External Cephalic Version BY ABHISHEK JAGUESSAR

Spontaneous version
After 32/40 is as high as 57% and after 36/40 may still be as high as 25%. Is more in multiparous. Less likely in primipara and extended breech.

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External Cephalic Version

Promotion of spontaneous version

Any factor which promotes disengagement. Postural changes (Knee-chest position).

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External Cephalic Version

ECV
Before 1970: Performed without tocolysis. Prior to 36/40. With or without sedation.

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External Cephalic Version

After 1978,after 36/40: Preferably with tocolysis. Lower incidence of complications Avoidance of PTL and delivery.

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Risks of ECV
Severe bradycardia requires immediate delivery by CS. 1% IUFD. Spontaneous reversion.

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Results of meta-analysis
Reduction in breech birth from 78% to 44%. Reduction in CS rate from 29% to 15%.

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External Cephalic Version

Benefits to fetus
Decreases the risks of foetal trauma. Decreases the incidence of cord prolapse. Decreases the rate of unattended breech delivery.

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Risks to the foetus

Review of 979 cases: 8% bradycardia due to short term hypoxia. (49) 5% Feto-maternal haemorrhage with tocolysis and 285 (29%) without.

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External Cephalic Version

Benefits to the mother

Reduction in significant maternal complication Cs may compromise future reproduction. Emotional sequelae. Higher maternal death.

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Indications and contraindications

37/40 and above: Gestational age-37,38,40: 40 more successful than 39,38 more than 37. EFW: the bigger the foetus the less successful ECV. Tense abdomen/uterus. Difficulty in palpating the foetal head. Increasing parity.

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AF less than 2 cm in any pocket. Back of the foetus anteriorly. Maternal obesity.

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Indications
Any breech after 36/40. Un-engaged breech.

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Contra-indications
Absolute: Multiple pregnancy. APH, P.Praevia. Ruptured membranes. Significant foetal abnormalities. Need for CS for other indications. Tocolysis is C/I in congenital or acquired heart disease, DM or thyroid disease.

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Relative: Previous CS. IUGR. Severe protienuric PIH. RH iso-immunization. (Evidence of macrosomia). (Grand-multi-para).
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(Anterior placenta). (Precious baby). (Previous APH). (Suspected foetal compromise). (Uterine anomaly).

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Pre-requisites
USS to confirm normal baby and normal AFV. Reactive CTG. Informed concent: PTL, ROM,cord and placental accident. Facilities for immediate CS. Kleihauer test.

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IV line. Clinical pelvimetry.

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Procedure
Position: -slight lateral tilt - trendelenburg. Tocolysis. One operator. Continuous pressure should be limited to 5 minutes. Dis-engagement of the breech.

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Forward or backward methods with flexion or slight extension. CTG.

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Maternal and foetal factors in breech

228 singleton breech; 96 remained as breech at delivery. 132 turned sopntaneously. Nulliparas comprised 60%. Gestational age was 10 days less in the beech group. Weight, length and HC at birth were lower in the breech.

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AFV was lower in the breech, 8 oligohydramnios to 1. Only 15% of the breech had identifiable cause.

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Conclusion
Current evidence indicates that ECV performed at term with tocolysis is safe procedure for carefully selected cases. The short term complications are negligible and the long term ones are hard to determine.

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