External Cephalic Version (ECV)

What is External Cephalic Version (ECV)?

External Cephalic Version (ECV), also known simply as “version,” is a non-surgical procedure for turning the term breech baby from a transverse or breech presentation (breech position) to a head-first position before the mother goes into labor. It is a procedure in which the fetus is rotated from a non-cephalic to a cephalic presentation by manipulation through the mother’s abdomen.

In a breach fetal presentation, the baby is poised to come out feet first or buttocks first. In transverse position, the baby is lying sideways across the mother’s pelvis. Neither of these positions is well-suited for a vaginal birth.

ECV can improve your chance of having a vaginal delivery. If the fetus is breech and your pregnancy is greater than 36 weeks your health care professional may suggest ECV. Before labor begins, your OB-GYN will try to position the baby head-first, and if the procedure is unsuccessful, a cesarean delivery (cesarean section) might be recommended to preserve the health of you and your baby.

Before the resurgence of the use of an external cephalic version, the only mode of delivery choices for breech delivery was a cesarean section or a trial of labor.

How common are adverse events?

American College of Obstetricians and Gynecologists indicate that because the risk of an adverse event occurring as a result of the external cephalic version is small and the cesarean delivery rate is significantly lower among women who have undergone successful external cephalic version, all women who are near term with breech presentations should be offered an external cephalic version attempt if there are no contraindications.

Having a cesarean delivery also can lead to serious problems in future pregnancies, such as rupture of the uterus and complications with the placenta.

External Cephalic Version Procedure

Usually, an external cephalic version is conducted for around 37 weeks gestation. Before 36 weeks, there’s a good chance that the baby will turn around on its own. Too long after that, the baby may start to descend into the pelvis, which would make a version much more difficult.

Version is typically performed in a hospital or surgical center. This is because there is a very small chance that the procedure will trigger early labor or put the fetus into distress. In the worst-case scenario, the doctor would perform an emergency cesarean section.

To avoid the worst-case scenario, your doctor will conduct fetal monitoring of the baby’s position and health with a fetal ultrasound and electronic fetal heart monitoring. If the baby becomes distressed, the doctor may stop the version procedure.

Your health care provider will conduct ECV by placing his or her hands on your abdomen. Firm pressure is applied to the abdomen so that the fetus rolls into a head-down position. The breach is lifted out of the pelvis with one hand, and the other hand is used to apply pressure to the back of the fetal head to attempt a forward roll. Two people may be needed to perform ECV. Ultrasound also may be used to help guide the turning of the baby.

The procedure is considered uncomfortable for the mother, especially if it triggers uterine contractions. Your doctor may suggest an epidural anesthetic to help you relax. ECVs succeed about half the time. If your doctor can’t get your baby to flip after the first attempt, she may try again after a week or so.

Is Version Right for My Pregnancy?

The success rate for version procedures is just under 60%. Some conditions help a version to be successful, and some conditions make a version impossible. Your doctor will evaluate your condition and make an appropriate recommendation.

A version can only be attempted when:

• Between 36-42 weeks of pregnancy
• There is only one baby
• The baby’s bottom, foot, or leg has not descended into the pelvis
• There is plenty of amniotic fluid to facilitate the baby’s movement

Usually, a version will work best if the mother has already carried at least one pregnancy to term. This means that her uterine tissue is strong and elastic.

A version usually won’t be attempted if:

• The water has broken
• The mother has heart or other health problems
• Presence of vaginal bleeding
• The mother’s uterus is abnormally shaped
• There are problems with the placenta (placenta previa or placenta abruptio)
• The fetus is in poor health or is in a dangerous position in the womb

External Cephalic Version Risks

Because your fetus will be under constant monitoring, the risks with this procedure are low. If anything starts to go wrong, there is immediate feedback from the ultrasound and fetal heart rate monitor to alert the doctor. The procedure can be stopped at any time. In a breech presentation, the body comes out first, leaving the baby’s head to be delivered last. The baby’s body may not stretch the cervix enough to allow room for the baby’s head to come out easily.

There is a risk that the baby’s head or shoulders may become wedged against the bones of the mother’s pelvis. Another problem that can happen during a vaginal breech birth is a prolapsed umbilical cord. It can slip into the vagina before the baby is delivered. If there is pressure put on the cord or it becomes pinched, it can decrease the flow of blood and oxygen through the cord to the baby.

However, as with any medical procedure, there are some risks for complications.

• The procedure may squeeze or twist the umbilical cord, which would decrease blood flow and oxygen to the fetus.
• The procedure may trigger preterm labor, beginning with your water breaking early (premature rupture of membranes).
• The placenta may become separated from the uterine wall (placental abruption) or damage may be done to the uterus or umbilical cord.
• There may be internal bleeding, causing the baby and pregnant woman’s blood to mix. If the two are Rh incompatible, the pregnant woman may need to be treated for Rh sensitization.

After an ECV, sometimes babies flip to the headfirst position, then flip back to breech. And sometimes breech babies flip on their own before birth, though the bigger they get, the less room there is to move.

These complications are very rare. If any of these should arise, and you do require an emergency C-section, you are in the best possible hands with your doctor and the surgical staff on hand at the hospital. A scheduled cesarean section is used to deliver most breech births if a version doesn’t work.

If every pregnant woman with a breech baby at term attempted a version then about half would be successful ECV. Of those with successful external cephalic versions, about three quarters would eventually give birth vaginally. This means that more than a third of people with term breech pregnancies could avoid a cesarean section (C-section) if everyone attempted a version.

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