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Expert commentary on Practice Bulletin No. 161: External Cephalic Version
American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e54-61. Full text of Practice Bulletin #161 is available to ACOG members at http://www.acog.org/Resources%20And%20Publications/Practice%20Bulletsin/Committee%20on%20Practice%20Bulletins%20Obstetrics/External%20Cephalic%20Version.aspx
EXTERNAL CEPHALIC VERSION In the United States, there is a widespread belief that the overall cesarean delivery rate is higher than necessary. Eff orts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean delivery, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.
Used with permission. Copyright the American College of Obstetricians and Gynecologists.
ECV: A tool to prevent the first cesarean
by Stephen F Thung, MD, MSCI
Dr Thung is Associate Professor of Maternal Fetal Medicine, Clinical Chief of Obstetrics and Medical Director of Patient Flow Management, The Ohio State University, Columbus, Ohio
When I was a resident at New York University/Bellevue Hospital, one of my least favorite procedures was external cephalic version (ECV). Converting a breech fetus to cephalic was just another lost vaginal breech opportunity-an experience that became more and more scarce when I trained in the 1990s. Enthusiasm for delivering breech fetuses vaginally has waned over the years. For most of us, an unresolved breech at the time of delivery now means taking the path of least resistance-performing a quick and typically uneventful primary cesarean delivery.
Term fetal malpresentation occurs frequently-in about 3% of pregnancies-and is a common indication for cesarean. As the Chief of the Obstetrical Service at Ohio State University trying to find methods to reduce our primary cesarean rates, I now find ECV to be one of my best allies and an important tool for preventing that first cesarean. ACOG’s Practice Bulletin on ECV has been updated after 17 years and is a concise summary of the latest information that every obstetrical provider needs to be familiar with and is designed to help make ECV safe and successful.1
ECV is a long-standing procedure that increases the likelihood that a baby is in cephalic presentation at the time of birth. Data from the Cochrane Database clearly support this practice as it reduces the risk of cesarean birth [RR 0.57; 95% CI, 0.40- 0.82) when compared to no ECV attempt.2 ACOG strongly supports universal screening for presentation at 36 weeks’ gestation for those eligible for vaginal birth, and routine counseling of women on this option beginning at 37 weeks’ gestation. Women with malpresentation also should be counseled starting at 37 weeks.
Given that many women are not receiving this opportunity, ACOG has proposed a metric: Percentage of women identified with fetal malpresentation without contraindications to vaginal birth who are also counseled about their ECV options.
One Cochrane study demonstrated excellent outcomes in women undergoing ECV with no differences in Apgars, umbilical cord pH, or neonatal deaths compared to women who do not have ECV.2 Although there have been case reports of adverse events, it has always been challenging to attribute these rare events to ECV itself. ACOG continues to support performing ECV at sites where immediate evaluation and emergency cesarean are available.
Immediate induction after successful ECV is not supported. As a clinician, I know it is tempting, but please resist the temptation, particularly before 39 weeks.
The best timing of ECV is controversial. It has been modified from later than 36 weeks’ gestation to early term-37 weeks or greater. When compared with term ECV (37+ weeks), preterm ECV (34–35 weeks) has been associated with increased short-term success with cephalic presentation, higher rates of reversion to breech in the ensuing weeks, and cesarean delivery risk reduction [RR 0.90; 95% CI 0.83–0.97]. However, preterm ECV is also associated with an increased risk of premature birth [RR 1.51; 95% CI 1.03–2.21].3
The current recommendation for ECVs at term could reduce their frequency and prevent unnecessary prematurity at the expense of a potentially small increase in cesarean delivery risk.
Parenteral tocolysis (beta agonist) should be used if there are no contraindications. Many of us already use some form of tocolysis to reduce uterine tone. Recent data support what many of us have suspected-that a tocolytic improves ECV success [RR 1.68; 95% CI, 1.14–2.48] and reduces cesarean delivery risk [RR 0.77; 95% CI, 0.67–0.88]. Although my experience has been with either magnesium or terbutaline, ACOG recommends the latter, citing insufficient evidence to support the use of alternative tocolytics.4
Is early labor or prior uterine scar a contraindication to ECV? Information is insufficient to make clear recommendations on this practice. The likelihood of success is not likely to significantly differ from that in women without these conditions, however, the magnitude of pregnancy risk has not been quantified due to insufficient study. ACOG does not consider these conditions to be contraindications to ECV and care of women in these situations should be individualized.
Whether to offer regional anesthesia at the time of ECV remains unclear, with discordant results in randomized trials exploring this question. Although there are some advantages, such as being able to offer cesarean delivery immediately if complications arise, the data do not currently support routine use. A recent meta-analysis demonstrated greater immediate ECV success, but did not show a significant reduction in cesarean delivery risk with regional anesthesia [RR 0.80; 95% CI, 0.55–1.17]. These findings did not differ for spinal or epidural.5
Although many factors have been associated with success and failure, unlike predicting successful trial of labor after cesarean section, no reliable or validated scoring system exists to counsel patients regarding their likelihood of avoiding a cesarean delivery.
Non-stress test monitoring should occur before and after ECV. Testing should continue for at least 30 minutes after the procedure. Anti-D immune globulin should be given to Rh-negative mothers who have no plans for delivery within 72 hours after ECV.
This new ACOG guidance is a reminder of the importance of routine screening for malpresentation in the third trimester. The evidence justifies ECV as a critical tool for providers to prevent cesarean delivery. Moreover, available evidence continues to be a useful guide for accomplishing a safe and effective ECV.
1. External cephalic version. Practice Bulletin No. 161. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;127:e54-61.
2. Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database Syst Rev. 2015:4.
3. Hutton EK, Hofmeyr GJ, Dowswell T. External cephalic version for breech presentation before term. Cochrane Database Syst Rev. 2015:7.
4. Cluver C, Gyte GM, Sinclair M, Dowswell T, Hofmeyr GJ. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database Syst Rev. 2015:2.
5. Goetzinger KR, Harper LM, Tuuli MG, Macones GA, Colditz GA. Effect of regional anesthesia on the success rate of external cephalic version: a systematic review and meta-analysis. Obstet Gynecol. 2011:118(5):1137-44.