External Cephalic Version (ECV)

Contributor: A. Lane, MD; S. Chapman, MD

Date: May 2020

Introduction:

The incidence of breech presentation at term is approximately 3 to 4% with the majority of these fetuses delivering via cesarean section.  External cephalic version (ECV) provides a means of avoiding the risk of a cesarean delivery.

Guidelines:

When breech presentation is noted at >36 weeks gestation, the patient should be counseled about the fetal presentation and options for delivery including the availability of ECV.  If a formal ultrasound is needed it can be scheduled several days in advance of 37 weeks.  ECV should be scheduled in the labor and delivery unit ideally during week 37.  The procedure may be performed later, but because of the increased likelihood of engagement of the presenting part, the procedure is less likely to be successful.

Exclusions:

Any condition that would preclude vaginal delivery is a contraindication.  Examples include:

• Prior cesarean, if the patient is not a candidate for VBAC
• Third trimester bleeding deemed to be placental in origin
• Patients with severe cardiac/vascular disease, need to be individualized
• Uterine anomalies, need to be individualized
• Multiple gestation
• Suspected placental insufficiency
• Abnormal NST
• Severe oligohydramnios
• Placenta previa/funic presentation

Risks:

The risk of ECV include (<1% each): Placental abruption, umbilical cord prolapse, rupture of membranes, fetal maternal hemorrhage and stillbirth.  Fetal heart rate changes are not uncommon during the procedure, but usually stabilize when the procedure is discontinued.  Additionally there is a risk of reversion after successful ECV of approximately 5%.

Procedure:

• Patient should be NPO after midnight, or for 8 hours on the day of procedure.
• Document persistent breech presentation on ultrasound and absence of contraindication.
• Signed consent for ECV including risk of fetal distress requiring emergent cesarean delivery.
• Perform NST.
• Anesthesia evaluation and coordination of care.
• Obtain IV access and preoperative blood samples for CBC and type and screen. Labs may be held and sent only if cesarean delivery becomes necessary.
• If no contraindication to beta-mimetics, administer terbutaline 250 mcg subcutaneous just prior to procedure.
• Discuss with attending physician, the potential use of regional anesthesia in certain settings.
• Elevate the presenting part (slight Trendelenburg position may help). May be done by 1 or 2 operators.  If two, the assistant maintains elevation of the breech while the main operator manipulates the head.  If one, the operator rotates the fetus with one hand on the head and the other guiding the breech.  Monitor the fetal heart rate between attempts.  If fetal bradycardia develops, give O2 in place in left lateral tilt position.  Further attempts depend on the patient’s acceptance of another attempt and how well the fetus tolerates further manipulation.
• Document a reactive NST following the procedure.
• Administer RhoGam for Rh- patients.
• If successful ECV, patient may be discharged for routine prenatal follow-up. Of note, up to 5% of fetuses may revert to breech.
• If unsuccessful, the patient may be scheduled for cesarean delivery at 39 weeks gestation. Advised the patient to report to labor and delivery at the earliest signs of labor or rupture of membranes.

References

External Cephalic Version. ACOG Practice Bulletin No. 221. American College of Obstetricians and Gynecologists. Obstet Gynecol 2020;135:e203-12.