Subject: COUNSELING ABOUT AND OFFERING A PATIENT EXTERNAL CEPHALIC VERSION

 

 

Breech presentation complicates 2 to 3 percent of all term deliveries and a higher proportion of preterm deliveries. Breech presentation is more common when a patient has had a breech presentation in an earlier pregnancy.  External version (ECV) is the manual turning of a fetus in breech presentation to the cephalic presentation. In an attempt to turn the fetus, one or two providers will push on the fetus through the patient’s abdomen and uterus.

 

The only benefit of ECV is that if successful, the patient can possibly avoid a cesarean section. Currently, we are not offering an attempt at vaginal delivery to patients who present in labor with a breech fetus. Therefore, if a patient who is carrying a breech fetus wants to avoid a cesarean section, she may elect to attempt ECV.

 

Overall, the success rate for ECV is approximately 50%.

The following factors increase the success rate:

1)    Women with several previous deliveries;

a.     Nulliparous patients have a 40% success rate;

b.     Parous patients have a 60% success rate;

2)    Women with a relaxed uterus;

3)    Women whose breech fetus is not engaged;

4)    Women with a generous amount of amniotic fluid (although there is a higher rate of reversion to breech).

 

The patient should be told that, overall, ECV is a safe procedure. There are some uncommon risks of ECV that the patient should be made aware:

1)    Slowing of the fetal heart rate. In approximately 40% of attempts there is a temporary slowing of the fetal heart rate. This is caused by a vagal response due to head compression. This slowing is temporary and is not harmful to the fetus.

2)    Preterm labor (< 5%);

3)    Cord entanglement (< 1.5%);

4)    Need for emergent cesarean section (< 1%);

5)    Preterm rupture of membranes (< 1%);

6)    Abruptio placentae (< 1%);

7)    Fetomaternal hemorrhage (< 1%);

8)    Rupture of the uterus (rare);

9)    Injury to the fetus (rare);

10)Death of the fetus (rare).

 

1)    Women with a breech presentation;

2)    Women with a reassuring fetal heart rate tracing (This will be determined when the patient arrives to Labor and Delivery on the day of her attempted ECV.).

 

1)    Absolute contraindications for ECV;

a.     Women with multiple gestations;

b.     Women with contraindications to vaginal delivery (e.g., active herpes simplex virus infection, placenta previa);

c.      Women with nonreassuring fetal heart rate tracings.

2)    Relative contraindications for ECV (Patients still may be offered ECV but patients must be made aware that there is increased risk for complications an/or a decreased risk of success.);

a.     Women with polyhydramnios;

b.     Women with oligohydramnios;

c.     Women with fetal growth restriction;

d.     Women with uterine malformation;

e.     Women with a fetal anomaly;

f.      Women with a prior uterine incision.

 

Patients should be told that the earlier in pregnancy an ECV is attempted, the higher the success rate but the higher the rate the fetus will revert back to breech.

1)    If a patient who is more than 34 weeks’ gestation is thought to have a fetus in breech presentation, the provider should perform an informal ultrasound to confirm the presentation or schedule arrangements to confirm the presentation.

2)    A formal ultrasound should be scheduled between 36-37 weeks’ gestation to:

a.     Re-confirm the breech presentation;

b.     Screen for fetal anomalies (breech fetuses have a higher rate of anomalies);

c.     Screen for contraindications to attempting ECV;

3)    After the formal ultrasound’s results are known, the provider should;

a.     Again discuss the pros and cons of ECV;

b.     Call Duke Labor and Delivery to schedule the ECV – the ECV should be done ideally between 36 and 38 weeks’ gestation, but can be done anytime before labor starts;

c.     Inform the patient that she MUST BE NPO starting after midnight the day of the ECV and she cannot eat or drink anything until after the procedure. The patient needs to understand that any deviation of this NPO order (other than required medications with a small sip of water) will cause her ECV to be cancelled.

4)    The provider should NOT offer ECV the same day a breech is discovered. ECV is always an elective procedure and should be treated as such.

5)    For patients carrying a fetus with growth restriction or carrying a fetus with anomaly, before the ECV is scheduled, the patient’s case must be approved by an MFM attending.

6)    If the provider does not schedule a formal ultrasound before the ECV is scheduled, then a Maternal-Fetal Medicine attending physician must be consulted and it must be documented why the ECV is scheduled without a formal ultrasound.

 

1)    The patient should be told that the procedure is painful. The patient should be told that she may tell the operators to stop at any time during the procedure.

2)    The patient should be told that she may or may not be offered pain medicine and/or anesthesia during the procedure. This decision will be on the day of the procedure and will be made by the ECV operators. The providers in the prenatal clinic will NOT and CANNOT make any suggestion about or promise of analgesia or anesthesia.

3)    The patient should be told that she may or may not be offered tooclytics during the procedure. This decision will be on the day of the procedure and will be made by the ECV operators. The providers in the prenatal clinic will NOT and CANNOT make any suggestion about or promise of tocolytics during the procedure.

4)    The patient should be told that regardless of the success or failure of the procedure, the patient will have to remain in Labor and Delivery for a minimum of 4 hours after the procedure. She will not be allowed to eat or drink anything for the 4 hours.

 

1)    If the procedure was successful and there were no complications, most often, the patient will be discharged home. She should return to the clinic/health department were she was having her prenatal care.

2)    If the procedure was unsuccessful and there were no complications, the providers at the hospital may or may not schedule an elective cesarean section for the patient. She then will be discharge home. She should return to the clinic/health department were she was having her prenatal care. If the hospital providers did not schedule the cesarean section, then it should be scheduled from the clinic/health department.

3)    Occasionally, there may be obstetrical or medical factors that would necessitate the patient staying afterwards for labor induction or cesarean delivery. If possible these situations should be discussed with and confirmed with a Maternal-Fetal Medicine attending before scheduling the procedure. If the factor(s) could not be foreseen, then the hospital providers will discuss the situation(s) with the patient at that time.

4)    Regardless of the success or failure of the procedure, there may be complications that would necessitate the patient being transferred to another clinic. These situations will be discussed and the transfers made during the patient’s stay at the hospital.

 

 

Prepared in conjunction with the

Division of Maternal-Fetal Medicine

Duke University Medical Center

 

                                                                                                                                    Director 

                                                                      7/20/08                                                              Date

 

 

 

 

 

 

 

 

The Clinical Care Guidelines Development Committee of the Perinatal Improvement Board of Duke University Health System has developed a series of multi-disciplinary protocols to offer guidance to health care providers who are caring for pregnant women with high risk conditions.

 

These protocols are designed to assist health care providers in the management of a variety of problems that occur in pregnancy and the time of delivery. They should not be interpreted as standard of care, but instead represent only general guidelines for the care of pregnant women with high risk conditions.  We recognize that services offered by individual providers depend not only on their training, experience and institutional resources, but on the medical facts and circumstances of the specific care situation.

The protocols remain the intellectual property of the Duke University Health System.  They cannot be reproduced in whole or part without the expressed permission of the Health System.

 

These protocols are reviewed by the Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine, the Department of Pediatrics Division of Neonatology and the Department of Anesthesiology Division of Women’s Anesthesia.  Please contact Andra H. James (andra.james@duke.edu), Chair, Clinical Care Guidelines Development Committee of the Perinatal Improvement Board with ideas for additional protocols.