VERSION BY EXTERNAL MANEUVER (VEM) (1) 

Dr. Claude Allouche, gynecologist
Ahuza Clinic, Ra'anana
058 726 02 64

MAZÉ? INDICATIONS AND CONTRAINDICATIONS

Definition
This is an obstetrical technique that consists of turning a fetus that is presented by the seat (“buttocks down”), in the cephalic position (“head down”).
The purpose of the external version is to reduce the risk of breech delivery by allowing delivery by cephalic presentation.
In Hebrew the external maneuver version translates to the word "ipukh" (היפוך)
 

Indications
A version by external maneuvers (VME) can be proposed between 35 and 37 weeks of amenorrhea when the fetus is presented by the seat or in transverse presentation.
Alternative techniques such as acupuncture or postural methods (Indian bridge position) can precede the VEM attempt, without replacing it in case of failure.

Contraindications
Certain situations constitute a contraindication to VEM:

scarred uterus;
Placenta previa;
Uterine malformation;
Fetal suffering.

WHAT ARE THE RISKS AND BENEFITS?

RISKS:

External Cephalic Version (ECV), known as "ipoukh" in Hebrew, is a common procedure with straightforward outcomes in the majority of cases.

Despite all the advancements and efforts, there still remains a low maternal and fetal risk:

Onset of uterine contractions;
Rupture of membranes with the risk of premature delivery;
Uterine bleeding;
Retroplacental hematoma with premature placental detachment;
Fetal distress requiring emergency cesarean section;
Intrauterine fetal death. This risk is very rare and is lower than the risk of mortality associated with vaginal breech delivery.
Due to these various risks, informed consent must be obtained from the patient prior to ECV.

BENEFITS:

Approximately 2.5% of fetuses present in breech position towards the end of pregnancy.
Breech presentation increases neonatal morbidity and mortality by a factor of 4 compared to cephalic presentation (the factor of 4 is approximate and should be considered in context as severe complications are rare when all precautions are taken).
Given these risks, a pregnant woman has about three times the risk of having a cesarean section when the fetus presents in breech position towards the end of pregnancy compared to cephalic presentation.
The goal of external cephalic version is therefore to reduce the risks of breech delivery or cesarean section by facilitating cephalic presentation.
The success rate of ECV is approximately 50%. In case of failure, based on various parameters, the decision for vaginal delivery or scheduled cesarean section is made by the obstetrician and the pregnant woman.
Other publications on the same topic:

HOW IS IT PERFORMED?

How is an external maneuver version (ipoukh in Hebrew) performed?

EMV is performed by manipulating the uterus with the hands. It is performed in the hospital or clinic, by an obstetrician, under ultrasound control.

These manipulations are supervised by a few precautions, before, during and after the version:

- Ultrasound verification of fetal presentation, abundance of amniotic fluid, placental location;

- Vaginal examination to assess the degree of descent of the fetal mobile;

- Fetal monitoring (recording of the fetal heart rate) to ensure the absence of pre-existing fetal distress;

- Administration of "tocolytics" (drugs that relax the uterine muscle) intravenously or in suppositories 30 minutes before ECV;

- Manipulation under ultrasound control;

- Checking of fetal monitoring immediately after ECV, then in the evening and the following day;

- Injection of anti-D gammaglobulins in the case of a negative Rh blood group

- Promptly report to the doctor the occurrence of abnormal uterine pain or genital bleeding occurring following ECV.

ECV itself:

- Patient lying on her back, legs slightly bent, empty bladder;

- Gently pressing on the lower pole of the fetus in order to raise it initially;

- Gradually supporting the fetal head in a forward rotation movement (or backward in case of failure), while continuing to raise the buttocks in the opposite direction.

- The version lasts about 5 minutes.

- The manipulations are unpleasant but not painful.

- Return home is the same day or the next day, depending on the team.

In case of failure, a scannopelvimetry or an MRI of the pelvis is prescribed in France in order to assess the dimensions of the maternal pelvis, as well as the evaluation of the fetal weight by ultrasound.

These two examinations are important in the decision of the delivery route during a breech presentation.