- Email: [email protected]
The incidence of spontaneous version after failed external cephalic version
Research
www. AJOG.org
OBSTETRICS
The incidence of spontaneous version after failed external cephalic version Assaf Ben-Meir, MD; Tamar Elram, MD; Avi Tsafrir, MD; Uriel Elchalal, MD; Yossef Ezra, MD OBJECTIVE: The objective of the study was to assess the rate of spontaneous version after failed external cephalic version (ECV) at term.
sions, 3 were in the nulliparous group (2.3%) and 12 in the multiparous group (12.5%).
STUDY DESIGN: We prospectively collected data from all trials of ECV
CONCLUSION: The incidence of spontaneous version after failed ECV is small, at least in nulliparous women. We recommend that ECV attempts should be undertaken in a setting prepared for elective cesarean section in the event of ECV failure, if vaginal breech delivery is not considered an option, and preferably after 39 weeks to decrease neonatal morbidity from respiratory complications.
in our center between January 1997 and June 2005. Collected data included demographic and obstetric parameters. RESULTS: Six hundred three ECV attempts were included in the study. Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Of the 226 failed attempts (8 were lost to follow-up), the rate of spontaneous version to vertex presentation before the onset of labor was 6.6%. Of all 15 spontaneous ver-
Key words: breech presentation, cesarean section, external cephalic version, spontaneous version
Cite this article as: Ben-Meir A, Elram T, Tsafrir A, et al. The incidence of spontaneous version after failed external cephalic version. Am J Obstet Gynecol 2007;196;157.e1-157.e3.
B
reech presentation occurs in 3-4% of all pregnancies at term and is a major contributor to the cesarean section (CS) rate. The findings of the Term Breech Trial1 resulted in a greatly reduced occurrence of vaginal breech delivery in developed countries. However, external cephalic version (ECV) at term is associated with a significant reduction in noncephalic births and CS rates.2 The latest guidelines of both the American College of Obstetricians and Gynecologists3 and the British Royal College of Obstetricians and Gynaecologists4 recommend ECV to reduce the rate of breech presentation at term.3,4 Under these circumstances, the impact of ECV on the CS rate would be expected to be greater than when vaginal breech delivery was a common practice. From the Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel Received April 30, 2006; revised September 18, 2006; accepted October 24, 2006. Reprints will not be available from the authors. 0002-9378/free © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.10.889
The reported success rate of ECV varies from 35% to 86%.5,6 Several factors were associated with successful ECV, but a prediction model based on clinical parameters was found to be insufficiently accurate in predicting ECV outcome.5,6 Despite extensive clinical experience with ECV, the optimal course of action following failed ECV is still unclear. In some cases, spontaneous version to cephalic presentation occurs at term; thus, expectant management until the onset of labor may be beneficial for some women who wish to give birth vaginally. However, if the fetus remains in breech presentation, an urgent CS will be needed when labor ensues. A nonelective abdominal delivery is associated with a higher complication rate as well as an additional logistic burden on the obstetric unit. Some reports have described the chances of spontaneous version of breech presentation near term. However, little is known about the natural history following a failed ECV. The aims of this study were to investigate the natural course of pregnancy after a failed attempt of cephalic version and to define the preferred clinical management in this situation.
M ATERIALS AND M ETHODS The study population consisted of all women with singleton pregnancies who had an attempt of ECV at or after 37 weeks’ gestation between January 1997 and June 2005. During the study period, in the absence of contraindication, ECV was offered to all women with singleton pregnancy in breech presentation at 37 weeks’ gestation or beyond. Contraindications for ECV were active labor, amnionitis, placental abruption, nonreassuring fetal heart rate monitoring, and ruptured fetal membranes. Furthermore, we did not include in this study patients with previous cesarean section. However, anterior placentation or low amniotic fluid index (AFI) were not considered exclusion criteria for ECV. Following a biophysical profile and a nonstress fetal heart rate test (FHR), all ECVs were performed in the delivery room by an experienced senior obstetrician with the aid of sonography. Tocolysis by intravenous ritodrine (until 2003) or oral nifedipine (beginning in 2003) was used unless the patient had a contraindication for these medications. Following the ECV procedure (successful or unsuccessful) and recording of a reassuring FHR, the patient was dis-
FEBRUARY 2007 American Journal of Obstetrics & Gynecology
157.e1
Research
Obstetrics
www.AJOG.org
TABLE
General characteristics of ECV attempts (n ⴝ 603) No. of nulliparae (percent of total)
256 (42.4)
No. of multiparae (percent of total)
347 (57.6)
Parity (mean ⫾ SD)
1.39 ⫾ 1.80
BMI (mean ⫾ SD)
27.1 ⫾ 4.0
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Previous cesarean section, no. (%)
35 (5.7)
..............................................................................................................................................................................................................................................
charged for routine obstetric care until the onset of spontaneous labor. Before the ECV attempt, data on several maternal demographic and obstetric parameters were collected, including parity, weight, height, previous CS, placental location, fetal weight estimation, type of noncephalic presentation, and AFI.
AFI, no. (%)
.....................................................................................................................................................................................................................................
Oligohydramnios
23 (3.8)
.....................................................................................................................................................................................................................................
Appropriate
544 (90.2)
.....................................................................................................................................................................................................................................
Polyhydramnios
36 (6.0)
..............................................................................................................................................................................................................................................
Placental location, no. (%)
.....................................................................................................................................................................................................................................
Anterior
216 (35.8)
Posterior
210 (34.8)
Fundal
134 (22.2)
Corner
43 (7.2)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Type of breech, no. (%)
.....................................................................................................................................................................................................................................
Frank
247 (41.0)
Complete
329 (54.6)
Incomplete
27 (4.4)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Sonographic EFW (g), mean ⫾ SD
2979 ⫾ 435
Clinical EFW (g), mean ⫾ SD
3032 ⫾ 408
Lag to delivery (days), mean ⫾ SD
10.0 ⫾ 8.8
Gestational age at ECV attempt (wks), mean ⫾ SD (range)
38.3 ⫾ 1.2 (37-42)
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
BMI, body mass index; EFW, estimated fetal weight.
FIGURE
Summary characteristics of ECV population Trial of ECV N=603 (100%)
Primiparae n=256
Successed ECV n=118 (46.1%)
Multiparae n=347
Failed ECV n=138 (53.9%)
Successed ECV n=251 (72.3%)
R ESULTS There were 603 ECV attempts during the study period (Table). The success rate of ECV was 72.3% and 46.1% for multiparas and nulliparas, respectively. There was 1 case of mild placental abruption following a repeated attempt of ECV after a failed attempt a week earlier. The mean lag time between the ECV attempt and the onset of labor was 9.07 ⫾ 7.71 days (range 0-28, data available for 203 patients). The CS rate of patients with successful ECV who presented in active labor with cephalic presentation was 9.7%. (The primary CS rate in our institution was 5.5% during that period.) Indications for CS were arrest of head decent and nonreassuring fetal heart rate. Of the 603 ECV attempts, there were 234 failures (38.8%). Eight (3.4%) were lost to follow-up (Figure). The overall spontaneous version rate after failed ECV to vertex presentation before the onset of labor was 6.6%. AFI did not correlate with chances for spontaneous version after failed ECV, and all these cases had normal AFI. In this group mean lag time from ECV attempt to delivery was 12.3 ⫾ 9.3 days (range 1-24 days), and mean birth weight was 3129.4 ⫾ 391.6 g (range 2350-3910 g). There was no case of spontaneous version to breech after successful ECV.
Failed ECV n=96 (27.7%)
C OMMENT Lost to follow up n=8
Persistent breech n=127
157.e2
Persistent breech n=84
Spontaneous cephalic version n=3 (2.3%)
American Journal of Obstetrics & Gynecology FEBRUARY 2007
Spontaneous cephalic version n=12 (12.5%)
The present study examined the natural course of pregnancy after a failed trial of ECV. We followed up a relatively large group of patients from the failed ECV attempt without further intervention until the onset of spontaneous labor. We found that the overall rate of spontaneous version of breech presentation after
Obstetrics
www.AJOG.org failed ECV attempt at term was extremely low. Our results are generally in agreement with other reports. However, the existing reports are very few and usually nondirective. In the series of Impey and Pandit,7 there were 4 cases of spontaneous versions of 124 (3.2%) cases that had a repeat trial of ECV. There is no information regarding the parity of these spontaneous versions. In a multicenter early ECV trial, only 1 case (1 of 60, 1.7%) of spontaneous version was found in the term group.8 In a smaller study, Rozenberg et al9 reported on 41 patients after a failed repeated trial of ECV under epidural anesthesia. In this series there was no case of spontaneous version to vertex presentation. Following a failed ECV, the clinician and patient who are unwilling to consider a vaginal breech delivery need to decide whether to perform a planned cesarean delivery or to await a spontaneous delivery with the hope of spontaneous version to cephalic presentation. Our study, supported by the literature, shows that there is a very low chance for spontaneous version in nulliparas and a small chance in multiparas. Accumulating evidence favors a planned CS, compared with a nonscheduled CS. According to the report on confidential inquiries into maternal deaths in the United Kingdom (1997-1999), the relative risks for mortality in cases of scheduled CS and intrapartum CS were 0.8 and 12.0, respectively, with the risk of intrapartum mortality in vaginal delivery considered to be 1.0.10 According to the data from the Term Breech Trial, the risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio 0.13).11 The ECV procedure is not free of risk, as summarized recently by Collaris and Oei.12 In their study, the most frequently reported complications were transient
FHR changes (5.7%), persistent FHR changes (0.37%), and vaginal bleeding (0.4%). The incidence of reported placental abruption was 0.12% (in our series, 0.16%). The reported incidence of fetomaternal hemorrhage was 3.7%, and emergency CS was performed in 0.43% of cases. Perinatal mortality was 0.16%. Some of these consequences may present only after the patient has been discharged. Immediate delivery after ECV would be expected to reduce these potential complications. In addition, a policy of immediate and elective cesarean delivery after failed ECV might decrease the burden of emergent CS on delivery room staff. Finally, because epidural analgesia appears to increase the chance for a successful ECV,9,13 CS performed immediately after a failed ECV using the existing anesthesia is expected to obviate an unnecessary second anesthesia. Delivering women by cesarean section before 39 weeks would lead to an increase in neonatal morbidity from respiratory complications14; thus, it may be beneficial to perform ECV and delivery at 39 weeks or later. In conclusion, the chance for spontaneous version after a failed ECV at term is small, especially in nulliparae. When vaginal breech delivery is not an option, we recommend a policy of performing ECV close to 39 weeks and after a failed attempt to offer a cesarean delivery as soon as possible. However, multiparous women should be made aware of these results, and from then on it becomes a judgment call. f 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;356:1375-83.
Research
2. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Databases Syst Rev 1996;1:CD000083. 3. Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. No. 265, December 2001. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 2002;77:65-6. 4. Royal College of Obstetricians and Gynaecologists. The management of breech presentation. Guideline no. 20. RCOG Clinical Green Top Guidelines, 2001. 5. Chan LY, Leung TY, Fok WY, Chan LW, Lau TK. Prediction of successful vaginal delivery in women undergoing external cephalic version at term for breech presentation. Eur J Obstet Gynecol Reprod Biol 2004;116:39-42. 6. Ezra Y, Elram T, Plotkin V, Elchalal U. Significance of success rate of external cephalic versions and vaginal breech deliveries in counseling women with breech presentation at term. Eur J Obstet Gynecol Reprod Biol 2000;90:63-6. 7. Impey L, Pandit M. Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebocontrolled trial. Br J Obstet Gynaecol 2005;112:627-31. 8. Hutton EK, Kaufman K, Hodnett E, et al. External cephalic version beginning at 34 weeks’ gestation versus 37 weeks’ gestation: a randomized multicenter trial. Am J Obstet Gynecol 2003;189:245-54. 9. Rozenberg P, Goffinet F, de Spirlet M, et al. External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics. BJOG 2000;107:406-10. 10. Drife J, Lewis G. Why mothers die. Confidential enquiries into maternal deaths in the United Kingdom 1997-1999. London, UK: RCOG Press; 2001. 11. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189:740-5. 12. Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand 2004;83:511-8. 13. Hofmeyr GJ, Gyte G. Interventions to help external cephalic version for breech presentation at term. Cochrane Databases Syst Rev 2004;1:CD000184. 14. Morrison JJ, Rennie JM, Milton PJ, Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
FEBRUARY 2007 American Journal of Obstetrics & Gynecology
157.e3
www. AJOG.org
OBSTETRICS
The incidence of spontaneous version after failed external cephalic version Assaf Ben-Meir, MD; Tamar Elram, MD; Avi Tsafrir, MD; Uriel Elchalal, MD; Yossef Ezra, MD OBJECTIVE: The objective of the study was to assess the rate of spontaneous version after failed external cephalic version (ECV) at term.
sions, 3 were in the nulliparous group (2.3%) and 12 in the multiparous group (12.5%).
STUDY DESIGN: We prospectively collected data from all trials of ECV
CONCLUSION: The incidence of spontaneous version after failed ECV is small, at least in nulliparous women. We recommend that ECV attempts should be undertaken in a setting prepared for elective cesarean section in the event of ECV failure, if vaginal breech delivery is not considered an option, and preferably after 39 weeks to decrease neonatal morbidity from respiratory complications.
in our center between January 1997 and June 2005. Collected data included demographic and obstetric parameters. RESULTS: Six hundred three ECV attempts were included in the study. Success rates were 72.3% and 46.1% for multiparas and nulliparas, respectively. Of the 226 failed attempts (8 were lost to follow-up), the rate of spontaneous version to vertex presentation before the onset of labor was 6.6%. Of all 15 spontaneous ver-
Key words: breech presentation, cesarean section, external cephalic version, spontaneous version
Cite this article as: Ben-Meir A, Elram T, Tsafrir A, et al. The incidence of spontaneous version after failed external cephalic version. Am J Obstet Gynecol 2007;196;157.e1-157.e3.
B
reech presentation occurs in 3-4% of all pregnancies at term and is a major contributor to the cesarean section (CS) rate. The findings of the Term Breech Trial1 resulted in a greatly reduced occurrence of vaginal breech delivery in developed countries. However, external cephalic version (ECV) at term is associated with a significant reduction in noncephalic births and CS rates.2 The latest guidelines of both the American College of Obstetricians and Gynecologists3 and the British Royal College of Obstetricians and Gynaecologists4 recommend ECV to reduce the rate of breech presentation at term.3,4 Under these circumstances, the impact of ECV on the CS rate would be expected to be greater than when vaginal breech delivery was a common practice. From the Department of Obstetrics and Gynecology, Hadassah Hebrew University Medical Center, Ein-Kerem, Jerusalem, Israel Received April 30, 2006; revised September 18, 2006; accepted October 24, 2006. Reprints will not be available from the authors. 0002-9378/free © 2007 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2006.10.889
The reported success rate of ECV varies from 35% to 86%.5,6 Several factors were associated with successful ECV, but a prediction model based on clinical parameters was found to be insufficiently accurate in predicting ECV outcome.5,6 Despite extensive clinical experience with ECV, the optimal course of action following failed ECV is still unclear. In some cases, spontaneous version to cephalic presentation occurs at term; thus, expectant management until the onset of labor may be beneficial for some women who wish to give birth vaginally. However, if the fetus remains in breech presentation, an urgent CS will be needed when labor ensues. A nonelective abdominal delivery is associated with a higher complication rate as well as an additional logistic burden on the obstetric unit. Some reports have described the chances of spontaneous version of breech presentation near term. However, little is known about the natural history following a failed ECV. The aims of this study were to investigate the natural course of pregnancy after a failed attempt of cephalic version and to define the preferred clinical management in this situation.
M ATERIALS AND M ETHODS The study population consisted of all women with singleton pregnancies who had an attempt of ECV at or after 37 weeks’ gestation between January 1997 and June 2005. During the study period, in the absence of contraindication, ECV was offered to all women with singleton pregnancy in breech presentation at 37 weeks’ gestation or beyond. Contraindications for ECV were active labor, amnionitis, placental abruption, nonreassuring fetal heart rate monitoring, and ruptured fetal membranes. Furthermore, we did not include in this study patients with previous cesarean section. However, anterior placentation or low amniotic fluid index (AFI) were not considered exclusion criteria for ECV. Following a biophysical profile and a nonstress fetal heart rate test (FHR), all ECVs were performed in the delivery room by an experienced senior obstetrician with the aid of sonography. Tocolysis by intravenous ritodrine (until 2003) or oral nifedipine (beginning in 2003) was used unless the patient had a contraindication for these medications. Following the ECV procedure (successful or unsuccessful) and recording of a reassuring FHR, the patient was dis-
FEBRUARY 2007 American Journal of Obstetrics & Gynecology
157.e1
Research
Obstetrics
www.AJOG.org
TABLE
General characteristics of ECV attempts (n ⴝ 603) No. of nulliparae (percent of total)
256 (42.4)
No. of multiparae (percent of total)
347 (57.6)
Parity (mean ⫾ SD)
1.39 ⫾ 1.80
BMI (mean ⫾ SD)
27.1 ⫾ 4.0
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
Previous cesarean section, no. (%)
35 (5.7)
..............................................................................................................................................................................................................................................
charged for routine obstetric care until the onset of spontaneous labor. Before the ECV attempt, data on several maternal demographic and obstetric parameters were collected, including parity, weight, height, previous CS, placental location, fetal weight estimation, type of noncephalic presentation, and AFI.
AFI, no. (%)
.....................................................................................................................................................................................................................................
Oligohydramnios
23 (3.8)
.....................................................................................................................................................................................................................................
Appropriate
544 (90.2)
.....................................................................................................................................................................................................................................
Polyhydramnios
36 (6.0)
..............................................................................................................................................................................................................................................
Placental location, no. (%)
.....................................................................................................................................................................................................................................
Anterior
216 (35.8)
Posterior
210 (34.8)
Fundal
134 (22.2)
Corner
43 (7.2)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Type of breech, no. (%)
.....................................................................................................................................................................................................................................
Frank
247 (41.0)
Complete
329 (54.6)
Incomplete
27 (4.4)
..................................................................................................................................................................................................................................... ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Sonographic EFW (g), mean ⫾ SD
2979 ⫾ 435
Clinical EFW (g), mean ⫾ SD
3032 ⫾ 408
Lag to delivery (days), mean ⫾ SD
10.0 ⫾ 8.8
Gestational age at ECV attempt (wks), mean ⫾ SD (range)
38.3 ⫾ 1.2 (37-42)
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. ..............................................................................................................................................................................................................................................
BMI, body mass index; EFW, estimated fetal weight.
FIGURE
Summary characteristics of ECV population Trial of ECV N=603 (100%)
Primiparae n=256
Successed ECV n=118 (46.1%)
Multiparae n=347
Failed ECV n=138 (53.9%)
Successed ECV n=251 (72.3%)
R ESULTS There were 603 ECV attempts during the study period (Table). The success rate of ECV was 72.3% and 46.1% for multiparas and nulliparas, respectively. There was 1 case of mild placental abruption following a repeated attempt of ECV after a failed attempt a week earlier. The mean lag time between the ECV attempt and the onset of labor was 9.07 ⫾ 7.71 days (range 0-28, data available for 203 patients). The CS rate of patients with successful ECV who presented in active labor with cephalic presentation was 9.7%. (The primary CS rate in our institution was 5.5% during that period.) Indications for CS were arrest of head decent and nonreassuring fetal heart rate. Of the 603 ECV attempts, there were 234 failures (38.8%). Eight (3.4%) were lost to follow-up (Figure). The overall spontaneous version rate after failed ECV to vertex presentation before the onset of labor was 6.6%. AFI did not correlate with chances for spontaneous version after failed ECV, and all these cases had normal AFI. In this group mean lag time from ECV attempt to delivery was 12.3 ⫾ 9.3 days (range 1-24 days), and mean birth weight was 3129.4 ⫾ 391.6 g (range 2350-3910 g). There was no case of spontaneous version to breech after successful ECV.
Failed ECV n=96 (27.7%)
C OMMENT Lost to follow up n=8
Persistent breech n=127
157.e2
Persistent breech n=84
Spontaneous cephalic version n=3 (2.3%)
American Journal of Obstetrics & Gynecology FEBRUARY 2007
Spontaneous cephalic version n=12 (12.5%)
The present study examined the natural course of pregnancy after a failed trial of ECV. We followed up a relatively large group of patients from the failed ECV attempt without further intervention until the onset of spontaneous labor. We found that the overall rate of spontaneous version of breech presentation after
Obstetrics
www.AJOG.org failed ECV attempt at term was extremely low. Our results are generally in agreement with other reports. However, the existing reports are very few and usually nondirective. In the series of Impey and Pandit,7 there were 4 cases of spontaneous versions of 124 (3.2%) cases that had a repeat trial of ECV. There is no information regarding the parity of these spontaneous versions. In a multicenter early ECV trial, only 1 case (1 of 60, 1.7%) of spontaneous version was found in the term group.8 In a smaller study, Rozenberg et al9 reported on 41 patients after a failed repeated trial of ECV under epidural anesthesia. In this series there was no case of spontaneous version to vertex presentation. Following a failed ECV, the clinician and patient who are unwilling to consider a vaginal breech delivery need to decide whether to perform a planned cesarean delivery or to await a spontaneous delivery with the hope of spontaneous version to cephalic presentation. Our study, supported by the literature, shows that there is a very low chance for spontaneous version in nulliparas and a small chance in multiparas. Accumulating evidence favors a planned CS, compared with a nonscheduled CS. According to the report on confidential inquiries into maternal deaths in the United Kingdom (1997-1999), the relative risks for mortality in cases of scheduled CS and intrapartum CS were 0.8 and 12.0, respectively, with the risk of intrapartum mortality in vaginal delivery considered to be 1.0.10 According to the data from the Term Breech Trial, the risk of adverse perinatal outcome was lowest with prelabor cesarean section (odds ratio 0.13).11 The ECV procedure is not free of risk, as summarized recently by Collaris and Oei.12 In their study, the most frequently reported complications were transient
FHR changes (5.7%), persistent FHR changes (0.37%), and vaginal bleeding (0.4%). The incidence of reported placental abruption was 0.12% (in our series, 0.16%). The reported incidence of fetomaternal hemorrhage was 3.7%, and emergency CS was performed in 0.43% of cases. Perinatal mortality was 0.16%. Some of these consequences may present only after the patient has been discharged. Immediate delivery after ECV would be expected to reduce these potential complications. In addition, a policy of immediate and elective cesarean delivery after failed ECV might decrease the burden of emergent CS on delivery room staff. Finally, because epidural analgesia appears to increase the chance for a successful ECV,9,13 CS performed immediately after a failed ECV using the existing anesthesia is expected to obviate an unnecessary second anesthesia. Delivering women by cesarean section before 39 weeks would lead to an increase in neonatal morbidity from respiratory complications14; thus, it may be beneficial to perform ECV and delivery at 39 weeks or later. In conclusion, the chance for spontaneous version after a failed ECV at term is small, especially in nulliparae. When vaginal breech delivery is not an option, we recommend a policy of performing ECV close to 39 weeks and after a failed attempt to offer a cesarean delivery as soon as possible. However, multiparous women should be made aware of these results, and from then on it becomes a judgment call. f 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;356:1375-83.
Research
2. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Databases Syst Rev 1996;1:CD000083. 3. Committee on Obstetric Practice. ACOG committee opinion. Mode of term singleton breech delivery. No. 265, December 2001. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 2002;77:65-6. 4. Royal College of Obstetricians and Gynaecologists. The management of breech presentation. Guideline no. 20. RCOG Clinical Green Top Guidelines, 2001. 5. Chan LY, Leung TY, Fok WY, Chan LW, Lau TK. Prediction of successful vaginal delivery in women undergoing external cephalic version at term for breech presentation. Eur J Obstet Gynecol Reprod Biol 2004;116:39-42. 6. Ezra Y, Elram T, Plotkin V, Elchalal U. Significance of success rate of external cephalic versions and vaginal breech deliveries in counseling women with breech presentation at term. Eur J Obstet Gynecol Reprod Biol 2000;90:63-6. 7. Impey L, Pandit M. Tocolysis for repeat external cephalic version in breech presentation at term: a randomised, double-blinded, placebocontrolled trial. Br J Obstet Gynaecol 2005;112:627-31. 8. Hutton EK, Kaufman K, Hodnett E, et al. External cephalic version beginning at 34 weeks’ gestation versus 37 weeks’ gestation: a randomized multicenter trial. Am J Obstet Gynecol 2003;189:245-54. 9. Rozenberg P, Goffinet F, de Spirlet M, et al. External cephalic version with epidural anaesthesia after failure of a first trial with beta-mimetics. BJOG 2000;107:406-10. 10. Drife J, Lewis G. Why mothers die. Confidential enquiries into maternal deaths in the United Kingdom 1997-1999. London, UK: RCOG Press; 2001. 11. Su M, McLeod L, Ross S, et al. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189:740-5. 12. Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand 2004;83:511-8. 13. Hofmeyr GJ, Gyte G. Interventions to help external cephalic version for breech presentation at term. Cochrane Databases Syst Rev 2004;1:CD000184. 14. Morrison JJ, Rennie JM, Milton PJ, Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J Obstet Gynaecol 1995; 102:101-6.
FEBRUARY 2007 American Journal of Obstetrics & Gynecology
157.e3