**6. ECV impact on the reduction of caesarean deliveries and breech presentation at birth**

The Cochrane, in a systematic review, assessed the external cephalic version at term effects. The results proved a clinically and statistically significant reduction of breech babies as well as of caesareans deliveries when the external cephalic version was used. No significant effects on perinatal mortality were observed. No significant differences in the incidence on Apgar score were observed (7 at the first minute or at the fifth minute, low umbilical artery PH level or perinatal death.

In fact, the Cochrane Foundation recommended offering the external version to every woman with normal pregnancies and breeching presentation at term (37th-42nd week) (level of recommendation A).

The cephalic version at term reduces the incidence of breech presentation (risk difference 52%, NNT 2) as well as the caesarean rate (risk difference 17%, NNT 6) at birth. In daily

The External Version in Modern Obstetrics 195

Secondly, the baby's must be move by palpating the backbone. This can be achieved by using both hands simultaneously. While with one hand, the babies feet are moved upwards, with the other hand the baby's head must be moved to the opposite side and towards the pelvis. The rotation must continue until achieving the optimal vertex position

It must not be performed any sudden manoeuvres, but moderate and sustained pressure, trying that the fetus make the rest of the movement. Basically, the purpose is that the fetus

Fig. 2. Maneuvers to secure the cephalic presentation in fetuses with breech presentation.

During the maneuver the fetal presentation must be monitored with the ultrasound scan and the fetal cardiac frequency with continuous cardiotocography. Transitional fetal bradycardia commonly occurs. It is spontaneously solved in most of cases. However, the version must be stopped if it is sustained and still continues after relieving the pressure. It will also be stopped if it does not succeed after a short period of time or in case of severe pain. The benefit of performing the version without anesthesia is that the pain suffered is an indicator of the limit of pressure in the maneuver. Furthermore, the use of epidural analgesia has not proved neither a greater success in the maneuver, nor a reduction in subsequent caesarean rate (Hofmeyr, 2003). After the procedure, the tocolytics perfusion will be stopped and the success of the manoeuvre will be confirmed by ultrasound

Regardless of the success or the failure of the version, the fetal status must be evaluated again after performing the procedure. The fetus must be monitored for at least 45 minutes. If the cardiotocographic record is normal and there is no vaginal bleeding or pain, the patient can be discharged, although a 24 hour relative rest will be

itself finds a more comfortable position than the one that it has under pressure.

(SEGO, 2001).

scanning.

recommended.

clinical practice, most of breech babies are born by elective caesarean, without considering the vaginal delivery possibility. That is why the number of caesarians has a further increase in daily clinical practice that in the projects. This reduction in the number of caesareans continues in spite of the increase of intrapartum caesareans (which has been observed in cephalic babies after a successful version in comparison to babies with spontaneous cephalic presentation). Furthermore, this increase is regardless of a higher induction rate and it is caused by both maternal and fetal indications.


Table 1. Definitions of Grade of Recommendation.

With respect to the external cephalic version effect on the perinatal outcome, the Cochrane data base indicates that, even though no statistically significant differences on perinatal mortality were observed, there is not enough evidence to precisely evaluate the risks related to the process. More projects must be carried out to determine the adverse effects as well as on the external version practice at birth or on the foetuses in non-longitudinal situation. with to
