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External cephalic version, an alternative to turn a breech baby and avoid cesarean section

The external cephalic version (ECV) is a technique whose objective is to manually turn the baby that is poorly positioned in order to avoid a breech delivery or a cesarean section .

Despite being the best alternative, recommended by the World Health Organization for its effectiveness and safety, to avoid the risk of infant and maternal morbidity associated with both a vaginal delivery and a caesarean section in the breech position, it is still an uncommon practice in some countries.

Many mothers are not offered this alternative when their babies are misplaced.

What is the external cephalic version?

In an ECV, the gynecologist tries to reposition the baby manually from the outside, applying pressure on the mother’s gut or with a light massage. By rotating the fetus from breech to cephalic position using the external cephalic version, an attempt is made to reduce the chances of breech presentation at the time of delivery, in order to avoid the adverse effects of vaginal breech delivery or caesarean section .

Generally, the mother is first given tocolytics, drugs to prevent uterine contractions, to relax the muscles of the uterus and abdomen, and to facilitate maneuvering.

Before, after, and during the procedure, the fetal heartbeat is monitored several times to rule out fetal distress.

When my third daughter decided to go breech in the 39th week of pregnancy and I opted for ECV, what the doctor did was try to make her uncomfortable so that she would turn over. He placed two fingers behind the baby’s neck (always on the outside) and gently guided him with them until the head was down. It did not take more.

Are all pregnant women a candidate for ECV?

No, there are certain risk factors that advise against this practice in the following cases:

  • Previous placenta
  • Existence of uterine scars from caesarean sections or previous interventions
  • Multiple pregnancy
  • Previous vaginal bleeding
  • Intrauterine growth retardation
  • Presence of stress or fetal bradycardia
  • Risk of preterm birth
  • Oligohydramics
  • If the fetus has a complete cord loop at the neck
  • Presence of fetal malformations
  • Maternal hypertension or obesity

What is the best time to do a CEV?

ECV before term is not recommended as it is less effective, the baby may roll over again, and has more associated risks. Ideally, do not try before 37 weeks of pregnancy.

What risks does it have?

Although there is the possibility of vaginal bleeding, placental abruption, rupture of the amniotic sac or the umbilical cord wrapping around the baby’s neck, if practiced under the right conditions , the WHO considers that there is no real risk neither for the fetus nor for the mother. Fetal losses associated with this maneuver have not been recorded in series of 1000 ECV.

Is it painful, do we need anesthesia?

ECV is a technique that can be performed on an outpatient basis since it does not require anesthesia of any kind (although spinal anesthesia is used in some centers) or subsequent hospitalization. Depending on how easy or difficult it is to turn the baby, it can be somewhat uncomfortable but should not be painful.

Also, it is not recommended to apply pressure to the uterus for more than five minutes. If after this time the baby has not been turned around, the mother is allowed to rest and tries again a while later.

In my case, the only moment that hurt was when the baby turned his feet through the placenta. The rest was completely painless and caused very little discomfort. The maneuver itself took about two minutes.

An ECV should not be overstressed , if the baby resists turning or the procedure is extremely uncomfortable or painful for the mother, the doctor will decide to stop and try again perhaps a few days later.

Does it always work?

It doesn’t always work . In some cases there is an unknown physical reason for the baby to be in a breech position and not allow himself to be turned, other babies are reluctant to turn for whatever reason and, the more stubborn, may return to the breech position after a successful version . The probability that the procedure will work and the baby will not roll over again is 58% .

However, the success rates are very high and the associated risks and costs are very low, so we have nothing to lose by trying.

How many times can it be done?

An ECV can be tried or repeated several times, although it is not recommended to do it more than three times in the same pregnancy.

What is needed for an ECV?

Actually, as indicated by the WHO, to practice ECV you only need a stretcher and a stethoscope. However, the ideal conditions for the practice of this maneuver would also require the possibility of performing fetal ultrasound before and after the maneuver to verify the fetal position, a fetal monitor to perform a stress test before and after the procedure, and immediate availability of an operating room in case it produces any complication.

It is also very important that expert hands perform the technique to avoid complications; not all centers do it.

Indeed, with the data in hand, the external cephalic version is the best alternative to prevent breech delivery and should be offered to all pregnant women whose babies are poorly positioned.

More information | who
In Babies and more | Learn about the new WHO recommendations for a positive birth experience, The incredible collection of photos of the natural delivery of a baby who was born breech

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