Ecv rcog2006


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Ecv rcog2006

  1. 1. External cephalic version RCOG, 2006 Aboubakr Elnashar Prof . Obs Gyn Benha University Hospital
  2. 2. Reduction of incidence of breech presentation have become more important 1. Breech:  3–4% of all term deliveries 2. CS for breech  increased markedly in the last 20 ys  safer for the fetus & of similar safety to the mother (The term breech trial).
  3. 3. Impact of ECV on the incidence of breech presentation at delivery ECV reduces the chance of breech presentation at delivery. Spontaneous version: 8% Spontaneous version after unsuccessful ECV: 5% Success rates of ECV: 30–80%. Spontaneous reversion to breech after successful ECV: 5%.
  4. 4. Effect of ECV on CS rate ECV lowers CS rate Labour with a cephalic presentation following ECV is associated with a higher rate of obstetric intervention than when ECV has not been required. Risk difference: 17% NNT: 6
  5. 5. Success rate of ECV 50% 30%-80% Nulliparous: 40% multiparous 60%
  6. 6. Factors affecting success 1. Race 2. Parity 3. uterine tone 4. liquor volume, 5. engagement of the breech 6. whether the head is palpable 7. use of tocolysis
  7. 7. The highest success rates 1. Multiparous 2. non-white women 3. Relaxed uterus 4. breech is not engaged 5. head is easily palpable. 6. increasing liquor volume. N.B. very high liquor volume may be associated with spontaneous reversion.
  8. 8. Less important factors: 1. Maternal weight 2. placental position 3. Gestation 4. fetal size 5. position of the legs
  9. 9. Tocolysis either routinely or if an initial attempt has failed. beta-sympathomimetics increase the success rate: ritodrine, salbutamol, terbutaline slow IV or SC bolus Not glyceryl trinitrate nifedipine.
  10. 10. Methods to increase the success rate of ECV 1. Second attempt: particularly with a second operator or where the back has been in the midline 2. Tocolysis 3. Fetal acoustic stimulation: where the back is in the midline 4. Regional analgesia: success rate is evident with epidural but not spinal As maternal pain might indicate a complication, concerns regarding safety
  11. 11. Timing of ECV Nulliparous: 36 w Multiparous: 37 w {ECV before 36 w is not associated with a significant reduction in noncephalic births or CS}. No upper time limit on the appropriate gestation for ECV. Successes has been reported at 42 w can be performed in early labour provided that the membranes are intact.
  12. 12. Complications Rare 1. placental abruption 2. uterine rupture 3. fetomaternal haemorrhage. 4. immediate emergency CS: 0.5% 5. Transient alterations in fetal parameters:
  13. 13. 5. Transient alterations in fetal parameters: Fetal bradycardia Nonreactive CTG Alterations in umbilical artery and middle cerebral artery waveforms increase in AFV. The significance of these is unknown. No increase in neonatal morbidity and mortality Labour
  14. 14. Prerequisites 1. Facilities for monitoring US: FHR visualisation CTG: before & after procedure 2. Facilities for immediate delivery 3. Anti-D immunoglobulin to rhesus-negative
  15. 15. Not necessary 1. Kleihauer testing 2. Preoperative preparations for CS Starvation anaesthetic premedication intravenous access
  16. 16. ECV & pain can be painful No discomfort: few women High pain scores: 5%: stop Pain is greater where the procedure fails.
  17. 17. Contraindications Absolute ● where CS is required ● antepartum haemorrhage within the last 7 days ● abnormal CTG ● major uterine anomaly ● ruptured membranes ● multiple pregnancy (except delivery of second twin).
  18. 18. Relative ● small-for-gestational-age fetus with abnormal Doppler parameters ● proteinuric pre-eclampsia ● oligohydramnios ● major fetal anomalies ● scarred uterus: The available data on ECV after one caesarean section are reassuring, but are insufficient to confidently conclude that the risk is not increased. ● unstable lie: ECV is only logical in the context of a stabilising induction. There are few available data on this procedure, which should only be performed for a valid indication and may be associated with a significant intrapartum complication rate.
  19. 19. Increasing the uptake of ECV Local policies should be implemented to actively increase the number of women offered and undergoing ECV. Obstetricians and midwives should be able to discuss the benefits and risks of ECV
  20. 20. Alternatives to ECV 1. Postural management: insufficient evidence 2. Moxibustion: should not be recommended burnt at the tip of the fifth toe (acupuncture point BL67)
  21. 21. Developing an ECV service 1. An ECV service should be available to all women with a breech presentation at term. 2. ECV is not difficult and skills should be developed, if necessary, by visiting other hospitals. ECV can be performed by suitably trained midwives; experience with ultrasound is essential. 3. All women undergoing ECV should be offered detailed information (preferably written) concerning the risks and benefits of the procedure. 4. Consent may also be appropriate.
  22. 22. 1-2: 0% 9-10: 100% 210 >210Parity Lat, funpostantPlacenta 01-2>3Dilatation >3.52.5-3.5<2.5EFW -3-2-1Station
  23. 23.  Head palpable.  Breech unengagement  Symphysisfundal height  Uterine relaxation
  24. 24. Procedure  Prepare for the possibility of CS  U/S: confirm breech check growth AFV F anomalies  NST  ECV can be performed with 2 operators.  Mg. sulfate: 4 amp 10 ml,10% IV within 20 m.  ECV is accomplished by judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus..
  25. 25. Judicious manipulation of the fetal head toward the pelvis while the breech is brought up toward the fundus
  26. 26.  Following an ECV attempt, repeat NST  Administer Rh-immune globulin to women who are Rh negative.  Be prepared for an unsuccessful ECV.  Some physicians induce labors following successful ECV