II. Indication

  1. Breech Presentation at 34-36 weeks

III. Contraindications

  1. Pregnancy Induced Hypertension
  2. Prior uterine surgery (e.g. Cesarean Section)
  3. Multiple Gestation with first twin Breech
    1. May be attempted if first vertex, second Breech
  4. Non-reassuring Fetal Heart Tracing
  5. Utero-placental insufficiency
  6. Placenta Previa

IV. Preparation

  1. Requires two examining physicians
  2. One physician performs manual version
  3. Other physician monitors fetus by Obstetric Ultrasound
  4. Immediate ceserean delivery available if needed
  5. Consider Terbutaline 0.25 mg SQ 15 minutes before
  6. RhoGAM if patient Rh negative
  7. Patient preparation
    1. Empty Bladder before procedure
    2. Patient NPO in case of ceserean
    3. Intravenous Access

V. Technique

  1. Fetal Assessment
    1. Before: Non-Stress Test or Biophysical Profile
    2. During: Ultrasound or doppler every 30 seconds
    3. After: Non-Stress Test, Ultrasound for confirmation
  2. Mother supine, Trendelenburg, and knees slightly bent
    1. Helps Breech fetus rises above pelvic brim
  3. Examiner 1
    1. Elevate Breech by pushing buttock up suprapubically
  4. Examiner 2
    1. Flex head and rotate fetus into Oblique Lie
    2. Apply 2/3 pressure to Breech, 1/3 to head
    3. Use massaging motion to rotate baby
    4. Do not use excessive force
  5. Breech rotated while applying pressure between hands
    1. Breech eased away from Pelvis with one hand
    2. Other hand applies fundal pressure
    3. Fetus is in maximally flexed position
  6. Fetus rotates past transverse position
    1. Examiner hands push fetus into vertex presentation
  7. Indications to stop procedure
    1. Woman feels sharp pain
    2. No success after 20 minutes
    3. Fetal Bradycardia
      1. If persists, then return fetus to original Breech
      2. If still persists, then pursue ceserean section

VI. Efficacy

  1. Success Rate: 58%

VII. Reasons for failed procedure

  1. Fetal Macrosomia
  2. Oligohydramnios
  3. Fetus fully extended and SplintingUterus
  4. Abnormal Uterus
  5. Short Umbilical Cord
  6. Anterior placenta
  7. Nulliparity
  8. Obesity
  9. Low station for Breech
  10. Attempted version after 37 weeks

VIII. Complications

  1. Common, spontaneously resolving (40% of cases)
    1. Fetal Bradycardia
    2. Fetal Heart Rate decelerations
  2. Rare, serious complications
    1. Partial Placental Abruption
    2. Uterine Rupture
    3. Umpilical cord accident
    4. Amniotic Fluid Embolism

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