Use of External Abdominal Ice to Complete External Cephalic Version in Term Breech Pregnancy

Case Report

The patient is a 36-year-old woman, gravida 4 para 3, whose only complicating factors during pregnancy were a history of herpes simplex virus infection and advanced maternal age. She underwent genetic counseling and level II ultrasound in the second trimester and was found to have no increased risk for trisomy 21. She was seen at the 36-week visit, and her physician determined that her fetus was in the breech position, confirmed by ultrasound

The patient was interested in pursuing both traditional and nontraditional methods of inducing cephalic version. She was instructed to assume knee-to-chest position twice a day for twenty minutes and scheduled for external cephalic version at 37 weeks’ gestation. Her physician also recommended that she apply ice to the fundus of her uterus for 20 minutes daily to induce spontaneous version. She agreed to do this and applied ice to her abdomen that evening at home. Within 10 minutes of initiation, she felt dramatic fetal movement. She returned to the office the next day and was confirmed to be in vertex position by ultrasound. She successfully delivered a vertex female infant at 39 weeks’ gestation.

Discussion

At 32 weeks’ gestation, approximately 16% of fetuses are in the breech position.1 This rate decreases to 3 to 4% at term. Historical data show that after 36 weeks, the chance of spontaneous version is only 25%.2 A wide range of success rates for external cephalic version are reported in the literature. Institutions routinely offering external cephalic version have success rates ranging from 35% to 76%.3–5 External cephalic version has been shown to decrease the number of noncephalic births as well as decrease the rate of cesarean delivery.3

Several nontraditional version methods have been previously evaluated. Moxibustion (burning of the herb Mugwort on acupuncture points) has been proven to increase rates of spontaneous versions in one clinical trial.6 The knee-to-chest position has also been proven to increase spontaneous version rates.7 Glyceryl trinitrate spray has minimal effect versus control group,8 and nitroglycerin has not proven to be successful9,10 in increasing likelihood of version. The use of epidurals and spinal anesthesia has not proven harmful but also has not been proven to statistically increase version success rates.11–13 Transabdominal amnioinfusion, although increasing risk to the fetus, has little increase in overall version success rates.14 Other ineffective methods include playing classical music between the legs of the patient and shining a light onto the abdomen just above the pubis.7

The mechanisms of moxibustion, knee-to-chest position, or glyceryl trinitrate sprays are unknown. However, the relative uterine relaxation that any of these techniques could cause may play a part in increasing spontaneous version. Ice application to the fundus of the uterus does not relax the uterus, so the most likely cause of spontaneous version in these patients is direct stimulus to the fetus inciting spontaneous version.

Conclusion

This report is the first known publication to describe application of ice to the uterine fundus to successfully induce fetal version. Abdominal ice has the potential to augment and perhaps even substitute for external cephalic versions if pilot studies confirm its efficacy and safety. Reducing the small, but defined, risks of placental abruption from manual version is a worthy goal to pursue.