External Cephalic Version
External cephalic version should be discussed with all birthing people who are carrying a breech presenting singleton fetus as early as the clinician feels is suitable. The discussion and its conclusion should be documented in the prenatal record.
- Patient Selection
External cephalic version is precluded in anyone with a contraindication to vaginal delivery or evidence of fetal compromise.
A discussion with the patient should precede the performance of the procedure and include:
- pregnancy management after a successful or unsuccessful version,
- success rate of attempted version,
- risks and benefits of the procedure, and
- when to call following the procedure.
See Appendix E for a sample consent form for this procedure. This, or a reasonable facsimile, should be reviewed with and signed by the patient prior to the procedure.
- Prior to the Procedure
- arrange a location in close proximity to the delivery unit;
- confirm that an immediate pre-procedure non-stress test is reactive;
- perform an immediate pre-procedure sonogram to confirm presentation and that there is normal amniotic fluid volume;
- perform a formal fetal anatomy survey (if one has not been performed previously), to evaluate the possibility of significant congenital anomalies;
- consider a tocolytic agent (tocolytics are relatively contraindicated in patients with heart disease); and
- consider regional anesthesia if the procedure is to be performed in the operating room.
- During the Procedure
Monitor the fetal heart rate, at minimum, every 30 seconds during the procedure.
- Following the Procedure
- observe the patient for at least one hour;
- continuously monitor the fetal heart rate and pattern via electronic fetal monitor apparatus for a minimum of one hour;
- confirm a Category I fetal heart rate tracing postprocedure, prior to discharge;
- administer RhoGAM if indicated;
- instruct the patient about follow-up plans, and advise whom to call in the event of any issues;
- give the patient a written discharge instruction sheet.
- Documentation of the Procedure
The details on the procedure should be recorded in the patient’s medical record, including:
- gestational age;
- Rh blood typ;
- results of pre-procedure testing;
- medication administered;
- details on the version attempt, whether it was successful or unsuccessful;
- post-procedure testing; and
- future plans.
Delivery Options: Breech Singleton
Cesarean delivery is the most usual method for delivery of a breech singleton living fetus without any significant congenital anomalies. Assessment of the fetal presentation should be performed immediately prior to a scheduled cesarean.
Planned vaginal delivery of a term singleton breech may be reasonable under hospital-specific protocol for both eligibility and management of labor (including use of oxytocin).1,2 If the patient opts for a vaginal breech delivery, a detailed written informed consent shall be obtained and placed in the medical record. Patients should be informed that the risk of perinatal or neonatal mortality or short-term serious morbidity may be higher than for cesarean delivery.
In this circumstance:
- the obstetrician must be skilled in vaginal breech delivery or have adequate back-up consultants available;
- the adequacy of the pelvis must be assessed; the estimated fetal weight, type of breech, and fetal attitude shall be determined;
- labor dysfunction of any type warrants delivery by cesarean; and
- breech delivery should be permitted to occur spontaneously, or by assisted breech delivery maneuvers as indicated.
- Mode of term singleton breech delivery. ACOG Committee Opinion No. 745. August 2018. American College of Obstetricians and Gynecologists.
- External cephalic version. ACOG Practice Bulletin No. 221. May 2020. American College of Obstetricians and Gynecologists.
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