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.

Risk factors and outcomes of abnormal bleeding after external cephalic version.

OBJECTIVES: To present the consequences of and risk factors for abnormal bleeding after ECV (external cephalic version). METHODS: We conducted a retrospective chart review at a single center in Japan. Abnormal bleeding was defined as vaginal bleeding and/or intrauterine hemorrhage. We descriptively assessed birth outcomes among women with abnormal bleeding, and investigated the risk factors using a logistic regression analysis. RESULTS: Of 477 women who received ECV, 39 (8.2%) showed abnormal bleeding, including 16 (3.4%) with intrauterine hemorrhage. Of the 16 women with intrauterine hemorrhage, 14 required emergency cesarean section; none experienced placental abruption, a low Apgar score at 5 min (<7), or low umbilical cord artery pH (<7.1). Among 23 women who had vaginal bleeding without intrauterine hemorrhage, four cases underwent emergency cesarean section and one case of vaginal delivery involved placental abruption. The risk of abnormal bleeding was higher in women with a maximum vertical pocket (MVP) of <40 mm in comparison to those with an MVP of >50 mm (adjusted odds ratio [OR]: 3.48, 95% confidence interval [CI]: 1.23-9.90), as was higher in women with unsuccessful ECV than in those with successful ECV (aOR: 4.54, 95% CI: 1.95-10.6). CONCLUSIONS: A certain number of women who underwent ECV had abnormal bleeding, including vaginal bleeding and/or intrauterine hemorrhage, many of them resulted in emergency cesarean section. Although all of cases with abnormal bleeding had good birth outcomes, one case of vaginal bleeding was accompanied by placental abruption. Small amniotic fluid volume and unsuccessful ECV are risk factors for abnormal bleeding.

Association of Persistent Breech Presentation With External Cephalic Version Success.

OBJECTIVE: To evaluate a possible correlation between a new variable-persistent breech presentation-and the success rate of external cephalic version (ECV). METHODS: This was a retrospective study of ECVs performed from January 2008 through January 2019 in an Israeli tertiary care hospital. The study group included all pregnant women who underwent an ECV at or beyond 37 weeks of gestation. Persistent breech presentation was defined as persistent breech presentation during all ultrasound examinations performed between the anatomy scan at mid-pregnancy and the gestational week when ECV was attempted. Women in whom cephalic presentation was documented at least once on these ultrasound examinations were defined as not having persistent breech presentation. The primary outcome was defined as the success rate of ECV, and the secondary outcome was defined as the mode of delivery after a successful ECV. RESULTS: We identified 1,271 women with breech presentation during the study period. They had undergone median of five (range 2-7) ultrasound examinations. External cephalic version was attempted in 684 women (53.8%), with a success rate of 61.5%. External cephalic version succeeded in 19.6% of those with persistent breech presentation (44/224) compared with 82.0% (377/460) of those without persistent breech presentation (P<.001). Ultimately, women with persistent breech presentation and successful ECV experienced a lower rate of vaginal delivery (27.3% vs 79%, P<.001), and a higher rate of instrumental (29% vs 13%, P<.001) and cesarean deliveries (43% vs 7%, P<.001) compared with the nonpersistent breech presentation group. The rate of noninstrumental vaginal delivery among women with persistent breech presentation, regardless of ECV, was 5.4%. CONCLUSION: Women with persistent breech presentation experienced a high rate of ECV failure and a low rate of spontaneous vaginal delivery.

Outcomes of a Breech Birth Program in Canada, Quality Assurance Project.

OBJECTIVE: To report antenatal, intrapartum, and postnatal factors associated with breech birth from our Breech Program at South Health Campus, Calgary. METHODS: We reviewed all maternal and neonatal patient records where breech birth was documented from 2013 to 2018. Neonatal blood gas values, Apgar scores, birth weight, admissions to NICU, antenatal ultrasound reports, inpatient electronic medical records, and operative and delivery reports, were reviewed. Any indices known as indications, contraindications, or outcomes associated with breech birth were recorded and summarized. RESULTS: Among the 499 breech births that occurred over the study period, there were109 attempted external cephalic versions, 411 planned and 39 unplanned cesarean deliveries, and 49 vaginal deliveries. Unplanned cesarean delivery was performed for newly diagnosed breech presentation in labour (14), footling presentation in labour (9), abnormal fetal heart rate (4), labour dystocia (8), ultrasound findings of low fluid (2) or unfavourable fetal position (1), and worsening maternal hypertension (1). CONCLUSION: Despite the absence of reported contraindications in the majority of patients and the presence of a program that supported vaginal breech delivery, cesarean delivery was more common. Mothers who chose to labour were highly successful in achieving vaginal birth with excellent maternal and neonatal outcomes.

Vaginal Delivery After External Cephalic Version in Patients With a Previous Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the rate of vaginal delivery after successful external cephalic version for breech presentation in women with compared with without a previous cesarean birth. DATA SOURCES: We searched MEDLINE, Scopus, EMBASE, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials for studies comparing the mode of delivery after successful external cephalic version in women with and without a previous cesarean birth. METHODS OF STUDY SELECTION: Two reviewers independently identified studies, extracted data, and evaluated study quality. The rate of vaginal delivery after successful external cephalic version in women with and without a previous cesarean birth was compared, and odds ratios (ORs) with 95% CIs were estimated. TABULATION, INTEGRATION, AND RESULTS: Six cohort studies and two case-control studies, reporting on 14,515 women were identified. The median point prevalence of a successful external cephalic version was 74% (interquartile range 63-81%) in women with a previous cesarean birth compared with 69% (interquartile range 64-83%) in women without a previous cesarean birth. The overall success rate of external cephalic version in women with a previous cesarean birth was similar compared with women without a previous cesarean birth (pooled OR 0.84, 95% CI 0.61-1.15). The median point prevalence of a vaginal delivery was 75% (interquartile range 61-84%) in women with a previous cesarean birth compared with 92% (interquartile range 85-95%) in women without a previous cesarean birth after a successful external cephalic version. The overall success rate of a vaginal delivery in women with a previous cesarean birth was less compared with women without a previous cesarean birth (pooled OR 0.26, 95% CI 0.14-0.50). A planned subgroup analysis on studies that included only multiparous women in the control group (parity one or greater) noted the overall success rate of external cephalic version in women with a previous cesarean birth 76% (853/1,123) was lower compared with multiparous women without a previous cesarean birth 84% (9,911/11,855) (pooled OR 0.70, 95% CI 0.54-0.89, I 37%). The overall success rate of a vaginal delivery in women with a previous cesarean birth 83% (666/806) was less compared with women without a previous cesarean birth 97% (9,449/9,746) (pooled OR 0.21, 95% CI 0.12-0.39, I 73%). CONCLUSION: Women with previous cesarean birth have similar rates of successful external cephalic version when compared with women without a cesarean birth. Although the rate of vaginal delivery is lower, the majority of patients have a successful vaginal birth after cesarean. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42020160145.

Management of labor after external cephalic version.

OBJECTIVES: Current literature evaluating the role of induction of labor (IOL) following successful external cephalic version (ECV) attempt as compared to expectant management is limited. We aim to assess the risk of cesarean delivery in those undergoing immediate IOL following successful ECV as compared to those who were expectantly managed. METHODS: A retrospective cohort study of successful external cephalic versions. The study group included 57 women that were induced after procedure in the lack of maternal or fetal indications for induction of labor. These women were compared to 341 expectantly managed women. Maternal and fetal characteristics and outcomes were compared. RESULTS: Gestation age at delivery was higher among the expectant management group (401/7 vs. 384/7, median, p=0.002) as compared to the induction group. Cesarean delivery rates were similar between both groups (28 [8.2%] vs. 3 [5.3%], p=0.44). In a multivariate logistic regression analysis, only nulliparity was significantly associated with cesarean delivery (adjusted odds ratio 3.42, confidence interval 1.61-7.24, p=0.001). No correlation was found between the version-to-delivery interval and the risk for cesarean delivery. CONCLUSIONS: Induction of labor after successful ECV was not shown to influence cesarean delivery rates. As immediate IOL may result in higher rate of early-term deliveries, and in light of the lack of clinical benefit, we advocate against elective IOL following successful ECV.

Obstetrical and neonatal outcomes after successful external cephalic version relative to those after spontaneous cephalic presentations.

OBJECTIVE: External cephalic version (ECV) is a procedure during which the fetus is rotated from breech or transversal to cephalic presentation. Our aim was to assess the outcomes of successful ECV in terms of obstetrical and immediate neonatal outcomes relative spontaneous cephalic presentation. METHODS: We performed a retrospective single-center observational study from January 2007 to December 2017. All included participants benefited from trial of labor with delivery of the fetus in cephalic presentation. They were divided into two groups depending on whether an ECV had been successfully performed or cephalic presentation was spontaneous. RESULTS: The cephalic presentation after ECV and spontaneous cephalic groups comprised 55 and 244 patients, respectively. The two groups differed significantly in terms of the proportion of induced labor (20 [36.4 %] and 56 [22.9 %], p = 0.04), use of oxytocin during labor (31 [56.4 %] and 100 [49.9 %], p = 0.04), duration of labor (342 ± 183 min and 279 ± 140 min, p = 0.008), spontaneous delivery (38 [69.1 %] and 199 [81.5 %], p = 0.04), intrapartum cesarean section (9 [16.4 %] and 16 [6.6 %], p = 0.02), occiput-posterior variety at birth (20 [36.4 %] and 56 [22.9 %], p = 0.04), and brace umbilical positioning at birth (3 [5.4 %] and 2 [0.8 %], p = 0.04), respectively. There were no significant intergroup differences in terms of APGAR score, cord arterial pH/lactates, or reanimation/intensive care admission. CONCLUSION: A successful ECV does not seem to guaranty an identical labor progress and obstetrical outcome as spontaneous cephalic presentations. Immediate neonatal state, on the other hand, seems unaffected by a history of ECV.

Delivery outcomes in subsequent pregnancy following primary breech cesarean delivery: a retrospective cohort study.

Background: Women may be unaware of the potential impact on subsequent deliveries of the decision to undergo primary breech cesarean (PBC) delivery rather than attempt external cephalic version (ECV). We investigated cesarean delivery rates and adverse maternal outcomes in the subsequent delivery following management of breech presentation by ECV versus PBC.Methods: This retrospective study identified women who delivered subsequent to breech presentation managed by attempted ECV or PBC. We assessed cesarean delivery rates and adverse maternal outcomes including hemorrhage, placental complications, infection, and obstetric complications in the subsequent delivery following attempted ECV versus PBC.Results: We identified 307 women who had attempted ECV and 508 with PBC in the index breech pregnancy. Following attempted ECV, 47 (15.3%) women had cesarean delivery in the subsequent pregnancy versus 246 (48.4%) following PBC, adjusted OR 0.24, 95% CI 0.16-0.35 for subsequent cesarean delivery after attempted ECV in the index pregnancy. The frequency of composite adverse outcomes related to cesarean delivery was 30 (9.8%) following attempted ECV versus 104 (20.5%) after PBC, p < .0001. The frequency of composite severe adverse maternal outcome was similar following attempted ECV 25 (8.8%) versus PBC 59 (11.9%).Conclusions: The current study suggests that attempted external cephalic version was associated with a five-fold decrease risk to undergo cesarean in the subsequent delivery and a significantly decreased frequency of composite adverse outcomes related to cesarean delivery in the subsequent delivery.

Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation.

OBJECTIVE: Undiagnosed non-cephalic presentation in labor carries increased risks for both the mother and baby. Routine pregnancy care based on maternal abdominal palpation fails to detect the majority of cases of non-cephalic presentation. The aim of this study was to report the incidence of non-cephalic presentation at a routine scan at 35 + 0 to 36 + 6 weeks' gestation and the subsequent management of such pregnancies. METHODS: This was a retrospective analysis of prospectively collected data in 45 847 singleton pregnancies that had undergone routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. Patients with breech or transverse/oblique presentation were divided into two groups; first, those who would have elective Cesarean section for fetal or maternal indications other than the abnormal presentation, and, second, those who would potentially require external cephalic version (ECV). The latter group was reassessed after 1-2 weeks and, if there was persistence of abnormal presentation, the parents were offered the option of ECV or elective Cesarean section at 38-40 weeks' gestation. Multivariable logistic regression analysis was carried out to determine which of the factors from maternal and pregnancy characteristics provided a significant contribution in the prediction of, first, non-cephalic presentation at the 35 + 0 to 36 + 6-week scan, second, successful ECV from non-cephalic to cephalic presentation, and, third, spontaneous rotation from non-cephalic to cephalic presentation that persisted until delivery. RESULTS: First, at 35 + 0 to 36 + 6 weeks, the fetal presentation was cephalic in 43 416 (94.7%) pregnancies, breech in 1987 (4.3%) and transverse or oblique in 444 (1.0%). Second, multivariable analysis demonstrated that the risk of non-cephalic presentation increased with increasing maternal age and weight, decreasing height and earlier gestational age at scan, was higher in the presence of placenta previa, oligohydramnios or polyhydramnios and in nulliparous than parous women, and was lower in women of South Asian or mixed racial origin than in white women. Third, 22% of cases of non-cephalic presentation were not eligible for ECV because of planned Cesarean section for indications other than the malpresentation. Fourth, of those eligible for ECV, only 48.5% (646/1332) agreed to the procedure, which was successful in 39.0% (252/646) of cases. Fifth, the chance of successful ECV increased with increasing maternal age and was lower in nulliparous than parous women. Sixth, in 33.9% (738/2179) of pregnancies with non-cephalic presentation in which successful ECV was not carried out, there was subsequent spontaneous rotation to cephalic presentation. Seventh, the chance of spontaneous rotation from non-cephalic to cephalic presentation increased with increasing interval between the scan and delivery, decreased with increasing birth-weight percentile, was higher in women of black than those of white racial origin, if presentation was transverse or oblique rather than breech and if there was polyhydramnios, and was lower in nulliparous than parous women and in the presence of placenta previa. Eighth, in 109 (0.3%) cephalic presentations, there was subsequent rotation to non-cephalic presentation and, in 41% of these, the diagnosis was made during labor. Ninth, of the total 2431 cases of non-cephalic presentation at the time of the scan, presentation at birth was cephalic in 985 (40.5%); in 738 (74.9%) this was due to spontaneous rotation and in 247 (25.1%) this was due to successful ECV. Tenth, prediction of non-cephalic presentation at the 35 + 0 to 36 + 6-week scan and successful ECV from maternal and pregnancy factors was poor, but prediction of spontaneous rotation from non-cephalic to cephalic presentation that persisted until delivery was moderately good and this could be incorporated in the counseling of women prior to ECV. CONCLUSIONS: The problem of unexpected non-cephalic presentation in labor can, to a great extent, be overcome by a routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. The incidence of non-cephalic presentation at the 35 + 0 to 36 + 6-week scan was about 5%, but, in about 40% of these cases, the presentation at birth was cephalic, mainly due to subsequent spontaneous rotation and, to a lesser extent, as a consequence of successful ECV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]. / Présentation du siège. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

OBJECTIVES: To determine the optimal management of singleton breech presentation. MATERIALS AND METHODS: The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS: In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C). CONCLUSION: In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

Maternal and perinatal outcomes in external cephalic version: prognostic factors for the success of the technique.

Background We aimed to analyze the success rate of external cephalic version (ECV) for breech presentations performed in our center between March 2011 and March 2016. We evaluated factors related to a successful ECV, delivery mode, complications and newborn status after ECV. Methods Analysis of assembled data of 327 consecutive ECVs in the third trimester was done. Results The total success rate was 56.6%. After a successful ECV, 85.9% of the fetuses were delivered vaginally. Logistic regression analysis of background factors leading to a successful ECV showed that tocolysis with ritodrine and anterior placenta were each significantly correlated with the rate of successful version. No severe complications were registered during the ECVs, and all babies had normal Apgar scores at delivery. Conclusion These findings suggest that attempting an ECV in breech presentations, once or even twice, seems to be an appropriate management given that a successful ECV decreases the rate of cesarean section in this group of patients and by doing so, it might also decrease the risk of cesarean sections in future pregnancies.

External cephalic version at term: A 6-year single-operator experience.

BACKGROUND: External cephalic version (ECV) should be offered for patients presenting with a noncephalic pregnancy that are willing to deliver vaginally. Various reports have evaluated predictors for successful ECV. Yet, none have reported a single-operator large cohort experience. We aim to analyze the outcome of referrals for ECV. METHODS: We conducted a retrospective cohort study of prospectively collected data. We performed a multivariate analysis of data with respect to ECV procedures performed by a single operator in a 6-year period. Maternal and fetal characteristics were compared between ECV success and failure groups. RESULTS: Six hundred and two women underwent ECV. Of them, ECV was successful in 432 (71.7%). A multivariate binary logistic regression model demonstrated that high liquor volume was a predictor of ECV success (Adj OR 1.17 [95% CI 1.09-1.26]). Failure of ECV was correlated with anterior placenta (0.44 [0.56-0.76]) and nulliparity (0.21 [0.11-0.36]). Adverse events were rare and mostly minor, occurring in 1% of procedures. CONCLUSIONS: ECV has a high success rate and a low complication rate, enabling vaginal birth and avoiding cesarean. The role of manipulation of modifiable determinants such as liquor volume should be further assessed in future studies.

The impact of maternal body mass index on external cephalic version success.

OBJECTIVE: The purpose of this study is to determine the association between body mass index (BMI) and success of ECV. METHODS: This is a cross-sectional analysis of singleton live births in the USA from 2010 to 2014 using birth certificate data. Patients were assigned a BMI category according to standard WHO classification. Comparisons of success of ECV between the BMI categories were made using chi-square analysis with normal BMI as the reference group. Cochran-Armitage test was performed to look for a trend of decreasing success of ECV as BMI increased. The odds for successful ECV were estimated using multivariate logistic regression analysis, adjusting for possible confounders. RESULTS: A total of 51,002 patients with documented ECV were available for analysis. There was a decreased success rate for ECV as BMI increased (p < .01). Women with a BMI of 40 kg/m2 or greater had a 58.5% success rate of ECV; women with a normal BMI had 65.0% success rate of ECV. Multivariate analyses demonstrated significant decrease in success of ECV in women with BMI of 40 kg/m2 or greater (OR 0.621, CI 0.542-0.712). Among women with BMI of 40 kg/m2 or greater with successful ECV, 59.5% delivered vaginally. In contrast, 81.0% of women with normal BMI and successful ECV delivered vaginally. CONCLUSIONS: Morbidly obese women have decreased success rate of ECV as BMI increases and decreased vaginal delivery rates after successful ECV.

Predictors of a successful external cephalic version: A population-based study of Washington state births.

BACKGROUND: Breech presentation affects approximately 3% of women with singleton pregnancies. External cephalic version is a manual procedure that reorients a foetus to cephalic position in preparation for birth, reducing indications for caesarean birth. However, unsuccessful attempts are associated with some adverse health outcomes. Versions are successful in 17-86% of attempts. Temporal trends in version success and association between maternal height or prenatal care and version success are unknown. Few population-based studies and no recent investigations in the United States have evaluated predictive factors for version success. OBJECTIVES: This study aimed to estimate the proportion of successful version procedures in the United States and to evaluate factors associated with version success. METHODS: We used birth certificate and hospital administrative data. The study included all women who had a singleton birth in Washington State between 2003-2014 following a version procedure (total n=4981). Prevalence ratios and 95% confidence intervals were calculated using Poisson regression. FINDINGS: 57.2% of version attempts were successful. Primiparity (Prevalence Ratio:1.43; 95% Confidence Interval:1.29-1.60) and multiparity (Prevalence Ratio:1.68; 95% Confidence Interval:1.50-1.88) were associated with procedure success. Oligohydramnios was associated with lower version success (Prevalence Ratio:0.75; 95% Confidence Interval:0.57-1.00). Maternal height, pre-pregnancy weight, polyhydramnios, frequency of prenatal care, smoking, infant sex, and year of birth were not significantly associated with version outcome. CONCLUSION: We found that most version procedures are successful. This reinforces that procedures may be able to reduce the frequency of caesarean birth. These contemporary results can help women and clinicians make decisions with realistic estimates of success.

External cephalic version at term: a cohort study of 18 years' experience.

OBJECTIVE: To analyse the outcome of referrals for external cephalic version (ECV). DESIGN: Retrospective cohort study of prospectively collected data. SETTING: Major university hospital, UK. SAMPLE: Women with non-cephalic presentation at term and no prior caesarean, referred to a specialist clinic. METHODS: Details of referrals, ECV attempts, and perinatal outcomes were prospectively collected and analysed. Multivariate binary logistic regression models were created to determine independent predictors of ECV success, reversion, and spontaneous version. MAIN OUTCOME MEASURES: External cephalic version success rates, predictors of success and cephalic presentation at birth, and perinatal outcomes. RESULTS: Three thousand eight had confirmed breech presentation; 2614 women underwent ECV. Ineligibility for ECV occurred in 117 breech presentations (3.9%), and 297 eligible women (10.2%) declined it. ECV was successful in 1280 (49.0%, 95% CI 47.0-50.9%) (40% in nulliparous women; 64% in others); 1234 (97.3%) were cephalic at birth. Spontaneous version after failure occurred in 4.3% and was more common in multiparas (aOR 2.47, 95% CI 1.43-4.26) and those with a posterior fetal back (aOR 6.09, 95% CI 1.90-19.53). Reversion after successful ECV occurred in 2.2%. In women with a successful ECV whose fetus remained cephalic at birth, 85.7% delivered vaginally. The corrected perinatal mortality of the ECV cohort was 0.12%. CONCLUSION: External cephalic version has a low complication rate and is effective for most breech presentations, enabling vaginal birth and avoiding caesarean section. TWEETABLE ABSTRACT: External cephalic version can safely be performed with most breech presentations.

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

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

Development and internal validation of a clinical prediction model for external cephalic version.

OBJECTIVE: To develop a prediction model for the chance of successful external cephalic version (ECV). STUDY DESIGN: This is a secondary analysis of a multicenter, open-label randomized controlled trial that assessed the effectiveness of atosiban compared to fenoterol as uterine relaxant during ECV in women with a singleton fetus in breech presentation with a gestational age of 36 weeks or more. Potential predictors included maternal, pregnancy, fetal, and treatment characteristics and were recorded in all participants. Multivariable logistic regression analysis with a stepwise backward selection procedure was used to construct a prediction model for the occurrence of successful ECV. Model performance was assessed using calibration and discrimination. RESULTS: We included a total of 818 women with an overall ECV success rate of 37%. Ten predictive factors were identified with the stepwise selection procedure to be associated with a successful ECV: fenoterol as uterine relaxant, nulliparity, Caucasian ethnicity, gestational age at ECV, Amniotic Fluid Index, type of breech presentation, placental location, breech engagement, possibility to palpate the head and relaxation of the uterus. Our model showed good calibration and a good discriminative ability with a c-statistic of 0.78 (95% CI 0.75 to 0.81). CONCLUSION: Prediction of success of ECV seems feasible with a model showing good performance. This can be used in clinical practice after external validation.

A novel and dedicated multidisciplinary service to manage breech presentation at term; 3 years of experience in a tertiary care maternity unit.

OBJECTIVE: In order to provide uniform and unbiased multidisciplinary counselling on the options available, including vaginal breech delivery (VBD) and external cephalic version (ECV), the latter of which could then be performed, a weekly Breech Clinic was introduced to a tertiary care maternity unit in Northern Ireland in June 2013, replacing the traditional ECV Clinic introduced in June 2012. METHODS: Retrospective data collection was undertaken using clinic proformas, Northern Ireland Maternity System data and case notes of women who attended the clinics (ECV and Breech) from June 2012 to May 2015. RESULTS: There were 434 referrals to the clinic over the 3-year period; 356 women attended. The proportion of women attending increased from 69% to 85% since the introduction of the Breech Clinic. Two hundred and thirty-two were deemed eligible and 179 of these underwent ECV after counselling. Although the proportion of women undergoing ECV decreased from 69% to 46%, 11 women opted for and achieved VBD during the 2 years of the Breech Clinic, compared with one woman in the year of the ECV Clinic. Seventy-one of the attempted ECVs were successful, with 61 women having a normal vaginal delivery. Notably, the success rate of ECV increased from 33% to 42%. The number of caesarean sections performed solely for breech at term decreased from 199 in the 12 months before the introduction of ECV clinic, to 188 during the ECV clinic, and 154 in the final 12 months of Breech Clinic. CONCLUSIONS: A dedicated service to counsel women on the management of breech presentation can decrease caesarean sections for breech presentation through increased uptake and success of ECV, and encouraging suitable women to opt for VBD when ECV is unsuccessful, contraindicated or declined.

Labour Outcomes After Successful External Cephalic Version Compared With Spontaneous Cephalic Version.

OBJECTIVE: This study sought to compare obstetrical outcomes for women with a cephalic presentation at birth resulting from successful external cephalic version (ECV) compared to those resulting from spontaneous cephalic version (SCV). METHODS: Secondary analysis was performed on Early External Cephalic Version Trial data. A total of 931 study participants had breech presentations between 34 and 36 weeks' gestation and cephalic presentations at birth. The incidence of intrapartum interventions was compared between patients with successful ECV (557) and those with SCV (374). A generalized linear mixed model was used to determine ORs for our primary outcomes. Parity, maternal BMI, previous CS, and enrolment centre were controlled for in the analysis. RESULTS: No differences were found after ECV compared with SCV in the incidence of CS (96 of 557 and 76 of 374, respectively; adjusted OR [aOR] 0.89; 95% CI 0.63-1.26), instrumental birth (68 of 557 and 29 of 373, respectively; aOR 1.55; 95% CI 0.96-2.50), or normal vaginal birth (393 of 557 and 268 of 373, respectively; aOR 0.92; 95% CI 0.68-1.24). Multiparous women with successful ECV were half as likely to require a CS compared with those with SCV and no ECV (28 of 313 and 42 of 258, respectively; aOR 0.45; 95% CI 0.26-0.80). CONCLUSION: This is the first study to compare birth outcomes of breech pregnancies that convert to cephalic presentation by means of SCV with birth outcomes of breech pregnancies that have ECV. Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.

Comparison of Fetomaternal Outcome between 47 Deliveries Following Successful External Cephalic Version for Breech Presentation and 7456 Deliveries Following Spontaneous Cephalic Presentation.

BACKGROUND: Achieving a cephalic position after a successful external cephalic version (ECV) is desired to result in delivery and fetal outcomes that are similar to those of deliveries following spontaneous cephalic presentation. METHODS: We performed a retrospective cohort study including patients with successful ECV following fetal breech position (ECV cohort, n = 47) or with a singleton spontaneous cephalic pregnancy at ≥37 weeks of gestational age (control group, n = 7,456) attempting a vaginal delivery between 2010 and 2013 at the University Hospital Ulm. The mode of delivery and fetal outcome parameters were compared between these 2 groups using nonparametric statistics. RESULTS: ECV cohort and control group did not differ with respect to maternal age, parity, gestational age at birth, and fetal gender. There were no significant differences between the 2 groups with regard to all parameters indicating fetal outcome. However, the rate of cesarean sections was higher after successful ECV compared to spontaneous cephalic presentation (27.7 vs. 12.8%, OR 2.615). CONCLUSION: While vaginal delivery is less likely to happen after a successful ECV compared to spontaneous cephalic singleton pregnancies, fetal outcome parameters showed no difference between the 2 groups. Physicians should be counseling and encouraging women to attempt ECV, as it is a safe and effective procedure.