ECV: A tool to prevent the first cesarean
When I was a resident at New York University/Bellevue Hospital, one of my least favorite procedures was external cephalic version (ECV). Converting a breech fetus to cephalic was just another lost vaginal breech opportunity—an experience that became more and more scarce when I trained in the 1990s. Enthusiasm for delivering breech fetuses vaginally has waned over the years. For most of us, an unresolved breech at the time of delivery now means taking the path of least resistance—performing a quick and typically uneventful primary cesarean delivery.
Term fetal malpresentation occurs frequently—in about 3% of pregnancies—and is a common indication for cesarean. As the Chief of the Obstetrical Service at Ohio State University trying to find methods to reduce our primary cesarean rates, I now find ECV to be one of my best allies and an important tool for preventing that first cesarean. ACOG’s Practice Bulletin on ECV has been updated after 17 years and is a concise summary of the latest information that every obstetrical provider needs to be familiar with and is designed to help make ECV safe and successful.1
ECV is a long-standing procedure that increases the likelihood that a baby is in cephalic presentation at the time of birth. Data from the Cochrane Database clearly support this practice as it reduces the risk of cesarean birth [RR 0.57; 95% CI, 0.40- 0.82) when compared to no ECV attempt.2 ACOG strongly supports universal screening for presentation at 36 weeks’ gestation for those eligible for vaginal birth, and routine counseling of women on this option beginning at 37 weeks’ gestation. Women with malpresentation also should be counseled starting at 37 weeks.
Given that many women are not receiving this opportunity, ACOG has proposed a metric: Percentage of women identified with fetal malpresentation without contraindications to vaginal birth who are also counseled about their ECV options.
Is ECV safe?
One Cochrane study demonstrated excellent outcomes in women undergoing ECV with no differences in Apgars, umbilical cord pH, or neonatal deaths compared to women who do not have ECV.2 Although there have been case reports of adverse events, it has always been challenging to attribute these rare events to ECV itself. ACOG continues to support performing ECV at sites where immediate evaluation and emergency cesarean are available.
Immediate induction after successful ECV is not supported. As a clinician, I know it is tempting, but please resist the temptation, particularly before 39 weeks.