j. Perinat Med. External cephalic version: a clinical

O'Grady et al., External cephalic version 189

j. Perinat Med.14 (1986) 189

External cephalic version: a clinical experience

John P. O'Grady, Jean-Claude Veille, Robert L. Holland, and Katherine A·Burry

Department of Obstetrics and Gynecology, Oregon Health Sciences University,Portland, Oregon, U.S.A.

1 Introduction

The elective vaginal delivery of breech presenta-tion infants has become less frequent due to theconcern of clinicians about perinatal morbidityand mortality. Thus, cesarean delivery forbreech presentation has increased to reduce oravoid fetal trauma and/or asphyxia [5]. How-ever, the risks of vaginal breech delivery can beavoided if the fetus is manipulated from breechto cephalic presentation by external cephalicversion (ECV) [6, 9, 13, 14, 16, 17, 18, 20, 21].Randomized prospective studies have indicatedthat 3rd trimester ECV performed with toco-lysis following real time ultrasound and cardi-otocography screening, involves minimal fetalrisk and is 60-90% successful [9, 18]. As therole for late third trimester ECV is not estab-lished in pregnancies with breech presentation,we initiated a prospective clinical trial of ECVto evaluate the safety and utility of the proce-dure. Our experience constitutes the basis forthis report.

2 Materials and methods

101 patients with normal pregnancy, from pri-vate and university services were referred forECV (figure 1) and prospectively managed byprotocol. Entry requirements were breech pre-sentation at > 35 weeks from the last menstrualperiod and normal gestation.

Curriculum vitae

JOHN PATRICK O'GRADY,M. D., was born in Dallas,Texas in 1945. He gradu-ated from Stanford Univer-sity with a Bachelor's andMaster's Degree inAnthropology in 1969 andreceived his MedicalDegree from Yale Univer-sity in 1972. Following Re-sidency Training at YaleNew-Haven Hospital and aFellowship at The King-Drew Medical Center, he joinedthe Faculty at Oregon Health Sciences University. Cur-rently, he is Associate Professor of Obstetrics and Gyne-cology and Chief: Maternal Fetal Medicine at the Mac-Donald Hospital for Women, Case Western Reserve Uni-versity, Cleveland, Ohio.

Patients excluded from consideration for trialincluded those with: 1) a fixed, engaged present-ing part; 2) multiple gestation; 3) serious medi-cal disorders of pregnancy (e. g. insulin-requir-ing diabetes, hypertension, etc.); 4) known orsuspected fetal anomaly; and 5) known or sus-pected serious pregnancy complications (e. g.,premature membrane rupture, abruptioplacentae etc.). Initial screening was performedby clinicians who then referred selected patientsto our research unit for the ECV protocol.A screening real time ultrasound examinationand an unstressed cardiotocogram (NST) was

1986 by Walter de Gruyter & Co. Berlin · New York

190 O'Grady et al., External cephalic version

Screening, History and P.E.

I Screening Ultrasound I

Re evaluate Patientand Reconsider.Version

N S T

^| Not Acceptable j

|

Re evaluate:Consider Re-versionor Delivery

\Acceptable |

|Discharge

toHome

*At Discretion of Operator

Figure 1. Version protocol.

performed. The NST was classified as reactiveand acceptable if two or more fetal heart rateaccelerations of > 15 bps for > 15 seconds wasobserved over 20 minutes. Gestational age wasestablished by menstrual dating and ultrasonicexamination based on biparietal diameter,head/body ratio and long bone length. Discrep-ancies exceeding + 2 weeks were reconciled bypediatric examination of the neonate utilizingDUBOWITZ criterion with reassignment of dat-ing if appropriate.Following informed consent, 0.25 mg. of terbu-taline sulfate was administered subcutaneously.Only a single injection was given. Manipula-tions were performed 30 minutes later. Mineraloil was applied as a maternal abdominal lubri-cant. Versions were performed with the patientsupine in TRENDELENBERG'S position. A head-

over-heels technique with the operation at thepatient's right side was preferred. Back-flips asdescribed by SALING and MÜLLER-HOLVE [14]were performed if the initial procedure failed.Firm, but slow movements proved most suc-cessful. Following manipulations, the fetalheart was ultrasonically visualized, the rate ob-served, and fetal position confirmed. Finally, anadditional electronic fetal heart rate monitoringwas performed to assure fetal well being.If two attempts in each direction failed toachieve version or the patient proved intolerantto manipulation, the procedure was terminated.Rh negative women were administered immu-noglobulin if any manipulations, either success-ful or unsuccessful had been performed. KLEIN-HAUER-BETKE examinations were not performed.Following the procedure the patients were rest-ed in left lateral recumbency until the cardioto-cography was judged normal, thereafter theywere discharged to home. Subsequent manage-ment was by standard clinical procedures ofthe responsible clinician.Date was analyzed by Chi square or t-testanalysis with p < 0.05 accepted as the levelindicating significance.

3 ResultsWe attempted version on 85 of 101 patients.Initial cephalic presentation [11], marked oli-gohydramnios [3], encephalocele [1], and a non-reactive, suspicious initial electronic monitoringtracing [1] led to candidate rejection (figure 2).In 53/85 cases (62.5%) ECV was successful.Our requirements for gestational age for trialof ECV were based on clinical criteria, i. e.,menstrual dating. We subsequently discoveredthat using 35 weeks as a minimum .gestationalage for referral resulted in a patient group withthe eventual assignment of gestational agesranging from 33 to 41 weeks (figure 3). Whenthe date was evaluated for mean maternal age,gestational age and eventual delivery weight —all were found to be unrelated to ECV success.However, parity was observed to be a signifi-cant factor (tables I, II).

J. Perinat. Med. 14 (1986)


10116

85

Version Candidate·Excluded from Trial:Cephalic (1 1), Ollgohydramnlo» (3)Fetal Anomaly (1), Susp Nst/Cst (1)Total Version Attempts

Table II. Version success and maternal parity.

Failure**32 (37.5%)

\Success

53 (62.5%)

15 Caesarean 15 Vaginal DeliverySection

5 CaesareanSection

\46 Vaginal

Delivery

3 Cephalic 12 Breech

^Subsequent Spontaneous Version**2 Lost to Follow-up

***2 Lost to Follow-up

2 Failure to Progress1 PROM, Failed Induction1 Reverted to Transverse

2 days Post Version1 Compound Presentation

Figure 2. Results of version trials (see text for details).

16

15

14

13

12

11

10** 9ΟS 8

^ 7Φi β5

4

3

2

1

ι Success

I Failure

< 34 34 35 36 37 38Gestational Age

39 40 40+

Figure 3. Success or failure of version attempts by gesta-tional age (see text for details).

Table I. Version success and maternal age, gestationalage, and delivery weight.

N = 53ECV success

N = 32.ECV failure

Maternal age 25.7 ± 5.4 yrs.** 25.5 ± 5.4 yrs.Gestational age 38.0 ± 1.5 wkas.** 37.4±1.7wks.Delivery weight 3481 ± 485 gms.** 3324 ± 400 gms

* Based on N = 81, 4 patients lost to follow-up. Seetext for details.

** p = ns.

ParityN = 53ECV sucess

N = 32ECV failure

0 15(28.3%)38(71.6%)

20 (62.5%)12 (37.5%)

Four patients (4/85 = 4.7%), 2 from eachgroup, were lost to follow-up (figure 2). Onegravida could not be contacted, two womenhad left the state, and one the country prior todelivery.Fifty percent of the ECV failure patients subse-quently delivered by cesarean section. However,abdominal delivery was required in only 9.8%(5/51) of those cases in which version had beensuccessful. Of interest, in three cases spon-taneous version to cephalic presentation oc-curred after failed ECV (3/30 = 10.0%) (tableIII).

Table III. Cephalic presentation and cesarean section atdelivery.

N = 51*ECV success

N = 30*ECV failure

Cephalic presen-tation at delivery 50(98.1%)Cesarean section 5 ( 9.8%) p nn<- 3(10.0%)

'uu:> 15 (50.0%)

4 patients lost to follow-up.

Table IV. Delivery complications.

Cord around neckShoulder dystocia*Marginal abruptio placentaeCord prolapseMeconium5 Minute APGAR < 7Compound presentation

N = 51successgroup

511171**1

N = 30failuregroup

010011***0

* Both infants cephalic at delivery. Not fetal or ma-ternal injury.

** Lethal congenital cardiac defect.*** Meconium aspiration during vaginal breech deli-

very.


192 O'Grady et aL, External cephalic version

Table IV outlines the complications observed have aortic atresia. This infant tolerated laborin the 81 cases for which complete delivery data and was delivered vaginally, but succumbed onis available. day four during attempted corrective surgery.

4 DiscussionExternal manipulation of the fetus can convert60 — 90% of breech presentations to cephalicdepending upon technique, the skill of the op-erator, use of tocolysis, and the population se-lected for trial [6, 7, 9, 13, 14, 16, 18, 20, 21].The relative influence of gravity, uterine shape,or placentation in eventual fetal polarity is notestablished [15, 19]. At the beginning of the 3rdtrimester, 20 — 30% of fetuses present by thebreech. However, as gestation proceeds, enlar-gement of the fetus, diminution of amnioticfluid volume, and adjustment of the uterus pre-dispose to cephalic presentation. Studies of fetallife note that the infant spontaneously assumesa cephalic presentation by the 34th week ofgestation in all but 2—4% of normal pregnan-cies [19]. Thus, if version is attempted in theearly 3rd trimester it is often easy, but fre-quently unnecessary, and re-version may occur.However, once a pregnancy passes into the late3rd trimester, spontaneous version is uncom-mon (< 15%), and the probability of the exist-ing presentation persisting to term is high.These facts must be considered in the criticalevaluation of the role of ECV in the obstetricalmanagement of malpresentation.In this study, 16 of 101 patients were excludedfrom trial of version by the combined resultsof real time ultrasonic scanning and EFM. Inone case, with spontaneous contractions, suspi-cious decelerations occurred in a pregnancy inwhich the fetus was found to be growth retard-ed. In the other instance, a large fetal encepha-locele was observed on the initial ultrasoundscan. On initial scanning 11 fetuses were foundto be in cephalic presentation and version wasnot attempted. Marked oligohydramnios led tothe exclusion of 3 additional cases early inthe course of the study. Yet, one serious fetalanomaly was missed. We evaluated and success-fully verted a fetus that subsequently proved to

Transient fetal heart decelerations frequentlyaccompany version attempts and were observedin this series [16]. In some instances maternalsymptoms implied a supine hypertensive syn-drome likely exacerbated by the abdominal ma-nipulations of version. In most circumstances,however, the changes were of unestablishedcause but were likely due to transient cordcompression. In our series, re-version for per-sisting fetal bradycardia was never necessaryand in no instance was acute delivery requiredfor conditions arising from the procedure.However, one compound (head/arm) presenta-tion occurred following version. In this case,dystocia ensued during labor and operative de-livery was necessary. Such complications, albeituncommon, have been previously observed [1].

The single serious fetal complication in thisseries, meconium aspiration, occurred in a va-ginally delivered breech infant. An unsuccessfulversion attempt had occurred 16 days pre-viously. While meconium was present in 8 addi-tional cases, in none was it associated with fetaldistress. A larger series is needed to establishany association between the manipulations ofversion and meconium passage. The other com-plications observed, cord prolapse, and a mar-ginal abruptio placentae occurred more than10 days after ECV and are difficult to ascribeto the procedure.

Clinically, failure to elevate the presenting partwas the most consistent cause of ECV failure.We could not discern specific ultrasonic find-ings that others have reported [7, 10, 20] pre-dicting success in version, except engagementof the breech. In our series attempted vaginalmanipulations to dislodge an engaged breechwere in all but one instance unsuccessful as wellas uncomfortable for the patient. In addition,neither placental locale nor low amnionic fluidvolume (unless marked oligohydramnios waspresent) modified our version protocol. Noneof the gravids examined in this series had clini-cal or ultrasonic evidence of placentation suffi-



ciently low lying to permit the diagnosis ofplacenta previa. Further, we did not observedifferences in success based on placental locali-zation.Initially, we utilized terbutaline tocolysis onlyin cases in which initial manipulation failed toachieve easy version. However, we soon dis-covered that betamimetic assisted version waseasier for both patient and operator, and there-after, we administered tocolytics routinely(overall in 43/85 or 50.5%). Betamimetics arenot without serious complications, but neitherwe nor others have observed complicationsfrom acute administration for ECV [6, 14, 18].Terbutaline was chosen because of our success-ful prior experience with this agent; the routeof administration by convenience and economy.Due to the fact that our patients frequentlytraveled long distances for the procedure andwith uncertainties of patient follow-up, weroutinely administered immune globulin to allRh negative patients with an ECV attempt [9,11, 12]. In series in which KLEINHAUER-BETKEstudies have been performed, 4 — 28% of ver-sion patients have shown evidence of measur-able fetomaternal bleeding [8, 16].

Based on our experience, factors important tothe success and safety of late third trimesterversion include:

1) Operator experience and careful patient se-lection,

2) The use of firm but smooth movements dur-ing manipulation,

3) Screening by both real time ultrasound andelectronic fetal heart rate monitoring,

4) The use of tocolysis,5) A setting permitting prompt intervention if

required.

In sum, while the numbers involved in this trialare limited, we conclude that major risks donot accompany late 3rd trimester version ifreasonable care is taken and careful pre-at-tempt fetal evaluation is performed. However,practitioners and patients need to remain awarethat fetal manipulations cannot invariably befree from complications [1, 2, 3, 4, 8, 12]. Thus,it seems prudent to carefully evaluate the fetusboth anatomically as well as biophysically priorto an attempt at version in a setting whereintervention, if indicated, is possible.

Summary

Eighty-five normal women underwent external cephalicversion (ECV) for breech presentation in the late 3rdtrimester (figures 1, 2). The protocol included real timeultrasonic scanning and pre- and post-procedure elec-tronic fetal monitoring. Subcutaneous terbutaline sulfate(0,25 mg.) was administered to (43/85 or 50.5%) of ECVcandidates and rendered the procedure easier for patientand operator. A single operator, head-over-heels tech-nique assisted by supine TRENDELENBERG'S position wasused. Rh negative women were routinely administered300 meg of immune globulin. Successful ECV (53/85,62.5%) was related to maternal parity, but not tp gesta-tional age nor eventual delivery weight (tables I, II).There were no acute maternal or fetal complicationsreferrable to ECV. One neonatal loss occurred due to alethal congenital cardiac anomaly (table IV). In thisseries only engagement of the breech was reliable inpredicting ECV failure.Fifty of 51 (98.1%) successfully verted women delivereda cephalic presentation infant at term. Cesarean sectionwas performed in 5/51 of these patients (9.8%) for

routine obstetrical indications. In one case, compoundpresentation at term resulting in dystocia and eventualcesarean section was believed related to prior successfulversion. In contrast, 15/30 (50%) of the ECV failurepatients went on to operative delivery despite a liberalinstitutional policy toward term vaginal breech trials. Inaddition, the only serious fetal complication in thisseries, meconium aspiration, occurred in a vaginallydelivered breech infant (tables III, IV).It is unlikely that late 3rd trimester ECV will impact onour overall rate of cesarean delivery. In North Americaprematurity is the greatest risk factor in malpresentationand our policy increasingly is to permit attempts atterm breech vaginal delivery. Nonetheless, ECV deservesserious consideration. When successful, ECV avoids thecosts and/or risks of either cesarean section or vaginaltrial of breech. As opposed to version practiced earlierin gestation, the merit of late 3rd trimester ECV isthat more than 80% of spontaneous versions will haveoccurred by the time the procedure is attempted. Thus,most successful late version procedures occur in cases


194 O'Grady et al., External cephalic version

- rwhere spontaneous conversion is unlikely. In addition,babies successfully verted late in gestation are unlikelyto spontaneously revert to breech (1/51 or 2% in ourseries).

Keywords: Breech presentation, external cephalic version, late pregnancy tocolysis.

Under the protocol described herein, and in a limitedseries of patients, we have found late 3rd trimester ECV62.5% successful and clinically safe.

Zusammenfassung

Äußere Wendung — ein klinischer ErfahrungsberichtWegen Beckenendlage (BEL) im fortgeschrittenen drit-ten Trimenon wurde bei 85 Frauen eine äußere Wendungvorgenommen (Abb. l, 2). Zur Protokollierung gehörteneine Ultraschall-Untersuchung sowie ein elektronischesMonitoring des Feten vor und nach der Wendung.Durch subkutane Injektion von 0,25 mg Terbutalinsulfatbei 43 von 85 Frauen (50.5%) wurde der Vorgang fürPatient und Operateur erleichtert. Die Wendung wurdeim Sinne einer Rückwärtsrolle des Feten durch einePerson ausgeführt. Rh-negativen Frauen wurde routine-mäßig 300 g Anti-D verabreicht. Die erfolgreichenWendungen (53 von 85, d. h. 62.5%) wurden zur Parität,nicht aber zum Gestationsalter oder zum geschätztenGeburtsgewicht in Beziehung gesetzt (Tabellen I, II).Akute mütterliche oder fetale Komplikationen, die aufdie Wendung zurückzuführen waren, traten nicht auf.Ein neonataler Todesfall war auf eine angeborene letaleHerzmißbildung zurückzuführen. Über den Erfolg bzw.Mißerfolg einer Wendung entschied in der Untersu-chungsreihe allein die Lage des Steißes.50 von 51 Frauen mit erfolgreicher Wendung (98,1%)wurden am Termin von einem Kind aus Schädellageentbunden. Dabei war bei 5 der 51 Frauen (9,8%) ausverschiedenen geburtshilflichen Gründen eine Sectio in-diziert. In einem Fall kam es am Termin zu einer Dysto-kie und schließlich zu einer Sectio; hier glauben wir,einen Zusammenhang zu der vorher erfolgreich durchge-führten Wendung herstellen zu können. Auf der anderen

Seite wurden 15 von 30 Frauen (50%) nach erfolgloserWendung per Sectio entbunden, obwohl wir bezüglichvaginaler BEL-Geburten einen liberalen Standpunkt ein-nehmen. Die einzige ernsthafte Komplikation, eine Me-koniumaspiration, trat in unserer Untersuchungsreihejedoch bei einem Kind nach vaginaler BEL-Geburt auf(Tabellen III, IV).Es ist unwahrscheinlich, daß eine Wendung im fortge-schrittenen dritten Trimenon einen Einfluß auf die Ge-samtsectiorate hat; in Nordamerika ist Frühgeburtlich-keit der größte Risikofaktor für BEL. Ein anderer Punktist die Haltung zu vaginalen BEL-Geburten am Termin.Trotzdem soll die äußere Wendung ernsthaft erwogenwerden; ist sie erfolgreich, werden Kosten und Risikeneiner Sectio bzw. einer vaginalen BEL-Geburt vermie-den. Der Hauptvorteil gegenüber einem frühen Wen-dungsversuch liegt darin, daß bei der Wendung im fort-geschrittenen dritten Trimenon mehr als 80% der Wen-dungen bereits spontan erfolgt sind. Die späten Wen-dungsversuche werden also dann durchgeführt, wenneine spontane Drehung unwahrscheinlich ist. Hinzukommt, daß nach einer erfolgreichen späten Wendungdas Zurückdrehen in die BEL unwahrscheinlich ist (lvon 51 bzw. 2% in unserer Untersuchungsreihe).Bei der beschriebenen Vorgehensweise und dem begrenz-ten Kollektiv können wir sagen, daß die äußere Wen-dung im fortgeschrittenen dritten Trimenon in 62,5%der Fälle erfolgreich und klinisch sicher war.

Schlüsselwörter: Äußere Wendung, Beckenendlage, Tokolyse in der Spätschwangerschaft.

Resume

Version par manoeuvres externes — experience cliniqueQuatre-vingt cinq femmes normales ont subi une versionpar manoeuvres externes (VME) a la fin du troisiemetrimestre pour une presentation du siege (figures l, 2).Le protocole comprenait une echographie en temps reelet un enregistrement du rythme cardiaque foetal avantet apres les manoeuvres. On a administre en sous-cutanedu sulfate de terbutaline (0.250 mg> a 43 canditates a laVME sur 85 (50,5%) ce qui facilitait les manoeuvrespour les patientes et pour Foperateur.Un seul Operateur utilisait la technique de la tete sur lestalons aide d'une position de trendelenbourg. Les fem-

mes rhesus negatif ont re$u systematiquement 300 mcgde gammaglobuline. Les succes de la VME (53/85;62,5%) sont correles a la parite maternelle, mais ni äTage gestationel, ni au poids de naissance (tableaux I,II). II n'y a pas eu de complication aigüe maternelle oufoetale implicable ä la VME. Un deces neonatal estsurvenu, secondaire ä une anomalie cardiaque congeni-tale lethale (tableau IV). Dans cette serie, seul Fengage-ment du siege etait correle ä la prevision d'un echec dela VME.Cinquante des 51 (98,1%) ayant eu une version efficaceont donne naissance, ä terme, ä un enfant en presenta-



tion cephalique. Chez ces patientes, une cesarienne ä etepratiquee 5 fois/51 (9,8%) pour des indications obstetri-cales de routine. Dans un cas, un procubitus d'un mem-bre a terme a entraine une dystocie et on a considerela cesarienne comme secondaire a la version efficaceanterieure. A Finverse 15/30 (50%) des patientes ayanteu un echec de la VME ont subi une cesarienne malgreune attitude institutionelle liberale face aux sieges äterme. En outre, la seule complication foetale severedans cette serie, ä savoir une inhalation meconiale, estsurvenue chez un enfant en presentation du siege ne parvoie vaginale (tableau III, IV).II est peu probable que la VME a la fin du troisiemetrimestre influencera le taux global de cesarienne enAmerique du Nord et ceci pour deux raisons: la premiereest que la prematurite est encore le facteur de risque leplus important pour la presentation defavorables, et ladeuxieme est du ä une politique plus liberale de Faccou-

chement du siege par voie basse a terme. Neanmoins, laVME mnrite une consideration importante. Lorsqu'ellereussit la VME evite le coüt et/ou les risques de lacesarienne et de Paccouchement du siege par voie basse.A Foppose de la version pratiquee plus tot au cours dela grossesse, le merite de la VME a la fin du troisiemetrimestre est que plus de 80% des versions spontaneesauront deja eu lieu au moment de la tentative. Ainsi,beaucoup de versions efficaces par monoeuvres externestardives surviennent dans des cas ou la version spontaneeest peu probable. En outre, les foetus verses en presenta-tion cephalique tardivement au cours de la grossesse ontpeu de risque de se retourner spontanement en siege (I/51 ou 2% dans notre serie).Selon le protocole decrit ci-dessus et dans une serielimitee de patientes, nous avons trouve que la VME äla fin du troisieme trimestre ä 62,5% de succes et qu'elleest cliniquement sans danger.

Mots-cles: Presentation du siege, tocolyse de fin de grossesse, version par manoeuvre externe.

Acknowledgements: The paper was presented in part at the Society of Perinatal Obstetricians Annual MeetingFebruary 2—4, 1984, San Antonio, Texas.

References

[1] ANG LT: Compound presentation following ex-ternal version. Aust NZ Obstet Gynaecol 18 (1978)213

[2] BERG D, U KUNZE: Critical remarks on externalcephalic version under tocolysis. Report on a caseof antepartum fetal death. J Perinat Med 5 (1977)32

[3] BRADLEY-WATSON PJ: The decreasing value of ex-ternal cephalic version in modern obstetric practice.Am J Obstet Gynecol 123 (1975) 237

[4] BROSSET A: The value of prophylactic external ver-sion on cases of breech presentation. Acta ObstetGynecol Scand 35 (1956) 555

[5] COLLEA JV: The intrapartum management ofbreech presentation. Clin Perinatol 8 (1981) 173

[6] FALL O, BA NILSSON: External cephalic version inbreech presentation under tocolysis. Obstet Gyne-col 53 (1979) 712

[7] FIANU S, V VACLAVINKOVA: External cephalic ver-sion in the management of breech presentation withspecial reference to the placental location. ActaObstet Gynecol Scand 58 (1979) 209

[8] GJODE P, TB RASMUSSEN, J JORGENSEN: Feto-ma-ternal bleeding during attempts at external version.Br J Obstet Gynaecol 87 (1980) 571

[9] HOFMEYR GJ: Effect of external cephalic version inlate pregnancy on breech presentation and cesareansection rate: A controlled trial. Br J Obstet Gynae-col 90 (1983) 392

[10] KIRKINEN P, P YLOSTALO: Ultrasonic examinationbefore external version of breech presentation. Gy-necol Invest 13 (1982) 90

[11] MARCUS RG, H CREWE-BROWN, S KRAWITZ, JKATZ: Fetomaternal haemorrhage following suc-cessful and unsuccessful attempts at external ce-phalic version. Br J Obstet Gynaecol 82 (1975) 578

[12] POLLACK A: Transplacental hemorrhage after ex-ternal cephalic version. Lancet 1 (1968) 612

[13] RANNEY B: The gentle art of external cephalic ver-sion. Am J Obstet Gynecol 116 (1973) 239

[14] SALING E, W MULLER-HOLVE: External cephalicversion under tocolysis. J Perinat Med 3 (1975) 115

[15] STEVENSON CS: Certain concepts in the handling ofbreech transverse presentations in late pregnancy.Am J Obstet Gynec 62 (1951) 488

[16] STINE LE, JP PHELAN, R WALLACE, GS EGLINTON,JP VAN DORSTEN, BS SCHBFRIN: Update on externalcephalic version performed at term. Obstet Gynecol65 (1985) 642

[17] VAN DORSTEN JP: Safe and effective external cephal-ic version with tocolysis. Contemp Obstet Gynecol19 (1982) 44

[18] VAN DORSTEN JP, BS SHIFRIN, RL WALLACE: Ran-domized control trial of external cephalic versionwith tocolysis in late pregnancy. Am J Obstet Gyne-col 141 (1981) 417


196 OOrady et aL, External cephalic version

[19] VARTON CK: The behavior of the foetus in uterowith special reference to the incidence of breechpresentation at term. J Obstet Gynaecol Br Cwlth52 (1945) 417

[20] YEAST JD, TJ GAKITE: External version for breechfetuses — a neglected alternative? Contemp ObstetGyixecol 25 (1985) 45

[21] YLIKORKALA O, AL HARTKAINEN-SORRI: Value ofexternal version in fetal malpresentation in combi-nation with use of ultrasound. Acta Obstet GynecolScand 56 (1977) 63

Received September 10, 1984. Revised June 28, 1985.Accepted July 29, 1985.

John Patrick O'Grady, M. P.Chief, Maternal Fetal MedicineAssociate ProfessorDepartment of Obstetrics and GynecologyUniversity Hospitals of ClevelandMacDonald Hospital for Women2065 Adelbert RoadCleveland, Ohio 44106, U.S.A.

J. Perinat Med. 14 (1986)

Documents

j. Perinat Med. External cephalic version: a clinical