Cephalic Version For Breech Presentation Research Articles

Retrospective Analysis of Pregnancy Outcomes Following External Cephalic Version for Breech Presentation.

We explored the feasibility and safety of external cephalic version (ECV) for cases of breech presentation. We retrospectively analyzed data from 158 singleton pregnant women with breech presentation at 36 weeks gestation, admitted to Guangzhou Hospital of Integrated Traditional and Western Medicine from January 2018 to March 2022. 42 underwent ECV, categorized as the ECV group, while 116 without ECV comprised the control group. Systematic collection and evaluation of pregnancy outcomes were conducted for both groups. Within the control group, 16 cases experienced a spontaneous transition to head presentation, among which 14 cases resulted in successful vaginal deliveries. In 2 cases, cesarean deliveries were performed due to fetal macrosomia and persistent posterior occipital presentation. Furthermore, 2 cases of breech presentation in pregnant women were successfully delivered vaginally through breech traction, necessitating an emergency procedure due to the wide opening of the uterus. Within the ECV group, 28 cases were successfully inverted to the cephalic presentation. Among them, 1 case underwent an emergency cesarean delivery due to fetal distress during cephalic delivery, 3 cases required cesarean deliveries due to abnormal labor, and 24 cases were successfully delivered vaginally. The comparative analyses showed that the cesarean section rate (18/42 vs 100/116) and non-cephalic delivery rate (14/42 vs 100/116) in the ECV group were significantly lower than those in the control group (P < 0.001). There was no statistically significant differences between the two groups with respect to the rate of newborns with Apgar score < 7 (1/42 vs 3/116), premature rupture of membrane (3/42 vs 20/116), acute fetal distress (2/42 vs 2/116), and cord prolapse (0/42 vs 1/116) (P > 0.05). ECV can effectively reduce the rate of cesarean delivery and non-cephalic deliveries. However, it but requires strict adherence to indications and continuous monitoring.

EXAMINING PREGNANCY OUTCOMES AFTER EXTERNAL CEPHALIC VERSION FOR BREECH PRESENTATION

External cephalic version (ECV) is a non-invasive procedure performed to reposition a breech fetus into the cephalic position before labor, thus reducing the risk of cesarean delivery. This study aims to examine pregnancy outcomes following external cephalic version for breech presentation. A retrospective analysis of maternal and neonatal outcomes was conducted among women who underwent ECV for breech presentation at a tertiary care center over a specified period. Data on the success rate of ECV, mode of delivery, neonatal outcomes, and maternal complications were collected and analyzed. The findings provide insights into the safety and effectiveness of ECV in improving pregnancy outcomes for women with breech-presenting fetuses.

Evaluating the effectiveness of lateral postural management for breech presentation: study protocol for a randomized controlled trial (BRLT study)

BackgroundBreech presentation is observed in 3–4% at term of pregnancy and is one of the leading causes of cesarean section. There is no established treatment for breech presentation before 36 weeks. A retrospective cohort study was conducted to demonstrate that the lateral position is effective for breech presentation. However, there are no randomized controlled trials evaluating lateral position management for breech presentation. Here, we described the methodology of a randomized controlled trial of a cephalic version for breech presentation in the third trimester by lateral postural management (BRLT study).MethodsThe BRLT study is an open-label, randomized controlled trial with two parallel groups allocated in a 1:1 ratio to examine the lateral position management for breech presentation, as compared with expectant management care. An academic hospital in Japan will enroll 200 patients diagnosed with a breech presentation by ultrasonography between 28 + 0 weeks and 30 + 0 weeks. Participants in the intervention group will be instructed to lie on their right sides for 15 min three times per day if the fetal back was on the left side or lie on their left sides if the fetal back was on the right side. The instruction will be given every 2 weeks after confirmation of fetal position, and the lateral position will be instructed until the cephalic version, and after the cephalic version, the reverse lateral position will be instructed until delivery. The primary outcome is cephalic presentation at term. The secondary outcomes are cesarean delivery, cephalic presentation 2, 4, and 6 weeks after the instruction, and at delivery, recurrent breech presentation after cephalic version, and adverse effects.DiscussionThis trial will answer whether the lateral positioning technique is effective in treating breech presentation and, depending on the results, may provide a very simple, less painful, and safe option for treating breech presentation before 36 weeks, and it may impact breech presentation treatment.Trial registrationUMIN Clinical Trials Registry UMIN000043613. Registered on 15 March 2021 https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800.

Use of external cephalic version for breech presentation at term: A national survey of Norwegian birth units

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.

Rebozo and External Cephalic Version in breech presentation (RECEIVE): A randomised controlled study.

To investigate if a hospital-initiated home-based rebozo intervention performed by the pregnant woman and her partner before external cephalic version (ECV) would increase the rate of cephalic presentations at birth. A multicentre randomised controlled trial. Three university hospitals in Copenhagen, Denmark. Pregnant women with a breech or transverse presentation at 35weeks or more of gestation eligible for ECV. We compared rebozo before ECV with ECV alone. The randomisation was computer-generated in blocks and stratified by parity. The woman and her partner were instructed in the technique by a project midwife and performed the technique at home three times daily for 3-5days before the scheduled ECV. Analyses were by intention-to-treat. The number of cephalic presentations at the time of birth. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 372 women were randomly assigned (1:1) to either rebozo intervention (n=187) or control (n=185). At birth, 95 (51%) in the intervention group versus 112 (62%) in the control group had a fetus in cephalic presentation (OR 0.61; 95% CI 0.40-0.95). No adverse events were observed in relation to the intervention. In breech or transverse presentation, home-based rebozo exercise before ECV lowered the overall rate of cephalic presentation at birth. Home-based rebozo for breech presentation before external version reduces the rate of cephalic presentation at birth.

Effects of external cephalic version for breech presentation at or near term in high-resource settings: A systematic review of randomized and non-randomized studies.

INTRODUCTIONExternal cephalic version (ECV) for breech presentation involves manual manipulation of the fetus from breech to cephalic presentation at or near term, in an attempt to avoid breech birth. This systematic review summarizes the literature on the effects of ECV at or near term on pregnancy outcomes in high-resource settings.METHODSThe MEDLINE, Embase, CINAHL, Cochrane Library, MIDIRS, and SweMED+ databases were searched for relevant articles published through April 2019, with no limitation on publication date. Clinical trials comparing the effects of ECV at ≥36 weeks, with or without tocolysis, with that of no ECV, conducted in northern, western, and central Europe, the USA, Canada, Australia, and New Zealand were eligible for inclusion.RESULTSNine articles reporting on 184704 breech pregnancies were included. Pooled data showed that ECV attempts reduced the failure to achieve vaginal cephalic birth (risk ratio, RR=0.56; 95% CI: 0.45–0.71), caesarean section performance (RR=0.57; 95% CI: 0.50–0.64), and non-cephalic presentation at birth (RR=0.45; 95% CI: 0.29–0.68) compared with no ECV. ECV attempts also increased the incidence of Apgar score <7 at 5 minutes (RR=1.29; 95% CI: 1.10–1.52).CONCLUSIONSWomen for whom ECV is attempted at or near term are at reduced risk of caesarean section, non-cephalic presentation at term, and failure to achieve vaginal cephalic birth. Compared with no ECV, attempted ECV was also associated with a slightly increased risk of a low Apgar score at 5 minutes. The evidence is limited by the scarcity of high-quality research and the presence of risks of bias.

External cephalic version for breech presentation: The guideline landscape and a quest for an optimal approach

ObjectivesThe aim of this study was to illuminate differences in guidelines for external cephalic version (ECV) for breech presentation at or near term and assess their impact on effectiveness of the procedure in order to improve policymaking. Study designGuidelines from all Swedish ECV providers (hospitals with labor wards, n = 44) were retrieved in 2019 and assessed for similarities and differences. The scoring system based on the identified differences in timing, contraindications and periprocedural care was created. The hospitals were subsequently classified into either restrictive or liberal with regard to ECV. This classification was verified by comparing selection of patients for ECV attempts between the two groups. Our main outcomes were ECV success rate and effectiveness in reducing the remaining breech births and breech cesarean sections. ResultsImportant differences in timing of ECV, contraindications, periprocedural care, and counselling after failed ECV attempt were found. Two thirds of the hospitals were considered liberal and one third restrictive with regard to ECV. ECV success rate was significantly higher in hospitals with a liberal attitude towards ECV compared with restrictive hospitals (54.0 % vs 50.5 %, p = 0.015). Liberal hospitals had a significantly lower proportion of remaining breech births (2.81 % vs 3.01 %, p = 0.009) and breech cesarean sections at or near term (2.49 % vs 2.72 %, p = 0.003). ConclusionImportant differences in ECV guidelines were found. Hospitals with guidelines reflecting a liberal attitude to ECV had a higher ECV success rate, despite a less strict patient selection, and a lower proportion of breech births and breech cesarean sections, which is the aim of ECV. We recommend avoiding routine ill-founded restrictivity in ECV guidelines and support a more nuanced counselling.

Vaginal Delivery After External Cephalic Version in Patients With a Previous Cesarean Delivery: A Systematic Review and Meta-analysis.

To estimate the rate of vaginal delivery after successful external cephalic version for breech presentation in women with compared with without a previous cesarean birth. We searched MEDLINE, Scopus, EMBASE, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials for studies comparing the mode of delivery after successful external cephalic version in women with and without a previous cesarean birth. Two reviewers independently identified studies, extracted data, and evaluated study quality. The rate of vaginal delivery after successful external cephalic version in women with and without a previous cesarean birth was compared, and odds ratios (ORs) with 95% CIs were estimated. Six cohort studies and two case-control studies, reporting on 14,515 women were identified. The median point prevalence of a successful external cephalic version was 74% (interquartile range 63-81%) in women with a previous cesarean birth compared with 69% (interquartile range 64-83%) in women without a previous cesarean birth. The overall success rate of external cephalic version in women with a previous cesarean birth was similar compared with women without a previous cesarean birth (pooled OR 0.84, 95% CI 0.61-1.15). The median point prevalence of a vaginal delivery was 75% (interquartile range 61-84%) in women with a previous cesarean birth compared with 92% (interquartile range 85-95%) in women without a previous cesarean birth after a successful external cephalic version. The overall success rate of a vaginal delivery in women with a previous cesarean birth was less compared with women without a previous cesarean birth (pooled OR 0.26, 95% CI 0.14-0.50). A planned subgroup analysis on studies that included only multiparous women in the control group (parity one or greater) noted the overall success rate of external cephalic version in women with a previous cesarean birth 76% (853/1,123) was lower compared with multiparous women without a previous cesarean birth 84% (9,911/11,855) (pooled OR 0.70, 95% CI 0.54-0.89, I 37%). The overall success rate of a vaginal delivery in women with a previous cesarean birth 83% (666/806) was less compared with women without a previous cesarean birth 97% (9,449/9,746) (pooled OR 0.21, 95% CI 0.12-0.39, I 73%). Women with previous cesarean birth have similar rates of successful external cephalic version when compared with women without a cesarean birth. Although the rate of vaginal delivery is lower, the majority of patients have a successful vaginal birth after cesarean. PROSPERO, CRD42020160145.

Nitrous oxide analgesia for external cephalic version: A randomized controlled trial

Study objectiveOur study sought to determine whether or not nitrous oxide analgesia decreases pain compared to oxygen placebo during external cephalic version for breech presentation. Procedural success may be limited by pain and anxiety. Although neuraxial anesthesia has been studied extensively for these procedures, many centers lack resources for routine use. Nitrous oxide is noninvasive, has minimal side effects and requires limited facilities. We hypothesized that its analgesic properties would decrease pain compared to oxygen placebo during external cephalic version. DesignDouble-blinded randomized placebo-controlled trial. SettingLabor and delivery triage room. PatientsForty-eight patients, ≥18 years of age, 37-weeks' gestation or beyond, singleton pregnancy, breech presentation, and American Society of Anesthesiology physical status I-III, having an external cephalic version. InterventionsPatients undergoing external cephalic version were randomized to receive self-administered 50% nitrous oxide/50% oxygen versus 100% oxygen placebo. MeasurementsThe primary outcome measured was intra-procedural pain. Secondary outcomes were intra-procedural anxiety, patient satisfaction, and procedure difficulty. Main resultsForty-eight patients were enrolled; 23 received nitrous oxide and 25 received oxygen. No difference was noted in mean pain scores (nitrous oxide 5.5 ± 2.3, placebo 5.4 ± 2.7, [CI95% = −1.40, 1.51]; P = 0.943) or anxiety scores (nitrous oxide 1.6 ± 2.0, placebo 1.2 ± 1.8, [CI95% = −0.74, 1.45]; P = 0.515). Procedural difficulty (1–10 scale, 1 = very easy, 10 = extremely difficult) was not different between groups (nitrous oxide 6.1 ± 2.2, placebo 6.1 ± 3.2, [CI95% = −1.54, 1.66]; P = 0.944). There was a significant increase in the number of version attempts in the nitrous oxide group (nitrous oxide 3.9 ± 1.9, placebo 2.8 ± 1.4, [CI95% = 0.05, 2]; P = 0.046). Patient satisfaction was significantly lower in the nitrous oxide group (nitrous oxide 4.3 ± 4.0, placebo 6.9 ± 3.6, [CI95% = −4.93, −0.34]; P = 0.025). ConclusionDespite the desirable properties of nitrous oxide, there was no analgesic benefit over oxygen for external cephalic version. Its routine use for these procedures was not supported.

Successful vaginal delivery after external cephalic version (ECV): does time interval from ECV to delivery make a difference? A multicenter study

The risk of cesarean delivery after a successful external cephalic version for breech presentation is higher as compared with fetuses in cephalic presentation. However, the role of the time interval between version attempt to delivery on the risk for cesarean delivery is unclear. We aimed to study the effect of the time interval from a successful external cephalic version to delivery on the risk for cesarean delivery and assess factors associated with cesarean delivery after a successful version. We conducted a multicenter, retrospective cohort study, including all successful external cephalic version at two medical centers between 2011 and 2019. We compared patient baseline characteristics, obstetric characteristics, maternal and neonatal outcomes in women that delivered by vaginal delivery with those who delivered by cesarean delivery. Overall, 769 deliveries were included. Of these, 98 women (12.7%) had cesarean delivery and 671 (87.3%) had vaginal delivery. Women who had cesarean delivery had a higher rate of obesity (44.9% vs 21.9%, p < 0.001; OR 2.88, CI 1.65-5.03) and nulliparity (45.9% vs 24.5%, p < 0.001; OR = 2.58, CI 1.67-3.98). The risk for intrapartum cesarean delivery did not differ according to time interval from external cephalic version to delivery. The time interval between successful external cephalic version and delivery was not associated with mode of delivery. This finding is in contrast to previous reports. The risk for cesarean delivery after successful version is higher in nulliparous, obese women, and women whose weight gain in pregnancy was higher.

Systematic Kleihauer-Betke Test after External Cephalic Version for Breech Presentation: Is It Useful?

The incidence of fetomaternal hemorrhage (FMH) after external cephalic version (ECV) has been poorly reported. In this study, we evaluated the frequency of FMH, diagnosed by positive Kleihauer–Betke test (KBT), after ECV attempt and then evaluate the relevance of its routine use after procedure. A total of 282 women with a term breech presentation and who had ECV attempt were recruited from January 2014 and December 2018. After ECV attempt, women were systematically screened for FMH using KBT. Data on ECV attempt, KBT results, perinatal and neonatal outcomes were collected and compared between women with positive (cases) and negative KBT (controls) after ECV. The success rate of ECV was 22.0% (62/282). Eight women (2.9%) experienced transient fetal heart rate (FHR) abnormalities after ECV. In five (1.8%) women, KBT was positive after ECV. Obstetrical management was modified for two of these five women due to continuous positivity of KBT at day 1 and day 7 controls after ECV attempt. A cesarean section was planned 7 days earlier due to persistent high FMH on day 7 (6 mL fetal blood) in one woman and the labor was induced for persistent high FMH on day 7 (20 mL fetal blood) for another woman. No newborns have signs of fetal anemia at birth and there was no significant difference in neonatal status between two groups. FMH after ECV attempt are rare, and no negative fetal or neonatal outcomes were observed when KBT was positive, even strongly (>5 mL fetal blood). It appears that systematic KBT after attempted ECV is probably not useful.

Prediction of Success in External Cephalic Version for Breech Presentation at Term: Correction.

Prediction of Success in External Cephalic Version for Breech Presentation at Term: Correction.

328: Prediction of success in external cephalic version for breech presentation at term

We aimed at designing a clinically based predictive model for the likelihood of successful external cephalic versions (ECVs) near term. This single-center retrospective study was conducted in a single center between 2016 and 2018 and included all candidates for ECV between 35 and 41 weeks' gestation. The versions were performed by a single experienced obstetrician. Variables that may potentially affect the success rate of external version were collected for all participants and included: BMI, AFI, gestational age, parity, location of placenta, fetal trunk posture, period of time in breech presentation prior to the procedure and the size of the amniotic fluid preceding the fetal presenting part (fore-bag). Patients' characteristics were compared between successful and unsuccessful versions based on multiple logistic regression models in order to generate a discriminative model depicted by a conditional inference classification tree (ctree). Overall 250 pregnant women were eligible and opted for a trial of ECV with a success rate of 64.8%. Variables such as location of the placenta, period of time at breech presentation and previous uterine scar had no statistically significant impact on the success rate of ECV while BMI, size of fore-bag and parity were independent determinants of the final presentation. Prediction model for the outcome of ECV based on the most discriminatory factors is suggested and shown as a classification tree. According to our model, patients with a forebag size of 0 had a predicted probability of 10% for successful version, patients with a forebag size >0 and a BMI >29 had a probability of 0%, patients with a forebag size >1 and BMI <=29 had a probability of 96.3% and patients with forebag size =1 and BMI <=29 and number of previous births>0 had a probability of 81.25%. The model accuracy was 91.9%±5.4% which is significantly better than the no information rate of 64.8% (P<0.001). Sensitivity for predicting successful versions was 0.975 and specificity was 0.818. A prediction model composed of three easily measurable variables enables accurate outcome prediction of ECV at term. Fore-bag was identified as the most important discriminator. Our model holds in internal validation and it can be used to support patient counseling and decision making for ECV.

External cephalic version without anaesthesia for breech presentation in singleton term pregnancies: a retrospective analysis of 195 cases

Objective To investigate the safety and effectiveness of external cephalic version for breech presentation in singleton term pregnancies. Methods This study retrospectively analyzed the clinical data of 195 singleton pregnancies with gestational weeks ≥37 and breech presentation that has received external cephalic version in University of Hong Kong-Shenzhen Hospital from January 2014 to December 2016. The success rate of external cephalic version, delivery modes, maternal and neonatal complications and adverse outcomes were analyzed. Results Of the 195 cases, 62.6% (122/195) were successful, among which 107 vaginally delivered and 15 underwent the cesarean section. Maternal and neonatal outcomes of all 195 cases were good. The success rate of external cephalic version in the multipara was higher than that of the primipara [84.5%(71/84) vs 45.9%(51/111), χ2=30.383, P<0.001]. No neonatal asphyxiation or postpartum hemorrhage was reported. Conclusions External cephalic version is an effective and safe method to convert breech presentation and reduce cesarean section rate in the third trimester. Key words: Version, fetal; Breech presentation; Retrospective studies

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial

(Anesthesiology 2017;127:625–632) Increased rate of cesarean delivery without measurable improvements in maternal or neonatal outcomes is a major public health problem. Breech presentation is a major contributor to the incidence of cesarean delivery and can be prevented by external cephalic version (ECV). Neuraxial blockade for ECV improves maternal satisfaction and procedural success and decreases maternal pain. Meta-analysis of randomized controlled trials suggests that administering higher doses of local anesthetic (LA) for neuraxial block leads to increased ECV success, although the protocol for providing neuraxial blockade for this procedure has not yet been standardized.

Moxibustion for Cephalic Version of Breech Presentation.

Moxibustion, a form of traditional Chinese medicine (TCM), is the burning of the herb moxa (Folium Artemisiae argyi or mugwort) over acupuncture points. It is often used in China to facilitate cephalic version of breech presentation. This article reviews the history, philosophy, therapeutic use, possible mechanisms of action, and literature pertaining to its use for this indication. For moxibustion, moxa can be rolled into stick form, placed directly on the skin, or placed on an acupuncture needle and ignited to warm acupuncture points. Studies have demonstrated that moxibustion may promote cephalic version of breech presentation and may facilitate external cephalic version. However, there is currently a paucity of research on the effects of moxibustion on cephalic version of breech presentation, and thus there is a need for further studies. Areas needing more investigation include efficacy, safety, optimal technique, and best protocol for cephalic version of breech presentation.

Does external cephalic version for breech presentation performed prior to an estimated gestational age of 37 weeks offer any benefits or pose any risks compared with external cephalic version performed at term?

EVIDENCE-BASED ANSWER Compared with term external cephalic version, preterm (<37 weeks' gestation) external cephalic version decreases the rate of noncephalic presentation at birth by 19% and the rate of vaginal breech birth by 56%, but increases the risk of late preterm birth by 50% (SOR: A, systematic review of RCTs). The 2016 American College of Obstetrician and Gynecologists guidelines for the management of external cephalic version recommend offering the procedure near term. In comparison, the 2010 guidelines from the Royal College of Obstetricians and Gynaecologists recommend external cephalic version at 36 weeks for nulligravidas and 37 weeks for multigravidas (SOR: C, systematic guidelines).

Effect of Intrathecal Bupivacaine Dose on the Success of External Cephalic Version for Breech Presentation: A Prospective, Randomized, Blinded Clinical Trial.

Breech presentation is a leading cause of cesarean delivery. The use of neuraxial anesthesia increases the success rate of external cephalic version procedures for breech presentation and reduces cesarean delivery rates for fetal malpresentation. Meta-analysis suggests that higher-dose neuraxial techniques increase external cephalic version success to a greater extent than lower-dose techniques, but no randomized study has evaluated the dose-response effect. We hypothesized that increasing the intrathecal bupivacaine dose would be associated with increased external cephalic version success. We conducted a randomized, double-blind trial to assess the effect of four intrathecal bupivacaine doses (2.5, 5.0, 7.5, 10.0 mg) combined with fentanyl 15 μg on the success rate of external cephalic version for breech presentation. Secondary outcomes included mode of delivery, indication for cesarean delivery, and length of stay. A total of 240 subjects were enrolled, and 239 received the intervention. External cephalic version was successful in 123 (51.5%) of 239 patients. Compared with bupivacaine 2.5 mg, the odds (99% CI) for a successful version were 1.0 (0.4 to 2.6), 1.0 (0.4 to 2.7), and 0.9 (0.4 to 2.4) for bupivacaine 5.0, 7.5, and 10.0 mg, respectively (P = 0.99). There were no differences in the cesarean delivery rate (P = 0.76) or indication for cesarean delivery (P = 0.82). Time to discharge was increased 60 min (16 to 116 min) with bupivacaine 7.5 mg or higher as compared with 2.5 mg (P = 0.004). A dose of intrathecal bupivacaine greater than 2.5 mg does not lead to an additional increase in external cephalic procedural success or a reduction in cesarean delivery.

Comparison of Fetomaternal Outcome between 47 Deliveries Following Successful External Cephalic Version for Breech Presentation and 7456 Deliveries Following Spontaneous Cephalic Presentation

Background: Achieving a cephalic position after a successful external cephalic version (ECV) is desired to result in delivery and fetal outcomes that are similar to those of deliveries following spontaneous cephalic presentation. Methods: We performed a retrospective cohort study including patients with successful ECV following fetal breech position (ECV cohort, n = 47) or with a singleton spontaneous cephalic pregnancy at ≥37 weeks of gestational age (control group, n = 7,456) attempting a vaginal delivery between 2010 and 2013 at the University Hospital Ulm. The mode of delivery and fetal outcome parameters were compared between these 2 groups using nonparametric statistics. Results: ECV cohort and control group did not differ with respect to maternal age, parity, gestational age at birth, and fetal gender. There were no significant differences between the 2 groups with regard to all parameters indicating fetal outcome. However, the rate of cesarean sections was higher after successful ECV compared to spontaneous cephalic presentation (27.7 vs. 12.8%, OR 2.615). Conclusion: While vaginal delivery is less likely to happen after a successful ECV compared to spontaneous cephalic singleton pregnancies, fetal outcome parameters showed no difference between the 2 groups. Physicians should be counseling and encouraging women to attempt ECV, as it is a safe and effective procedure.

A century of changing views on ECV.

Antenatal external version of babies presenting by the breech has been described for millennia but while extensively practised in continental Europe, was rarely practised in the United Kingdom, in part because abdominal palpation during pregnancy was considered unnecessary and therefore breech presentation was rarely diagnosed before labour (Spencer HR Br Med J 1901;1:1192–6). Even after routine antenatal assessments were introduced, there was a prejudice against the procedure. White, in 1956, counselled against routine version because (1) in 30% of nulliparous women and 70% of parous women spontaneous version occurred before the onset of labour, (2) fetal mortality from version ‘usually exceeded 1%’ and (3) breech delivery in hospital with appropriate medical staff present was ‘a safe procedure’ (White J Obstet Gynaecol Br Emp 1956;63:706–19). In 1959 Hay opined that ‘it is obviously safer nowadays, therefore, with a foetal loss of around 1% for breech delivery, for the baby to be delivered either vaginally as a breech or by caesarean section in selected cases than to have “external cephalic version” performed upon it’ (Hay J Obstet Gynaecol Br Emp 1959;66:529–47). During my training at King's College, St Mary's and Queen Charlotte's Hospitals in London, I never saw external cephalic version for breech presentation and so performing one never crossed my mind, until as a junior resident in 1978 I was teaching two medical students at Kingston Hospital. We came to a woman at 41 weeks of gestation with a baby presenting by the breech. One of the attending consultant obstetricians insisted on inducing labour in women with breech presentation at 39 weeks, which I and the senior resident thought was unnecessary and potentially dangerous, so we used to ‘hide’ such women on the antenatal ward and wait for the onset of spontaneous labour. I was explaining to the students the risks associated with breech presentation when the woman herself said ‘if my baby is the wrong way round, why don't you turn it the right way round?’. I smiled at her and explained to the students that at 41 weeks there was likely to be reduced amniotic fluid which would make it impossible to turn the baby even if I tried. So I demonstrated this and to my amazement the baby turned really easily. After that I used to do versions (at term) routinely in my clinic without any specific precautions and never saw any problems, except in one case where I turned the baby without specific consent and the mother was upset at being deprived of the elective caesarean section she had been promised—her mother and relatives were flying in from Denmark for the birth and had booked their flights appropriately. Luckily she did not make a formal complaint and I did not make that mistake again. External version is now regarded as a service which ‘should be available to all women at term’ with ‘few absolute contraindications’, although it should only be performed ‘where facilities for monitoring and immediate delivery are available’ (https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg20a/). None declared. Completed disclosure of interests form 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.