Outcome Of External Cephalic Version Research Articles

An Updated Systematic Review on Prediction Models for Successful External Cephalic Version

Purpose: Current practice guidelines recommend offering patients an external cephalic version (ECV) when a fetus is found to be in breech position. If successful, vaginal delivery can then safely follow an ECV. ECV for a term breech presentation varies widely in success but is a well-studied topic, with many variables identified which relate to its success. This has led to a multitude of predictor models for ECV success. A systematic review by Velzel et al. published in 2015 examined prior predictor models for ECV success; however, many models have since been published. We aim to update this systematic review with the new predictive models published in the last seven years and thus review the decision aids currently available or being developed to predict a patients’ odds that their external cephalic version (ECV) will be successful. Methods: We searched PubMed/MEDLINE, Cochrane Central, and ClinicalTrials.gov from 2015-2022. Articles from a pre-2015 systematic review were also included. A clinical librarian helped with conducting a thorough search strategy. We selected English-language articles describing or evaluating models (prediction rules) designed to predict an outcome of ECV for an individual patient. Acceptable model outcomes included cephalic presentation after the ECV attempt and whether the ECV ultimately resulted in a vaginal delivery. Two authors independently performed article selection following PRISMA 2020 guidelines. Since 2015, 380 unique records underwent title and abstract screening, and 49 reports underwent full-text review. Ultimately, 17 new articles and 8 from the prior review were included. Of the 25 articles, 22 proposed 1-2 models each for a total of 25 models, while the remaining 3 articles validated prior models without proposing new ones. The studies were then analyzed for quality and risk of bias using a customized framework which analyzed four main domains: participants, predictors, outcome, and analysis. Ultimately, the largest factor considered when assessing study quality was whether the outcome was likely to be different amongst groups within a similar population. We then assessed the model’s calibration and discrimination metrics (if reported) to evaluate their overall model performance. Results: Of the 17 new articles, 10 were low, 6 moderate, and 1 high risk of bias. Studies were considered to have moderate risk of bias and quality if model-building strategies were not described, as it introduces concerns regarding consistency in applying the models to a similar population. Almost all articles were from Europe (11/25) or Asia (10/25); only one study in the last 20 years was from the USA. Four of the 17 new articles had some form of overlap with articles from the prior systematic reviews. The remaining 13 new articles used datasets, proposed models, and were performed by researchers that were entirely distinct from the 8 original articles The most included characteristics were parity (19/25), placental location (12/25), and breech engagement or station (10/25). Although many studies included BMI (8/25), only a few indicated whether this was to be pregravid, peri-ECV, or peripartum BMI. Some metrics for model discrimination (e.g., sensitivity, AUC, accuracy, PPV) was displayed in 17 of the 25 models. The models found had diverse presentations including score charts, decision trees (flowcharts), and equations. The majority (13/25) had no form of validation and only 5/25 reached external validation. Only the Newman-Peacock model (USA, 1993) was repeatedly externally validated (Pakistan, 2012 and Portugal, 2018). Most models (14/25) were published in the last 5 years. In general, newer models were designed more robustly, used larger sample sizes, and were more mathematically rigorous. Thus, although they await further validation, there is great potential for these models to be more predictive than the Newman-Peacock model. Based on the findings in this review, the Newman-Peacock model to predict ECV success (odds of cephalic presentation after the ECV procedure) is currently the most clinically useful model. Even though it is the oldest model in the review, it includes three of the most widely included prediction features: parity, placental location, and station. Furthermore, it is the only model that has been externally validated in a significantly different population and by a different investigational team than what was used to create the model. Conclusion: Only the Newman-Peacock model is ready for regular clinical use in predicting ECV success. Many newer models are promising but require further validation.

Prediction Models for Successful External Cephalic Version: An Updated Systematic Review.

To review the decision aids currently available or being developed to predict a patient's odds that their external cephalic version (ECV) will be successful. We searched PubMed/MEDLINE, Cochrane Central, and ClinicalTrials.gov from 2015 to 2022. Articles from a pre-2015 systematic review were also included. We selected English-language articles describing or evaluating models (prediction rules) designed to predict an outcome of ECV for an individual patient. Acceptable model outcomes included cephalic presentation after the ECV attempt and whether the ECV ultimately resulted in a vaginal delivery. Two authors independently performed article selection following PRISMA 2020 guidelines. Since 2015, 380 unique records underwent title and abstract screening, and 49 reports underwent full-text review. Ultimately, 17 new articles and 8 from the prior review were included. Of the 25 articles, 22 proposed one to two models each for a total of 25 models, while the remaining 3 articles validated prior models without proposing new ones. Of the 17 new articles, 10 were low, 6 moderate, and 1 high risk of bias. Almost all articles were from Europe (11/25) or Asia (10/25); only one study in the last 20 years was from the United States. The models found had diverse presentations including score charts, decision trees (flowcharts), and equations. The majority (13/25) had no form of validation and only 5/25 reached external validation. Only the Newman-Peacock model (United States, 1993) was repeatedly externally validated (Pakistan, 2012 and Portugal, 2018). Most models (14/25) were published in the last 5 years. In general, newer models were designed more robustly, used larger sample sizes, and were more mathematically rigorous. Thus, although they await further validation, there is great potential for these models to be more predictive than the Newman-Peacock model. Only the Newman-Peacock model is ready for regular clinical use. Many newer models are promising but require further validation. · 25 ECV prediction models have been published; 14 were in the last 5 years.. · The Newman-Peacock model is currently the only one with sufficient validation for clinical use.. · Many newer models appear to perform better but await further validation..

Success Rate and Clinical Outcomes of External Cephalic Version with or without Anesthesia for Breech Presentation at Term in China

Background: To determine whether neuraxial anesthesia (NA) can improve the success rate of external cephalic version (ECV), and evaluate the clinical outcomes. Methods: This study included 201 consecutive participants who had a breech presentation at term and received ECV between 2014 and 2022. Participants who received ECV without NA were included in Group 1, while participants with NA were included in Group 2. Outcomes assessed were the success rate of ECV and clinical outcomes. Results: In total, 201 participants who had a breech presentation at term and received ECV met the inclusion criteria. Totally, 134 participants performed ECV without NA were included in Group 1, while 67 participants performed the ECV with NA were included in Group 2. The success rate of ECV among the participants was 66.2% (133/201). The rate of placental abruption during or after ECV and neonatal intensive care unit (NICU) admission in Group 2 was statistically significant higher than in the Group 1 (p < 0.05). Conclusions: This study suggested that the use of NA did not increase ECV success rates after 37 weeks of gestation. The recommendation of NA for the ECV may be not suitable for all pregnancies unless the participants request. A large and high-quality study should be conducted to verify the role of NA in ECV, if any.

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.

Assessment of the Successful External Cephalic Version Prognostic Parameters Effect on Final Mode of Delivery.

AimThis study aims to evaluate the prognostic parameters of successful approach for an external cephalic version (ECV) procedure by considering the vaginal delivery as the optimal mode of delivery.MethodologyA retrospective cohort study was done during June 2019 in the obstetrics and gynecology department at King Abdulaziz University Hospital. Data were collected between May 2009 and May 2019 and included all pregnant women who were candidates for the ECV. The primary objective was to assess the final mode of delivery in relation to the outcome of ECV followed by the secondary objective which was the prognostic parameters of the ECV procedure (body mass index, amniotic fluid index, parity, estimated fetal weight). Additional variables were maternal age, placental position and ethnicity.ResultsWe have studied 86 pregnant women with ECV attempts the overall ECV success rate was for 46 women (59.7%). For the final mode of delivery, after a successful ECV procedure, 40 women (87%) whom had spontaneous vaginal delivery, in association to successful ECV, the prognostic parameters recorded the highest success rate were multiparous 35 (76.1%), body mass index between 25 and 29.9 (53.1%), women older than 30 years old (60.9%), gestational age between 37 to 39.6 weeks (56.5%). Posterior placental location 55.6%, estimated fetal weight more than 2500 (73.9%).ConclusionSuccessful ECV cases have recorded a significant increase in the incidence of spontaneous vaginal delivery and the outcome of ECV which is affected by many prognostic parameters such as parity, maternal age, gestational age, body mass index, amniotic fluid index (AFI) and estimated fetal weight (EFW).

Development of prediction models for successful external cephalic version and delivery outcome.

To develop prediction models for the chance of successful external cephalic version (ECV) and delivery outcome. This is a single-center retrospective study including 350 pregnant women with a singleton non-cephalic pregnancy at or after 36weeks of gestational age. We selected 22 factors for ECV prediction and 21 for delivery outcome after successful ECV prediction as candidate predictors. Multivariable logistic regression with a stepwise backward selection procedure was used to construct a prediction model for the chance of successful ECV and the other for the delivery outcome. The discrimination and calibration of the models were assessed and internal validation was done with bootstrapping. ECV was successfully performed in 232 cases (66.3%) among 343 women. Eight predictive factors were identified to be associated with a successful ECV: Gestational week at ECV < 39weeks, multiparous, BMI before pregnancy < 22kg/m3, palpable fetal head, breech engagement, larger AFI, larger BPD and posterior placenta. This model showed good calibration and good discrimination (c-statistic = 0.82, 95% CI 0.76-0.88). Six predictive factors were identified to be associated with vaginal delivery after successful ECV: age < 35, multiparous, BMI before pregnancy < 22kg/m3, anterior placenta, lateral placenta and none-front fetal spine position. This model showed fair discrimination (c-statistic = 0.79, 95% CI 0.72-0.85). However, its calibration was not so satisfactory especially when the predicted probability was low. We validated a prediction model for ECV and delivery outcome, showing that the model's overall performance is good. This can be used in clinical practice after external validation.

Scoring system to predict the success rate of external cephalic versions and determine the timing of the procedure.

We aimed to examine the prenatal clinical characteristics of women with single pregnancies undergoing external cephalic version (ECV) without anesthesia, develop a novel scoring system for predicting the ECV success rate, and demonstrate that this scoring system can be used to individualize the timing of ECV attempts. We enrolled 270 women who underwent ECV without anesthesia at 37-40 weeks of gestation in the Fujian Maternity and Child Health Hospital from 2016 to 2019 and divided them into two ECV outcome groups (success vs. failure). We identified five clinical features (the fetal buttocks' station, the sum of the fundal height and station, the fetal head location, and whether the fetal head or buttocks could be grasped) as independent factors affecting the ECV success rate, and we scored them using a regression coefficient. Women with scores of 0-3 points had ECV success rates, vaginal delivery rates, and delivery gestational ages at 16.67%, 16.67%, and 38.88 weeks, respectively; those with scores of 4-6 points had ECV success rates, vaginal delivery rates, and delivery gestational ages at 65.75%, 58.90%, and 39.62 weeks, respectively; and those with scores of 7-9 points had ECV success rates, vaginal delivery rates, and delivery gestational ages at 93.71%,74.83%, and 40.00 weeks, respectively. The ECV success and vaginal delivery rates increased with the score, and the delivery gestational age showed an initial increase. To optimize the ECV procedure and reduce the hospital burden, this scoring system should be used routinely to predict the ECV success rate and determine the timing of ECV attempts.

Outcomes of external cephalic version for antenatal women with breech presentation in a secondary hospital in Vellore, Tamil Nadu - a retrospective review

Objective:Breech presentation is the most common fetal malpresentation at term, with an incidence of 3-4%. External cephalic version (ECV) is a procedure that can be offered to women with breech presentation beyond 36 weeks of gestation to convert it to cephalic presentation, reducing the risks of a vaginal breech delivery and the morbidities associated with caesarean section.Material and Methods:We retrospectively reviewed the records of women who underwent ECV between October 2012 and June 2020 with the objectives of determining the success rate of the procedure, the mode of delivery, the maternal and neonatal outcomes, periprocedural complications and their management.Results:Among the 200 women who underwent the procedure with a 64% success rate (128 women), there were 110 vaginal deliveries (56.7%) including five vaginal breech deliveries, and 84 women (43.2%) underwent caesarean section, which included 24 women who had successful ECV but needed emergency caesarean for other indications. There was no significant difference in the neonatal APGAR scores in those who had a successful ECV and those who did not. Only three women (1.5%) experienced any significant periprocedural complication.Conclusion:These results suggest that ECV improves the possibility of a vaginal delivery with an overall low complication rate, reducing the neonatal risks associated with vaginal breech delivery and the maternal morbidity of a caesarean section. It may thus contribute to reducing the primary caesarean section rate, making it a useful intervention, especially in limited resource settings.

Nifedipine versus ritodrine during external cephalic version procedure: a case control study

Objective Published series regarding interventions for facilitating external cephalic version (ECV) have concluded that parenterally administered beta-stimulant tocolytics, increased ECV success rate and reduced the number of cesarean sections. However, there were insufficient data regarding calcium channel blockers to provide good evidence regarding its efficacy. Given the paucity of literature, we aimed to compare the efficacy of nifedipine to that of ritodrine on ECV success rates. Methods This is a retrospective case control study of prospectively collected data of patients who underwent ECV between January 2012 and December 2013 at Bikur Cholim Medical Center and Hadassah-Hebrew University Medical Center in Jerusalem, Israel. Patient undergoing ECV with tocolysis by ritodrine were compared with those using nifedipine as tocolysis. Patients were matched in a one-to-one ration by parity and placental location. Results Overall, 148 women received ritodrine and 148 women received nifedipine before ECV procedure. Overall success rate was higher among the ritodrine group (82.4 vs. 63.5%, p < .001). Among nulliparous and among parous, success rate was higher in the ritodrine group (78.9 vs. 57.9 and 88.6 vs. 73.5%, p = .001, p = .04, respectively). Vaginal delivery rate was higher among the ritodrine group (86.5 vs. 68.9%, p < .001). Cesarean delivery rate was 31.1% for the nifedipine group versus 13.5% in the ritodrine group (p < .001). Number needed to treat to benefit (NNTb) 5.7 (95% confidence interval 3.7–12.1). Overall, 216 of 296 (72.9%) of ECV were successful. Ritodrine was associated with higher success rates as compared with nifedipine (56.5 vs. 32.5%, p < .001). In a multivariate analysis, ritodrine tocolytic therapy was independently associated higher ECV success rates as compared to nifedipine (OR 4.54, 95% CI 2.38–9.09). Higher amniotic fluid index (OR 1.16, 95% CI 1.05–1.28) and nulliparity (OR 0.16, 95% CI 0.08–0.30) were additional independent predictors of ECV outcome. Conclusion Ritodrine significantly improve the success of ECV compared with nifedipine. Both drugs are shown to be safe.

The role of bladder volume in the success of external cephalic version

ObjectiveNumerous studies have evaluated the factors associated with ECV success. Yet, bladder volume has never been examined. We hypothesize that maternal bladder volume may affect ECV success rate. We aim to evaluate the role of maternal bladder volume during external cephalic version (ECV) on the procedure success rates. Study designWe reviewed prospective collected data of all patients who underwent ECV at our center during 2001–2012. The study group included 100 patients that underwent ECV with bladder volume below 400 ml. These patients were matched to 400 patients that underwent ECV with bladder volume equal or above 400 ml which composed the control group. Maternal and fetal characteristics and outcomes were compared. ResultsECV was successfully performed in 80/100 (80.0%) of patients in the study group as compared to 257/400 (64.3%) in the control group (P = 0.002). Factors associated with ECV success were older age (P = 0.003), having prior delivery (P < 0.0001), higher amniotic fluid index (AFI) (P = 0.001) and placenta located in the posterior wall (P = 0.001).In a logistic regression analysis, bladder volume was found to be an independent predictor of ECV success Odds radio (OR) for ECV success 2.5 (CI 1.42–4.34). Posterior placenta and higher AFI were found to be an independent predictors of ECV success as well; OR 2.7 (CI 1.74–4.34) and OR 1.07 (CI 1.02–1.13) respectively. ConclusionECV is more successful in patient with bladder volume below 400 ml. Amniotic fluid volume and placental location were found as independent predictors of ECV outcome as well.

External cephalic version experiences in Korea.

ObjectiveThe aim of this study was to evaluate obstetric outcomes of external cephalic version (ECV) performed at or near term.MethodsSingle pregnant woman with breech presentation at or near term (n=145), who experienced ECV by one obstetrician from November 2009 to July 2014 in our institution were included in the study. Maternal baseline characteristic and fetal ultrasonographic variables were checked before the procedure. After ECV, the delivery outcomes of the women were gathered. Variables affecting the success or failure of ECV were evaluated.ResultsSuccess rate of ECV was 71.0% (n=103). Four variables (parity, amniotic fluid index, fetal spine position and rotational direction) were observed to be in correlation with success or failure of ECV. In contactable 83 individuals experienced successful ECV, cesarean delivery rates were 18.1%, 28.9%, and 5.3% in total, nulliparas, and multiparas, respectively.ConclusionBased on the results, ECV is proposed to be safe for both mother and her fetus. In addition, it is a valuable procedure that increases probability of vaginal delivery for women with breech presentation.

Obstetric outcome after successful external cephalic version for breech presentation at term

Age, y 78 28.8 ± 6.9 28.5 17.0 43.0 BMI 64 28.5 ± 6.8 27.2 18.2 45.0 External cephalic version (ECV) should be considered for all women with a singleton pregnancy and noncephalic presentation at 37 weeks [1]. Successful ECV does not always translate to a vaginal delivery and a cesarean may still be required [2]. A meta-analysis showed that successful ECV at term compared with spontaneous cephalic presentation was associatedwith a doubling of the cesarean delivery rate [3]. By contrast, a case− control study concluded that the risk of cesarean delivery after successful ECV was not increased [4]. The aim of the present study was to report the obstetric outcome following successful ECV for breech presentation at term performed at a hospital in South Africa. A retrospective descriptive study was conducted to audit the outcome of successful ECV performed at the Fetal Evaluation Clinic at Tygerberg Hospital, Cape Town, over a seven-year period between April 2005 and April 2012. Nominal variables were compared using the χ test and the significance level was set at 0.05. The t test was used to compare normally distributed outcome variables and the Mann-Whitney test was used for non-normally distributed variables. Statistical analysis was performed using SAS version 9.3 (SAS Institute Inc, Cary, NC, USA). Ethical approval was obtained with waiver of informed consent from the Human Research Ethics committee of Stellenbosch University (S11/10/009).

Fear for external cephalic version and depression: predictors of successful external cephalic version for breech presentation at term?

BackgroundObjective was to determine whether fear for external cephalic version (ECV) and depression are associated with the success rate of ECV in women with a breech presentation at term.MethodsProspective study conducted in the Catharina Hospital Eindhoven between October 2007 and May 2012. Participants fulfilled The Edinburgh Depression Scale (EDS) questionnaire and expressed their degree of fear on a visual analogue scale from one to ten before ECV. Obstetric factors were evaluated as well. Primary outcome was the relation between psychological factors (fear for ECV and depression EDS scores) and ECV success rate. Secondary outcome was a possible relation between fear for ECV and increased abdominal muscle tension.ResultsThe overall success rate was 55% and was significantly lower (p < 0.001) in nulliparous women (44.3%) compared with parous women (78.0%). Fear for ECV and depression EDS-scores were not related with ECV success rate. Parity, placental location, BMI and engagement of the fetal breech were obstetric factors associated with ECV outcome. There was no relation between fear for ECV and abdominal muscle tone.ConclusionFear for ECV and depression were not related with ECV success rate in this study. Engagement of the fetal breech was the most important factor associated with a successful ECV.Trial registrationEBIS: The Eindhoven Breech Intervention Study, NCT00516555.

Determinants of pain perception after external cephalic version in pregnant women

ObjectiveA considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV. DesignProspective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt. SettingDepartment of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands. MethodsPrior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV. FindingsMultivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors. ConclusionApart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt. Implication for practiceMaternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.

External cephalic version does not increase the risk of intra-uterine death: a 17-year experience and literature review

Objective: To assess the risk of intra-uterine death (IUD) after external cephalic version (ECV). Methods: In this retrospective cohort study, 1078 consecutive ECVs performed between January 1994 and March 2011 in an University teaching hospital were extracted from the computerized database to examine the risk of IUD after ECV. Results: A total of 1078 consecutive ECVs were performed over the study period. The overall successful rate was 72.8%, the successful rate was 63.1% in nulliparous and 82.7% in multiparous, respectively (p < 0.001). There was no IUD identified within 24 h after the procedure and there was only one case of IUD (0.09%) that occurred 4 weeks after an uncomplicated ECV. Conclusions: ECV is a safe procedure that does not increase the risk of IUD within and after 24 h of enrolment irrespective of outcome of ECV. Our findings have important clinical implication in terms of patient counseling regarding the decision on term breech management.

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.

Clinical score for the outcome of external cephalic version: A two‐phase prospective study

To design a score based on clinical parameters to predict the outcome of external cephalic versions (ECVs) at term. A two-phase study was conducted (analysis/design and prospective validation) regarding 1000 versions performed between March 2002 and November 2010. The variables considered in the score were selected based on the results of multiple logistic regression models and multiple correspondence analyses published by our group. The predictive capacity was estimated through the area under the ROC curve. The success rates for ECV in phases 1 and 2 were 52.2 and 51.2%, respectively, making the overall success rate 51.7%. The score was designed with the variables parity, placental location, breech variety and amount of amniotic fluid giving a value for each one. A clinical recommendation, based on the result of the score, was the estimated success rate with the 95% confidence interval. The predictive capacity of the score for the outcome of ECV at term was 70.1% (95% CI 66.9-73.4). A score composed of four easily measurable variables enabled us to predict the outcome of ECV at term.

External Validation of a Prediction Model for Successful External Cephalic Version

We sought external validation of a prediction model for the probability of a successful external cephalic version (ECV). We evaluated the performance of the prediction model with calibration and discrimination. For clinical practice, we developed a score chart to calculate the probability of a successful ECV. We studied 320 women undergoing ECV, of which 117 (37%) were successful. The model underestimated the success rate by 4 to 14%. The area under the receiver operating characteristic curve was moderate (0.66; 95% confidence interval: 0.60 to 0.72), but the model was able to make good distinction between women with a higher predicted probability of a successful ECV (more than 50%) compared with women with a lower predicted probability of a successful ECV (less than 20%). Our model to predict the outcome of ECV holds in external validation. It can be used to support patient counseling and decision making for ECV in singleton term breech presentations.

Editorial: Alternative approaches to breech presentation

Editorial: Alternative approaches to breech presentation

The relation between umbilical cord characteristics and the outcome of external cephalic version

Background Umbilical cords of fetuses in breech presentation differ in length and coiling from their cephalic counterparts and it might be hypothesised that these cord characteristics may in turn affect ECV outcome. Aim To investigate the relation between umbilical cord characteristics and the outcome of external cephalic version (ECV). Study design Prospective cohort study. Subjects Women (> 35 weeks gestation) with a singleton fetus in breech presentation, suitable for external cephalic version. Demographic, lifestyle and obstetrical parameters were assessed at intake. ECV success was based on cephalic presentation on ultrasound post-ECV. Umbilical cord length (UCL) and umbilical coiling index (UCI) were measured after birth. Outcome measure The relation between umbilical cord characteristics (cord length and coiling) and the success of external cephalic version. Results ECV success rate was overall 79/146 (54%), for multiparas 37/46(80%) and for nulliparas 42/100 (42%). Multiple logistic regression showed that UCL (OR: 1.04, CI: 1.01–1.07), nulliparity (OR: 0.20, CI: 0.08–0.51), frank breech (OR: 0.37, 95% CI: 0.15–0.90), body mass index (OR: 0.85, CI: 0.76–0.95), placenta anterior (OR: 0.27, CI: 0.12–0.63) and birth weight (OR: 1.002, CI: 1.001–1.003) were all independently related to ECV success. Conclusions Umbilical cord length is independently related to the outcome of ECV, whereas umbilical coiling index is not.