Successful External Cephalic Version Research Articles

The Optimal Prediction Model for Successful External Cephalic Version.

The majority of breech fetuses are delivered by cesarean birth as few physicians are trained in vaginal breech birth. An external cephalic version (ECV) can prevent cesarean delivery and the associated morbidity in these patients. Current guidelines recommend that all patients with breech presentation be offered an ECV attempt. Not all attempts are successful, and an attempt does carry some risks, so shared decision-making is necessary. To aid in patient counseling, over a dozen prediction models to predict ECV success have been proposed in the last few years. However, very few models have been externally validated, and thus, none have been adopted into clinical practice. This study aims to use data from a U.S. hospital to provide further data on ECV prediction models. This study retrospectively gathered data from Carle Foundation Hospital and used it to test six models previously proposed to predict ECV success. These models were Dahl 2021, Bilgory 2023, López Pérez 2020, Kok 2011, Burgos 2010, and Tasnim 2012 (GNK-PIMS score). A total of 125 patients undergoing 132 ECV attempts were included. A total of 69 attempts were successful (52.2%). Dahl 2021 had the greatest predictive value (area under the curve [AUC]: 0.779), whereas Tasnim 2012 performed the worst (AUC: 0.626). The remaining models had similar predictive values as each other (AUC: 0.68-0.71). Bootstrapping confirmed that all models except Tasnim 2012 had confidence intervals not including 0.5. The bootstrapped 95% AUC confidence interval for Dahl 2021 was 0.71 to 0.84. In terms of calibration, Dahl 2021 was well calibrated with predicted probabilities matching observed probabilities. Bilgory 2023 and López Pérez were poorly calibrated. Multiple prediction tools have now been externally validated for ECV success. Dahl 2021 is the most promising prediction tool. · Prediction models can be powerful tools for patient counseling.. · The odds of ECV success can estimated based on patient factors and clinical findings.. · Of the six tested models, only Dahl 2021 appears to have good predictive value and calibration..

External Cephalic Version: A Retrospective Chart Review at a Canadian Tertiary Care Centre

ObjectivesThe primary objective is to identify our local external cephalic version (ECV) success rate, variables associated with increased likelihood of success, and complication rates. The secondary objective is to allow obstetrical care providers to accurately counsel patients undergoing a trial of ECV. MethodsWe analysed patient charts between January 2018 and December 2022 who underwent ECV. Variables included maternal age, parity, gestational age at the time of ECV attempt, breech type, anesthetic, uterine relaxant, placental location, neonatal birthweight, and provider seniority. Outcomes were ECV success, mode of delivery, emergent cesarean delivery rate due to ECV, and neonatal intensive care unit admission. Appropriate statistical analysis was performed. ResultsOverall, 258 patients were included. Overall success rate was 31%. Multiparity, transverse presentation, and neonatal birthweight >3.3 kg were associated with significantly increased success rates. Uterine relaxant use was associated with a lower success rate than no relaxant use, which is potentially explained by significantly more frequent relaxant use in non-transverse presentations and a non-significant trend in increased relaxant use in primiparous patients. Other factors including anesthetic use, maternal age, gestational age, placental location, and provider seniority did not significantly impact success. The emergency cesarean delivery rate was 10% and the neonatal intensive care unit admission rate was 8%, both of which were higher than anticipated. ConclusionsECV remains an option for the management of the term breech. Obstetrical providers at our centre and in others may use this study to more accurately counsel patients using local data and optimize the likelihood of success based on patient and peri-procedural factors.

Impact of a simulator-based training program on the success rate of external cephalic version

ObjectiveTo compare the success and complication rates of external cephalic version before and after the implementation of a simulator-based training program at a tertiary care university centre with a dedicated external cephalic version team. Study designIn this single-center intervention study, the success rate and the complication rates of external cephalic version in the two years before the implementation of a simulation-based training program for all specialists and residents, were compared with the two years following the event. T- student, Mann-Whitney, and Chi-square tests were used. All data were extracted from the hospital’s electronic patient records. ResultsA total of 96 external cephalic versions were performed in the 2 years before the training program, and 74 after the training program. The overall success rates were similar between the two groups: 44.8 % before training and 43.2 % after training (p = 0.824). No major complications occurred, and no emergency cesarean deliveries were performed in either period. ConclusionIn a tertiary care university training center with a dedicated team in external cephalic version, a structured simulation-based training program did not impact the success rate or the complication rates of the procedure.

Impact of a regional simulation-based training course in the implementation of external cephalic version: Intervention study.

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

Neonatal Outcome following External Cephalic Version (ECV)-Comparison between Vaginal Birth after Successful ECV and Elective Caesarean Section after Unsuccessful ECV.

Introduction: In 3-6% of pregnancies, foetuses can be expected to be in a breech presentation near term. Consultation concerning further management of the pregnancy, including the option of an external cephalic version (ECV), is recommended by international guidelines (RCOG, ACOG, and DGGG). With regards to an ECV, there need to be two assumptions. Firstly, the procedure is safe, which has been shown adequately. Secondly, a vaginal birth after a successful ECV needs to prove to be non-inferior to the alternative of an elective caesarean section. The aim of this study is to assess the non-inferiority assumption. Methods: Overall, 142 singleton pregnancies were analysed that presented a foetus in a non-cephalic presentation and underwent an ECV near term between 2011 and 2020. The ECV was performed at 36 weeks of gestation for primiparous women and at 37/38 weeks of gestation for multiparous women. To assess neonatal outcome, the following parameters were recorded: arterial and venous umbilical cord blood pH, APGAR scores and admission to the neonatal intensive care unit (NICU). Data were analysed under the assumption that neonatal outcome does not differ between elective caesarean sections with or without an ECV in advance. Results: The success rate of an ECV was 56.3% (80/142). In the case of a successful ECV, there was a 77.5% (62/80) chance for a vaginal delivery. The mean arterial pH for neonates born vaginally after successful ECV was 7.262 (SD 0.089), compared to 7.316 (SD 0.051) for those born via elective caesarean section (p < 0.001). APGAR scores at 1, 5, and 10 min were similar between the groups, with a slightly higher proportion of neonates scoring below the median in the caesarean section group. Specifically, 13.7% (7/51) at 1 min, 15.7% (8/51) at 5 min, and 9.8% (5/51) at 10 min in the caesarean section group were below the median, compared to 4.92% (3/61), 4.92% (3/61), and 3.28% (2/61) in the vaginal birth group. NICU admission rates were 3.28% for vaginal births and 3.92% for elective caesarean sections (p > 0.05). Conclusions: Women with a successful ECV can expect a neonatal birth outcome after a vaginal birth that is non-inferior to an alternative elective caesarean section.

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.

Ultrasonic convex array probe applied to increase success rate of external cephalic version without anesthesia

Objective: To explore the feasibility of using ultrasonic convex array probe compressing abdominal wall to increase success rate of external cephalic version (ECV) without anesthesia in full-term and near-term pregnancy. Methods: Totally 190 singleton and non-cephalic presentation pregnant women in 36-39+4 weeks of gestation performed ECV from April 2019 to August 2023 in the First Affiliated Hospital of Nanjing Medical University were analyzed. According to whether use the ultrasound probe compressing fetal breech or not, the pregnant women were divided into two groups: 81 cases in the probe-compressing group (including primipara 61 cases and multipara 20 cases) and 109 cases in the non-probe-compressing group(including primipara 72 cases and multipara 37 cases). Clinical data, ECV related factors and complications were analyzed and compared between the two groups. Results: (1) The overall success rate of ECV was 64.2% (122/190). There was no significant difference in the success rate of ECV between probe-compressing group and non-probe-compressing group [69.1% (56/81) vs 60.6% (66/109), χ2=1.490, P=0.222]. The total vaginal delivery rate after successful ECV was 81.1% (99/122), while 71.1% (54/76) in primipara and 97.8% (45/46) in multipara, respectively. (2) Compare to the non-probe-compressing group, the success rate of ECV in primipara was significantly higher in the probe-compressing group [45.8% (33/72) vs 70.5% (43/61)], but the gestational age was shorter and the height was higher in the probe-compressing group (all P<0.05). The success rate of ECV of multipara in the probe-compressing group (65.0%, 13/20) was lower than that in the non-probe-compressing group (89.2%, 33/37), but there was no significant difference between the two groups (P>0.05). (3) Multivariate logistic regression analysis showed that abdominal wall compressed by ultrasound probe (OR=2.601, 95%CI: 1.113-6.075; P=0.027) and amniotic fluid index (AFI; OR=1.010, 95%CI: 1.001-1.020; P=0.028) were positive factors for the successful rate of ECV in primipara pregnant women. (4) The main complication of ECV was transient fetal heart rate reduction (8.9%,17/190), the incidence in the probe-compressing group was significantly higher than that in the non-probe-compressing group [14.8% (12/81) vs 4.6% (5/109); χ2=5.967, P=0.015]. No statistical differences were found in rates of complications between the ECV successful and unsuccessful pregnant women, and between probe-compressing and non-probe-compressing groups (all P>0.05). No adverse maternal and neonatal outcomes related to ECV were observed. Conclusions: The ultrasonic convex array probe compressing could significantly improve the success rate of ECV in primipara without increasing the incidence of adverse maternal and fetal outcomes. The success rate of ECV in primipara is influenced by AFI and operation mode.

A Comprehensive Review of the Research Literature on External Cephalic Version (ECV)

External cephalic version (ECV) is an approach to turning a fetus from the breech presentation by external maneuvering of the fetus through the maternal abdominal wall into a cephalic presentation. We conducted a systematic search of the current literature on ECV to provide a comprehensive overview of the procedure and associated success rates, risks, and alternatives to ECV. Tocolytics can improve ECV success, but none of the tocolytics shown to be effective for ECV are currently available in Canada. The factors that can best predict ECV success are low uterine tone (associated with parity or tocolytics), easy palpation of the fetal head, and an unengaged breech. The most common side effect of ECV is transient fetal bradycardia with an incidence of one to six percent of all ECV procedures. The risk of requiring an emergency caesarean section because of ECV appears to be around 0.5% or one in 200 ECV procedures performed. Our review suggested no significant risk of fetal/neonatal mortality or serious morbidity associated with ECV. Few alternative approaches to turning a fetus in the breech presentation have been adequately studied. ECV should be considered for all women with a fetus in the breech presentation at term in the absence of any contraindications to the procedure.

External cephalic version - single-center experience.

External cephalic version (ECV) is an alternative to caesarean section for abnormal fetal position. ECV is recommended by the most important scientific committees in the world. ECV complications are rare and occur in 6.1% of cases, however severe complications requiring urgent caesarean section are found in less than 0.4%. Our aim was to demonstrate the effectiveness and safety of ECV and to present our own experience with the procedure of ECV. ECV was performed on 62 patients (32 nulliparas and 30 multiparas). Qualification criteria included: singleton gestation, gestational age > 36 + 6, longitudinal pelvic lie, no uterine contractions, intact membranes. Indications for immediate cesarean section within 24 hours of ECV were considered a procedural complication. In patients with complications, the condition of the newborn was checked according to the APGAR score and the day of discharge of the mother and child from the maternity ward was analyzed. ECV finished successfully in 66.1% (nulliparas 56.2% and multiparas 76.7%). Patients with a successful ECV were significantly older and had higher median gestational age. ECV was more often successful when placenta was located on the posteriori wall. In our patients, there were 4 cases of complications requiring delivery at the time of ECV. No serious consequences associated with increased maternal or neonatal morbidity or mortality were reported. ECV seems to be a safe alternative for women wishing to deliver vaginally, as this procedure does not increase the risk of adverse obstetric outcomes.

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..

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version – A chance to take a closer look

ObjectiveUterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes. Study DesignWe recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly ‘de novo’ diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed. ResultsThe ‘de novo’ diagnosis of UA at 36–37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12–7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs. ConclusionBreech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

Impact of full vs empty urinary bladder on external cephalic version success: a randomized controlled trial

External cephalic version is a procedure used to turn a fetus from a breech position to a cephalic position before delivery. The success rate of the external cephalic version can be affected by various factors; however, the effect of bladder volume on the success rate of the external cephalic version remains controversial. This study aimed to determine the effect of urinary bladder status (full or empty) on the success rate of the external cephalic version through a prospective randomized study. This was a prospective randomized controlled trial conducted at a tertiary care obstetrical center. Overall, 70 women with a singleton breech presentation at term undergoing external cephalic version were randomly allocated into 2 groups: external cephalic version with an empty bladder and external cephalic version with a full bladder. The external cephalic version procedure was performed by experienced obstetricians under ultrasound guidance. The primary outcome was the success rate of the external cephalic version. The success rate of the external cephalic version was 67.56% (25/37) in the full bladder group and 54.54% (18/33) in the empty bladder group, with no statistically significant difference between the groups (P=.26). In addition, the relative risk of successful external cephalic version was 1.23 (95% confidence interval, 0.84-1.81), indicating no significant difference. This randomized controlled trial demonstrated that the presence of a full or empty urinary bladder does not significantly affect the success rate of the external cephalic version in women with singleton breech presentation at term. Our findings suggest that women undergoing an external cephalic version do not need to have a full bladder to improve the success rate of the procedure.

External Validation of a Prediction Model for External Cephalic Version Success.

External cephalic version (ECV) success correlates with numerous maternal and pregnancy factors. A prior study developed an ECV success prediction model based on body mass index, parity, placental location, and fetal presentation. We performed external validation of this model using a retrospective cohort of ECV procedures from a separate institution between July 2016 and December 2021. Four hundred thirty-four ECV procedures were performed, with a 44.4% success rate (95% CI 39.8-49.2%), which was similar to the derivation cohort (40.6%, 95% CI 37.7-43.5%, P =.16). There were significant differences in patients and practices between cohorts, including the rate of neuraxial anesthesia (83.5% derivation cohort vs 10.4% our cohort, P <.001). The area under the receiver operating characteristic curve (AUROC) was 0.70 (95% CI 0.65-0.75), which was similar to that in the derivation cohort (AUROC 0.67, 95% CI 0.63-0.70). These results suggest the published ECV prediction model's performance is generalizable outside the original study institution.

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 &lt; 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.

Predictive factors for successful external cephalic version with regional anesthesia.

We aimed to investigate predictive factors of successful external cephalic version (ECV) using regional anesthesia. In this retrospective study, we included women who underwent ECV at our center from 2010 to 2022. The procedure had been conducted using regional anesthesia and the administration of intravenous ritodrine hydrochloride. The primary outcome was the success of ECV, which was defined as the rotation from a non-cephalic to a cephalic presentation. Primary exposures were maternal demographic factors and ultrasound findings at ECV. To determine predictive factors, we conducted a logistic regression analysis. Of 622 pregnant women who underwent ECV, missing data on any variables (n=14) were excluded and the remaining 608 were analyzed. The success rate during the study period was 76.3%. Multiparous women had significantly higher success rates than primiparous women (adjusted odds ratio [OR]: 2.06 [95% confidence interval (CI): 1.31-3.25]). Women with a maximum vertical pocket (MVP) of <4cm had significantly lower success rates than those with 4cm < MVP ≤6cm (OR: 0.56 [95% CI: 0.37-0.86]). The non-anterior placental location was associated with higher success rates than the anterior placental location (OR: 1.46 [95% CI: 1.00-2.17]). Multiparity, MVP >4cm, and non-anterior placental locations were associated with successful ECV. These three factors could be useful for patient selection for successful ECV.

External cephalic version success rate and associated factors: Experience from a tertiary center in Sub-Saharan Africa: A cross-sectional study.

To determine the success rate of external cephalic version (ECV) and its associated factors in an Ethiopian setting. A total of 152 ECVs performed at the St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia from June 1, 2018, up to March 30, 2019, were analyzed, using a prospective cross-sectional study design. Data were analyzed using SPSS version 21. Chi-square test of association was applied for categorical data analysis. Multivariate logistic regression analysis was used to determine predictors of success of ECV. Odds ratio, 95% CI, and P-value<0.05 were used to describe findings' significance. The success rate of ECV was 71.7%. ECV success rate did not differ between multiparous and nulliparous (AOR = 1.4, 95% CI 0.07-2.35), according to abdominal wall thickness status (AOR = 3.5, 95% Cl 0.29-42.40), and between unengaged and engaged presenting part (AOR = 1.1, 95% CI 0.26-4.74). A posterior placenta was associated with ECV success compared to anterior placenta (AOR = 1.14, 95% CI 1.03-2.60). Likewise, cases that experience no pain was associated with a higher ECV success rate (AOR 14.68, 95% CI 1.65-34.97). Soft uterine tone was also associated with a higher success rate compared to tense uterine tone (AOR = 3.89, 95% CI 0.02-0.39). Eighty-four percent of those mothers who had successful ECV had spontaneous vertex vaginal delivery. The success rate of ECV in this study is found to be 71.7%, which is higher than reports from previous studies. Absence of pain during the procedure, posterior placenta, and soft uterine tone were associated with successful ECV.

Role of individual provider in success of external cephalic version

External cephalic version (ECV) decreases cesarean delivery for malpresentation. However, the procedure is successful in only 50% of patients. Prior attempts to predict ECV success have focused on patient factors. The role of the individual provider has not been well studied. The objective of this study was to evaluate the association between ECV provider and success rates while controlling for patient factors. We conducted a retrospective cohort study of all ECVs performed at a single academic hospital between July 2016 and December 2021. Patients who had ECVs by providers who performed at least 8 ECVs (median) during this time were included. Our primary outcome was a fetus in a vertex presentation following ECV. Patient and provider characteristics were compared between those with a successful and unsuccessful ECV with t-tests and Chi-square tests. We applied a previously published prediction model for ECV success to our entire population, which only contained patient factors (BMI, parity, placental location, and fetal presentation). We then compared this to a model with those factors and a fixed-effect for the performing provider. Delong’s test was used to compare area under the ROC curves. There were 354 ECVs included in the study with an overall success rate of 45.2%. Twenty providers were included, performing a median 16 ECVs during the study period (IQR 9-18.5). Individual provider ECV success rates ranged from 12 – 70%. The model for ECV that used patient factors produced an AUC of 0.70 (95% CI 0.65-0.75). With the fixed-effect term for provider, the AUC improved to 0.77 (95% CI 0.72-0.81), p=0.002. After accounting for patient characteristics, the incorporation of individual providers improved a prediction model for ECV success. This suggests individual providers have an impact on a patient’s chance of a successful ECV. Future investigations should focus on identifying characteristics and techniques of providers with high success rates that could be translated into educational or simulation programs for providers seeking to improve their success rates.

TOLAC outcomes after a successful external cephalic version

Patients undergoing a trial of labor after successful external cephalic version (ECV) have lower rates of vaginal delivery. The aim of this study was to determine whether patients undergoing a trial of labor after cesarean delivery (TOLAC) after a successful ECV are at risk of poor TOLAC outcomes. A retrospective cohort study was conducted at a single university-affiliated medical centre between the years 2012-2018. Patients who underwent a TOLAC attempt after a successful ECV comprised the study group. Outcomes were compared to patients who underwent TOLAC in a vertex presentation without a history of ECV. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery and adverse neonatal outcomes including 5 minute Apgar score < 7, umbilical cord pH < 7.1. Patients undergoing TOLAC with a history of 2 previous cesarean deliveries were excluded from this study. 7693 patients underwent a TOLAC attempt during the study period. 66 patients had a successful ECV and comprised the study group. Outcomes were compared to 7627 patients undergoing TOLAC who did not have an ECV. There were no significant between-group differences in maternal age (31.6± 4.6 Vs 32.4± 5.3, p< 0.19), parity (4.3±2.4 Vs 4.4±2.6 p=0.81 ), gestational age at delivery (39.4±1.2 Vs 39.4±1.4 p=0.51) or birthweight (3338.0±440.9 Vs 3364.9±442.1 p=0.69). Patients who underwent ECV were just as likely to have a successful TOLAC (87.9% Vs 93.5% OR 0.49 95%CI 0.25-1.12 p=0.07) and did not have an increased risk of operative vaginal delivery (13.6% Vs 8.4% OR 1.74 95% CI 0.8-3.4 p=0.13), 5 minute APGAR score < 7 (0% Vs 0.4% OR 0.16 95% CI 0.03-1.8 p=1.0) or umbilical cord pH < 7.1 (1.5% Vs 0.2% OR 7.6 95% CI 0.3-39.8 p=0.15) compared to the control group. TOLAC after a successful ECV is associated with a high rate of vaginal birth after cesarean (VBAC) without an increased risk of adverse neonatal outcomes.

Effect of Super-Specialization in External Cephalic Version: A Comparative Study

Background: The introduction of an experienced dedicated team is not a completely studied fact. Several studies reported a high external cephalic version (ECV) success rate when the procedure is executed by a single operator or a dedicated team. This study aims to compare the effectiveness and safety of the ECV when the procedure is performed by senior experienced obstetricians or by super-specialized professionals who composed a dedicated team. Methods: Longitudinal retrospective analysis of ECV performed in a tertiary hospital. From 1 January 2018 to 1 October 2019, ECV were performed by two senior experienced obstetricians who composed the dedicated team for ECV, designed as Group A. From 1 October 2019 to 31 December 2019, ECV was performed by two seniors obstetricians, designed as Group B. Ritodrine was administered during 30 minutes just before the procedure. Propofol was used for sedation. Results: 186 pregnant women were recruited (150 patients in group A and 36 patients in group B). ECV success rate increased from 47.2% (31.7–63.2) in Group B to 74.0% (66.6–80.5) in Group A (p = 0.002). The greatest increase in the success rate of ECV was seen in nulliparae, from 38.5% (21.8–57.6) in group B to 69.1% (59.4–77.6) (p = 0.004). Complications rate decreased from 22.2% (11.1–37.6) in Group B to 9.3% (5.5–14.8) in Group A (p = 0.032). Conclusions: The introduction of an experienced dedicated team improves ECV success rate, especially in primiparas, and it also reduces ECV complications rate.

External cephalic version for a malpresenting first twin before labor: a prospective case series

In twin pregnancies where the presenting twin is not cephalic, cesarean delivery is the standard of care. External cephalic version (ECV) has been used for malpresenting singleton pregnancies with low risk of complications. ECV in twin pregnancies is poorly studied. To assess feasibility and report any complications of ECV of a malpresenting twin before labor. This is a prospective cohort of twin pregnancies with malpresenting first twin. Inclusion criteria included English or Spanish speaking women. Exclusions included cases where there was a contraindication to vaginal delivery. ECV was performed according to the institutional singleton protocol. Fetal testing of both twins was performed before and after procedure. A vaginal hand was used during ECV as needed. The primary outcome was success of the procedure. Secondary outcomes included delivery characteristics and neonatal outcomes. Five patients were enrolled in this study. Four patients underwent successful ECV and vaginal delivery occurred in 2 of the 4 patients. ECV procedure was performed at a mean gestational age of 36+0 weeks in the successful ECV group and 36+6/7 weeks for the unsuccessful group. Latency to delivery was 4.5 days in the successful ECV group and 1 day in the unsuccessful ECV group. No maternal or neonatal complications occurred in any participating women. ECV in twin pregnancies where the first twin is malpresenting was feasible in our cohort. More research is needed to better characterizer the safety and efficacy of this procedure in this patient population.