View source for External cephalic version

{{Short description|Way to turn breech babies during pregnancy}}
{{Infobox interventions |
  Name        = External cephalic version |
  Image       = As tabula IX and Child presenting feet Wellcome L0009819.jpg|
  Caption     = Child presenting head first (top) and feet first (bottom)<ref>{{cite web |last1=Burton |first1=John |title=An essay towards a complete new system of midwifry, theoretical and practical. Together with the descriptions,causes and methods of removing, or relieving the disorderspeculiar to pregnant ... women, and new-born infants |url=http://catalogue.wellcomelibrary.org/record=b1070675 |publisher=J. Hodges |access-date=25 September 2018 |date=1751}}</ref>|
 specialty    = [[Obstetrics]]|
  ICD10       = |
  ICD9        = {{ICD9proc|73.91}} |
  MeshID      = |
  OPS301      = |
  OtherCodes  = |
  HCPCSlevel2 =
}}
'''External cephalic version''' ('''ECV''') is a process by which a [[breech birth|breech baby]] can sometimes be turned from [[buttocks]] or foot first to head first. It is a manual procedure that is recommended by national guidelines for [[breech birth|breech]] presentation of a pregnancy with a single baby, in order to enable [[vaginal delivery]].<ref name=":Sharoni2015">{{Cite journal|last=Sharoni|first=L|s2cid=71800278|date=March 2015|title=Anesthesia and external cephalic version|journal=Current Anesthesiology Reports|volume=5|pages=91–99|doi=10.1007/s40140-014-0095-0}}</ref><ref name=StatPearls>{{Citation|last1=Shanahan|first1=Meaghan M.|title=External Cephalic Version|date=2020|url=https://www.ncbi.nlm.nih.gov/books/NBK482475/|work=StatPearls|publisher=StatPearls Publishing|pmid=29494082|access-date=14 April 2020|last2=Gray|first2=Caron J.}}</ref> It is usually performed late in pregnancy, that is, after 36 [[Gestational age (obstetrics)|gestational weeks]],<ref name="RCOG2017">{{Cite web|url=https://www.rcog.org.uk/globalassets/documents/patients/patient-information-leaflets/pregnancy/breech-baby-patient-information-leaflet.pdf|title=Breech baby at the end of pregnancy|date=July 2017|website=www.rcog.org|language=en-US|access-date=23 September 2018}}</ref> preferably 37 weeks,<ref name="ArnoldFlint2017">{{cite book|url=https://books.google.com/books?id=6181DwAAQBAJ|title=Obstetrics Essentials: A Question-Based Review|last1=Arnold|first1=Kate C.|last2=Flint|first2=Caroline J.|publisher=Springer|year=2017|isbn=978-3-319-57674-9|location=Oklahoma, USA|pages=231–235|doi=10.1007/978-3-319-57675-6|s2cid=38547277}}</ref> and can even be performed in the early stages of childbirth.<ref name="RCOG2017"/>

ECV is endorsed by the [[American College of Obstetricians and Gynecologists]] (ACOG) and [[Royal College of Obstetricians and Gynaecologists]] (RCOG) as a mode to avoid the risks associated with a vaginal breech or [[cesarean delivery]] for singleton breech presentation.<ref name=":Sharoni2015" /><ref name=":0" />

ECV can be contrasted with "internal cephalic version", which involves a hand inserted through the [[cervix]].<ref name="pmid13669146">{{cite journal |author=Neely, M. R. |title=Combined internal cephalic version |journal=Ulster Medical Journal  |volume=28 |issue=1 |pages=30–4 |date=May 1959 |pmid=13669146 |pmc=2384304 }}</ref>

==Medical use==
ECV is one option of intervention should a breech position of a baby be found after 36 weeks gestation. Other options include a planned caesarian section or planned vaginal delivery.<ref name="RCOG2017"/>

=== Success rates ===
ECV has an average success rate of around 58%,<ref name=StatPearls/> between 40 and 64% depending on whether it is the mother's first child or not. (40% for first-time mothers and closer to 60% for women who have had previous children.{{citation needed|date=April 2020}}

Various factors can alter the success rates of ECV. Practitioner experience, maternal weight, obstetric factors such as uterine relaxation, a palpable fetal head, a non-engaged breech, non-anterior placenta, and an amniotic fluid index above 7–10&nbsp;cm, are all factors which can be associated with higher success rates. In addition, the effect of [[neuraxial blockade]] on ECV success rates have been conflicting, although ECV appears easier to perform under [[epidural block]].<ref name=":Sharoni2015" /><ref>{{Cite book|chapter-url=https://books.google.com/books?id=G1dISojMmh4C&q=epidural+analgesia+external+cephalic+version|title=Evidence-Based Obstetric Anesthesia|last=Wight|first=William|date=2008|publisher=John Wiley & Sons|isbn=978-0-7279-1734-8|editor-last=Halpern|editor-first=Stephen H.|pages=217–224|language=en|chapter=18. External cephalic version|editor-last2=Douglas|editor-first2=M. Joanne}}</ref>

Following successful ECV, with the baby turned to head first, there is a less than 5% chance of the baby turning spontaneously to breech again.<ref name="rcog2010"/>

==Contra-indications==
Some situations exist where ECV is not indicated or may cause harm. These include recent [[antepartum haemorrhage]], [[placenta praevia]], abnormal fetal monitoring, [[ruptured membranes]], [[multiple pregnancy]], [[pre-eclampsia]], [[oligohydramnios|reduced amniotic fluid]] and some other abnormalities of the uterus or baby.<ref name="rcog2010"/>

==Risks==
As with any procedure there can be complications most of which can be greatly decreased by having an experienced professional on the birth team.  An [[ultrasound]] to estimate a sufficient amount of amniotic fluid and monitoring of the fetus immediately after the procedure can also help minimize risks.<ref name="Kok2009">{{Cite journal|last1=Kok|first1=M.|last2=Cnossen|first2=J.|last3=Gravendeel|first3=L.|last4=Van Der Post|first4=J. A.|last5=Mol|first5=B. W.|date=January 2009|title=Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis|journal=Ultrasound in Obstetrics and Gynecology|volume=33|issue=1|pages=76–84|doi=10.1002/uog.6277|pmid=19115237|s2cid=12917755|issn=0960-7692|doi-access=free}}</ref>

Evidence of complications of ECV from clinical trials is limited, but ECV does reduce the chance of breech presentation at birth and caesarian section. The 2015 ''Cochrane review'' concluded that "large observational studies suggest that complications are rare".<ref name="rcog2010">{{Cite web|url=https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf|title=External Cephalic Version and Reducing the Incidence of Breech Presentation|date=2010|website=www.rcog.org.uk|access-date=23 September 2018}}</ref><ref name=CochraneReview2015>{{cite journal | doi=10.1002/14651858.CD000083.pub3 | title=External cephalic version for breech presentation at term | year=2015 | last1=Hofmeyr | first1=G Justus | last2=Kulier | first2=Regina | last3=West | first3=Helen M. | journal=Cochrane Database of Systematic Reviews | volume=2019 | issue=5 | article-number=CD000083 | pmid=25828903 | pmc=6505738 }}</ref>

Typical risks include [[umbilical cord entanglement]], [[Placental abruption|abruption of placenta]], preterm labor, [[premature rupture of the membranes]] (PROM) and severe maternal discomfort. Overall complication rates have ranged from about 1 to 2 percent since 1979. While somewhat out of favour between 1970 and 1980, the procedure has seen an increase in use due to its relative safety.<ref name=Coco1998>{{Cite journal|last1=Coco|first1=Andrew S.|last2=Silverman|first2=Stephanie D.|date=1998-09-01|title=External Cephalic Version|url=https://www.aafp.org/afp/1998/0901/p731.html|journal=American Family Physician|language=en|volume=58|issue=3|pages=731–8, 742–4|pmid=9750541|issn=0002-838X}}</ref>

Successful ECV significantly decreases the rate of cesarean section, however, women are still at an increased risk of instrumental delivery ([[ventouse]] and [[forceps delivery]]) and cesarean section compared to women with spontaneous cephalic presentation (head first).<ref name="RCOG2017" /><ref>{{cite journal|last1=de Hundt|first1=M|last2=Velzel|first2=J|last3=de Groot|first3=CJ|last4=Mol|first4=BW|last5=Kok|first5=M|s2cid=16394070|title=Mode of delivery after successful external cephalic version: a systematic review and meta-analysis.|journal=Obstetrics and Gynecology|date=June 2014|volume=123|issue=6|pages=1327–34|pmid=24807332|doi=10.1097/aog.0000000000000295}}</ref>

==Technique==
The procedure is undertaken by either one or two physicians and where emergency facilities to undertake instrumental delivery and caesarian section are at hand. Blood is also taken for [[cross-matching]] should a complication arise.<ref name=Coco1998/> Prior to performing ECV, an [[ultrasound]] of the abdomen is performed to confirm the breech position and the mother's blood pressure and pulse are taken. A [[cardiotocography]] (CTG) is also performed to monitor the baby's heart.<ref name="RCOG2017" /><ref>{{Cite news|url=https://www.webmd.com/baby/external-cephalic-version-overview#1|title=What Is External Cephalic Version?|work=WebMD|access-date=23 September 2018|language=en-US}}</ref>

The procedure usually lasts a few minutes and is monitored intermittently with CTG.<ref name=":0">{{Cite journal|last=Ehrenberg-Buchner|first=Stacey|date=3 August 2018|title=External Cephalic Version: Overview, Technique, Periprocedural Care|url=https://emedicine.medscape.com/article/1848353-overview#a2|journal=Medscape|url-access=subscription}}</ref> With a covering of [[lubricant|ultrasonic gel]] on the abdomen to reduce friction,<ref name=Coco1998/> the physician's hands are placed on the mother's [[abdomen]] around the baby. Then, by applying firm pressure to manoeuvre the baby up and away from the [[human pelvis|pelvis]] and to gently turn in several steps from breech, to a sideways position, the final manipulation results in a head first presentation.<ref name="RCOG2017" /><ref>{{Cite web|url=https://www.nct.org.uk/pregnancy/37weeks|title=37 weeks pregnant|website=www.nct.org.uk|access-date=23 September 2018}}</ref> The procedure is discontinued if maternal distress, repeated failure or [[fetal distress|fetal compromise]] on monitoring occurs.<ref name=Coco1998/>

ECV performed before term may decrease the rate of breech presentation compared to ECV at term, but may increase the risk of [[preterm delivery]].<ref>{{cite journal|last1=Hutton|first1=EK|last2=Hofmeyr|first2=GJ|last3=Dowswell|first3=T|title=External cephalic version for breech presentation before term.|journal=The Cochrane Database of Systematic Reviews|date=29 July 2015|volume=2015|issue=7|article-number=CD000084|pmid=26222245|doi=10.1002/14651858.CD000084.pub3|pmc=9188447 }}</ref>
There is some evidence to support the use of [[tocolytic]] drugs in ECV.<ref name=Cluver2015>{{cite journal|last1=Cluver|first1=C|last2=Gyte|first2=GM|last3=Sinclair|first3=M|last4=Dowswell|first4=T|last5=Hofmeyr|first5=GJ|title=Interventions for helping to turn term breech babies to head first presentation when using external cephalic version.|journal=The Cochrane Database of Systematic Reviews|date=9 February 2015|volume=2|issue=2|article-number=CD000184|pmid=25674710|doi=10.1002/14651858.CD000184.pub4|hdl=10019.1/104301|hdl-access=free|pmc=10363414}}</ref> Given by injection, tocolytics relax the uterus muscle and may improve the chance of turning the baby successfully. This is considered safe for the mother and baby, but can cause the mother to experience [[Flushing (physiology)|facial flushing]] and a feeling of a [[Palpitations|fast heart rate]].<ref name="RCOG2017" />
Use of intravenous [[nitroglycerin]] has been proposed.<ref name="pmid19701035">{{cite journal  |vauthors=Hilton J, Allan B, Swaby C, etal |title=Intravenous nitroglycerin for external cephalic version: a randomized controlled trial |journal=Obstet Gynecol |volume=114 |issue=3 |pages=560–7 |date=September 2009 |pmid=19701035 |doi=10.1097/AOG.0b013e3181b05a19 |s2cid=9757809 }}{{subscription required}}</ref>

Following the procedure, a repeat CTG is performed and a repeat ultrasound will confirm a successful turn.<ref name="RCOG2017" /> Should this first attempt fail, a second attempt on another day can be considered.<ref name="rcog2010"/>

In addition, to prevent [[Rh disease]] after the procedure, all [[Rh blood group system|rhesus D negative]] pregnant women are offered an [[intramuscular injection]] of anti-Rh antibodies ([[Rho(D) immune globulin]]).<ref name="RCOG2017" />

==History==
ECV has existed since 384–322 B.C., the time of [[Aristotle]].<ref name=Coco1998/> Around 100 A.D., [[Soranus of Ephesus]] included guidance on ECV as a way to reduce complications of vaginal breech birth. 17th century French obstetrician, [[François Mauriceau]], is alleged to have described ECV as "a little more difficult than turning an omelette in a frying pan".<ref name=":Paul2017">{{Cite journal|last=Paul|first=Carolyn|date=22 March 2017|title=The baby is for turning: external cephalic version|journal=BJOG: An International Journal of Obstetrics & Gynaecology |volume=124|issue=5|page=773|doi=10.1111/1471-0528.14238|issn=1470-0328|pmid=28328063|doi-access=free}}</ref> [[Justus Heinrich Wigand]] published an account of ECV in 1807 and the procedure was increasingly accepted following [[Adolphe Pinard]]'s demonstration of it in France. In 1901, British obstetrician, [[Herbert R. Spencer]], advocated ECV in his publication on breech birth. In 1927, obstetrician George Frederick Gibberd, reviewed 9,000 consecutive births around [[Guy's Hospital]], London. Following his study, he recommended ECV, even if it failed and needed to be repeated and even if it required [[anaesthesia]].<ref name=":Paul2017"/>

ECV's safety has continued to be a longstanding controversy. Following a protocol developed in Berlin, ECV did increase in popularity in the United States in the 1980s.<ref name=Coco1998/> The procedure has been increasingly considered as low risk of complications and its improvement in safety as a result of the routine use of electronic fetal monitoring, waiting until closer to term and the replacement of anaesthesia by tocolysis,<ref name=":Paul2017"/> has seen a recent resurgence.<ref name=":0" />

==References==
{{reflist}}

==External links==

{{Obstetrical procedures}}

{{DEFAULTSORT:External Cephalic Version}}
[[Category:Obstetrical procedures]]