External cephalic version for the management of breech presentation

External cephalic version is an inexpensive manoeuvre that can be performed at the outpatient clinic. It is safe and highly successful and when performed at term it reduces the risk of vaginal breech delivery and caesarean section. Ensuring easy access to operation facilities is recommended before attempting this procedure.

RHL Commentary by Lede R

1. EVIDENCE SUMMARY

External cephalic version (ECV) is employed to avoid breech delivery in the management of breech presentation. Although ECV is apparently safe and highly successful when it is attempted before term, it is effective in reducing rates of vaginal breech delivery and caesarean section only when it is performed at term. None of the three studies included in the Cochrane Review, which analysed the use of ECV before term, detected a statistically significant reduction in breech delivery although, the results of repeated ECV were somewhat promising. Of the trials of ECV at term, all but one achieved a significant reduction in the rates of breech delivery.

Practitioners became enthusiastic with ECV before term in view of its high immediate success rate (about 70%), but this is followed by a high reversion rate. On the other hand, when ECV is practised at term non-cephalic presentation rate at delivery is lower than in the non-ECV group (32.6% vs. 78.3%). Caesarean section rate is not reduced if ECV is performed before term but it is almost halved when performed at term (15.8% vs. 30.1%). To this end, caesarean section rates in individual studies vary between 8% and 28% in the ECV groups and 11% and 74% in the control groups. Undoubtedly, these figures reflect the different management policies for breech presentation at delivery.

All identifiable clinical controlled trials met the predefined criteria for inclusion. All of them were included.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS

2.1. Magnitude of the problem

Breech presentation adversely affects perinatal outcome. At term, about 3%-5% of the presentations are breech. Vaginal breech deliveries are associated with increased maternal and newborn morbidity and mortality, but delivery by caesarean section does not eliminate the possibility of a difficult delivery of the aftercoming head. However, the findings of a recent randomised controlled trial (1), suggest that caesarean section is the recommended option to deliver a fetus in breech presentation (relative risk for adverse perinatal outcome: 0.33; 95% confidence interval: 0.19 to 0.56). No difference was detected on adverse maternal outcome (RR 1.24; 95% CI 0.79-1.95).

2.2. Feasibility of the intervention

External Cephalic Version is an inexpensive manoeuvre that can be performed at the outpatient clinic. It is done by applying gentle pressure over the maternal abdominal wall, directed first towards reducing fetal longitudinal axis and, then, to promote a forward somersault. Only one to three attempts are recommended. To repeat ECV attempts few days after failure is the usual practice but it has not been specifically evaluated. ECV does not require a highly skilled practitioner, only a judicious one. Auscultation of the fetal heart rate during the procedure is recommended in order to detect fetal bradycardia, though this is not very common. Tocolysis during the procedure improves the ECV success rate. Tocolysis is recommended when the first attempt without tocolysis fails. Other complications such as vaginal bleeding, abruptio placenta and fetal death are rare but have been described mainly when ECV was done before term.

2.3. Applicability of the results of the Cochrane Review

All trials included in this Cochrane Review considered approximately the same exclusion criteria for ECV: uterine scars, previous vaginal bleeding, multiple pregnancy, previous caesarean sections, intrauterine growth retardation (IUGR), non-reactive stress test, threatened premature labour and oligohydramnios. Thus, the conclusions apply only to low-risk patients with breech presentation of a healthy singleton fetus. The studies reviewed included women of different ethnic origins. The outcomes do not differ between ethnic groups, which improves the validity of the conclusions. Besides, the studies reviewed included both term ECV and preterm ECV, allowing sound conclusions to be made in both cases.

2.4. Implementation of the intervention

Prior to attempting ECV fetal presentation should be accurately determined. This can usually be accomplished by a careful clinical examination. It is also important to know the gestational age of the fetus and to get the parents' authorization. ECV does not require very special conditions for its successful implementation; an examination table and a fetal stethoscope are adequate. To confirm fetal presentation it is advisable to get a second opinion from a senior obstetrician/midwife. If available, an ultrasonograph should also be used. Immediate availability of operative facilities is recommended before attempting ECV.

2.5. Research

The role of ECV in the management of breech presentation during labour, second twin in breech presentation and after the rupture of amniotic membranes remain to be evaluated appropriately.

References

  • Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. The lancet 2000;356:1368-1369.

This document should be cited as: Lede R. External cephalic version for the management of breech presentation: RHL commentary (last revised: 13 March 2006). The WHO Reproductive Health Library; Geneva: World Health Organization.