Management of external cephalic version in France: A national practice survey.

INTRODUCTION: The breech presentation represents 4,7% of deliveries at term. There is a method of external cephalic version (ECV) performed from 36 weeks of gestation. French guidelines for the clinical practice of ECV were published in 2020. OBJECTIVE: To evaluate the national practices of ECV in French maternity units, especially on the use of tocolysis, 1 year after publication of the French clinical recommendations guidelines by the French national college of obstetricians and gynecologists (CNGOF). METHODS: Data self-reported for this national descriptive study were collected from March to May 2021 by an online questionnaire distributed to all French maternities. The 25 items of the questionnaire collected information of maternity units, the general practice of ECV, use or not of tocolysis for ECV attempt and the relevance of a prospective study. RESULTS: Of the 517 French maternity units, 150 (29%) responded to the online survey.  95,3% systematically performed ECV. A Kleihauer test was routinely performed in 71 units (49.7%). A tocolysis was associated with ECV attempt in 52.4% of cases. The drugs used were intravenous atosiban (30,7%), mainly in levels 2b and 3 maternity units, intravenous salbutamol (24%), other mode of administration of salbutamol (14,7%) and oral nifedipine (22,6%) mainly in levels 1 and 2a maternity units. Adverse effects were described in 20%, mainly with the use of salbutamol (73,3%). CONCLUSIONS: 52.4% of the French maternity units surveyed used tocolysis for the ECV attempt, although it is systematically recommended. The choice of tocolytic drug differed according to the maternity units.

External Cephalic Version: ACOG Practice Bulletin Summary, Number 221.

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

External Cephalic Version: ACOG Practice Bulletin, Number 221.

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Global competencies for midwives: external cephalic version; ultrasonography, and tobacco cessation intervention.

PROBLEM AND BACKGROUND: The International Confederation of Midwives (ICM) conducts regular updates to the Essential Competencies for Basic Midwifery Practice to determine the introduction or retention of items in the global scope of midwifery practice guidance document. AIM: This article presents the review process that underpinned the deliberation about three specific clinical practices: external cephalic version, prenatal ultrasonography, and tobacco cessation interventions that occurred during the 2016-2017 global update study. METHODS: A brief outline of the research methodology used in the 2016-2017 study is provided. Literature summaries about safety and effectiveness of three clinical skills are offered. Data addressing global and regional variations in support of each practice and final disposition of the items are documented. FINDINGS: External cephalic version did not receive sufficient document support for inclusion in the initial list of items to be tested in the study. Prenatal ultrasonography was supported as an advanced (76.6%) or country-specific (18.8%) skill that midwives could acquire, to promote wider global access for pregnant women. Midwives' participation in tobacco cessation counselling was supported (≥85%) in each of ICM's regions. Knowledge about World Health Organization recommendations for nicotine replacement therapy was endorsed as an additional (62.4%) or country-specific (29.3%) skill. DISCUSSION AND CONCLUSION: The current evidence of safety of midwives performing external cephalic version led to the recommendation that it be considered in the next document update. Conflicting views of midwives' role in acquiring skills to conduct prenatal ultrasound were evident. There was strong support for participation in smoking cessation counselling, but knowledge of World Health Organization recommendations was not highly endorsed.

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

OBJECTIVE: to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. DESIGN: prospective matched cohort study. SETTING: 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. PARTICIPANTS: singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. MEASUREMENTS AND FINDINGS: of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). KEY CONCLUSIONS: women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. IMPLICATION FOR PRACTICE: ECV is an important tool to reduce the caesarean section rates.

Versión cefálica externa (actualizado marzo de 2014) / External cephalic version (updated March 2014)

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Recuperación del parto vaginal de nalgas y versión cefálica externa / Reintroduction of vaginal breech delivery and external cephalic version

Objetivo. Se analizan retrospectivamente los resultados obstétricos y neonatales de la aplicación de un protocolo de parto vaginal de nalgas tras 10 años de su abandono. Métodos. Las pacientes eran derivadas a una unidad específica en la semana 36 donde se les ofrecía una versión cefálica externa. Si la presentación de nalgas persistía, eran seleccionadas para intento de parto vaginal si cumplían los siguientes criterios: a) peso fetal estimado 2.500-3.600g; b) nalgas puras o completas; c) cabeza fetal no hiperextendida, y d) pelvis clínicamente adecuada. El progreso del parto requería: a) primer estadio ≥1cm/h; b) segundo estadio 90 min para el descenso pasivo de las nalgas y una hora de pujos activos, y c) se estableció la disponibilidad de experto localizado. Resultados. Se encontró a 93 pacientes con presentación de nalgas única y viva tras la aplicación de la versión cefálica externa. En 69 (73,4%) se indicó una cesárea electiva, y 24 (26,6%) fueron candidatas para parto vaginal, 19 de las cuales lo lograron (20,1%). La tasa de cesáreas por esta indicación se redujo significativamente del 5,7% en 2009 a 2,02% (p<0,001). No se observó ningún resultado fetal adverso (muerte fetal, test de Apgar<7 en 5 min, pH de la arteria umbilical < 7 o traumatismos fetales). Conclusiones. El cumplimiento de los criterios anteparto e intraparto y la disponibilidad de expertos localizados hacen posible un parto vaginal seguro. La aplicación combinada de versión e intento de parto vaginal reduce la tasa de cesáreas por presentación de nalgas(AU)

Objective: To review the obstetric and neonatal outcomes of the application of an updated vaginal breech delivery protocol 10 years after this practice had been discontinued. Methods: Breech presentations were referred to a dedicated breech unit at 36 weeks where the external cephalic version was offered. If breech presentation persisted, the patients were selected to undergo attempted vaginal delivery if the following criteria were met: a) estimated fetal weight of 2.500-3.600 g; b) frank or complete breech presentation; c) absence of hyperextension of the fetal head; and d) a clinically adequate pelvis. Intrapartum criteria included: a) progression of labor of 1 cm/hour in the first hour; b) In the second stage, 90 minutes were allowed for adequate descent of the breech, and 1 hour of active pushing, and c) the availability of an on-call expert. Results: A total of 93 patients showed single live pregnancies in breech presentation after external cephalic version. Sixty-nine patients (73.4%) underwent elective prelabor cesarean delivery, and 24 (26.6%) progressed to attempted vaginal breech delivery, which was successful in 19 (20.1%). Cesarean indications for breech presentation were reduced from 5.7% in 2009 to 2.02% after the application of external cephalic version and vaginal breech delivery (P<.001). We observed no fetal deaths, no Apgar test at 5 minutes of less than 7, no umbilical artery pH of less than 7, and no fetal injuries. Conclusions: . When antepartum and intrapartum criteria are met, vaginal breech delivery is safe. The availability of an on-call expert allows vaginal breech delivery to be safely performed. The combination of external cephalic version and vaginal breech delivery decreases the cesarean rate for breech presentation(AU)

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.

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 < or = 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 < or = 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 < or = 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.

External cephalic version.

External cephalic version is a procedure that externally rotates the fetus from a breech presentation to a vertex presentation. External version has made a resurgence in the past 15 years because of a strong safety record and a success rate of about 65 percent. Before the resurgence of the use of external version, the only choices for breech delivery were cesarean section or a trial of labor. It is preferable to wait until term (37 weeks of gestation) before external version is attempted because of an increased success rate and avoidance of preterm delivery if complications arise. After the fetal head is gently disengaged, the fetus is manipulated by a forward roll or back flip. If unsuccessful, the version can be reattempted at a later time. The procedure should only be performed in a facility equipped for emergency cesarean section. The use of external cephalic version can produce considerable cost savings in the management of the breech fetus at term. It is a skill easily acquired by family physicians and should be a routine part of obstetric practice.

Fetal acoustic stimulation as an adjunct to external cephalic version.

OBJECTIVE: To evaluate fetal acoustic stimulation (FAS) as an adjunct to external cephalic version in a midline fetal spine presentation. STUDY DESIGN: Breech presentation in a woman presenting for attempted version at 37 weeks' gestation with a fetus in a midline position and the spine anterior is difficult to convert to a vertex. An evaluation of FAS to assist in repositioning the fetus in a more spine lateral position was carried out. Patients with a failed version attempt and a midline breech presentation were enrolled in the study. The patient served as her own control. If that attempt failed, an electrolarynx device was used to produce a one- to three-second stimulus, and then another version attempt was made. RESULTS: Sixteen patients were enrolled. Prior to FAS, 0/16 fetuses were successfully turned. FAS altered the position in 100% of patients from spine midline to lateral. After FAS, 15/16 (94%) were successfully converted to vertex presentation. The one patient whose fetus failed to convert also failed her second version attempt (P < .0005). CONCLUSION: FAS may improve the opportunity for successful external cephalic version in the properly selected candidate with a fetus in a midline position with the spine anterior.

External cephalic version.

External cephalic version has been used periodically for centuries to manage breech presentations. As cesarean section rates have escalated in the last two decades, ways to curb this rise have been evaluated. By reducing the number of infants that arrive in labor in a malpresentation, it is possible to impact the overall cesarean section rate. External cephalic version is a safe, effective method when used in appropriate cases of breech presentation. A forward or backward roll can be accomplished in women at term with singleton gestations, adequate amniotic fluid, and reactive nonstress tests. Parity, fetal and placental position, and descent of the presenting part may all influence the success rate of the version.

[Breech extraction of the second twin with or without version by internal maneuvers]. / La grande extraction du deuxième jumeau avec ou sans version par manoeuvres internes.

A retrospective study was done to appraise the recent practice of breech extraction of the second twin (with or without internal version) in our unity. From January 1st, 1988 to April 30, 1991 23 patients with a twin gestation were delivered in our unity (0.5% of all deliveries). Nineteen patients (83%) were delivered vaginally. Each procedure was done by a resident under control of a senior obstetrician and in the presence of two midwives, a pediatrician, and an anesthesiologist. Ten patients having had a breech extraction (GE group) were studied, 13 patients were excluded for not having had a breech extraction. In the GE group the presentations were: 7 vertex/breech and 3 breech/breech. Mean Apgar scores of the second twin at 3 minutes were 8 in the GE group. These results suggest that breech extraction of the second twin is not a pernicious technique if done by trained operators with precise limits. These results need to be confirmed through a prospective randomized and comparative study.

[A study and reflections on version by external maneuvers. A prospective, multicentric study at the level of 4 maternity units at the regional hospital centers of the Western Group]. / Etude et réflexions sur la version par manoeuvres externes. A propos d'un travail prospectif, multicentrique, au niveau de 4 maternités des CHR du Groupement de l'Ouest.

In order to test what could be justification for external cephalic version (ECV) in breech presentations, the authors carried out a prospective study in the four university maternity units throughout the year 1989. This brought together 262 breech presentations of more than 30 weeks duration. They compared the results in two units where ECV is carried out frequently with two where it is carried out rarely. Comparing the two groups there was very little difference in the incidence of breech presentation at the onset of labour after 36 weeks (the difference being 33.6%). An analysis according to the parity of the mothers however shows that for primigravidae there was very little difference, but is was a little above 50% in women who were low grade multi-gravidae. Incidents or accidents connected with ECV were very rare. The discussion centres more on the values to the mother and the fetus than at the level of the obstetrician himself. From this study and the reflections on it, there is no single feature that shows in the present circumstances anything for or against ECV. This is because although there has been a large multicentre study they have not compared the maternal/fetal prognosis after 36 weeks of vaginal breech delivery and Caesarean delivery as compared with those deliveries for cephalic presentations. Only a study like that could make it possible to respond to the basic question whether ECV is justified and what attitude should be taken when it fails as far as delivering the breeches that remain is concerned.