The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Outline and Bibliography for External Version

EXTERNAL CEPHALIC VERSION

1. History
1. Probably practiced in antiquity
2. Referenced in 1807 OB textbook (Wigand).
1. 1843, Hubert (Correction of 'vicious' presentations)
2. 1889, Pinard (as in fetoscope)
3. "Treatise on abdominal palpation" included how-to's on external version
3. Popular until the 1940s in the USA, fell into disuse
4. Has had fervent advocates and opponents throughout.
5. Resurrected as a high-tech procedure in the mid 1970s
2. Philosophy...Paradigms and Protocols
1. What is external cephalic version?
1. Version equals turning
2. External: from the outside
3. Cephalic: so the head is down
4. Could be through any of a number of techniques
5. Other version..internal podalic..not today's topic
2. Why turn babies?
1. Risks of breech delivery (vaginal or abdominal)
2. T-Lie: birth impossible sans version or Caesarean
3. Relative risk:benefit ratio questions
1. Reduce the rate of Caesareans
2. Reduce the cost of care ($) (Gifford, et al., 1995)
4. Routine ECV reduces the rate of malpresentation at onset of labor from 3-4% to less than 2%
3. Why not turn babies?
1. Safety questions
1. Cord accidents
2. Placental accidents
3. Fetomaternal bleeds (2% - 28% range)
4. Fetal intracranial bleeds? (Becroft, 1989)
2. Most babies will turn on their own, anyhow
1. Spontaneous version rate after 32 wks = 57% (Westgren et al., 1985)
2. Spontaneous version rate after 33 weeks = 26% (Van Veelen et al. 1989)
3. Spontaneous version rate after 37 wks = 18% (Wallace et al. 1984)
3. Caesareans are a safe option
1. Slight increase in maternal morbidity and mortality
4. When should versions be done? (or not done)
1. Early and often (74-97% success) (Scaling 1988; Ranney 1973)
2. > 37 weeks G.A. (46-68% success, various studies)
3. Anytime the baby is non-cephalic (incl. SROM)
5. Where should versions be done?
1. In the practitioner's office
2. In a tertiary care setting, with an OR ready
3. Wherever the woman happens to be
6. Who should perform the version?
1. The woman's primary care provider
2. A perinatologist
3. The TBA or a other culturally appropriate person
4. The woman herself (posture, visualization)
7. How is version accomplished?
1. Literature references to hypnosis, moxibustion, auricular plasters, prayer, homeopathy, visualization, and postural changes (breech tilt, etc.)
2. Massage techniques such as la sobada
3. Tocolysis, anesthesia, ultrasound guidance
4. Abdominal/uterine relaxation necessary
5. Placental location?
6. Forward roll vs. back flip (baby, not mother!)
3. What is the role of the midwife?
1. Assess fetal lie and position each visit
2. Educate self to the controversies and options available
3. Possible strategies to encourage spontaneous version
1. Relaxation, "self-hypnosis", incorporate the mother's personal and spiritual beliefs (mind-body connection)
2. Breech tilt exercises (not well studied)
1. knee-chest q 2hrs ATC p. 37 weeks
2. supine, pelvis elevated. 10 min. tid p. 30 wks
3. Refer for version as appropriate. In some settings, the midwife may perform versions.
4. External version by any means (conventional or unconventional) is an intervention! Be honest with oneself!

BIBLIOGRAPHY

• Becroft, D. M. and Gunn, T. R. (1989) Prenatal cranial haemorrhages in 47 Pacific Islander infants: is traditional massage the cause? New Zealand Medical Journal 102(867): 207-210
• Bergstrom, S. (1992) External cephalic version and daily post-versional maternal self-assessment of fetal presentation. A prospective study. Gynecological and Obstetric Intervention 33(1): 15-18
• Bewley, S.,Robson, S.C., Smith, M., Glover, A., & Spencer, J. A.(1993) The introduction of external cephalic version at term into routine clinical practice. European Journal of Obstetrics, Gynecology, and Reproductive Health 52(2): 89-93
• Brennan, P. (1992) Using homeopathy to turn babies Midwifery Today and Childbirth Education 24: 16
• Cardini, F., Basevi, V., Valentini, A., & Martellato, A. (1991) Moxibustion and breech presentation: preliminary results. American Journal of Chinese Medicine 19(2): 105-114
• Cardini, F. & Marcolongo, A. (1993) Moxibustion for correction of breech presentation - a clinical study with retrospective control. American Journal of Chinese Medicine 21(2): 133-138
• Chenia, F., & Crowther, C. A. (1987) Does advice to assume the knee-chest position reduce the incidence of breech presentation at delivery? A randomized clinical trial. Birth 14(2): 75-78
• Clay, L. S. , Criss, K., & Jackson, U. C. (1993) External cephalic version Journal of Nurse-Midwifery 38(2supp): 72s-79s
• Cox, L. W. (1986) Breech presentation: a review of current practice. Midwifery 2(2): 71-80
• Drexler, B., David, V. A. , & Newman, L. A. (1991) External cephalic version with ruptured membranes and adequate amniotic fluid volume. American Journal of Perinatology 8(3): 220-221
• Egge, T, Schauberger, C., & Schaper, A. (1994) Dysfunctional labor after external cephalic version. Obstetrics and Gynecology 83(5 Pt 1): 771-773
• Gaskin, I. M. (1978)Spiritual Midwifery pp. 337-338 Summertown, TN: Book Publishing
• Gdje, P., Rasmussen, T. B., & Jrgensen, J. (1980) Fetomaternal bleeding during attempts at external version. British Journal of Obstetrics and Gynecology 87(7): 571-573
• Gifford, D. S., Keeler, E., & Kahn, K. L. (1995)Reductions in cost and caesarean rate by routine use of external cephalic version: A decision analysis. Obstetrics and Gynecology 85(6): 930-936
• Goh, J. T., Johnson, C. M., & Gregora, M.G. (1993) External cephalic version at term. Australian and New Zealand Journal of Obstetrics and Gynaecology 33(4): 364-366
• Hanss, J.W. Jr. (1990) The efficacy of external cephalic version and its impact on the breech experience. American Journal of Obstetrics and Gynecology 162(6): 1459-1464
• Hellstrom, A. C., Nilsson, B., St~ange, L., & Nylund, L. (1990) When does external cephalic version succeed? Acta Obstetricia et Gynecologica Scandinavica 69(4): 281-285
• Hofmeyr, G. J. (1987) Cephalic version and ethnicity. Commentary. Birth 14(2): 81
• Hofmeyr, G. J. (1983) Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial. British Journal of Obstetrics and Gynaecology 90(5): 392-399
• Hofmeyr, G. J., Sadan, O., Galal, K. C. , & Simko, G. (1986) External cephalic version and spontaneous version rates: ethnic and other determinants. British Journal of Obstetrics and Gynaecology 93(1): 13-16
• Jordan, B. (1982) External cephalic version Women and Health 7(3-4): 83-101
• Kasule, J., Chimbira, T.H., & Brown, I. M. (1985) Controlled trial of external cephalic version. British Journal of Obstetrics and Gynaecology 92(1): 14-18
• Lumley, J. (1987) How to find out if assuming the knee-chest position is superior to external cephalic version in turning the breech. Commentary. Birth 14(2): 79-80
• Mehl, L. E. (1994) Hypnosis and conversion of the breech to the vertex presentation. Archives of Family Medicine 3(10): 881-887
• O'Grady, J. P., Veille, J. C., Holland, R. L. & Burry, K. A. (1986) External cephalic version: a clinical experience. Journal of Perinatal Medicine 14(3): 189-196
• Qin, G. F. & Tang, H. J. (1989) 413 cases of abnormal fetal position corrected by auricular plaster therapy. Journal of Traditional Chinese Medicine 9(4): 235-237
• Ranney, B. (1973) The gentle art of external cephalic version American Journal of Obstetrics and Gynecology 116: 239-251
• Robertson, A.W., Kopelman, J.N., Read, J. A., Duff, P., Magelssen, D. J., & Dashow, E. E. (1987) External cephalic version at term: is a tocolytic necessary? Obstetrics and Gynecology 70(6): 696-699
• Scaling, S.T. (1988) External cephalic version without tocolysis. American Journal of Obstetrics and Gynecology 158(6 pt 1): 1424-1430
• Shalev, E., Battino, S., Giladi, Y., & Edelstein, S. (1993) External cephalic version at term-using tocolysis. Acta Obstetricia et Gynecologica Scandinavica 72(6): 455-457
• Stevenson, C. S. (1951) Certain concepts in the handling of breech and transverse presentations in late pregnancy American Journal of Obstetrics and Gynecology 62(3): 488-504
• Van Veelen, A.J., Van Cappellen, A. W., Flu, P. K., Straub, M.J., & Wallenburg, H. C. (1989) Effect of external cephalic version in late pregnancy on presentation at delivery: a randomized controlled trial. British Journal of Obstetrics and Gynaecology 96(8): 916-921
• Wallace, R.L., VanDorsten, J. P., Eglinton, G.S., Meuller, E., McCart, D., & Schifrin, B.S. (1984) External cephalic version with tocolysis. Observations and continuing experience at LAC/USC Medical Center. Journal of Reproductive Medicine 29(10): 745-748
• Westgren, M., Edvall, H., Nordstrom, L., Svalenius, E., & Ranstam, J. (1985) Spontaneous cephalic version of breech presentation in the last trimester. British Journal of Obstetrics and Gynaecology 92(1): 19-22
• Zhang, J., Bowes, W.A. Jr., & Fortney, J.A. (1993) Efficacy of external cephalic version: a review, Obstetrics and Gynecology 82(2): 306-312