ACOG updates guidelines on External Cephalic Version

According to the new practice bulletin published in the February issue of Obstetrics & Gynecology, all antenatal patients near term with breech presentation should be offered External Cephalic Version (ECV)  to decrease unnecessary C-sections provided they have no contraindication for it.

This replaces the earlier guidelines issued in February 2000.

The ACOG committee member says that “[ECV] is a valuable management technique and, in a properly selected population, poses little risk to either the woman or the fetus. If successful, ECV provides a clear benefit to the woman by allowing her an opportunity for a successful vertex vaginal delivery,"  

These recommendations are based on previous studies showing successful vaginal birth after ECV and a movement to decrease unnecessary Cesarean Deliveries.

The 6 points in the guidelines included 1 Level  A recommendation, 3 Level  B recommendations  and 2 recommendation based on expert opinion and consensus.

Level A recommendations:

1)      Every woman near term, with breech presentation should be offered ECV attempt near term unless contraindicated.  Women may choose not to undergo ECV because of fear of the procedure, incomplete information, and preference for scheduled cesarean delivery.

Level B recommendations:

1)      Fetal presentation should be confirmed beginning at 36 weeks to plan for ECV. The spontaneous version would have happened most likely by 36 weeks and chances of reversion to breech after ECV is also less at this time in pregnancy .

2)      Having a history of previous C-section  does not lessen the chance of success, but whether it augments the risk for uterine rupture is not known.

3)      Using parenteral beta-agonist improves the chance of successful version.

Expert opinion recommendations:

1)      A biophysical profile and nonstress test must be carried out before and after the ECV to ascertain fetal well being.

2)      The procedure should only be attempted in s setting where facilities for emergency C section are available round the clock.  

If ECV persists after the version, the mode of delivery should depend on the expertise of healthcare provider.

Absolute contraindications for ECV are those which are likely to be associated with increased mortality or morbidity:

1. where caesarean delivery is required
2. antepartum haemorrhage within the last 7 days
3. abnormal cardiotocography
4. major uterine anomaly
5. ruptured membranes
6. multiple pregnancy (except delivery of second twin).

Relative contraindications where ECV might be more complicated:

1. small-for-gestational-age fetus with abnormal Doppler parameters
2. proteinuric pre-eclampsia
3. oligohydramnios
4. major fetal anomalies
5. scarred uterus
6. unstable lie

References:

https://www.rcog.org.uk/globalassets/documents/guidelines/gt20aexternalcephalicversion.pdf

http://journals.lww.com/greenjournal/Abstract/2016/02000/Practice_Bulletin_No__161_Summary___External.44.aspx

http://libraryguides.missouri.edu/ACOG