External Cephalic Version

External Cephalic Version

Is your baby breech? Are you considering an External Cephalic Version? This post is for you! It’s full of facts about the procedure, including a list of variables that may make your chances of success higher or lower. At the end of the post, you will find additional resource links.

For me, an External Cephalic Version (also referred to as an ECV or version) was a last resort, and I tried several more conservative techniques first (see this post). My initial impression was that an ECV was too forceful and risky. However, after the more conservative approaches failed, I looked into this procedure in more detail. I read numerous articles and talked to multiple doctors, L&D nurses, and other care providers. I ended up scheduling an ECV in a last attempt to reposition my baby and hopefully avoid a c-section. Lucky for me, it worked!

Good luck with your decision-making. I know it’s not easy. I wish the very best for you and your little one!

What is an External Cephalic Version?

An External Cephalic Version is a manual procedure that can sometimes turn a breech baby into a cephalic (head-down) position. Use of the procedure has shown to reduce the need for cesarean deliveries. An ECV is performed by a trained clinician (sometimes two clinicians). The clinician(s) place their hands on your abdomen and apply firm pressure in an attempt to lift your baby out of your pelvis and rotate him/her into a head-down position.

To improve the chances of success, a medication (usually terbutaline) is often given beforehand to relax the uterus. I was assured that terbutaline is not harmful to the fetus, although it can cause increased heart rate for mom (like a caffeine rush or adrenaline buzz). Occasionally, practitioners use regional anesthesia, a spinal, or an epidural. These methods are less common, but can be helpful in certain situations.

An ECV is almost always performed in a hospital setting, where your baby can be closely monitored. To ensure your baby is doing well, a non-stress test is typically performed before and after the procedure. An operating room and surgical team will be on stand-by, should an emergent cesarean become necessary due to any rare complications.

Immediate induction following a successful version is generally not recommended. However, it is sometimes considered after 39 weeks gestation.

Most literature suggests that an ECV is an underutilized procedure.

When should the procedure be performed?

This is somewhat controversial. However, most clinicians suggest 37 weeks as an optimal time. Only 8% of breech fetuses will flip on their own after 36 weeks (4).

Generally speaking in regards to a gestation timeline, performing an ECV earlier means:

  • higher chances of success (yay!)
  • higher likelihood that baby will spontaneously flip back to the breech position once the procedure is completed. (darn!)

On the other hand, if an ECV is successful later in pregnancy, a baby is more more likely to stay in the head-down position until delivery. Unfortunately, waiting longer to perform an ECV also reduces the chances of success. 

Because rare complications could lead to emergency cesarians, it’s often recommended to wait until baby is full term (37 weeks). Occasionally, ECVs are attempted in early labor.

How successful is the procedure?

The numbers vary a little depending on the source. Generally, ECVs are considered to have a 50-60% success rate. Your chance of success can be individualized, depending on a variety of factors. Certain variables can increase or decrease your likelihood of success. Consider the following:

  1. Amniotic fluid levels. Your doctor will likely check your fluid levels. Having normal fluid levels increases your chance of success. If your fluid levels are low, your baby will have less room to turn. If you have really high fluid levels, your chance of reversion (returning to a breech position) may be higher.
  2. Placenta Position. Having a posterior placenta (in the back) is considered best for this procedure. An anterior placenta (in the front) is associated with reduced success rates, and it might increase the risk of placenta abruption.
  3. Number of pregnancies. Some say that the chances of success are lower for first time moms.
  4. Gestational age. See “when should the procedure be performed” above.
  5. Fetal station in the pelvis. If your baby is more engaged in your pelvis, it may be harder to manipulate their position. (2,5)
  6. Mom’s size. The procedure is often easier on a more slender person. Maternal obesity has been associated with decreased success. On another note, if your baby’s head is easily palpable, this may increase chances of success. (3,5)

It is important to realize that sometimes babies are breech because this is the safest position for them. A woman’s uterus shape, pelvic anatomy, a short umbilical cord, a cord wrapped around baby, a low-lying placenta, or other things could potentially prevent a baby from flipping head-down. For these reasons, I asked my doctor to go about my procedure gently, and to not force through any restrictions. If your version is unsuccessful, take heart, because your baby may be doing what is best for her.

What are the risks associated with a Version?

An ECV does not come without risks. An abnormal fetal heart rate is the most common complication (occurring about 5% of the time (2,5)), but this is typically short-lived. Other complications include going into active labor, requiring an emergency cesarean delivery, water breaking, placental abruption, cord prolapse, and hemorrhaging. More serious complications occur <1% of the time. (2,4,5)

If you are Rh-negative, you may receive a medication after the procedure to minimize risks associated with potential mixing of maternal and fetal blood (a rare complication).

One thing I took into consideration when deciding to try an ECV (aside from the variables listed above), was the risks I might face if my baby remained breech. There are also risks associated with a cesarean or a breech vaginal delivery. I will not go into these here, but it’s a good discussion to have with your practitioner.

Who should NOT have a version?

You will want to discuss your specific case with your doctor. Many clinicians recommend foregoing the procedure in the presence of certain anatomical abnormalities, abnormal fetal monitoring, severe pre-eclampsia, or in a pregnancy with multiples (however ECV is sometimes used for the second twin after delivery of the first).

Thus far, research has shown that mothers who have had a previous Cesarean birth can have a successful version. (5)

Is an ECV painful? How long is the procedure?

This varies from mother to mother. I noticed a couple trends in my research. It seemed that mothers who had successful versions often reported less pain and shorter procedures. On the contrary, mothers who had unsuccessful versions often reported more pain and longer procedures.

My experience: In terms of pain, there was A LOT of pressure, but I wouldn’t call the procedure painful. I used some repeated deep breathing during the manipulation, which seemed to help. I focused on staying relaxed, as I didn’t want to fight the doctor by contracting my abdominal muscles. In terms of procedure duration, the actual manipulation part lasted no more than 10-15 seconds. My doctor stated that he typically gave the procedure 3 attempts. If the third attempt didn’t work, he stopped trying.

Resources and Additional Information:

  1. ACOG Guidelines at a Glance: External Cephalic Version.  by Stephen F Thung, MD, MSCI
  2. Shanahan MM, Gray CJ. External Cephalic Version. [Updated 2018 Oct 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482475/ 
  3. Impey LWM, Murphy DJ, Griffiths M, Penna LK on behalf of the Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Term Breech Presentation. BJOG 2017; 124:e178e192.
  4. Lerner, H. M., MD. (2017, September). External cephalic version: How to increase the chances for success. OBG Management, 29(9), 26, 28-32. Retrieved December 12, 2018, from https://www.mdedge.com/obgyn/article/145621/obstetrics/external-cephalic-version-how-increase-chances-success
  5. The Evidence on: Breech Version. By Rebecca Dekker, PhD, RN, APRN

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