1. VERSION

2. Definition
Version is an operation in which the presentation of the fetus is artificially altered, either substituting one pole of the longitudinal fetus to the other, or converting an oblique or transverse lie into a longitudinal lie.

3. History Hippocrates Aeitus and Celsius Galen
Ambroise Pare (1510 – 1590)
Wigand (1807)
Braxton Hicks

4. Types of Version External Cephalic version Internal Podalic version
Bipolar version

5. External version Definition:
External cephalic version is done to convert a transverse lie or oblique lie or a breech presentation into a cephalic presentation by abdominal manipulation.

6. Indications
Breech Presentation
Transverse or oblique lie

7. Contraindications Multiple pregnancy Ante partum hemorrhage
Severe pregnancy induced hypertension
Major degree of pelvic contraction
Planned caesarean section
Scar on the uterus of previous surgery
Rh – isoimmunization
Preterm labour in current pregnancy
Patient is still preterm
Elderly primigravida
Threatened rupture of uterus
Conditions that contraindicate tocolytic agents
Gross fetal abnormality

8. Prerequisites for ECV Presenting part must not be engaged
Abdominal wall must be sufficiently thin to allow palpation
The abdominal and uterine wall must not be highly irritable
The uterus must contain sufficient amount of liquor amnii to allow easy movement of the fetus
Gestational age more than 32 weeks, referably 34 to 36 weeks

9. Technique

11. Postoperative Management
Bed rest in left lateral position
Tocolytic therapy for 2 hours
Monitor fetal heart rate every 15 minutes for 2 hours
Monitor maternal vital parameters every 15 minutes for 2 hours
Watch for bleeding per vaginum, leaking and abdominal pain

12. Causes for Failure Complications Too big baby
Too little amount of liquor
Frank breech
Obesity
Uterine leiomyomas
Uterine anomalies
Short umbilical cord
Complications
Preterm labour
Abruptio placenta
Looping of cord
Umbilical cord presentation
Intra uterine death
Premature rupture of membranes
True knots in the cord

13. Internal Podalic Version
Internal podalic version is the conversion of the fetal presentation from a transverse or cephalic presentation by both intrauterine manipulations as well as abdominal maneuvers

14. Indications Second twin in transverse lie
Failure of external cephalic version
Transverse lie in multipara with full cervical dilatation
Placenta praevia with excessive vaginal bleeding
Fetus (dead or too preterm) to survive after a caesarean section

15. Contraindications A scar on the uterus from a previous operation
Threatened rupture of the uterus
Multiple pregnancy
Congenital malformation of the uterus
Major degree of pelvic contraction
Placenta praevia degree III and IV

16. Prerequisites Cervix must be at least ¾ dilated
Membranes intact or just ruptured
Uterus contracting intermittently with relaxation in between

17. Technique Instrument trolley Iodine for part preparation
Simple urinary catheter
Sterile drapes:4
Sponge holding forceps:4
Version gloves:2 pairs
Episiotomy scissors
Instrument for suturing an episiotomy

18. 2. General anesthesia is given along with an uterine relaxant
3. Lithotomy position
4. Episiotomy is made
5. Glove application
6. Introduce the well lubricated right hand into the uterine cavity.
7. Rupture membranes if they are intact
8. Pass the hand on the dorsal aspect of the fetus to its ventral aspect along its breech. The superior leg is grasped and delivered across the ventral aspect of the foetus.
9. The leg is being brought down and the fetal head is manipulated abdominally and shifted to the uterine fundus.

19. 10. An immediate breech extraction may be planned.
11. Soon after the delivery, the uterine cavity is explored for injury
12. Halothane is discontinued.
13. Oxytocin infusion is started.

21. Complications Uterine rupture Postpartum hemorrhage Puerperal sepsis
Foetal injury or death

22. Role of a nurse External cephalic version
Check fetal heart rate before the procedure.
Pre medications
Fetal heart rate assessment soon after the procedure every 15 minutes for 2 hours.
Observe for vaginal bleeding contractions and leaking.
Internal podalic version
Arrange for blood
Preparation for general anesthesia
Arrange operation theatre
Resuscitation of newborn.

23. Thank you