EDMONTON ZONE WOMEN’S HEALTH PROGRAM CLINICAL PRACTICE GUIDELINES

TITLE: EXTERNAL CEPHALIC VERSION

APPROVING AUTHORITY: REPLACING: Edmonton Women’s Health Zone Clinical Department Executive Committee March 2004 REVISED: January 2012

1.0 INTRODUCTION

The rationale for external Cephalic version is to decrease the number of breech presentations at the time of delivery.1 Cephalic presentation, as compared with breech presentation at delivery, is associated with lower short term morbidity for the although no significant difference in long‐ 2 term outcome has been documented. External Cephalic Version (ECV) involves applying pressure to the mother’s abdomen to turn the breech fetus in either a forward or backward somersault to achieve a vertex presentation. A recent meta‐analysis concluded that the procedure is considered safe with a risk of emergency cesarean delivery of 1 in 286 and a risk of fetal death of 1 per 5,000 ECV attempts.3 Cephalic presentation carries a lower rate of Cesarean delivery than a breech presentation. Thus, a successful ECV has the potential to decrease risk in both the current as well as in future .

2.0 MANAGEMENT

2.1 Prior to the Procedure • Patient should be fully informed and written consent obtained prior to attempting ECV. • Patient should be informed as to what to expect with regards to discomfort. • Patients undergoing ECV must be cared for in a labour & delivery or fetal assessment unit, with ready access to Cesarean delivery services. • Patients undergoing ECV will be prepared as if they were having a scheduled Cesarean birth. o Patient should be NPO for 6 hours due to the potential for urgent delivery. o Ensure patient has stable vital signs. • Ensure there is a reactive NST and/or a reassuring biophysical profile to confirm fetal well being. • Patients must undergo continuous electronic fetal heart rate monitoring for a minimum of 15 minutes before ECV. • ECV is to be performed by an obstetrician who is familiar with the procedure. • ECV should be attempted under ultrasound surveillance of fetal heart activity. • Regional anesthesia/analgesia may be used although this is not common practice. • Consider tocolysis. If used, approved research or published protocols should be followed.

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• ECV attempts should be limited to one of less than five minutes duration and discontinued if patient discomfort is intolerable or if non‐reassuring FHR or significant decelerations are noted.

Note1: As this is an elective procedure, in the interest of patient and fetal safety, prior to commencement of the procedure, it must be assured that there is an available operating theatre, staff and anesthetist to conduct an emergency Cesarean section, if required.

2.1 Post Procedure: • Patients must undergo continuous electronic fetal heart rate monitoring for a minimum of 30 minutes after attempted ECV. • Administer Rh D immunoglobulin post procedure as appropriate.

Note2: Failure at ECV does not mean proceed to immediate Cesarean section. Cesarean section should be performed at 39+ weeks electively, unless there is immediate fetal heart rate abnormalities post ECV that require immediate delivery.

3.0 PATIENT SELECTION

3.1 SELECTION OF PATIENTS AT TERM (≥37 WEEKS) IS ADVISED FOR SEVERAL REASONS: • If spontaneous version is going to occur, it is likely to have taken place by 37 weeks. • If complications arise during an attempted version, emergency delivery of a term infant can be accomplished. 0 6 o Hutten et al. found that early ECV (34 and 35 weeks) increases the likelihood of cephalic presentation at birth but it does not decrease the Cesarean section rate and it may increase the rate of preterm births.4

3.2 CLINICAL FACTORS PREDICTIVE OF A SUCCESSFUL ECV INCLUDE:5 • Multiparity (greater than 1) • Lack of engagement • Relaxed state of the uterus • Ability to palpate the fetal head • Maternal weight less than 65 Kg

4.0 CONTRAINDICATIONS

Contraindications to ECV are based on a common sense approach designed to minimize the risks of an adverse outcome and to maximize chances for success. The following medical and/or obstetric complications are contraindications to ECV:

• Multiple pregnancy • Third‐trimester bleeding • Evidence of uteroplacental insufficiency, suspected intrauterine growth restriction, or uterine malformation • Placenta previa • Maternal cardiac disease • Pregnancy‐induced hypertension, or uncontrolled hypertension • A non‐reassuring fetal heart rate pattern

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• Major fetal anomaly • Classical Cesarean scar.*

*Previous Cesarean delivery is not associated with a lower rate of success, however, the magnitude of the risk of uterine rupture is not known. For the time being, a classical (vertical) Cesarean scar should probably be considered a contraindication.

5.0 OTHER CONSIDERATIONS OR RELATIVE CONTRAINDICATIONS

• Active labour • Premature rupture of membranes • Macrosomia (greather than 4000 grams) • Hyperextension of the fetal head • 2 or more previous Cesarean sections • Excess maternal obesity

6.0 COMPLICATIONS

Serious adverse effects associated with ECV do not occur often, and there have been few randomized controlled trials large enough to cite specific rates of each risk. In a recently published prospective meta‐analysis based on 84 studies and 12,955 ECV procedures reported:3

REPORTED COMPLICATIONS AND THEIR RELATIONSHIP WITH EXTERNAL CEPHALIC VERSION OUTCOME No. Pooled Odds Ratio No. of Studies Reporting on Relation Complications Reporte d (95% confidence With ECV Outcome (%) interval) Stillbirth 12(0.09) 8 1.8 ().65‐4.9) Placental abruption 11 (0.08) 6 1.1 (0.32‐3.5) Cord prolapse 8 (0.06) 3 1.1 (0.19‐6.2) Abnormal 766 (6.1) ‐ • Fetal bradycardia 517 (4.0) 10 1.3 (0.94‐1.9) • Fetal tachycardia 21 (0.16) 2 1.2 (0.29‐5.1) • Leading to Cesarean delivery 29 (0.22) ‐ Vaginal bleeding 40 (0.3) 4 0.33 (0.14‐0.82)* Fetomaternal transfusion 25 (0.9) 2 1.2 (0.18‐7.4) Ruptured membranes 23 (0.2) 3 0.33 (0.07‐1.7) * significant odds ratio Table 1, page 1146

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REFERENCES

1 Royal College of Obstetricians and Gynaecologists. (2010). Green Top Guideline No. 20a. External Cephalic Version and Reducing the Incidence of Breech Presentation. Dec. 2006, Reviewed 2010, Downloaded from http://www.rcog.org.uk/guidelines, November, 2011

2 Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, & Willan AR. Planned versus planned vaginal birth for breech presentation at term: A randomized multicentre trial. Lancet 2000;356:1375‐1383

3 Grootscholten K, Kok M, Oei SG, Mol BWJ, & van der Post JA. External cephalic version‐related risks: A meta‐analysis. Obstet Gynecol 2008;112(5);1143‐1151. downloaded from: http://ovidsp.tx.ovid.com, Nov 18, 2011

4 Hutton EK, Hannah ME, Ross SJ, Delisle MF, Carson GD, Windrim R, Ohlsson A, Willan AR, Gafni A, Sylvestre G, Natale R, Barrett Y, Pollard JK, Dunn MS, Turtle P. The early external eephalic version (ECV) 2 trial: An international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG 2011;8(5):564‐577

5 Kok M, Cnossen J, Gravendeel L, van der Post J, Opmeer B, & Mol BW. (2008). Clinical factors to predict the outcome of external cephalic version: A meta‐analysis. Am J Obstet Gynecol 2008;199:630.e7. Downloaded from www.AJOG.org Nov. 2011