Types and evolution of obstetric version
In modern obstetric practice, there are two main types of interventions:
- External cephalic version (ECV).
- Combined internal-external version (subdivided into classical internal podalic version at full cervical dilation and Braxton Hicks version at incomplete cervical dilation).
External cephalic version was first proposed by B.A. Arkhangelsky in 1941. Subsequently, the method raised concerns for a long time due to the risk of severe complications — placental abruption (abruptio placentae) and preterm labor (PTL).
The renewed interest in the procedure is associated with the introduction of two technologies:
- Ultrasonography (ultrasound) — allows visual monitoring of fetal movement and assessment of its condition during the procedure.
- $\\beta$-adrenomimetics (tocolytics) — ensure effective relaxation of the myometrium, significantly facilitating the manipulation.
Indications and contraindications for the procedure
Performing an external cephalic version is possible only if the following mandatory conditions are met:
- Satisfactory condition of the fetus and pregnant woman;
- Sufficient fetal mobility within the uterine cavity;
- Singleton pregnancy;
- Normal placental location;
- Physiological (normal) pelvic dimensions.
Contraindications for the procedure:
- Somatic pathologies: arterial hypertension, severe cardiovascular disorders.
- Complications of the current pregnancy: severe preeclampsia, oligohydramnios or polyhydramnios, macrosomia, nuchal cord, threatened preterm labor, abnormal placentation.
- Pathologies of the birth canal: uterine myoma, uterine scar, anatomical pelvic contraction.
Preparation and technique
The optimal time for the version is 38–39 weeks of gestation provided the cervix is ripe. Preparation includes counseling the patient, obtaining written consent, and mandatory emptying of the bladder and bowels.
The patient is placed on the examination couch. $\\beta$-adrenomimetics are administered intravenously by drip infusion 60 minutes before the start and throughout the entire procedure. The manipulation is performed strictly under continuous ultrasound monitoring.
Technique of bimanual version:
- The right hand moves the fetal pelvic end to the side: in the first position — to the left, in the second position — to the right.
- The left hand holds the fetal head in a flexed state.
- Carefully and systematically, the pelvic end is displaced upward and toward the back, the back toward the head, and the head is directed toward the pelvic inlet.
Crucial rule: if difficulties arise during the manipulation, overcoming them by force is strictly prohibited.
Outcomes and subsequent management
After the successful conversion of the fetus to a longitudinal lie, amniotomy is performed.
Results of the procedure:
- In 80% of cases, subsequent labor proceeds favorably in cephalic presentation.
- In other cases, recurrence is observed — the fetus reverts to its initial breech presentation.
Briefly: answers to topical questions
What complications can occur during an external cephalic version?
During an external cephalic version, severe maternal and fetal complications may occur.
The main obstetric complications include:
- Placental abruption — abruptio placentae.
- Preterm labor — premature onset of labor activity.
- Prelabor rupture of membranes — PROM.
- Uterine rupture — severe organ damage.
- Amniotic fluid embolism — entry of amniotic fluid into the maternal bloodstream.
Immunological risks (fetomaternal hemorrhage, risk of Rh-sensitization) and fetal complications are also possible: transient bradycardia, distress (intrauterine compromise), and, in rare cases, stillbirth.
What is the technique of classical internal podalic version?
The technique of classical internal podalic version involves simultaneous actions of both obstetric hands (one is inserted into the uterine cavity, the other acts externally) and includes three stages.
- First stage — selection and insertion of the obstetrician's hand (hand folded into a cone like the "obstetric hand") into the uterine cavity.
- Second stage — searching for, identifying, and grasping the fetal foot (grasping the entire leg with the hand, or two fingers on the ankle is preferred).
- Third stage — the version itself: the internal hand pulls the foot downward, while the external hand simultaneously moves the fetal head toward the uterine fundus.
The operation is considered complete when the popliteal fossa appears from the vulvar cleft.
What are the indications for classical internal podalic version?
The main and practically sole modern indication for classical internal podalic version is the transverse lie of the second twin in a twin pregnancy.
The intervention in this situation is technically straightforward because the birth canal has already been prepared by the first twin. If difficulties arise during the version, a Cesarean section is indicated. Overall, the procedure is used extremely rarely due to the high risk and trauma for a viable fetus, as it can lead to hypoxia, intracranial injury, or cervical spine trauma.
The rule for displacing the pelvic end according to positions: "First — left, second — right" (1st position — buttocks moved to the left, 2nd position — to the right). The right hand displaces the pelvis, the left hand keeps the head flexed.
Class and exam questions
What is the main difference between external cephalic version and Braxton Hicks version?
External version is performed exclusively through the abdominal wall to a cephalic presentation. The Braxton Hicks version refers to the combined internal-external version and is performed with incomplete cervical dilation.
What medical management is required during an external version?
$\\beta$-adrenomimetics (tocolytics) are administered intravenously by drip. The infusion is started 60 minutes before the procedure and continued directly during the version to relax the uterus.
What are the main historical reasons for abandoning Arkhangelsky's version?
The main reasons were severe complications arising during the procedure: placental abruption (premature separation of a normally implanted placenta) and preterm labor.
What is done immediately after a successful external cephalic version?
After the fetus is successfully converted to a longitudinal lie, an amniotomy is performed on the patient.
What else to study on this topic
- Technique of combined external-internal podalic version
- Specifics of performing Braxton Hicks version
- Protocol for medical abortion (Mifepristone and Misoprostol)
- Specific complications of late pregnancy termination
- Technique of mini-Cesarean section for pregnancy termination at 18–21 weeks
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