External Cephalic Version For Breech Presentation Research Articles

Outcome of external cephalic version in breech presentation

Breech presentation is the most common abnormal foetal presentation with an incidence of 3–4% at term. It is associated with increased perinatal mortality and morbidity irrespective of the route of delivery. There is higher incidence of premature rupture of membranes, premature labour, prolapsed cord, traumatic deliveries, perinatal mortality and morbidity including various birth injuries, which makes breech an unfavourable presentation. Not only is the foetal asphyxia more commonly seen in breech, the incidence of traumatic morbidity like intracranial haemorrhage, visceral injuries, fractures, dislocations, and peripheral nerve injuries are encountered more frequently.1 With the passage of time, the art of assisted breech delivery has suffered significant setback. Most of the cases of unfavourable presentation like breech are subjected to caesarean section in the current obstetric practice. The elective caesarean section does not guarantee the improved outcome of the baby and may also increase the risk for the mother, compared to vaginal delivery.2 This situation is further compounded by current small family norms and fear of litigation. In view of this, converting an unfavourable presentation like breech into cephalic presentation by carrying out an external cephalic version (ECV) is a viable option. With ECV the expected 3–4% incidence of breech presentation at delivery may be reduced to 1%. Besides, ECV may also protect against premature labour, its complications, and permit a higher percentage of term deliveries as 20–30% of obstetric patients with breech presentation deliver prematurely.3 External cephalic version is also a potentially hazardous procedure. There is increased risk of ante partum haemorrhage, foeto-maternal haemorrhage, and foetal distress, rupture of membranes, placental abruption, and cord complications. External cephalic version is a strong stimulant of foeto-placental unit as evident by increased middle cerebral arterial blood flow and increased cell free foetal deoxyribonucleic acid in maternal circulation. In the hands of an experienced surgeon and with aid of tocolytics, ultrasonography, and cardiotocography the overall success rate of the procedure is 77% with very small risk of complications.4 Moreover, low cost, ease of procedure, and patient preparation are the added advantages. The delay to attempt ECV at or after 37 weeks of gestation has obvious advantages like management of complications by emergency caesarean section, giving time for spontaneous version to take place with the requirement of fewer procedures.5,6 Thus, there are some uncertainties related to the role and outcome of ECV in breech presentation. The present study aims to determine the outcome of ECV in breech presentation.

Randomized Controlled Trial of External Cephalic Version in Term Multiparae With or Without Spinal Analgesia

Background Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia. Methods Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests. Results Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia ( P =0.009; 95% CI of difference: 0.075–0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without ( P P =0.0003) and easily treated without adverse outcome. No complications were noted after the ECV. Conclusions Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.

Tocolysis for Repeat External Cephalic Version in Breech Presentation at Term: A Randomized, Double-Blind, Placebo-Controlled Trial

External cephalic version (ECV) lowers the incidence of breech presentation at term and limits the need for cesarean section in noncephalic births. Although tocolytic agents may improve success rates, they are time-consuming, may cause side effects, and have not been documented to lower rates of section delivery. The investigators attempted to determine whether tocolysis is helpful when ECV is tried again after an initial failed attempt. Using a randomized, double-blind, placebo-controlled design, 124 women with breech presentation at term were enrolled in the study. All of them had undergone attempted ECV without tocolysis but had failed to respond. None of them had an abnormal cardiotocograph after the attempt and none had heart disease, diabetes, or hypertension. Participants were randomly assigned to receive either tocolysis with ritodrine or placebo during a repeat attempt at ECV. Ritodrine at a concentration of 3 mg/mL was administered by syringe pump, starting at 1 mL/hour and increasing up to a maximum of 5 mL/hour. The mother's pulse was kept below 120 beats/min. A decrease in the need for elective cesarean section for breech presentation was the major reason for a decrease in operative deliveries. The frequency of cephalic presentation at delivery was significantly increased after tocolysis (relative risk [RR], 3.21; 95% confidence interval [CI], 1.23-8.39). The incidence of cesarean section declined (RR, 0.33; 95% CI, 0.14-0.80). For multiparous women, the RR for cephalic presentation at delivery was 9.38 (95% CI, 1.64-53.62). No significant effect of tocolysis was evident in nulliparous women. There were no changes in maternal or neonatal morbidity. Although pain scores did not differ between the active treatment and placebo groups, only one woman remained totally free of pain and approximately three fourths of women experienced discomfort. A second attempt at ECV for breech presentation will be substantially more effective if tocolysis is used, and fewer cesarean sections will be necessary. Using tocolysis only after a first attempt at ECV has failed, rather than in all nulliparous women, may well produce higher overall success rates with fewer side effects.

Tocolysis in term breech external cephalic version

Objectives To study the effect of ritodrine tocolysis on the success of external cephalic version (ECV) and to assess the role of ECV in breech presentation at our centre. Material and methods A prospective randomized double-blind-controlled trial comparing ritodrine and placebo in ECV of singleton term breech pregnancy at a tertiary hospital. Results Among the 60 patients who were recruited, there was a success rate of 36.7%. Ritodrine tocolysis significantly improved the success rate of ECV (50% vs. 23%; P=0.032). There was a marked effect of ritodrine tocolysis on the ECV success in nulliparae (36.4% vs. 13.0%) and multiparae (87.5% vs. 57.1%). External cephalic version has shown to reduce the rate of cesarean section for breech presentation by 33.5% in our unit. Conclusion External cephalic version significantly reduced the rate of cesarean section in breech presentation, and ritodrine tocolysis improved the success of ECV and should be offered to both nulliparous and parous women in the case of term breech presentation.