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External cephalic verson
External cephalic version is a process by which a breech baby can sometimes be turned from buttocks or foot first to head first. It should only be attempted from 34 weeks on and often is reserved for later because breech presentation greatly decreases with every week.
External verson is a non surgical method in which a doctor can help move the baby within the uterus. A medication to help relax the uterus might be given as well as an ultrasound exam, to better check the position of the baby, the location of the placenta, and the amount of amniotic fluid in the uterus. Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version, the baby's heartbeat will be checked closely so that if any problems should occur, the health care provider will stop turning immediately. Most attempts at external version are successful; however, as the due date gets closer this procedureis more difficult.
In this procedure hands are placed on the mother's abdomen around the baby. The baby is moved up and away from the pelvis and gently turned in several steps from breech, to a sideways position, and finally to a head first presentation. In any attempt to move the baby should be encouraged to keep its knees pulled in so as not to further complicate things.
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.
There are a few cases in which there can be a greater risk, these include pre-eclampsia, uterine scarring, and multiple pregnancies or fetal abnormality.
External Cephalic VersionANDREW S. COCO, M.D., M.S., and STEPHANIE D. SILVERMAN, M.D.
Lancaster General Hospital, Lancaster, Pennsylvania
A patient information handout on external cephalic version, written by the authors of this article, is provided on page 744.
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External cephalic version is a procedure that externally rotates the fetus from a breech presentation to a vertex presentation. External version has made a resurgence in the past 15 years because of a strong safety record and a success rate of about 65 percent. Before the resurgence of the use of external version, the only choices for breech delivery were cesarean section or a trial of labor. It is preferable to wait until term (37 weeks of gestation) before external version is attempted because of an increased success rate and avoidance of preterm delivery if complications arise. After the fetal head is gently disengaged, the fetus is manipulated by a forward roll or back flip. If unsuccessful, the version can be reattempted at a later time. The procedure should only be performed in a facility equipped for emergency cesarean section. The use of external cephalic version can produce considerable cost savings in the management of the breech fetus at term. It is a skill easily acquired by family physicians and should be a routine part of obstetric practice.
The incidence of breech presentation at term is about 4 percent.1 Multiple factors may cause a fetus to present breech instead of vertex, including placenta previa, multiple gestation, uterine anomalies, fetal anomalies, poor uterine tone and prematurity. The majority of cases have no apparent cause. Physicians performing external cephalic version (also referred to as external version) externally rotate the fetus from a breech presentation to a vertex presentation. Over the past 15 years, external cephalic version has become a valuable, although underused, option in the management of the breech fetus at term.
The most important reason to wait until the fetus is at term is to avoid iatrogenic prematurity if complications arise.
Before the resurgence of the use of external cephalic
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version, management of breech presentation consisted of either routine cesarean delivery or a selected trial of labor. However, over the past two decades, theoretically for safety concerns regarding the fetus, the rate of cesarean delivery for breech presentation increased from 14 percent in 1970 to the current rate of up to 100 percent at some institutions.2 Very few trials of labor are being attempted. Approximately 12 percent of cesarean deliveries in the United States are performed for breech presentation. Breech presentation ranks as the third most frequent
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indication for cesarean section, following previous cesarean section and labor dystocia.3 Routine use of external version could reduce the rate of cesarean delivery by about two thirds.4
This article reviews the rationale for the use of external version and its technical aspects, including the currently accepted protocol and manual maneuvers, factors predicting success and cost-effectiveness.
History of External Cephalic Version
TABLE 1
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Selection Criteria for Vaginal Breech Delivery
Estimated fetal weight from 2,000 to 4,000 g (4 lb, 6 oz to 8 lb, 13 oz)
Frank or complete breech presentation
Flexed fetal head
No major fetal anomalies or placenta previa on ultrasound
Adequate magnetic resonance, computed tomography or x-ray pelvimetry
Reprinted with permission from Eller DP, Van Dorsten JP. Breech presentation. Curr Opin Obstet Gynecol 1993;5:664-8.
External version has a
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pparently been practiced since the time of
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Aristotle (384 to 322 b.c.), who stated tha
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t many of his fellow authors advised midwiv
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es who were confronted with a breech presen
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tation to "change the figure and place the
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head so that it may present at birth." Howe
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ver, external version eventually fell out o
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f favor as a result of several concerns: it
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s high rate of spontaneous reversion (turni
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ng back to breech presentation) if performe
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d before 36 weeks of gestation, possible fe
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tal complications, and the assumption that
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an external version converts only those fet
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uses to vertex that would have converted sp
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ontaneously anyway.
The rebirth of the use
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of external version occurred in the early
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1980s in the United States, after a protoco
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l developed in Berlin was replicated with f
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avorable results in several U.S. studies.5
,
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6
Consumer demands for more nonintervention
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al birth experiences also played a role in
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its resurgence. Currently, external version
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is performed in many institutions, and the
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procedure is taught in most obstetric resi
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dency programs and in some family practice
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residency programs.
The safety of vaginal b
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reech delivery has been a longstanding cont
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roversy. In a recent retrospective study,7
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investigators found that the risk of fetal
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morbidity and mortality is increased when v
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aginal delivery is attempted and concluded
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that cesarean section should be recommended
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routinely. In another study,8
however, inv
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estigators reached an opposite conclusion.
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They calculated a corrected perinatal morta
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lity of zero based on a series of 316 women
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undergoing a trial of labor.
Other studie
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s have documented the success and safety of
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external version. The authors of a recent
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literature review4
of 25 studies on the eff
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icacy of external cephalic version calculat
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ed an overall success rate of 63.3 percent,
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with a range of 48 to 77 percent. Most of
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these studies used the currently accepted p
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rotocol that is discussed in this article.
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These studies documented minimal risks, inc
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luding umbilical cord entanglement, abrupti
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o placenta, preterm labor, premature ruptur
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e of the membranes (PROM) and severe matern
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al discomfort. Overall complication rates h
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ave ranged from about 1 to 2 percent since
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1979.4
In another study,9
fetal heart rate
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changes occurred in 39 percent of fetuses d
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uring external version attempts, but these
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changes were transient and had no relations
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hip to the final outcome. Importantly, the
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literature provides overwhelmingly reassuri
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ng evidence regarding the risk of fetal dea
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th. Before 1980, four fetal deaths from ext
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ernal cephalic version had been reported. A
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ll of these deaths occurred in association
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with attempts at external version using gen
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eral anesthesia.1
0
Since 1980, only two fet
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al deaths have been reported with external
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version. Both occurred without the use of f
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etal heart rate monitoring or ultrasonograp
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hy in preterm infants in Zimbabwe.1
1
A rece
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nt study1
2
reported a success rate for exte
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rnal cephalic version of 69.5 percent. Note
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worthy was the fact that among fetuses unde
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rgoing successful version, the incidence of
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intrapartum cesarean section was 16.9 perc
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ent, a figure that was 2.25 times higher th
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an that in the control group. The high rate
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of cesarean delivery resulted from a signi
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ficantly higher incidence of fetal distress
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and labor dystocia in the group receiving
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external version. Results of this study dem
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onstrate that even after successful version
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, a higher rate of intrapartum abnormalitie
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s may occur.
Algorithm for external cephalic version.
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Prospe
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ctive, randomized trials regarding vaginal
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breech delivery are not available and are u
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nlikely to be carried out because of liabil
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ity concerns. A consensus in the obstetric
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literature is lacking, and the optimal rate
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of cesarean section is likely to remain el
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usive and controversial. A policy of routin
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e cesarean section eliminates the fetal ris
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ks, but considerably increases the risks of
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maternal morbidity. Neither option address
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es the primary problem of the breech presen
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tation, which the external version can answ
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er in selected situations.
First, the degree of engagement of the presenting part should be determined and gentle disengagement performed if possible.
Sele
ction cri
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teria for a safe attempt at vaginal breech delivery are listed in Table 113
When these cri
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teria are applied, approximately 70 percent of women with a vaginal breech presenta
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tion will be candidates for attempted vaginal delivery. Of these, approximately two thir
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ds will have a successful delivery.If inclusion criteria are routinely used, the calculated
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success rate for vaginal delivery of a fetus in the breech position is just over 40 percent.
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Or, conversely, about 60 percent of fetuses presenting in the breech position will be deliv
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ered by cesarean section despite optimal attempts to achieve a vaginal delivery.
Not only
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does external cephalic version significantly reduce the number of breech presentations
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at term, its use also reduces the high rate of cesarean delivery for this indication. Any
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reduction in the primary rate of cesarean delivery has an additive effect on the overall ra
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te by decreasing the number of women undergoing repeat cesarean delivery. The maj
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or benefits of external cephalic version are reduced maternal morbidity and mortality fro
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m surgery.
Timing of Breech Version at Term
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Figure 2. The breech should be mobilized. This may require a second person to vaginally disengage the breech.
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