External cephalic version

External cephalic version

Anesthesia type	None or epidural/CSE
Airway	Natural
Lines and access	1 PIV
Monitors	Standard OB bedside monitors (EKG, pulse ox, NIBP, fetal HR monitoring)
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating	Comprehensive
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An external cephalic version is a maneuver performed by obstetric physicians to rotate a baby into vertex position in preparation for vaginal delivery. It may be done without any anesthesia, or with neuraxial (epidural, spinal, combined spinal epidural) depending on patient and provider preference.

Overview

Indications

• Breech or transverse presentation
  • Ideally around 36-37 weeks gestation before the baby is too large

Surgical procedure

The maneuver can be performed at bedside using external force on the abdomen to rotate the baby. Ultrasound is used to confirm head position before, during, and after the maneuver. Fetal heart rate monitoring is used to closely monitor for fetal distress

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

CBC -- in particular, platelets if neuraxial anesthesia will be used

Operating room setup

Generally, ECV is performed in a labor room or PACU area, where neuraxial anesthesia can be provided if needed. ECV can be performed in the operating room if there is a high risk of requiring emergent Cesarean section. Having an operating room on standby and ready to use is prudent.

Regional and neuraxial techniques

• An epidural or combined spinal epidural (CSE) can be offered for patients who wish to have analgesia, as the pressure applied to the abdomen can be quite significant and may prevent success of the maneuver.
  • Yoshida et al. reported a 78.8% success rate in patients who received an epidural compared to 55.9% success rate in patients who did not (OR: 1.75; 95% CI: 1.26 to 2.44).
• Spinal dose: bupivacaine ~7.5 mg intrathecally (~1 mL bupivacaine 0.75%)
  • CSE can be used to titrate up to effect
• Epidural dose: lidocaine 2% ~10 mL

Intraoperative management

Monitoring and access

• EKG
• pulse oximetry
• NIBP
• fetal HR monitoring

Induction and airway management

Natural airway, oxygen (nasal cannula or mask) can be used for comfort if needed

Positioning

• Supine

Maintenance and surgical considerations

If an epidural is used, additional titration may be needed to tolerate the procedure. Careful observation of blood pressure is important as hypotension is common. Maintaining uterine artery blood flow is critical to avoiding fetal distress.

Postoperative management

Disposition

Generally, the fetus is monitored for several hours. If neuraxial anesthesia is used, patient must regain motor and sensory function.

Pain management

Generally, the procedure has minimal pain once completed. The epidural, if placed, can be titrated as needed

Potential complications

There is imminent risk of fetal distress with the ECV, thus there should always be an available operating room for emergent Cesarean section.

Procedure variants

	Variant 1	Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications