Use of external cephalic version in Portuguese public hospitals.

The possibility of a noncephalic (breech) presentation at birth can be markedly reduced by the use of external cephalic version (ECV). Using ECV, practitioners place their hands on the woman's abdomen and gently turn the baby from the breech to cephalic position. A major review reported that ECV at or near term (≥36 weeks) reduced the occurrence of noncephalic births by 62% and the rate of cesarean section by 45%. In New Zealand and in many other countries, ECV is now recommended to all eligible women presenting with breech presentation at birth. This prospective study assessed: (1) the success rate for ECV at a tertiary teaching hospital in New Zealand, (2) the factors predicting success, (3) perinatal outcomes among women who underwent ECV, and (4) the percentage of women with term breech presentation who attempted the procedure. From 2002 to 2006, a prospective audit was conducted in all women with singleton breech presentation ≥36 weeks who attended the ECV clinic. Of the 255 women presenting for ECV, the procedure was successful in 150 (59%). Multivariate analysis showed that an unengaged presenting part was the strongest predictor of success; the adjusted relative risk (aRR) was 3.3, with a 95% confidence interval (CI) of 2.2 to 5.1. Other predictors of success were multiparity (aRR, 1.2; 95% CI, 1.0-1.4), and a lateral spine position (aRR, 1.5; 95% CI, 1.1-2.0). Among the 150 women with successful ECV, 100 (67%) had a vaginal birth; of the 105 women with unsuccessful ECV, only 1 had a virginal birth. To prevent 1 caesarean birth, 3 women had to attempt ECV. The rate of referral was low; only 26% of women with singleton term breech presentation attempted ECV. The success rate of ECV in reducing beech presentation at term in this study is consistent with that reported in previous studies. The procedure restored the rate of cesarean section to that of a cephalic singleton pregnancy at term. Further study is needed to address the low rate of referral and barriers to use of ECV in this population.

There is good evidence to support the use of external cephalic version (ECV) to reduce non-cephalic presentation at birth and promote cephalic vaginal birth (Hofmeyr et al. Cochrane Database Syst Rev 2012, Issue 10). ECV is considered a safe procedure for women with a breech-presenting fetus and no contraindication to the procedure. Major obstetric and midwifery societies recommend that ECV be offered to all women with otherwise low-risk pregnancies who have a breech presentation at (or near to) term. However, studies in a variety of jurisdictions indicate that not all obstetricians who provide maternity care offer ECV. As a result, women with breech presentations do not have universal access to ECV and uptake of the procedure among eligible women is considerably lower than it might be. These findings suggest a need to reconsider ECV as a procedure available primarily through referral care and raises the question as to why all primary-care providers are not providing ECV as part of low-risk antenatal care. Midwives have a long history of involvement in repositioning of the fetus that dates back to antiquity. There are reports that, in the time of Aristotle, midwives were directed to turn the fetus and position the head to present at birth. In more modern times, and up until the mid-1970s many midwives and family physicians (general practitioners) offered ECV as part of their routine care to low-risk pregnant women. Considering the practice developments around ECV since then might aid us in understanding why the question of who should be undertaking ECV is now, more than 40 years later, under debate. In the mid-1970s, following a publication that showed increased mortality and morbidity associated with ECV (Bradley-Watson Am J Obstet Gynecol 1975;123:237–40) and promoted caesarean for breech presenting fetuses, ECV was all but abandoned in many jurisdictions. The subsequent introduction of tocolysis as an adjunct to ECV relaxing the uterus and allowing ECV to be undertaken at term gestation, shifted the procedure from the realm of primary into secondary care. However, in 2012, WHO recommended that midwives perform ECV in the context of rigorous research (World Health Organization. 2012; ISBN 978 92 4 150484) and recent reports of midwife-provided ECV demonstrate safety and efficacy outcomes similar to those of their obstetric peers (Taylor et al. Br J Midwif 2003;11:207–21; Beuckens BJOG 2015;122:DOI: 10.1111/1471-0528.13234). It is certain that midwives (or family physicians or general practitioners) undertaking ECV should have adequate training in the procedure. Further, arrangements for adequate assessment and follow up of women are essential, including if necessary referral to secondary (obstetric) care for management of rare outcomes that could require surgical delivery. This need for interdisciplinary collaboration perhaps begs a more interesting debate around how to best organise access for all women to ECV. There are reports of successfully run ECV clinics where a few practitioners in a community develop particular expertise with the procedure. When a clinic is run on a regular basis, it is likely that more practitioners will refer their clients for ECV, as scheduling and making arrangements is likely to become more straightforward. Inter-professional approaches might make such approaches more feasible in some communities. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

External cephalic version in twin pregnancies with non-vertex-presenting twin.

IntroductionInternational guidelines recommend that external cephalic version (ECV) be offered to all women with single fetuses in breech presentation at term. In Norway, ECV is not offered routinely; the national clinical guidelines advice that birth units capable of offering ECV for breech pregnancies make their own practice decisions. This study was performed to determine the extent to which Norwegian birth units offer ECV to pregnant women with fetuses in breech presentations at term, and to identify factors that might influence the use of ECV. Material and methodsA survey of all 39 obstetric birth units providing ECV in Norway was conducted using a self‐reporting questionnaire about ECV availability, attitudes, clinical procedures, perceived competence, and outcome expectations. ResultsChief obstetricians from all birth units responded. Twenty-six (67%) respondents reported that their units offered ECV for breech presentation at term to a large degree. Thirty-one (80%) respondents reported a large degree of competence in performing ECV. Thirty-three (85%) units followed local ECV procedures. Nineteen (49%) units provided standardized information about the procedure to pregnant women. The respondents had different views about who should be offered ECV, and varying knowledge about ECV outcomes. ConclusionsThe majority of Norwegian birth units offer ECV to pregnant women with fetuses in breech position to a large extent. However, the survey results reveal challenges related to ECV information provision to pregnant women, determination of women’s eligibility for ECV attempts, and familiarity and agreement with the knowledge base regarding ECV.

External cephalic version (ECV) can effectively reduce the chance of non-cephalic presentation at birth and reduce caesarean section rate for breech presentation at term. It is recommended in New Zealand to offer ECV to all eligible women with breech presentation at term. This study aims to determine the ECV success rate at our hospital, factors that predict ECV success, and perinatal outcomes for women who had ECV, and to estimate the ECV attempt rate at our hospital. A prospective audit was performed of all women with singleton non-cephalic presentation>or=36 weeks who attended the ECV clinic at National Women's Health in Auckland from July 2002 to January 2006. Two hundred and fifty five women presented for ECV during the study period, and the ECV success rate was 59%. The strongest predictor of ECV success was an unengaged presenting part. Women with successful ECV had a vaginal birth rate of 67%. Three women needed to have an ECV attempt in order to prevent one caesarean section. We estimated that 26% of women with term breech presentation had an ECV attempt. ECV at National Women's Health is effective at reducing beech presentation at term and at restoring a caesarean section rate equivalent to that of cephalic singleton pregnancy at term. However, the low rate of referral should be addressed.

IntroductionBreech presentation complicates 3–4% of all deliveries. Vaginal breech delivery is associated with increased risk to the fetus. External cephalic version (ECV) can avoid the need for caesarean section. The...

Use of External Cephalic Version for Breech Pregnancy and Mode of Delivery for Breech and Twin Pregnancy: A Survey of Canadian Practitioners

The overall incidence of breech presentation at delivery remained at 2 to 3% in a unit where external cephalic version (ECV) was the preferred treatment option for term singleton breech presentation. The objective of this study was to investigate which factors accounted for this high residual incidence, so that the impact of ECV could be further increased. All breech deliveries and ECVs over a 1-year period in a teaching hospital are reviewed. The incidence of term singleton breech delivery was 1.96% among 7,702 total deliveries. There were 115 patients counselled for ECV, of which 15.7% declined the offer and 4.1% went into labour before their scheduled ECV. Among the 93 ECVs performed, 74 were successful and 56 delivered vaginally in cephalic presentation. ECV was not performed in 131 cases. The major reasons were patients' refusal (13.7%), breech first diagnosed in labour or after rupture of membranes (44.3%), oligohydramnios or growth retardation (9.9%) and previous Caesarean section (8.4%). Only 5 patients were not counselled for ECV in the absence of contraindications. The practice of ECV reduced the overall Caesarean section rate by 0.65%, or 4.3% of the total number of Caesarean sections. In conclusion, ECV at term definitely reduces the Caesarean section rate. However, it is unlikely that the overall Caesarean section rate could be reduced by more than 1% even with 100% uptake of ECV unless the use of ECV is to be extended to those with prior Caesarean section, ruptured membranes, oligohydramnios, growth retardation or those who are in labour.

There is increasing use of external cephalic version (ECV) in women with previous cesarean delivery (CD) and a breech-presenting fetus who want a vaginal delivery. However, clear evidence to support its use is lacking and some clinicians believe that prior CD is a relative contraindication for a trial of ECV. This retrospective study investigated the effectiveness and safety of ECV in a study group of 42 singleton women with 1 previous cesarean delivery (CD) and a breech-presenting fetus at term. The study was conducted at a single medical center between 1997 and 2005. The comparison group was multiparous women at the same institution who had an ECV without a previous CD during the same time period. A Medline search was performed for the years 1966–2008 to provide data from other published studies evaluating attempted ECV in women with prior CD. The success rate of ECV was 74.0% (31/42) in the study group and 72.3% (251/347) in the comparison group. Eighty-four percent of the study group women with successful ECV were delivered vaginally and 91% with failed ECV delivered by CD. Among the 162 publications from the Medline search, the 4 meeting inclusion criteria included a total of 124 patients and had a mean ECV success rate of 76.6%. Adding data from this study to that in the 4 Medline reports showed an average success rate of 76.5% for ECV performed in 166 women with 1 previous CD. There were no serious maternal or fetal complications or outcomes with a rate of emergency CD of only 0.6% (1/166 cases). Accumulating evidence for the efficacy and safety of ECV among women with a breech presenting-fetus at term and previous CD leads the investigators to conclude that such women who desire a vaginal delivery should be offered a trial of ECV.

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

External Cephalic Version: Some Tricks of the Trade.

In recent years external cephalic version (ECV) has been increasingly recommended as a safe alternative to either vaginal breech delivery or cesarean delivery. Reports suggest that both the latter outcomes are in fact less frequent with ECV, but fetal risk has not been reliably assessed. This study is a 10-year review of ECV performed at three hospitals from 1988 through 1997. Women having a single fetus in breech presentation, confirmed ultrasonically, were entered into the study when they agreed to attempted version. Version was done using a tocolytic agent, ritodrine, to relax the uterus, but without maternal analgesia. Electronic fetal monitoring was used to detect fetal cardiac dysfunction. The “forward roll” version technique was used; a “back flap” technique was occasionally tried if the fetus did not cross the midline. A second attempt was allowed if the first failed or if the fetus resumed a breech position. Among 923 women enrolled in the study, ECV succeeded in 62.7% of cases, with comparable rates at all three participating hospitals. Success rates were higher in multiparas than in nulliparas (76.6% vs. 55.3%), with a normal amniotic fluid volume (93% with polyhydramnios vs. 65% with a normal fluid volume and 29.6% with oligohydramnios), and incomplete compared with frank breeches (77.3% vs. 56.6%). Version succeeded in converting 72% of 30 transverse-lie fetuses. Two-thirds of 19 women having previous cesarean delivery and three-fourths of those undergoing myomectomy had a successful outcome. Logistic regression analysis disclosed that polyhydramnios was the strongest predictor of success, with a relative risk of 5.8. Version attempted on a multipara or for incomplete breech was 2.5-fold likelier to succeed than when done on a nullipara or for a frank breech. A posterior rather than anterior placenta also was a favorable factor. A second attempt succeeded in 10 of 24 women when the initial attempt failed and in all 8 women when an initially successful result reverted to breech. The risk of vaginal bleeding after version was 1.5%, and that of transient fetal bradycardia, 5.8%. The rate of cesarean delivery was 43% at these hospitals, where it is standard practice to perform cesarean delivery in cases of breech presentation. With one exception (femoral fracture when cesarean delivery followed a failed version), neonatal outcomes were favorable. The investigators believe that ECV is effective in lowering the need for cesarean delivery in term infants in breech presentation. No major adverse infant outcomes have been noted.

The use of external cephalic version (ECV) is increasingly seen as an important clinical management strategy for breech presentation infants. Currently, 75% of women with breech presentation at term undergo Cesarean delivery risking adverse outcomes and incurring higher costs. ECV, if successful, reduces the rate of breech presentation at delivery and the need for Cesarean delivery. Data from an inner-city population of delivering women were examined to determine the effectiveness of ECV among these minority, low income women. Hospital clinical and Medicaid claims data for 679 deliveries with breech presentation were studied. Decision tree analysis indicated ECV was successful for 48% of those attempted. Based on amounts billed Medicaid, attempting ECV reduced the use of resources by a little over $3,000 per delivery. Sensitivity analysis showed, however, that the savings may be as low as $906. Multivariate analysis confirmed the independent effect of attempting ECV on the probability of Cesarean delivery.

External Cephalic Version (ECV) and the Early ECV Trial

The aims of this study were to assess whether a regional simulation-based training course in external cephalic version (ECV) would lead to the adoption of this technique in hospitals where it was not previously practiced, and to improve success rates in those already performing it. This was an intervention study where two specialists in obstetrics and gynecology from 10 Portuguese public maternity hospitals attended a structured simulation-based training in ECV. Hospitals were categorized based on whether ECV was conducted prior to the training program, and on their annual number of deliveries. Main outcomes were the number of ECVs performed in the 2 years before and after the course, and their success rates. Implementation of ECV was achieved in four additional hospitals during the 2 years following the course. Among the three hospitals already performing ECV and able to report their data, no significant differences in success rates were observed in the 2 years following the course (45.6% vs. 47.9%, P = 0.797). After a successful ECV, 77.7% of women had a vaginal delivery. A regional simulation-based training course in ECV led to an increase in the number of hospitals implementing the technique in the subsequent 2 years, but it did not impact the success rates in centers where it was already performed. This study highlights the potential of simulation-based courses in ECV, as well as the need to improve patients' access to the technique and to centralize ECV services at a regional level.