**7. ECV procedure**

Before starting the version, the woman must be informed about the importance of keeping calm. She must also know that the procedure can be uncomfortable, although it is not painful. The external version cannot be performed without her consent or when the abdominal wall shows resistance. For this reason, the woman must be aware of the importance of her cooperation.

 Before the performance, the abdomen is liberally coated with ultrasonic gel in order to decrease friction and lessen the chances of an over vigorous manipulation

First of all, the baby must be moved up and away from the pelvis in the right direction in order to increase the fetal flexion. If this manoeuvre is not successful, the next version trial must not be carried out. With both hands on the surface of the baby's buttocks, they must be gently elevated. It can also be possible to try to move the baby's head towards one of both sides, but this must never be done before the buttocks have been moved. Sometimes, you may need help to handle one of the fetal poles. The relaxation of the uterus, abdomen and legs and the Trendelenburg position will facilitate the maneuver.

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

A Body of evidence can be trusted to guide practice

B Body of evidence can be trusted to guide practice in most situations

<sup>C</sup>Body of evidence provides some support for recommendation(s) but care

<sup>D</sup>Body of evidence is weak and recommendation must be applied with

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

Before starting the version, the woman must be informed about the importance of keeping calm. She must also know that the procedure can be uncomfortable, although it is not painful. The external version cannot be performed without her consent or when the abdominal wall shows resistance. For this reason, the woman must be aware of the

Before the performance, the abdomen is liberally coated with ultrasonic gel in order to

First of all, the baby must be moved up and away from the pelvis in the right direction in order to increase the fetal flexion. If this manoeuvre is not successful, the next version trial must not be carried out. With both hands on the surface of the baby's buttocks, they must be gently elevated. It can also be possible to try to move the baby's head towards one of both sides, but this must never be done before the buttocks have been moved. Sometimes, you may need help to handle one of the fetal poles. The relaxation of the uterus, abdomen

decrease friction and lessen the chances of an over vigorous manipulation

and legs and the Trendelenburg position will facilitate the maneuver.

should be taken in its application

caution

caused by both maternal and fetal indications.

Table 1. Definitions of Grade of Recommendation.

recommendation Description

Grade of

situation.

**7. ECV procedure** 

importance of her cooperation.

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 (SEGO, 2001).

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

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 scanning.

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 recommended.

The External Version in Modern Obstetrics 197

Determining which situations could be considered as relative contraindications is more

Regarding the previous caesarean, there are not any randomised projects yet, so there

The spontaneous version rate in nulliparous women, as of the 36th week, is 8%. However, if the version is not successful, this rate is only 5%. The probability of reversion after a

Depending on the series, the external version success oscillates between 30-80%. This success also depends on the race, parity, uterine tone, amniotic fluid volume, cephalic engagement, possibility of palpation of cephalic pole and use of tocolytics. The highest success rates have been observed in multiparous nonwhite women with relaxed uterus, when the breech presentation is not fixed and the cephalic pole can be easily palpated (Lau et al, 1997). This would be the optimal condition in order to obtain a successful

Many authors have been looking for patterns aiming at predicting the cephalic version success or failure (Newman et al, 1993). Those factors considered as the most significant tones in a failed external version are the following: the cephalic pole palpation, the engagement presentation level and a tense uterus when palpated. When these factors are missing, the probability of a failed external version is only 6%. However, the failure probability increases over 80% if more than one of these three factors occurs. Thus, in a group composed of 243 pregnant women subject to an external cephalic version, the ECV was successful in 94% of the cases when none of these factors occurred, as well as in at least 20% of the cases if two of those factors occurred and 0% of the cases if the three factors took

Nevertheless, other factors considered as significant independent predictors in the past, as the placental location, the backbone position, the breech type, the maternal body mass index and the fetal weight seem to be less significant if the three factors mentioned above are controlled (they are not independent factors). However, it must be taken into account that the usefulness of these indicators is still awaiting confirmation by further research.

are not enough data to advise for or against performing it in this situation.

 Hypertensive disorders during pregnancy (preeclampsia with proteinuria). Delayed fetal growth with alteration in uteroplacental Doppler flow.

 Severe uterine anomaly. Alterations of coagulation.

Deflexed fetal head.

 Anterior placenta. Already initiated labour. Unstable fetal position.

successful version is only 5%.

version.

place.

Existence of some caesarean delivery indicators.

difficult, but the following are some of them:

Estimated weight >3800-4000 grams.

**10. ECV: Predictors and success rate** 

If this technique does not succeed and the fetus returns to breech presentation, the version can be repeated after 5-7 days. It is estimated that 5-10% of the fetus return to the presentation previous to the version, as the cause that generated the abnormal presentation continues. This spontaneous reversion is more common in multiparous than in nulliparous mothers. However, there is no scientific evidence recommending the immediate labor induction in order to reduce the possibility of reversion (American College of Obstetricians and Gynecologist [ACOG], 2001).

Rh (-) patients will be given anti-D gamma globulin after the version, as it is estimated that the risk of fetomaternal hemorrhage is approximately 1%.
