External cephalic version (ECV) is a procedure used to manually turn a fetus from a breech position to a head-down position in utero. ECV is generally performed after 36 weeks of gestation with tocolysis to reduce risks. It can successfully turn 44-57% of breech fetuses, reducing the need for cesarean section. Risks of ECV include brief fetal bradycardia in 8% of cases and 5% risk of fetomaternal hemorrhage. However, meta-analyses show ECV significantly reduces breech birth, cesarean rates, and risks to the fetus and mother when compared to breech vaginal delivery or planned cesarean. ECV

1. External
Cephalic
Version

2. Spontaneous version
 After 32/40 is as high as 57% and after 36/40 may still
be as high as 25%.
 Is more in multiparous.
 Less likely in primipara and extended breech.
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3. Promotion of spontaneous
version
 Any factor which promotes disengagement.
 Postural changes (Knee-chest position).
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4. ECV
 Before 1970:
 Performed without tocolysis.
 Prior to 36/40.
 With or without sedation.
After 1978,after 36/40:
 Preferably with tocolysis.
 Lower incidence of complications
 Avoidance of PTL and delivery.
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5. Risks of ECV
 Severe bradycardia requires immediate delivery by CS.
 1% IUFD.
 Spontaneous reversion.
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6. Results of meta-analysis
 Reduction in breech birth from 78% to 44%.
 Reduction in CS rate from 29% to 15%.
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7. Benefits to fetus
 Decreases the risks of foetal trauma.
 Decreases the incidence of cord prolapse.
 Decreases the rate of unattended breech delivery.
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8. Risks to the foetus
Review of 979 cases:
 8% bradycardia due to short term hypoxia.
 (49) 5% Feto-maternal haemorrhage with tocolysis and
285 (29%) without.
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9. Benefits to the mother
 Reduction in significant maternal complication
 Cs may compromise future reproduction.
 Emotional sequelae.
 Higher maternal death.
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10. Indications and contra-
indications
 37/40 and above:
 Gestational age-37,38,40: 40 more successful than 39,38
more than 37.
 EFW: the bigger the foetus the less successful ECV.
 Tense abdomen/uterus.
 Difficulty in palpating the foetal head.
 Increasing parity.
 AF less than 2 cm in any pocket.
 Back of the foetus anteriorly.
 Maternal obesity.
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11. Indications
 Any breech after 36/40.
 Un-engaged breech.
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12. Contra-indications
Absolute:
 Multiple pregnancy.
 APH, P.Praevia.
 Ruptured membranes.
 Significant foetal abnormalities.
 Need for CS for other indications.
 Tocolysis is C/I in congenital or
acquired heart disease, DM or thyroid
disease.
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13. Relative:
 Previous CS.
 IUGR.
 Severe protienuric PIH.
 RH iso-immunization.
 (Evidence of macrosomia).
 (Grand-multi-para).
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14.  (Anterior placenta).
 (Precious baby).
 (Previous APH).
 (Suspected foetal compromise).
 (Uterine anomaly).
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15. Pre-requisites
 USS to confirm normal baby and normal AFV.
 Reactive CTG.
 Informed concent: PTL, ROM,cord and placental accident.
 Facilities for immediate CS.
 Kleihauer test.
 IV line.
 Clinical pelvimetry.
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16. Procedure
 Position: -slight lateral tilt
 - trendelenburg.
 Tocolysis.
 One operator.
 Continuous pressure should be limited to 5 minutes.
 Dis-engagement of the breech.
 Forward or backward methods with flexion or slight
extension.
 CTG.
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17. Maternal and foetal factors in
breech
 228 singleton breech;
 96 remained as breech at delivery.
 132 turned sopntaneously.
 Nulliparas comprised 60%.
 Gestational age was 10 days less in the beech group.
 Weight, length and HC at birth were lower in the breech.
 AFV was lower in the breech, 8 oligohydramnios to 1.
 Only 15% of the breech had identifiable cause.
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18. Conclusion
 Current evidence indicates that ECV performed at term
with tocolysis is safe procedure for carefully selected
cases.
 The short term complications are negligible and the long
term ones are hard to determine.
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