Role of individual provider in success of external cephalic version

Abstract

External cephalic version (ECV) decreases cesarean delivery for malpresentation. However, the procedure is successful in only 50% of patients. Prior attempts to predict ECV success have focused on patient factors. The role of the individual provider has not been well studied. The objective of this study was to evaluate the association between ECV provider and success rates while controlling for patient factors. We conducted a retrospective cohort study of all ECVs performed at a single academic hospital between July 2016 and December 2021. Patients who had ECVs by providers who performed at least 8 ECVs (median) during this time were included. Our primary outcome was a fetus in a vertex presentation following ECV. Patient and provider characteristics were compared between those with a successful and unsuccessful ECV with t-tests and Chi-square tests. We applied a previously published prediction model for ECV success to our entire population, which only contained patient factors (BMI, parity, placental location, and fetal presentation). We then compared this to a model with those factors and a fixed-effect for the performing provider. Delong’s test was used to compare area under the ROC curves. There were 354 ECVs included in the study with an overall success rate of 45.2%. Twenty providers were included, performing a median 16 ECVs during the study period (IQR 9-18.5). Individual provider ECV success rates ranged from 12 – 70%. The model for ECV that used patient factors produced an AUC of 0.70 (95% CI 0.65-0.75). With the fixed-effect term for provider, the AUC improved to 0.77 (95% CI 0.72-0.81), p=0.002. After accounting for patient characteristics, the incorporation of individual providers improved a prediction model for ECV success. This suggests individual providers have an impact on a patient’s chance of a successful ECV. Future investigations should focus on identifying characteristics and techniques of providers with high success rates that could be translated into educational or simulation programs for providers seeking to improve their success rates.