VERSION

Version is a manipulative procedure in which the presentation of the fetus is altered artificially
either substituting one pole of a longitudinal presentation for the other or converting an oblique
or transverse lie into a longitudinal presentation.

CEPHALIC VERSION
When the cephalic pole is brought down to the lower pole of the uterus
PODALIC VERSION –
When the podalic pole is brought down.

TYPES OF VERSION

Version is of three types-

1. External version - is done by external manipulation.
2. Internal version - is done by introducing one hand into the uterus and the other hand
abdominally.
3. Bipolar version - is done by introducing two fingers through the cervix and the other hand
on the abdomen.

EXTERNAL CEPHALIC VERSION

INTRODUCTION AND DEFINITION
External cephalic version (ECV) involves turning the fetus externally to bring the cephalic pole
into the lower pole of the uterus, i.e. it is done to convert a breech or transverse lie to a cephalic
presentation. ECV has been practised since the time of Hippocrates and has got renewed interest
recently. The overall success of the procedure is between 35-76%, and it reduces the incidence
of breech presentation at delivery from 3-4% to 1-1.5%. Both the Royal College of Obstetricians
and Gynaecologists UK (RCOG) and the American College of Obstetricians and Gynecologists
(ACOG) recommend that all women with an uncomplicated breech presentation near term
should be offered an attempt at version (Level IA evidence). It decreases the chance of non-
cephalic presentation at the onset of labor and decreases the rate of caesarean delivery.

INDICATIONS OF ECV

1. Uncomplicated breech pregnancy at term

2. Transverse lie at term (not in labor)
3. Second fetus of twin pregnancy in transverse lie after the delivery of the first twin
CONTRAINDICATIONS OF ECV
Absolute Contraindications
1. indications for cesarean delivery irrespective of fetal position (e.g. placenta previa,
contracted
2. Multiple pregnancy
3. Significant fetal or uterine anomaly
4. Fetal death
5. Ruptured membranes
6. Non reassuring fetal status
7. Hyperextended fetal head
8. Cord completely encircling fetal neck on ultrasound
9. Declined consent

Relative Contraindications

1. Previous cesarean delivery (some obstetricians do ECV)

2. Maternal cardiac disease
3. Hypertensive disorders of pregnancy
4. Maternal diabetes
5. Maternal obesity (BMI > 20%% of ideal): (Procedure is less likely to succeed)
6. Fetal growth restriction
7. Oligohydramnios
8. Isoimmunization

TIMING OF ECV
ECV Was previously performed at 32-34 weeks, due to small fetus and abundant liquor making
the procedure easy. However, the present RCOG recommendation is to perform ECV after 36
weeks. Delaying up to 36 weeks has the following advantages, even though it may be slightly
more difficult at this time.

1. Fewer procedures are needed as spontaneous version occurs in many cases.

2. Reversion to breech after the procedure is less likely.
3. If fetal complications develop during version, they can be managed by immediate
cesarean delivery, as the fetus will be mature.
4. Some of the contraindications to version and indications for cesarean delivery, like fetal
growth restriction, may be evident only in the later weeks.
PRE-REQUISITES
Following pre-requisites should be fulfilled before trying ECV.

1. There should be no contraindication to vaginal delivery.

2. Absence of fetal anomaly that may interfere with vaginal delivery.
3. Gestational age > 36 weeks.
4. Estimated fetal weight<3.5kg
5. Complete breech presentation.
6. No hyperextension of fetal head.
7. Facilities for continuous fetal heart rate monitoring should be available.
8. Skilled obstetrician and pediatrician should be available.
9. Facility for immediate cesarean delivery should be present in the center.

PRE – PROCEDURE PREPARATION

1. Informned consent should be taken after explaining the nature, risks, success and failure
of the procedure.
2. Bladder should be empty and the woman relaxed and comfortable.
3. The procedure should be performed by an experienced operator, making sure operation
theatre is available.
4. Ultrasound should be done to assess fetal position, confirm breech presentation or
transverse lie, amount of liquor, placental localization and rule out any grosS congenital
fetal malformations.
5. Cardiotocography (CTG) monitoring should preferably be available during the procedure.
6. A reactive non-stress test (NST) should be obtained prior to the procedure.
7. Fetal heart should be auscultated every 2 minutes, if continuous CTG is not available and
the procedure interrupted if bradycardia occurs or if the woman experiences discomfort.
Maternal pulse and blood pressure should be taken every 5 minutes, especially if a
tocolytic is being used.
8. After successful version, the position of the fetus should be maintained manually fora few
minutes.
9. With multiple failed attemnpts, the procedure should be abandoned in that sitting.
10. If the first attempt has been without a tocolytic, the procedure may be repeated under
tocolysis a week later.

PROCEDURE- In breech presentation: The maneuver is carried out after 36 weeks in the labor
room. Drinking plenty of fluids before attempting ECV may optimize liquor volume
making ECV easier. There is no need for starvation. There Is insufficient data about use of
analgesia including epidural or spinal before ECV and it should not be done Under
general anesthesia , Vibroacoustic stimulation of Fetus and amnio infusion before ECV
have been tried but not routinely recommended. Any one of the following tocolytic drugs
(Terbutaline 0.25 mg subcutaneously or Isoxsuprine 50-100 mg intravenously), if
required, can be administered. Real time ultrasound examination is done to confirm the
diagnosis and adequacy of amniotic fluid volume. A reactive non-stress test (NST) should
precede the maneuver.
STEPS
1. Each step of the procedure is carefully explained to the woman and she is asked to keep her
abdominal muscles fully relaxed and inform the operator in case of any discomfort. Position
of the fetal back is confirmed.
2. The Woman is placed on a firm examination table with Operat1ve Obstetric.s the fetal back
towards the operator (if a backward tip is to be attempted) or opposite to the operator (r
forward somersault is to be done). She should be tilted on her side towards the operator
with a wedge/ cushion under the back.
3. Talcum powder is spread on the abdomen, to allow the skin to slide under the operator's
hands and prevent friction. Ultrasound jelly can also be used in place of powder.

Step- I
The breech is manipulated out of pelvis by steady and continous abdominal pressure to one
iliac fossa towards which the back of the fetus lies. The podalic pole is grasped by the right
hand while the head is grasped by the left hand. The two methods to rotate the breech may
be a backward flip or a forward somersault. The basic principle is to keep the baby's back
flexed and follow the shortest path to a cephalic position. Slow and steady pressure should
be used, rather than repeated jerky movements. Continuous pressure on the uterus should
be limited to 5 minutes.

Step- ll
In forward somersault method, the pressure is exerted to the head and the breech in the
opposite directions to keep the trunk well flexed facilitating version. The pressure should be
intermittent to push the head down towards the pelvis and the breech towards the fundus
until the lie becomes transverse. The fetal heart is checked once more.
Step- lll
The hand is now changed one after the other to hold the fetal poles to prevent crossing of
the hand. The intermittent pressure is exerted till the head is brought to the lower pole of
the uterus.

Instructions:-
 The patient is advised to comne for follow-up to check the corrected position.
 To report to the physician if there is vaginal bleeding or escape of liquor amnii or if labor
starts.
 Rh-negative non immunized woman must be protected by intramuscular administration of
100 ug anti-D immunoglobulin

COMPLICATION
1. Risks to the mother include discomfort, need for emergency cesarean delivery and
possible negative psychological effects in the event of failure.
2. The fetal risks are in the form of non-reassuring fetal heart rate patterns (non-reactive
tracings, transient bradycardia) which are the most common and may persist for 20-40
minutes.
3. Placental abruption.
4. Fetomaternal hemorrhage.
5. Isoimmunization.
6. Preterm labor.
7. Prelabor preterm rupture of membranes.
8. Uterine rupture.
9. Amniotic fluid embolism.
10. Brachial plexus injury.
11. Rarely, it may be a cause of perinatal mortality. Fetal loss rate used to be quoted 1% in
old studies but is much less in recent studies.

Small procedure related risks must be weighted with the risk associated with persistent
breech presentation, including cord prolapse. Cesarean delivery can also result in trauma
to the baby and elective cesarean may carry the risks of transient tachypnea of the
newborn and pulmonary hypertension. However, ECV has been reported to be cost
effective from studies in the US and UK
FACTORS ASSOCIATED WITH SUCCESSFUL VERSION

1. Multiparity
2. Flexed breech (extended legs are a hindrance to version)
3. Adequate liquor

FACTORS ASSOCIATED WITH FAILURE OF ECV

1. Nulliparity
2. Anterior, lateral or cornual placentation
3. Decreased or increased liquor
4. Descent of breech into pelvis
5. Maternal obesity
6. Posteriorly located fetal spine
7. Frank breech
8. Short umbilical cord

EXTERNAL VERSION IN TRANSVERSE LIE

The version is much easier than in breech. The presenge of placernta previa or congenital
malformation of he uterus should be excluded. The steps are simlar as in breech, except that
the first step is not required. Tie complications are also similar.

EXTERNAL PODALIC VERSION

The external podalic version may be done with falure of the external cephalic verrsion for the
transverse lie of the second twin.

INTERNAL PODALIC VERSION

Internal podalic version consists of turning the lie d the fetus by inserting a hand into the
uterine cavity and seizing one or both feet and bringing them down and trans-abdominally
pushing the upper portion of the fetal body upwards with the other hand. The operation a
followed by breech extraction.

INDICATION
1. Delivery of the second twin is the only indication of this procedure in modern obstetric
with live fetus.
2. Rare indications: Cesarean facilities are not available with the following possibilities:
I.Transverse lie with fully dilated cervix
II. Cord prolapse with fully dilated cervix.
III.Transverse lie with very preterm non incompatible with life.
CONTRAINDICATION

1. Big baby
2. Contracted
3. Obstructed labor with impending rupture
4. Scanty liquor
5. Septate uterus
6. Previous cesarean delivery

TIMING AND PRE-REQUISITES

1. Cervix must be full dilated
2. Membranes absent but recently ruptured, ensuring adequate liquor
3. Baby of average size
4. No contraindication to vaginal delivery

PRE-PROCEDURE PREPARATION

1. Informed consent is mandatory, explaining the nature, risks and success of the procedure
2. Bladder should be empty and the woman relaxed and comfortable.
3. Good uterine relaxation is necessary.
4. The procedure should be performed by an experienced operator.
5. Pediatrician should be available.
6. Per-abdominal examination should be done to assess fetal position, amount of liquor and
fetal heart sounds.
7. Per-vaginal examination should confirm that cervix is fully dilated and pelvis is adequate.
8. Menmbranes, if present, should be ruptured.

PROCEDURE

1. It is performed under deep anesthesia, preferably general anesthesia.

2. Place the woman in lithotomy position and continuously monitor fetal heart rate.
3. Under all aseptic precautions, one hand is introduced into the uterine cavity in a cone-
shaped manner and taken along the thigh of the baby.
4. If the lower limbs are on the mother's right side, the left hand should be employed and if
on the mother's left it is preferable to use the right hand for convenience. Howwever,
many obstetricians find it easier to use their right hand irrespective of the position of
podalic pole.
5. The foot is identified by the prominence of heel and one foot or both feet are brought
down gently.
 6. The abdominal hand of operator or hand of assistant aids in pushing the head up towards
the fundus to facilitate rotation.
7. The baby is delivered by breech extraction.

POST- PROCEDURE CARE -

1. Uterine rupture should be ruled out.

2. Lacerations to the genital tract must be looked for and managed.
3. Oxytocis should le given to avoid postpartum hemorrhage.

Maternal Risks

1. Placental abruption.
2. Tears of cervix, vagina and perineum.
3. Uterine rupture.
4. Postpartum hemorrhage.
5. Increased morbidity

Fetal Risks
Perinatal mortality can be there mainly due to hazards of breech delivery.

1. Asphyxia
2. Intracranial hemorrhage
3. Stillbirth
4. Cord prolapse
BIPOLAR VERSION
Bipolar version is named after Braxton-Hicks. It is not routinely done and is almost obsolete in
modern obstetrics.
INDICATION
Lesser degree of placenta previa with dead, deformed or very preterm fetus. It can be a life-
saving procedure in smaller places where facilities for cesarean delivery are not available and
patient cannot be shifted to a bigger hospital. The cervix should be at least 2 cm dilated for
manipulations in which head is pushed to one iliac fossa and one leg is grasped at ankle and is
brought down compressing the placenta to stop bleeding. Simultaneously, external hand
facilitates the procedure

NURSING CARE
Nursing Care Nursing care of the womarn having external version includes assisting with the
procedure and observine the mother and fetus afterward for 1 to 2 hours. Base. line maternal
vital signs and a fetal monitor strip (part of the NST Or BPP) are taken before the version, The
mother's vital signs and the fetal heart rate are observed to ensure return to normal levels
after the version ie complete. Vaginal leaking of amniotic fluid suggests that manipulating the
fetus caused a tear in the membranes, and this is reported. Uterine contractions usually
decrease or stop shortly after the version. The physi cian is notified if they do not. The nurse
reviews signs of labor with the woman because version is performed near term, when
spontaneous labor is expected.
 BIBLIOGRAPHY

1. Sharma, J. B. (2012). Textbook of obstetrics, (3rd ed.), published by: AVICH AL PUBLISHING
COMPANY. Page No- 698- 702.
2. Leifer, Textbook of Introduction to Maternity & Pediatric Nursing (6th edition) Elsevier
publishers,186-188.
3. Sneh Lata Manocha , textbook of Procedures And Practices In Midwifery , Kumar publishers, 259-
262.