多学科联合对足月单胎臀位外倒转43例临床分析

目的:探讨多学科联合对足月单胎臀位外倒转术的可行性及安全性。方法:≥孕37周的43例单胎臀位孕妇,在多学科联合下由受过严格训练的施术者进行外倒转术。结果:43例孕妇外倒转成功35例(81.4%),8例失败;阴道分娩27例(62.8%),剖宫产16例(37.2%),无一例回复及出现严重母婴并发症。结论:在多学科联合下,对足月单胎臀位孕妇行外倒转术是安全、可行的。     

足月臀位外倒转术成功的相关因素分析

目的:探讨足月臀位外倒转术成功的相关因素。方法:以2014年4月至2017年4月在首都医科大学附属北京妇产医院定期产检的≥孕37周单胎臀位行外倒转术(均行椎管内麻醉)的孕妇149例为研究对象,按照倒转成功与否分为成功组和失败组,将相关因素(产妇年龄、产次、孕周、体质量指数、脐带长度、羊水指数、新生儿体质量、臀先露类型、绕颈与否、胎盘位置、是否使用宫缩抑制剂)行单因素分析和Logistic回归多因素分析。结果:149例行足月臀位外倒转术的孕妇中,成功59例,成功率39.60%。单因素分析结果提示:成功组(59例)与失败组(90例)脐带长度(54.00±5.92 cm vs 49.89±9.95 cm)和产次(初产妇与经产妇)差异有统计学意义(P0.05)。多因素分析结果提示:产次、宫缩抑制剂、脐带长度是足月臀位外倒转手术成功的影响因素(P0.05)。结论:多学科联合下进行足月臀位外倒转术是安全可行的,其成功的相关因素可能与产次、使用宫缩抑制剂和脐带长度有关。选择合适的病例,术前使用宫缩抑制剂,建议行椎管内麻醉,术中及术后加强观察和母儿监护,以达到安全分娩的目的。     

改良倒转术应用于单胎足月臀位妊娠28例

改良倒转术应用于单胎足月臀位妊娠２８例６７１０００云南省大理白族自治州人民医院李振燕，舒成欢１９９１年７月至１９９２年９月我们对单胎足月臀位，采取了垫臀配合改良倒转术纠正臀位，施术２９例，手术成功２０例，现小结如下。一、对象与方法（一）对象：１９９１...     

椎管内麻醉联合盐酸利托君对臀位外倒转术效果分析

目的探讨采取椎管内麻醉联合静脉推注盐酸利托君注射液应用于臀位外倒转术的效果及对母儿妊娠结局的影响。方法回顾性分析2015年1月至2020年12月在首都医科大学附属北京妇产医院行臀位外倒转术的孕37～40周单胎孕妇的临床资料,分为药物组(101例)和对照组(261例)。两组均在椎管内麻醉后超声监测下行外倒转术,药物组在麻醉后静脉推注盐酸利托君注射液后实施手术。结果 362例孕妇行臀位外倒转术,成功150例,总体外倒转术成功率41.4%,药物组成功率77.2%(78/101),高于对照妇(27.6%,72/261),差异有统计学意义(P0.05);总自然分娩率34.3%(124/362),其中药物组的自然分娩率55.4%(56/101),对照组26.4%(69/261),差异有统计学意义(P0.05)。两组产后出血率、新生儿窒息率比较,差异无统计学意义(P0.05)。结论采取椎管内麻醉联合静推盐酸利托君注射液应用于臀位外倒转术,可有效提高手术成功率,降低初次剖宫产率,提高阴道分娩率。     

臀位改良倒转术—附669例报告

对妊娠30－40周单胎臀位，具有倒转术适应证的669例孕妇，术前半－1小时，口服硫酸舒喘灵4．8mg，术中根据臀先露类型，先露部进入骨盆腔的深度，选用外倒转术或／和阴道－腹部双合倒转术矫正臀位，术后又采用综合措施防治臀位复变，手术成功率为96．71％，单胎臂位发生率，剖宫产率，臀位剖宫产率等质量指标，经统计学验证，较未行手术矫正前有显著降低，尚未发手术并发症。     

妊娠晚期臀位用宫缩抑制剂行外倒转术的讨论

在围产期,臀位的危险性很大。处理臀位是产科重要课题之一,轻易采用剖宫产亦非良策。历来减少臀位分娩的方法之一是在妊娠8～9个月之间行臀位外倒转术。为避免因外倒转引起的早产、早破水,胎盘早剥、脐带扭转等所致的胎死宫内,减少再复臀位率,1975年Saling等提出将施术时间放在孕37周后,并在胎心监护下进行妊娠晚期臀位外倒转术(late external cep halic version,简称lateEC V),认为是一种新的臀位处理法。作者的临床实施结果如下: 对象为1983年7月～1986年9月间妊娠36周以后的臀位22倒。其中单(伸腿)臀14例,混合臀位8例。     

足月臀位外倒转术成功的影响因素分析

目的探讨影响足月臀位外倒转术(ECV)成功的因素。方法收集2018年2月至2020年12月在复旦大学附属妇产科医院就诊的所有接受臀位ECV的孕妇为研究对象。根据手术是否成功,分为成功组及失败组,将相关因素进行单因素分析后,采用非条件logistic回归分析臀位ECV成功的影响因素。结果 134例足月孕妇行ECV,总成功率76.12%(102/134),成功后阴道分娩率75.49%(77/102);成功组与失败组之间单因素统计分析:生育史、胎盘位置、胎背方向、新生儿性别、术前麻醉情况差异具有统计学意义(P0.05)。多因素分析结果显示:生育史、胎盘位置是影响手术成功的因素(P0.05)。结论生育史、胎盘位置是ECV成功率的影响因素。臀位ECV操作可靠性及安全性高,并发症少。有意愿孕妇均可评估后尝试实施。     

对臀位外倒转术成功与否的预测

臀位外倒转术由于并发症发生率高,并且未能改善相对较高的自然回转率,其应用日见减少。至80年代,足月妊娠时臀位外倒转术的应用又得以恢复,其成功率为60％～70％,相应地减少了臀位产及因之而行的剖宫产数。 一些研究试图确定影响外倒转术成败的母儿因素,但大多数仅注重了某一因素的重要性,因而其研究结果常相互矛盾。作者通过回顾性分析,建立了一个预测外倒转术成功的评分系统,并对该系统进行了前瞻性检验。 资料来自南卡罗来那医科大学行外倒转术的108位单胎妊娠妇女。病人入院时行超声检查、NST及盆腔检查。确定胎位、羊水量,估计胎儿体重,以及发现明显的胎儿畸形和胎盘定位。胎盘位置分为:前壁、后壁、宫底及侧壁胎盘。NST     

晚期妊娠臀先露的自然回转

如何管理臀位孕妇及应否施外倒转术至今仍有争论。自然回转为头位的可能性以及何时应施行外倒转术尚未系统研究。本文拟研究妊娠末三月臀位自发回转为头位的总数,发生时间并评价有关因素。收集1982年7月至1983年10月孕32周以后妊娠经超声检查4,690例中有310例(6.7%)为单胎臀位,以后每周触诊复查胎位不明确时再次超声检查,直至分娩。孕妇分成两组:持续性臀位(PB)组133例(43%),自发回转为头位(SCV)组177例(57%)。孕32周超声检查显示两组胎双顶径、腹径、股骨长径、胎儿大小及胎盘位置均无差别;两组胎姿态不同。屈膝者 SCV 组(52%)比 PB 组(20%)多(P<0.001)。PB 组80%胎儿为伸腿。PB 组比 SCV 组更早发生早产(P<0.001)。PB 组胎儿体重,身长和脐带长度值均较小。如按分娩时     

对臀位外倒转术的评价

关于臀位的处理.无论是产前需否协助纠正胎位,或者采取何种分娩方式,至今仍是一个有争论的问题。关于产前需否做外倒转术,亦即究竟外倒转能否降低臀位分娩率,文献所述意见不一。这里涉及单胎臀位妊娠有多少在孕末期可自然回转成头位。     

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.     

What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.     

External cephalic version: a clinical experience

Eighty-five normal women underwent external cephalic version (ECV) for breech presentation in the late 3rd trimester. The protocol included real time ultrasonic scanning and pre- and post-procedure electronic fetal monitoring. Subcutaneous terbutaline sulfate (0.25 mg.) was administered to (43/85 or 50.5%) of ECV candidates and rendered the procedure easier for patient and operator. A single operator, head-over-heels technique assisted by supine Trendelenberg's position was used. Rh negative women were routinely administered 300 mcg of immune globulin. Successful ECV (53/85, 62.5%) was related to maternal parity, but not to gestational age nor eventual delivery weight. In this series only engagement of the breech was reliable in predicting ECV failure. Fifty of 51 (98.1%) successfully verted women delivered a cephalic presentation infant at term. Cesarean section was performed in 5/51 of these patients (9.8%) for routine obstetrical indications. In one case, compound presentation at term resulting in dystocia and eventual cesarean section was believed related to prior successful version. In contrast, 15/30 (50%) of the ECV failure patients went on to operative delivery despite a liberal institutional policy toward term vaginal breech trials. In addition, the only serious fetal complication in this series, meconium aspiration, occurred in a vaginally delivered breech infant. It is unlikely that late 3rd trimester ECV will impact on out overall rate of cesarean delivery. In North America prematurity is the greatest risk factor in malpresentation and our policy increasingly is to permit attempts at term breech vaginal delivery. Nonetheless, ECV deserves serious consideration. When successful, ECV avoids the costs and/or risks of either cesarean section or vaginal trial of breech.(ABSTRACT TRUNCATED AT 250 WORDS)     

External cephalic version beginning at 34 weeks' gestation versus 37 weeks' gestation: a randomized multicenter trial

OBJECTIVE: In about 3% to 4% of all pregnancies at term, the fetal presentation will be noncephalic. External cephalic version (ECV) at term has been shown to decrease the rate of noncephalic presentation at birth and to decrease the rate of cesarean section associated with breech presentation. However, success rates for ECV are low. We did a randomized trial to compare a policy of beginning ECV early, at between 34 and 36 weeks' gestation, and beginning ECV at 37 to 38 weeks' gestation. STUDY DESIGN: At 25 centers in seven countries, 233 women with a singleton breech fetus were randomly assigned to having an ECV procedure done early (at between 34 weeks 0 days and 36 weeks 0 days), or delayed (at between 37 weeks 0 days and 38 weeks 0 days). An experienced practitioner undertook the ECV procedure, and repeat ECV procedures were allowed. Tocolytics and use of epidural analgesia were included as part of the protocol. The primary outcome was the rate of noncephalic presentation at birth. An intention-to-treat analysis was used. RESULTS: Data were received for 232 women, with 116 women in each of the early and delayed ECV groups. Of these, 86.2% in the early ECV group and 67.2% in the delayed ECV group had at least one ECV performed. The rate of noncephalic presentation at birth in the early ECV group was 66 of 116 (56.9%) and 77 of 116 (66.4%) in the delayed ECV group (relative risk [RR] [95% CI] 0.86 [0.70-1.05], P =.09). The rate of serious fetal complications and the rate of preterm birth at <37 weeks were not significantly increased in the early ECV group compared with the delayed ECV group (6.9% vs 7.8%, RR [95% CI] 0.89 [0.36-2.22], P =.69 and 8.6% vs 6.1%, RR [95% CI] 1.42 [0.56-3.59], P =.31, respectively). The rate of cesarean section in the early ECV group was 75 of 116 (64.7%) and 83 of 116 (71.6%) in the delayed ECV group (RR [95% CI] 0.90 [0.76-1.08], P =.32). Neonatal outcomes were comparable in the two groups. The rate of reversion to noncephalic was low in both groups. The majority of women in both groups indicated that they would consider having an ECV in another pregnancy. CONCLUSION: Early ECV performed at 34 to 36 weeks compared with 37 to 38 weeks may reduce the risk of noncephalic presentation at delivery. A large pragmatic trial of early ECV is now required to assess this approach further in terms of cesarean section rates and neonatal outcomes before changes in clinical practice.     

Changing attitudes toward mode of delivery and external cephalic version in breech presentations.

OBJECTIVES: To compare the attitude of gravid women in breech presentation towards external cephalic version (ECV) and mode of delivery between 1995 and 2001. METHODS: A questionnaire on ECV and mode of delivery was distributed to women in the third trimester of pregnancy with breech presentation, attending our departmental clinic for a routine check-up once in 1995 and again in 2001 in order to analyze changing attitudes. RESULTS: One hundred fifty-four women completed the questionnaire in 1995 and 127 in 2001. There were no statistically significant differences between the groups in age, gestational age, gravidity, parity, or level of education. In 1995, more than half the women (52.7%) had heard of ECV and 53.8% were willing to consider it, whereas in 2001, 73.2% had heard of it but only 23.9% were willing to consider it. In both groups, the women who were familiar with ECV were more likely to work outside of the home, have a higher level of educated than the women who were not. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. The percentage of women who would choose planned cesarean section if the presentation remained breech was significantly higher in 2001 (97%) than in 1995 (64.7%). CONCLUSIONS: Attitudes toward breech delivery have changed since 1995. More women are aware of the option of ECV but are less inclined to consider it. Planned cesarean section for breech presentation is the overwhelming choice of women in general, with a significant increase in 2001 compared with 1995.     

Significance of success rate of external cephalic versions and vaginal breech deliveries in counseling women with breech presentation at term

OBJECTIVE: To appreciate the role of success rates of external cephalic versions and breech deliveries, in order to assess the risk reduction in women with breech presentation at term. STUDY DESIGN: We reviewed the patient files of all women with breech presentation whom had an attempt of external cephalic version (ECV) at term. Most of the ECVs were performed under intravenous ritodrine infusion. All women had a trial of labor (TOL) as long as they did not meet one or more of the exclusion criteria of vaginal delivery. Success rates of ECV and TOL were assessed, and statistical analysis was performed by using the student t-test for continuous data, and the Chi-square and Fisher's exact tests for categorical data. Statistically significant differences required a P value of <0.05. RESULTS: Of all women with breech presentation at term and not in labor, who had no contraindication for an ECV, 164 consented and were included in the study. The success rate of ECV was 30% (22/74) and 67% (60/90) for nulliparae and multiparae, respectively. Multiparity was the only significant positive predicting variable for ECV success (OR=4.73, 95% CI 4.19-5.27, P=0.00001). Of all the women that underwent a successful ECV, 18/22 primiparae (82%), and 52/60 multiparae (87%) had a vaginal delivery, compared to only 52% of the primiparae and 63% of the multiparae that reached labor with a breech presentation. There were no significant perinatal complications except for one case of mild placental abruption. In the primiparous women, ECV decreased the chance of cesarean delivery by only 9% (P=0.2), compared to a 16% decrease in the multiparae (P=0.019). CONCLUSIONS: When counseling women with breech presentation at term, complete information is needed for consent, and should take into account the success rate of ECVs and of vaginal breech deliveries in the specific center.     

Vaginal delivery for the selected frank breech infant at term

A retrospective analysis of 254 term breech deliveries was done, with term breech presentations managed by a protocol in which cesarean section was done for nonfrank breech presentation, or estimated fetal weight in excess of 4000 g. Patients with frank breech presentation were assigned to one of three groups based on x-ray pelvimetry and estimated fetal weight. Of 70 group 1 patients (adequate pelvis with estimated fetal weight less than 3600 g), 79% had a vaginal delivery. Of 21 group 2 patients (borderline pelvis or estimated fetal weight of 3600 to 4000 g), 67% delivered vaginally. In group 3 (contracted pelvis or estimated fetal weight greater than 4000 g), all patients were delivered by cesarean section. The overall cesarean section rate for frank breech infants was 36%. Apgar scores were not significantly different for infants delivered vaginally or abdominally. The crude perinatal mortality rate was 11.8; the corrected perinatal mortality rate was 0. These findings further substantiate the safety of these criteria in management of term breech presentations.     

Safety of term vaginal breech delivery

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.     

External cephalic version (ECV): experience in a sub-Saharan African hospital.

External cephalic version (ECV) is not a popular procedure in developing countries such as Nigeria. Over a 3-year period, we prospectively studied women who had ECV in a Nigerian University Teaching hospital. Comparative analysis was made between the successful ECV and the unsuccessful ECV groups. Following adequate counselling, Nigerian women were willing to accept an ECV for the singleton term breech. The ECV success rate was 67%. Favourable factors for success were multiparity (Relative Risk, RR 3.8; 95% confidence interval, CI 1.14 - 12.1), flexed breech (RR 2.4; 95% CI 1.02 - 5.7), unengaged breech (RR 4.8; 95% CI 1.3 - 17.2), normal liquor volume (RR 4.8; 95% CI 1.3 - 17.1) and a posterior placenta (RR 6.8; 95% CI 2.8 - 16). Once turned, 97% of the babies remained cephalic until delivery. The caesarean section rate in each group was higher than the unit rate of 12.7%. There was one fetal death from cord prolapse in the vaginal breech delivery group.     

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.