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The efficacy of external cephalic version and its impact on the breech experience
The efficacy of external cephalic version and its impact on the breech experience Joseph W. Hanss, Jr., MD Phoenix, Arizona With the introduction of ultrasonography, tocolysis, and electronic fetal monitoring, external cephalic version is considered safer and is more frequently used for the management of breech presentation. A retrospective review of a level III obstetric unit for the year 1988 is reported. Three hundred fifty-seven breech births were recorded. One hundred twelve patients were seen for external cephalic version. Forty-seven patients (48.9%) were successfully converted from breech. The cesarean section rate of successful versus unsuccessful version was 17.2% and 77.5%, respectively, which demonstrates the effectiveness of the technique. The overall impact is small. Success measured as a vaginal cephalic delivery of a previously known breech presentation represented <0.5% of all deliveries and <10% of all breech deliveries at this institution dunng 1988. (AM J OBSTET GYNECOL 1990;162:1459-64.)
Key words: External cephalic version, breech presentation, reducing cesarean section rates Breech presentation has always been a challenge to those physicians who are involved with the birthing process. A historical study of ohstetric care for hreech presentation reveals the following: Hippocrates was said to practice external cephalic version, but when all attempts failed, fetal destruction was carried out and a large number of enabling instruments were designed over the ensuing cent 1I rit's.' Mau riceau. Slllcllie, Veit, and Braxton Hicks were but a few who began to understand the mechanism of breech delivery and to develop techniques of assisting and extracting the hreech." Piper added forceps to the ahercoming head." Some, such as Potter, became so enamored with breech delivery that all of his infants were delivered by breech extraction, even with internal version if necessary. During the twentieth century. cesarean senion became safer for mothers and its liberal use has nearly eliminated the fetal mortality associated with breech presentation: Our ethical dilemmas through the years have progressed through maternal mortality. fetal mortality, fetal morbidity, and currently, cesarean section rates. The science and philosophy of the above tend to be interpreted within the egocentric framework of the "art" and the "technology" of obstetrics. Beginning in the late 1960s, neonatal life support technology advanced so rapidly that in less than 20 years the age of viability decreased from 35 to 25 weeks' ~('station. The survival of very-low-birth-weight infants From North Central Obstetrics and GVllewlo[0. l.imited. }"l'Iented by invitation a/ the Fifty-sixth Annual Meeting of the Pacific Coast Obslftrical and (;ynecologital Society. Coronado. California, SI'/JlemiJer 1 i -21, 1989. NI'/Jlint requfsts:.!osl'jJh W. flallS.I • .!r.. 1'\;l]). 2320 X. Jrd SI., PhoelIix. AZ 85004. 6/6/19933
in today's neonatal intensive care units has nearly elimillated the heartrending decision as to when appropriate and safe operative intervention of pregnancy is reasonable. Because the incidence of breech presentation is inversely related to the gestational age at birth,' and since the overwhelming evidence supports cesarean section as the delivery method of choice for the premature breech, it would follow that the number of infants born from the breech may increase as the age of viability continues to decrease and the number of cesarean sections will correspondingly increase. The obstetric delivery method of choice for the term breech is not as clearly defined. b •R Cesarean section today has significantly reduced neonatal mortality. However, neonatal morhidity with cesarean section and vaginal delivery seemingly are the same.'; This article addresses the following questions: (1) is external cephalic version near term effective? (2) is it safe? and, (3) in a large obstetric service, does it have any impact on the overall breech experience and cesarean section rate?
Material and methods A retrospective review of a leveilII obstetric service in a community teaching hospital was completed for the year 1988. Attention focused on all patients scheduled for external cephalic versions, and all those with breech presentations at the time of delivery. Our protocol provides that any candidate for external cephalic version be admitted to the labor suite to ensure the availability of emergency services. After appropriate informed consent and permit signatures, fetal monitors are applied and ultrasonographic evaluation is done to determine presentation, placental localization, and amniotic fluid volume. Ultrasono1459
1460
Hanss
June 1990 Am J Obstet Gynecol
Table I. Scheduled outpatient appointments for external cephalic version
No. Total (%)
Appointments
Failed appointments
Appeared
Vertex on admission
Attempted version
148 100
36 24.3
112 75.7
16 10.8
96 64.9
Table II. Number and percent of successful and unsuccessful external cephalic versions
No. Total (%)
Attempted
Successful
96 100
47 48.9
Unsuccessful
49
51.0
graphically directed manipulation of the breech under tocolysis with either intramuscular or intravenous terbutaline is followed by electronic fetal monitoring. Rh immune globulin is administered when indicated. With adequate reassurance of fetal well-being, the patient is usually discharged to continue prenatal care at home and to await the onset of labor. A successful version is defined as a conversion from breech to cephalic presentation. The ultimate outcome of pregnancy in both groups, successful version and unsuccessful version, is evaluated and compared. All breeches, corrected breeches, and the overall cesarean section rates for 1988 are then related to cephalic version. One hundred forty-eight patient appointments for external cephalic versions were scheduled during the year 1988 (Table I). One hundred twelve visits were recorded. Thirty-six patients failed to keep their appointments. Ultrasonographic screening revealed an additional 16 patients whose fetal presentation was cephalic. External cephalic version was therefore attempted on 96 patients. Results
Forty-seven (48.9%) successful versions from breech to cephalic presentation were accomplished (Table II). Forty-nine (51.0%) attempts were unsuccessful. Subsequent follow-up (Table III) revealed that 38 (80.8%) of the patients with successful versions were delivered vaginally. Eight patients (17.0%) were delivered by cesarean section and one was lost to follow-up. One fetus reconverted to a single footling breech and was delivered by cesarean section. The most common indication for cesarean section was failure to descend in labor. Forty-nine attempts at cephalic version were unsuccessful. Examination of this group showed that 38 (77.5%) were eventually delivered by cesarean section, and five (10.2%) were delivered vaginally, (three breech, two cephalic). One of the cephalic presentations followed a repeat and successful version. One sponta-
neously converted to a cephalic presentation. Four patients of this group were lost to follow-up. The common indication for cesarean section of this group was breech presentation. Sixteen patients admitted for external version were found to have a cephalic presentation. Follow-up of this group showed that 10 women were delivered vaginally, four by cesarean section, and one was lost to follow-up. All vaginal deliveries were cephalic presentations. Two of the cesarean sections were for breech presentation. Thirty-five patients failed to keep appointments for external version. Follow-up of this group was nearly impossible. Pregnancy outcome could be determined in only seven of those 35 patients. Two were delivered vaginally and five had cesarean sections. There was no recorded morbidity associated with the version procedure within the study. Maternal or fetal hemorrhage, fetal injury, fetal distress, premature labor, or premature rupture of membranes were not observed. In 1988, 6627 births were recorded in the index institution (Table IV). There were 908 (13.7%) primary cesarean sections and 539 (8.1 %) repeat cesarean sections [total, 1447 (21.8%)]. Three hundred fifty-seven (5.4%) of all infants were born from a breech presentation. Of all breech presentations (357), 73 (20.4%) were delivered vaginally, 284 (79.5%) were delivered by cesarean section (231 (64.7%) primary, and 53 (14.8%) repeat cesarean sections). It is customary in the literature to correct breech presentation statistics for intrauterine death, twins, and congenital anomalies. Table V lists by weight-specific category all infants born from a breech presentation excluded according to these criteria. Table VI shows that 36 (13.6%) corrected breech infants were delivered vaginally. Two hundred twenty-eight (86.3%) were delivered by cesarean section. Therefore, excluding those breeches associated with intraute~ine death, multiple gestation, and congenital anomalies, the corrected number of breech deliveries was 264. Excluding prematurity, and thereby focusing on singl~ healthy infants with birth weights greater than 2500 gm, there was a total of 150 term healthy breech infants. One hundred thirty-four (89.3%) of these were delivered by cesarean section and 16 (10.7%) were delivered vaginally. In summary, of 6627 recorded births during 1988, 1447 (21.8%) were delivered by cesarean section. After
Effect of cephalic version on breech presentation
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Table III. Mode of delivery and presentation at birth of those patients scheduled for external cephalic version Vaginal delivery
Successful version Unsuccessful version Vertex on admission No shows
No.
No.
47 49* 16 36
38 5 10 2
I
Cesarean section
%
No.
80.8 10.2 62.5
8 38 5 5
I
Presentation at birth
%
Vertex
17.0 77.5 31.2
45 2 13 2
I
I
Breech I
Unknown I
41 2 5
4 1 28
* Includes two repeat attempts at version.
Table IV. Comparison of delivery for all births and breech presentations for 1988
All presentations Breech presentations
Number
Vaginal
6627 (100) 357 (5.4) [100]
5180 (78.2) 73 (l.l)
[20.4]
Primary cesarean section
Repeat cesarean section
Total cesarean section
908 (13.7) 231 (3.5) [64.7]
539 (8.1) 53 (0.8) [14.8]
1447 (21.8) 284 (4.3) [79.5]
Numbers in parentheses represent the percentage of all presentations; numbers in brackets represent the percentage of all breech presentations. correction for prematurity, fetal death, multiple gestation, and congenital anomalies, 150 term infants were delivered from the breech presentation. One hundred thirty-four (89.3%) were delivered by cesarean section. Sixteen (10.7%) were delivered vaginally. In addition to the above breech presentations, 47 successful cephalic versions were accomplished. If it is assumed that the cesarean section rate for these cases is 89.3%, if the infants had remained in the breech presentation, an additional 41 cesarean sections would have been required to deliver all breech cases for the year 1988. The overall cesarean section number would rise from 1447 (21.8%) to 1488 (22.4%), a difference of 0.6%. Comment
The management of breech presentation and delivery in the United States has encompassed scientific, legal, and ethical consideration of both mothers and infants. Within the lifetimes of many of us, maternal risk from cesarean section has been dramatically reduced. It is my opinion that too many of our recently trained specialists consider cesarean section a safer and better method of breech delivery for both mother and baby than use of forceps, or any manual manipulation of the fetus. Without exception, no other obstetric variation but the breech presentation has provided us the opportunity to abandon all scientific information, and to plunge forthwith into operative intervention. This is substantiated in this review by the following observations. Almost 90% of all term breech presentations were delivered by cesarean section, and there was an alarm-
Table V. Number of breech infants by weight-specific categories excluded for intrauterine death, twins, and congenital anomalies Birth weight Delivery method
Vaginal delivery Intrauterine fetal death Twins Congenital anomalies Subtotal Primary cesarean section Intrauterine fetal death Twins Congenital anomalies Subtotal Repeat cesarean sections Intrauterine fetal death Twins Congenital anomalies Subtotal TOTAL
0-750 gm
>2500 gm
8
6
2
0
4 0
2 2
7 0
6 0
12
10
9
6
0
0
0
0
3 0
7 0
21 1
10 4
3
7
22
14
0
0
0
0
0 0
0 0
7 0
3 0
0 15
0 17
7 38
3 23
ing lack of documentation concerning the classification of the breech presentation. The predominant indication for operative intervention was "breech in labor." There has been a significant effort both in the profes-
1462
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June l'l'JO A 1ll.J Obstcl C;vnecol
Table VI. Uncorrected and corrected breech presentations by weight-specific categories and mode of delivery Tutal M ode of delivery Vaginal Primary cesarean section Repeat cesarean section All cesarean sections TOTAL
No.
I
73 (36) 231 (185) 53 (43) 284 (228) 357 (264)
Bn-th weight %
0-750 gm
20.4 (13.6) 64.7 (70.1) 14.8 (16.2) 79.5 (86.3) 100 (100)
22 (10) 8 (5) I
(1) 9 (6) 31; 8.7% (16)(6.1%)
I
750-1500 gm
I
II (I)
31 (24) 8 (8) 39 (32) 50; 14.0% (33)(l2 ..~%)
1500-2500 grn 18 (9) 73 (51) 12 (5) 85 (56) 103; 28.8% (65)(24.6%)
r
>250(} gm 22 ( ](i)
119 (lOS)
32
(29) 151 (134) 17~1; 48.5% (150)(56.10/,)
Numbers in parentheses are corrected.
sional and lay literature to resurrect the technique of external cephalic version as a means of reducing our increasing and alarming cesarean section rate. Resurrection of the technique itself is not new. In another age, according to Edgar in 1904, I "Before the sixteenth century, it (cephalic version) was practically the only version used, but at that time podalic version was introduced and because of the ease of its performance, became very popular, and on this account. cephalic version was almost abandoned, although more recently revived by some obstetricians." External cephalic version became a well-recognized procedure after the publication of Hubert and Pinard in the 1800s," it was found to produce a zero neonatal mortality by Mehta in 1944: was advocated by Macarther in 1964,9 and was said to have decreasing value by Bradley-Watson in 1975.10 Ylikorkala and Hartikainen-Sorri" first reported the use of ultrasonography in conjunction with external version, and finally tocolysis became a factor that was to further reduce the complications and increase the success of cephalic version. 12 ." In this review, I was surprised, as were Flanagan et al. in their presentation to this society in 1987,15 to discover that our current success for external cephalic version was <50%. This success rate, despite ultrasonography and tocolysis, is little different than that reported by both Williams 2 and Edgar! at the turn of the century. However, the overwhelming difference in the rate of cesarean section versus vaginal delivery among successful versus unsuccessful versions is striking. The study demonstrates that in a community-based level III teaching obstetric service, 38 women who underwent cephalic version near term were delivered vaginally, thereby avoiding maternal risk, cost, and neonatal morbidity associated with cesarean section for breech presentation. The technique of version is apparently safe. At no time in the 96 attempted external versions was a major maternal or fetal complication recorded.
Finally, is there a major impact on the 1988 cesarean section rate by the use of external cephalic versions? Routine cesarean section for breech presentation was initially recommended in 1959 7 and became common in the United States in the mid-1970s, presumably as the legal risk of vaginal delivery of a breech presentation increased. This review demonstrated an almost 90% cesarean section rate for corrected term breech delivery. With this approach to the treatment of the breech, any attempt to prevent a breech presentation is valuable. Successful cephalic version allowed 38 women to be delivered vaginally and thereby avoid cesarean section. On a service where 6664 obstetric deliveries were recorded. 1447 cesarean sections were performed. Sixteen singleton term breeches were permitted to be delivered vaginally. External cephalic version reduced the potential cesarean section rate by 0.6%. The resurrection of an ancient technique for a far different reason than during the days of Hippocrates remains valid. To consider cephalic version a solution to our current problem of high cesarean section rates is not substantiated and we must seek other studies to determine methods that might significantly lower the cesarean section rate in the United States. REFERENCES 1. Edgar C]. The practice of obstetrics. 2nd ed. Philadelphia: Blakiston's Son & Co, 1904:987. 2. Williams ]W. Obstetrics. D. Appleton & Co, 1906:392. 3. Piper EB, Bachman C. The prevention of fetal injuries in breech delivery.]AMA 1929;92:217-21. 4. Mehta C. External version for breech presentation. Br Med] 1937; 706-9. 5. Weisman AI. An antepartum study of fetal polarity and rotation. AM J OBSTET GYNECOL 1944;4S:550-2. 6. C;reenJE, McLean F, Smith LP, Usher R. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J OBSTET GYNECOI. 1982;142:643-8. 7. Wright RC. Reduction of prenatal mortality and morbidity in breech delivery through random use of cesarean section. Obstet Gynecol 1959; 14:758-63. 8. Gimovsky ML, Wallace RL. Randomized management of
Volume 162
Effect of cephalic version on breech presentation
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Number G
9. 10. II.
12. 13. 14. 15.
the non frank breech presentation at term: a preliminary report. AM J OBSTET GYNECOL 1983; 146:34-40. Macarthur JL. Reduction of the hazards of breech presentation by external cephalic version. AM J OBSTET GyNECOL 1964;88:302-6. Bradley-Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. AM J OBSTET GYNECOL 1975;123:237-40. Ylikorkala 0, Hartikainen-Sorri A. Value of external version in fetal malpresentation at term: a preliminary report. Acta Obstet Gynecol Scand 1977;56:63-7. Fall O. Nilsson BA. External cephalic version in breech presentation under tocolysis. Obstet Gynecol 1979;53: 7I 2-5. Wallace RL, VonDorsten JP, Eglinton GS. Meuller E, McCart D. Schifrin BS. External cephalic version with lOcolysis. J Reprod Med 1984;29:745-8. Morrison JC, Myatt RE, Martin IN Jr, et al. External cephalic version of the breech presentation under tocolysis. AM J OBSTET GYNECOL 1986; 154:900-3. Flanagan TA. Mulchahey KM. Korenbrot CC, Green JR. Laros RK Jr. Management of term breech presentation. AMJ OBSTE1' GYNECOL 1987;156:1492-1502.
Editors' note: This manuscript was revised after these discussions were presented. Discussion
DR. DAVID PENT, Phoenix, Arizona. There has been considerable interest, both within our profession and in the media, concerning the high cesarean section rate and how to lower it. Dr. Brooks Ranney, in his 1973 paper, "The Gentle Art of External Cephalic Version," which detailed his experience with 860 attempted cephalic versions, stated that "conservatively estimated in various ways, the probable cesarean section rate for this entire group, without the use of version, would have been between 9% and 10%," instead of the 7.2% rate he reported.' As recently as last year, the "Update" audio cassette tapes,2 sponsored by the American College of Obstetricians and Gynecologists, in an issue on cesarean sections, noted that the rate could be reduced by an increase in vaginal births after cesarean section and by the more widespread use of external cephalic version. Dr. Hanss' paper beautifully illustrates that in his hospital the impact of external version on the section rate is disappointingly small. Even his figures, I believe, are optimistic. Very simply, we do not know how many of the fetuses who were successfully turned by external version would have turned spontaneously before the onset of labor. The patients in this series were at 36 weeks or later in gestation. Dr. Raymond Jennett graciously provided me a computer printout of his statistics from St. Joseph's Hospital in Phoenix. At 36 weeks' gestation 8.168% of the deliveries were breech, and at 40 weeks' this figure was 4.403%. This represents a spontaneous 46% change, remarkably similar to Dr. Hanss' reported 49% successful version rate. Obviously there are errors inherent in the comparison, including the fact that some of the version patients were past the thirty-sixth week, and also that the percentage of breeches delivered at any gestational age is greater than the percentage of fetuses in the breech position, since the latter position is thought to be conducive to pre-
mature labor. Similarly, it is unfortunate that more data could not be obtained regarding the patients who failed to keep their appointments for external version. Of the seven patients for whom we have data, two converted spontaneously. That represents 29%, but of course the numbers are too small for statistical significance. Brooks Ranney notes that attitudes concerning external cephalic version may be summarized by quoting J. L. Macarthur, who wrote, "There are those who enthusiastically recommend it, others who violently oppose it and still others who express a rather elegant distaste for it.'" Indeed as one reviews the literature, one sees dogmatic statements made both for and against version, with an extreme paucity of any type of data to support the conclusions. What is needed, now that we have entered the era of ultrasonography, fetal monitoring, and tocolysis, is data to relate how many fetuses are breech presentations at any given time in gestation and what is their "natural history." This could be ascertained by ultrasonographic examination, which would be able to define the exact presentation, because it is thought that frank breeches are more difficult to turn, with the extended legs acting as splints. Therefore there may be value in identifying a subgroup of breech presentation for whom version mayor may not be of value. It also would be profitable to compare hospitals, or groups of physicians, who do versions with those who do not. This has been reported in the past, and claims were made that hospitals that do not do versions had lower morbidity and mortality rates, but the exact figures are hard to determine and do not reflect the techniques currently being used. Finally, we need more data to evaluate cost effectiveness. At Dr. Hanss' hospital, the hospital charge for a vaginal delivery ranges from $1800 to $2600. The hospital charge for an external cephalic version is $900, one third to one half the (ost of a vaginal delivery. At that price we will have difficulty teaching versions to residents, so that they can develop the important necessary experience. I have two questions for Dr. Hanss. First, he mentions one unsuccessful version that was converted on a second attempt. Were there any other patients who underwent more than one attempt at cephalic version? Dr. Ranney probably holds the record in this regard, finally turning a baby on his eighth attempt and raising the question as to who was more stubborn-the fetus or the physician. Second, what were the contraindications for external cephalic version in these cases?
REFERENCES I. Ranney B. The gentle art of external cephalic version. AM
J OBS1'ET GYNECOL 1973; 116:239-51. 2. Jonas HS, Cefalo RC, Spellacy WN. Cesarean delivery. Update 1987;13:no. 5. 3. Macarthur JL. Reduction of the hazards of breech presentation by external cephalic version. AM J OBS1'ET (;YNECOL 1964;88:302-6.
DR. HANSS (Closing). Dr. Pent, there were only two repeat versions attempted. There is no effort on our
1464 Hanss
service to select patients based on the volume of amniotic fluid nor on the type of breech. All women who were seen with breech presentations were accepted for an attempt at version. Perhaps that lack of selection lowered the percentage of success. The earlier that version is attempted-at 28,30, or 32 weeks-the greater the success rate. Not only are there more breech cases at 30 weeks, but at this gestational age the majority would spontaneously convert to cephalic presentation. The only contraindications to version in this study were ruptured membranes or loss of heart rate variability on the monitor. Green et al. 1 pointed out in 1982 that the perinatal morbidity associated with vaginal delivery of a breech presentation is similar to that with cesarean section. In my review, I found a number of breech infants born by cesarean section who had low Apgar scores. I did not count them so I do not have a definite answer. We
June 1990 Am J Obstet Cynecol
can certainly eliminate the destructive instruments that obstetricians have known in the past, but we still must teach our residents the mechanism of breech delivery and some techniques for breech delivery including the Mauriceau-Smellie-Veit, the modified Prague maneuver, and the use of Piper forceps. Delivering a breech infant through an abdominal wall incision is very little different in terms of the mechanisms from delivering a breech through the vaginal canal. Today, many of our residents are deficient in the knowledge and skill necessary to safely extract a breech from the uterus, even through a lower uterine incision. REFERENCE 1. GreenJE, McLean F, Smith LP, Usher R. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J OBSTET GYNECOL 1982; 142:643-8.
Key words: External cephalic version, breech presentation, reducing cesarean section rates Breech presentation has always been a challenge to those physicians who are involved with the birthing process. A historical study of ohstetric care for hreech presentation reveals the following: Hippocrates was said to practice external cephalic version, but when all attempts failed, fetal destruction was carried out and a large number of enabling instruments were designed over the ensuing cent 1I rit's.' Mau riceau. Slllcllie, Veit, and Braxton Hicks were but a few who began to understand the mechanism of breech delivery and to develop techniques of assisting and extracting the hreech." Piper added forceps to the ahercoming head." Some, such as Potter, became so enamored with breech delivery that all of his infants were delivered by breech extraction, even with internal version if necessary. During the twentieth century. cesarean senion became safer for mothers and its liberal use has nearly eliminated the fetal mortality associated with breech presentation: Our ethical dilemmas through the years have progressed through maternal mortality. fetal mortality, fetal morbidity, and currently, cesarean section rates. The science and philosophy of the above tend to be interpreted within the egocentric framework of the "art" and the "technology" of obstetrics. Beginning in the late 1960s, neonatal life support technology advanced so rapidly that in less than 20 years the age of viability decreased from 35 to 25 weeks' ~('station. The survival of very-low-birth-weight infants From North Central Obstetrics and GVllewlo[0. l.imited. }"l'Iented by invitation a/ the Fifty-sixth Annual Meeting of the Pacific Coast Obslftrical and (;ynecologital Society. Coronado. California, SI'/JlemiJer 1 i -21, 1989. NI'/Jlint requfsts:.!osl'jJh W. flallS.I • .!r.. 1'\;l]). 2320 X. Jrd SI., PhoelIix. AZ 85004. 6/6/19933
in today's neonatal intensive care units has nearly elimillated the heartrending decision as to when appropriate and safe operative intervention of pregnancy is reasonable. Because the incidence of breech presentation is inversely related to the gestational age at birth,' and since the overwhelming evidence supports cesarean section as the delivery method of choice for the premature breech, it would follow that the number of infants born from the breech may increase as the age of viability continues to decrease and the number of cesarean sections will correspondingly increase. The obstetric delivery method of choice for the term breech is not as clearly defined. b •R Cesarean section today has significantly reduced neonatal mortality. However, neonatal morhidity with cesarean section and vaginal delivery seemingly are the same.'; This article addresses the following questions: (1) is external cephalic version near term effective? (2) is it safe? and, (3) in a large obstetric service, does it have any impact on the overall breech experience and cesarean section rate?
Material and methods A retrospective review of a leveilII obstetric service in a community teaching hospital was completed for the year 1988. Attention focused on all patients scheduled for external cephalic versions, and all those with breech presentations at the time of delivery. Our protocol provides that any candidate for external cephalic version be admitted to the labor suite to ensure the availability of emergency services. After appropriate informed consent and permit signatures, fetal monitors are applied and ultrasonographic evaluation is done to determine presentation, placental localization, and amniotic fluid volume. Ultrasono1459
1460
Hanss
June 1990 Am J Obstet Gynecol
Table I. Scheduled outpatient appointments for external cephalic version
No. Total (%)
Appointments
Failed appointments
Appeared
Vertex on admission
Attempted version
148 100
36 24.3
112 75.7
16 10.8
96 64.9
Table II. Number and percent of successful and unsuccessful external cephalic versions
No. Total (%)
Attempted
Successful
96 100
47 48.9
Unsuccessful
49
51.0
graphically directed manipulation of the breech under tocolysis with either intramuscular or intravenous terbutaline is followed by electronic fetal monitoring. Rh immune globulin is administered when indicated. With adequate reassurance of fetal well-being, the patient is usually discharged to continue prenatal care at home and to await the onset of labor. A successful version is defined as a conversion from breech to cephalic presentation. The ultimate outcome of pregnancy in both groups, successful version and unsuccessful version, is evaluated and compared. All breeches, corrected breeches, and the overall cesarean section rates for 1988 are then related to cephalic version. One hundred forty-eight patient appointments for external cephalic versions were scheduled during the year 1988 (Table I). One hundred twelve visits were recorded. Thirty-six patients failed to keep their appointments. Ultrasonographic screening revealed an additional 16 patients whose fetal presentation was cephalic. External cephalic version was therefore attempted on 96 patients. Results
Forty-seven (48.9%) successful versions from breech to cephalic presentation were accomplished (Table II). Forty-nine (51.0%) attempts were unsuccessful. Subsequent follow-up (Table III) revealed that 38 (80.8%) of the patients with successful versions were delivered vaginally. Eight patients (17.0%) were delivered by cesarean section and one was lost to follow-up. One fetus reconverted to a single footling breech and was delivered by cesarean section. The most common indication for cesarean section was failure to descend in labor. Forty-nine attempts at cephalic version were unsuccessful. Examination of this group showed that 38 (77.5%) were eventually delivered by cesarean section, and five (10.2%) were delivered vaginally, (three breech, two cephalic). One of the cephalic presentations followed a repeat and successful version. One sponta-
neously converted to a cephalic presentation. Four patients of this group were lost to follow-up. The common indication for cesarean section of this group was breech presentation. Sixteen patients admitted for external version were found to have a cephalic presentation. Follow-up of this group showed that 10 women were delivered vaginally, four by cesarean section, and one was lost to follow-up. All vaginal deliveries were cephalic presentations. Two of the cesarean sections were for breech presentation. Thirty-five patients failed to keep appointments for external version. Follow-up of this group was nearly impossible. Pregnancy outcome could be determined in only seven of those 35 patients. Two were delivered vaginally and five had cesarean sections. There was no recorded morbidity associated with the version procedure within the study. Maternal or fetal hemorrhage, fetal injury, fetal distress, premature labor, or premature rupture of membranes were not observed. In 1988, 6627 births were recorded in the index institution (Table IV). There were 908 (13.7%) primary cesarean sections and 539 (8.1 %) repeat cesarean sections [total, 1447 (21.8%)]. Three hundred fifty-seven (5.4%) of all infants were born from a breech presentation. Of all breech presentations (357), 73 (20.4%) were delivered vaginally, 284 (79.5%) were delivered by cesarean section (231 (64.7%) primary, and 53 (14.8%) repeat cesarean sections). It is customary in the literature to correct breech presentation statistics for intrauterine death, twins, and congenital anomalies. Table V lists by weight-specific category all infants born from a breech presentation excluded according to these criteria. Table VI shows that 36 (13.6%) corrected breech infants were delivered vaginally. Two hundred twenty-eight (86.3%) were delivered by cesarean section. Therefore, excluding those breeches associated with intraute~ine death, multiple gestation, and congenital anomalies, the corrected number of breech deliveries was 264. Excluding prematurity, and thereby focusing on singl~ healthy infants with birth weights greater than 2500 gm, there was a total of 150 term healthy breech infants. One hundred thirty-four (89.3%) of these were delivered by cesarean section and 16 (10.7%) were delivered vaginally. In summary, of 6627 recorded births during 1988, 1447 (21.8%) were delivered by cesarean section. After
Effect of cephalic version on breech presentation
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1461
Table III. Mode of delivery and presentation at birth of those patients scheduled for external cephalic version Vaginal delivery
Successful version Unsuccessful version Vertex on admission No shows
No.
No.
47 49* 16 36
38 5 10 2
I
Cesarean section
%
No.
80.8 10.2 62.5
8 38 5 5
I
Presentation at birth
%
Vertex
17.0 77.5 31.2
45 2 13 2
I
I
Breech I
Unknown I
41 2 5
4 1 28
* Includes two repeat attempts at version.
Table IV. Comparison of delivery for all births and breech presentations for 1988
All presentations Breech presentations
Number
Vaginal
6627 (100) 357 (5.4) [100]
5180 (78.2) 73 (l.l)
[20.4]
Primary cesarean section
Repeat cesarean section
Total cesarean section
908 (13.7) 231 (3.5) [64.7]
539 (8.1) 53 (0.8) [14.8]
1447 (21.8) 284 (4.3) [79.5]
Numbers in parentheses represent the percentage of all presentations; numbers in brackets represent the percentage of all breech presentations. correction for prematurity, fetal death, multiple gestation, and congenital anomalies, 150 term infants were delivered from the breech presentation. One hundred thirty-four (89.3%) were delivered by cesarean section. Sixteen (10.7%) were delivered vaginally. In addition to the above breech presentations, 47 successful cephalic versions were accomplished. If it is assumed that the cesarean section rate for these cases is 89.3%, if the infants had remained in the breech presentation, an additional 41 cesarean sections would have been required to deliver all breech cases for the year 1988. The overall cesarean section number would rise from 1447 (21.8%) to 1488 (22.4%), a difference of 0.6%. Comment
The management of breech presentation and delivery in the United States has encompassed scientific, legal, and ethical consideration of both mothers and infants. Within the lifetimes of many of us, maternal risk from cesarean section has been dramatically reduced. It is my opinion that too many of our recently trained specialists consider cesarean section a safer and better method of breech delivery for both mother and baby than use of forceps, or any manual manipulation of the fetus. Without exception, no other obstetric variation but the breech presentation has provided us the opportunity to abandon all scientific information, and to plunge forthwith into operative intervention. This is substantiated in this review by the following observations. Almost 90% of all term breech presentations were delivered by cesarean section, and there was an alarm-
Table V. Number of breech infants by weight-specific categories excluded for intrauterine death, twins, and congenital anomalies Birth weight Delivery method
Vaginal delivery Intrauterine fetal death Twins Congenital anomalies Subtotal Primary cesarean section Intrauterine fetal death Twins Congenital anomalies Subtotal Repeat cesarean sections Intrauterine fetal death Twins Congenital anomalies Subtotal TOTAL
0-750 gm
>2500 gm
8
6
2
0
4 0
2 2
7 0
6 0
12
10
9
6
0
0
0
0
3 0
7 0
21 1
10 4
3
7
22
14
0
0
0
0
0 0
0 0
7 0
3 0
0 15
0 17
7 38
3 23
ing lack of documentation concerning the classification of the breech presentation. The predominant indication for operative intervention was "breech in labor." There has been a significant effort both in the profes-
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June l'l'JO A 1ll.J Obstcl C;vnecol
Table VI. Uncorrected and corrected breech presentations by weight-specific categories and mode of delivery Tutal M ode of delivery Vaginal Primary cesarean section Repeat cesarean section All cesarean sections TOTAL
No.
I
73 (36) 231 (185) 53 (43) 284 (228) 357 (264)
Bn-th weight %
0-750 gm
20.4 (13.6) 64.7 (70.1) 14.8 (16.2) 79.5 (86.3) 100 (100)
22 (10) 8 (5) I
(1) 9 (6) 31; 8.7% (16)(6.1%)
I
750-1500 gm
I
II (I)
31 (24) 8 (8) 39 (32) 50; 14.0% (33)(l2 ..~%)
1500-2500 grn 18 (9) 73 (51) 12 (5) 85 (56) 103; 28.8% (65)(24.6%)
r
>250(} gm 22 ( ](i)
119 (lOS)
32
(29) 151 (134) 17~1; 48.5% (150)(56.10/,)
Numbers in parentheses are corrected.
sional and lay literature to resurrect the technique of external cephalic version as a means of reducing our increasing and alarming cesarean section rate. Resurrection of the technique itself is not new. In another age, according to Edgar in 1904, I "Before the sixteenth century, it (cephalic version) was practically the only version used, but at that time podalic version was introduced and because of the ease of its performance, became very popular, and on this account. cephalic version was almost abandoned, although more recently revived by some obstetricians." External cephalic version became a well-recognized procedure after the publication of Hubert and Pinard in the 1800s," it was found to produce a zero neonatal mortality by Mehta in 1944: was advocated by Macarther in 1964,9 and was said to have decreasing value by Bradley-Watson in 1975.10 Ylikorkala and Hartikainen-Sorri" first reported the use of ultrasonography in conjunction with external version, and finally tocolysis became a factor that was to further reduce the complications and increase the success of cephalic version. 12 ." In this review, I was surprised, as were Flanagan et al. in their presentation to this society in 1987,15 to discover that our current success for external cephalic version was <50%. This success rate, despite ultrasonography and tocolysis, is little different than that reported by both Williams 2 and Edgar! at the turn of the century. However, the overwhelming difference in the rate of cesarean section versus vaginal delivery among successful versus unsuccessful versions is striking. The study demonstrates that in a community-based level III teaching obstetric service, 38 women who underwent cephalic version near term were delivered vaginally, thereby avoiding maternal risk, cost, and neonatal morbidity associated with cesarean section for breech presentation. The technique of version is apparently safe. At no time in the 96 attempted external versions was a major maternal or fetal complication recorded.
Finally, is there a major impact on the 1988 cesarean section rate by the use of external cephalic versions? Routine cesarean section for breech presentation was initially recommended in 1959 7 and became common in the United States in the mid-1970s, presumably as the legal risk of vaginal delivery of a breech presentation increased. This review demonstrated an almost 90% cesarean section rate for corrected term breech delivery. With this approach to the treatment of the breech, any attempt to prevent a breech presentation is valuable. Successful cephalic version allowed 38 women to be delivered vaginally and thereby avoid cesarean section. On a service where 6664 obstetric deliveries were recorded. 1447 cesarean sections were performed. Sixteen singleton term breeches were permitted to be delivered vaginally. External cephalic version reduced the potential cesarean section rate by 0.6%. The resurrection of an ancient technique for a far different reason than during the days of Hippocrates remains valid. To consider cephalic version a solution to our current problem of high cesarean section rates is not substantiated and we must seek other studies to determine methods that might significantly lower the cesarean section rate in the United States. REFERENCES 1. Edgar C]. The practice of obstetrics. 2nd ed. Philadelphia: Blakiston's Son & Co, 1904:987. 2. Williams ]W. Obstetrics. D. Appleton & Co, 1906:392. 3. Piper EB, Bachman C. The prevention of fetal injuries in breech delivery.]AMA 1929;92:217-21. 4. Mehta C. External version for breech presentation. Br Med] 1937; 706-9. 5. Weisman AI. An antepartum study of fetal polarity and rotation. AM J OBSTET GYNECOL 1944;4S:550-2. 6. C;reenJE, McLean F, Smith LP, Usher R. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J OBSTET GYNECOI. 1982;142:643-8. 7. Wright RC. Reduction of prenatal mortality and morbidity in breech delivery through random use of cesarean section. Obstet Gynecol 1959; 14:758-63. 8. Gimovsky ML, Wallace RL. Randomized management of
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Effect of cephalic version on breech presentation
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9. 10. II.
12. 13. 14. 15.
the non frank breech presentation at term: a preliminary report. AM J OBSTET GYNECOL 1983; 146:34-40. Macarthur JL. Reduction of the hazards of breech presentation by external cephalic version. AM J OBSTET GyNECOL 1964;88:302-6. Bradley-Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. AM J OBSTET GYNECOL 1975;123:237-40. Ylikorkala 0, Hartikainen-Sorri A. Value of external version in fetal malpresentation at term: a preliminary report. Acta Obstet Gynecol Scand 1977;56:63-7. Fall O. Nilsson BA. External cephalic version in breech presentation under tocolysis. Obstet Gynecol 1979;53: 7I 2-5. Wallace RL, VonDorsten JP, Eglinton GS. Meuller E, McCart D. Schifrin BS. External cephalic version with lOcolysis. J Reprod Med 1984;29:745-8. Morrison JC, Myatt RE, Martin IN Jr, et al. External cephalic version of the breech presentation under tocolysis. AM J OBSTET GYNECOL 1986; 154:900-3. Flanagan TA. Mulchahey KM. Korenbrot CC, Green JR. Laros RK Jr. Management of term breech presentation. AMJ OBSTE1' GYNECOL 1987;156:1492-1502.
Editors' note: This manuscript was revised after these discussions were presented. Discussion
DR. DAVID PENT, Phoenix, Arizona. There has been considerable interest, both within our profession and in the media, concerning the high cesarean section rate and how to lower it. Dr. Brooks Ranney, in his 1973 paper, "The Gentle Art of External Cephalic Version," which detailed his experience with 860 attempted cephalic versions, stated that "conservatively estimated in various ways, the probable cesarean section rate for this entire group, without the use of version, would have been between 9% and 10%," instead of the 7.2% rate he reported.' As recently as last year, the "Update" audio cassette tapes,2 sponsored by the American College of Obstetricians and Gynecologists, in an issue on cesarean sections, noted that the rate could be reduced by an increase in vaginal births after cesarean section and by the more widespread use of external cephalic version. Dr. Hanss' paper beautifully illustrates that in his hospital the impact of external version on the section rate is disappointingly small. Even his figures, I believe, are optimistic. Very simply, we do not know how many of the fetuses who were successfully turned by external version would have turned spontaneously before the onset of labor. The patients in this series were at 36 weeks or later in gestation. Dr. Raymond Jennett graciously provided me a computer printout of his statistics from St. Joseph's Hospital in Phoenix. At 36 weeks' gestation 8.168% of the deliveries were breech, and at 40 weeks' this figure was 4.403%. This represents a spontaneous 46% change, remarkably similar to Dr. Hanss' reported 49% successful version rate. Obviously there are errors inherent in the comparison, including the fact that some of the version patients were past the thirty-sixth week, and also that the percentage of breeches delivered at any gestational age is greater than the percentage of fetuses in the breech position, since the latter position is thought to be conducive to pre-
mature labor. Similarly, it is unfortunate that more data could not be obtained regarding the patients who failed to keep their appointments for external version. Of the seven patients for whom we have data, two converted spontaneously. That represents 29%, but of course the numbers are too small for statistical significance. Brooks Ranney notes that attitudes concerning external cephalic version may be summarized by quoting J. L. Macarthur, who wrote, "There are those who enthusiastically recommend it, others who violently oppose it and still others who express a rather elegant distaste for it.'" Indeed as one reviews the literature, one sees dogmatic statements made both for and against version, with an extreme paucity of any type of data to support the conclusions. What is needed, now that we have entered the era of ultrasonography, fetal monitoring, and tocolysis, is data to relate how many fetuses are breech presentations at any given time in gestation and what is their "natural history." This could be ascertained by ultrasonographic examination, which would be able to define the exact presentation, because it is thought that frank breeches are more difficult to turn, with the extended legs acting as splints. Therefore there may be value in identifying a subgroup of breech presentation for whom version mayor may not be of value. It also would be profitable to compare hospitals, or groups of physicians, who do versions with those who do not. This has been reported in the past, and claims were made that hospitals that do not do versions had lower morbidity and mortality rates, but the exact figures are hard to determine and do not reflect the techniques currently being used. Finally, we need more data to evaluate cost effectiveness. At Dr. Hanss' hospital, the hospital charge for a vaginal delivery ranges from $1800 to $2600. The hospital charge for an external cephalic version is $900, one third to one half the (ost of a vaginal delivery. At that price we will have difficulty teaching versions to residents, so that they can develop the important necessary experience. I have two questions for Dr. Hanss. First, he mentions one unsuccessful version that was converted on a second attempt. Were there any other patients who underwent more than one attempt at cephalic version? Dr. Ranney probably holds the record in this regard, finally turning a baby on his eighth attempt and raising the question as to who was more stubborn-the fetus or the physician. Second, what were the contraindications for external cephalic version in these cases?
REFERENCES I. Ranney B. The gentle art of external cephalic version. AM
J OBS1'ET GYNECOL 1973; 116:239-51. 2. Jonas HS, Cefalo RC, Spellacy WN. Cesarean delivery. Update 1987;13:no. 5. 3. Macarthur JL. Reduction of the hazards of breech presentation by external cephalic version. AM J OBS1'ET (;YNECOL 1964;88:302-6.
DR. HANSS (Closing). Dr. Pent, there were only two repeat versions attempted. There is no effort on our
1464 Hanss
service to select patients based on the volume of amniotic fluid nor on the type of breech. All women who were seen with breech presentations were accepted for an attempt at version. Perhaps that lack of selection lowered the percentage of success. The earlier that version is attempted-at 28,30, or 32 weeks-the greater the success rate. Not only are there more breech cases at 30 weeks, but at this gestational age the majority would spontaneously convert to cephalic presentation. The only contraindications to version in this study were ruptured membranes or loss of heart rate variability on the monitor. Green et al. 1 pointed out in 1982 that the perinatal morbidity associated with vaginal delivery of a breech presentation is similar to that with cesarean section. In my review, I found a number of breech infants born by cesarean section who had low Apgar scores. I did not count them so I do not have a definite answer. We
June 1990 Am J Obstet Cynecol
can certainly eliminate the destructive instruments that obstetricians have known in the past, but we still must teach our residents the mechanism of breech delivery and some techniques for breech delivery including the Mauriceau-Smellie-Veit, the modified Prague maneuver, and the use of Piper forceps. Delivering a breech infant through an abdominal wall incision is very little different in terms of the mechanisms from delivering a breech through the vaginal canal. Today, many of our residents are deficient in the knowledge and skill necessary to safely extract a breech from the uterus, even through a lower uterine incision. REFERENCE 1. GreenJE, McLean F, Smith LP, Usher R. Has an increased cesarean section rate for term breech delivery reduced the incidence of birth asphyxia, trauma and death? AM J OBSTET GYNECOL 1982; 142:643-8.