Snapshot

SYNOPSIS:

In this protocol (Chapter-16.pdfChapter-16.pdf), Dr. Hankins reviews the pathophysiology, diagnosis, and management of external cephalic version. Included are step-by-step guidelines for performing the procedure with illustrations of the maneuvers required for successful cephalic version with 2 operators or 1.293 334Figure1.jpg http://www.wiley.com/WileyCDA/WileyTitle/productCd-1405196505.html As the author notes, careful assessment of fetal presentation in the third trimester is important. Otherwise, patients may be deprived of the option of external cephalic version to decrease the risk of cesarean delivery. Before the procedure, fetal well-being and the presence of any contraindications should be ascertained. Informed consent and counseling with regard to the likelihood of success of the procedure should be performed. Post-version assessment for fetal presentation on subsequent encounters is vital in these patients.

KEY MESSAGES:

Breech presentation at term complicates 3% to 4% of pregnancies. Contributing factors include early gestational age, uterine and/or abdominal laxity associated with multiparity, multiple gestation, and polyhydramnios, as well as constricted fetal movements due to oligohydramnios, uterine leiomyomas, placenta previa, and fetal anomalies. Breech presentation is associated with an increased risk of cerebral palsy regardless of method of delivery. The American College of Obstetricians and Gynecologists recommends that obstetricians continue their efforts to reduce breech presentations in term singleton gestations by performing external cephalic version whenever possible. Success rates with the procedure average 60% to 70%, resulting in a reduction in the cesarean rate to 30% to 40% in women with a breech presentation at term. To determine fetal presentation, Leopold maneuvers should be done at each clinic visit during the third trimester. If you suspect breech presentation, perform an ultrasonographic (U/S) examination for confirmation. Schedule external cephalic version on labor and delivery at ≥37 weeks' gestation and ensure that anesthesia and immediate operative facilities are available, should an emergency cesarean delivery be necessary. Perform real-time U/S before and after version to confirm non-vertex presentation and version outcome, respectively. A non-stress test should be done and IV access secured before the procedure. A uterine relaxant can be administered before version. The least complex and cheapest tocolytic for this purpose is subcutaneous terbutaline. Anesthesia is not recommended. Version can be done with 1 or 2 operators. Dr. Hankins prefers the single-operator method. Always administer Rh immune globulin to Rh-negative unsensitized women after external cephalic version. If the procedure fails, counsel the woman on the risks and benefits of all treatment options, including cesarean delivery. MATERIAL USED WITH THE PERMISSION OF WILEY-BLACKWELL

Gary D. V. Hankins,

MD, Professor and Chair, Department of Obstetrics and Gynecology, and Jennie Sealy Distinguished Professor in Obstetrics and Gynecology, University of Texas Medical Branch at Galveston