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Meta-Analysis
. 2015 Feb 9;2015(2):CD000184.
doi: 10.1002/14651858.CD000184.pub4.

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

Catherine Cluver  1 , Gillian M L Gyte, Marlene Sinclair, Therese Dowswell, G Justus Hofmeyr
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. .

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 so as to avoid the adverse effects of breech vaginal birth or caesarean section. Interventions such as tocolytic drugs and other methods have been used in an attempt to facilitate ECV.

Objectives: To assess, from the best evidence available, the effects of interventions such as tocolysis, acoustic stimulation for midline spine position, regional analgesia (epidural or spinal), transabdominal amnioinfusion, systemic opioids and hypnosis, or the use of abdominal lubricants, on ECV at term for successful version, presentation at birth, method of birth and perinatal and maternal morbidity and mortality.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) 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 specially designed data extraction form.

Main results: We included 28 studies, providing data on 2786 women. We used the random-effects model for pooling data because of clinical heterogeneity between studies. A number of trial reports gave insufficient information to allow clear assessment of risk of bias. We used GradePro software to carry out formal assessments of quality of the evidence for beta stimulants versus placebo and regional analgesia with tocolysis versus tocolysis alone.Tocolytic parenteral beta stimulants were effective in increasing cephalic presentations in labour (average risk ratio (RR) 1.68, 95% confidence interval (CI) 1.14 to 2.48, five studies, 459 women, low-quality evidence) and in reducing the number of caesarean sections (average RR 0.77, 95% CI 0.67 to 0.88, six studies, 742 women, moderate-quality evidence). Failure to achieve a cephalic vaginal birth was less likely for women receiving a parenteral beta stimulant (average RR 0.75, 95% CI 0.60 to 0.92, four studies, 399 women, moderate-quality evidence). No clear differences in fetal bradycardias were identified, although this was reported for only one study, which was underpowered for assessing this outcome. Failed external cephalic version was reported in nine studies (900 women), and women receiving parenteral beta stimulants were less likely to have failure compared with controls (average RR 0.70, 95% CI 0.60 to 0.82, moderate-quality evidence). Perinatal mortality and serious morbidity were not reported. Sensitivity analysis by study quality was consistent with overall findings.For other classes of tocolytic drugs (calcium channel blockers and nitric oxide donors), evidence was insufficient to permit conclusions; outcomes were reported for only one or two studies, which were underpowered to demonstrate differences between treatment and control groups. Little evidence was found regarding adverse effects, although nitric oxide donors were associated with increased risk of headache. Data comparing different tocolytic drugs were insufficient.Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing successful versions (assessed by the rate of failed ECVs; average RR 0.61, 95% CI 0.43 to 0.86, five studies, 409 women, moderate-quality evidence), and no difference was identified in cephalic presentation in labour (average RR 1.63, 95% CI 0.75 to 3.53, three studies, 279 women, very low-quality evidence), caesarean sections (average RR 0.74, 95% CI 0.40 to 1.37, three studies, 279 women, very low-quality evidence) nor fetal bradycardia (average RR 1.48, 95% CI 0.62 to 3.57, two studies, 210 women, low-quality evidence), although studies were underpowered for assessing these outcomes. Studies did not report on failure to achieve a cephalic vaginal birth (breech vaginal deliveries plus caesarean sections) nor on perinatal mortality or serious infant morbidity.Data were insufficient on the use of regional analgesia without tocolysis, vibroacoustic stimulation, amnioinfusion, systemic opioids and hypnosis, and on the use of talcum powder or gel to assist external cephalic version, to permit conclusions about their effectiveness and safety.

Authors' conclusions: Parenteral beta stimulants were effective in facilitating successful ECV, increasing cephalic presentation in labour and reducing the caesarean section rate, but data on adverse effects were insufficient. Data on calcium channel blockers and nitric acid donors were insufficient to provide good evidence.The scope for further research is clear. Possible benefits of tocolysis in reducing the force required for successful version and possible risks of side effects need to be addressed further. Further trials are needed to compare the effectiveness of routine versus selective use of tocolysis and the role of regional analgesia, fetal acoustic stimulation, amnioinfusion and abdominal lubricants, and the effects of hypnosis, in facilitating ECV. Although randomised trials of nitric oxide donors are small, the results are sufficiently negative to discourage further trials. Intervention fidelity for ECV can be enhanced by standardisation of the techniques and processes used for clinical manipulation of the fetus in the abdominal cavity and ought to be the subject of further research.

PubMed Disclaimer

Conflict of interest statement

TD is paid by the UK NHS to work on a range of Cochrane Reviews. The Funders have no influence on the content or conclusions of the reviews I work on. I have received payment from NIHR for my work on this and other reviews.

GJH receives royalties for two chapters authored in UpToDate.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 1 Cephalic presentation at birth (primary).
1.2
1.2. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 2 Failure to achieve cephalic vaginal birth (composite outcome: caesarean section + vaginal breech birth).
1.3
1.3. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 3 Caesarean section (primary).
1.4
1.4. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 4 Fetal bradycardia (primary).
1.5
1.5. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 5 Failed external cephalic version.
1.6
1.6. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 6 Difficult external cephalic version.
1.7
1.7. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 7 Maternal palpitations.
1.8
1.8. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 8 Maternal headaches.
1.9
1.9. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 9 Maternal hypotension.
1.10
1.10. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 10 Operative vaginal birth.
1.13
1.13. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 13 Perinatal mortality.
1.15
1.15. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 15 Vaginal breech birth.
1.16
1.16. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 16 Apgar < 7 at 5 minutes (not prespecified).
1.17
1.17. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 17 Neonatal seizures (not prespecified).
1.18
1.18. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 18 Admission to neonatal unit (not prespecified).
1.19
1.19. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 19 Birth trauma (not prespecified).
1.20
1.20. Analysis
Comparison 1 Tocolytic drugs (A) vs placebo, Outcome 20 Maternal flushing (not prespecified).
2.1
2.1. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 1 Cephalic presentation at birth (primary).
2.2
2.2. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 2 Failure to achieve cephalic vaginal birth (composite outcome: caesarean section + vaginal breech birth).
2.3
2.3. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 3 Caesarean section (primary).
2.4
2.4. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 4 Fetal bradycardia (primary).
2.5
2.5. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 5 Failed external cephalic version.
2.6
2.6. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 6 Difficult external cephalic version.
2.7
2.7. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 7 Maternal palpitations.
2.8
2.8. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 8 Maternal headaches.
2.9
2.9. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 9 Maternal hypotension.
2.16
2.16. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 16 Apgar < 7 at 5 minutes (not prespecified).
2.18
2.18. Analysis
Comparison 2 Tocolytic drug 1 (A) vs tocolytic drug 2 (A), Outcome 18 Admissions to neonatal unit (not prespecified).
3.5
3.5. Analysis
Comparison 3 Vibroacoustic stimulation (B) vs placebo, Outcome 5 Failed external cephalic version.
6.1
6.1. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 1 Cephalic presentation at birth (primary).
6.3
6.3. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 3 Caesarean section (primary).
6.4
6.4. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 4 Fetal bradycardia (primary).
6.5
6.5. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 5 Failed external cephalic version.
6.9
6.9. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 9 Maternal hypotension.
6.15
6.15. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 15 Placental abruption (not prespecified).
6.16
6.16. Analysis
Comparison 6 Regional analgesia (with or without tocolysis) vs no intervention of regional analgesia (with or without tocolysis), Outcome 16 Maternal discomfort (not prespecified).
15.3
15.3. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 3 Fetal bradycardia (primary).
15.4
15.4. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 4 Caesarean section (primary).
15.5
15.5. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 5 Failed external cephalic version.
15.10
15.10. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 10 Operative vaginal birth.
15.15
15.15. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 15 Pain score (0‐10 scale, lowest best) (non‐prespecified).
15.16
15.16. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 16 Maternal satisfaction score (lower score worst) (non‐prespecified).
15.17
15.17. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 17 Nausea and vomiting (non‐prespecified).
15.18
15.18. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 18 Dizziness (non‐prespecified).
15.19
15.19. Analysis
Comparison 15 Systemic opioids (E) vs placebo, Outcome 19 Drowsiness (non‐prespecified).
18.2
18.2. Analysis
Comparison 18 Systemic opioids (E) vs regional anaesthesia (C), Outcome 2 Failure to achieve cephalic vaginal birth (composite outcome: caesarean section + vaginal breech birth).
18.3
18.3. Analysis
Comparison 18 Systemic opioids (E) vs regional anaesthesia (C), Outcome 3 Caesarean section (primary).
18.4
18.4. Analysis
Comparison 18 Systemic opioids (E) vs regional anaesthesia (C), Outcome 4 Fetal bradycardia (primary).
18.5
18.5. Analysis
Comparison 18 Systemic opioids (E) vs regional anaesthesia (C), Outcome 5 Failed external cephalic version.
21.1
21.1. Analysis
Comparison 21 Tocolytics vs placebo ‐ nullips vs multips, Outcome 1 Cephalic presentation at birth (primary).
21.2
21.2. Analysis
Comparison 21 Tocolytics vs placebo ‐ nullips vs multips, Outcome 2 Caesarean section (primary).
21.4
21.4. Analysis
Comparison 21 Tocolytics vs placebo ‐ nullips vs multips, Outcome 4 Failed external cephalic version.
22.4
22.4. Analysis
Comparison 22 Tocolytic (nifedipine) vs tocolytic (terbutaline) ‐ nullips vs multips, Outcome 4 Failed ECV.
23.5
23.5. Analysis
Comparison 23 Hypnosis vs neurolinguistic programming, Outcome 5 Failed external cephalic version.
23.15
23.15. Analysis
Comparison 23 Hypnosis vs neurolinguistic programming, Outcome 15 Good pain relief (higher scores better) (non‐prespecified).
24.5
24.5. Analysis
Comparison 24 Talcum powder vs gel, Outcome 5 Failed external cephalic version (after first round of attempts).
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References

References to studies included in this review

Bujold 2003a {published data only}
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Vallikkannu 2014 {published data only}
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Weiniger 2010 {published data only}
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Yanny 2000 {published data only}
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References to studies excluded from this review

Dockeray 1984 {published data only}
    1. Dockeray CJ, Gleeson RP. An evaluation of perinatal outcome following external cephalic version under general anaesthesia. Irish Journal of Medical Science 1984; Vol. 153:325.
Guittier 2013 {published data only}
    1. Guittier MJ, Guillemin F, Farinelli EB, Irion O, Boulvain M, Tejada BM. Hypnosis for the control of pain associated with external cephalic version: a comparative study. Journal of Alternative & Complementary Medicine 2013;19(10):820‐6. - PubMed
Wallace 1984 {published data only}
    1. Wallace RL, 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

Andarsio 2000 {published data only}
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Hollard 2003 {published data only}
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Tan 2008 {published data only}
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References to ongoing studies

Burgos 2012 {published data only}
    1. Burgos J. Open randomized controlled trial to evaluate the efficacy and safety of remifentanil versus nitrous oxide in external cephalic version at term in singleton pregnancy in breech presentation (REMIVER), 2012. ClinicalTrials.gov (http://clinicaltrials.gov/) (accessed 21 May 2013).
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Passerini 2013 {published data only}
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References to other published versions of this review

Cluver 2012
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