External cephalic version: what it is, when and how it is performed
Manuel FernándezIf you are here, it is very likely that you are expecting a baby and that someone has mentioned the external cephalic version technique to you. Do not worry, you are in the right place! At Happymami we are midwives and in this blog we bring you the latest scientific evidence with everything you need to know about external cephalic version in a simpler way. From exactly what it is, to why it might be necessary and how it is carried out. So relax, take your moment and get ready to learn everything about this exciting stage of pregnancy.
Let's get started!
What is external cephalic version?
The External Cephalic Version (ECV) is a medical procedure carried out during pregnancy to try to change the position of the baby in the mother's uterus. The main aim of ECV is to change the position of the baby, who is in a breech presentation or in a position that is not optimal for birth, into a cephalic presentation, that is, with the head down.
This is important because most vaginal births tend to be safer and less complicated when the baby is in this position.
The External Cephalic Version (ECV) is carried out by a healthcare professional, usually an obstetrician (gynaecologist), in a hospital or clinical setting.
The procedure involves applying external pressure to the mother's abdomen to manoeuvre the baby and gently guide it into a cephalic position. It is typically performed after 36 weeks of gestation, when the baby has not yet descended completely into the pelvis and has room to move.
It is important to mention that the External Cephalic Version (ECV) is not suitable for every situation and is not without risks. Before carrying it out, various factors must be considered, such as the mother's health, the exact position of the foetus, the amount of amniotic fluid and other medical conditions. Healthcare professionals carefully assess whether the External Cephalic Version (ECV) is a safe option in each individual case.
If external cephalic version (ECV) is successful and the baby moves into the cephalic position, the likelihood of a successful vaginal birth can be increased. If it is not successful or if complications arise, it may be necessary to plan a caesarean section.
How is external cephalic version performed?
- Explanation and comfort: First of all, I want you to know that every step will be carefully explained to you before starting, so that you feel calm. Then you will be settled on a couch that may be a little narrow, but is firm.
Some hospitals perform this technique in the operating theatre itself, in case there is any incident and an emergency caesarean section is needed, so that you are already in the right place.
- Support cushion: In some situations, a special cushion is used to gently tilt your uterus towards the doctors. This helps to reduce the pressure on some important blood vessels.
- Tocolysis for contractions: In most cases, you are given a medicine called “tocolysis” which helps to relax your uterus and to stop or reduce contractions if you are having a premature labour.
- Relaxation of the abdominal muscles: You will be asked to keep your abdominal muscles relaxed. If you feel any discomfort, please let them know instead of tensing your muscles. This helps them to carry out the procedure more effectively.
- Ultrasound gel: They apply a special gel to your abdomen. This makes it easier for their hands to slide gently while they work with the baby. They use this especially if we are monitoring your baby's heart rate with ultrasound.
- Careful manipulation: In ECV they begin to gently move the back of the baby out of the pelvis using our hands. In some cases, two doctors may work together, one for the back of the baby and the other for the head.
- Choice of manoeuvre: Depending on your baby's position, it will be decided whether we turn the baby to one side or the other with a “backward somersault” or a “forward somersault”. The choice depends on the situation. In both cases, gentle and constant pressure is used to help the baby turn.
- Constant monitoring: Throughout the whole procedure, your baby's heart rate will be monitored. If there were any issue with the heart rate, the procedure would be stopped immediately.
It is a relatively common technique, which means that, being routine, it gives the mother greater peace of mind. That does not change the fact that every case is different and it is not always successful, which is why so many precautions are taken.
Factors that increase the success of external cephalic version
Amniotic fluid level above 10 cm
When the amniotic fluid around the baby is more than 10 centimetres, it is good for performing an External Cephalic Version (ECV). This is because there is enough space for the baby to move, which makes the procedure easier and safer. But remember, the decision to perform an external cephalic version (ECV) depends on many factors and must be assessed by a doctor.
Complete breech presentation
If the baby is breech but with the legs stretched out, it is easier to perform an External Cephalic Version (ECV). This is because the baby has more space in the uterus and is not engaged in the pelvis. But even so, the gynaecologist must assess whether external cephalic version (ECV) is suitable in each case, as there are always risks.
Non-longitudinal position
If the baby is in an oblique or transverse position (not head down), it is sometimes simpler to turn it into the correct position for birth. This is because only small movements are needed to do so.
Placenta located at the back
If the placenta is at the back of the uterus, it is easier to move the baby during external cephalic version (ECV). This is because the placenta does not block the way to the pelvis. But remember, the location of the placenta is only one of the factors taken into account. The final decision must always be made by a doctor, who will assess the whole situation.
The involvement of a team specialised in external cephalic version (ECV)
Having a team of professionals specialised in ECV is essential. This guarantees that the procedure is carried out safely and efficiently, increasing the chances of success and reducing the risks for both the mother and the baby. As we mentioned earlier, it is a technique that is performed routinely, so we are very well trained for it.
Front part not engaged
If the front part of the baby is not engaged in the pelvis, it is easier to turn it into the cephalic position during ECV. This makes the procedure easier.
Risks of external cephalic version
We want to talk about some important aspects related to external cephalic version, or ECV, so that you are well informed during your pregnancy. Although it is important to understand these topics, we want to emphasise that the risks we will mention are uncommon, and external cephalic version (ECV) is often performed successfully without complications.
External cephalic version: risks for the baby
Some of the risks that have been associated with external cephalic version (ECV) include the possibility that the baby does not tolerate the procedure well, which in very rare cases could lead to the need for an emergency caesarean section. There is also the remote possibility that the placenta may separate prematurely (placental abruption), also requiring an emergency caesarean section, but again, this is uncommon.
Other risks include the possibility that the umbilical cord becomes tangled or compressed during the procedure, which could cause changes in the baby's heart rate. In addition, although it is rare, there is a small risk of uterine rupture, especially if the mother has had a previous caesarean section or uterine surgery. Uterine contractions or even a premature start of labour may also occur.
It is important that pregnant women who are considering ECV discuss these risks with their healthcare provider. The doctor will assess the health of the mother and the baby, as well as other factors, such as the amount of amniotic fluid and the exact position of the umbilical cord, to determine whether ECV is a safe and appropriate option. The decision to proceed with an ECV should be informed and agreed, taking into account both the benefits and the possible risks.
Risks of breech presentation
Let's now talk about the complications related to persistent breech presentation. This could lead to situations such as cord prolapse, which may require a caesarean section, or complications during a breech birth, whether vaginally or by caesarean section. These scenarios are uncommon, but it is important to keep them in mind.
In some cases, it may be necessary to schedule a caesarean section, especially if labour is very quick and does not leave time for a planned external cephalic version. However, we must remember that any surgery carries certain risks for the mother, such as infection or haemorrhage, although this is always anticipated in the intervention itself, by giving antibiotics before the surgery.
These risks have been examined in various studies, which included many pregnant women. The most important thing is that you talk to your gynaecologist about your concerns and questions, as they will be able to give you the right guidance according to your specific situation. Your health and your baby's health are the most important thing, and we are here to support you every step of the way.
Complication rate of external cephalic version
An overall complication rate of external cephalic version of 6.1% was recorded (95% CI: 4.7-7.8). These complications include stillbirths, placental abruption, the need for an emergency caesarean section, umbilical cord prolapse, temporary abnormal changes in the foetal heart rate, vaginal bleeding, rupture of membranes and foetomaternal transfusion.
The risk in this case is that the complications mentioned may occur in a percentage of cases (6.1%) within a 95% confidence interval, which means that there is some uncertainty in the exact estimate of the complication rate, but it is likely to be within the range between 4.7% and 7.8%.
Stillbirth
A combined risk of foetal death of 0.19% was observed (95% CI: 0.12-0.27), which is equivalent to 1 case for every 5,000 attempts at external cephalic version (ECV). Of the 12 deaths recorded, only 2 were attributed to ECV, while the rest showed no relation or explanation.
Placental abruption
The combined risk of placental abruption was 0.18% (95% CI: 0.12-0.26), that is, 1 case for every 1,200 ECV attempts.
Emergency caesarean section
There were 49 cases of emergency caesarean sections, which represented a combined risk of 0.35% (95% CI: 0.26-0.47), that is, 1 case for every 286 ECV attempts.
No clear correlation was identified between the risk of complications and the success or failure of ECV. However, it is important to point out that this analysis had certain limitations, such as variations in study design, patient populations, external cephalic version (ECV) techniques and the definition of outcomes. Since many studies did not adequately assess the outcomes in patients with breech presentation who did not undergo ECV, it was not possible to make a reliable comparison of the risk of ECV against the option of not performing it. In addition, aspects such as maternal satisfaction, including the level of discomfort and possible adverse psychological effects in the event of failure, were not assessed
Conclusion on external cephalic version
To conclude this article, we can point out that external cephalic version (ECV) involves turning the foetus from a position that is not head down into a cephalic position by manipulating the mother's abdomen.
Generally, it is performed in cases where the birth is not at term or is close to it, with the aim of increasing the chances of a vaginal birth with the baby's head first. It is typically performed after 36 weeks of gestation, when the baby has not yet descended completely into the pelvis and has room to move.
It is true that the final decision on whether or not to perform an external cephalic version is the mother's, so you may have many doubts. Our advice: go to your midwife and your gynaecologist, explain your doubts, it may be useful to bring them prepared on a piece of paper, and they will be able to help you with your choice. Every case is different and a full assessment is needed in order to decide.
Remember that at Happymami we make bottles made to measure, so if you need to use a bottle, with your made-to-measure Happymami, as you have the bottle that best represents your anatomy, you increase the bottle acceptance rate and prevent nipple confusion in your baby, protecting your breastfeeding. Design yours with no obligation.
Design your Bottle ®Bibliography
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