Intrapartum external cephalic version

Intrapartum external cephalic version at term was employed in 15 patients with intact membranes and breech presentations; successful version occurred in 11 patients. There were no untoward maternal or fetal outcomes.     

Repeated external cephalic version at term.

External version was performed three times in a patient at term because of spontaneous reversion to breech presentation. She was then delivered vaginally. Spontaneous reversion to breech presentation can be managed with additional external cephalic version procedures.     

A training model for external cephalic version.

The Royal College of Obstetricians and Gynaecologists (RCOG) has recommended that all women with an uncomplicated pregnancy and a breech presentation at term should be offered external cephalic version (ECV) but only 43% of consultants in England practice ECV. There is a need to train clinicians to perform ECV safely and effectively. A model abdomen is described which fulfils these requirements. The model is adjustable to represent a continuum from an easy procedure to an impossible procedure. The model was used to train and assess two midwives in the technique of ECV. This model is a valuable method of both training a clinician to perform ECV and also providing an objective method of assessing their technique. It has the potential to maximise the success rate of the newly trained clinician prior to performing ECV on women.     

Controlled trial of external cephalic version

Summary. A prospective randomized, controlled trial involving 640 singleton breech presentations after 30 weeks gestation was conducted to assess the value of external cephalic version. In 310 patients external cephalic version was attempted; the other 330 patients in whom version was not attempted constituted a control group. There were three perinatal deaths directly attributable to external cephalic version. No significant differences were found between the study and control groups respecting the incidence of vaginal breech delivery, caesarean section rate, perinatal mortality and morbidity. Our results suggest that there is no place for external cephalic version before 36 weeks gestation.     

Controlled trial of external cephalic version

A prospective randomized, controlled trial involving 640 singleton breech presentations after 30 weeks gestation was conducted to assess the value of external cephalic version. In 310 patients external cephalic version was attempted; the other 330 patients in whom version was not attempted constituted a control group. There were three perinatal deaths directly attributable to external cephalic version. No significant differences were found between the study and control groups respecting the incidence of vaginal breech delivery, caesarean section rate, perinatal mortality and morbidity. Our results suggest that there is no place for external cephalic version before 36 weeks gestation.     

Tocolysis in term breech external cephalic version.

OBJECTIVES: To study the effect of ritodrine tocolysis on the success of external cephalic version (ECV) and to assess the role of ECV in breech presentation at our centre. MATERIAL AND METHODS: A prospective randomized double-blind-controlled trial comparing ritodrine and placebo in ECV of singleton term breech pregnancy at a tertiary hospital. RESULTS: Among the 60 patients who were recruited, there was a success rate of 36.7%. Ritodrine tocolysis significantly improved the success rate of ECV (50% vs. 23%; P=0.032). There was a marked effect of ritodrine tocolysis on the ECV success in nulliparae (36.4% vs. 13.0%) and multiparae (87.5% vs. 57.1%). External cephalic version has shown to reduce the rate of cesarean section for breech presentation by 33.5% in our unit. CONCLUSION: External cephalic version significantly reduced the rate of cesarean section in breech presentation, and ritodrine tocolysis improved the success of ECV and should be offered to both nulliparous and parous women in the case of term breech presentation.     

Intravenous salbutamol for external cephalic version

OBJECTIVE: To evaluate the success of external cephalic version (ECV) using an adjusted bolus dose of intravenous salbutamol compared with no tocolysis. METHODS: An open-label randomized study of 114 women with a term breech fetus randomized to receive either an intravenous bolus dose of 0.1 mg salbutamol with further boluses every 5 minutes, as required, before commencing ECV, or no tocolysis. Primary outcomes were successful ECV and rate of cesarean delivery. RESULTS: Salbutamol tocolysis resulted in a higher rate of successful ECV compared with no tocolysis (70.2% [40/57] vs 36.8% [21/57]; RR 1.9, 95% CI 1.3-2.8; P<0.001). Cesarean delivery rate was lower in the salbutamol group compared with the control group (31.6% [18/57] vs 63.2% [36/57]; RR 0.5, 95% CI 0.3-0.8; P=0.001). Salbutamol dose ranged from 0.1-0.4 mg and outcome was not related to dose. CONCLUSION: Adjusted dose intravenous salbutamol tocolysis prior to ECV increases its success rate and reduces the cesarean delivery rate.     

Fetomaternal hemorrhage during external cephalic version

OBJECTIVE: To estimate the frequency and volume of fetomaternal hemorrhage during external cephalic version for term breech singleton fetuses and to identify risk factors involved with this complication. METHODS: A prospective observational study was performed including all patients undergoing a trial of external cephalic version for a breech presentation of at least 36 weeks of gestation between 1987 and 2001 in our center. A search for fetal erythrocytes using the standard Kleihauer-Betke test was obtained before and after each external cephalic version. The frequency and volume of fetomaternal hemorrhage were calculated. Putative risk factors for fetomaternal hemorrhage were evaluated by chi(2) test and Mann-Whitney U test. RESULTS: A Kleihauer-Betke test result was available before and after 1,311 trials of external cephalic version. The Kleihauer-Betke test was positive in 67 (5.1%) before the procedure. Of the 1,244 women with a negative Kleihauer-Betke test before external cephalic version, 30 (2.4%) had a positive Kleihauer-Betke test after the procedure. Ten (0.8%) had an estimated fetomaternal hemorrhage greater than 1 mL, and one (0.08%) had an estimated fetomaternal hemorrhage greater than 30 mL. The risk of fetomaternal hemorrhage was not influenced by parity, gestational age, body mass index, number of attempts at version, placental location, or amniotic fluid index. CONCLUSION: The risk of detectable fetomaternal hemorrhage during external cephalic version was 2.4%, with fetomaternal hemorrhage more than 30 mL in less than 0.1% of cases. These data suggest that the performance of a Kleihauer-Betke test is unwarranted in uneventful external cephalic version and that in Rh-negative women, no further Rh immune globulin is necessary other than the routine 300-microgram dose at 28 weeks of gestation and postpartum. LEVEL OF EVIDENCE: II.     

Cardiotocographic changes after external cephalic version

Summary. Cardiotocographic tracings before and after 53 attempts at external cephalic version (ECV) in 52 patients were analysed. Hexoprenaline (Ipradol) was used to facilitate ECV in 25 of the 53 attempts. There was a significant decrease in fetal movements and fetal heart rate (FHR) variability and reactivity after external cephalic version; temporary baseline bradycardia occurred in five patients. The most likely explanation for the changes observed is that they represent the fetal response to a period of stress caused by decreased uteroplacental blood flow during the procedure.     

Antepartum external cephalic version under tocolysis

Reported are 172 patients considered for external cephalic version at gestational age greater than 37 weeks. Their outcome was compared with 40 similar patients in whom external version was not attempted. One hundred fifty-eight patients had attempted version, and success was achieved in 122 (77%). Intrapartum vertex presentation occurred in 12% of the control population and in 77% of the version patients. Cesarean section was performed in 80% of the control patients and in 32% of the version patients. There were no maternal or fetal complications directly attributable to external cephalic version. Antepartum external cephalic version under tocolysis is associated with a high success rate, an acceptably low rate of complications, and a decreased incidence of cesarean section for breech presentation at term.     

Cardiotocographic changes after external cephalic version

Cardiotocographic tracings before and after 53 attempts at external cephalic version (ECV) in 52 patients were analysed. Hexoprenaline (Ipradol) was used to facilitate ECV in 25 of the 53 attempts. There was a significant decrease in fetal movements and fetal heart rate (FHR) variability and reactivity after external cephalic version; temporary baseline bradycardia occurred in five patients. The most likely explanation for the changes observed is that they represent the fetal response to a period of stress caused by decreased uteroplacental blood flow during the procedure.     

Intrapartum external cephalic version of footling-breech presentation

BACKGROUND: External cephalic version is attempted prior to the onset of labor. Women who present in labor with footling breech presentation are usually delivered by cesarean section. We present our experience of external version in women in labor. MATERIAL AND METHODS: External cephalic version was attempted in thirteen patients in labor with footling breech presentation with the breech out of the pelvis. RESULTS: The procedure was successful in twelve of the thirteen patients. Ten of them delivered vaginally. There were no maternal or neonatal complications. CONCLUSIONS: It may be reasonable to attempt external cephalic version in patients in labor prior to performing a cesarean section.     

Ultrasonography and external cephalic version at term

Sixty-five patients with nonvertex presentations at term were evaluated by ultrasonography to determine which factors were associated with a successful external cephalic version. Amniotic fluid volume, placental localization, type of breech, position of the fetal spine, and whether the breech had descended were determined and analyzed by chi 2 analysis. Only a frank breech and an anteriorly located fetal spine were associated with a successful version. Four episodes of fetal bradycardia occurred, none requiring operative intervention. There were no episodes of maternal bleeding or dislodgement of the placenta. Fifty-eight percent of all breech presentations were converted and 62% were delivered vaginally. We conclude that ultrasonography is useful in the evaluation of patients with a nonvertex presentation at term and can be used to predict which patients are likely to undergo a successful external cephalic version.