External cephalic version: An old art with new relevance

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Dear Editor, External cephalic version (ECV) is a manoeuvre by which an unfavourable presentation like breech or transverse lie is converted into a favourable one i.e. cephalic vetex presentation. This is a simple procedure usually done after 36th week of gestation for breech presentations by applying gentle pressure externally on the anterior abdominal wall of the mother so that the fetus is given either the ‘forward roll’ or ‘backward flip’ taking the shortest route to bring about the change in presentation. There is certainly an increased risk of neonatal morbidity [1] and even mortality, at times, associated with vaginal breech delivery. Although the concept of ECV appears attractive, it can lead to placental abruption, cord entanglement, foetal distress and even rupture uterus if the force used is excessive. This is an old art and has received renewed interest and relevance today, on two counts. Firstly, currently most breech presentations are subjected to caesarean sections due to the fear of litigation on account of adverse perinatal outcome along with the fast vanishing art of conducting an assisted vaginal breech delivery. Secondly, with the widespread availability of ultrasound and electronic foetal monitoring devices a better patient selection, higher success rate and an early detection of any adverse foetal effects of the procedure per se, have been made possible. Besides this, use of tocolytics like Inj Terbutaline 250 mg subcutaneously prior to the procedure may be of considerable help in primigravidas and in those with an irritable uterus. ECV has been conclusively shown to be associated with a significant reduction in the number of breech births and caesarean sections for breech presentation in randomized controlled trials [2,3]. The obstetrician should keep in mind that whereas an adequate amount of liquor with a floating breech are associated with higher chances of success, other factors such as obesity, an engaged breech which required disimpaction or lifting up from the pelvis, foetal back in posterior position or a frank breech with the splinting effect of foetal legs on the skull are all associated with a higher rate of failure of version. A few contraindications for version are a malformed baby, a previously scarred uterus, a contracted pelvis or any condition where vaginal delivery is contraindicated. The average success rate of ECV varies from 40-60% according to different series. A few studies have shown that the rate of LSCS after successful versions is higher compared to primary cephalic presentation [4], but other studies do not corroborate the same. Inspite of this, version does help in reducing the LSCS rate significantly because most obstetricians prefer to do an LSCS for breech presentation so that caesarean rate for breech, approaches close to 100% in many institutions. Very few venture to give a trial of vaginal delivery for breech presentation, in modern obstetric practice. To conclude, ECV should be put to greater use in cases of breech presentation, where contraindications do not exist, to reduce the morbidity associated with operative delivery.