Standard Protocol for Performing an ECV

Pre-Procedure

• Hospital setting with immediate access to perform an emergency cesarean delivery ​

• Ultrasound prior to the procedure to confirm:​

• External fetal monitoring to assess fetal heart rate and contractions​

• Non-stress test or biophysical profile prior to the procedure​

• Informed consent including risks, benefits, use of tocolytics and neuraxial analgesia ​

During Procedure

Monitoring

• Intermittent use of ultrasonography to examine fetal heart rate and position​

Parameters for discontinuing procedure

1. Prolonged fetal bradycardia​
2. Patient discomfort/maternal request​
3. Unable to convert to cephalic presentation with forward or backward somersault​

Procedural techniques

1. Forward Somersault

2. Backward Somersault

Is there a role for tocolysis?

1. Parenteral beta stimulants (e.g., terbutaline IV/SC, salbutamol IV/PO/inhaler)​:

Conclusion: Beta stimulant tocolysis is associated with an increased success rate, a reduction in c-sections.​

BUT! Terbutaline not available in Canada and no dosing guidelines for salbutamol in Canada.​

2. Calcium channel blockers

• 2 trials compared nifedipine to terbutaline ​
• Lower rates of success with nifedipine (n = 176, RR 0.67, 95% CI 0.48-0.93)​
• 1 Trial compared nifedipine to placebo (n = 320) ​
• No significant difference in ECV success rate (41.6% vs 37.2%, P=0.43)​

Conclusion: No evidence for the use of calcium channel blockers.​

3. Nitric oxide donors (e.g., nitroglycerine IV or SL)​

• Three studies using nitric oxide donors compared with placebo ​
• No reduction in failure of ECV ​
• Resulted in more headaches ​

Conclusion: No evidence for the use of IV or SL nitric oxide donors.​

HOWEVER… There is a possible role for inhaled nitrous oxide in parous women.

• Prospective, randomized, single-blind, controlled trial ​
• 1:1 nitrous oxide in a 50:50 mix of oxygen versus medical air ​
• Overall no difference in ECV success rate​
• Parous women had higher success in the nitrous oxide group (47.1% vs 23.5%, P=0.042)​

Conclusion: Possible role of inhaled nitrous oxide in parous women.​

Is there a role for anesthesia in ECV?

• No significant difference in ECV success rate between the group with spinal analgesia and those without (44% vs 42%, P=0.863). ​
• Spinal analgesia with tocolysis increased ECV success when compared with tocolysis alone (87.1% vs 57.5%, 95% CI 0.075-0.48, P=0.009)​

Conclusion: Neuraxial analgesia in combination with tocolysis can be considered a reasonable intervention. However, this is limited in Canada given the limitation of tocolytic availability. ​

After Procedure

• External fetal monitoring to assess fetal heart rate and contractions​.
• Non-stress test or biophysical profile after procedure (at least 30 minutes)​.
• Anti-D immune globulin for all Rh negative patients.
• No evidence for immediate induction of labour to minimize reversion.
• If reconverts to breech after a successful ECV, can consider a repeat ECV.

Next Section