External Cephalic Version Attempt Research Articles

149: Characteristics associated with Attempt of External Cephalic Version in the U.S. Birth Certificate Data

Malpresentation is the indication for 10-15% of cesarean deliveries (CD). External cephalic version (ECV) is a safe and effective procedure to reduce CD. We could not identify prior studies that investigated characteristics associated with attempt of ECV. Our objective is to detect associations between patient characteristics and ECV attempt to identify populations that may experience barriers to ECV. Data was obtained from the National Center for Health Statistics birth certificate data from 2014-2016. We analyzed singleton, live, non-anomalous births to women with ≤1 prior CD delivered at 36-42 weeks. We reasoned that subjects who either had ECV attempt (whether successful or unsuccessful) or were non-cephalic at the time of delivery constituted an ECV eligible cohort. Subjects with incomplete data on ECV, mode of delivery, or presentation at time of delivery were excluded. We examined the association between patient characteristics and ECV attempt using logistic regression to obtain odds ratios and 95% confidence intervals. We found 10,016,394 deliveries met our inclusion criteria, of which 414,866 subjects were considered ECV eligible. Only 6.8% of the ECV eligible population had an ECV attempt. Of ECV attempts, 55.3% were successful. Of successful ECV attempts 78.6% delivered vaginally. Of total ECV attempts, 48.2% delivered vaginally; 339 of these were breech vaginal deliveries. We found that Hispanic and non-Hispanic black race, unmarried status, lack of college degree, age <24, Medicaid or self-paying status, nulliparity, and prior CD to be associated with non- attempt of ECV. Association between examined characteristics with ECV attempt are described in Table 1. Our findings are limited by quality of data collection, but strongly suggest that ECV is underutilized. Reasons for this remain unclear, but likely include both provider and patient preference. We identified characteristics associated with ECV attempt. Further investigation should focus on barriers that exist to this effective means of CD reduction. Reporting of ECV attempts in eligible patients at a hospital level could be considered a quality metric.

External cephalic version at term: a cohort study of 18years' experience.

To analyse the outcome of referrals for external cephalic version (ECV). Retrospective cohort study of prospectively collected data. Major university hospital, UK. Women with non-cephalic presentation at term and no prior caesarean, referred to a specialist clinic. Details of referrals, ECV attempts, and perinatal outcomes were prospectively collected and analysed. Multivariate binary logistic regression models were created to determine independent predictors of ECV success, reversion, and spontaneous version. External cephalic version success rates, predictors of success and cephalic presentation at birth, and perinatal outcomes. Three thousand eight had confirmed breech presentation; 2614 women underwent ECV. Ineligibility for ECV occurred in 117 breech presentations (3.9%), and 297 eligible women (10.2%) declined it. ECV was successful in 1280 (49.0%, 95% CI 47.0-50.9%) (40% in nulliparous women; 64% in others); 1234 (97.3%) were cephalic at birth. Spontaneous version after failure occurred in 4.3% and was more common in multiparas (aOR 2.47, 95% CI 1.43-4.26) and those with a posterior fetal back (aOR 6.09, 95% CI 1.90-19.53). Reversion after successful ECV occurred in 2.2%. In women with a successful ECV whose fetus remained cephalic at birth, 85.7% delivered vaginally. The corrected perinatal mortality of the ECV cohort was 0.12%. External cephalic version has a low complication rate and is effective for most breech presentations, enabling vaginal birth and avoiding caesarean section. External cephalic version can safely be performed with most breech presentations.

External cephalic version after previous cesarean section: A cohort study of 100 consecutive attempts

ObjectiveExternal cephalic version is commonly not performed in women with a previous cesarean section. Fear of uterine rupture and cesarean section in labor are prominent. The risks, however, of these are unclear. This study aims to document the safety and efficacy of external cephalic version in women with a prior cesarean section in a series of 100 consecutive attempts, and to perform a literature of the existing literature. Study designThis is a retrospective cohort study of prospectively collected data of external cephalic version attempts in women at term with a previous cesarean section, and a literature review of previously published series. External cephalic version was performed by one of 3 experienced operators, with salbutamol tocolysis if appropriate, using ultrasound to visualize the fetal heart and place of fetal parts. Results100 women with a prior cesarean section underwent external cephalic version over a 16-year period in one institution. 68% had no previous vaginal delivery. The external cephalic version success rate was 50%, and 30 (63.8%) of these subsequently delivered vaginally. There were no cases of uterine rupture or other complications. A literature review of series containing a total of 549 cases revealed no cases of uterine rupture or perinatal death. ConclusionsExternal cephalic version in women with a prior cesarean section is safe but enables a vaginal birth in only about a third of women.

Maternal and Neonatal Outcomes after Attempted External Cephalic Version among Women with One Previous Cesarean Delivery.

Objective This study was aimed to evaluate success rates of (1) external cephalic version (ECV) among women with one prior cesarean delivery (CD) and (2) maternal and neonatal outcomes after ECV among women with prior CD. Study Design Two linked studies using U.S. Natality Database were performed. First we performed a retrospective cohort comparing ECV success rates of women with prior CD and women without prior CD. Then we compared the outcomes of TOLACs (trial of labor after cesarean delivery) that occurred after ECV with those that occurred without ECV. Multivariable logistic regression analysis was used to estimate adverse outcomes. Results A total of 715 women had ECV after 36 weeks with prior CD and 9,976 had ECV without prior scar. ECV success rate with scar was 80.6% and without scar was 86.4% ( p < 0.001). Seven hundred and sixteen women underwent TOLAC after ECV attempt and 234,617 underwent TOLAC without a preceding attempt. Women with preceding version had increased risks of maternal transfusion (1 vs. 0.4%, adjusted OR [odds ratio]: 2.48 [95% CI (confidence interval): 1.17–5.23]), unplanned hysterectomy (0.4 vs. 0.06%, adjusted OR: 6.90 [95% CI: 2.19–21.78]), and low 5-minute Apgar's score (2.5 vs. 1.5%, adjusted OR: 1.76 [95% CI: 1.10–2.82]). Conclusion Women with prior CD may have a decrease in the rate of successful ECV. While the absolute risks are low, ECV appears to increase risks of adverse maternal and neonatal outcomes among women undergoing a trial of labor.

Clinical outcomes after external cephalic version with spinal anesthesia after failure of a first attempt without anesthesia

To determine whether repeat external cephalic version (ECV) with spinal anesthesia affects clinical outcomes and cesarean delivery rates. A retrospective study was conducted using data collected at one hospital in Israel between January 1, 2009, and December 31, 2015. Women with non-vertex singleton pregnancies (≥37weeks) who had a failed ECV attempt without spinal anesthesia were included in the analysis. All women were offered a repeat ECV with spinal anesthesia. Outcomes assessed were rates of vertex presentation at delivery, successful repeat ECV, and cesarean delivery. Overall, 145 of 213 ECV attempts without spinal anesthesia were successful. Of the 68 women with a failed attempt, 5 (7%) experienced spontaneous version and 18 (26%) delivered at another institution or went into spontaneous labor. Among the remaining 45 women, 28 (62%) agreed to a repeat ECV with spinal anesthesia; 11 (39%) of these procedures were successful. All 11 women experienced vertex presentation at delivery versus none of the 17 women who refused repeat ECV (P=0.003). The cesarean delivery rate was 64% (18/28) versus 100% (17/17), respectively (P=0.007). Repeat ECV with spinal anesthesia after a failed first attempt without spinal anesthesia increased vertex presentation at birth and decreased the rate of cesarean delivery.

Uptake of external cephalic version for term breech presentation: an Australian population study, 2002\u20132012

BackgroundThe safety, efficacy, and cost-effectiveness of external cephalic version (ECV) for term breech presentation has been demonstrated. Clinical guidelines recommend ECV for all eligible women, but the uptake of this procedure in the Australian healthcare setting is unknown. This study aimed to describe ECV uptake in New South Wales, the most populous state of Australia, during 2002 to 2012.MethodsData from routine hospital and birth records were used to identify ECVs conducted at ≥36 weeks’ gestation. Women with ECV were compared to women who were potentially eligible for but did not have ECV. Eligibility for ECV was based on clinical guidelines. For those with ECV, birth outcomes following successful and unsuccessful procedures were examined.ResultsIn N = 32,321 singleton breech pregnancies, 10.5% had ECV, 22.3% were ineligible, and 67.2% were potentially eligible but did not undergo ECV. Compared to women who were eligible but who did not attempt ECV, those who had ECV were more likely to be older, multiparous, overseas-born, public patients at delivery, and to deliver in tertiary hospitals in urban areas (p < 0.01). Fewer women who underwent ECV smoked during pregnancy, fewer were morbidly obese, and fewer had a hypertensive disorder of pregnancy, compared to those who were eligible. Caesarean section occurred in 25.9% of successful compared to 95.6% of unsuccessful ECVs. Infant outcomes did not differ by ECV success.ConclusionsThe majority of women with a breech presentation did not receive ECV. It is unclear whether this is attributable to issues with service provision or low acceptability among women. Policies to improve access to and information about ECV appear necessary to improve uptake among women with term breech presentation. Improved data collection around the diagnosis of breech presentation, ECV attempts, and outcomes may help to identify specific barriers to ECV uptake.

External cephalic version at Izola Maternity Hospital

Background : Almost all babies in breech presentation at term are delivered by caesarean section. Professional guidelines recommend an attempt of external cephalic version to reduce breech presentations at birth and thus the proportion of caesareans. Our aim was to analyse the clinical and ultrasound factors to predict the outcome of version and check the hypothesis, if the implementation of the external cephalic version helps to reduce the number of caesareans. Methods : The study included all attempts of external cephalic version after 36 weeks of pregnancy at the Department of Obstetrics and Gynaecology in Izola General Hospital from 2002 to 2010. Results : 68/143 (47.6 %) external cephalic versions were successful. the success of intervention was mostly influenced by a greater amount of amniotic fluid, higher fetal position in the pelvis and transverse or oblique lie of the fetus. With 100 attempts of external cephalic version 32 caesareans were avoided or one cesarean per 3.1 attempts. Conclusions : the study has confirmed that by performing external cephalic version the number of caesareans can be reduced. The proportion of successful versions was comparable to studies in the literature despite the minimal use of uterine muscle relaxants.

Zunanji obrat ploda na glavico v Porodnišnici Izola

Background: Almost all babies in breech presentation at term are delivered by caesarean section. Professional guidelines recommend an attempt of external cephalic version to reduce breech presentations at birth and thus the proportion of caesareans. Our aim was to analyse the clinical and ultrasound factors to predict the outcome of version and check the hypothesis, if the implementation of the external cephalic version helps to reduce the number of caesareans.Methods: The study included all attempts of external cephalic version after 36 weeks of pregnancy at the Department of Obstetrics and Gynaecology in Izola General Hospital from 2002 to 2010.Results: 68/143 (47.6 %) external cephalic versions were successful. the success of intervention was mostly influenced by a greater amount of amniotic fluid, higher fetal position in the pelvis and transverse or oblique lie of the fetus. With 100 attempts of external cephalic version 32 caesareans were avoided or one cesarean per 3.1 attempts.Conclusions: the study has confirmed that by performing external cephalic version the number of caesareans can be reduced. The proportion of successful versions was comparable to studies in the literature despite the minimal use of uterine muscle relaxants.

Amnioinfusion for women with a singleton breech presentation and a previous failed external cephalic version: a randomized controlled trial

Purpose: Our trial aimed to assess the effectiveness of amnioinfusion for a second attempt at external cephalic version (ECV). Material and methods: This open randomized controlled trial was planned with a sequential design. Women at a term ≥36 weeks of gestation with a singleton fetus in breech presentation and a first unsuccessful ECV were recruited in two level-3 maternity units. They were randomly allocated to transabdominal amnioinfusion with a 500-mL saline solution under ultrasound surveillance or no amnioinfusion before the second ECV attempt. Trained senior obstetricians performed all procedures. The primary outcome was the cephalic presentation rate at delivery. Analyses were conducted according to intention to treat (NCT00465712). Result: Recruitment difficulties led to stopping the trial after a 57-month period, 119 women were randomized: 59 allocated to amnioinfusion + ECV and 60 to ECV only. Data were analyzed without applying the sequential feature of the design. The rate of cephalic presentation at delivery did not differ significantly according to whether the second version attempt was or was not preceded by amnioinfusion (20 versus 12%, p = .20). Premature rupture of the membranes occurred for 15% of the women in the amnioinfusion group. Conclusion: Amnioinfusion before a second attempt to external version does not significantly increase the rate of cephalic presentation at delivery.

670: Is there an association between attempted external cephalic version and neonatal morbidity?

External cephalic version (ECV) can be complicated by fetal bradycardia, abruption, or cord prolapse leading to adverse neonatal outcomes. However the alternative to ECV, expectant management, also carries risks associated with an unscheduled presentation in labor with a non-cephalic fetus. We sought to examine whether, in the setting of non-cephalic presentation, women who undergo an ECV attempt have greater neonatal morbidity than those who do not and are expectantly managed. A retrospective cohort study of women with non-anomalous singleton gestations in non-cephalic presentation delivering at a tertiary care institution from 2006-2016. Women attempting ECV at ≥37 weeks were compared to those who did not undergo an ECV attempt with a noncephalic neonate and delivered at ≥37 weeks. The primary outcome was a composite neonatal morbidity including stillbirth, neonatal death within 72 hours, Apgar score <5 at 5 minutes, cord artery pH <7.0 or base deficit ≥12 mmol/L, or neonatal brain cooling. Secondary outcomes were neonatal intensive care unit (NICU) admission and neonatal anemia (Hgb <13.5 g/dL). Bivariable analyses and multivariable logistic regression were performed. Of a total of 4117 women, 1262 (30.7%) attempted ECV; 508 (40.3%) of these attempts successfully converted the fetus to cephalic presentation. In bivariable analyses, women who attempted ECV were more likely to be non-Hispanic white and multiparous, and had a lower mean body mass index at delivery. The composite neonatal morbidity outcome did not differ significantly between the groups. The frequencies of NICU admission and neonatal anemia were also similar (Table). After adjusting for potential confounders, ECV attempt was still not significantly associated with composite neonatal morbidity (aOR 1.02, 95% CI 0.66-1.35). Using an alpha of 0.05, we had 80% power to detect a minimum relative risk of 1.7 for composite neonatal morbidity associated with ECV attempt. Compared to expectant management, an ECV attempt at ≥37 weeks is not associated with increased neonatal morbidity.

Maternal outcomes of term breech presentation delivery: impact of successful external cephalic version in a nationwide sample of delivery admissions in the United States.

BackgroundWe aimed to define the frequency and predictors of successful external cephalic version in a nationally-representative cohort of women with breech presentations and to compare maternal outcomes associated with successful external cephalic version versus persistent breech presentation.MethodsUsing the Nationwide Inpatient Sample, a United States healthcare utilization database, we identified delivery admissions between 1998 and 2011 for women who had successful external cephalic version or persistent breech presentation (including unsuccessful or no external cephalic version attempt) at term. Multivariable logistic regression identified patient and hospital-level factors associated with successful external cephalic version. Maternal outcomes were compared between women who had successful external cephalic version versus persistent breech.ResultsOur study cohort comprised 1,079,576 delivery admissions with breech presentation; 56,409 (5.2 %) women underwent successful external cephalic version and 1,023,167 (94.8 %) women had persistent breech presentation at the time of delivery. The rate of cesarean delivery was lower among women who had successful external cephalic version compared to those with persistent breech (20.2 % vs. 94.9 %; p < 0.001). Compared to women with persistent breech at the time of delivery, women with successful external cephalic version were also less likely to experience several measures of significant maternal morbidity including endometritis (adjusted Odds Ratio (aOR) = 0.36, 95 % Confidence Interval (CI) 0.24–0.52), sepsis (aOR = 0.35, 95 % CI 0.24–0.51) and length of stay > 7 days (aOR = 0.53, 95 % CI 0.40–0.70), but had a higher risk of chorioamnionitis (aOR = 1.83, 95 % CI 1.54–2.17).ConclusionsOverall a low proportion of women with breech presentation undergo successful external cephalic version, and it is associated with significant reduction in the frequency of cesarean delivery and a number of measures of maternal morbidity. Increased external cephalic version use may be an important approach to mitigate the high rate of cesarean delivery observed in the United States.

Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney.

To report the complication rate associated with external cephalic version (ECV) at term. Single-centre retrospective study. A major tertiary hospital in Sydney, Australia. All women who underwent an ECVatRoyal Prince Alfred Hospital from 1995-2013 were included. ECV was attempted on all consenting women with a breech presentation at term in the absence of contraindications. Complications were classified as minor (transient cardiotocography abnormalities, ruptured membranes, small antepartum haemorrhage) or serious (fetal death, placental abruption, fetal distress requiring emergency caesarean section, fetal bone injury, cord prolapse). ECV success rates and rate of reversion to breech were recorded. The primary outcome was the incidence of serious complications. Secondary outcome measures were the rate of minor complications and reversion to breech. Of 1121 patients that underwent ECV, five (0.45%) experienced a serious complication. There was one placental abruption, one emergency caesarean section for fetal distress and two cord prolapses. There was one fetal death attributable to a successful ECV. Forty-eight women (4.28%) experienced a minor complication. Reversion to the breech occurred in sixteen patients (3.32%). ECV at term is associated with a low rate of serious complications. Study of 1121 consecutive ECV attempts shows low rate of complications although one fetal death reported.

Impact de la version par manœuvre externe sur le pronostic obstétrical dans une équipe à fort taux de réussite de l’accouchement vaginal du siège

To analyse the impact of external cephalic version (ECV) on caesarean section rate in a team with a high success rate of vaginal delivery in breech presentation. Retrospective monocentric study including 298patients with a breech presentations between 33 and 35weeks of amenorrhea followed at our university hospital and delivered after 35weeks, between 1stJanuary2011 and 31stDecember2013. Patients were divided into 2groups: planned ECV (n=216patients) versus no planned ECV (n=57patients). Our rate of successful vaginal breech delivery over the period of the study was 61.1%. We performed 165ECV, with a 21.8% success rate. The average term of the attempt of ECV was 36.7weeks of amenorrhea. The caesarean section rate was not significantly different in the planned ECV group, even after adjustment on age, parity and previous caesarean delivery (adjusted OR=1.67 [0.77-3.61]). Attempt of ECV did not reduce the number of breech presentation at delivery (61.1% versus 61.4% [P=0.55]). Planned ECV in our center with a high level of breech vaginal delivery did not significantly impact our cesarean section rate.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study

Objectiveto assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. Designprospective matched cohort study. Setting25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. Participantssingleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. Measurements and findingsof 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62–0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29–0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2–2.5)). Key conclusionswomen who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. Implication for practiceECV is an important tool to reduce the caesarean section rates.

Predictors for a successful external cephalic version: a single centre experience.

The external cephalic version (ECV) is one of the options patients presenting with a breech pregnancy should be offered. Various fetal, maternal and other predictors for a successful ECV have been published in the past. This is a retrospective multivariate analysis of our ECV patient database at the Department of Obstetrics and Gynaecology at the University Hospital Ulm. In an outpatient setting, patients with fetal breech position were routinely offered an ECV attempt after 36 weeks of gestation if the patient was willing to consent. Contraindications for ECV were placental abruption, placenta praevia, uterus malformations, regular contractions, premature rupture of membranes, and non-reassuring fetal heart rate patterns. From January 1st 2010 to July 31st 2013, 444 patients with a minimum of 36 weeks gestational age (i.e. >35 + 6 weeks) attended our clinic with a breech presentation. Of those 118 had an ECV attempt and an extended ultrasound examination within 21 days. In 33 patients the procedure was successful (success rate 28 %). A multivariate binary logistic regression analysis revealed that an increased Amniotic Fluid Index (AFI; p < 0.001), at least one prior vaginal delivery (p = 0.002) or a high estimated fetal weight (p = 0.045) were significant independent predictors for a successful ECV. In our series no delivery occurred within 48 h after the ECV. An ECV is a safe procedure. ECV should be offered as an option for the mother-to-be on the basis of an informed consent. Identified fetal and maternal factors can help to estimate the chances of success and in particular multi-parity and increased amniotic fluid seem to be associated with successful ECV.

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version

Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2–6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1–8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.

Prediction of Success in External Cephalic Version under Tocolysis: Still a Challenge.

External cephalic version is a procedure of fetal rotation to a cephalic presentation through manoeuvres applied to the maternal abdomen. There are several prognostic factors described in literature for external cephalic version success and prediction scores have been proposed, but their true implication in clinical practice is controversial. We aim to identify possible factors that could contribute to the success of an external cephalic version attempt in our population. We retrospectively examined 207 consecutive external cephalic version attempts under tocolysis conducted between January 1997 and July 2012. We consulted the department's database for the following variables: race, age, parity, maternal body mass index, gestational age, estimated fetal weight, breech category, placental location and amniotic fluid index. We performed descriptive and analytical statistics for each variable and binary logistic regression. External cephalic version was successful in 46.9% of cases (97/207). None of the included variables was associated with the outcome of external cephalic version attempts after adjustment for confounding factors. We present a success rate similar to what has been previously described in literature. However, in contrast to previous authors, we could not associate any of the analysed variables with success of the external cephalic version attempt. We believe this discrepancy is partly related to the type of statistical analysis performed. Even though there are numerous prognostic factors identified for the success in external cephalic version, care must be taken when counselling and selecting patients for this procedure. The data obtained suggests that external cephalic version should continue being offered to all eligible patients regardless of prognostic factors for success.

External cephalic version for breech presentation before term.

External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation). To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies. Randomised controlled trials (RCTs) of ECV attempted before term (37 weeks' gestation) or commenced before term, compared with a control group of women (in breech presentation) in which either no ECV attempted or ECV was attempted at term. Cluster-randomised trials were eligible for inclusion but none were identified. Quasi-RCTs or studies using a cross-over design were not eligible for inclusion. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. Studies were assessed for risk of bias and for important outcomes the overall quality of the evidence was assessed using the GRADE approach. Five studies are included (2187 women). It was not possible for the intervention to be blinded, and it is not clear what impact lack of blinding would have on the outcomes reported. For other 'Risk of bias' domains studies were either at low or unclear risk of bias.One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared with no ECV. No difference was found in the rate of non-cephalic presentation at birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.64 to 1.69; participants = 102). One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared with no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (RR 0.59, 95% CI 0.45 to 0.77; participants = 179).Three studies reported on ECV started at between 34 to 35 weeks' gestation compared with beginning at 37 to 38 weeks' gestation. Pooled results suggested that early ECV reduced the risk of non-cephalic presentation at birth (RR 0.81, 95% CI 0.74 to 0.90; participants = 1906; studies = three; I² = 0%, evidence graded high quality), failure to achieve vaginal cephalic birth (RR 0.90, 95% CI 0.83 to 0.97; participants = 1888; studies = three; I² = 0%, evidence graded high quality), and vaginal breech delivery (RR 0.44, 95% CI 0.25 to 0.78; participants = 1888; studies = three; I² = 0%, evidence graded high quality). The difference between groups for risk of caesarean was not statistically significant (RR 0.92, 95% CI 0.85 to 1.00; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks (6.6% in the ECV group and 4.3% for controls) (RR 1.51, 95% CI 1.03 to 2.21; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was no clear difference between groups for low infant Apgar score at five minutes or perinatal death (stillbirth plus neonatal mortality up to seven days) (evidence graded as low quality for both outcomes). Compared with no ECV attempt, ECV commenced before term reduces non-cephalic presentation at birth. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non-cephalic presentation, and risk of vaginal breech birth. However, early ECV may increase risk of late preterm birth, and it is important that any future research reports infant morbidity outcomes. Results of the review suggest that there is a need for careful discussion with women about the timing of the ECV procedure so that they can make informed decisions.

The Impact of an ECV Service is Limited by Antenatal Breech Detection: A Retrospective Cohort Study.

External cephalic version (ECV) reduces the chance of breech presentation at term birth and lowers the chance of a cesarean delivery. ECV services are now in place in many units in the United Kingdom but their effectiveness is unknown. The aim of this study was to investigate the reasons for breech presentation at term birth. We performed a retrospective cohort study of 394 consecutive babies who were in breech presentation at term birth in a large United Kingdom maternity unit that offers ECV. The cohort was analyzed over two time periods 10years apart: 1998-1999 and 2008-2009. Only 33.8 percent of women had undergone a (failed) ECV attempt. This low proportion was mainly because breech presentation was not diagnosed antenatally (27.9%). Other contributing factors were: ECV not offered by clinicians (12.2%), ECV declined by women (14%), and contraindications to ECV (10.7%). Over the 10-year period, the proportion of breech presentations that were not diagnosed antenatally increased from 23.2 to 32.5 percent (p=0.04), which constituted 52.8 percent of women who had not undergone an ECV attempt in 2008-2009. Failure of clinicians to offer ECV reduced from 21.6 to 3.0 percent (p=0.0001) and the proportion of women declining ECV decreased from 19.1 to 9.0 percent (p=0.005). Overall, ECV attempts increased from 28.9 to 38.5 percent (p=0.05). Although ECV counseling, referral, and attempt rates have increased, failure to detect breech presentation antenatally is the principal barrier to successful ECV. Improved breech detection would have a greater impact than methods to increase ECV success rates.

The changing practice of the obstetrician.

The study by Beuckens et al. (BJOG 2015;in press) describes a clinical programme in which midwives were trained to perform external cephalic version (ECV) as part of routine prenatal care. Their overall success rate was 47% following one or more ECV attempts. Nearly three-quarters of the versions were attempted in a primary health care (PHC) setting. Approximately 2.6% of patients experienced fetal death, placental abruption, or preterm birth at any point after ECV in the PHC setting. Although the study design does not allow for a direct comparison with procedures performed exclusively in the inpatient environment, their results highlight that care providers other than obstetricians can be taught to successfully perform ECV; however, larger studies confirming the safety of out-patient ECV without antepartum testing and tocolysis are needed before hospital-based practice should be changed. Although the setting for this study was the Netherlands, where a large proportion of women receive care by midwives with a substantial number of deliveries at home, the training and performance of ECV by midwives and other providers should be considered if appropriately powered prospective randomized trials show no difference in outcomes. Given the shortages of obstetricians in various regions of the world, appropriately trained midwives might be able to offer ECV in regions where obstetricians are in short supply. On a grander scale, however, this work is further evidence of the changing practice of the classically trained obstetrician. Increasingly, procedures that characterised the daily activities of the obstetrician are being performed by other providers or are being eliminated all together. Vaginal breech deliveries are disappearing. Vacuum delivery has supplanted forceps, and may be performed by midwives and family physicians. Twin pregnancies are increasingly being delivered abdominally. These changes in obstetric practice have resulted in an increased rate of caesarean delivery. Although caesarean delivery is usually performed by obstetricians, both qualified surgeons and family medicine physicians can also perform caesarean delivery. With the advent of middle cerebral artery velocimetry for the detection of suspected fetal anaemia and the use of non-invasive prenatal testing for aneuploidy detection, the use of amniocentesis and chorionic villus sampling have declined substantially (Larion et al. Am J Obstet Gynecol 2014;123:651.e1–7). So where does this leave the obstetrician? Perhaps one area where the obstetrician simply cannot be replaced is in providing the obstetrical judgment that comes with their clinical obstetrical experience, detailed knowledge of the history of the field and maternal–fetal physiology, and appreciation of the contemporary scientific literature. Whereas virtually anyone can successfully perform a vaginal delivery, complex pregnancies require the wisdom of a skilled and experienced obstetrician for optimal outcomes; however, this does not negate the need for the specialty of obstetrics to contemplate redefining itself, as the technical skills required to be an obstetrician have so dramatically changed in such a short period of time. Changes in the length of training, the design of training programmes, and the pipeline to subspecialty training should be considered. As the curriculum of medical school education is being restructured, so should the curriculum of obstetrical postgraduate training. No relevant financial or other conflicts of interest.