, as is normal. Around 3–5% of pregnant women at term have a breech baby. Due to their higher than average rate of possible complications for the baby, breech births are generally considered higher risk. Breech births also occur in many other mammals such as dogs and horses, see veterinary obstetrics.

Fetal distress, also known as non-reassuring fetal status, is a condition during pregnancy or labor in which the fetus shows signs of inadequate oxygenation. Due to its imprecision, the term "fetal distress" has fallen out of use in American obstetrics. The term "non-reassuring fetal status" has largely replaced it. It is characterized by changes in fetal movement, growth, heart rate, and presence of meconium stained fluid.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

<span class="mw-page-title-main">Umbilical cord prolapse</span> Complication of pregnancy where the umbilical cord slips out of the uterus prior to birth

Umbilical cord prolapse is when the umbilical cord comes out of the uterus with or before the presenting part of the baby. The concern with cord prolapse is that pressure on the cord from the baby will compromise blood flow to the baby. It usually occurs during labor but can occur anytime after the rupture of membranes.

<span class="mw-page-title-main">Placental abruption</span> Medical condition

Placental abruption is when the placenta separates early from the uterus, in other words separates before childbirth. It occurs most commonly around 25 weeks of pregnancy. Symptoms may include vaginal bleeding, lower abdominal pain, and dangerously low blood pressure. Complications for the mother can include disseminated intravascular coagulopathy and kidney failure. Complications for the baby can include fetal distress, low birthweight, preterm delivery, and stillbirth.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Medical condition

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Cervical effacement</span>

Cervical effacement or cervical ripening refers to the thinning and shortening of the cervix. This process occurs during labor to prepare the cervix for dilation to allow the fetus to pass through the vagina. While this a normal, physiological process that occurs at the later end of pregnancy, it can also be induced through medications and procedures.

In case of a previous caesarean section a subsequent pregnancy can be planned beforehand to be delivered by either of the following two main methods:

<span class="mw-page-title-main">Obstetrical forceps</span> Medical instrument used for the delivery of a baby

Obstetrical forceps are a medical instrument used in childbirth. Their use can serve as an alternative to the ventouse method.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

<span class="mw-page-title-main">Shoulder presentation</span> Medical condition

A shoulder presentation is a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, a shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section (C/S) is performed.

<span class="mw-page-title-main">Monoamniotic twins</span> Identical twins sharing the same amniotic sac in the womb

Monoamniotic twins are identical or semi-identical twins that share the same amniotic sac within their mother's uterus. Monoamniotic twins are always monochorionic and are usually termed Monoamniotic-Monochorionic twins. They share the placenta, but have two separate umbilical cords. Monoamniotic twins develop when an embryo does not split until after formation of the amniotic sac, at about 9–13 days after fertilization. Monoamniotic triplets or other monoamniotic multiples are possible, but extremely rare. Other obscure possibilities include multiples sets where monoamniotic twins are part of a larger gestation such as triplets, quadruplets, or more.

Amnioinfusion is a method in which isotonic fluid is instilled into the uterine cavity.

Locked twins is a rare complication of multiple pregnancy where two fetuses become interlocked during presentation before birth. It occurs in roughly 1 in 1,000 twin deliveries and 1 in 90,000 deliveries overall. Most often, locked twins are delivered via Caesarean section, given that the condition has been diagnosed early enough. The fetal mortality rate is high for the twin that presents first, with over 50% being stillborn.

<span class="mw-page-title-main">Prolonged labor</span> Medical condition

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. Failure to progress can take place during two different phases; the latent phase and active phase of labor. The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. The active phase of labor, on the other hand, if prolonged, can result in long term complications.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

<span class="mw-page-title-main">Operative vaginal delivery</span>

Operative vaginal delivery, also known as assisted or instrumental vaginal delivery, is a vaginal delivery that is assisted by the use of forceps or a vacuum extractor.

References

  1. ↑ Burton, John (1751). "An essay towards a complete new system of midwifry, theoretical and practical. Together with the descriptions,causes and methods of removing, or relieving the disorderspeculiar to pregnant ... women, and new-born infants". J. Hodges. Retrieved 25 September 2018.
  2. 1 2 3 Sharoni, L (March 2015). "Anesthesia and external cephalic version". Current Anesthesiology Reports. 5: 91–99. doi:10.1007/s40140-014-0095-0. S2CID   71800278.
  3. 1 2 Shanahan, Meaghan M.; Gray, Caron J. (2020), "External Cephalic Version", StatPearls, StatPearls Publishing, PMID   29494082 , retrieved 14 April 2020
  4. 1 2 3 4 5 6 7 8 9 "Breech baby at the end of pregnancy" (PDF). www.rcog.org. July 2017. Retrieved 23 September 2018.
  5. ↑ Arnold, Kate C.; Flint, Caroline J. (2017). Obstetrics Essentials: A Question-Based Review. Oklahoma, USA: Springer. pp. 231–235. doi:10.1007/978-3-319-57675-6. ISBN   978-3-319-57674-9. S2CID   38547277.
  6. 1 2 3 Ehrenberg-Buchner, Stacey (3 August 2018). "External Cephalic Version: Overview, Technique, Periprocedural Care" . Medscape.
  7. ↑ Neely, M. R. (May 1959). "Combined internal cephalic version". Ulster Medical Journal. 28 (1): 30–4. PMC   2384304 . PMID   13669146.
  8. ↑ Wight, William (2008). "18. External cephalic version". In Halpern, Stephen H.; Douglas, M. Joanne (eds.). Evidence-Based Obstetric Anesthesia. John Wiley & Sons. pp. 217–224. ISBN   9780727917348.
  9. 1 2 3 4 "External Cephalic Version and Reducing the Incidence of Breech Presentation" (PDF). www.rcog.org.uk. 2010. Retrieved 23 September 2018.
  10. ↑ Kok, M.; Cnossen, J.; Gravendeel, L.; Van Der Post, J. A.; Mol, B. W. (January 2009). "Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis". Ultrasound in Obstetrics and Gynecology. 33 (1): 76–84. doi: 10.1002/uog.6277 . ISSN   0960-7692. PMID   19115237. S2CID   12917755.
  11. ↑ Hofmeyr, G Justus; Kulier, Regina; West, Helen M. (2015). "External cephalic version for breech presentation at term". Cochrane Database of Systematic Reviews. 2019 (5): CD000083. doi:10.1002/14651858.CD000083.pub3. PMC   6505738 . PMID   25828903.
  12. 1 2 3 4 5 6 Coco, Andrew S.; Silverman, Stephanie D. (1998-09-01). "External Cephalic Version". American Family Physician. 58 (3): 731–8, 742–4. ISSN   0002-838X. PMID   9750541.
  13. ↑ de Hundt, M; Velzel, J; de Groot, CJ; Mol, BW; Kok, M (June 2014). "Mode of delivery after successful external cephalic version: a systematic review and meta-analysis". Obstetrics and Gynecology. 123 (6): 1327–34. doi:10.1097/aog.0000000000000295. PMID   24807332. S2CID   16394070.
  14. ↑ "What Is External Cephalic Version?". WebMD. Retrieved 23 September 2018.
  15. ↑ "37 weeks pregnant". www.nct.org.uk. Retrieved 23 September 2018.
  16. ↑ Hutton, EK; Hofmeyr, GJ; Dowswell, T (29 July 2015). "External cephalic version for breech presentation before term". The Cochrane Database of Systematic Reviews. 2015 (7): CD000084. doi:10.1002/14651858.CD000084.pub3. PMC   9188447 . PMID   26222245.
  17. ↑ Cluver, C; Gyte, GM; Sinclair, M; Dowswell, T; Hofmeyr, GJ (9 February 2015). "Interventions for helping to turn term breech babies to head first presentation when using external cephalic version". The Cochrane Database of Systematic Reviews. 2 (2): CD000184. doi:10.1002/14651858.CD000184.pub4. hdl: 10019.1/104301 . PMID   25674710.
  18. ↑ Hilton J, Allan B, Swaby C, et al. (September 2009). "Intravenous nitroglycerin for external cephalic version: a randomized controlled trial". Obstet Gynecol. 114 (3): 560–7. doi:10.1097/AOG.0b013e3181b05a19. PMID   19701035. S2CID   9757809.(subscription required)
  19. 1 2 3 Paul, Carolyn (22 March 2017). "The baby is for turning: external cephalic version". BJOG: An International Journal of Obstetrics & Gynaecology. 124 (5): 773. doi: 10.1111/1471-0528.14238 . ISSN   1470-0328. PMID   28328063.
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