Correct Answer: B. External cephalic version
External cephalic version (ECV) is the first-line management for transverse lie at term in a woman with no contraindications. This patient is an ideal candidate: she is at 36+6 weeks (term), has adequate liquor, normal placenta, no obstetric risk factors, and a proven pelvis (two previous normal vaginal deliveries). ECV has a success rate of 50–60% in multiparous women and significantly reduces the need for cesarean delivery. The procedure involves gentle manipulation of the fetus through the abdominal wall to convert transverse lie to cephalic or breech presentation. It should be performed in a setting where emergency cesarean section is available, with tocolytics (nifedipine or terbutaline) to relax the uterus and improve success. Fetal heart rate monitoring before and after the procedure is mandatory. According to RCOG and ACOG guidelines (adopted in Indian practice), ECV should be offered to all women with transverse lie at term unless there are specific contraindications (placenta previa, previous cesarean with classical incision, rupture of membranes, fetal compromise, or maternal medical conditions). Success in multiparous women with adequate liquor and normal placenta is high, making this the most appropriate management to avoid unnecessary cesarean delivery.
Why the other options are wrong
A. Cesarean section — This is wrong because cesarean delivery is reserved for failed ECV or contraindications to the procedure. Performing primary cesarean section for transverse lie without attempting ECV first increases maternal morbidity (infection, hemorrhage, thromboembolism) and future obstetric complications. In a multiparous woman with a proven pelvis and no contraindications, ECV should always be attempted first. Cesarean section would be the fallback if ECV fails or is contraindicated. C. Expectant management — This is wrong because expectant management (watchful waiting) is not appropriate at 36+6 weeks with confirmed transverse lie. Transverse lie persisting beyond 36 weeks carries significant risk of cord prolapse, fetal compromise, and obstructed labor if vaginal delivery is attempted. Expectant management is only considered before 36 weeks when spontaneous version may still occur. At term with transverse lie, active intervention (ECV) is mandatory to prevent these complications. D. Induction of labor — This is wrong because induction of labor with transverse lie is contraindicated and dangerous. Labor with transverse lie leads to obstructed labor, uterine rupture, cord prolapse, and fetal death. Induction does not address the underlying malpresentation and would precipitate obstetric emergencies. The fetus must be in cephalic or breech presentation before labor is induced or allowed to progress. ECV must be attempted first to achieve a favorable presentation.
High-Yield Facts
- ECV success rate is 50–60% in multiparous women and 40–50% in nulliparous women; higher success with adequate liquor, normal placenta, and no uterine scars.
- Contraindications to ECV: placenta previa, previous classical cesarean, rupture of membranes, fetal compromise, maternal medical disease, or abnormal CTG.
- Tocolytics (nifedipine 10–20 mg or terbutaline 0.25 mg SC) are given 15–20 minutes before ECV to relax the uterus and improve success.
- Transverse lie at term carries risk of cord prolapse, obstructed labor, and fetal death if vaginal delivery is attempted; cesarean is needed only if ECV fails.
- Proven pelvis (two previous normal vaginal deliveries) is a favorable factor for ECV success and supports vaginal delivery after successful version.
Mnemonics
ECV FIRST (when to attempt) Early term (36+ weeks), Clear contraindications (none), Valid indication (transverse lie) → First-line, Interventional, Reduced cesarean, Success high, Tocolytics given CONTRA-ECV (contraindications) Classical cesarean, Oligohydramnios, Normal placenta (previa), Torn membranes, Recent bleeding, Abnormal CTG → avoid ECV
NBE Trap
NBE may lure students into choosing cesarean section by emphasizing "36+6 weeks" and "transverse lie," forgetting that ECV is the standard first-line intervention at term in uncomplicated cases. The trap is equating malpresentation with automatic cesarean delivery, rather than recognizing that ECV is the evidence-based, cost-effective, and safer approach in eligible candidates.
Clinical Pearl
In Indian obstetric practice, ECV is often underutilized due to fear of complications or lack of training, leading to unnecessary cesarean sections. However, in a multiparous woman with a proven pelvis and no contraindications, ECV has a >50% success rate and should always be offered before resorting to cesarean delivery—this reduces maternal morbidity and preserves future reproductive options.
_Reference: DC Dutta's Textbook of Obstetrics (8th ed.), Ch. 24 (Malpresentations); RCOG Green-top Guideline 20b (External Cephalic Version)_