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Keywords:

  • Breech presentation;
  • caesarean section;
  • fetal version;
  • previous caesarean section

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Objective

To determine if external cephalic version (ECV) can be performed with safety and efficacy in women with previous caesarean section.

Design

Prospective comparative cohort study.

Setting

Cruces University Hospital (Spain).

Population

Single pregnancy with breech presentation at term.

Methods

We compared 70 ECV performed in women with previous caesarean section with 387 ECV performed in multiparous women (March 2002 to June 2012).

Main outcome measures

Success rate, complications of the ECV and caesarean section rate.

Results

The success rate of ECV in women after previous caesarean section was 67.1% versus 66.1% in multiparous women (= 0.87). The logistic regression analysis confirmed this result (odds ratio 0.93, 95% CI 0.52–1.68; = 0.82) adjusted by the variables associated with success of ECV. There were no complications in the previous caesarean section cohort. The vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (< 0.01). There were no cases of uterine rupture.

Conclusion

Based on our data, we conclude that complications are uncommon with ECV in women with previous caesarean section, with a success rate comparable to that of multiparous women. Uterine scar should not be considered a contraindication and ECV should be offered to women with previous caesarean section with breech presentation at term.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

External cephalic version (ECV) is a manoeuvre performed to rotate the fetal presenting part from breech to cephalic presentation. This technique has been known for centuries. However, since publication of the Term Breech Trial[1] and the subsequent rise of caesarean section as the preferred mode of delivery in breech presentations, ECV has increased in importance. The Cochrane Collaboration[2] and the major scientific societies[3-5] recommend its use. Still its implementation in medical centres is discreet and its degree of acceptance among women remains low.

Safety and efficacy of ECV are key points for clinicians to implement a technique. There is strong evidence for ECV indication in most pregnancies with breech presentation at term. However, there are still specific situations where scientific evidence is limited, such as in the presence of a uterine scar. Uterine scars are frequent in women who undergo ECV[6] and it has been hypothesised that they are a risk factor for ECV at term.[7] The risk of dehiscence of the scar, the lower success rate of ECV and the higher rate of caesarean delivery are the most important reasons to take into account this clinical situation as a relative contraindication.[2] However, the available data on ECV after caesarean section are reassuring[8-12] but are insufficient to confidently conclude that the risk is not increased.[2] The aim of the present study was to determine ECV success, complication and caesarean rates in women with a breech-presenting fetus and previous caesarean section.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

The current study is based on prospectively collected data of ECV performed from March 2002 to June 2012 at Cruces University Hospital (n = 1426). The study population were all women with a singleton pregnancy and one previous caesarean section who had an attempted ECV at or after 37 weeks of gestation (n = 70). ECV was offered to all women with singleton breech-presenting gestations at term and the procedure was performed following our guidelines.[13, 14] Briefly, exclusion criteria to the use of ECV in our hospital were placenta praevia, premature placental abruption, oligohydramnios (amniotic fluid index <5), signs of fetal compromise, fetal death, severe malformations, multiple gestation, isoimmunisation, coagulation disorders and indication of caesarean section not related to fetal presentation. All women were informed in detail about the procedure, explaining the benefits and risks. Before ECV, cardiotocography was performed to confirm fetal wellbeing. As a tocolytic we used intravenous ritodrine (Prepar; Laboratorios Reig Jofre SA, Barcelona, Spain). It was administered via continuous 200 mg infusion pump starting 30 minutes before the version and was maintained during the manoeuvre. Atosiban was used only if the woman had any contraindication for ritodrine (Tractocile; Laboratorios Ferring SA, Madrid, Spain). It was administered intravenously in a single 0.9-ml bolus 2 minutes before the technique was applied. The procedure was considered to be successful if the breech presentation rotated to cephalic. Following the version attempt, continuous cardiotocography was performed for a total of 60 minutes to verify fetal status and the presence of any adverse effects in the woman. Anti-D was also administered if indicated. Thirty minutes after the procedure, the level of pain was assessed by a numeric rating scale on which 1 and 10 represented the minimum and maximum levels of pain, respectively. If no further complications arose, the woman was discharged and monitored until delivery. Vaginal birth after caesarean section and vaginal birth in breech presentation at term were protocolised in our hospital and the induction in both was performed based on maternal or obstetric indications. We allowed vaginal birth after caesarean section if there were no contraindications (previous history of one classical caesarean section, previous uterine surgery with access to uterine cavity, previous uterine rupture, contraindication for vaginal birth or more than three caesarean sections). We allowed vaginal birth in breech presentation at term when the presentation was frank or complete, fetal head attitude was not hyperextended and estimated fetal weight was ≤4000 g.

We compared our study group with all ECV performed on multiparous women in the same time period (n = 387). We analysed maternal characteristics, success rate adjusted by the variables associated with success of ECV in our group[6] and complication rate of ECV. We categorised the amount of liquid based on the fifth centile (scarce) and 95th centile (abundant) of amniotic fluid index of our ECV cohort. We also studied obstetric variables (presentation at delivery, route of delivery) as well as perinatal results (Apgar scores <7 at 5 minutes, pH of umbilical cord <7.10, neonatal intensive care unit admission). We performed statistical analysis using spss Statistics v21 software (IBM, Armonk, NY, USA). Significance was set at a P < 0.05.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Table 1 shows the characteristics of the two cohorts and Figure 1 shows the number of women in both cohorts by year. There were no statistical differences in weeks of gestation at the moment of ECV, maternal body mass index, placental location, breech variety, amount of fluid and estimated fetal weight. The success rate of ECV in the previous caesarean section cohort was 67.1% versus 66.1% in the multiparous cohort (P = 0.87). Logistic regression analysis confirmed this result adjusted by the variables associated with success of ECV in our group (Table 2). Median of pain score was 5 in the previous caesarean section cohort versus 6 in the multiparous cohort (P = 0.94). The median number of attempts was two in both cohorts.

Table 1. Comparative analysis of descriptive variables
 Previous caesarean section (n = 70)Multiparous (n = 387)P-value
Weeks in ECV
3754 (77.1%)296 (76.5%)0.95
389 (12.9%)56 (14.5%)
≥397 (10%)35 (9%)
Body mass index (kg/m 2 ) 29.20 ± 5.1928.32 ± 4.00.15
Parity
Biparous62 (88.6%)326 (84.4%)0.37
Triparous or more8 (11.4%)61 (15.8%)
Placental location
Anterior23 (32.8%)156 (40.3%)0.48
Posterior38 (54.3%)190 (49.1%)
Others9 (12.9%)41 (10.6%)
Breech variety
Frank30 (42.8%)214 (55.3%)0.05
Complete14 (20.0%)78 (20.2%)
Footling10 (14.3%)31 (8.0%)
Incomplete10 (14.3%)36 (9.3%)
Missing6 (8.7%)28 (7.2%)
Amount of fluid
Normal61 (88.4%)300 (92%)0.08
Scarce2 (2.9%)16 (4.9%)
Abundant6 (8.7%)10 (3.1%)
Estimated fetal weight (g) 3084 ± 4532987 ± 3530.09
Tocolytic
Ritodrine55 (78.6%)262 (80.9%)0.66
Atosiban15 (21.4%)62 (19.1%)
Table 2. Logistic regression analysis for the variables significantly associated with success of ECV
 Bivariate analysisMultivariable analysis
P valueOR95% CIP-valueOR95% CI
Parity
Biparous 1   1  
Triparous or more0.041.831.013.320.081.790.933.45
Placental location
Anterior0.011  0.011  
Fundal-lateral0.921.030.541.960.910.960.481.91
Posterior0.011.881.242.860.011.951.253.04
Breech variety
Frank0.151  0.131  
Complete0.221.380.832.310.171.450.852.48
Incomplete0.640.860.451.630.590.830.431.61
Footling0.052.150.984.710.062.160.964.86
Amount of amniotic fluid
Normal0.111  0.331  
Scarce0.230.570.231.440.520.730.281.89
Abundant0.092.920.8410.150.192.400.658.93
Study
Previous caesarean section0.871.050.611.800.820.930.521.68
image

Figure 1. Number of women in both cohorts by year.

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There were seven women with complications (1.8%) in the multiparous cohort (three abnormal cardiotocography, three vaginal haemorrhage and one pulmonary oedema). We performed urgent caesarean section in two cases of vaginal haemorrhage and one case of abnormal cardiotocography (0.77% urgent caesarean rate). There were no complications in the previous caesarean section cohort.

Vaginal delivery rate in the previous caesarean section cohort was 52.8% versus 74.9% in the multiparous cohort (< 0.01). There were no cases of uterine rupture. No differences were described in perinatal outcome between both cohorts (Table 3).

Table 3. Perinatal outcomes
 Previous caesarean section (n = 70)Multiparous (n = 387)P-value
Mean weight at birth3306 ± 4313298 ± 4390.90
5-minute Apgar <71 (1.42%)3 (0.76%)0.88
pH umbilical cord <7.108 (11.42%)31 (8.01%)0.35
Admission to neonatal care unit07 (1.8%)0.54
Mortality00 

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Main findings

The results of this study showed that ECV performed in women with previous caesarean section had a similar success rate to ECV in the comparative cohort. There were no complications in the previous caesarean section cohort. The caesarean rate was higher in women with previous caesarean section than in the comparative cohort, probably because of the lower rate of vaginal birth in women with previous caesarean section.

Strengths and limitations

Our hospital has a large prospective well-established ECV cohort. The method was well established, as recommended to improve the prognostic factor research, there was a prospective cohort with clear inclusion criteria, follow-up data were complete and the factors and outcomes were specified in advance.[15] This study is the largest cohort of ECV performed in women with previous caesarean section.

Moreover, this is the first comparative analysis between two ECV cohorts adjusted by the factors associated with ECV success in the same group.[6] Despite being the largest cohort; the main limitations are the design and the number of women. Our results are consistent with those of other studies. The analysis of all the women included in these studies (Table 4) provides enough scientific evidence to draw conclusions. In many countries the rate of caesarean section is high, and the possibility of performing an ECV in women with a previous caesarean section is a real clinical situation. Therefore, the availability of best evidence is important to support this clinical practice. Prospective multicentre randomised clinical trials provide the best evidence but are not always feasible. The safety of ECV in women with previous caesarean section is very good. In the 270 ECV in women with a previous caesarean section published up until now there was no case of uterine rupture or fetal mortality.

Table 4. Studies about external cephalic version in previous caesarean section
AuthorYear n SuccessUrgent caesarean sectionUterine ruptureVaginal delivery
Flamm[8]19915682%1.8%0%53.6%
Schachter[7]199411100%0%0%54.5%
De Meuss[9]19983865.8%0%0%50%
Regalia[12]20001968%0%0%
Abenhaim[10]20093650%
Sela[11]20094274%0%0%64%
This study 7067.1%0%0%52.8%
Total 27270.2% (191/272)0.4% (1/239)0%54.8% (119/217)

Interpretation

Previous caesarean section is an important obstetric risk factor. The risk of uterine rupture is increased at the end of the pregnancy, especially during delivery. Due to the rising caesarean rate, the presence of breech presentation at term is becoming more frequent in women with previous caesarean section.[6] The arguments that have been used to consider previous caesarean section as a relative contraindication for ECV are the risk of uterine rupture during the ECV manipulation, a low rate of success of the manoeuvre and a higher rate of caesarean section in these women.[2, 7] However, these considerations have been based on limited scientific evidence. The first article about ECV in women with a previous caesarean section was published in 1991[8] with 56 women, remaining the largest published to date. Success rate was 82% without differences in complication rates and no case of uterine rupture. Thereafter five studies have been published with similar results (Table 4).[7-12]

Our study was conducted on 70 ECV at term in women with previous caesarean section. The results have been compared with 387 ECV in multiparous women performed in the same period of time. We have chosen this control group because parity is a factor associated with the success rate in our group.[6] We performed a logistic regression analysis to adjust the success rate according to factors associated with ECV success in our group.[6] These variables have demonstrated in a specific study their association with the success of ECV. For this reason we considered that all of them must be included in the model. We have not included the bivariate analysis of the other variables (maternal age, maternal body mass index, pregnancy week, estimated fetal weight) because the association of these variables to ECV was discarded in our previous specific studies.[6, 13]

The results of our study have shown that there was no difference in the success rate of the ECV or in the complications rate. The pain referred to by women of both groups was similar. Uterine scar and surgical modifications had no impact on the number of ECV attempts. Differences in caesarean section rate were explained by the lower rate of vaginal birth after caesarean section. Perinatal outcomes were similar in both groups. Table 4 summarises the most important data from published studies to date.

Our results can be used by providers of obstetric care and women and their families during the decision-making process regarding breech presentations and previous caesarean section. There is a clear demand for such information, and guidance is expected from medical personnel. Interpreted in conjunction with our previous report, we conclude that benefit from the use ECV, at the institutional or individual level, has already been demonstrated.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References

Based on our data, we conclude that complications are uncommon for ECV in women with previous caesarean section. The success rate of ECV in women with previous caesarean section is comparable to that in multiparous women. Despite the small numbers in the current study not allowing for definitive conclusions to be drawn regarding safety and rare adverse events, we think that the uterine scar should not be considered a contraindication for ECV; therefore it should be offered to women with a previous caesarean section with breech presentation at term. Further prospective studies are needed to confirm our findings and to develop a consensus about ECV in women with previous caesarean section.

Disclosure of interests

The authors declare no competing interest in this article.

Contribution to authorship

JB and PC designed the study, analysed the data and wrote the paper. CO, MMC and LFLL performed external cephalic version. LR and TMA interpreted the data and reviewed the manuscript.

Details of ethics approval

The Clinical Research Ethics Committee of Cruces University Hospital approved this prospective cohort of external cephalic version at term (CEIC 20/09/2006).

Funding

This study received no financial support.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  • 1
    Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group. Lancet 2000;356:137583.
  • 2
    Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2012;10:CD000083.
  • 3
    RCOG. External cephalic version RCOG Guideline. RCOG Guidelines, 2006 [www.rcog.org.uk]. Accessed 15 April 2013.
  • 4
    American College of Obstetricians and Gynecologists. External cephalic version. ACOG Practice Bulletin No. 13. Obstet Gynecol 2000;95:17.
  • 5
    SEGO. External cephalic version in breech presentation. Protocolos SEGO, 2001. [www.prosego.com]. Accessed 15 April 2013.
  • 6
    Burgos J, Melchor JC, Pijoán JI, Cobos P, Fernández-Llebrez L, Martínez-Astorquiza T. A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet 2011;112:4851.
  • 7
    Schachter M, Kogan S, Blickstein I. External cephalic version after previous cesarean section—a clinical dilemma. Int J Gynaecol Obstet 1994;45:1720.
  • 8
    Flamm BL, Fried MW, Lonky NM, Giles WS. External cephalic version after previous cesarean section. Am J Obstet Gynecol 1991;165:3702.
  • 9
    de Meeus JB, Ellia F, Magnin G. External cephalic version after previous cesarean section: a series of 38 cases. Eur J Obstet Gynecol Reprod Biol 1998;81:658.
  • 10
    Abenhaim HA, Varin J, Boucher M. External cephalic version among women with a previous cesarean delivery: report on 36 cases and review of the literature. J Perinat Med 2009;37:15660.
  • 11
    Sela HY, Fiegenberg T, Ben-Meir A, Elchalal U, Ezra Y. Safety and efficacy of external cephalic version for women with a previous cesarean delivery. Eur J Obstet Gynecol Reprod Biol 2009;142:1114.
  • 12
    Regalia AL, Curiel P, Natale N, Galluzzi A, Spinelli G, Ghezzi GV, et al. Routine use of external cephalic version in three hospitals. Birth 2000;27:1924.
  • 13
    Burgos J, Melchor JC, Cobos P, Centeno M, Pijoan JI, Fernandez-Llebrez L, et al. Does fetal weight estimated by ultrasound really affect the success rate of external cephalic version? Acta Obstet Gynecol Scand 2009;88:11016.
  • 14
    Burgos J, Eguiguren N, Quintana E, Cobos P, Del Mar Centeno M, Larrieta R, et al. Atosiban vs. ritodrine as a tocolytic in external cephalic version at term: a prospective cohort study. J Perinat Med 2010;38:238.
  • 15
    Riley RD, Hayden JA, Steyerberg EW, Moons KGM, Abrams K, Kyzas PA, et al. Prognosis Research Strategy (PROGRESS) 2: prognostic factor research. PLoS Med 2013;10:e1001380.

TOLAC following ECV: turn with care

 In this edition of the journal, Burgos et al. report on a 10–year experience with external cephalic version (ECV) in patients with a prior caesarean section. They compared the ECV success rate and perinatal outcome of 70 women at term with a singleton breech and with one prior low-segment caesarean section against ECV in 387 multiparous women at term with a singleton breech and without a prior caesarean section. The cases and controls were matched for parity, body mass index (BMI), placental location, breech variety, amniotic fluid volume, and estimated fetal weight. Standard consent, ECV protocol, and vaginal birth after caesarean (VBAC) protocol were in place and operative throughout the period of study. Their results demonstrate a success rate of ECV in women with a previous caesarean section of 67.1 versus 66.1% in multiparous control women (= 0.87). Logistic regression analysis adjusted by the variables associated with the success of ECV confirmed this result (OR 0.93, 95% CI 0.52–1.68, = 0.82). There were no complications in the previous caesarean section cohort, and no difference in any perinatal outcomes studied (there were seven complications in the multiparous control cohort, necessitating urgent caesarean section in three women, for a 0.77% urgent caesarean rate). The vaginal delivery rate in the previous caesarean section cohort was 52.8 versus 74.9% in the multiparous cohort (< 0.01). There were no cases of uterine rupture. Based on their data and a review of earlier studies, the authors conclude that a prior uterine scar should not be considered a contraindication to ECV, and that the procedure should be offered to women with previous caesarean section with breech presentation at term.

As the authors note, this study represents the largest contribution so far to the literature on ECV and prior caesarean section. By extension, it is also the largest contribution so far to the literature on trial of labour after caesarean section (TOLAC) following ECV. Although tempting to see these risks and outcomes in a unified manner, ECV in women with a prior caesarean section and TOLAC following ECV are in fact two separate procedures, with related but also discrete risks and outcomes. The results of this study are in line with the generally reassuring outcomes previously reported. Nonetheless, the data is scant − 272 total cases, including this contribution – and pales in comparison with the vastly greater experience of both ECV in women without a prior caesarean section and TOLAC in women who have not had an ECV. If anything, the 0% rate of uterine rupture with TOLAC in these cases in the published literature so far, including this study, highlights the limitations of the available data. The 2000 (reaffirmed 2012) Practice Bulletin on ECV from the American College of Obstetricians and Gynecologists (ACOG) states that ‘previous cesarean delivery is not associated with a lower rate of success; however, the magnitude of the risk of uterine rupture is not known’ (External cephalic version. Practice Bulletin No. 13. American College of Obstetricians and Gynecologists. 2000). The bulletin rates this recommendation as level–B evidence (limited or inconsistent scientific evidence). Affirming the limited data available and the level–B evidence, the 2010 (reaffirmed 2013) ACOG Practice Bulletin on Vaginal Birth After Prior Cesarean Section, states that ‘external cephalic version for breech presentation is not contraindicated in women with a prior low transverse uterine incision who are at low risk for adverse maternal or neonatal outcomes from external cephalic version and TOLAC’ (Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63).

Although adding in a thoughtful manner to the available literature, the results of this study, in isolation or in combination with earlier work, fall short of transforming the current limited state of our knowledge on this topic. Women with a prior caesarean section who are considering an ECV should be advised of these limitations.

Disclosure of interests

 None.

  • YY El-Sayed

  • Room HH333, Department of Obstetrics and Gynecology, Stanford University, Stanford, CA, USA