7.7 External version


A procedure to convert:
– a transverse lie into a longitudinal (cephalic or breech) presentation,
or
– a breech presentation into a cephalic presentation.

7.7.1 Conditions

– Pregnancy near term (37 weeks LMP)
– Prior to labour, or at the very start of labour
– Relaxed uterus
– No obstacle to vaginal delivery
– Membranes intact

External version is very rarely associated with complications. Complications have, however, been reported (placental abruption, rupture of a scarred uterus and foeto-maternal haemorrhage). Therefore, this manoeuvre should only be attempted in a CEmONC facility.

7.7.2 Contra-indications

Absolute

– Placenta praevia
– Twin pregnancy (for the first twin)

Relative

– Foetal distress
– Severe intrauterine growth restriction
– Prematurity
– Scarred uterus
– HIV infection

Note: in case of transverse lie when referral is not possible, in the interest of the mother external version may be attempted to permit vaginal delivery, without taking into account relative contra-indications.

7.7.3 Technique

– Woman lying on her back, legs half bent, bladder empty.
– Perform when the uterus is relaxed.
– First, push back the breech or shoulder, which is often down in the pelvis (vertical movement), then attempt rotation slowly, and always in the direction of foetal flexion: thus bringing either the head or the breech to the pelvic inlet by the shortest possible route (Figures 7.2).
– Monitor the foetal heart rate after each attempt, and stop if the rate slows. In most cases, foetal heart rate abnormalities improve within 30 minutes.
– External version should be followed by 24 hours of bed rest and monitoring.

Figures 7.2 - Version to convert a breech presentation to a cephalic presentation