Maternal and Neonatal Outcomes after Attempted External Cephalic Version among Women with One Previous Cesarean Delivery

External cephalic version following prior cesarean delivery: A comparative cohort analysis

OBJECTIVE

To analyze the success rate of external cephalic version (ECV) in pregnant women with a history of previous cesarean section, as well as to describe the rate of complications associated with the procedure.

METHODS

A retrospective cohort study of women who were offered an ECV at "Virgen de la Arrixaca" Clinic University Hospital (Murcia, Spain) between January 2014 and December 2023. We collected data for previous cesarean delivery, obstetric history, fetal presentation, amniotic fluid volume, ECV success rate, complications related to ECV, mode of delivery, and neonatal outcomes. The study confidently performed ECV under sedation with propofol and tocolysis with ritodrine. Univariate and multivariate analyses were conducted to compare the success rate of ECV, ECV complications, and mode of delivery between women with and without previous cesarean sections.

RESULTS

Of 1116 pregnant women who were offered ECV, 911 were included in the study, with 42 having a previous cesarean section. The success rate of ECV in pregnant women with a previous cesarean section was 78.6% (adjusted odds ratio 1.18; 95% confidence interval 0.49-2.86; P = 0.708), with a low complication rate of 9.5%, such as non-reassuring fetal heart rate (7.1%) or major vaginal bleeding (2.4%). Of the women who attempted a vaginal delivery after ECV, 80.8% were successful.

CONCLUSIONS

These findings support that ECV is a safe and effective option for women with a previous cesarean section, with success rates comparable to those in women without a previous cesarean section.

Trial of labor after cesarean, vaginal birth after cesarean, and the risk of uterine rupture: an expert review

The decision to pursue a trial of labor after cesarean delivery is complex and depends on patient preference, the likelihood of successful vaginal birth after cesarean delivery, assessment of the risks vs benefits of trial of labor after cesarean delivery, and available resources to support safe trial of labor after cesarean delivery at the planned birthing center. The most feared complication of trial of labor after cesarean delivery is uterine rupture, which can have catastrophic consequences, including substantial maternal and perinatal morbidity and mortality. Although the absolute risk of uterine rupture is low, several clinical, historical, obstetrical, and intrapartum factors have been associated with increased risk. It is therefore critical for clinicians managing patients during trial of labor after cesarean delivery to be aware of these risk factors to appropriately select candidates for trial of labor after cesarean delivery and maximize the safety and benefits while minimizing the risks. Caution is advised when considering labor augmentation and induction in patients with a previous cesarean delivery. With established hospital safety protocols that dictate close maternal and fetal monitoring, avoidance of prostaglandins, and careful titration of oxytocin infusion when induction agents are needed, spontaneous and induced trial of labor after cesarean delivery are safe and should be offered to most patients with 1 previous low transverse, low vertical, or unknown uterine incision after appropriate evaluation, counseling, planning, and shared decision-making. Future research should focus on clarifying true risk factors and identifying the optimal approach to intrapartum and induction management, tools for antenatal prediction, and strategies for prevention of uterine rupture during trial of labor after cesarean delivery. A better understanding will facilitate patient counseling, support efforts to improve trial of labor after cesarean delivery and vaginal birth after cesarean delivery rates, and reduce the morbidity and mortality associated with uterine rupture during trial of labor after cesarean delivery.

Safety and efficacy of external cephalic version after a previous caesarean delivery: A systematic review

BACKGROUND

External cephalic version (ECV) is a common procedure and has been shown to be safe and effective in turning a baby from a breech to cephalic presentation. However, whether ECV is safe and effective in women with a scarred uterus from a previous caesarean section remains contentious.

AIM

To evaluate the safety and efficacy of external cephalic version in women with a singleton breech pregnancy and at least one previous caesarean delivery.

MATERIAL AND METHODS

Literature searches were conducted on MEDLINE, PUBMED, EMBASE, CINAHL and SCOPUS up to June 2020. The search strategy included the following keywords: ('external cephalic version OR ECV') AND ('previous OR prior OR past' AND 'caesarean OR caesarean OR uterine scar'). Studies were included if they evaluated the efficacy and/or safety of external cephalic version in women after 36 weeks' gestation with a singleton breech pregnancy and at least one previous caesarean delivery.

RESULTS

Nine studies were included in the review. ECV success rates and subsequent vaginal delivery rates ranged from 50 to 100% and from 50 to 74.9%, respectively. ECV complications reported included abnormal fetal heart rate, abnormal cardiotocography and transient vaginal bleeding. No studies reported cases of uterine rupture.

CONCLUSIONS

ECV in women with a previous caesarean delivery is a relatively successful and low-risk procedure compared to women without a previous caesarean delivery. The results from this systematic review provide useful information for professional bodies in updating clinical guidelines such that ECV may be offered to women with one previous caesarean delivery.

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.

External Cephalic Version: ACOG Practice Bulletin, Number 221

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Correlation of Obesity with External Cephalic Version Success among Women with One Previous Cesarean Delivery

Objective  Our aim was to assess the correlation of body mass index (BMI) with the success rate of external cephalic version (ECV) among women with one prior cesarean delivery. Study Design  A cross-sectional study of pregnant women with one previous cesarean delivery who underwent ECV. The relationship between BMI and success rate of ECV was assessed. Adverse outcomes were also compared between women with an ECV attempt, and women who had a repeat cesarean delivery. Data were extracted from the U.S. Natality Database from 2014 to 2017. Pearson's correlation coefficient was performed to assess the relationship between BMI and success rate of ECV. Results  There were 2,329 women with prior cesarean delivery underwent an ECV attempt. The success rate of ECV among the entire cohort was 68.3%. There was no correlation between BMI and success rate of ECV ( r  = 0.024, p  = 0.239). Risks of adverse maternal and neonatal outcomes were similar between the ECV attempt group and the repeat cesarean delivery group. Conclusion  There was no correlation of BMI with the rate of successful ECV among women with one prior cesarean delivery. Given the similar success rates of ECV and adverse outcomes, obese women with one prior cesarean delivery should be offered ECV.