Wednesday, November 29, 2017

Can a breech baby be turned during labor?

When a woman has a singleton breech presentation at term, she is usually presented with one or more of the following three options:
  • Planned cesarean section (universally offered)
  • External cephalic version, usually at or after 37 weeks (sometimes offered)
  • Planned vaginal breech birth (rarely offered)
However, a fourth option exists: an external cephalic version during labor. While this is usually done on a breech 2nd twin after the 1st twin is born, it also works for singleton babies.

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Intrapartum external cephalic version (IP ECV) is strategy for avoiding both a cesarean and the risks of vaginal birth in a singleton breech presentation, especially for unfavorable presentations such as footling breech.

Kaneti et al (2000) analyzed a prospective series of in-labor ECVs for unengaged term footling breeches with intact membranes. Of 21 eligible women, 8 chose cesarean section and 13 chose IP ECV. 12/13 versions were successful and 10/12 women gave birth vaginally. Of the two failed vaginal births, one was for cord presentation and the other for arrest of labor. The babies were turned between 2-8 cm dilatation.

All women were multips; the physicians would have been willing to attempt IP ECV in primips as well, but never had the opportunity. The ECVs were done in the OR with Ritodrine and regional anesthesia when possible. The woman with an unsuccessful ECV went straight to cesarean while the twelve women with successfully turned babies received amniotomy and continued their labors in the labor ward. The one failed ECV was with a woman at 8 cm whose membranes ruptured at the beginning of the version. There was no maternal or neonatal morbidity, and all Apgars were 9 or 10.

Ferguson and Dyson (1985) report on a similar series of 15 women in labor with term breech presentations and intact membranes. Earlier in the study period, they had attempted IP ECV on women with ruptured membranes, but with no success. The authors do not specify type of breech presentation, other than that the women were not considered good candidates for vaginal breech birth. 6 were primips and 9 were multips.

They followed a similar protocol to Kaneti’s (versions were done in the OR under tocolysis between 1-8 cm dilation; successful versions were returned to the labor ward). 3/15 had epidural anesthesia during the version. 11/15 versions were successful (2/6 for primips, 9/9 for multips) and 10/11 women gave birth vaginally. The one failed vaginal birth was due to arrest of labor in a primip. Maternal and neonatal outcomes were good.

Leung, Pun, and Wong (1999) mention performing IP ECV on 5 out of 28 undiagnosed breeches in early labor, of which 2 turned successfully and both ended in vaginal births.

Belfort (1993) includes a case report of a multiparous woman presenting in labor with an unengaged complete breech with both feet palpable through the intact membranes. When she was 5 cm and 70% effaced, an IP ECV was performed in the delivery room with IV nitroglycerin. The procedure was successful. The woman received amniotomy and oxytocin to restart contractions and had an uneventful vaginal birth 8 hours later.


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