External cephalic version for breech presentation at term

Abstract

Background: Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure.

Objectives: The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately.

Search methods: We searched the Cochrane Pregnancy and Childbirth Trials Register (28 February 2015) and reference lists of retrieved studies.

Selection criteria: Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation.

Data collection and analysis: Two review authors assessed eligibility and trial quality, and extracted the data.

Main results: We included eight studies, with a total of 1308 women randomised. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic presentation at birth (average risk ratio (RR) 0.42, 95% confidence interval (CI) 0.29 to 0.61, eight trials, 1305 women); vaginal cephalic birth not achieved (average RR 0.46, 95% CI 0.33 to 0.62, seven trials, 1253 women, evidence graded very low); and caesarean section (average RR 0.57, 95% CI 0.40 to 0.82, eight trials, 1305 women, evidence graded very low) when ECV was attempted in comparison to no ECV attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (average RR 0.67, 95% CI 0.32 to 1.37, three trials, 168 infants) or five minutes (RR 0.63, 95% CI 0.29 to 1.36, five trials, 428 infants, evidence graded very low), low umbilical vein pH levels (RR 0.65, 95% CI 0.17 to 2.44, one trial, 52 infants, evidence graded very low), neonatal admission (RR 0.80, 95% CI 0.48 to 1.34, four trials, 368 infants, evidence graded very low), perinatal death (RR 0.39, 95% CI 0.09 to 1.64, eight trials, 1305 infants, evidence graded low), nor time from enrolment to delivery (mean difference -0.25 days, 95% CI -2.81 to 2.31, two trials, 256 women).All of the trials included in this review had design limitations, and the level of evidence was graded low or very low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in several studies. Three of the eight trials had serious design limitations, however excluding these studies in a sensitivity analysis for outcomes with substantial heterogeneity did not alter the results.

Authors' conclusions: Attempting cephalic version at term reduces the chance of non-cephalic presentation at birth, vaginal cephalic birth not achieved and caesarean section. There is not enough evidence from randomised trials to assess complications of ECV at term. Large observational studies suggest that complications are rare.

Conflict of interest statement

GJ Hofmeyr (GJH) is an author of one of the papers included in this review (Hofmeyr 1983) but he was not involved in assessing this study for inclusion, assessing trial quality, or data extraction. GJH receives royalties from UpToDate for chapters related to breech pregnancy, delivery of a baby in breech presentation and external cephalic version. UpToDate is an electronic publication by Wolters Kluwer to disseminate evidence‐based medicine (such as Cochrane reviews).

Figures

1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

1.1. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 1 Vaginal cephalic birth not achieved (CS + breech vaginal birth) (not prespecified).

1.2. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 2 Caesarean section.

1.3. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 3 Non‐cephalic presentation at birth.

1.4. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 4 Vaginal breech birth (not prespecified).

1.5. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 5 Apgar score

1.6. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 6 Apgar score

1.7. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 7 Umbilical vein pH

1.8. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 8 Perinatal death.

1.9. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 9 Neonatal admission.

1.10. Analysis

Comparison 1 External cephalic version at term versus no ECV attempt, Outcome 10 Enrolment‐delivery interval (not prespecified).

2.1. Analysis

Comparison 2 Sensitivity analysis (excluding studies with high risk of bias), Outcome 1 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

2.2. Analysis

Comparison 2 Sensitivity analysis (excluding studies with high risk of bias), Outcome 2 Caesarean section.

2.3. Analysis

Comparison 2 Sensitivity analysis (excluding studies with high risk of bias), Outcome 3 Non cephalic presentation at birth.

2.4. Analysis

Comparison 2 Sensitivity analysis (excluding studies with high risk of bias), Outcome 4 Vaginal breech birth.

3.1. Analysis

Comparison 3 Sensitivity analysis (excluding studies in Africa), Outcome 1 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

3.2. Analysis

Comparison 3 Sensitivity analysis (excluding studies in Africa), Outcome 2 Caesarean section.

3.3. Analysis

Comparison 3 Sensitivity analysis (excluding studies in Africa), Outcome 3 Non cephalic presentation at birth.

3.4. Analysis

Comparison 3 Sensitivity analysis (excluding studies in Africa), Outcome 4 Vaginal breech birth.