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CARE OF THE MOTHER, CHILD

AT RISK OR WITH PROBLEMS
(ACUTE AND CHRONIC)
NCM 109

ZAMORA, ELIZABETH O.
NR 23

PROF. ELIZABETH D. CRUZ, RN, MAN

March 20, 2021

 EXTERNAL CEPHALIC VERSION
Meaghan M. Shanahan; Caron J. Gray.

Introduction

About 25% of fetuses will be in breech presentation at 28 weeks, and this decrease to
about 3% to 4% of term pregnancies. Most of these patients will be delivered by cesarean delivery.
It is held that the overall cesarean delivery rate is higher than it should be, and efforts to prevent
the first cesarean section often present obstetricians with the task of decreasing the number of
cesarean deliveries they perform. One alternative to cesarean delivery is an external cephalic
version (ECV). Simply, it is a procedure to change the presentation of the fetus from breech,
transverse, or oblique to vertex by applying pressure externally to the fetus through the gravid
abdomen. The overall success rate for the procedure is about 58% and can lead to decreased
cesarean delivery rates.

Anatomy and Physiology

ECV can be attempted with malpresentation of the fetus such as breech, transverse and
oblique presentations. Complete breech occurs when the fetus has the buttocks as the presenting
part and the knees are flexed with the feet near the buttocks. Frank breech occurs when the
buttocks are the presenting part, and the legs are extending with the feet near the fetal head.
Incomplete breech involves one bent leg and one extended leg. Transverse presentations occur
when the long axis of the fetus is at a right angle to the mother with the fetal head to one side of
the maternal abdomen and the back noted to be either be up or down in relation to the rest of
the fetal body. Oblique presentation is when the long axis of the fetus is at a 45-degree angle to
the mother, with the fetal head usually in the right or left lower quadrants.

Indications

Indications for ECV include a fetus with greater than 36 weeks of gestation with
malpresentation, reassuring fetal status, and no contraindications to vaginal delivery. Most
practitioners will proceed with ECV at 37 weeks to decrease the risk of preterm delivery. Factors
that may increase success include multiparity, transverse or oblique presentation, complete
breech, adequate amniotic fluid, and unengaged presenting part. Factors that are associated with
decreased success include nulliparity, advanced dilation, estimated fetal weight of less than 2,500
grams, anterior, lateral or cornual placenta, decreased amniotic fluid or ruptured membranes,

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maternal obesity, frank breech, fetal spine in the posterior position, and low station with an
engaged presenting part.

One alternative to ECV is expectant management with possible spontaneous version,

although most fetuses that will spontaneously change presentations to vertex will do so before 36
weeks gestation and are noted more often in multiparous than nulliparous women. Other
alternatives are expectant management with a vaginal or cesarean delivery of the breech fetus.

Contraindications

Any contraindication to vaginal delivery would also be a contraindication to ECV. These

include but are not limited to placenta previa, vasa previa, active genital herpes outbreak, and
prior classical cesarean delivery. Prior low transverse cesarean delivery is not a contraindication
to external cephalic version, although not much data is available on uterine rupture rates.

Antepartum ECV is contraindicated in multiple gestations, although it can be utilized for

delivery of the second twin.

Consideration should be used in patients with severe oligohydramnios, no reassuring fetal

monitoring, hyperextended fetal head, significant fetal or uterine anomaly, fetal growth
restriction, and maternal hypertension due to these situations being associated with a low
likelihood of success of ECV and possible increased risk to the fetus from the procedure.

If a woman presents in labor with malpresentation, ECV could be a reasonable option if

she is in early labor, the presenting part is unengaged, there is a normal amniotic fluid index, and
no contraindications to vaginal delivery or ECV

Equipment

Not much equipment is necessary for this procedure as it is performed with the
physician's own hands. Fetal monitoring and ultrasonography are necessary components for
safety and reassurance.

Personnel

An obstetrician experienced in external cephalic version is needed to perform an ECV.

The procedure can be performed by one or two people. Not necessary in the room, but those
that should be aware of the ECV procedure would be those needed in case of emergency
cesarean delivery, such as nursing, operating room, and anesthesia staff.

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Preparation

In preparation for ECV, the fetal presentation must be determined by ultrasound and
fetal well-being must be assessed, usually by a nonstress test. Contraindications are reviewed with
the patient to confirm that they have none. Risks, benefits, and alternatives are reviewed with the
patient, and informed consent is obtained. Rh status should be known before the procedure and
anti-D immune globulin administered after the procedure if indicated.

Technique

Some practitioners choose to administer a tocolytic, usually terbutaline 0.25 mg

subcutaneously, 15 to 30 minutes before the procedure, if are no contraindications. Data does
not support either calcium channel blockers or nitroglycerin for tocolysis in this situation.[6]
Some practitioners choose to use regional anesthesia in the form of either a spinal or epidural,
but data is insufficient to recommend this for all external cephalic version attempts, although it
may add to success if tocolysis alone is not successful.[7]

The patient is lying supine, with a sideways tilt with a wedge to keep pressure off the aorta
and vena cava. If the fetal presentation is breech, then the breech is lifted out of the pelvis with
one hand, and the other hand is used to apply pressure to the back of the fetal head to attempt
a forward roll. If a forward roll is unsuccessful, then a backward roll can be attempted. If the
fetus is in either a transverse or oblique presentation, similar manipulation of the fetus is used to
attempt to move the fetal head to the pelvis, noting a shorter distance to move than if the fetus is
in a breech presentation.

Intermittent use of ultrasonography during the procedure can be used to document fetal
heartbeat and current presentation. The procedure should be abandoned if there is significant
fetal bradycardia, discomfort to the patient, or if the procedure is not completed easily.
Afterward, the patient should be monitored for at least 30 minutes, with fetal heart rate tracing
and anti-D immune globulin given if indicated. Immediate induction is not recommended to
minimize reversion, although this could be considered after 39 weeks of gestation. If ECV is
unsuccessful, additional attempts can be made at the same admission or in one or more days
following the initial procedure.

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Complications

The most common complications associated with ECV are fetal heart rate abnormalities,
occurring at a rate of 4.7%, but these usually are transient and improve upon completion or
abandonment of the procedure. More severe complications of ECV occur at a rate of less than
1% and include emergency cesarean section, premature rupture of membranes, cord prolapse,
vaginal bleeding, placental abruption, fetomaternal hemorrhage, and stillbirth. Although
complications are rare, ECV should be attempted in locations where an emergency cesarean
section can be performed. For this reason, some practitioners chose to perform ECV in the
operating room, although this is not necessary.[9]

Clinical Significance

Patients should be counseled on and offered ECV when appropriate. Some data show
that only 20% to 30% of eligible candidates are offered ECV.

Women who have a successful ECV have a lower cesarean delivery rate than women who
do not, although they are still at a higher risk of cesarean delivery than women with cephalic
presenting fetuses and no ECV. ECV is cost effective if the probability of a successful ECV is
greater than 32%.

Reference:

Shanahan, M. M., & Gray, C. (2020, July 10). External Cephalic Version. StatPearls [Internet].
https://www.ncbi.nlm.nih.gov/books/NBK482475/.

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 EXTERNAL CEPHALIC VERSION: JOURNAL REFLECTION
Elizabeth O. Zamora

External Cephalic Version or ECV is one of the alternative ways to prevent cesarean
section, and to have a normal way of delivery or vaginal delivery. This is being done by the
physician, when the baby inside the mother’s womb is on breech presentation at the time of 36
weeks and above.

We all know that normal delivery should be the head of the baby first or what we call
cephalic presentation or vertex presentation. There are different types of other presentation
where ECV may be done or can be done, these are: oblique presentation is when the long axis
of the fetus is at a 45-degree angle to the mother, with the fetal head usually in the right or left
lower quadrants, transverse presentation occur when the long axis of the fetus is at a right angle
to the mother with the fetal head to one side of the maternal abdomen and the back noted to be
either be up or down in relation to the rest of the fetal body, frank breech occurs when the
buttocks are the presenting part, and the legs are extending with the feet near the fetal head.
Incomplete breech involves one bent leg and one extended leg, and complete breech occurs
when the fetus has the buttocks as the presenting part and the knees are flexed with the feet near
the buttocks.

Just like what is mentioned earlier, ECV is being done at 36 weeks of gestation, when the
baby is still at different presentation, other than cephalic presentation, that time. Most of ECV is
successful when the mother is not her first pregnancy, the baby is on transverse, oblique or
complete breech presentation, there is enough amniotic fluid inside the mother’s womb, and the
presenting part at the pelvic cavity of the mother is not yet engaged, or still can be move and pull.
ECV has a possibility of not being successful when it is mother’s first pregnancy, advanced
dilation, estimated fetal weight of less than 2,500 grams, anterior, lateral or cornual placenta,
oligohydramnios, ruptured membranes, maternal obesity, frank breech, fetal spine in the
posterior position, and the presenting part at the pelvic cavity is already engaged or cannot be
pulled and moved. Also, ECV is not advisable in multiple gestation however, it can be done at
the second twin.

In comes of the equipment needed in doing ECV, physician’s hand is the key. Though,
ultrasonography and fetal monitoring must be on standby for necessary situations. The physician
must be knowledgeable before doing ECV, this can be done by one or two practitioners. There

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is no specific type of room where you will conduct ECV but, cesarean section may be done that’s
why operating and nursing room should be on standby, also the staffs needed.

There is correct positioning and way in conducting ECV. The mother should be lying,
on supine position, but not totally flat because pregnant women are at risk of supine hypotensive
syndrome because major vessels are being compressed by the big tummy of the mother. There
is also proper technique in moving and positioning the baby inside the mother’s womb that’s why
it is very important that the physician has enough knowledge and experienced in conducting
ECV.

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