Interventions for helping to turn term breech babies to head first presentation when using external cephalic version

Abstract

Background Breech presentation is associated with increased complications. Turning a breech baby to head first presentation using external cephalic version (ECV) attempts to reduce the chances of breech presentation at birth, and reduce the adverse effects of breech vaginal birth or caesarean section. Tocolytic drugs and other methods have been used in an attempt to facilitate ECV. Objectives To assess interventions such as tocolysis, fetal acoustic stimulation, regional analgesia, transabdominal amnioinfusion or systemic opioids on ECV for a breech baby at term. Search methods We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register (30 September 2011) and the reference lists of identified studies. Selection criteria Randomised and quasi-randomised trials comparing the above interventions with no intervention or other methods to facilitate ECV at term. Data collection and analysis We assessed eligibility and trial quality. Two review authors independently assessed for inclusion all potential studies identified as a result of the search strategy and independently extracted the data using a designed data extraction form. Main results We included 25 studies, providing data on 2548 women. We used the random-effects model for pooling data due to clinical heterogeneity in the included studies in the various comparisons. The overall quality of the evidence was reasonable, but a number of assessments had insufficient data to provide an answer with any degree of assurance. Tocolytic drugs, in particular betastimulants, were effective in increasing cephalic presentations in labour (average risk ratio (RR) 1.38, 95% confidence interval (CI) 1.03 to 1.85, eight studies, 993 women) and in reducing the number of caesarean sections (average RR 0.82, 95% CI 0.71 to 0.94, eight studies, 1177 women). No differences were identified in fetal bradycardias (average RR 0.95, 95% CI 0.48 to 1.89, three studies, 467 women) although the review is underpowered for assessing this outcome. We identified no difference in success, cephalic presentation in labour and caesarean sections between nulliparous and multiparous women. There were insufficient data comparing different groups of tocolytic drugs. Sensitivity analyses by study quality agreed with the overall findings. Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone in terms of increasing successful versions (assessed by the rate of failed ECVs, average RR 0.67, 95% CI 0.51 to 0.89, six studies, 550 women) but there was no difference identified in cephalic presentation in labour (average RR 1.63, 95% CI 0.75 to 3.53, three studies, 279 women) nor in caesarean sections (average RR 0.74, 95% CI 0.40 to 1.37, three studies, 279 women) or fetal bradycardia (average RR 1.48, 95% CI 0.62 to 3.57, two studies, 210 women). There were insufficient data on the use of vibroacoustic stimulation, amnioinfusion or systemic opioids. Authors’ conclusions Betastimulants, to facilitate ECV, increased cephalic presentation in labour...

Prediction of Success in External Cephalic Version under Tocolysis: Still a Challenge

“…According to the Cochrane Database of Systematic Reviews, the use of betamimetics to facilitate ECV is associated with an increase in cephalic presentation in labor and birth. 27 A decrease in cesarean section rate in both nulliparous and multiparous women Values are given as mean ± standard deviation or absolute number (percentage). NS: Not significant.…”

“…27 In particular, salbutamol is effective as an adjunct for ECV. 28 There is, however, insufficient evidence regarding adverse effects and comparison between routine and selective use of tocolysis.…”

“…28 There is, however, insufficient evidence regarding adverse effects and comparison between routine and selective use of tocolysis. 27 In this study, we attempted to exclude biases by analyzing results using a binary logistic regression, which clearly contributed to the lack of association. We highlight that care must be taken when assuming a determined factor is associated with the outcome of the procedure, as there are multiple confounding variables that may not be accounted for.…”

Reducing the cesarean delivery rates for breech presentations: administration of spinal anesthesia facilitates manipulation to cephalic presentation, but is it cost saving?

“…Uptake of ECV can be encouraged if success rates of ECV are maximally high; for example through use of neuraxial blockade [12-14]. …”

Breech repositioning unresponsive to Webster technique: coexistence of oligohydramnios

“…It involves practitioners attempting to manually reposition the fetus through the woman's abdominal wall. 28 Evidence currently supports use of ECV to reduce the chance of fetal malpresentation and cesarean delivery at full term [28][29][30] but not at preterm. 6 The success rate of ECV have been shown to be approximately 68%, and adverse maternal and fetal outcomes from ECV are rare.…”