EDMONTONZONEWOMENSHEALTHPROGRAM

CLINICALPRACTICEGUIDELINES

TITLE: EXTERNALCEPHALICVERSION
APPROVINGAUTHORITY: REPLACING:
EdmontonWomensHealthZoneClinicalDepartmentExecutiveCommittee March2004
REVISED:
January2012

1.0 INTRODUCTION

TherationaleforexternalCephalicversionistodecreasethenumberofbreechpresentationsat
thetimeofdelivery. 1 Cephalicpresentation,ascomparedwithbreechpresentationatdelivery,is
associatedwithlowershorttermmorbidityforthefetusalthoughnosignificantdifferenceinlong
termoutcomehasbeendocumented. 2
ExternalCephalicVersion(ECV)involvesapplyingpressuretothemothersabdomentoturnthe
breechfetusineitheraforwardorbackwardsomersaulttoachieveavertexpresentation.A
recentmetaanalysisconcludedthattheprocedureisconsideredsafewithariskofemergency
cesareandeliveryof1in286andariskoffetaldeathof1per5,000ECVattempts. 3 Cephalic
presentationcarriesalowerrateofCesareandeliverythanabreechpresentation.Thus,a
successfulECVhasthepotentialtodecreaseriskinboththecurrentpregnancyaswellasinfuture
pregnancies.

2.0 MANAGEMENT

2.1 PriortotheProcedure
PatientshouldbefullyinformedandwrittenconsentobtainedpriortoattemptingECV.
Patientshouldbeinformedastowhattoexpectwithregardstodiscomfort.
PatientsundergoingECVmustbecaredforinalabour&deliveryorfetalassessmentunit,
withreadyaccesstoCesareandeliveryservices.
PatientsundergoingECVwillbepreparedasiftheywerehavingascheduledCesareanbirth.
o PatientshouldbeNPOfor6hoursduetothepotentialforurgentdelivery.
o Ensurepatienthasstablevitalsigns.
EnsurethereisareactiveNSTand/orareassuringbiophysicalprofiletoconfirmfetalwell
being.
Patientsmustundergocontinuouselectronicfetalheartratemonitoringforaminimumof15
minutesbeforeECV.
ECVistobeperformedbyanobstetricianwhoisfamiliarwiththeprocedure.
ECVshouldbeattemptedunderultrasoundsurveillanceoffetalheartactivity.
Regionalanesthesia/analgesiamaybeusedalthoughthisisnotcommonpractice.
Considertocolysis.Ifused,approvedresearchorpublishedprotocolsshouldbefollowed.
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ECVattemptsshouldbelimitedtooneoflessthanfiveminutesdurationanddiscontinuedif
patientdiscomfortisintolerableorifnonreassuringFHRorsignificantdecelerationsare
noted.

Note1: Asthisisanelectiveprocedure,intheinterestofpatientandfetalsafety,priorto
commencementoftheprocedure,itmustbeassuredthatthereisanavailable
operatingtheatre,staffandanesthetisttoconductanemergencyCesareansection,if
required.

2.1 PostProcedure:
Patientsmustundergocontinuouselectronicfetalheartratemonitoringforaminimumof30
minutesafterattemptedECV.
AdministerRhDimmunoglobulinpostprocedureasappropriate.

Note2: FailureatECVdoesnotmeanproceedtoimmediateCesareansection.Cesarean
sectionshouldbeperformedat39+weekselectively,unlessthereisimmediatefetal
heartrateabnormalitiespostECVthatrequireimmediatedelivery.

3.0 PATIENTSELECTION
3.1 SELECTIONOFPATIENTSATTERM(37WEEKS)ISADVISEDFORSEVERALREASONS:
Ifspontaneousversionisgoingtooccur,itislikelytohavetakenplaceby37weeks.
Ifcomplicationsariseduringanattemptedversion,emergencydeliveryofaterminfantcanbe
accomplished.
o Huttenetal.foundthatearlyECV(340and356weeks)increasesthelikelihoodofcephalic
presentationatbirthbutitdoesnotdecreasetheCesareansectionrateanditmay
increasetherateofpretermbirths. 4

3.2 CLINICALFACTORSPREDICTIVEOFASUCCESSFULECVINCLUDE: 5
Multiparity(greaterthan1)
Lackofengagement
Relaxedstateoftheuterus
Abilitytopalpatethefetalhead
Maternalweightlessthan65Kg

4.0 CONTRAINDICATIONS
ContraindicationstoECVarebasedonacommonsenseapproachdesignedtominimizetherisks
ofanadverseoutcomeandtomaximizechancesforsuccess.Thefollowingmedicaland/or
obstetriccomplicationsarecontraindicationstoECV:

Multiplepregnancy
Thirdtrimesterbleeding
Evidenceofuteroplacentalinsufficiency,suspectedintrauterinegrowthrestriction,or
oligohydramniosuterinemalformation
Placentaprevia
Maternalcardiacdisease
Pregnancyinducedhypertension,oruncontrolledhypertension
Anonreassuringfetalheartratepattern
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Majorfetalanomaly
ClassicalCesareanscar.*

*PreviousCesareandeliveryisnotassociatedwithalowerrateofsuccess,however,
themagnitudeoftheriskofuterineruptureisnotknown.Forthetimebeing,a
classical(vertical)Cesareanscarshouldprobablybeconsideredacontraindication.

5.0 OTHERCONSIDERATIONSORRELATIVECONTRAINDICATIONS

Activelabour
Prematureruptureofmembranes
Macrosomia(greatherthan4000grams)
Hyperextensionofthefetalhead
2ormorepreviousCesareansections
Excessmaternalobesity

6.0 COMPLICATIONS

SeriousadverseeffectsassociatedwithECVdonotoccuroften,andtherehavebeenfew
randomizedcontrolledtrialslargeenoughtocitespecificratesofeachrisk.Inarecently
publishedprospectivemetaanalysisbasedon84studiesand12,955ECVproceduresreported:3

REPORTEDCOMPLICATIONSANDTHEIRRELATIONSHIPWITHEXTERNALCEPHALICVERSIONOUTCOME
No. PooledOddsRatio
No.ofStudiesReportingonRelation
Complications Reported (95%confidence
WithECVOutcome
(%) interval)
Stillbirth 12(0.09) 8 1.8().654.9)
Placentalabruption 11(0.08) 6 1.1(0.323.5)
Cordprolapse 8(0.06) 3 1.1(0.196.2)
Abnormalcardiotocography 766(6.1)
Fetalbradycardia 517(4.0) 10 1.3(0.941.9)
Fetaltachycardia 21(0.16) 2 1.2(0.295.1)
LeadingtoCesareandelivery 29(0.22)
Vaginalbleeding 40(0.3) 4 0.33(0.140.82)*
Fetomaternaltransfusion 25(0.9) 2 1.2(0.187.4)
Rupturedmembranes 23(0.2) 3 0.33(0.071.7)
*significantoddsratio
Table1,page1146

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REFERENCES

1
RoyalCollegeofObstetriciansandGynaecologists.(2010).GreenTopGuidelineNo.20a.External
CephalicVersionandReducingtheIncidenceofBreechPresentation.Dec.2006,Reviewed2010,
Downloadedfromhttp://www.rcog.org.uk/guidelines,November,2011

2
HannahME,HannahWJ,HewsonSA,HodnettED,SaigalS,&WillanAR.PlannedCaesareansection
versusplannedvaginalbirthforbreechpresentationatterm:Arandomizedmulticentretrial.Lancet
2000;356:13751383

3
GrootscholtenK,KokM,OeiSG,MolBWJ,&vanderPostJA.Externalcephalicversionrelatedrisks:A
metaanalysis.ObstetGynecol2008;112(5);11431151.downloadedfrom:http://ovidsp.tx.ovid.com,
Nov18,2011

4
HuttonEK,HannahME,RossSJ,DelisleMF,CarsonGD,WindrimR,OhlssonA,WillanAR,GafniA,
SylvestreG,NataleR,BarrettY,PollardJK,DunnMS,TurtleP.Theearlyexternaleephalicversion
(ECV)2trial:AninternationalmulticentrerandomisedcontrolledtrialoftimingofECVforbreech
pregnancies.BJOG2011;8(5):564577

5
KokM,CnossenJ,GravendeelL,vanderPostJ,OpmeerB,&MolBW.(2008).Clinicalfactorstopredict
theoutcomeofexternalcephalicversion:Ametaanalysis.AmJObstetGynecol2008;199:630.e7.
Downloadedfromwww.AJOG.orgNov.2011