Use Of External Cephalic Version Research Articles

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.

Use of external cephalic version in Portuguese public hospitals.

To evaluate the use of external cephalic version (ECV) in Portuguese public hospitals with maternity services, as well as exploring the main motives for not offering the technique. A cross-sectional observational study was conducted involving an online survey with 34 questions, accessed via an email addressed to all Heads of Department of Portuguese state-owned hospitals with maternity services. In centers where the technique was performed, information was requested on success rates, contraindications for the procedure, and practical aspects related to its use. In centers where ECV was not offered, the underlying reasons for this were queried. Answers were received from 41 out of the 43 state hospitals with maternity services (95.3%). Sixteen hospitals perform the technique (39%), with reported annual numbers ranging from 3 to 51, and success rates ranging from 25% to 85% (12 respondents). The main reasons for not offering the technique were lack of experience and lack of conditions to perform it safely. Most centers (87.8%) reported that they would welcome hands-on training in ECV. ECV is used in a minority of Portuguese state-owned hospitals. Efforts are needed to achieve a wider implementation of the technique, with a particular focus on simulation-based training.

Reviving external cephalic version: a review of its efficacy, safety, and technical aspects.

Currently, the rate of cesarean sections being performed in Korea is approximately 40%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries. Breech presentation at term is an important indication for cesarean section among other factors, including medicolegal concerns and pregnancies in women of advanced maternal age. Term breech presentation is associated with a higher fetal mortality rate than that associated with a cephalic presentation. Therefore, in Korea, most of these women deliver by cesarean section to avoid the complications of vaginal breech delivery. However, cesarean section is itself associated with considerable obstetric morbidity and sometimes, mortality. External cephalic version (ECV) is a useful method to reduce the cesarean section rate in women with breech presentation and therefore to reduce the incidence of breech presentation at delivery. Studies have shown that routine use of ECV reduces the cesarean section rate by approximately two-thirds in term pregnancies with breech presentation. ECV is accepted as a safe, efficacious, and cost-effective method and is recommended by both the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists in all pregnancies with term breech presentation, if not contraindicated. In Korea, although most clinicians are aware of the option of ECV, their relative lack of experience in performing the procedure and fear of complications render them hesitant to perform ECV. This review is aimed at guiding obstetricians by describing the efficacy, safety concerns, and technical aspects of this procedure.

Reduction of maternal and neonatal harm through prevention of the primary Cesarean section

While there are clear life-saving indications for Cesarean section (C-section), rates of this procedure have seen a continued rise without a concomitant improvement in maternal or neonatal outcomes. There is some evidence that outcomes may actually be worse for low-risk C-sections versus vaginal delivery. However, this is not necessarily common knowledge for healthcare providers, and therefore, their patients. Measures to safely reduce the C-section rate target management of labour arrest and specific indications for progression to C-section. In the active phase of the first stage of labour, C-section should be considered only in cases of failure to progress after 4 hours of adequate uterine contraction, or 6 hours of inadequate contraction. In the second stage of labour, expectant management of 3 hours of pushing in nulliparous women and 2 hours in multiparous women is safe and appropriate. Furthermore, manual rotation and operative vaginal delivery in the second stage are reasonable alternatives to C-section. Expectant management is also appropriate for certain non-reassuring fetal heart rate tracings. In post-dates pregnancies, induction of labour reduces both rates of C-section and neonatal mortality. Finally, evidence supports the use of external cephalic version in breech presentation as well as a more conservative approach to suspected macrosomia and multiple pregnancy. Taken together, these measures target the most common indications for progression to C-section and can allow us to safely reduce the C-section rate. Educating patients and physicians on the risks of the procedure and reasonable alternatives can improve outcomes for mothers and neonates.

Contribution of changing risk factors to the trend in breech presentation at term.

Recent population-wide changes in perinatal risk factors may affect rates of breech presentation at birth, and have implications for the provision of breech services and training in breech management. To investigate whether changes in maternal and pregnancy characteristics explain the observed trend in breech presentation at term. All singleton term (≥37 week) births in New South Wales during 2002-2012 were identified through birth and associated hospital records. Annual rates of breech presentation were determined. Logistic regression modelling was used to predict expected rates of breech presentation and these were compared with observed rates over time. A priori predictors included maternal age, country of birth, parity, smoking during pregnancy, diabetes, pregnancy hypertension, placenta praevia, previous singleton term breech, previous caesarean section, infant sex, gestational age, birthweight and congenital anomalies. Hospital and Medicare data were used to assess concomitant trends in external cephalic version. Among 914 147 singleton term births, 3.1% were breech at delivery. Rates of breech presentation declined from 3.6% in 2002 to 2.7% in 2012 (test for trend P < 0.001), but was predicted to increase from 3.6% in 2002 to 4.3% in 2012 because of increased maternal age, nulliparity, maternal diabetes, history of breech presentation and previous caesarean section. However, use of external cephalic version appears to have increased over time. Breech presentation at delivery has decreased in New South Wales. Increased use of external cephalic version likely accounts for this decline, as changes in risk factors do not.

External cepahlic version should be undertaken by midwives

There is good evidence to support the use of external cephalic version (ECV) to reduce non-cephalic presentation at birth and promote cephalic vaginal birth (Hofmeyr et al. Cochrane Database Syst Rev 2012, Issue 10). ECV is considered a safe procedure for women with a breech-presenting fetus and no contraindication to the procedure. Major obstetric and midwifery societies recommend that ECV be offered to all women with otherwise low-risk pregnancies who have a breech presentation at (or near to) term. However, studies in a variety of jurisdictions indicate that not all obstetricians who provide maternity care offer ECV. As a result, women with breech presentations do not have universal access to ECV and uptake of the procedure among eligible women is considerably lower than it might be. These findings suggest a need to reconsider ECV as a procedure available primarily through referral care and raises the question as to why all primary-care providers are not providing ECV as part of low-risk antenatal care. Midwives have a long history of involvement in repositioning of the fetus that dates back to antiquity. There are reports that, in the time of Aristotle, midwives were directed to turn the fetus and position the head to present at birth. In more modern times, and up until the mid-1970s many midwives and family physicians (general practitioners) offered ECV as part of their routine care to low-risk pregnant women. Considering the practice developments around ECV since then might aid us in understanding why the question of who should be undertaking ECV is now, more than 40 years later, under debate. In the mid-1970s, following a publication that showed increased mortality and morbidity associated with ECV (Bradley-Watson Am J Obstet Gynecol 1975;123:237–40) and promoted caesarean for breech presenting fetuses, ECV was all but abandoned in many jurisdictions. The subsequent introduction of tocolysis as an adjunct to ECV relaxing the uterus and allowing ECV to be undertaken at term gestation, shifted the procedure from the realm of primary into secondary care. However, in 2012, WHO recommended that midwives perform ECV in the context of rigorous research (World Health Organization. 2012; ISBN 978 92 4 150484) and recent reports of midwife-provided ECV demonstrate safety and efficacy outcomes similar to those of their obstetric peers (Taylor et al. Br J Midwif 2003;11:207–21; Beuckens BJOG 2015;122:DOI: 10.1111/1471-0528.13234). It is certain that midwives (or family physicians or general practitioners) undertaking ECV should have adequate training in the procedure. Further, arrangements for adequate assessment and follow up of women are essential, including if necessary referral to secondary (obstetric) care for management of rare outcomes that could require surgical delivery. This need for interdisciplinary collaboration perhaps begs a more interesting debate around how to best organise access for all women to ECV. There are reports of successfully run ECV clinics where a few practitioners in a community develop particular expertise with the procedure. When a clinic is run on a regular basis, it is likely that more practitioners will refer their clients for ECV, as scheduling and making arrangements is likely to become more straightforward. Inter-professional approaches might make such approaches more feasible in some communities. Full disclosure of interests available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Management of breech presentation at term: a retrospective cohort study of 10 years of experience.

To evaluate the impact of management of childbirth (external cephalic version (ECV) plus planned vaginal delivery (PVD)) of breech presentation at term (⩾37 weeks of gestation). This retrospective cohort study was based on data collected of singleton breech presentations at term in the Obstetrics and Gynaecology Service, Cruces University Hospital (Biscay, Spain), from January 2003 to December 2012. We attended 2377 singleton breech pregnancies at term. We attended 1684 singleton breech term deliveries, attempting vaginal delivery after selection in 52.9% of cases and were successful in 57.5% of attempts. A total of 1360 ECV were attempted, with a success rate of 50.3% of those attempted. The use of ECV has decreased the rate of breech presentation at delivery by 39.0%, the rate of breech presentation as a caesarean section (CS) indication by 47.1% (CS due to breech presentation/total of CS) and the rate of CS for breech presentation out of the total of deliveries by 39.1% (CS due to breech presentation/total of deliveries). Early postnatal parameters (5-min Apgar score, umbilical cord arterial pH and acid-base analysis) were significantly lower following PVD compared with planned CS for breech presentation. However, we did not find any differences in the rates of admissions to the neonatal unit or neonatal mortality. Management of breech presentation with a protocol that includes ECV, careful selection criteria and active management of vaginal delivery achieve a great decrease in the rate of CS for breech presentation.

Audit of performance of regional ECV services against RCOG standards

IntroductionBreech presentation complicates 3–4% of all deliveries. Vaginal breech delivery is associated with increased risk to the fetus. External cephalic version (ECV) can avoid the need for caesarean section. The...

Atosiban vs. ritodrine as a tocolytic in external cephalic version at term: a prospective cohort study

To compare the success rate of external cephalic version (ECV) at term using ritodrine or atosiban as a tocolytic agent. Prospective cohort study with a sample of 236 pregnant women with a breech presentation at term, from November 2006 to March 2008. Data have been analyzed from the moment the cephalic version is performed until the time of delivery. ECV success rate using ritodrine as a tocolytic agent was 56.8% compared to 31.4% with atosiban. Ritodrine increases the version success potential more significantly than atosiban (P<0.05). In both cases, the use of ECV reduced the rate of cesarean sections, although a higher number of versions are required with atosiban [numbers needed to treat (NNT)=9.08] to avoid a cesarean section compared to ritodrine (NNT=3.41). Ritodrine seems better than atosiban as tocolytic agent for ECVs.

Safety and Efficacy of External Cephalic Version for Women With a Previous Cesarean Delivery

There is increasing use of external cephalic version (ECV) in women with previous cesarean delivery (CD) and a breech-presenting fetus who want a vaginal delivery. However, clear evidence to support its use is lacking and some clinicians believe that prior CD is a relative contraindication for a trial of ECV. This retrospective study investigated the effectiveness and safety of ECV in a study group of 42 singleton women with 1 previous cesarean delivery (CD) and a breech-presenting fetus at term. The study was conducted at a single medical center between 1997 and 2005. The comparison group was multiparous women at the same institution who had an ECV without a previous CD during the same time period. A Medline search was performed for the years 1966–2008 to provide data from other published studies evaluating attempted ECV in women with prior CD. The success rate of ECV was 74.0% (31/42) in the study group and 72.3% (251/347) in the comparison group. Eighty-four percent of the study group women with successful ECV were delivered vaginally and 91% with failed ECV delivered by CD. Among the 162 publications from the Medline search, the 4 meeting inclusion criteria included a total of 124 patients and had a mean ECV success rate of 76.6%. Adding data from this study to that in the 4 Medline reports showed an average success rate of 76.5% for ECV performed in 166 women with 1 previous CD. There were no serious maternal or fetal complications or outcomes with a rate of emergency CD of only 0.6% (1/166 cases). Accumulating evidence for the efficacy and safety of ECV among women with a breech presenting-fetus at term and previous CD leads the investigators to conclude that such women who desire a vaginal delivery should be offered a trial of ECV.

Successful but Limited Use of External Cephalic Version in Auckland

The possibility of a noncephalic (breech) presentation at birth can be markedly reduced by the use of external cephalic version (ECV). Using ECV, practitioners place their hands on the woman's abdomen and gently turn the baby from the breech to cephalic position. A major review reported that ECV at or near term (≥36 weeks) reduced the occurrence of noncephalic births by 62% and the rate of cesarean section by 45%. In New Zealand and in many other countries, ECV is now recommended to all eligible women presenting with breech presentation at birth. This prospective study assessed: (1) the success rate for ECV at a tertiary teaching hospital in New Zealand, (2) the factors predicting success, (3) perinatal outcomes among women who underwent ECV, and (4) the percentage of women with term breech presentation who attempted the procedure. From 2002 to 2006, a prospective audit was conducted in all women with singleton breech presentation ≥36 weeks who attended the ECV clinic. Of the 255 women presenting for ECV, the procedure was successful in 150 (59%). Multivariate analysis showed that an unengaged presenting part was the strongest predictor of success; the adjusted relative risk (aRR) was 3.3, with a 95% confidence interval (CI) of 2.2 to 5.1. Other predictors of success were multiparity (aRR, 1.2; 95% CI, 1.0-1.4), and a lateral spine position (aRR, 1.5; 95% CI, 1.1-2.0). Among the 150 women with successful ECV, 100 (67%) had a vaginal birth; of the 105 women with unsuccessful ECV, only 1 had a virginal birth. To prevent 1 caesarean birth, 3 women had to attempt ECV. The rate of referral was low; only 26% of women with singleton term breech presentation attempted ECV. The success rate of ECV in reducing beech presentation at term in this study is consistent with that reported in previous studies. The procedure restored the rate of cesarean section to that of a cephalic singleton pregnancy at term. Further study is needed to address the low rate of referral and barriers to use of ECV in this population.

Is there a place for selective vaginal breech delivery in Malaysian hospitals: experiences from the Ipoh hospital

Background. The ‘Term Breech Trial’ (TBT) results of 2001 have impacted on the mode of delivery of breech with a low threshold for caesarean delivery (CD) worldwide.Aims. The trends in mode of delivery in developing countries have also changed. The aims of this retrospective analysis of all breech presentation was to see if similar trends are seen in Ipoh Hospital in Malaysia and if perinatal outcome is affected by mode of delivery.Methods. All breech pregnancies presenting in the labour at the Ipoh Hospital, Malaysia, irrespective of gestation or booking status were analysed with respect to mode of delivery, fetal outcome and maternal mortality.Results. Out of 4886 breech presentation between 1992 and 2004, 3725 cases were evaluable. The prevalence of breech at birth was 3%. Vaginal breech deliveries decreased from 70.4% in 1994 to 13.1% in 2004. Consequently, CDs rose to 86.9% in CDs. There were 107 perinatal deaths (1994–2004) in the series and the crude perinatal mortality rate (PNMR) was four times higher than the hospital PNMR (11.4/1000 in 2004).Conclusion. Although the CD rates rose exponentially with the release of the ‘TBT’, the mode of delivery did not impact on better PNMR in breech cases in this hospital. The need for selective vaginal births for breech, increased use of external cephalic version and the long implications of a uterine scar in future pregnancies in the ‘shared antenatal care in the local context in a developing country is discussed.

Sheffield modified technique for external cephalic version

SummaryExternal cephalic version (ECV) is the manipulation of the fetus, through the maternal abdomen, to a cephalic presentation. The incidence of caesarean section for breech presentation has increased markedly in the last 20 years. External version has become more popular in the past 10 years because of the increasing evidence of risks from vaginal breech delivery, increasing demand on the reduction of caesarean sections, a strong safety record, and high success rate of ECV of up to 80%. The use of external cephalic version can produce considerable cost savings in the management of the breech presentation at term; however, there is a wide variation in the success rate, with a range between 30–80%. The ECV technique has remained unchanged for many generations without any modification. This paper provides the outcome of a small prospective study implementing a modified technique for ECV, which has a high success rate.

Successful but limited use of external cephalic version in Auckland

External cephalic version (ECV) can effectively reduce the chance of non-cephalic presentation at birth and reduce caesarean section rate for breech presentation at term. It is recommended in New Zealand to offer ECV to all eligible women with breech presentation at term. This study aims to determine the ECV success rate at our hospital, factors that predict ECV success, and perinatal outcomes for women who had ECV, and to estimate the ECV attempt rate at our hospital. A prospective audit was performed of all women with singleton non-cephalic presentation>or=36 weeks who attended the ECV clinic at National Women's Health in Auckland from July 2002 to January 2006. Two hundred and fifty five women presented for ECV during the study period, and the ECV success rate was 59%. The strongest predictor of ECV success was an unengaged presenting part. Women with successful ECV had a vaginal birth rate of 67%. Three women needed to have an ECV attempt in order to prevent one caesarean section. We estimated that 26% of women with term breech presentation had an ECV attempt. ECV at National Women's Health is effective at reducing beech presentation at term and at restoring a caesarean section rate equivalent to that of cephalic singleton pregnancy at term. However, the low rate of referral should be addressed.

Cord Blood Acid-Base Status at Delivery After Successful External Cephalic Version

Pregnancies after successful external cephalic version (ECV) are generally regarded as being normal. Nevertheless, increased levels of thyroid-stimulating hormone, an indicator of perinatal stress, recently were reported in cord blood in infants delivered vaginally after successful ECV. This retrospective study was an attempt to learn whether such infants are compromised, in particular, whether there are abnormalities of acid-base balance in cord blood. The 89 study cases were singleton deliveries at or after 37 weeks gestation that followed successful version. The same number of pregnancies with spontaneous cephalic presentation made up the control group. Women in the ECV group were significantly older, but there were no significant differences in birth weights or Apgar scores. Women in the ECV group had significantly more emergency cesarean deliveries than did control women. Cord blood arterial and venous acid-base parameters were similar in the 2 groups, as were the proportions of fetuses with a cord blood pH less than 7.20. Even after adjusting for maternal age, gestational age at delivery, mode of delivery, birth weight, spontaneous or induced labor, and duration of labor, differences in cord blood pH between the ECV and control groups were not significant. These findings support the use of ECV for term breech presentation. These infants may be more vulnerable biologically to the stress of labor, but with adequate intrapartum care, they should not be at increased risk of being acidotic at the time of birth. ECV may entail more emergency section deliveries, but it does lessen the incidence of cesarean deliveries for breech pregnancies.

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Breech birth at term: vaginal delivery or elective cesarean section? A systematic review of the literature by a Norwegian review team

Use of External Cephalic Version for Breech Pregnancy and Mode of Delivery for Breech and Twin Pregnancy: A Survey of Canadian Practitioners

Objectives: (1) To understand how external cephalic version (ECV) is used in the management of breech pregnancies; (2) to determine if Canadian practitioners have changed their recommendations regarding the mode of breech delivery since becoming aware of the findings of the Term Breech Trial; and (3) to establish a baseline of how twins are being delivered in Canada.Methods: In March 2001, a survey was mailed to 920 obstetrician/gynaecologists, 409 family physicians, and 62 midwives from the membership list of the Society of Obstetricians and Gynaecologists of Canada.Results: The response rate was 52% (476/920) for obstetrician/gynaecologists, 22% (90/409) for family physicians, and 53% (32/62) for midwives. Eighty-nine percent of practitioners routinely offered women ECV. The median self-estimated ECV success rate for nulliparous women was 30%, and for multiparous women, it was 58%. Forty-seven percent of practitioners used tocolytics 9% used analgesics, and 14% recommended repeat ECV when initial attempts failed. Eighty-four percent of practitioners recommended vaginal breech birth before learning the results of the Term Breech Trial, and 14% afterwards. When both twins present as vertex, most respondents planned vaginal delivery (100% for term, 95% for preterm > 32 weeks, and 73% for preterm ≤ 32 weeks). Vaginal birth was recommended for Twin A vertex, Twin B breech at term by 92% of practitioners for frank, 92% for complete, and 88% for footling breech at Preterm > 32 weeks by 84% of practitioners for frank, 81% for complete, and 78% for footling breech; and at preterm ≤ 32 weeks by 43% of practitioners for frank, 42% for complete, and 39% for footling breech pregnancies. When Twin A was non-footling breech and Twin B vertex 7%, 5% and 2% of practitioners recommended vaginal birth for term, preterm > 32 weeks, and preterm ≤ 32 weeks pregnancies, respectively. Sixty-four percent of respondents on twin births were interested in a randomized controlled trial to compare planned Caesarean section with planned vaginal birth for twin pregnancies.Conclusion: Although the use of ECV is high in Canada, the success rate is low. Increasing the use of tocolytics, considering epidural analgesic, and repeating the procedure when the initial attempt fails may increase success and decrease Caesarean section rates. The survey results reflect a dramatic shift toward recommending Caesarean section for management of term breech pregnancies. Vaginal birth is the method of delivery of choice for most twin pregnancies of 32 weeks’ gestation, especially for vertex/vertex presentations.

Routine Use of External Cephalic Version in Three Hospitals

In recent years external cephalic version (ECV) has been increasingly recommended as a safe alternative to either vaginal breech delivery or cesarean delivery. Reports suggest that both the latter outcomes are in fact less frequent with ECV, but fetal risk has not been reliably assessed. This study is a 10-year review of ECV performed at three hospitals from 1988 through 1997. Women having a single fetus in breech presentation, confirmed ultrasonically, were entered into the study when they agreed to attempted version. Version was done using a tocolytic agent, ritodrine, to relax the uterus, but without maternal analgesia. Electronic fetal monitoring was used to detect fetal cardiac dysfunction. The “forward roll” version technique was used; a “back flap” technique was occasionally tried if the fetus did not cross the midline. A second attempt was allowed if the first failed or if the fetus resumed a breech position. Among 923 women enrolled in the study, ECV succeeded in 62.7% of cases, with comparable rates at all three participating hospitals. Success rates were higher in multiparas than in nulliparas (76.6% vs. 55.3%), with a normal amniotic fluid volume (93% with polyhydramnios vs. 65% with a normal fluid volume and 29.6% with oligohydramnios), and incomplete compared with frank breeches (77.3% vs. 56.6%). Version succeeded in converting 72% of 30 transverse-lie fetuses. Two-thirds of 19 women having previous cesarean delivery and three-fourths of those undergoing myomectomy had a successful outcome. Logistic regression analysis disclosed that polyhydramnios was the strongest predictor of success, with a relative risk of 5.8. Version attempted on a multipara or for incomplete breech was 2.5-fold likelier to succeed than when done on a nullipara or for a frank breech. A posterior rather than anterior placenta also was a favorable factor. A second attempt succeeded in 10 of 24 women when the initial attempt failed and in all 8 women when an initially successful result reverted to breech. The risk of vaginal bleeding after version was 1.5%, and that of transient fetal bradycardia, 5.8%. The rate of cesarean delivery was 43% at these hospitals, where it is standard practice to perform cesarean delivery in cases of breech presentation. With one exception (femoral fracture when cesarean delivery followed a failed version), neonatal outcomes were favorable. The investigators believe that ECV is effective in lowering the need for cesarean delivery in term infants in breech presentation. No major adverse infant outcomes have been noted.

The use of audit to explain the rise in caesarean section

An audit was undertaken in a maternity unit in 1996. The caesarean section in the unit studied in 1996 was 21.7% compared to a UK national rate at that time of 13%. The unit staff believed the main reason for these figures was the influence of maternal request. The aims of the study were to: identify factors influencing the CS rate, assess physiological and psychological implications to both the mother and baby, make recommendations to reduce the rate both safely and effectively, and identify resource implications. Recommendations made include the need to introduce multi-professional evidence-based guidelines on the management of fetal distress, trial of labour with history of previous CS and the use of external cephalic version in the cases of the uncomplicated breech presentation. The need to ensure that women electing to have a CS are fully informed of the risks related to CS was also highlighted.

Routine use of external cephalic version in three hospitals.

External cephalic version has been advocated as a safe alternative to vaginal breech delivery or cesarean birth. The purpose of this study was to determine the efficacy of routine use of external cephalic version at 36 weeks or more of gestation in three different levels of hospitals. External cephalic version was performed on 923 women with a single breech fetus at three hospitals in Italy. The procedure was attempted with a tocolytic agent for uterine relaxation and with no maternal analgesia. The version technique adopted was the "forward roll." Version was successfully performed on 579 fetuses (62.7%); each hospital had a similar success rate, and 56.9 percent of the women delivered vaginally. The procedure was more successful in multiparas and in women with an incomplete type of breech, polyhydramnios, and posterior localization of the placenta. Vaginal bleeding was experienced by 14 women; eight cesarean sections were performed for suspected abruptio placentae, confirmed in four cases. Two cephalic-turned fetuses experienced an episode of persistent bradycardia and were turned again to breech; in five cases a nonstress test recorded after the version showed repeated variable decelerations and in one case a cesarean section was performed. Neonatal outcomes were good in 922 infants. A fracture of the femur attributable to the version was observed in one newborn. External cephalic version is effective in reducing the number of cesarean deliveries in term breech infants in different obstetric settings, with no major neonatal adverse outcomes.