External Cephalic Version (ECV)

What is ECV?
An ECV or External Cephalic Version is when the practitioner uses her hands on your belly to nudge and push the baby into a head-down position. Rates of effectiveness vary enormously with the practitioner. It went out of style for a while but is coming back into practice. When I had mine done by an OB (in the states), there were about a hundred students in there to see it. (exaggeration, yes) It is usually considered the thing to try when nothing else works because most everything else you can do is either completely harmless or very nearly so.

Is ECVsafe?
In Thinking Woman’s Guide to a Better Birth, Henci Goer studied 3,700 women in twenty-six studies on ECV. There were only complications leading to cesarean in two cases. It is considered very safe, but in many cases is done in a labor and delivery ward in case it puts you into labor or distresses the baby. The practitioner needs to be very careful of the cord and of course know where and how much to press. Some doctors recommend continuous ultrasound with someone watching the screen. Accidents do happen with ECV, but very very rarely, especially with an experienced practitioner.Your opinion on all turning methods, and especially ECV, will depend on your sense of why your baby is breech, and if you believe it could be best for this particular baby to be breech. Some more natural birth professionals and moms would say it is invasive and dangerous and if you have to do an ECV to turn your baby, your baby just needs to be breech and you shouldn’t mess with it.Some midwives and doctors believe it too-often compromises the placenta. A breech experienced midwife I met said she believes it’s safer to come breech than to do an ECV for this reason.I did not want an ECV, but I knew it sure as hell beat a c-section.

The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:
The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.
In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.
ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

Does ECV hurt?
A version can be painful. Mine was mildly uncomfortable, but not anything I would call pain. Women report everything from no discomfort to very painful. I think it probably depends on how your baby is positioned, how you feel about it and especially who is doing it. Some practitioners do it with an epidural, which I think is pure crazy. Others like the woman to help guide them to do the version safely by complaining if it hurts, which seems very sensible. Ask your caregiver first if they think it will hurt.

What is an ECV like?
Well, some midwives do them while you lay on your couch. And some doctors have you all hooked up and with an epidural, so it varies widely.Most commonly, they are done at a hospital in a labor ward. You will be in a gown and hooked up: IV, fetal monitor, blood pressure cuff, pulse monitor. They will make you sign all the papers as if you were going to deliver right there today. Don’t freak out.If the baby’s heart rate looks good, they will do ultrasound to check position and give you a drug (shot) to relax your uterus. (This is usually terbutaline. It can make some women jumpy and cause heart racing. Studies show that these tocolytic drugs are not required for success and in most cases don’t even offer any advantages. Then the doctor puts one hand on the baby’s head and one on the butt and tries to push and roll her to head-down. If it doesn’t work, they may recommend you try again. Or you can ask to have it done again later, perhaps with an epidural if relaxation/pain was a problem. You and baby will be monitored for a time afterwards.

Can I get one?
If you can find someone you trust to do it, probably. The establishment(s) are starting to recommend them whenever possible to avoid c-section. Some midwives do them.

Though it varies widely and is hotly disputed, I have seen the following contraindications for ecv, including:

Oligohydramnios (Not enough amniotic fluid)
Antepartum Hemorrhage (Bleeding)
Ruptured Membranes (Water broken)
Obesity
Diabetes
Multiple Pregnancy (Twins or more)
Severe fetal abnormality
Odd placental position
Caesarean Section necessary for other indications
Previous Caesarean Section (ACOG recommends against it, so it’s a legal thing.)
Poor fetal growth
Hypertension/Pre-eclampsia
Hyper-extended fetal head

When should I get an ECV?
The studies for ECV done earlier in the last trimester have a higher success rate. You can always get it done again. Most doctors say the optimal time seems to be 37-38 weeks. If you do it much earlier it is riskier because the procedure does carry a risk of putting you into labor or distressing the baby and sending you to the ER for a cesarean. You tend to have more amniotic fluid at this time in your pregnancy as well. If your fluids are low, it is a good idea to do things that increase your fluid levels before going in for the procedure.

In Benna Waites’ book Breech Birth (highly recommended if you have the time), she tells us about a paper written in 1973 by a Dr. Ranney, an OB who used ECV to turn almost 91% of his breech mamas’ babies. He would start at 30-34 weeks and try ECV over and over at every visit until the baby turned, sometimes even during labor (as long as the mama’s water was unbroken, there was enough fluid, and she relaxed between contractions). One of his patients had 8 ECV attempts before the baby stayed head-down. Dr. Ranney’s paper is called “The Gentle Art of ECV” and Waites quotes him as saying, “This is no place for a hasty or domineering approach which is futile and possibly dangerous…If not today, then probably at the next office visit” (p. 61).

Does ECV work?
In general, it has about a 65% success rate. But it varies an enormous amount by practitioner. Ask around. It is more likely to work if you have had previous pregnancies, the baby is not engaged, is transverse, has flexed legs, is not huge, is not tiny, you are not dilated, your fluid level or placental location are not off. Studies also show an association between ECV failure and a posterior baby.

Here’s another ECV video: