External Cephalic Version
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Direct answer
External cephalic version is the manual turning of a breech or transverse fetus to a cephalic presentation through the maternal abdominal wall, usually from 36 weeks onward. It is performed with ultrasound, fetal monitoring and tocolysis, and it reduces the need for breech delivery. The main risks are abruption, cord entanglement and fetal bradycardia, so it is confined to units able to perform an emergency caesarean section.
What you must remember
- Timing: usually from 36 weeks, because earlier attempts may be unnecessary when the fetus turns spontaneously.
- Tocolysis: given to relax the uterus before the manoeuvre, commonly with a beta-agonist such as subcutaneous terbutaline, as local protocol specifies.
- Anti-D: given to Rh-negative women after the procedure, because manipulation can cause fetal-maternal haemorrhage.
- Contraindications: placenta praevia, antepartum haemorrhage, ruptured membranes, an abnormal trace, multiple pregnancy, severe pre-eclampsia and uterine anomalies, with previous caesarean a relative concern.
- Predictors of success: multiparity, adequate liquor, a mobile breech and a breech that is not deeply engaged are associated with a better chance of turning.
- Complications: placental abruption, cord entanglement, fetal bradycardia and the need for emergency caesarean section.
- Analgesia: regional analgesia is sometimes used in some centres to ease the manoeuvre and reduce maternal discomfort.
A stepwise approach to version at 36 weeks and beyond
The procedure runs in a fixed sequence, and most of the marks in an examination lie in the safety checks before the first pressure is applied. Skipping any step is the commonest error students make when describing the technique.
- Confirm the presentation. Ultrasound establishes the breech, its engagement, the placental site, the liquor volume and the cord position before the attempt.
- Check for contraindications. Placenta praevia, antepartum haemorrhage, ruptured membranes, an abnormal trace or a uterine anomaly rules the procedure out.
- Record a baseline trace. A reassuring cardiotocograph is a precondition, and the fetal heart is monitored throughout and afterwards.
- Give tocolysis and analgesia. Uterine relaxation is achieved before the manoeuvre, and regional analgesia may be added in some centres.
- Perform the version. The obstetrician guides the breech upward and the head downward with both hands, using gentle, controlled movements rather than force.
- Reassess and stop if needed. The fetal heart and uterine tone are checked after each attempt, and the procedure is stopped if the trace deteriorates or the fetus does not turn.
- Confirm and protect. Ultrasound confirms the new lie, anti-D is given to Rh-negative women, and the woman is observed for abruption or the onset of labour.
Where the exam tries to catch you
Examiners want the candidate to know the timing, the safety gate and the complications, rather than the mechanics alone.
- Trap: attempting version at 34 weeks to avoid a caesarean section Correct: version is usually offered from 36 weeks, because the fetus may still turn spontaneously before then.
- Trap: going ahead with version after the membranes have ruptured Correct: ruptured membranes are a contraindication, since manipulation of a fetus with a ruptured sac increases the risk to cord and placenta.
- Trap: assuming a successful turn guarantees vaginal delivery Correct: the fetus may turn back, and labour is managed on the usual obstetric grounds with monitoring.
Frequently asked questions
At what gestation is external cephalic version usually performed?
External cephalic version is usually performed from 36 weeks onward in a breech or transverse fetus. Earlier attempts are avoided because the fetus may still turn spontaneously. The timing is chosen so that delivery is safe if an emergency caesarean section becomes necessary.
Why is tocolysis given during external cephalic version?
Tocolysis relaxes the uterine muscle, which makes external cephalic version easier and less painful. It reduces the chance that a uterine contraction will oppose the manoeuvre. It is given after the baseline trace and before the version is attempted.
Which factors predict success of external cephalic version?
Multiparity, adequate amniotic fluid and a breech that is mobile and not deeply engaged are the factors most often linked with success. A nulliparous woman with low liquor has a lower chance of a successful turn. Success is never guaranteed, so counselling forms part of the process.
Why is anti-D given after external cephalic version in a Rh-negative woman?
Anti-D immunoglobulin is given to a Rh-negative woman after external cephalic version because the manipulation can cause fetal-maternal haemorrhage. It prevents Rhesus alloimmunisation in a later pregnancy. Offering it after the procedure is the standard recommendation.
What complications should be watched for after external cephalic version?
Placental abruption, cord entanglement, fetal bradycardia and emergency caesarean section are the complications to watch for after external cephalic version. The fetal heart rate is monitored after the procedure. Any bleeding, pain or an abnormal trace needs immediate obstetric review.