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  • Nathan Riley, MD

Obgyno Wino Podcast Episode 50 - External Cephalic Version

"Everyone who is seriously interested in the pursuit of science becomes convinced that a spirit is manifest in the laws of the universe - a spirit vastly superior to man, and one in the face of which our modest powers must seem humble." - Albert Einstein

2018 Corbières Col des Vents by Castelmaure

PB#221 - Published May 2020


Five Pearls

1. Training physicians in external cephalic version (ECV) and encouraging the practice of this procedure could significantly reduce c-section rate

2. It's best to wait until 37w0d to attempt ECV due to high likelihood of spontaneous version prior to that but likelihood of success decreases with advancing gestational age beyond 37w0d

3. Risks to mom/fetus include: cord prolapse, fetomaternal hemorrhage, terminal deceleration, placental abruption, or demise but these risks are all <1%

4. Administration of a tocolytic agent like terbutaline can increase rate of success.

5. ECV is really f*cking easy to learn and perform



Basics

- What is ECV? Using your hands to rotate the baby inside a woman uterus from non-cephalic presentation to cephalic presentation

- 3-4% of fetuses present breech at term, which has contributed significantly to rising c-section rates, partly because up to 30% of these women are not offered external cephalic version (ECV)

- knowledge of ECV is critical if we are going to stop teaching the maneuvers to facilitate vaginal breech birth





Who should be recommended for ECV?

- I check for fetal presentation starting at 34-36 wga; I use Leopold's maneuvers

- if there's any doubt, you can easily identify a breech baby with bedside ultrasound

- most of the time a breech baby resolves itself to cephalic prior to onset of labor

- if at 36 wga fetus is still breech, consider ECV in order to encourage the kiddo to flip


Leopold's Maneuvers: a) fundus (butt or head?), b) where's the back?, c) confirm presentation at pelvic inlet, d) neck flexed or extended?

- good candidates is woman in which success is more likely, but you could attempt an ECV safely on most women/fetuses (more on that later)

- success rates range from 16-100% depending on a variety of clinical factors, including experience of the provider, volume of amniotic fluid, and location of placenta (anterior versus posterior)

- factors that increase success rate: higher parity, transverse or oblique presentation (compared to breech), and posterior placenta, use of tocolytic agent prior to ECV attempt

- some studies have also found higher success rate when epidural anesthesia was used during procedure; the data was biased, however, by low overall success rates and provider preference (in other words: crappy trial design); a meta-analysis of the available trials concluded evidence of insufficient to recommend use of neuraxial anesthesia alone, but there seems to be a benefit when it's combined with a tocolytic agent

- best to wait until 37w0d due to high likelihood of spontaneous version prior to that but likelihood of success decreases as advancing gestational age beyond 37w0d

- also, preterm ECV success rates are high but so are the rates of spontaneous reversion back to breech

- best to attempt prior to labor because a relaxed uterus is easier to manipulate; however, success rate of 65% was reported in one study that looked at ECVs offered and performed upon presentation to L&D unit in active labor

- no absolute contraindications to ECV apart from contraindications to vaginal birth (like presence of genital HSV lesions)


Counseling

- risk and benefits are required for informed decision-making, then it's your job to make a recommendation and support her decision, whether or not she accepts your recommendation

Benefits

- avoid c-section (!!), meaning...

- shorter hospital stay

- reduced postpartum pain and mobility

- faster postpartum recovery

- lesser chance for puerperal infection

- less financial burden to the patient and system

- improved immediate bonding between mom and baby

- avoidance of the emotional trauma many women report after c-section

- avoidance of risks in future pregnancies incurred through history of prior c-section such as abnormal placentation, the need to find a TOLAC-friendly hospital, or the additive risks of repeat c-section


Risks

- can be uncomfortable for the patient

- can lead to terminal deceleration, placental abruption, cord prolapse, rupture of membranes, fetomaternal hemorrhage, or fetal demise: risk of any of these is <1% (don't believe me? Check here or here)

- fetal heart rate may drop during or immediately after ECV attempt but it normally returns to baseline soon after

- what about uterine rupture risk if prior CS? Available evidence does not suggest an increased risk of uterine rupture w/ ECV attempt


So how is it done, doc?

  1. Counsel your patient: It's going to be a little uncomfortable, but generally not painful. Risks versus benefits, as always.

  2. Ensure that your staff knows that you are preparing for ECV in event of one of those very rare events that may prompt emergency c-section

  3. Ultrasound the fetus, noting EFW, presentation, and position, and amniotic fluid volume

  4. Administer terbutaline 0.250 mg IM/IV (let her know that she will likely feel her heart racing!)

  5. Thirty minutes later, apply mineral oil to her abdomen. Ask her to flex her knees to relax the abdominal wall.

  6. Place your non-dominant hand on the fetal rump, likely just above the pubic symphysis if breech, and lift the fetus out of the pelvis. Simultaneously, apply pressure with your dominant hand to the fetal head to encourage the kiddo to somersault forward (ultrasound guidance can be helpful)

  7. After three good college tries, you should have an idea as to whether or not it will work. Babies either flip or don't flip. If you try to force a kid to flip, you're more likely to end up with a problem (in my experience)

  8. Whether successful or not, monitor for at least 30 minutes after the procedure for labor, bleeding, or fetal distress. I will also offer induction of labor after successful version if there's a concern that the fetus will revert out of cephalic.

Here is a video of ECV being practice by some randos wearing scrubs. Gives you a general impression, and this is actually how I learned. But I've change my technique dramatically as the technique shown in the video includes some jabby hands into an abdominal wall, which would make me want to cut a d*ck if it were me.



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