Spontaneous cephalic version of breech presentation in the last trimester

A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.     

External cephalic version of the breech presentation under tocolysis

External cephalic version with tocolysis at or near term has been advocated to avoid cesarean birth for breech presentation. In our institution this maneuver was successfully performed in 207 of 304 parturients without major complications, and all but six had vertex presentation at delivery. The success of version was inversely correlated with gestational age but was not correlated with ease of version, number of attempts, or placental location. When this 3-year period was compared with the previous three years (1979 to 1981), there was a significant reduction in the number of breech presentations during labor, whereas the total delivery rate remained relatively constant over the 6-year period. It appears that in a carefully selected population, external version near term can be used safely to reduce the need for abdominal birth because of breech presentation.     

External cephalic version in breech presentation under tocolysis.

A prospective trial is presented of the benefits and risks of external cephalic version in breech presentation. From January through October 1977, attempts at external version were performed in 53 cases with a success rate of 70%. The version technique is described. Mode of delivery after the maneuver in mothers with breech presentation who for different reasons were not included in the series is reported as well. Both the incidence of breech presentation and the incidence of cesarean section in breech presentation were reduced during the period of study. No serious complications in association with attempts at external version were observed.     

External cephalic version as a possible treatment of breech presentation

BACKGROUND: Breech presentation shows 3-4% incidence on every foetal presentation at the time of delivery and is more correlated than vertex presentation to a foetal risk of perinatal mortality (with a frequency from 2 to 5 times higher) and to foetal malformations, low weight at birth and prematurity. On the other hand, without a careful case selection, breech delivery has a higher risk of perinatal morbidity and mortality in comparison to cephalic presentation. It is estimated that perinatal mortality for breech presentation at term is about 4-5% for vaginal delivery and about 2-4% for caesarean section. In addition caesarean section has a higher maternal morbidity and a small but significant risk of perinatal mortality, therefore, external cephalic version (ECV) can be a good choice to increase physiological deliveries. The aim of the present study is to evaluate the real efficacy of this obstetric manoeuvre to decrease the frequency of breech presentation at delivery. METHODS: The study group included 67 patients (age 29.5 +/- 3.8) with foetal breech presentation at gestational age 35.8 +/- 1.9 weeks, recruited at the Department of Obstetrics and Gynaecology of the Pavia University. Every patient underwent ECV. The same physician has performed every ECV attempt using the forward roll technique, with previous tocolysis in 50 cases (rithodrine vs isoxsuprine). The following variables have been taken into consideration: amount of amniotic fluid, gestational age, kind of tocolysis, placental location, foetal back position, parity, breech variety and foetal adnexial complication at birth. RESULTS: ECV succeeded in 77.6% (n = 52) and failed in 22.4% (n = 15) of cases. No maternal or foetal complications, side effects and spontaneous breech version occurred and in 74.6% of cases (n = 50) a vaginal delivery was performed. In 25.4% of cases (n = 17) a caesarean section was performed (15 breech presentation, 1 foetal distress in labour and 1 cervical dystocia). Among variables examined related to successful ECV, it has been observed that the amount of amniotic fluid (chi 2 = 15.33; p < 0.0000), the kind of tocolysis (chi 2 = 10.04; p < 0.007) and the umbilical cord rounds (chi 2 = 3.98; p < 0.045) were distributed in a significantly different way, whereas gestational age (p < 0.045) was significantly higher in unsuccessful ECV. CONCLUSIONS: The results obtained suggest that ECV may be a good therapeutic approach for decreasing the percentage of breech presentation at delivery.     

单胎臀位外倒转术的影响因素分析

目的探讨影响单胎臀位外倒转术成功率的相关因素。 方法对2015年11月至2016年4月就诊于广州医科大学附属第三医院妇产科进行外倒转术的20例单胎孕妇的临床资料进行回顾性分析,患者均为单胎妊娠,孕龄在35～38周之间,不合并绝对剖宫产指征,均愿接受行外倒转术。分析影响外倒转术成功率的相关因素,统计学采用χ²检验。 结果20例外倒转术有14例(70%)完成倒转,其中12例(60%)倒转成功并经阴道分娩。比较单臀位和复合臀位[7/9例与7/11例],初产妇及经产妇[5/8例与9/12例]、胎盘位于前壁、后壁和宫底[5/8例,6/8例与3/4例]、妊娠足月与否[4/6例与10/14例]、羊水量正常与否[12/17例与2/3例]、脐带绕颈与否[2/4例与12/16例]的外倒转成功率,差异无统计学意义(P>0.05)。胎儿窘迫、胎盘早剥和早产的发生率分别为10.0%(2/20)例、5.0%(1/20)例和2/14例。 结论外倒转术能较为安全有效将臀位转为头位,适用于足月或近足月妊娠,可达到降低剖宫产率的目的。     

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.     

Alternative methods instead of external cephalic version in the event of breech presentation. Review of the literature

Fetal breech presentation at term is more and more treated by a planned cesarean section. Considering the increased maternal morbidity and mortality in relation to abdominal delivery versus vaginal birth, natural and innocuous methods have been proposed for the promotion of a spontaneous fetal cephalic version during the last two Months of pregnancy. In order to stimulate fetal motility many techniques have been described, either advising postural methods (passive bridge, Indian version, knee-chest position) or using acupuncture (stimulation of the fifth toe and auricular points). Other techniques like chiropractic manipulations or hypnosis have also been tried. Unfortunately, most publications are retrospective and methodologically inaccurate, but it seems that their results may be favorably compared with that of the external cephalic version, a much more complex procedure, which is potentially dangerous and certainly time consuming and expensive. The only randomized controlled trial with a proven efficacy concerns moxibustion (burning herbs to stimulate the acupoint BL 67 or Zhiyin, located beside the outer corner of the fifth toenail).     

Cesarean delivery after successful external cephalic version of breech presentation at term: a comparative study

OBJECTIVE: The purpose of this study was to evaluate the rate and indications of cesarean delivery after a successful external cephalic version. STUDY DESIGN: A case-control study was performed from patients who were delivered in a tertiary care center between 1987 and 2000. Each patient who underwent a successful external cephalic version (study group) was compared with the next woman with the same parity, who was delivered at term (control group). Nulliparous and multiparous women were analyzed separately. Chi-squared, Mann-Whitney, and Student t tests were used for statistical analysis. Multivariate logistic regression analysis was performed where appropriate. RESULTS: A total of 602 patients were included in this study. The rates of cesarean delivery in nulliparous women (29.8% vs 15.9%; P<.001) and in multiparous women (15.9% vs 4.7%; P<.001) were significantly higher when compared with the control group. Patients with successful external cephalic version were more likely to have a cesarean delivery for dystocia (nulliparous, 22.5% vs 11.9%; P=.01; multiparous, 10.9% vs 1.3%; P<.01). After an adjustment for confounding variables, a successful external cephalic version was associated with an increased rate of cesarean delivery at term (nulliparous: odds ratio, 2.04; 95% CI, 1.13-3.68; multiparous: odds ratio, 4.30; 95% CI, 1.76-10.54). CONCLUSION: The rate of cesarean delivery for dystocia is increased after a successful trial of external cephalic version in both nulliparous and multiparous women.     

Management of term breech presentation: A protocl of external cephalic version and selective trial of labor

Objective: The results of a program of external version and selective trial of labor for term breech presentation are reviewed. This is a follow-up to our 1987 report describing management of singleton, term breech presentations and expands our 16-year experience to 1180 cases.Study design: All term breech presentations cared for in 1985 through 1992 are reviewed and outcome contrasted with those predicted in our earlier report. During these 8 years a trial of external version was offered if a breech presentation was identified after 36 completed weeks' gestation and before active labor. The criteria for allowing a trial of labor are detailed.Results: Four hundred sixty-four breech presentations were identified for review. Three hundred eighty-two (82%) were diagnosed before active labor. Of these, 344 (90%) underwent an attempt at external version, of which 174 (51%) were successful. The 290 breech presentations where version either was not attempted or was unsuccessful were stratified into three groups: cesarean section without labor (147), trial of labor with cesarean section (90), and trial of labor with vaginal delivery (53). The 174 cases where version was successful were stratified into two additional groups on the basis of the eventual route of delivery. Careful review of maternal and fetal variables indicates that a trial of labor in selected patients resulted in vaginal delivery in only 37% but was achieved without an increase in fetal or maternal mortality or morbidity. Surprisingly, 54 of the 174 cases where version was successful were ultimately delivered by cesarean section. This 31% rate of cesarean delivery is significantly higher than the 15% rate observed for all cases of term, singleton vertex presentation. A higher prevalence of cases complicated by failed progress in labor and failed induction contributed to the excess.Conclusion: External version is successful in 51% of cases of term breech presentation. With careful selection, cases where version has failed can be allowed to labor and be delivered vaginally. The incidence of cesarean section (31%) for those cases where a version had been successful was surprisingly high, largely because of an increase in labor abnomalities and failed labor inductions.     

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.     

An exploratory study of women's experiences and key stakeholders views of moxibustion for cephalic version in breech presentation

A phenomenological research approach was taken to explore women's feelings and experiences of using moxibustion for cephalic version in breech presentation. Eight women with an uncomplicated breech presentation at term were offered moxibustion. Qualitative interviews were carried out before and after the treatment and women completed daily logs of their experiences. Women experienced anxieties about the implications of breech presentation and the options offered to them. All women carried out the treatment successfully and overall experiences were positive. Compliance was excellent and women reported few negative effects. The partner's co-operation was important to ensure that the procedure was carried out effectively and safely. Key stakeholders were also interviewed to determine their views on the requirements of implementing moxibustion into the maternity services. The need for research evidence of effectiveness was a priority. In addition, a number of practical issues are suggested for consideration in the implementation of a service or in future research designs.     

External cephalic version for breech presentation at term: an effective procedure to reduce the caesarean section rate

AIM: Although term breech presentation is a relatively rare condition (3-5% of all births), it continues to be an important indication for caesarean section and has contributed to its increased use. Risk of complications may be increased for both mother and foetus in such a situation. Vaginal delivery of a breech presenting foetus is complex and may involve many difficulties, so today there is a general consensus that planned caesarean section is better than planned vaginal birth for the foetus in breech presentation at term. External cephalic version is one of the most effective procedures in modern obstetrics. It involves the external manipulation of the foetus from the breech into the cephalic presentation. A successful manoeuvre can decrease costs by avoiding operative deliveries and decreasing maternal morbidity. The aim of the present study is to evaluate the effectiveness of this obstetric manoeuvre to increase the proportion of vertex presentation among foetuses that were formerly in the breech position near term, so as to reduce the caesarean section rate. The safety of the version is also showed. METHODS: From 1999 to 2002, 89 women with foetal breech presentation underwent external cephalic version at the Department of Obstetrics and Gynaecology of the Brescia University. The gestational age was 36.8+/-0.8 weeks. The following variables have been taken into consideration: breech variety, placental location, foetal back position, parity, amount of amniotic fluid and gestational age. Every attempt was performed with a prior use of an intravenous drip of Ritodrine, and foetal heart rate was monitored continuously with cardiotocogram. RESULTS: The success rate of the procedure was 42.7% (n=38). No maternal or foetal complication or side effects occurred, both during and after the manoeuvre, except a transient foetal bradycardia that resolved spontaneously. Only one spontaneous reversion of the foetus occurred before delivery. Of all the women that underwent a successful version, 84.2% (n=32) had a non complicated vaginal delivery. Five women (15.8%) had a caesarean section. There was no significant interaction between the variables assessed. CONCLUSION: The external cephalic version is a safe and effective manoeuvre reducing the risks of vaginal breech delivery and the rate of caesarean section.