Why Midwives Are Not Permitted to Perform External Cephalic Version
External cephalic version (ECV) requires immediate access to emergency cesarean section capabilities and advanced obstetric skills to manage potentially life-threatening complications, which falls outside the standard scope of midwifery practice in most jurisdictions.
Serious Complication Risk Requiring Surgical Backup
ECV carries a 0.45-0.5% risk of serious complications including:
- Placental abruption requiring immediate cesarean delivery 1, 2
- Fetal distress necessitating emergency cesarean section (occurs in approximately 0.5% of cases) 1, 2
- Cord prolapse requiring immediate surgical intervention 1
- Fetal death (rare but documented, approximately 1 in 1000 cases) 1
The procedure must be performed with immediate access to an operating room for emergency cesarean section 3. This requirement inherently necessitates physician-level privileges and surgical team coordination that midwives do not possess.
Technical Complexity and Monitoring Requirements
ECV demands specific technical expertise and monitoring capabilities:
- Cardiotocography monitoring must be performed before and for 30 minutes after the procedure to detect transient fetal heart rate abnormalities, which occur in approximately 4.28% of cases 3, 1
- Parenteral tocolysis (β-mimetics or atosiban) should be administered to increase success rates, requiring physician prescription and monitoring 3
- Regional anesthesia is frequently used, particularly in twin gestations, requiring anesthesiologist involvement 4
Scope of Practice Limitations
The procedure requires:
- Surgical decision-making authority to immediately convert to emergency cesarean section when complications arise 3
- Advanced obstetric training in managing breech presentations and understanding cephalopelvic relationships 5
- Authority to administer tocolytic medications and manage their cardiovascular side effects 3
Critical Pitfalls
The most dangerous scenario is attempting ECV without immediate surgical backup—even a 5-10 minute delay in accessing cesarean capability could result in fetal death or severe neurological injury when complications occur 1, 2. Midwives appropriately refer breech presentations to obstetricians who can both perform ECV and immediately manage complications surgically.
The 57% success rate of ECV in appropriate candidates makes it valuable, but the requirement for emergency surgical intervention in 0.5% of cases makes it inherently a physician-performed procedure 4, 2.