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External Cephalic Version (GTG 20A - Mar 2017) - Coggle Diagram
External Cephalic Version
(GTG 20A - Mar 2017)
Epidemiology
Definition
: Manipulation of the fetus, through the maternal abdomen, to a cephalic presentation
Breech presentation complicates
3-4% of term deliveries
Undetected breech presentations at term
: 20-32.5% of all breech presentations
Commoner in nulliparous women and preterm deliveries
Associated with uterine and congenital abnormalities
Decrease in vaginal breech births following Term Breech Trial
Sensitivity of abdominal palpation: 70%
Recurrence rate after 1 breech presentation
: 9.9%
Efficacy
Success rate approximately 50%
; greater in multiparous women (60%) than nulliparous women (40%)
Following unsuccessful ECV at 36 weeks or later, only a few babies (3-7%) will spontaneously turn to cephalic
Spontaneous reversion to breech after successful ECV
: Rare (3%)
Counsel that successful ECV reduces chance of Caesarean section
Spontaneous version from breech to cephalic
: Rare at term (8% of primips after 36 weeks), more common in multiparous women
Labour after ECV associated with slightly increased rate of instrumental delivery and Caesarean section
Factors Influencing Success
Multiparity
Nonengagement of breech
Use of tocolysis
Palpable fetal head
Maternal weight <65kg
Posterior placenta
Complete breech
AFI >10
Tocolysis
Benefits
: Improves success rates of ECV, reduces risk of Caesarean section
Dose
: 250mcg terbutaline SC
Contraindications
: Significant cardiac disease, hypertension, those on beta-blockers (won't work)
Side effects
: Maternal palpitations, tachycardia, flushing, tremor, nausea
Analgesia
CONSIDER for repeat attempt or women unable to tolerate
: Routine use of regional analgesia is not recommended
Regional anaesthesia requires less force and may reduce failure rates, particularly in conjunction with tocolysis
Timing
OFFER
at term from
37 weeks
In nulliparous women
: May be offered from 36 weeks
Intrapartum
: Consider if informed consent possible, membranes intact, and no contraindications
Stabilising induction in unstable lie
: Potential risks include cord prolapse, transverse lie in labour, abnormal CTG
Contraindications
ECV after 1 Caesarean no greater risk than with unscarred uterus
Placental abruption
Severe pre-eclampsia or hypertension
Abnormal Dopplers
Abnormal CTG
Multiple pregnancy (except after delivery of 1st twin)
Absolute reason for Caesarean section exists: E.g.: Placenta praevia
Rhesus isoimmunisation
Current or recent (<1 week) vaginal bleeding
Rupture of membranes
Lack of consent
Oligohydramnios
Risks
Risk of emergency Caesarean section within 24 hours
: Approximately 0.5% (>90% due to vaginal bleeding or abnormal CTG)
Complications rare
Possible risks
: Fetomaternal haemorrhage (2.4% of women), neonatal unit admission following unsuccessful ECV
Safety
DO NOT
do more than 4 attempts, maximum time 10 minutes
Perform EFM before and after ECV attempt
When to deliver
: Vaginal bleeding, abdominal pain, persistent abnormal CTG
Ultrasound should be used during and after to confirm normal fetal heart rate
Transient (<3 minutes) fetal bradycardia is common
Women who are Rhesus negative should be tested for fetomaternal haemorrahge and offered
anti-D (500IU within 72 hours)
. If strongly positive (Kleihaur >30mls), review.
Alternative Methods
Consider use of moxibustion for breech presentation between 33 and 35 weeks
Mode of action thought to be promoting fetal activity
May be effective when combined with postural management techniques
When combined with acupuncture may result in fewer births by Caesarean section
No evidence that postural management alone promotes spontaneous version