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MoonDragon's Pregnancy Information
PERFORMING EXTERNAL CEPHALIC VERSION (ECV)
Turning A Breech Baby


This is for information only.
Do not attempt to perform this procedure without proper training
by a qualified health care provider.




If a situation arises which warrant an attempt at external version of the breech baby, then certain criteria must be met in order to assure the safety of such an attempt.

breech side view


PRE-PROCEDURE EVALUATION

A breech presentation occurs in about 3% of pregnancies. External Cephalic Version (ECV) is a method of converting a breech baby or transverse presentation into a cephalic (head down) presentation. With abdominal manipulation your birth attendant, midwife or health care provider may attempt to turn your baby. In 2009, according to the American College of Obstetricians and Gynecologists, ECV had an average success rate of 58%. If this is your first baby, the rate may drop to 45%. The success of this procedure is largely dependent upon the experience and confidence of the midwife or practitioner doing the ECV. Some experienced practitioners can have an 80% success rate.

If it is possible, a sonogram should be performed to ascertain the position, lie and attitude of the baby. It is also important to be certain of the placenta site. If a sonogram is not available, an attendant with adept skills in palpation and auscultation of the placental sounds may be comfortable proceeding without an ultrasound examination.

types of breech presentations


The ideal time for performing an external version is between 36 to 37 weeks, after maternal positional and other types of attempts to turn the baby have not been successful. This is close enough to term that if the version stimulates labor, it is safe and the baby usually will not be deeply engaged in the pelvis.

An explanation of this procedure must be given to the mother and her full cooperation elicited. The mother should not be sedated in any way since her assistance is required for her to relax her abdominal muscles and to breathe deeply during the attempted version.

MEDICAL PROCEDURE INTERVENTION CONCERNS

Keep in mind, this is a medical procedure which implies other medical interventions may be performed such as:
  • Fetal ultrasound to confirm the baby's position, assessment of the amount of amniotic flude and the position of your placenta. Fetal ultrasound may be used before, during or after the manipulation.

  • Non-Stress Test may be performed to assess the heart rate of the baby. It must show that your baby is healthy and fit to undergo ECV. You may hae to do a non-stress test once a week till childbirth.

  • Electronic fetal heart monitoring may be used before and after the cephalic version.

  • You may be connected to an IV and a blood sample may be taken to search for fetal cells.

  • If this is your first baby, you may be given a drug (magnesium sulfate, nitroglycerine, or other tocolytic medication) to help the uterus to remain relaxed.
As with any medical intervention there can be complications. Besides the discomfort of pressure on your belly, the risks are very low. Still, potential risks of ECV include:
  • Entanglement, squeezing or damage to the umbilical cord which can reduce the blood supply and oxygen to your baby.
  • Premature rupture of the membranes of the amniotic sac that will trigger a preterm labor.
  • A premature separation of the placenta from the uterus that known as abruptio placenta.
  • Your (stubborn) baby might turn back to the breech position after the external cephalic version is done.
Be clear about one thing before attempting the procedure. Babies who have the frank, complete or the footling breech position can be delivered naturally. Cesarean-section delivery is not necessarily the best option for a breech baby. The Society of Obstetricians and Gynecologists of Canada (SOGC) has made an impressive about-face concerning its earlier prohibition of vaginal breech birth. In 2009, the SOGC announced its new recommendations:
  • Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the SOGC.
  • The guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter birth canal with the buttocks or feet first.
  • Our primary purpose is to offer choices to women.
  • It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births.
  • Vaginal birth is the preferred method of having a baby because a C-section in itself has complications.
  • The safest way to deliver has always been the natural way.



DELIVERY GUIDELINES
C-SECTION NOT BEST OPTION FOR BREECH BIRTH
By Carla Wintersgill
The Globe and Mail
Published Wednesday, Jun. 17 2009, 7:06 PM EDT
Last updated Thursday, Aug. 23 2012, 11:23 AM EDT


Physicians should no longer automatically opt to perform a cesarean section in the case of a breech birth, according to new guidelines by the Society of Obstetricians and Gynecologists of Canada. Released yesterday, the guidelines are a response to new evidence that shows many women are safely able to vaginally deliver babies who enter the birth canal with the buttocks or feet first. Normally, the infant descends head first. "Our primary purpose is to offer choice to women," said André Lalonde, executive vice-president of the SOGC. "More women are feeling disappointed when there is no one who is trained to assist in breech vaginal delivery," he adds.

Since 2000, C-sections have been the preferred method of delivery in breech births. Studies suggested that breached births were associated with an increased rate of complication when performed vaginally. As a result, many medical schools have stopped training their physicians in breech vaginal delivery. The problem now, according to Dr. Lalonde, is that there is a serious shortage of doctors to teach and perform these deliveries.

With the release of the new guidelines, the SOGC will launch a nationwide training program to ensure that doctors will be adequately prepared to offer vaginal breech births. The new approach was prompted by a reassessment of earlier trials. It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births.

News of the change is a boon for the Ottawa-based Coalition for Breech Birth. "We're really, really pleased," said Robin Guy, co-founder of the coalition. Ms. Guy started the group after the birth of her second child in the fall of 2006. Although she had given birth to her first child at home with a midwife, Ms. Guy delivered her daughter in the hospital because of the baby's breech position. "I was cornered into an unneeded and unwanted C-section because the obstetrician that I had didn't have the experience to catch her," said Ms. Guy. The aim of the coalition is to ensure that women know what their options are when it comes to breech birth. Ms. Guy believes that many women don't realize that vaginal breech births are even possible. "Educating women is our primary goal because it takes more than just a guideline change," she said.

The SOGC stresses that because of complications that may arise, many breech deliveries will still require a cesarean section. Breech presentations occur in 3 to 4 per cent of pregnant women who reach term. That translates to approximately 11,000 to 14,500 breech deliveries a year in Canada. The new decision to offer vaginal breech birth aligns with the SOGC promotion of normal childbirth - spontaneous labor, followed by a delivery that is not assisted by forceps, vacuum or cesarean section. In December of 2008, the society release a policy statement that included its recommendation for a development of national practice guidelines on normal childbirth.

"The safest way to deliver has always been the natural way," said Dr. Lalonde. "Vaginal birth is the preferred method of having a baby because a C-section in itself has complications."

Cesarean sections, in which incisions are made through a mother's abdomen and uterus to deliver the baby, can lead to increased chance of bleeding and infections and can cause further complications for pregnancies later on. "There's the idea out there in the public sometimes that having a C-section today with modern anesthesia and modern hospitals is as safe as having a normal childbirth, but we don't think so," said Dr. Lalonde. "It is the general principle in medicine to not make having a cesarean section trivial." The SOGC believes that if a woman is well-prepared during pregnancy, she has the innate ability to deliver vaginally. The national average for babies delivered via cesarean section in Canada is 25 per cent.





ALTERNATIVE YOGA EXERCISES TO HELP BEFORE YOUR ECV

You can try some non-medical methods to help your breech baby adopt a optimal birth position. Acupuncture, osteopathy, and swimming or simply floating in water can encourage your baby to turn by himself. Plus, you will feel relaxed! Here are some alternative yoga poses and exercise that you can do to help before performing a ECV.

pelvic tilt

Pelvic Tilt can be practiced 30 times per day.


cat pose

Cat Pose can be practiced 30 times per day.


knee chest

You can also practice the Knee-Chest position for 30 minutes. It is a modification from the Cat Stretch Pose but you drop your chest as low as you can and your bottom as high as possible. You can enjoy these minutes and let yourself relax completely.


viparita karani - supported inverted pose
Viparita Karani (Supported Inverted Pose) is also a great breech correction technique. To do with an empty stomach (and an empty bladder!) when your baby is awake. Make sure that your lower back is heightened by 9 to 12 inches (22 to 30 cm). Place blankets or a bolster against the wall. Sit sideways on the edge of the bolster with one hip touching the wall. Shift the legs up the wall until the buttocks are flush with the wall and both legs are up on the wall, forming a 90 degree angle with the pelvis. Head, shoulders, and shoulder blades remain on the floor. Palms face up at your side. Keep the chest lifted from back to front. Practice 2 times a day for 15 minutes each time.





breech external version


THE PROCEDURE

1. Have the mother empty her bladder.

2. Make sure that the mother is very comfortable. It will help greatly if she is positioned at a slant with her hips and abdomen elevated slightly. She may have a pillow under her head.

3. Listen to fetal heart tones from one to three minutes before beginning the procedure, so that you will be able to quickly identify any variation of heart rate during the version.

4. Being very certain of the baby's position, begin to gently massage the mother's belly, talking softly to the baby as you do so. You can use lots of lotion or scented oil on your hands.

5. Listen to fetal heart tones every five minutes during the attempted version so that you will be certain of the baby's well being. If there is cord involvement, or any sign of distress, You must stop immediately!.

6. Begin the procedure by attempting to lift the presenting part out of the pelvic cavity. Having the mother at a slant (laying mother's head down on a slant board) will help. If the baby is deeply engaged, you may need to lift it out of the pelvis vaginally.

7. Secondly, grasp the baby's head with one hand and begin to exert pressure upon the back of the head, bringing it forward towards you. (Picture the baby doing a forward somersault). If the baby is not laying completely lengthwise in the uterus, do not be tempted to turn the baby the shortest distance if s/he is facing the other way. To turn her/him by pushing her/his head in a backward direction will result in a deflexed head with a brow, face or military position at the time of birth, which are all more difficult to manage than is the breech!

8. With your hand, lift the breech firmly and follow the direction of the head, until you can feel the head slip into the pelvis. The mother will be of great assistance at this point as she most assuredly will comment on the change in pressure on her rib cage.

9. Once you think that the breech has turned, check carefully, externally and internally, as it is possible that you will continue turning her/him all the way around and making him/her breech once more!

10. Continue listening to heart tones for the next five minutes to assure well being. There will be a slight variation in fetal heart rate as a result of the change in position, but it should normalize quickly.

11. Once the procedure is complete, it is very wise to advise the mother to assume an upright posture, or walk for an hour, squatting deeply every few minutes, to assist the baby in engaging in the pelvis, and remaining in the vertex position.

12. At no time should undue force be exerted in rotating the breech. You will find that once the breech is disengaged from the pelvis, turning it is not difficult. If it is difficult, there may be a predisposing factor, i.e., an anomaly or a very large or post dates baby inhibiting the version.

13. It is not unusual that this procedure may cause labor to begin, or at least some contractions to occur. Advise the mother accordingly.

Note: Sometimes the baby will turn back to breech after performing a successful external version. The baby refuses to stay head-down. There may be other factors influencing the baby's position preventing it from engaging head down and staying there. It may be suggested that an ultrasound be performed to check for these factors (such as a low-lying placenta or a uterine abnormality) before attempting the procedure again, and then it is up to the mother whether or not to she wants to try turning the baby again.

If it is determined that an external version is in the best interest of the mother and her baby, by all means attempt to do so. The obstetric model of version relies on the use of tocolytic drugs and continuous ultrasound. The drugs (to reduce contractibility of the uterus) have very negative side-effects and may prove to be very painful (most practitioners attempting this obstetric model of version and may be very rough and forceful, as well as unsuccessful).

BREECH LINKS

MoonDragon's Pregnancy Information: Ideas for Turning A Breech Presentation
MoonDragon's Pregnancy Information: Vaginal Breech Pictorial - Hospital with Episiotomy & Forceps
MoonDragon's Pregnancy Information: The Established Breech
MoonDragon's Pregnancy Information: Breech Labor - What to Expect
MoonDragon's Pregnancy Information: Breech Labor - How the Attendant May Assist
MoonDragon's Pregnancy Information: The Breech Delivery at Home
MoonDragon's Pregnancy Information: Pregnancy - Breech Presentation
MoonDragon's Birthing Guidelines - Variations of Labor & Birth
MoonDragon's Birthing Guidelines - The Unexpected Breech
Vaginal Breech Pictorial - Hospital without Pain Medication, Episiotomy & Forceps
The Website: "Heads Up! All About Breech Babies"
MoonDragon's Pregnancy Information: Pregnancy Information & Survival Tips
MoonDragon's Pregnancy Index
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