Current Approach for External Cephalic Version in Germany

Neonatal Outcome following External Cephalic Version (ECV)-Comparison between Vaginal Birth after Successful ECV and Elective Caesarean Section after Unsuccessful ECV

Introduction: In 3-6% of pregnancies, foetuses can be expected to be in a breech presentation near term. Consultation concerning further management of the pregnancy, including the option of an external cephalic version (ECV), is recommended by international guidelines (RCOG, ACOG, and DGGG). With regards to an ECV, there need to be two assumptions. Firstly, the procedure is safe, which has been shown adequately. Secondly, a vaginal birth after a successful ECV needs to prove to be non-inferior to the alternative of an elective caesarean section. The aim of this study is to assess the non-inferiority assumption. Methods: Overall, 142 singleton pregnancies were analysed that presented a foetus in a non-cephalic presentation and underwent an ECV near term between 2011 and 2020. The ECV was performed at 36 weeks of gestation for primiparous women and at 37/38 weeks of gestation for multiparous women. To assess neonatal outcome, the following parameters were recorded: arterial and venous umbilical cord blood pH, APGAR scores and admission to the neonatal intensive care unit (NICU). Data were analysed under the assumption that neonatal outcome does not differ between elective caesarean sections with or without an ECV in advance. Results: The success rate of an ECV was 56.3% (80/142). In the case of a successful ECV, there was a 77.5% (62/80) chance for a vaginal delivery. The mean arterial pH for neonates born vaginally after successful ECV was 7.262 (SD 0.089), compared to 7.316 (SD 0.051) for those born via elective caesarean section (p < 0.001). APGAR scores at 1, 5, and 10 min were similar between the groups, with a slightly higher proportion of neonates scoring below the median in the caesarean section group. Specifically, 13.7% (7/51) at 1 min, 15.7% (8/51) at 5 min, and 9.8% (5/51) at 10 min in the caesarean section group were below the median, compared to 4.92% (3/61), 4.92% (3/61), and 3.28% (2/61) in the vaginal birth group. NICU admission rates were 3.28% for vaginal births and 3.92% for elective caesarean sections (p > 0.05). Conclusions: Women with a successful ECV can expect a neonatal birth outcome after a vaginal birth that is non-inferior to an alternative elective caesarean section.

External Cephalic Version-A Chance for Vaginal Delivery at Breech Presentation

Background and Objectives: In recent years, the rate of caesarean section (CS) has increased constantly. Although vaginal breech delivery has a long history, breech presentation has become the third most common indication for CS. This study aims to identify factors associated with the success of external cephalic version (ECV), underline the success rate of ECV for breech presentation and highlight the high rate of vaginal delivery after successful ECV. Material and Methods: This retrospective observational study included 113 patients with singleton fetuses in breech presentation, who underwent ECV from January 2016 to March 2021 in the Clinic of Obstetrics and Gynecology, Diakonieklinikum Schwäbisch Hall, Germany. Maternal and fetal parameters and data related to procedure and delivery were collected. Possible predictors of successful ECV were evaluated. Results: The success rate of ECV was 54.9%. The overall rate of vaginal birth was 44.2%, regardless of ECV outcome. The vaginal birth rate after successful ECV was 80.6%. Overall, 79.0% of women with successful ECV delivered spontaneously without complications, 19.4% delivered through CS performed during labor by medical necessity, and 1.6% delivered through vacuum extraction. ECV was performed successfully in three of the four women with history of CS. Gravidity, parity, maternal age, gestational age, fetal weight, and amniotic fluid index (AFI) were significantly correlated with the outcome of ECV. Conclusions: ECV for breech presentation is a safe procedure with a good success rate, thus increasing the proportion of vaginal births. Maternal and fetal parameters can be used to estimate the chances of successful ECV.

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 at 38 weeks' gestation at a specialized German single center

Introduction

Cesarean section (CS) rates are increasing worldwide. One constant indication is the breech presentation at term. By offering external cephalic version (ECV) and vaginal breech delivery CS rates can be further reduced.

Objective

This study aimed to analyze the ECV at 38 weeks of gestation with the associate uptake rate, predicting factors, success rate, and complications at a tertiary healthcare provider in Germany specializing in vaginal breech delivery.

Methods

We conducted a prospective cohort study with retrospective data acquisition. All women with a singleton fetus in breech presentation presenting after 34 weeks of gestation for counseling between 2013 and 2017 were included. ECV impact factors were analyzed using logistic regression.

Results

A total of 1,598 women presented for breech birth planning. ECV was performed on 353 patients. The overall success rate was 22.4%. A later week of gestation (odds ratio [OR] 1.69), an abundant amniotic fluid index (AFI score) (OR 5.74), fundal (OR 3.78) and anterior (OR 0.39) placental location, and an oblique lie (OR 9.08) were significantly associated with successful ECV in our population. No major complications were observed. The overall vaginal delivery rates could be increased to approximately 14% with ECV.

Conclusion

The demand for alternative birth modes other than CS for breech birth is high in the area of Frankfurt, Germany. Our study offers evidence of the safety of ECV at 38 weeks. Centers with expertise in vaginal breech delivery and ECV can reduce CS-rates. To further establish vaginal breech delivery and ECV as alternate options, the required knowledge and skill should be implemented in the revised curricula.