Is External cephalic version (or ECV) the answer to curbing the rate of caesarean section births?
The rate of caesarean section births is on the rise. In Australia in 1991, 18% of women gave birth via caesarean section. By 2004 this figure had risen to 29% (Australian Bureau of Statistics). In the UK the statistics show the same pattern – in 1999 20% of deliveries were via caesarean section, compared with 11% only 10 years earlier (World Health Organisation). This steep rise in the number of caesarean deliveries is worrying for the public health system, which is under increasing pressure to cut back spending. It is also of significant concern to pregnant women, who face an increased risk of complications and mortality.
Caesarean sections are performed for a number of reasons, one of which is a breech presentation of the foetus. ‘Breech presentations’, which are estimated to account for approximately 4% of pregnancies, present with their bottom down and head up. In the past the only options for delivering a breech baby were attempted vaginal delivery (which is no longer recommended due to safety concerns regarding the foetus) or caesarean section. The preference for avoiding labour with breech presentations has contributed to the increasing rate of caesarean sections over the last 10 years.
What options are there for a breech baby?
So what other options are there for women whose baby is breech? External cephalic version (or ECV) may be the answer to curbing the rate of caesarean section births.
External cephalic version is a procedure in which the baby is manually turned from a breech presentation into a vertex (head down) position. Monash Medical Centre (part of Southern Health in Melbourne) runs a specialised clinic that performs ECV on a weekly basis.
ECV - A case study
This week Angie Amro is on the list to have her baby turned. She is 36 weeks and 5 days gestation. “This has to work,” she asserts. She will not accept the alternative. With two young children already at home she just ‘couldn’t’ have a caesarean section. Angie waits nervously for her name to be called. She wears a belt around her stomach that acts to monitor her baby’s heart beat. A machine to her left provides a constant printed record. None of this is new for Angie - her first child was also a breech presentation. A successful ECV during that pregnancy meant that Angie was able to proceed with a normal vaginal delivery. She hopes for the same outcome today.
The obstetrician, Dr Rabbi Kashyap, guides Angie into a darkened clinic room, only illuminated by two screens that will display an ultrasound image. Angie lies down, her husband and two year old son to her left, the obstetrician on her right. He squeezes gel over her bulging stomach and checks the position of the baby via ultrasound. The baby’s head is at the top of Angie’s uterus and its bottom sits in the pelvis, confirming a breech presentation.
Dr Kashyap begins to explain the risks associated with ECV, including cord entanglement, which may necessitate immediate delivery of the baby via caesarean section. All the while he is sweeping the inside of Angie’s right elbow with an alcohol wipe and injecting her with a smooth muscle relaxant, designed to relax the muscles of the uterus and facilitate manipulation of the baby’s position, making the procedure easier. With a nod of approval from Angie, he begins his work.
As with any procedure there are risks associated with ECV. “Very rarely we get a slowing in the baby’s heart beat if the cord gets tangled up.” There is also a risk of abruption of the placenta, premature rupture of the membranes and pre-term labour.
Using his finger tips and thumbs Dr Kashyap coaxes the baby’s bottom out of the pelvis. Then with his left hand up at the baby’s head and his right hand on the baby’s bottom, he gently encourages the baby to turn in an anti-clockwise direction as though kneading Angie’s stomach. After no more than two minutes Dr Kashyap announces, “It’s not normally that easy.” There is a nervous wait while he searches for the baby’s heart beat using ultrasound. Angie sighs with relief - there it is, present and strong, and the baby is now in a head down position ready for labour. Dr Kashyap gently wipes the gel from her stomach and it’s all done. She carefully makes her way back to the waiting area, where the baby’s heart rate is monitored for another half an hour. She holds a button in her hand that she presses intermittently – each press of the button is recording the baby’s movements. Despite reporting some pain during the actual procedure, Angie is more comfortable and relaxed now. “It’s a relief to know it’s the right way,” she says with a weary smile.
Monash Medical Centre has been performing this procedure for many years, but formalised the clinic approximately five years ago. “It was about providing a comprehensive service, rather than one on an ad-hoc basis, so that irrespective of which clinicians women were seeing, we have a clinic that we can send them to to get this done,” explains Professor Euan Wallace, Director of Obstetrics at Southern Health.
According to Professor Wallace Monash Medical Centre conducts ECV on 100 cases of breech pregnancies each year. According to Professor Wallace, the procedure is considered successful if the baby is turned into the right position and then stays in that position until the woman enters labour. Monash reports a success rate of approximately 60 percent for first pregnancies and 80 percent for subsequent pregnancies, which is in line with average success rates reported in the literature.
Unfortunately for another patient, Monda Takla, she is not one of the success stories. Monda is attending the Monash clinic at 37 weeks and 4 days gestation, hoping that ECV on her third child would mean avoiding a caesarean section. Dr Roshan Shamon, who is in his final year of obstetrics training, conducts the procedure. Monda begins to clench her toes and hold her breath as Dr Shamon works silently on coaxing her baby into a head down position. He narrows his eyes and purses his lips with concentration. His right hand begins to slide up toward her ribs and his left hand moves towards the pelvis. After a short while he pauses to apply some more gel and use ultrasound to check the baby’s position. He starts again, explaining that this baby’s position is particularly difficult. An anxious wait pursues. Still no luck. “One more try,” he reassures Monda and, perhaps, himself. After six minutes he shakes his head slowly. It hasn’t worked.
“Stubborn like his father,” Monda laughs, but it is clear that she is disappointed. He then explains that the most likely outcome now is a caesarean section. But Monda remains hopeful. “She’s an active baby, so maybe she’ll just turn by herself.”
There are many reasons why the procedure might fail: if the baby’s bottom is too low in the pelvis, the feet get caught inside the pelvis, the cord is in a position that is preventing the baby from turning safely or the placenta is positioned on the front wall of the uterus making it difficult to get a good grasp of the baby for turning. Sometimes it’s not appropriate to try the procedure at all. “If clinically we thought that the chance of success was very remote then we would say that in our discussions with the individual woman,” Professor Wallace explains.
As with any procedure there are risks associated with ECV. “Very rarely we get a slowing in the baby’s heart beat if the cord gets tangled up.” There is also a risk of abruption of the placenta, premature rupture of the membranes and pre-term labour.
“Less than once a year we need to do an emergency caesarean section. That’s why we do it at an advanced gestation stage so if we have to do [an emergency caesarean] it’s no drama. And that’s why we opt to do it in a hospital where we have immediate access to the foetus.”
According to Professor Wallace some women choose not to go through with the procedure once the risk of complications has been explained. “It’s about discussing it at length on an individualised basis with the woman or the couple. We have a philosophy of…being keen to offer and support it because it reduces the chance of the need for a caesarean section. But at the end of the day it’s very much a personal choice.”
Natalie Butler discovered that her first child was breech at 36 weeks gestation. She was referred to the Monash clinic for ECV. Unfortunately the procedure was unsuccessful and she gave birth via caesarean section. Her second child was breech but turned spontaneously, late in the pregnancy. This was a huge relief to Natalie and her husband, Gary. “It meant the decision [to have ECV] was not ours.” Natalie recalls the discomfort of the procedure and the emotional strain around making the decision to have their unborn baby manually turned. “I remember before Gary came to pick me up, sitting on the toilet in tears, going…‘Why are we forcing this baby to move; placing her at risk?’”
Euan Wallace believes that the benefits far outweigh the risks. “If you look at the benefits and risks of offering the service and not offering it, it is overwhelmingly in favour of offering it.” But is this driven by cost-saving benefits? “It’s not a factor at all. The service was introduced and is driven by clinicians who really aren’t considering costs; it’s all about what’s better healthcare of the individual woman.”
So could ECV be the answer to reducing the rapid increase in the rate of caesarean sections, not just in Australia, but world-wide? According to Professor Wallace, the UK is leading the way. In Britain it is an expectation that all maternity hospitals offer external cephalic version for breech pregnancies. “I would like to see it become more and more common because it would be another way of keeping our caesarean section rates down, which at the end of the day is good for the population.”
