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In carefully selected patients, an external cephalic version (ECV) may be an alternative to cesarean delivery for fetal malpresentation at term. ECV is a noninvasive procedure that manipulates fetal position through the abdominal wall of the gravida. With the global cesarean section rate reaching 34%, fetal malpresentation ranks as the third most common indication for cesarean delivery, accounting for nearly 17% of cases. Studies suggest a 60% mean success rate for ECV, emphasizing its cost-effectiveness and potential to decrease cesarean delivery rates significantly. While particularly crucial in resource-limited settings where access to medical services during labor is constrained or cesarean delivery is unavailable or unsafe, ECV presents a viable option to improve rates of vaginal delivery in singleton gestations in all settings. This activity reviews the indications, contraindications, necessary equipment, preferred personnel, procedural technique, risks, and benefits of ECV and highlights the role of the interprofessional team in caring for patients who may benefit from this procedure. Objectives: Select suitable candidates for an external cephalic version based on their clinical history and presentation. Screen patients effectively regarding the risks and benefits of an external cephalic version. Apply best practices when performing an external cephalic version. Develop and implement effective interpersonal team strategies to improve outcomes for patients undergoing external cephalic version. Access free multiple choice questions on this topic.

The global cesarean section rate has increased from approximately 23% to 34% in the past decade. Fetal malpresentation is now the third-most common indication for cesarean delivery, encompassing nearly 17% of cases. Almost one-fourth of all fetuses are in a breech presentation at 28 weeks gestational age; this number decreases to between 3% and 4% at term. In current clinical practice, most pregnancies with a breech fetus are delivered by cesarean section. Individual and institutional efforts are increasing to reduce the overall cesarean delivery rate, particularly for nulliparous patients with term, singleton, and vertex gestations.[1][2] An alternative to cesarean delivery for fetal malpresentation at term is an external cephalic version (ECV), a procedure to correct fetal malpresentation. ECV may be indicated when the fetus is breech or in an oblique or transverse lie after 37 0/7 weeks gestation.[3] The overall success rate for ECV approaches 60%, is cost-effective, and can lead to decreased cesarean delivery rates.[4] ECV is of particular importance in resource-poor environments, where patients may have limited access to medical services during labor and delivery or where cesarean delivery is unavailable or unsafe.

Complications of ECV are rare and occur in only 1% to 2% of attempts. The most common complication associated with ECV is fetal heart rate abnormalities, particularly bradycardia, occurring at a rate of 4.7% to 20%; these abnormalities usually are transient and improve upon completion or abandonment of the procedure. More severe complications of ECV occur at a rate of less than 1% and include premature rupture of membranes, cord prolapse, vaginal bleeding, placental abruption, fetomaternal hemorrhage, emergent cesarean delivery, and stillbirth. Many of these rare complications require emergent cesarean delivery; some clinicians choose to perform ECV in the operating room, although this is neither necessary nor universal.[22] ECV is associated with changes in Doppler indices that may reflect decreased placental perfusion. It appears these changes are short-lived and have no detrimental effects on the outcomes of uncomplicated pregnancies. A recent prospective study investigating the effects of ECV on fetal circulation in the antepartum period noted no differences in the Doppler evaluation of the middle cerebral artery or ductus venosus; all studied patients remained stable and were discharged home after the procedure.[18]

ECV is not a benign procedure and is most successful when performed under the care of an interprofessional team. Labor and delivery nurses play an integral role in the success of ECV as they frequently assist in the procedure, prepare the patient for ECV, and implement external fetal monitoring before, during, and after the procedure. Additionally, the support of emergent operating room staff promotes the safe delivery of a healthy fetus should complications arise during the ECV procedure. Clear and concise anticipatory interprofessional communication improves safety and outcomes for the gravida and the fetus should complications occur.