External cephalic version

-. EXTERNAL CEPHALIC VERSION

Lee s. Clay, CNM. MS, Karen Criss,

In 1979, a government panel sponsored by the National Institute of Child Health and Human Development registered its ccncem about the rising rate of cesarean childbirth (1). The trend could be safely “stopped and perhaps reversed.” the panel declared At the time, the rate of cesarcan section was 15% Today it is nearly 25% (2). In fact, the cesarean section rate in the United States rose steadily from 5.7% in 1970 (1) to 24.1% in 1986 13), when it then leveled to its current rate. The number of breech presentations delivered by cesarean section has also changed considerably in the p&two decades. The rate has grown from 12% to 14% tn 1970 to 26.7% in 1974,60% in 1978.80% in 1984, to today’s rate of 80% to 100% ll6). Furthermore. breech pwentations account for 12% to i5% of all cesarean sections done and, thus,

CNM.

MS,

and Unjeria C. Jackson, MD

conhibute to approximately 10% to 16%oftheriseintheoverallcesarean section rate since 1965 (1). The 11~ in operative deliveries for the breech presentatfon is a result of the controversy regarding the safety of va@nal breech delivery. The increased dsks of vaginal breech delivery for a preterm infant have been well documented (7-10). However, many authors have shown no difference in neonatal outcomes for carefully relected term breech presentations delivered vaginally or by cesarean section (11-13). Vaginal breech delivey has been supported by the Amertcan Colle9e of Obsteticlans and Gynecologists under selected conditions. which include a full-tetm infant in the frank breech position and an apetienced practitioner (14). Yet some studies question the safety of vaginal deliver of the term breech (15. 16). Moreo&r, it is often difffcult to l&e a practitioner willing to attempt a vaginal breech delivery. External cephalic version (ECV) can

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decrease the number of breech present&tons at term and impact the overall cesarean section and vaoinal breech delivey rates. This a&will review the literature. on ECV and explain the procedure for ECV. as well as describe a study that evaluates the use of ECV in a painatal center over a five-year period, BREECH POSITION The etiologic factors in the breechposNionare numerous and in many cases it is not pos&ible to identify the cawe of the malpresentation. Some of the more common causes of breech preeentetion are listed In Table 1. Prematurity Is associated with breech presentations whereas only 3% of cephalic babies are born prematurely, 15% of breech babies are born prematurely (17-19). This phenomenon is not completely understood, because it has not been deteermined whether breech presentation in itself results in an increased incidence of

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TABLE 1 Etiologic Factors in Breech Presentation

Premar”rity Multiple geStati0” Placenta preula &line anomaly Polyhydramnios Oligohydramnios Neuromuscular dysfunction Lax uterine tone

Prematurity xx whether breech presentation is a cofactor in prematurity (19). Breech presentation is also associated with placenta previas and utertne anomalies. These conditions may change the shape of the uterus

and, theoretically. may Impede the fetus’s ability to move into the cephalic position. Fetal anomalies, particularly hydrocephaly, may also prohibit the fetus horn turning to a cephalii position. Babies with newomuscular disorders are often unable to maneuver themselves around in the uterus (19). In women with polyhydmmnios. the infant is not foxed in!o one position but, rather, is able to move freely in the uterus because of the excessive amount of amniotic fluid. On the conimry, when oligohydmmnios is present. the fetus’s ability to change position in the uterus may be limited by a lack of rcan due to the low anwunt of amniotic fluid (17. 201. REVIEW @F THE LITERATURE

Cloy. CN”. MS. k 0” ~ociote forthe Journal of NurseMldwifey. She received a 6.S.N. degree from Duke “niunmty and on M.S. jrcm Columbia Uniuerrity. She is o clinical ossistont pro~ezsar ot the Nurse Midwvey Pmgmm at the Uniuenity of Medicine and Dentistry of New Jersey.

Lee.5

editor

degree

Karen Criss. crw MS, is a gmduate o, Fairleigh Dickinson “niwrsity and the Nurse Midu$ery Pmgmm c,~Columbia University. She is the dweetor of the Nurse Midwtery Service 01 Mom’stown MeemoCI Ho@tnl. Monistown. New Jemey. Karen 1so/so ~1clinical instructor ,or the Nurse Midwi,ery Pqmm d the “niuetsity of Medicine and Dentistry of New Jersqv She is cunentfy president of the New Jersey Chapter of the American College of Nurse-Midwwa. Unleria C. Jackson. MD. receiued her undergraduate degree from Yale “niuerrity ond her medical degree,mm Bcxton llniversi~ School o/ Medinne. She completed he, OB,GYN residency at Harlem Hospit in New York City and herfellowship in matemoi-fetal medicine at Columbia University. She is the director of the Division of Pefi”ot&x” (If Monis*olun Memoria, Hospital. nibnistown, New Jersey and IS bmrd certified in OB,GYN and motemol -fetal medicine.

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The practice of turning a malpresentinq fetus to win a more favorable fordekeyhas been used since the time of Hippocrates (21). Internal pod&c version was performed reaularlv duinq the time of Celsus. but for &know; reasons the procedure fell into oblivion during the Middle Ages (211. In the 15OOs, Ambraise Pare. surgeon to the King of France, reintroduced the technique of version and extraction (22,23). At that time, version was used in case5 of tra~verse lie. whereby the attendant inserted a hand into the uterus. grasped the baby by its feet, turned it. and then puffed it cut. still holdinq the feet f24i. Interestingly, the resurgence of this technique occurred at a time when there was a dramatic increase in the number of male birth attendants. Althcugh one historian claimed that version was used equally by male and female attendants, another stated that women did not have the requisite strength and intellect, and thus, the maneuver remained the domain of men “. with minds more alert than women’s” 122. 241. By the 19th century. version was beins performed internally, externallv. or as a combination of both rna~euven. The first person to unite

preseniiicm

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about external version was Wigand in 1807. Hii description of the OTOcedure included pl&tng the mdiher in a supine position with her knees flexed and manipulating the fetus through the abdominal wall (25). The procedilre pi>; carded out during labor between conhacticns. Subsequently, several authors detibad the techniques needed for combined version using an external and internal hand simultaneously. Similar methods desctibed by Busch. Wtight, and D’outiqxmt were all used late in labor. because they required the examiner’s entire hand to be placed into the uterus. Busch suggested seizing the head with the internal hand, whereas Wright and D’outrepont recommended grasping the siwulder. Wdght’s maneuver also desclibed using the external hand tr) dislodge the breech as an aid in completing the versiion 125). Advanced celvical dilatation was necessaw to perform these procedures. Hall -and Braxton Hicks described more useful methods that only required two fingers of the examiner’s hand ?o be placed in the uterus. Therefore, their procedure could be used earlier in labor. Bmxton Hi& technique of bipolar version, described in 1864, was thought to be one of the most imcontributions to obstehics in the 19th centurv. His prcxedure enabled the physician to perform the version early in labor and not imperil the integrity of the U*~IUE (25). However. version wdually fell into d&repute in the 26th ce&y. although external w&m and the Wright maneuver were occasionally performed (20-22). By the 1930s. hospitals were replacing homes as the &ce to give bitih. making surgical delivery easier and an alternative to difficult forceps delivery. The risks of cesarean section were greatly reduced in the mid-1900s with the advent of sterile technique, anesthesia, antibiotics. blood. and better surgical techniques (2, 4, 22). Starting in the 1960s and continuing into the 1970s. there was a

portant

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growing demand for a noninterw.., tim,ist approach to birth. Ot,stehics became more family centered and consumer oriented. Yet, duriw this same period, MS! technological advanceswere made in women’s he&x, including the increased use of the cesarean section (2, 4, 22, 26). Although the cesarean rate soared by 450% between 1965 and the present, the infant mortality and morbidity did not decline prop&onately (2). Moreover,agreaternumberofwomen were being exposed to the morbidity and mortality of major abdominal surwrv. Althoush the safety of this &r&n has improved d&&ally since the late 19th centiy, when a medical historian observed that a pregnant woman had a better chance if gored by a bull than if attended by a New York surgeon (21, the risk of morbidi with a cesarean section is two to four times higher than that for a vaginal delivery (2, 4, 22). The four most cormno” reasons cesareans are performed today are: repeat cesarean sectton, dystocta, fetal distress,and breech presentation (1, 4). In an attempt to impact the overall ce~arean section rate, it becomes ne-y to consider alternative ways to manage the breech baby safely. One solution is to change the malpresentattonto a cephalic presentation. Many advocate the use of the knee-chest position; however, only a single paper in the current literature studies this procedure. Chernia et al (27) found that advlstng women to use the knee-chest position for 15 minutes, three times a day for seven days was a simple, safe intenrentlon. In his studv. althoush this procedure reduced the frequency of breech presentation at delivey, the difference was not statistically significant when compared with spontaneous version rates. In a study of 76 women, 41% of the group advised to use the knee-chest position had a spontaneous version and 32.4% of the control group turned. The failure rate increased proportionately as the ge:bttonal age increased. This study

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is limited by its small number and short duration. External cephalic version has been the focusof severalstudies.Pl;blished reporis of successrates for ECV over a IO-year @cd are summarized in Table2 (5.6.28-41). Succeesfulversions in these studies va’y from 25% to 83%. This discrepancy in succe~ rates is largely due to differences in patient selectton cliterta and the amount of time and exertion used for the procedure. The rate of spontaneous conversion to breech presentation after a succe&l version ranges from 0 to 6.6% (2932.36, 39). A number of parameters, including gestational age, parity. and placental and fetal positions. have been widely studied as to their influence cm successrates for ECV. Sc&g (37) found ECVwas successfulin 74.3% ofcases when carried out between 30 and 34 weeks of gestation, whereas between 34 and 38 week it was successful only 45% of the lime. He reasoned that ECV is more successful at this earlier gestationbecausethere is more rwm in the utems, the presentingpart is not engaged, the uterus is less irrttable, and there is less dtwomfort perceived by the patient than at later gestattollal ages Van Veelen et al (381 hasalsoshwm higher rates of successwith ECV between 34 and 35 weeks of gestation. Critics of early ECV, however, point to the risks of an iatrcgenic preterm delivery, as well as to an increased need to repeat the procedure because the fetus is more likely to return to the breech position the eadier in gestation the ECV is perfoned. Also, before 36 weeks of gestation. SW”taneousversion &eed 20%6’(19, 33. 36. 38). Versions before this time rn”y be unnecessary because the fetus may assume a cephalic presentation spontaneously. Thus, most practitionersadvacate v/atWg until 36 to 37 weeks of gestation before attempting an ECC 50 that, in the unlikely event a complication adsesduring the procedure and delivey of the infant becomes necessary, the prob-

rates

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TABLE 2 Success Rates for ECV Study

Rote 1%)

I “an Dorsten1,981, Brockset al (19841 z* sene et al (1985) 73’ Dysonet al (19861 77* Morrisonet al (1986) CYGmdy 11986) %5* Ranagan et al (1987) Robertson et al (19871 66.7*,67.8* Fortunatoet al (19881 60’ Marchick(19881 60* Scaling 11988) 60.6$ 25: Van Veekn 11989) Donald and Barton (19901 58* flamm 11990) Mahomed (1991) 83’ De Rosaand And& 594* w911

481

szt8

lems inherent with a preterm delivery are avoided. Although ECV can be accomplished successfully after 38 week of gestation, as well as in early labor If the membranes are intact (42. 43). the procedure may be less successful at these times because the amount of amniotic tluid dlmtnishes and the stze of the infant increases with each week of gestation (26). Multiparous wmnen are more likely to experience a successfulECV than nulliparous women (5, 26, 36. 44). apparently becausethe abdamtnal and uiertne muxles in parous women are often more lax than in nulliparous women, allowing for easier maneuverability ot the fetus. There is no conclusive evidence as to the effect of fetal position on ECV. Ferguson et al 144) found the highest percent of successful versions In women with complete breeches I96”G). Success was less with frank breeches (65961. The investigators hypothesized that the position of the legs in a frank breech may act as a wedge, makin version of the fetus

Vol. 38, No. 2 (Supplement), March/April 1993

TABLE 3 Contraindications to External Cephalic Version

Cardiacdisease Diabetes Thyroid disease Chronichv,,ertenaan

more difficult. Thus, the ECV is less likely to be successful. In contrast, Donald an-’ Baton (6) had the meates! success with fmnk breech presentations 171461end less success with complete and incomplete breeches 153% and 30%. resoativelv~. Fergwon et ;I I&) have*also hypothesized that placentalposition influences the ability to maneuver the fetus because it either impedes the actual atten-mtto move the baby or alters the co&guration of the uterus. which, therefore, affects the available space necessaly for a successful VeF sion. Both Femuson et al 144) and Ranu and Va&vinkova I& concludedthat anterior and posteriorpkcentaswere associated with a greater success of ECV. Conversely. Kirkine and Ylostalo (46) claimed that placentas located on the anterior wall decreasethe ability to complete a version successfully. Other researchers have found little evidencesuppoting the notion that placentalposition signifkantly inffuencesthe version (6.33, 35). Another variable that may influence the outcome of ECV is the descent of the presenting part prior to attempting the version (5, 351. The txcedure becomesmore difficult and &ten fails if the presenting part has already engaged. In fact, engagement

.~~

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is considered by some praciitioners a contraindication to attempting a version. Houwer, if a version is attempted when the presenting part is engaged.it may be bzrzfidal to have a::other pra&oner availablewho can try to disengagethe presenting part during a va@malexam i1z.the version IS attemo!ed. .FtnaUy,other factors that have been imdicsted in the successrates of ECV in&de the weight of the fetus and the position of the letal spine in belation to the uterus. Some invest&ton have suggested that fetuses with an estimated fetal weight greater than 4000 g are more difficult to turn WI. However, other inve$$&xs hove reported that the estimated fetal weight does not influence the succes.sof the version (36. 44). A few researchers have conelated lower success rates with infants whose back, xe posterior because only the soft parts are easily palpable and. therefore. the manipulation is more difficult An anterior or lateral beck is therefore preferred (3544). The issue of tocolytic use for ECV continues to be debated. Those who believe in its use feel that the tocolytics relax the uterus, making the procedure safer, easier. and more likely to be completedsuccessfully(33). Yet, few controlled studies have adequately examined the use of tocoiytics m version. Host recent major studies on ECV have employed the use of tocolyticz in all patients (5, 6, 31.33.36, 40). Robertson et al 134). however, found no difference in success rates of ECV between matched groups of women using tocolyiics and not using them prior to attemptig version. The issue of whether wolytics are beneficialneeds to be studied more extensively. Because ECV is done at term. when Bmxton Hicks contractions occur frequently and because the uterus is sensitive to manipulation, tocolysis should be considered. The use of tocolytics may be beneficial becausethey decreasethe number of contractions. thereby eliminating the need to interrupt the

Vol. 38. No. 2 (Supplement).Mar~WApril 1998

procedure continually while wafting for a conirac+ionto pass. Some authors recommend the routine use of tomlyltcs if the version is attempted during labor (42.43). If ~woman who is a candidatefor ECV is Rh new&e. tocoivs’s should be strongly eicoumged because of the risks of fetal-maternal hemorrhageduring the pmedure. fn a stufy where tocoltics were not used. the incidence oi fetal-matemel hemorrhage was 28% (47). However, with the use of tocolysfs prior to version, the risk of fete-maternal hemorrhage drops to 4.7% (30. 47). Kleihauer-Betke analysts should be considered after ECV in Rh-native women end Rt-tmmuw globin&ould be administered appropriately 147). Previouscsareansectionwaronce considered an absolute contreindication to ECV (17, 30, 32. 34, 43). Hawver, a recentstudy indicatedthat theprocedurecanbep&xmed~ in these women if they meet selected criteria, including a low tmnsverse uterine incision (39). Fxtemel cephalfcversion canbe attempted in most women with a malpresenting ferns if the follting criteria are met: singteton pregnancy in the third himester. adequateamount of amniotic fluid, and a reactive nonaes. test or oeS&w contmctionstress IsI immedfate’~ prior io p@forn&g the procedure. In further evelua!ing a woman’s candidacyfor ECV, all contmindications to the procedure must be considered (Table 2). Absolute confxeindfations p&u& any attemptat ECV, whereas relative contraindications should be considered on a case-bycese basis. External cephalicversion should not be attempted in women with multiple gestations because of the risks of cord accident, entaglement and uterine rupture in en already overextended uterus. Fetuses with congenitalanomalies. severe in~auterinegrowthrrtardation, andoligohydramnios are akeady comjromised. and thus the added potential stress of ECV should be avoided.Fur-

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thermore, with severe oligohydramnios, the diminished amniotic fluid till

massive amniotic fluid embolus and sepsisfour days after a version. Nei-

likely prevent a successfulversion. As there is a risk of fetal-maternal hemorrhage during ECV, the procedure should not be performed in already isoimmunizedwomen. If a nuchal cord is identified, ECV should not be performed because of the risk of fetal distress.Maternal medical complicaiions such as diabetes, cardiac disease, and thyroid diseaseare relative contmindications to the procedure because the use of towlyiics may be contraindicated in these conditions, depending on the severity of the problem. Therefore, the method for ECV and tik4,beneftts of the procedure should be carefully considered. Chronic hypertension is a relative contraindication because It is often assxiated with poor placental perfusionani oligoh+mmim; thus ECV may be too great a stress for an already compromised fetus. Furthermore, because maternal hypeltension is associated with a higher incidenceof placental abmptlon, some consider this condition an absolute contraindication (261. The severity of the hypertension must be carefully evalu&d. Women with uterine anomalies should be considered for ECV on an individual ba?:;, depending on the severity of the anomaly and its potential impact on the outcome of ECV. In the cunent literature. the incidence of complications from ECV is rare. The most commonly reported side effect is transient bradycardia or abnormal fetal heart rate tmdng, which resolvesspontaneously once the procedure is stopped and the patient is repositioned (6, 29, 32. 37, 38). Flamm et al (39) reported fetal heart rate abnormalities that necessitateda cesareansection in two patients. Van Veelen et al (38) reported one case of slight w&al bleeding three days after ECV, lasting two days with no sequeiae. In Sline et al’s (301 study on 148 attempted versions,there was one fetal death three week after version ana one maternal death from a

ther case was thought

to be directly

related to version. In DeRosa andAn-

derle’s (41) study of 32 attempted ECVs, there was one stillborn from placenta abruption. 20 hours after a failed rersion-attempt. The authors stated tt was unclear whether or not the abruption occurred as a direct result of the version. Other authors reporting fetal complications in study groups have not associated these problems with ECV (29. 31, 33). Earlier studies on ECV showed higher incidences of fetal and maternal complications (26,48-50). A 1% to 2% fetal morbidity rate was found when general anesthesiawas used for version 1.26). This use of anesthesia also increased the incidence of antepartllm bleeding and placental abruption, most likely as a result of greater force being used for the vasion (26). There are no reports of maternal 01 fetal deaths directly caused by ECV when the procedure was performed w+th ultmsound,fetal heal rate monitoring, and tocolvtia after a reactive m&tress test (34). Nonetheless, women should be informed of all potential risk of ECV including premature mphtre of membranes, placental abruption, and fetal distress. These complications can be safely managed when versions are performed in well-equipped facilities. MATERIALS AND METHODS Patients with a singleton breech presentation were referred for ewaluatkm for ECV. The referrals were obtained from mivate and clinic wtients at Motiovm Memofial Ho&l (MMH) from August 1987 through August 1992. The average number of deliveries per year during the study period was 3,093. This studv is a retrcwective review of the “e&s &tern&d dming the study period to assessthe successand safety of the procedure. During the initial evaluation, pertinent historical and physical findings were assessed.Patients with the fo1.

Journal of Nurse-Mtdwlfery .

lowing conditionswere excluded from the procedure group: 1) nonreactive nonstresstat; 2) congenital anomalies; 3) severe oligohydramnios; 4) se vere maternal disease such as heal disease and poorly controlled diabetes; 5) intrauterine growth retardaiion; 6) Rh isoimmu&tion; and 7) multiple gestation. Previous cesarcan section was considered a contmi&&.ion until about 1.5 years ago. AU procedures were conducted either in the labor and delivenr suite or the antenatal testing center l&ted just down the corridor from the labor and delivey suite. A full explanation of the procedure, along with benefits and Tisk. were discussedwith the patient. Informed written consent was

obtained fmm those women who agreed to paticlpate. All patients except three were without labor. The medlcal and obstetric history of each patient was reviewed. An ulL tmsound was performed to confirm the breech presentation. to note the type of breech. and to was amniotic fluid volume and placental location as welt as to rule out fetal anomalies. Each patient for version was requested to empty her bladder. She was gowned and placed in the left lateal supine wsitton. at which time a nonski wasperformed.Blood for a type and ween and a complete blood count was obtained and held for use in the event of a complication. Intravenous access was established, usualfy wtth a solution of 5% dextrose in lactated Ringer’s A single dose of terbutaline sulfate 0.25 mg was administered subcutaneously. The actual version was accomplished by physical manual rotation in the tradlticmal forward roll 01 the more recent backflip method (51) (Figures 1 to 7). The procedure and manipulations to accomplish ECVare

tei

described below. The breech and the vertex of the fetus were located and grasped tmnsabdominally. Depending on the fetus’s mie”tatio”, gentle force was exerted to rotate in a fonvard or backward direction. This was usually

Vol. 30, No. 2 (SuppkmentL March/April 1993

FIGURE 1.

FIGURE 5. GxllpLetionOf externalYersi0”.

FIGURE 7. ’ Gently push breechdownward to direct vertexinto pelvis.

Journal cd Nwsxz~Midwifq

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acccmplished stepwtse by 90’ or cluarter rotations. If the attempts to proceed in one direction were not successful,then a rotation in the opposite direction was attempted. Once the fetus had been physically vetted, an effort was made to push the vertex. downward slightly to helpstabilize the position. The entire procedure was performed with simultaneous nwnit&rag of the fetal heat rate with ultmsound. If there was significant maternal discomfoti or fetal heart decelerations, the procedure was discontinued. When the procedure was finished, whether successfulor not. a nonstxss test was repeated (see Figure 8).

Vol. 38, No. 2 (Supplem.nt). March/April 1993

IEsIJL.TS

During

the study @cd. there were 83 attempted external cephalic versions at MMH. Overall, this number may appear small given that about 3,200 deliverres per year am performed at MMH. Hawver. this is a retletion of the prevailing aidtudes qading ECV. Few p+xtitihave been hained in theart ofECV. Therefore, the trend has ban to perform cesarean sections for breech presentations without consiclaaLion of attempting an ECV. Gradually, these attitudes are changing. AU procedures included in this study were performed by a single p&w&o&t In some

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REFERENCES 1. Shiono PH. McNelk D, Rho*& GG Reasonsfor the rising cesaman delivery rates. 1978-1984 Obste! Gynecol 1987;69:69&700. 2. Too many cwreans Consumer Reports. February 1991;120-6 3 Flacek PJ. T&e, SM. M&en M. 1986 <-arean sectionsrise VBAO inch upward.AmJPubltcHe&h 198837&5623 4. CohenJW, EstnerLJ Silent knife: ce58reanmevention and vasinal birth after cewe, (VBACI. South kdley (MA): Bergin & Gawey Publishers. 1983 5. Flanagan TA. Mukhahey KM, Korenbmt CC. Green JR. Lams RK Managementaltermbreech Presentation.Am J Obstet QJneccl 1987;lS6:1492502 6. Donald WL. Barton JJ. Ulwson~qhy and external cephalic version at term. Am J Obstet Gvnecol 1990: 162:1542-7. 7. Bcdmer B. Benjamin A. McLean FH, Usher RH. Has the use of cBarean sectionreduced the 11skrof dellvery in the pwterm breech presentation? Am J Obstet Gynecol 1986154:244-50. cases,the refening physician or “usemidwife participated either by assisting with the actuak versisionand/or by displacing the presentfnq DBII by pelvic examination. The success rate was 46% 198 of 83). Of these. 92.1% remained vertex at the time of labor. There were no instances of preteen labor, premaiure mptw of wmbmnes, placental abbruption. or fetal d&tress requtdng delively. There wae twocasvs (2.4% oftransientfetal h& deceleration secondary to maternai supine hypotension. In both cases.the fetal heart rates responded to changing the maternal position and infusmg more fluids. All fetuses had reactive postprocedure nonstress tests.

CONCLUSION Many ancient cultures have Practiced ECV for breech presentations. although the procedure’s popularity has varied throughout the a&. In the last decade, ECV has become safer and nwre successful when used in con-

785

junction with ultrasound, fetal monitoring. and tocoly+ks. Version can be a safe maneuver when used apPmprfately in selected women at wellequipped facilities. Studies have demonstrated success rates ransinq from 25% to 83%. The ~ucce~ z ECV is influenced bv wstational ase at the time of veai& and criteria fir patient selection. The overall success rate of 46% in this study is probably a reflection u; accepting all patienti for version except those with absolute

conttaindicati0ns. In electing to perform ECV. CNMs must adhere to American College of Nurse-Midwives guidelines for the incorpomtion of new procedures into nurse-midwtfew llrartke (52. 53). Expertise in ul&nography is al50 needed. A collaborating physician should be present.

the

a. Morales WJ. Kceden J. Obstetric mena(pment and inhaventdcul~r hemorrhage in ueo, low-birth-weight infants. Obrtet Gynecol 198&,68:35-40. 9. Westqen M. Dolfin T. Halpedn M. Miiligan J. Sherman A. Svennigsen NW, et al. Mode of delivq in the low birth fetus; d&very by vertex presentation. a study with long term follow-up Acta Obstet Gynecol Stand 1985;64:51-7. 10. -Kauppila 0. Gmnroos M. Am P Aihoniemi P. Kuappala M. Management of low bmh we,Qt and breech delivery shou,d ccesarean sec&xonbe routine? ‘,btie, Gynecol1981:57:289-94 11. Mahomed K. Breech delivery a critical evaluation of the mode of delivew and outcome of labour. Int J Gynecol Obstet 1988:27:17-20. 12. Luerkon M. Mar-1 K. Umbilical cord a&base state and Awar score in term breech neonates Acta Obstet Gvnecol Stand 1987;66:57. 13. Green JE, McLean F, Smith LP. “she, R. Has an increased cesxea” setdon mte for term breech deliver, reduced the incidence of birth asphyxia. tmums and death? Am J Obstet Gynecol 1982;142.643-8

14. Managmen, wntdon [ACOG

of the

breech

pre.

technical bulletin1 Washington. DC. American College of Obstetlicla”S and Gynecoiugals. 1986. 951. 15. Lyons ER Papsin FR. Cesarean se&x, in the management o, breech presentation Am J Obstet Gynecol 1978:130:558-61. 16 Mahomed K. Seems R. Coulson R. Breechdeliveryof infantweighing more than 2000 9-_a case controlled reho~ spectiveandynsof 751 pahents. IntJ Gyp necol Obstet 199OZlll-5 17. Hibbard BM. F’dnuple of obstetrics London. Buttersworth. 1988.557-8. 18. Gimovsky ML. Pa”, RH. Breech presentation. In: Pa”erslel” W. editor Clinical ObstetiCE.New York, John Wiley &Sons. 1987:50&7. 19. Brennor WE. Breech prpsentation Clin Obstet Gvnecol 1978:21:51131 20. Cunningham FG. MacDonald PC. Gant NE, editors. Williams obstetdcs. Nowalk. CT Appleton 8r Lange. 1989;393-403. 21 Douglas RG. Shamme WB. Operative obstetrics. 2nd ed. New York Meredith Publishing Co. 1965 22. Edwards M. Waldorf M Reclaiming birth: history of heroines of American childbirth reform. New York: The Crossing Press, 1984. 23. Ciendening L. The romance of medicine. New York: Garden Citv Publishing, 1933 24. Shorter E. A history of wo”,e”‘s bodies New York: Bask Books. 1982 25. LtiP WT Tha 5rience and an of midwifely. New York: D Appleton and Company. 1900.

26. Savona-Ventura C. The role ofexternal cephalic version in modern obstetrics. Obstet Gynecol Suw 1986;41:393400. 27. Cheni. C. Does advice lo assume the knee-chest position reduce incidence of breech presentation at delivery? a randomized clinical trial. Birth 1987:14:758.

pn~gm’ancy Am J Obstet Gyneco, 1981:141:417~24 29 BrocksV. PbilipsentT. Secher NJ A mndomved ma! of external cephalic version with tocolvsis m late preqnancy. Br J Obstet Gyne;al 1984.91.653-6 30. Sdne LE. Phelan JP. Wallace R

late

31. Dyson DC. Ferguson JE. Hensleigh P. Antepartum external cephalic “emon under focoly~~. Obstet Gynecol 1986:67:63-8 32 MonisonJC. Meek.5 GR Martin

Mvstl RE. MartIn JN.

RW. BUCO”az ET. et al External cephalic version of the breech presentation under locolys,s.Am J Obstet Gyrecol 1986.154:900-3. 33. D’Gmdy JP. V& JC. Holland RL. Bum, KA External ceohalic wasion- a .S”&l expzrience. j Pennat Med 1986:14 189-94. 34 Rob&son AW. Kopelman JN. Read JA. Du” P, Magelszen DJ. Dashow EE External cephalic “era” at term: is a tocolytic necessary? Obstet Gynecol 1987:70:896-9. 35 Fortunate S.J. Mercer W. Guzick DS. External cephalic version with tacolynx factorsassacratedwth succes* Obnet Gynecol 1988:72.59-62 36 Marchick R Antepartum external cephalic version with tocolysis:a study oi term singleton breech presentations Am J Obsfet Gynecol 1988;158:1339-46 37. Scaling ST. External cephahcver. sion without tocdysis. Am J Obsta Gynecol 198&15%142&30. 3S ~?.n?e&nAJ. VanCappeUen AW, Flu PK, Shaub MJPF, Wallenburg HCS Effect of external cephalic version in bte pregnancy on presentation at drliwy: a mndamized con&&d tial. Br J Obstet Gynaecol 1989;96:916-21. 39. Flamm BL. Fned MW. lanky NM, Glles WS. External cwhalic versio” after previo”s cesarem &‘on. Am J Obstet Gynecol1991:165:370-2 40. Mahomed K. Seeras R. Coufson R. External cephalic vetsion at term: a randomized controlled trial ushg tacolysis. Br J Obstet Gynaecol 1991:98:813.

breech presentation. Gynezd Obstet Inwt 1982:13:90-7. 47. Gjode P, RasmussenTB. Jorgensen J. Fete-maternal bleeding during attempts at external version. Br J Obstet Gynecol 1980;87.571~. 48. Bmdlev-Watson PJ. The decreasing value of external cepbakc uotiion in London obctetdc practice. Am J Obslet Gun& 1975:123:237-41. 49. Ellis R. External cephalic vel+ion under onestheda. J Obnef Gynaecol Br Commonw 1’358:75:8&70. 50 Neely MR. External cephalic MT. 5el under anesthesia:res”lb in a series of 102 cases.J Obstei Gynaecol Br Commonw 196%75:490-3. 51. Saling E. Muller-Halve W. Externa, cephalic region under tocoly& J Petinat Med 1975;3:115-22. 52. American College of Nurse-Midwives Guidelines far the incawmtion of new procedures into nurse-midwifery practice.Washington. DC: ACNM. 1991. 53. Avery MD. Advanced nurw-midwifq pmctlce @rofessional afhm exchange).J Nurse Mkk&ny 1991:37:1& 4.