- Hospital setting with immediate access to perform an emergency cesarean delivery
- Ultrasound prior to the procedure to confirm:
- Non-vertex presentation
- Normal amniotic fluid
- Exclusion of fetal anomalies
- Placental location
- 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
- Intermittent use of ultrasonography to examine fetal heart rate and position
Parameters for discontinuing procedure
- Prolonged fetal bradycardia
- Patient discomfort/maternal request
- Unable to convert to cephalic presentation with forward or backward somersault
- Forward Somersault
2. Backward Somersault
Is there a role for tocolysis?
- 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.
- 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.