7.8 Internal version

Manual intrauterine procedure to convert one presentation to another, usually a transverse lie into a breech.

7.8.1 Indications and conditions

– Shoulder presentation during labour, at complete dilation with a relaxed uterus. This manoeuvre should be performed with extreme caution (risk of uterine rupture).
– Delivery of a second twin in cephalic presentation or transverse lie: version to bring the foetus into the breech position and allow a total breech extraction (Chapter 6, Section 6.3).
– Conditions necessary in all cases: normal pelvis, presenting part not engaged, bladder empty.
– Grasping one or both feet is best done through membranes that have been left intact7.

7.8.2 Technique

– Strict asepsis: swab perineum with 10% povidone iodine, wear sterile gloves.
– Perform spinal anaesthesia if possible.
– Insert the hand and determine the position of the foetus:
• with the fingers in the form of a cone, go through the vaginal opening and the cervix toward the fundus;
• hold the fundus in place with the other hand on the abdomen.
– Grasp one foot or, if possible, both feet, firmly, without haste but not too slowly, since a prolonged manoeuvre might cause the uterus to contract (Figure 7.3a). It is better not to rupture the membranes immediately because the uterine retraction and lack of amniotic fluid will make it difficult to grasp and move the foetus. The membranes will spontaneously rupture when pulling the foot or will be artificially ruptured once the foot is down.
– Pull the foot/feet gently to the vaginal opening (Figure 7.3b).
– The delivery then continues normally as a breech delivery. For the second twin proceed with total breech extraction (Chapter 6, Section 6.3).
– Manually explore the uterus after delivery of the placenta (to look for uterine rupture), and administer routinely antibiotic prophylaxis (cefazolin or ampicillin slow IV: 2 g single dose)1 .

Figures 7.3 - Internal version

7.3a - Catch hold of one foot (preferably both feet)

7.3b - Bring the foot/feet down to the vaginal opening

Ref Notes
1 For patients with a history of immediate hypersensitivity reaction to penicillin (urticaria, respiratory problems or oedema): clindamycin IV 900 mg single dose + gentamicin IV 5 mg/kg single dose.