Obstetrics Simplified - Diaa M. EI-Mowafi

Version

Definition

It is changing the transverse lie to a longitudinal one or replacement the presenting pole by the other. If the aim is to make the head the presenting part it is called cephalic version and if the breech will be the presenting part it is podalic version.

Types

• External version, usually cephalic.
• Internal podalic version.
• Bipolar podalic version.

EXTERNAL CEPHALIC VERSION

Indications

• Breech presentation.
• Transverse or oblique lie.

Procedure

• No anaesthesia as the pain is a safe guard against rough manipulations.
• The patient evacuates her bladder.
• She lies in a Trendelenburg position with exposed vulva to detect any vaginal bleeding.
• The foetal position is determined and FHS is auscultated.
• One hand is applied externally to the foetal head and the other on its buttock, the two poles are approximated to flex the foetus and rotation is done by the two hands simultaneously to bring the head lower down.
• 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.

INTERNAL PODALIC VERSION

Indications

• Retained second twin in a transverse lie.
• Some cases of shoulder presentation.

Prerequisites

• General anaesthesia to guard against pain and give uterine and pelvic relaxation.
• Evacuation of the bladder.
• Complete aseptic conditions.
• Cervix is fully dilated.
• Uterus is not tonically contracted.
• No previous uterine scar.
• Adequate liquor amnii (intact or recently ruptured membranes).
• No obstruction to vaginal delivery whether maternal as contracted pelvis or foetal as hydrocephalus.

Procedure

• Lithotomy position.
• Episiotomy in primigravida.
• The hand is introduced through the cervix into the uterus and grasp the lower foot if the back is anterior and the upper foot if the back is posterior,so that the back is kept anterior during delivery.
• The other hand is pushing the head upwards while the foot is brought downwards.
• The other foot is brought down and breech extraction is done.
• The birth canal is explored after delivery for possible injuries.

Complications

• Maternal:
  • Shock (in light anaesthesia) .
  • Premature separation of the placenta.
  • Rupture uterus.                         
  • Cervical lacerations.
  • Postpartum haemorrhage.       
  • Puerperal sepsis.
• Foetal:
  • Asphyxia due to premature separation of the placenta or entangling of the cord.
  • Complications of breech delivery.

BIPOLAR PODALIC VERSION

It is outmoded of modern obstetrics.

Indications

It was done in a partially dilated cervix for:

• Correction of a transverse lie in a dead or markedly premature foetus.
• Compression of placenta praevia.

Procedure

Under general anaesthesia, 2 fingers are passed through the partially dilated cervix, the foot is grasped, as in internal podalic version, pulled through the cervix while the other hand is assisting the version externally.

Complications

As internal podalic version but higher in incidence due to the partially dilated cervix and presence of the placenta lower down in case of placenta praevia.

Links

• Breech presentation : Guidelines, reviews

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Edited by Aldo Campana,