A breech is one of the main reasons why women have a cesarean. Yet it is also one of the most preventable.
With a prior cesarean and a low-transverse uterine scar (bikini incision), an expectant mother with a breech who wants to have a VBAC can ask her care provider about the option of an external version.
The current ACOG guidelines for VBAC state that an external cephalic version (ECV) is an option for low risk women with a low transverse uterine scar. If the ECV is successful women can labor for a VBAC rather than schedule a repeat cesarean.
Towards the end of pregnancy, most babies will align themselves in the uterus into a head down position, the safest position for birth. However, in approximately 3-4% percent of pregnancies, the baby will present as a breech, with its feet or buttocks positioned close to the birth canal.
External cephalic version (ECV), also known as a breech version, is a procedure in which external manipulation is used to change a fetus from a breech presentation to a vertex (head down) presentation.
External version is a relatively safe and successful procedure for most women when performed by experienced caregivers. About 65% of breech versions are successful. Complications from ECV are rare.
ECVs are more successful with an experienced care provider. Other factors such as the position of the baby and the level of amniotic fluid also play a role.
According to U.S. birth data, in 2006 about 73 percent of ECVs were reported as successful. Women who had a successful ECV were more likely to have a vaginal delivery (77.7 percent) than women with a failed ECV (10.4 percent).
Preparing For ECV
Before doing an ECV most care providers will want to do an ultrasound exam to see the position of the baby, locate the umbilical cord and placenta, and determine the amount of amniotic fluid. Ultrasound is often used during the procedure. An electronic fetal heart monitor is used to measure the baby’s heart rate before and during the procedure. To make sure the baby’s heart rate has stabilized monitoring usually continues for about 30 minutes after. It is normal for the baby’s heart rate to increase while it is being moved. If the baby does not tolerate the procedure it will be stopped.
Care providers sometimes offer the mother a drug such as terbutaline to relax the uterine muscles, reduce contractions, and facilitate the breech version. Tocolytic drugs do have side effects for both mother and baby and women should find out what they are.
Mothers may be offered the option of having epidural anesthesia and should ask about the benefits and risks of an epidural for this procedure. If a woman has Rh-negative blood she will be offered Rh immune globulin to prevent incompatibility should her blood and her baby’s come into contact during the version. This happens in about 4.1% of external versions.
How A Breech Is Turned
To facilitate the movements of his hands over the mother’s abdomen, her care provider will rub a lubricant on her belly. With both hands on her abdomen, he will place one hand on her belly where her baby’s head would be and the other on the baby’s bottom. He will lift the baby’s bottom with one hand and gently push the head down with the other, backward or forward.
If the procedure is successful the expectant mother will likely go home. It is possible to have this procedure done again if the baby could not be moved into a head-down position. Some women find this procedure uncomfortable and sometimes painful. Although complications are rare, after the procedure, her care provider should give her information about possible complications that may develop such as vaginal bleeding, going into labor, or the early rupturing of the bag of waters.
Studies show that with a breech version mothers are more likely to have a vaginal birth.
There are specific techniques through fetal positioning to help a baby in utero turn from a breech to a cephalic position (head down). Sometimes this method works and mothers can avoid an ECV.
Few hospital-based care providers today are skilled at attending a breech vaginal birth and many worry about malpractice liability. There is a growing interest, however in supporting women who choose to have a breech vaginal birth given that the evidence supports breech vaginal birth in specific circumstances.
American Academy of Family Physicians. What Can I Do If My Baby is Breech?
Dr. Tucker performing an ECV. Youtube Video.
Cochrane Reviews. Cephalic version by postural management for breech presentation
Henci Goer. When Research is Flawed, Vaginal Breech Birth.
Royal College of Obstetricians and Gynaecologists, U.K. Turning A Breech Baby In The Womb
Society of Obstetricians and Gynecologists of Canada. No More Automatic C-section For Breech.