External cephalic version in the management of breech presentation with special reference to the placental location

Breech presentation and the cornual-fundal location of the placenta

AIM

To investigate the association of cornual-fundal location of the placenta and breech presentation at term delivery.

METHODS

This study was conducted at the Department of Obstetrics and Gynecology, Novi Sad, in 2011. The inclusion criteria were delivery at ≥37 weeks of gestation, singleton gestation, and cornual-fundal location of the placenta determined by ultrasonography at ≥37 weeks of gestation when 3/4 or more of the placenta was in the cornual-fundal region.

RESULTS

Out of 2750 ultrasound examinations performed, 143 showed cornual-fundal location of the placenta (frequency 5.2%). Eighty six cases had cephalic presentation (60.14%) and 57 (39.86%) had breech presentation. Of the remaining cases with non- cornual-fundal location, 2585 had cephalic presentation and 22 (0.84%) had breech presentation. The difference in the frequency of breech presentation between the cornual-fundal and non-cornual-fundal groups was significant (χ(2)=77.78, P<0.001).

CONCLUSION

Cornual-fundal location of the placenta may be an important clue in resolving the etiology of a number of cases of breech presentation at term delivery.

The impact of external cephalic version on the rate of vaginal and cesarean breech deliveries: a 3-year cumulative experience

The authors have reviewed the impact of their practice of external cephalic version (ECV) at term, with respect to success rate, factors associated with successful version and the effect of this protocol on the overall breech and cesarean breech rate. Two hundred and forty-nine parturients identified as having a breech presenting fetus after the 36th gestational week over a 3-year period, after excluding contraindicated cases, were offered a trial of ECV, with the use of ritodrine tocolysis. ECV was effected by one operator, using the minimally effective force necessary. Successful ECV was achieved in 196 attempts (78.7%). No deleterious effects in fetuses or mothers were noted. Of successfully turned fetuses, 78% eventually had a vaginal vertex delivery. Parity, birthweight and amount of amniotic fluid were found to have a significant effect on the success rate of ECV, whereas gestational age at version or placental location were not found to have a significant effect on success rate. Introduction of the ECV protocol effected a significant decrease in breech presentation at term, from 3.9 to 2.4% (P < 0.01), which can be translated into a decrease of 5.5% in the overall cesarean section rate. The authors conclude that ECV is a safe and effective procedure, in properly selected cases. Institution of a screening protocol to identify breech presentation after 36 weeks, and utilizing ECV where possible, may lead to a significant reduction in the breech delivery rate, and may prevent serious infant morbidity.

External cephalic version at term. A randomized controlled trial using tocolysis

OBJECTIVE

To assess the role of external cephalic version (ECV) at term, using tocolysis.

DESIGN

A randomized controlled trial over a 12 month period.

SETTING

Harare Maternity Hospital, Harare, Zimbabwe.

SUBJECTS

208 women with breech presentation at term were recruited after satisfying eligibility criteria. There were 103 women in the study group and 105 in the control group. At the end of the study a further 104 women were recruited for ECV.

INTERVENTION

ECV attempted after intravenous injection of 10 micrograms of hexaprenaline, using either forward or backward somersault over a maximum period of 5 min.

MAIN OUTCOME MEASURES

Success rate in terms of presentation during labour, need for caesarean section, and various variables related to fetal outcome.

RESULTS

ECV reduced the frequency of breech presentation during labour from 83% to 17% and that of caesarean section from 33% to 13%. There were no troublesome complications from the procedure.

CONCLUSION

In carefully selected women with breech presentation, ECV at term using tocolysis, safely reduced the rate of breech presentation in labour and also the caesarean section rate. Further research is needed to determine the role of ECV in early labour.

Ultrasonography and external cephalic version at term

Sixty-five patients with nonvertex presentations at term were evaluated by ultrasonography to determine which factors were associated with a successful external cephalic version. Amniotic fluid volume, placental localization, type of breech, position of the fetal spine, and whether the breech had descended were determined and analyzed by chi 2 analysis. Only a frank breech and an anteriorly located fetal spine were associated with a successful version. Four episodes of fetal bradycardia occurred, none requiring operative intervention. There were no episodes of maternal bleeding or dislodgement of the placenta. Fifty-eight percent of all breech presentations were converted and 62% were delivered vaginally. We conclude that ultrasonography is useful in the evaluation of patients with a nonvertex presentation at term and can be used to predict which patients are likely to undergo a successful external cephalic version.

Fetal heart rate changes following external cephalic version under tocolysis near term

Fifty eight gravidas near-term underwent external cephalic version using tocolytic treatment and continuous fetal monitoring by cardiotocograph and real-time ultrasound. No unfavorable maternal or fetal effects were recorded. Fetal heart rates showed a significant decline at 10 and 30 min after the procedure with complete recovery at 1 h after external version, but no pathologic tracing was recorded. No uniform heart rate patterns due to external cephalic version could be found.

External cephalic version and spontaneous version rates: ethnic and other determinants

Variable rates of external cephalic version (ECV) success in late pregnancy and of spontaneous version have been reported for different population groups. An ECV attempt by one operator in 80 patients beyond 36 weeks gestation was successful less frequently in white nulliparous patients and in those with lateral or cornual placental situation. A similar influence of ethnic and other variables was found on the spontaneous version rate in 108 patients in whom no ECV was attempted. Despite population differences in ECV success rates, the ratio of successful ECV to spontaneous version in reported randomized control trials is consistent at about 3:1.

External cephalic version: a clinical experience

Eighty-five normal women underwent external cephalic version (ECV) for breech presentation in the late 3rd trimester. The protocol included real time ultrasonic scanning and pre- and post-procedure electronic fetal monitoring. Subcutaneous terbutaline sulfate (0.25 mg.) was administered to (43/85 or 50.5%) of ECV candidates and rendered the procedure easier for patient and operator. A single operator, head-over-heels technique assisted by supine Trendelenberg's position was used. Rh negative women were routinely administered 300 mcg of immune globulin. Successful ECV (53/85, 62.5%) was related to maternal parity, but not to gestational age nor eventual delivery weight. In this series only engagement of the breech was reliable in predicting ECV failure. Fifty of 51 (98.1%) successfully verted women delivered a cephalic presentation infant at term. Cesarean section was performed in 5/51 of these patients (9.8%) for routine obstetrical indications. In one case, compound presentation at term resulting in dystocia and eventual cesarean section was believed related to prior successful version. In contrast, 15/30 (50%) of the ECV failure patients went on to operative delivery despite a liberal institutional policy toward term vaginal breech trials. In addition, the only serious fetal complication in this series, meconium aspiration, occurred in a vaginally delivered breech infant. It is unlikely that late 3rd trimester ECV will impact on out overall rate of cesarean delivery. In North America prematurity is the greatest risk factor in malpresentation and our policy increasingly is to permit attempts at term breech vaginal delivery. Nonetheless, ECV deserves serious consideration. When successful, ECV avoids the costs and/or risks of either cesarean section or vaginal trial of breech.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous cephalic version of breech presentation in the last trimester

A prospective longitudinal investigation of spontaneous cephalic version from breech presentation in the last trimester is reported. All pregnancies were assessed with ultrasound in the 32nd week of gestation, and were thereafter checked weekly. Of the 310 singleton breech presentations identified at 32 weeks, spontaneous cephalic version occurred in 177 (57%) while breech presentation persisted in 133 patients (43%). Of 140 patients with a breech presentation at delivery 95% were already presenting by the breech in the 32nd week. Spontaneous cephalic version was less likely in pregnancies with extended fetal legs, low birth-weight, short umbilical cord and primiparity.

Effect of external cephalic version in late pregnancy on breech presentation and caesarean section rate: a controlled trial

A prospective randomized controlled trial of external cephalic version (ECV) in late pregnancy is reported. All pregnancies were assessed with ultrasound and cardiotocography. ECV was successful in 29 out of 30 patients (97%). Breech presentation at delivery occurred in 67% of the control group and in 3% of the ECV group. The caesarean section rates were 43 and 20% respectively. Tocolysis was used in seven patients. A new technique of ECV with the steep lateral position is described. Complications were limited to cardiotocographic changes and one patient with unexplained vaginal spotting. The procedure is recommended provided appropriate patient selection and surveillance is practised.