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Meta-Analysis
. 2012 Jan 18:1:CD000184.
doi: 10.1002/14651858.CD000184.pub3.

Interventions for helping to turn term breech babies to head first presentation when using external cephalic version

Catherine Cluver  1 , G Justus Hofmeyr, Gillian Ml Gyte, Marlene Sinclair
Affiliations
Meta-Analysis

Interventions for helping to turn term breech babies to head first presentation when using external cephalic version

Catherine Cluver et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Breech presentation is associated with increased complications. Turning a breech baby to head first presentation using external cephalic version (ECV) attempts to reduce the chances of breech presentation at birth, and reduce the adverse effects of breech vaginal birth or caesarean section. Tocolytic drugs and other methods have been used in an attempt to facilitate ECV.

Objectives: To assess interventions such as tocolysis, fetal acoustic stimulation, regional analgesia, transabdominal amnioinfusion or systemic opioids on ECV for a breech baby at term.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2011) and the reference lists of identified studies.

Selection criteria: Randomised and quasi-randomised trials comparing the above interventions with no intervention or other methods to facilitate ECV at term.

Data collection and analysis: We assessed eligibility and trial quality. Two review authors independently assessed for inclusion all potential studies identified as a result of the search strategy and independently extracted the data using a designed data extraction form.

Main results: We included 25 studies, providing data on 2548 women. We used the random-effects model for pooling data due to clinical heterogeneity in the included studies in the various comparisons. The overall quality of the evidence was reasonable, but a number of assessments had insufficient data to provide an answer with any degree of assurance.Tocolytic drugs, in particular betastimulants, were effective in increasing cephalic presentations in labour (average risk ratio (RR) 1.38, 95% confidence interval (CI) 1.03 to 1.85, eight studies, 993 women) and in reducing the number of caesarean sections (average RR 0.82, 95% CI 0.71 to 0.94, eight studies, 1177 women). No differences were identified in fetal bradycardias (average RR 0.95, 95% CI 0.48 to 1.89, three studies, 467 women) although the review is underpowered for assessing this outcome. We identified no difference in success, cephalic presentation in labour and caesarean sections between nulliparous and multiparous women. There were insufficient data comparing different groups of tocolytic drugs. Sensitivity analyses by study quality agreed with the overall findings.Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone in terms of increasing successful versions (assessed by the rate of failed ECVs, average RR 0.67, 95% CI 0.51 to 0.89, six studies, 550 women) but there was no difference identified in cephalic presentation in labour (average RR 1.63, 95% CI 0.75 to 3.53, three studies, 279 women) nor in caesarean sections (average RR 0.74, 95% CI 0.40 to 1.37, three studies, 279 women) or fetal bradycardia (average RR 1.48, 95% CI 0.62 to 3.57, two studies, 210 women).There were insufficient data on the use of vibroacoustic stimulation, amnioinfusion or systemic opioids.

Authors' conclusions: Betastimulants, to facilitate ECV, increased cephalic presentation in labour and birth, and reduced the caesarean section rate in both nulliparous and multiparous women, but there were insufficient data on adverse effects. Calcium channel blockers and nitric acid donors had insufficient data to provide good evidence. At present we recommend betamimetics for facilitating ECV.There is scope for further research. The possible benefits of tocolysis to reduce the force required for successful version and the possible risks of maternal cardiovascular side effects, need to be addressed further. Further trials are needed to compare the effectiveness of routine versus selective use of tocolysis, the role of regional analgesia, fetal acoustic stimulation, amnioinfusion and the effect of intravenous or oral hydration prior to ECV.Although randomised trials of nitroglycerine are small, the results are sufficiently negative to discourage further trials.

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Figures

Figure 1
Figure 1. Risk of bias summary: review authors’ judgements about each risk of bias item for each included study
See this image and copyright information in PMC

Update of

References

References to studies included in this review

    1. *

    2. Bujold E, Boucher M, Rinfret D, Berman S, Ferreira E, Marquette GP. Sublingual nitroglycerin versus placebo as a tocolytic for external cephalic version: a randomized controlled trial in parous women. American Journal of Obstetrics and Gynecology. 2003;189:1070–3. - PubMed
    1. Bujold E, Boucher M, Rinfret D, Marquette G. Sublingual nitroglycerin versus placebo as a tocolytic for external cephalic version: a randomized controlled trial in parous women [abstract] American Journal of Obstetrics and Gynecology. 2002;187(6 Pt 2):S103.
    1. Bujold E, Marquette GP, Ferreira E, Gauthier RJ, Boucher M. Sublingual nitroglycerin versus intravenous ritodrine as tocolytic for external cephalic version: a double-blind randomized trial. American Journal of Obstetrics and Gynecology. 2003;188(6):1454–7. discussion 1457-9. - PubMed

    1. *

    2. Chung T, Neale E, Lau TK, Rogers M. A randomized, double blind, controlled trial of tocolysis to assist external cephalic version in late pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 1996;75:720–4. - PubMed
    1. Neale EJ, Lau TK, Chung A, Cohn M, Baldwin S, Rogers M. A randomized double blind controlled trial of tocolysis to assist external cephalic version in late pregnancy; 27th British Congress of Obstetrics and Gynaecology; Dublin, Ireland. 1995.Jul 4-7, 1995. p. 76. - PubMed

References to studies excluded from this review

    1. Dockeray CJ, Gleeson RP. An evaluation of perinatal outcome following external cephalic version under general anaesthesia. Irish Journal of Medical Science. 1984;153:325.
    1. Wallace RL, Van Dorsten JP, Eglinton GS. External cephalic version with tocolysis. Observations and continuing experience at the Los Angeles county/university of Southern California Medical Center. Journal of Reproductive Medicine. 1984;29:745–8. - PubMed

References to studies awaiting assessment

    1. Andarsio F, Feng TI. External cephalic version: nitroglycerin versus terbutaline. American Journal of Obstetrics and Gynecology. 2000;182(1 Pt 2):S161.
    1. Hollard A, Lyons C, Rumney P, Hunter M, Reed E, Nageotte M. The effect of intrathecal anesthesia on the success of external cephalic version (ECV) American Journal of Obstetrics and Gynecology. 2003;189(6):S140.
    1. Tan PC. [accessed 12.05.2010];A double-blind randomised trial of 250 μg versus 500 μg bolus dose of terbutaline as a tocolytic agent in external cephalic version. Current Controlled Trials. 2008 www.controlled-trials.com

Additional references

    1. Belfort MA. Intravenous nitroglycerin as a tocolytic agent for intrapartum external cephalic version. South African Medical Journal. 1993;83:656. - PubMed
    1. Benifla JL, Goffinet F, Bascou V, Darai E, Proust A, Madelenat P. Transabdominal amnio-infusion facilitates external version maneuver after initial failure. Six successful attempts. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 1995;24:319–22. - PubMed
    1. Bradley-Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. American Journal of Obstetrics and Gynecology. 1975;123:237–40. - PubMed
    1. Bricker L, Lavender T. Parenteral opioids for labor pain relief: a systematic review. American Journal of Obstetrics and Gynecology. 2002;186(5 Suppl):S94–S109. - PubMed
    1. Brosset A. The value of prophylactic external version in cases of breech presentation. Acta Obstetricia et Gynecologica Scandinavica. 1956;35:555–62. - PubMed

References to other published versions of this review

    1. Hofmeyr GJ, Pregnancy and Childbirth Module . Routine tocolysis for external cephalic version at term. [revised 04 October 1993] In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C, editors. The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM] 2. The Cochrane Collaboration; Oxford: 1995. Update Software.
    1. Hofmeyr GJ, Gyte GML. Interventions to help external cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews. 2004;(1) DOI: 10.1002/14651858.CD000184.pub2. - PubMed

    1. * Indicates the major publication for the study

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