External cepahlic version should be undertaken by midwives

There is good evidence to support the use of external cephalic version (ECV) to reduce non-cephalic presentation at birth and promote cephalic vaginal birth (Hofmeyr et al. Cochrane Database Syst Rev 2012, Issue 10). ECV is considered a safe procedure for women with a breech-presenting fetus and no contraindication to the procedure. Major obstetric and midwifery societies recommend that ECV be offered to all women with otherwise low-risk pregnancies who have a breech presentation at (or near to) term. However, studies in a variety of jurisdictions indicate that not all obstetricians who provide maternity care offer ECV. As a result, women with breech presentations do not have universal access to ECV and uptake of the procedure among eligible women is considerably lower than it might be. These findings suggest a need to reconsider ECV as a procedure available primarily through referral care and raises the question as to why all primary-care providers are not providing ECV as part of low-risk antenatal care. Midwives have a long history of involvement in repositioning of the fetus that dates back to antiquity. There are reports that, in the time of Aristotle, midwives were directed to turn the fetus and position the head to present at birth. In more modern times, and up until the mid-1970s many midwives and family physicians (general practitioners) offered ECV as part of their routine care to low-risk pregnant women. Considering the practice developments around ECV since then might aid us in understanding why the question of who should be undertaking ECV is now, more than 40 years later, under debate. In the mid-1970s, following a publication that showed increased mortality and morbidity associated with ECV (Bradley-Watson Am J Obstet Gynecol 1975;123:237–40) and promoted caesarean for breech presenting fetuses, ECV was all but abandoned in many jurisdictions. The subsequent introduction of tocolysis as an adjunct to ECV relaxing the uterus and allowing ECV to be undertaken at term gestation, shifted the procedure from the realm of primary into secondary care. However, in 2012, WHO recommended that midwives perform ECV in the context of rigorous research (World Health Organization. 2012; ISBN 978 92 4 150484) and recent reports of midwife-provided ECV demonstrate safety and efficacy outcomes similar to those of their obstetric peers (Taylor et al. Br J Midwif 2003;11:207–21; Beuckens BJOG 2015;122:DOI: 10.1111/1471-0528.13234). It is certain that midwives (or family physicians or general practitioners) undertaking ECV should have adequate training in the procedure. Further, arrangements for adequate assessment and follow up of women are essential, including if necessary referral to secondary (obstetric) care for management of rare outcomes that could require surgical delivery. This need for interdisciplinary collaboration perhaps begs a more interesting debate around how to best organise access for all women to ECV. There are reports of successfully run ECV clinics where a few practitioners in a community develop particular expertise with the procedure. When a clinic is run on a regular basis, it is likely that more practitioners will refer their clients for ECV, as scheduling and making arrangements is likely to become more straightforward. Inter-professional approaches might make such approaches more feasible in some communities. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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