External cephalic version (ECV): Experience in a sub-Saharan African hospital

External cephalic version success rate and associated factors: Experience from a tertiary center in Sub-Saharan Africa: A cross-sectional study

OBJECTIVE

To determine the success rate of external cephalic version (ECV) and its associated factors in an Ethiopian setting.

MATERIAL AND METHODS

A total of 152 ECVs performed at the St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia from June 1, 2018, up to March 30, 2019, were analyzed, using a prospective cross-sectional study design. Data were analyzed using SPSS version 21. Chi-square test of association was applied for categorical data analysis. Multivariate logistic regression analysis was used to determine predictors of success of ECV. Odds ratio, 95% CI, and P-value<0.05 were used to describe findings' significance.

RESULTS

The success rate of ECV was 71.7%. ECV success rate did not differ between multiparous and nulliparous (AOR = 1.4, 95% CI 0.07-2.35), according to abdominal wall thickness status (AOR = 3.5, 95% Cl 0.29-42.40), and between unengaged and engaged presenting part (AOR = 1.1, 95% CI 0.26-4.74). A posterior placenta was associated with ECV success compared to anterior placenta (AOR = 1.14, 95% CI 1.03-2.60). Likewise, cases that experience no pain was associated with a higher ECV success rate (AOR 14.68, 95% CI 1.65-34.97). Soft uterine tone was also associated with a higher success rate compared to tense uterine tone (AOR = 3.89, 95% CI 0.02-0.39). Eighty-four percent of those mothers who had successful ECV had spontaneous vertex vaginal delivery.

CONCLUSION

The success rate of ECV in this study is found to be 71.7%, which is higher than reports from previous studies. Absence of pain during the procedure, posterior placenta, and soft uterine tone were associated with successful ECV.

Successful external cephalic version: factors predicting vaginal birth

Purpose. To determine the maternal and fetal outcomes of successful external cephalic version (ECV) as well as factors predicting vaginal birth. Methods. The ECV data over a period of three years at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) between 1 September 2008 and 30 September 2010 was reviewed. Sixty-seven patients who had successful ECV were studied and reviewed for maternal, fetal, and labour outcomes. The control group comprised patients with cephalic singletons of matching parity who delivered following the index cases. Results. The mean gestational age at ECV was 263 ± 6.52 days (37.5 weeks ± 6.52 days). Spontaneous labour and transient cardiotocographic (CTG) changes were the commonest early adverse effects following ECV. The reversion rate was 7.46%. The mean gestational age at delivery of the two groups was significantly different (P = 0.000) with 277.9 ± 8.91 days and 269.9 ± 9.68 days in the study group and control groups, respectively. The study group needed significantly more inductions of labour. They required more operative deliveries, had more blood loss at delivery, a higher incidence of meconium-stained liquor, and more cord around the neck. Previous flexed breeches had a threefold increase in caesarean section rate compared to previous extended breeches (44.1% versus 15.2%, P = 0.010). On the contrary, an amniotic fluid index (AFI) of 13 or more is significantly associated with a higher rate of vaginal birth (86.8% versus 48.3%, P = 0.001). Conclusions. Patients with successful ECV were at higher risk of carrying the pregnancy beyond 40 weeks and needing induction of labour, with a higher rate of caesarean section and higher rates of obstetrics complications. Extended breech and AFI 13 or more were significantly more likely to deliver vaginally postsuccessful ECV. This additional information may be useful to caution a patient with breech that ECV does not bring them to behave exactly like a normal cephalic, so that they have more realistic expectations. However, these predictive factors needed further confirmation and hopefully, in the future, they would be able to further enhance counselling prior to ECV.

Cost-effectiveness of external cephalic version for term breech presentation

BACKGROUND

External cephalic version (ECV) is recommended by the American College of Obstetricians and Gynecologists to convert a breech fetus to vertex position and reduce the need for cesarean delivery. The goal of this study was to determine the incremental cost-effectiveness ratio, from society's perspective, of ECV compared to scheduled cesarean for term breech presentation.

METHODS

A computer-based decision model (TreeAge Pro 2008, Tree Age Software, Inc.) was developed for a hypothetical base case parturient presenting with a term singleton breech fetus with no contraindications for vaginal delivery. The model incorporated actual hospital costs (e.g., $8,023 for cesarean and $5,581 for vaginal delivery), utilities to quantify health-related quality of life, and probabilities based on analysis of published literature of successful ECV trial, spontaneous reversion, mode of delivery, and need for unanticipated emergency cesarean delivery. The primary endpoint was the incremental cost-effectiveness ratio in dollars per quality-adjusted year of life gained. A threshold of $50,000 per quality-adjusted life-years (QALY) was used to determine cost-effectiveness.

RESULTS

The incremental cost-effectiveness of ECV, assuming a baseline 58% success rate, equaled $7,900/QALY. If the estimated probability of successful ECV is less than 32%, then ECV costs more to society and has poorer QALYs for the patient. However, as the probability of successful ECV was between 32% and 63%, ECV cost more than cesarean delivery but with greater associated QALY such that the cost-effectiveness ratio was less than $50,000/QALY. If the probability of successful ECV was greater than 63%, the computer modeling indicated that a trial of ECV is less costly and with better QALYs than a scheduled cesarean. The cost-effectiveness of a trial of ECV is most sensitive to its probability of success, and not to the probabilities of a cesarean after ECV, spontaneous reversion to breech, successful second ECV trial, or adverse outcome from emergency cesarean.

CONCLUSIONS

From society's perspective, ECV trial is cost-effective when compared to a scheduled cesarean for breech presentation provided the probability of successful ECV is > 32%. Improved algorithms are needed to more precisely estimate the likelihood that a patient will have a successful ECV.