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External Cephalic Version

External Cephalic Version involves applying pressure to a woman’s abdomen to manipulate the fetus and turn it from breech to vertex presentation, which increases the likelihood of a vaginal delivery. Interest in the technique has increased in light of medicine’s movement to decrease caesarean deliveries, which particularly in North America has been standard procedure for breech presentations.
The American College of Obstetricians and Gynecologists (ACOG) now recommends that all eligible women with breech presentations who are near term should be offered external cephalic version (ECV) to cut down on the number of caesarean deliveries. It is a valuable management technique and, in a properly selected population, poses little risk to either the woman or the fetus. If successful, ECV provides a clear benefit to the woman by allowing her an opportunity for a successful vertex vaginal delivery. Obstet Gynecol. 2016;127:412-413
Spontaneous version of a breech presentation usually occurs by 36 weeks and is less likely after that time.
How effective is ECV in preventing non-cephalic birth?
• The success rate of ECV is approximately 50%.
• A successful ECV reduces the chance of caesarean section.
• Few babies revert to breech after successful ECV.
• After an unsuccessful ECV attempt at 36 weeks of gestation or later, only a few babies presenting by the breech will spontaneously turn to cephalic presentation.

Potential complications
There is no general consensus on the eligibility for, or contraindications to, ECV.
ECV after one caesarean delivery appears to have no greater risk than with an unscarred uterus.
Although case reports of placental abruption and large feto-maternal haemorrhage exist, complications associated with ECV are very rare. In a 2015 Cochrane systematic review, Hofmeyr et al.reported no significant differences in Apgar scores, neonatal admission or perinatal death according to whether ECV had been performed or not. A number of large consecutive series have reported no fetal deaths attributable to the procedure.
The reported risk of emergency caesarean section within 24 hours is approximately 0.5%, with the indication in over 90% being vaginal bleeding or an abnormal CTG following the procedure
If, after ECV, the breech persists, the best mode of delivery should depend on expertise of the healthcare provider.
References
• Royal College of Obstetricians and Gynaecologists. Management of Breech Presentation. Green-top Guideline No. 20b. London: RCOG; 2017.
• Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2015;(4):
• Tong Leung VK, Suen SS, Singh Sahota D, Lau TK, Yeung Leung T. External cephalic version does not increase the risk of intra-uterine death: a 17-year experience and literature review. J Matern Fetal Neonatal Med 2012;25:1774–8.
• Collins S, Ellaway P, Harrington D, Pandit M, Impey LW. The complications of external cephalic version: results from 805 consecutive attempts. BJOG 2007;114:636–8
• Leung TY, Lau TK. Prediction of outcome of external cephalic version for breech presentation at term. Fetal Matern Med Rev 2005;16:245–62.
• Burgos J, Cobos P, Rodrıguez L, Osuna C, Centeno MM, , et al. Is external cephalic version at term contraindicated in previous caesarean section? A prospective comparative cohort study BJOG 2014;121:230–5; discussion 235.
• Coyle ME, Smith CA, Peat B. Cephalic version by moxibustion for breech presentation. Cochrane Database Syst Rev 2012;(5):

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Exercise in Pregnancy

There is almost always a decline in physical activity during pregnancy in healthy pregnant women. A high proportion of pregnant women do not participate in any physical activity or exercise, putting them at increased risk of obesity, gestational diabetes mellitus (GDM), and other pregnancy-related diseases and complaints.
In pregnancy the expanding uterus displaces the centre of gravity, which results in the woman compensating to avoid falling forward. This may result in progressive lumbar lordosis and anterior rotation of the pelvis. Postural balance is affected after the first trimester of pregnancy. Subsequently, falling is a common cause of injury in the general pregnant population, and pregnant women are 2–3 times more likely to be injured by falling than are non-pregnant women. This should be taken into consideration when considering the type of exercise. Exercise training in pregnant women is influenced by the physiological changes however women with low-risk pregnancies can undertake the major types of training during pregnancy.
Physically active women are also less likely to develop pre-eclampsia
Appl Physiol Nutr Metab. 2006 Dec;31(6):661-74.
Weissgerber TL1, Wolfe LA, Davies GA, Mottola MF.
Compared with non-exercisers, women who exercised before and during pregnancy had a 36% reduction in pre-eclampsia.

In the general obstetric population, studies have shown inconsistent results with respect to relationships between exercise/physical activity and gestational weight gain.

The 2016 Evidence Summary From the IOC Expert Group Meeting, Lausanne encouraged elite women athletes to continue to participate in all Olympic sport disciplines, with specific guidelines for endurance and peak performance training.

Several studies on the benefits of prenatal yoga (maternity yoga) have been reported in recent years. The findings suggest that prenatal yoga may help reduce pelvic pain. It may also improve mental condition (stress, depression, anxiety, etc.), physical condition at the delivery and perinatal outcomes (obstetrical complications, delivery time, etc.). Overall, the evidence that yoga is well suited to pregnancy is positive.
Field T. Yoga clinical research review. Complementary Therapies in Clinical Practice. 2011;17(1):1–8.

The American College of Obstetrics and Gynaecology recommends 30 minutes or more of moderate exercise per day, unless there is a medical or pregnancy complication.
Exercise is not recommended if –
• There is history of vaginal bleeding or spotting
• Low-lying placenta (praevia)
• A history of miscarriage or preterm delivery
• Cervical incompetence
Women who were exercising regularly before pregnancy, and who are healthy during pregnancy, should be able to continue exercising as before, with slight changes depending on the trimester.
Women who have not been exercising before pregnancy will benefit from taking up a low-intensity program and gradually increasing to a higher activity level.
Exercise is recommended for 20 to 30 minutes each day. Most exercises are safe to perform during pregnancy if done with caution.

References
• Koshino T. Management of regular exercise in pregnant women. Journal of Nippon Medical School. 2003;70(2):124–128.
• Monk C, Fifer WP, Myers MM, et al. Effects of maternal breathing rate, psychiatric status, and cortisol on fetal heart rate. Developmental Psychobiology. 2011;53(3):221–233.
• Melzer K, Schutz Y, Soehnchen N, et al. Effects of recommended levels of physical activity on pregnancy outcomes. American Journal of Obstetrics and Gynecology. 2010;202(3):266.e1–266.e6.
• Davies GA, Wolfe LA, Mottola MF, et al. Exercise in pregnancy and the postpartum period. J Obstet Gynaecol Can 2003;25:516–29.
• Royal College of Obstetricians and Gynaecologists. Exercise in pregnancy 2006:1–7.
• Evenson KR, Barakat R, Brown WJ, et al. Guidelines for physical activity during pregnancy: comparisons from around the world. Am J Lifestyle Med 2014;8:102–21.
• Cakmak B, Ribeiro AP, Inanir A. Postural balance and the risk of falling during pregnancy. J Matern Fetal Neonatal Med 2016;29:1623–5.