Prevalence, outcome, and women's experiences of external cephalic version in a low-risk population

A prospective study using an individualized nomogram to predict the success rate of external cephalic version

To establish a clinical-based nomogram for predicting the success rate of external cephalic version (ECV) through a prospective study. This was a single-center prospective study that collected eligible breech pregnant women. 152 participants were enrolled in the training cohort, who received ECV procedures performed by a single operator. We used the training cohort to establish regression equations and prediction models. These variables include maternal factors (age, operation gestational age, pre-pregnancy BMI (Body Mass Index), operation BMI, BMI increase, multipara), ultrasound factors (fetal weight estimation, amniotic fluid index, placental location, type of breech presentation, spinal position), and anesthesia. Univariate and multivariable analyses were used to screen the factors affecting the success of ECV. A nomogram scoring model was established based on these factors. And C-index, DCA (Decision Curve Analysis) and calibration curve, Hosmer-Lemeshow test was used to verify the prediction effect of the model. Finally, 33 participants were enrolled in the testing cohort who received ECV with an unrestricted operator. We used C-index, DCA (decision curve analysis), and Hosmer-Lemeshow to verify the application value of the prediction model. The calibration curves and ROC curves of both the training cohort and testing cohort are plotted for internal and external validation of the model. The ECV success rate of the training cohort was 62.5%. Univariate analysis showed that the predictors related to the success rate of ECV were age, BMI increase value, AFI (amniotic fluid index), breech type, placental location, spinal position, anesthesia, and multipara. The prediction thresholds of the corresponding indexes were calculated according to the Youden index. Multivariate logistic regression analysis showed that BMI increase ≥ 3.85 kg/m2, AFI ≥ 10.6 cm, anesthesia, multipara, and non-anterior placenta were independent predictors of ECV success. Through the internal and external validation, it is confirmed that the model has a good calibration and prediction ability. Our nomogram has a good ability to predict the success rate of ECV.

Success rate of external cephalic version in relation to the woman's body mass index and other factors-a population-based cohort study

INTRODUCTION

The aim of this study was to evaluate the impact of women's body mass index (BMI) on the probability of a successful external cephalic version (ECV).

MATERIAL AND METHODS

A retrospective population-based observational study including all women that underwent an ECV in the southeast region of Sweden from January 2014 to December 2019. Data were collected from electronic medical records, Obstetrix, Cerner. The women were divided into BMI categories according to the World Health Organization classification. Women with a BMI below 25 kg/m² formed the reference group. Crude and adjusted odds ratios for unsuccessful ECV in each BMI group were calculated using binary logistic regression. Furthermore, the association between maternal characteristics and clinical and ultrasound variables at the time of the ECV and unsuccessful ECV was evaluated.

RESULTS

A total of 2331 women were included. The overall success rate of ECV was 53.4%. Women with a BMI below 25 kg/m² had a success rate of 51.3% whereas obese women had a success rate of 58.6%. The risk of an unsuccessful ECV among obese women (BMI ≥30 kg/m² ) had an OR of 0.74 (95% CI 0.59-0.94) compared with women with a BMI below 25 kg/m² . After adjusting for suitable confounding factors, the association was no longer significant. Higher maternal age, multiparity, higher gestational age, posterior placenta position, polyhydramnios and higher estimated weight of the fetus at the ECV significantly decreased the risk of an unsuccessful ECV.

CONCLUSIONS

Maternal obesity does not seem to negatively influence the success rate of ECV. This is a finding that may encourage both caregivers and obese pregnant women to consider an ECV and so avoid a planned cesarean section for breech presentation in this group.

Patient opinion of analgesia during external cephalic version at term in singleton pregnancy

To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it.

External cephalic version at term: a cohort study of 18 years' experience

OBJECTIVE

To analyse the outcome of referrals for external cephalic version (ECV).

DESIGN

Retrospective cohort study of prospectively collected data.

SETTING

Major university hospital, UK.

SAMPLE

Women with non-cephalic presentation at term and no prior caesarean, referred to a specialist clinic.

METHODS

Details of referrals, ECV attempts, and perinatal outcomes were prospectively collected and analysed. Multivariate binary logistic regression models were created to determine independent predictors of ECV success, reversion, and spontaneous version.

MAIN OUTCOME MEASURES

External cephalic version success rates, predictors of success and cephalic presentation at birth, and perinatal outcomes.

RESULTS

Three thousand eight had confirmed breech presentation; 2614 women underwent ECV. Ineligibility for ECV occurred in 117 breech presentations (3.9%), and 297 eligible women (10.2%) declined it. ECV was successful in 1280 (49.0%, 95% CI 47.0-50.9%) (40% in nulliparous women; 64% in others); 1234 (97.3%) were cephalic at birth. Spontaneous version after failure occurred in 4.3% and was more common in multiparas (aOR 2.47, 95% CI 1.43-4.26) and those with a posterior fetal back (aOR 6.09, 95% CI 1.90-19.53). Reversion after successful ECV occurred in 2.2%. In women with a successful ECV whose fetus remained cephalic at birth, 85.7% delivered vaginally. The corrected perinatal mortality of the ECV cohort was 0.12%.

CONCLUSION

External cephalic version has a low complication rate and is effective for most breech presentations, enabling vaginal birth and avoiding caesarean section.

TWEETABLE ABSTRACT

External cephalic version can safely be performed with most breech presentations.

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

Objective  This study was aimed to evaluate success rates of (1) external cephalic version (ECV) among women with one prior cesarean delivery (CD) and (2) maternal and neonatal outcomes after ECV among women with prior CD. Study Design  Two linked studies using U.S. Natality Database were performed. First we performed a retrospective cohort comparing ECV success rates of women with prior CD and women without prior CD. Then we compared the outcomes of TOLACs (trial of labor after cesarean delivery) that occurred after ECV with those that occurred without ECV. Multivariable logistic regression analysis was used to estimate adverse outcomes. Results  A total of 715 women had ECV after 36 weeks with prior CD and 9,976 had ECV without prior scar. ECV success rate with scar was 80.6% and without scar was 86.4% ( p  < 0.001). Seven hundred and sixteen women underwent TOLAC after ECV attempt and 234,617 underwent TOLAC without a preceding attempt. Women with preceding version had increased risks of maternal transfusion (1 vs. 0.4%, adjusted OR [odds ratio]: 2.48 [95% CI (confidence interval): 1.17-5.23]), unplanned hysterectomy (0.4 vs. 0.06%, adjusted OR: 6.90 [95% CI: 2.19-21.78]), and low 5-minute Apgar's score (2.5 vs. 1.5%, adjusted OR: 1.76 [95% CI: 1.10-2.82]). Conclusion  Women with prior CD may have a decrease in the rate of successful ECV. While the absolute risks are low, ECV appears to increase risks of adverse maternal and neonatal outcomes among women undergoing a trial of labor.

Fetal heart rate abnormalities during and after external cephalic version: Which fetuses are at risk and how are they delivered?

BACKGROUND

Fetal heart rate abnormalities (FHR) during and after external cephalic version (ECV) are relatively frequent. They may raise concern about fetal wellbeing. Only occasionally they may lead to an emergency cesarean section.

METHODS

Prospective cohort study in 980 women (> 34 weeks gestation) with a singleton fetus in breech presentation. During and after external cephalic version (ECV) FHR abnormalities were recorded. Obstetric variables and delivery outcome were evaluated. Primary outcome was to identify which fetuses are at risk for FHR abnormalities. Secondary outcome was to identify a possible relationship between FHR abnormalities during and after ECV and mode of delivery and fetal distress during subsequent labor.

RESULTS

The overall success rate of ECV was 60% and in 9% of the attempts there was an abnormal FHR pattern. In two cases FHR abnormalities after ECV led to an emergency CS. Estimated fetal weight per 100 g (OR 0.90, CI: 0.87-0.94) and longer duration of the ECV-procedure (OR 1.13, CI: 1.05-1.21) were factors significantly associated with the occurrence of FHR abnormalities. FHR abnormalities were not associated with the mode of delivery or the occurrence of fetal distress during subsequent labor.

CONCLUSIONS

FHR abnormalities during and after ECV are more frequent with lower estimated fetal weight and longer duration of the procedure. FHR abnormalities during and after ECV have no consequences for subsequent mode of delivery. They do not predict whether fetal distress will occur during labor.

TRIAL REGISTRATION

The Eindhoven Breech Intervention Study, NCT00516555 . Date of registration: August 13, 2007.

This baby is not for turning: Women's experiences of attempted external cephalic version

BACKGROUND

Existing studies regarding women's experiences surrounding an External Cephalic Version (ECV) report on women who have a persistent breech post ECV and give birth by caesarean section, or on women who had successful ECVs and plan for a vaginal birth. There is a paucity of understanding about the experience of women who attempt an ECV then plan a vaginal breech birth when their baby remains breech. The aim of this study was to examine women's experience of an ECV which resulted in a persistent breech presentation.

METHODS

A qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically.

RESULTS

Twenty two (n = 22) women who attempted an ECV and subsequently planned a vaginal breech birth participated. Twelve women had a vaginal breech birth (55 %) and 10 (45 %) gave birth by caesarean section. In relation to the ECV, there were five main themes identified: 'seeking an alternative', 'needing information', 'recounting the ECV experience', 'reacting to the unsuccessful ECV' and, 'reflecting on the value of an ECV'.

CONCLUSIONS

ECV should form part of a range of options provided to women, rather than a default procedure for management of the term breech. For motivated women who fit the safe criteria for vaginal breech birth, not being subjected to a painful experience (ECV) may be optimal. Women should be supported to access services that support vaginal breech birth if this is their choice, and continuity of care should be standard practice.

The Impact of an ECV Service is Limited by Antenatal Breech Detection: A Retrospective Cohort Study

BACKGROUND

External cephalic version (ECV) reduces the chance of breech presentation at term birth and lowers the chance of a cesarean delivery. ECV services are now in place in many units in the United Kingdom but their effectiveness is unknown. The aim of this study was to investigate the reasons for breech presentation at term birth.

METHODS

We performed a retrospective cohort study of 394 consecutive babies who were in breech presentation at term birth in a large United Kingdom maternity unit that offers ECV. The cohort was analyzed over two time periods 10 years apart: 1998-1999 and 2008-2009.

RESULTS

Only 33.8 percent of women had undergone a (failed) ECV attempt. This low proportion was mainly because breech presentation was not diagnosed antenatally (27.9%). Other contributing factors were: ECV not offered by clinicians (12.2%), ECV declined by women (14%), and contraindications to ECV (10.7%). Over the 10-year period, the proportion of breech presentations that were not diagnosed antenatally increased from 23.2 to 32.5 percent (p = 0.04), which constituted 52.8 percent of women who had not undergone an ECV attempt in 2008-2009. Failure of clinicians to offer ECV reduced from 21.6 to 3.0 percent (p = 0.0001) and the proportion of women declining ECV decreased from 19.1 to 9.0 percent (p = 0.005). Overall, ECV attempts increased from 28.9 to 38.5 percent (p = 0.05).

CONCLUSIONS

Although ECV counseling, referral, and attempt rates have increased, failure to detect breech presentation antenatally is the principal barrier to successful ECV. Improved breech detection would have a greater impact than methods to increase ECV success rates.

Implementation of external cephalic version in the Netherlands: a retrospective cohort study

BACKGROUND

External cephalic version (ECV) reduces the rate of elective cesarean sections as a result of breech presentation. Several studies have shown that not all eligible women undergo an ECV attempt. The aim of this study was to evaluate the implementation of ECV in the Netherlands and to explain variation in implementation rates with hospital characteristics and individual factors.

METHODS

We invited 40 hospitals to participate in this retrospective cohort study. We reviewed hospital charts for all singleton breech deliveries from 36 weeks' gestation and onwards between January 2008 and December 2009. We documented whether an ECV attempt was performed, reasons for not performing an attempt, mode of delivery, and hospital characteristics.

RESULTS

We included 4,770 women from 36 hospitals. ECV was performed in 2,443 women (62.2% of eligible women, range 8.2-83.6% in different hospitals). Implementation rates were higher in teaching hospitals, hospitals with special office hours for ECV, larger obstetric units, and hospitals located in larger cities. Suboptimal implementation was mainly caused by health care providers who did not offer ECV.

CONCLUSION

ECV implementation rates vary widely among hospitals. Suboptimal implementation is mostly caused by the care provider not offering the treatment and secondly due to women not opting for the offered attempt. A prerequisite for designing a proper implementation strategy is a detailed understanding of the exact reasons for not offering and not opting for ECV.

Determinants of pain perception after external cephalic version in pregnant women

OBJECTIVE

A considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV.

DESIGN

Prospective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt.

SETTING

Department of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands.

METHODS

Prior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV.

FINDINGS

Multivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors.

CONCLUSION

Apart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt.

IMPLICATION FOR PRACTICE

Maternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.

[External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention]

OBJECTIVES

To evaluate the efficacy and acceptability of external cephalic version (ECV).

MATERIALS AND METHOD

From 2004 to 2008, 212 pregnant women between 34-37 weeks of gestation with fetus in breech presentation were included in a randomized clinical trial and 125 externals cephalic versions were studied.

RESULTS

A success rate of 37.6%t was recorded. At 34 weeks of gestation, 80.6% of women were considering an ECV in the event of persistent breech position at 37 weeks. These women expressed the desire to give birth vaginally (52% versus 24.4%, P<0.001). In contrast, others women preferred an elective cesarean section to avoid the risk of a breech vaginal delivery. Women felt pain during the ECV and scored 60 on average using the analogical visual scale. Women rated on a verbal rating scale the ECV as severely painful to unbearable (68%), and as stressful (70%). Despite this, the majority of women would recommend ECV to their friends or would be willing to repeat it for themselves.

DISCUSSION AND CONCLUSION

ECV remains a scary and painful medical procedure. More research is needed to reduce the impact. The use of analgesic medication for this indication is controversial. Hypnosis could be an alternative to evaluate.

Patient's willingness to opt for external cephalic version

OBJECTIVE

External cephalic version (ECV) is a relatively simple and safe maneuver that reduces the cesarean section (CS) rate for breech presentation. There is professional consensus that ECV should be offered to all women, but only up to 70% of patients opt for this treatment. To improve counseling, we investigated the value patients place on various aspects of ECV.

METHODS

We studied patient preferences by means of a vignette study. Varying levels of treatment characteristics were investigated in 16 scenarios, all including the "opt out" alternative of an elective CS. The probability that women preferred ECV was estimated using a logistic regression approach.

RESULTS

Forty seven women participated in the study. Pain was the most important factor negatively influencing the willingness to opt for ECV (OR 0.11 (95% confidence interval (CI) 0.05-0.23) for a pain score of 8-10 compared to 1-2 on a visual analog scale of 0-10). Higher success rates of vaginal delivery after successful ECV increased women's willingness (OR 3.42 (95% CI 2.04-5.74), if chance of vaginal delivery after successful ECV increased from 24% to 52%). The risk of an emergency CS during ECV did not influence the willingness to opt for ECV (OR 0.83 (95% CI 0.59-1.18) of chance increased from 0% to 1%).

CONCLUSIONS

We conclude that expected pain during treatment and the success rate are the most important factors influencing the willingness to undergo ECV. Taking this information into account when counseling for ECV and reassuring women that unbearable pain is always a reason to stop ECV, and that the vast majority of women reported that the experienced pain is bearable, might improve the uptake of ECV and decrease the number of CS due to breech presentation.

A qualitative interview study exploring pregnant women's and health professionals' attitudes to external cephalic version

Background

Women who have a breech presentation at term have to decide whether to attempt external cephalic version (ECV) and how they want to give birth if the baby remains breech, either by planned caesarean section (CS) or vaginal breech birth. The aim of this study was to explore the attitudes of women with a breech presentation and health professionals who manage breech presentation to ECV.

Methods

We carried out semi-structured interviews with pregnant women with a breech presentation (n=11) and health professionals who manage breech presentation (n=11) recruited from two hospitals in North East England. We used purposive sampling to include women who chose ECV and women who chose planned CS. We analysed data using thematic analysis, comparing between individuals and seeking out disconfirming cases.

Results

Four main themes emerged from the data collected during interviews with pregnant women with a breech presentation: ECV as a means of enabling natural birth; concerns about ECV; lay and professional accounts of ECV; and breech presentation as a means of choosing planned CS. Some women’s attitudes to ECV were affected by their preferences for how to give birth. Other women chose CS because ECV was not acceptable to them. Two main themes emerged from the interview data about health professionals’ attitudes towards ECV: directive counselling and attitudes towards lay beliefs about ECV and breech presentation.

Conclusions

Women had a range of attitudes to ECV informed by their preferences for how to give birth; the acceptability of ECV to them; and lay accounts of ECV, which were frequently negative. Most professionals described having a preference for ECV and reported directively counselling women to choose it. Some professionals were dismissive of lay beliefs about ECV. Some key challenges for shared decision making about breech presentation were identified: health professionals counselling women directively about ECV and the differences between evidence-based information about ECV and lay beliefs. To address these challenges a number of approaches will be required.