Acog Pb 13

Front 1

What % breech at term?

Back 1

Breech presentation occurs in 3–4% of term pregnancies.

Front 2

Define external cephalic version and goals?

Back 2

External cephalic version involves applying pressure to the mother's abdomen to turn the fetus in either a forward or backward somersault to achieve a vertex presentation. The goal of ECV is to increase the proportion of vertex presentations among fetuses that were formerly in the breech position near term.

Front 3

Which patients are candidates for external cephalic version?

Back 3

Patients who have completed 36 weeks of gestation are preferred candidates for ECV for several reasons. First, if spontaneous version is going to occur, it is likely to have taken place by 36 completed weeks of gestation (2, 3). Second, risk of a spontaneous reversion is decreased after external cephalic version at term compared with earlier gestations. Preterm version attempts are associated with high initial success rates but also with higher reversion rates, necessitating additional procedures (4, 5). Third, if complications arise during an attempted version, emergency delivery of a term infant can be accomplished. Clearly any indication for a cesarean delivery in a patient, such as placenta previa, would be a contraindication to ECV

Front 4

What are the benefits and risks of external cephalic version?

Back 4

The ultimate goal is an uncomplicated vaginal delivery. Risks Fetal heart rate changes during attempted versions are not uncommon but usually stabilize when the procedure is discontinued . Serious adverse effects associated with ECV do not occur often, but there have been a few reported cases of placental abruption and preterm labor. perform ECV in a facility that has ready access to cesarean delivery services.

Front 5

What are the success rates for external cephalic version, and what factors are predictive of either success or failure?

Back 5

success rates for ECV range from 35% to 86%, with an average success rate of 58%. A transverse or oblique lie is associated with higher immediate success rates (13, 29, 30). Opinion is divided about the predictiveness of other factors, including amniotic fluid volume, location of placenta, and maternal weight. Some reports indicate an association between normal or increased amounts of amniotic fluid and successful ECV

Front 6

How does the use of tocolysis affect the success rate of external cephalic version?

Back 6

Finally, a randomized study of terbutaline found the success rate of version associated with use of this tocolytic to be almost double the rate without its use .

Front 7

How does the use of anesthesia affect the success rate of external cephalic version?

Back 7

A randomized study found a significantly greater success rate associated with the use of epidural anesthesia, although the success rate was unusually low for the women who did not receive epidural anesthesia (32%). Currently, there is not enough consistent evidence to make a recommendation favoring spinal or epidural anesthesia during ECV attempts.

Front 8

What is an example of a standard protocol for performing an external cephalic version attempt?

Back 8

Prior to attempting ECV, patients must provide informed consent and should undergo an ultrasound examination. The ultrasound examination is necessary to confirm the breech position of the fetus and rule out the presence of any anomalies that would complicate a vaginal delivery. Fetal well-being should be assessed by a prior nonstress test or concurrent biophysical profile (see Fig. 1).

Because there is a chance that an expedient delivery may become necessary, patients should have ready access to a facility that is equipped to perform emergency cesarean deliveries. One version technique involves lifting the breech upward from the pelvis with one hand and providing pressure on the head with the other hand to produce a forward roll. If the forward roll fails, a backward somersault may be attempted. Version may be performed by one person or two. A version attempt will be abandoned if there is significant fetal bradycardia, if there is discomfort to the patient, or if the attempt cannot be completed easily or is unsuccessful after a brief period. Following the attempt, fetal evaluation is repeated and the patient is monitored until stable. Rh-negative patients may receive anti-D im-mune globulin. There is no support for routine practice of immediate induction of labor to minimize reversion.

Front 9

Contraindications for ECV.

Back 9

• Breech firmly fixed in the pelvis
• Marked oligohydramnios
• Placenta previa
• Third trimester bleeding
• Prior uterine surgery (prior ltcsOK)
• Fetal distress

Front 10

What are complications of ECV?

Back 10

• Reversion 3%
• Fetal distress 0.5%
• Fetal Death 0.1%
• Admission to hosp for observation 5%
• Emergency C section 0.5%