External Cephalic Version: where are we now

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External Cephalic Versionwhere are we now?

• Vivian Cheng
• Perinatal Rounds
• RAH January 18, 2005

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Outline

• Objectives
• Background
• Guidelines
• Predictors
• Endpoints
• Summary

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Objectives

• To examine the factors that contribute to
  successful ECV
• To review the use of tocolysis in ECV
• To explore the effectiveness of anesthesia on ECV
• To compare early versus late ECV

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Background

• Breech presentation occurs in 3-4 of term
  pregnancies
• The Term Breech Trial (2000) has impacted
  management 3-4 increase in overall C/S rate
• Survey of centre collaborators (2003)
• 92.5 report change in practice to planned C/S
  13.8 report ECV offered/performed more
• Success rates for ECV 3586 (58)
• - Effective strategy in lowering the C/S rate for
  breech presentation at term

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ECV

• Involves applying pressure to the mothers
  abdomen to turn the fetus in either a forward or
  a backward somersault to achieve a vertex
  presentation so as to facilitate the chances of a
  vaginal delivery.

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Indications

• Breech presentation
• Term completed 36 wks GA

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Rationale for ECV at term

• Less chance of reversion to breech
• Spontaneous cephalic versions would have occurred
  by then
• If need for immediate delivery, babe already term

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Absolute Contraindications

• Multiple gestation
• IUGR, major anomaly
• Hyperextension of fetal head
• Premature ROM
• Oligohydramnios
• Ante partum bleeding
• Placenta previa
• PIH, preeclampsia
• Maternal cardiac disease
• Classical uterine scar
• Uterine malformation
• 
  Capital Health (2004)

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Relative Contraindications

• Macrosomia (gt4000g)
• Excess maternal obesity
• 2 or more previous C/S
• Active labor
• 
  
• 
  
  Capital Health (2004)

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Risks

• Placental abruption
• Preterm Labor
• Premature ROM
• Iso-immunization
• FHR changes (usually transient)
• Emergent delivery
• Intrauterine fetal demise
• (cord accident, unexplained etiology)
• 
  
  Capital Health (2004)

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ACOG guidelines (Feb, 2000)

• All women near term (gt36-6/7 wks) with breech
  presentations should be offered a version attempt
• Fetal assessment before and after procedure
• Attempt ECV only in settings in which C/S
  services are readily available
• ACOG
  Practice Bulletin 13 (2000)

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Capital Health Policy (March, 2004)

• Informed Consent
• Skilled Obstetrician
• Ready access to C/S facilities
• Ongoing Ultrasound surveillance of FHR
• FHR monitoring 15 mins before 30 mins after
  procedure
• RH immune globulin as required following
• 
  Womens Health Program Guidelines
  Protocols

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Predictors

• Success
• Parous (52-95)
• N/I amniotic fluid
• Transverse/Oblique lie
• Presenting part unengaged, mobile
• Palpable fetal head

• Failure
• Nulliparity (26-62)
• Tense uterine tone
• Maternal Obesity
• Anterior Placenta
• Fetal wgt lt 2500g
• Lau et al (1997) BJOG 104 798-802

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Amniotic Fluid

• Prospective Observational Study (Montreal)
• Single site, 2 MFM
• 1361 women
• 14 years (1987-2000)
• 3 groups
• Ritodrine main tocolytic used
• Boucher et al. (2003) AJOG 189751-4

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Tocolysis
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Tocolytic agents

• NTG associated with a higher frequency of
  headaches and symptomatic hypotension
• - although randomized trials with NTZ have been
  small, results have been unfavorable enough to
  discourage further investigation Hofmeyr (2004)
  Cochrane Review
• Terbutaline associated with higher frequency of
  maternal palpitations
• Ritodrine currently off market, discontinued by
  the manufacturer

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ECV without Tocolysis

• Impey Lissoni (1999) Ireland
• N356, one operator, single institution, no
  analgesia
• ECV success rate 33 nullip, 54 multip
• (43 overall)
• C/S rate 12.1 in successful versions fetal
  distress, dystocia
• 17 in study had had one previous C/S, 10
  successful ECV, 5 vaginal vertex delivery
  
• Perinatal mortality 0.8 (3) diaphragmatic
  hernia, trisomy 18, failed ECV stillbirth with
  cord prolapse congenital pneumonia
• 
  The Journal of Maternal Fetal
  Medicine 8203-7

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Use of Anesthesia

• Macarthur et al (2004) Meta-analysis Toronto
• Whether anesthesia facilitates ECV randomized
  clinical trials comparing anesthesia to no
  anesthesia
• Terbutaline used for tocolysis
• USA 2 (epidural n56/85), 2 (spinal n63/116)

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ECV previous C/S

• Breech presentation after previous C/S occurs
  0.3 of pregnancies
• Flamm et al. (1991) 56 pts 1 or gt previous
  LTCS
• - 4 patients had had 2 prior LTCS
• - 82 success with no uterine rupture (ECV,
  labor)
• De Meeus et al. (1998) 38 pts one previous
  LTCS
• - 65.8 success with no maternal / neonatal
  complic
• - 1 scar dehiscence noted at time of elective
  C/S 24h after failed ECV

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Early vs Late ECV

• Randomized controlled multicenter trial
• Hutton et al (2003)
• ECV at 34-36 wks vs 37-38 wks
• N232 at 25 centers
• Mixed parity (65 nullip, 34 multip)
• Tocolysis (42-49)
• Epidural anesthesia (4-5)
• 
  
  
  AJOG 189 245-54
• 
  
  
  

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Subject Criteria

• Inclusion
• Nulliparous women with any breech presentation or
  multiparous women with a frank breech
  presentation
• Live singleton fetus
• Gestational age between 34 and 36 weeks

• Exclusion
• Any contraindications to
• - labor or vaginal birth
• - ECV
• - early ECV
• Parity gt 4
• Plans to move to a non-trial center

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Outcomes

• PRIMARY rate of non-cephalic presentation at
  birth
• SECONDARY - Cesarean Section
• - Preterm birth (lt 37
  wks)
• - Serious fetal
  complications
• - Womens views

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Results

• Rate of serious fetal complications (p0.69)
• Rate of preterm birth (p0.31)
• Rate of C/S (p0.32) Not
  significantly increased
• Sample size calculated to detect 15 rate
  reduction in non-cephalic presentation. Actual
  reduction was 9.5. Study considered
  underpowered larger trial in progress.

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Womens Attitudes

• Questionnaire (Israel) third trimester
• 1995 (154) 52.7 aware, 53.8 consider
• 2001 (127) 73.2 aware, 23.9 consider
• 
  Yogev et al (2002) Int J
  Gynaecol Obstet 79 221-4
• Structured interview survey (HK) first prenatal
• 2000 (150) 82 chose ECV as allowed for
  vaginal delivery, safer and more natural
• 
  Leung et al (2002) Aust N Z J
  Obstet Gynaecol 40 253-9
• Questionnaire (Australia) ante-partum visit 20-38
  wks
• 2004 (174) 66 aware, 39 consider
• 72 would make decision in discussion with their
  doctor
• 
  Raynes-Greenow et al
  (2004) Midwifery 20 181-7

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Endpoints Pregnancy outcome after successful ECV

• Siddiqui et al (1999) retrospective case control
  study -- US
• n92 61 success rate 12 control
• C/S rate 22.8 study vs 23.4 control (results
  non-significant)
• Vezina et al (2004) case control study Montreal
• - n 602 50 success rate 11 control
• C/S rate 25.1 study vs 10.5 control (plt0.001)
• Increase in C/S rate remained statistically
  significant for both nullips and multips and was
  mainly attributed to dystocia
• Chan et al (2004) meta-analysis HK
• Studies between 1980-2000, six identified
• C/S rate 27.6 after ECV vs 12.5 control
• Increase in C/S rate primarily due to dystocia
  and fetal distress

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SummaryWhere are we now?

• Offer ECV for all singleton breech presentations
  at term
• Consider tocolytics, value of routine vs
  selective use requires further study
• Insufficient evidence regarding the use of
  anesthesia (epidural better than spinal)
• Previous LTCS not associated with lower success
  rate, however, the magnitude of risk of uterine
  rupture is unknown
• No support for immediate induction to minimize
  reversion

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ECV Algorithm
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References

• ACOG practice bulletin (2000) Number 13
• Capital Health Womens Health Program Guidelines
  Protocols ECV (March, 2004)
• Hannah, ME et al (2000) Planned C/S vs planned
  vaginal birth for breech presentation at term.
  Lancet356 1375-83
• Hogle, KL et al (2003) Impact of the
  international term breech trial on clinical
  practice and concerns a survey of centre
  collaborators. JOGC 25 (1) 14-6
• Boucher, M et al (2003) The relationship between
  AFI successful ECV a 14 yrs experience. AJOG
  189 751-4
• Hofmeyr, GJ (2004) Interventions to help ECV for
  breech presentation at term. Cochrane Database
  Syst Rev 2004 (1) CD000184
• Zhang, J et al (1993) Efficacy of ECV a review.
  Obstet Gynecol 82 306-12
• Lau, TK et al (1997) Predictors of successful ECV
  at term. BJOG 104 798-802
• Williams, J et al (1999) Prospective study of ECV
  in Glasgow. Journal of Obstetrics Gynecology
  19 598-601
• Nor Azlin, MI et al (2005) Tocolysis in term
  breech ECV. Int J Gynecol Obst 88 5-8

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References

• Yasser, YE et al (2004) Randomized comparison of
  intravenous NTG subcutaneous terbutaline for
  ECV under tocolysis. AJOG 191 2051-5
• Bujold, E et al (2003) Sublingual NTG versus
  Placebo as a tocolytic for ECV. AJOG 189 1070-3
• Bujold, E et al (2003) Sublingual NTG versus
  intravenous Ritodrine as tocolytic for ECV. AJOG
  188 1454-9
• Impey, L Lissoni, D (1999) Outcome of ECV after
  36 weeks Gestation without tocolysis. The Journal
  of Maternal-Fetal Medicine 8 203-7
• Macarthur, AJ et al (2004) Anesthesia
  facilitation of ECV A meta-analysis. AJOG 191,
  1219-24
• Hutton, EK et al (2003) ECV beginning at 34 wks
  gestation versus 37 wks gestation. AJOG 189
  245-54
• De Meeus, JB et al (1998) ECV after previous
  cesarean section. European J of Obstetrics
  Gynecology Reproductive Biology 8 65-68
• Flamm, BL et al (1991) ECV after previous
  cesarean section. AJOG 165 370-2
• Yogev, Y et al (2002) Changing attitudes toward
  mode of delivery ECV in breech presentations.
  Int J Gynaecol Obstet 79 221-4

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References

• Leung, TY et al (2000) A survey of pregnant
  womens attitude toward breech delivery and ECV.
  Aust N Z J Obstet Gynaecol 40 253-9
• Raynes-Greenow, CH et al (2004) Pregnant womens
  preferences and knowledge of term breech
  management, in an Australian setting. Midwifery
  20 181-7
• Siddiqui, D et al (1999) Pregnancy outcome after
  successful ECV. AJOG 181 1092-5
• Vezina, Y et al (2004) Cesarean delivery after
  successful ECV of breech presentation at term.
  AJOG 190 763-8
• Chan, LY et al (2004) Intra partum cesarean
  delivery after successful ECV a meta-analysis.
  Obstet Gynecol 104 155-60

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Questions
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