Version

• No anaesthesia 
• In breech presentation—The maneuver is carried out after 36 weeks in the labor delivery complex.
• A reactive NST should precede the maneuver

PRELIMINARIES:

• Patient evacuates her bladder
• Lies in a Trendelenburg position with thighs flexed,shoulders raised & exposed abdomen and vulva.
• The foetal position is determined and FHS is auscultated.
• “Forward roll” movement.
• Podalic pole is grasped by the right hand in a manner like that of Pawlik’s grip while the head is grasped by the left hand
• Intermittent Pressure is exerted to head and breech in opposite directions That keep trunk flexed and facilitates version.
• Again check FHS
• Hand is now changed one after other to hold   fetal poles to prevent crossing of hand
• Pressure is exerted till  head is brought to  lower pole of the uterus.
• Reactive NST should be obtained
• The FHS is auscultated again, if there is foetal distress lasting for more than 5 minutes, the foetus is returned back to its previous position as the cord might be coiled or entangled around the neck.
• If neither vaginal bleeding nor foetal distress results, an abdominal binder is applied to fix the new position and re-examined twice weekly. 
• If the original presentation returned again, the procedure of version can be repeated. 

CONTRAINDICATIONS:

• The association of placenta previa or congenital malformation of the uterus should be excluded.

EXTERNAL PODALIC VERSION

• Done when external cephalic version fails in transverse lie in case of the second baby of twins.

INTERNAL VERSION:

 

INDICATIONS:

• Transverse lie in case of the second baby of twins

CONDITIONS:

• Cervix must be fully dilated
• Liquor amnii must be adequate for intrauterine fetal manipulation
• Fetus must be living

CONTRAINDICATIONS:

• Neglected obstructed labor

PROCEDURES:

• Assessment of the lie, presentation and FHR
• Done under general or epidural anesthesia
• Position:Dorsal lithotomy
• If the podalic pole of the fetus is on the left side of the mother, the right hand is to be introduced in a cone-shaped manner and vice versa.
• Hand is pushed up into the uterine cavity until it reaches the podalic pole
• Then pass up to the breech and then along the thigh until a foot is grasped
• Foot is identified by palpation of the heel
• Leg is brought down by a steady traction, the cephalic pole is pushed up using the external hand.
• Delivery is completed with breech extraction during uterine contractions
• Routine exploration of the uterovaginal canal

COMPLICATIONS:

Maternal risk:

• Placental abruption
• Rupture of the uterus 
• Increased morbidity.

Fetal risk:

• Asphyxia
• Cord prolapse
• Intracranial hemorrhage

BIPOLAR VERSION:

INDICATIONS:

• Lesser degree of placenta previa when the fetus is dead, deformed or previable

PROCEDURE:

• Two finger dilated cervix
• Head is pushed upto one ilac fossa and one leg is grasped at ankle with simultaneous manipulation externally
• Bringing down one leg facilitates compression over the placenta and thereby stops the bleeding

Exam Question

 

• Indication of internal podalic version is Transverse lie of second twin
• Contraindication to External Cephalic Version are Contracted pelvis, Antepartum hemorrhage & Multiple pregnancy
• The danger of internal podalic version in obstructed labour is Rupture of lower uterine segment
•  Internal podalic version is done under General anaesthesia
• Incorrect about external cephalic version is Done at 34 week, Abruption of placenta is a complication & Done under general anesthesia
• External cephalic version is contraindicated in Twins, Placenta previa  
• External cephalic version (ECV) is CONTRAINDICATED in PIH
• A full-term multigravida is having breech presentation. Ideal management in this case would be External cephalic version followed by vaginal delivery
• Ideal management of 37 weeks uncomplicated breech pregnancy is External cephalic version and trial of vaginal delivery

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