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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 6-13

External Cephalic Version: Factors Associated with Successful Procedure and Obstetric Outcome at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria


1 Department of Obstetrics and Gynaecology, College of Medical Sciences, Gombe State University, Gombe, Nigeria
2 Department of Obstetrics and Gynaecology, College of Medical Sciences, University of Maiduguri, Maiduguri, Nigeria
3 Department of Obstetrics and Gynaecology, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria

Date of Submission25-Jul-2021
Date of Acceptance20-Dec-2021
Date of Web Publication30-Aug-2022

Correspondence Address:
Babagana Bako
Department of Obstetrics and Gynaecology, College of Medical Sciences, Gombe State University, Gombe
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnam.jnam_4_21

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  Abstract 

Background: External cephalic version (ECV) is the first-line treatment in the management of uncomplicated breech presentation at term. Objectives: The aim of this study was to determine the success rate, factors associated with success, and obstetric outcome of ECV for breech presentation at term. Materials and Methods: This was a longitudinal interventional study of patients with breech presentation at term who underwent ECV at the University of Maiduguri Teaching Hospital from January 1, 2017 to December 31, 2018. Data analysis was performed using IBM SPSS version 25.0 and a statistically significant association was determined using chi-square or Fisher exact test for categorical data as appropriate. Multinomial logistic regression was computed to find factors independently associated with ECV success. A value of P was set at <0.05. Result: The success rate of ECV was 78.5% (62/79). There were no differences in the mean age, parity, and gestational age at ECV between the successful and the unsuccessful groups with P = 0.19, 0.79, and 0.36, respectively. Multinomial logistic regression analysis showed that parous women, women who did not complain of pain during the procedure, women who weighed 80 kg or less, and women with an estimated fetal weight of <3.5 kg were significantly associated with successful ECV. There was an increased risk of postterm pregnancy and induction of labor among women with successful ECV. There were no maternal or fetal complications associated with the procedure. Conclusion: ECV is safe and associated with a high success rate. It should be offered routinely to all eligible women with breech at term.

Keywords: Breech presentation, external cephalic version, factors associated with success


How to cite this article:
Bako B, Geidam AD, Zaifada ZU, Musa FY. External Cephalic Version: Factors Associated with Successful Procedure and Obstetric Outcome at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. J Niger Acad Med 2022;1:6-13

How to cite this URL:
Bako B, Geidam AD, Zaifada ZU, Musa FY. External Cephalic Version: Factors Associated with Successful Procedure and Obstetric Outcome at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. J Niger Acad Med [serial online] 2022 [cited 2022 Nov 27];1:6-13. Available from: http://www.jnam.com/text.asp?2022/1/1/6/354769




  Introduction Top


External cephalic version (ECV) is an obstetric procedure that is known to reduce the incidence of breech presentation at term and improves the mother’s chances of having a vaginal cephalic birth.[1],[2] It provides a means of avoiding both the fetal risk associated with vaginal breech delivery and the maternal consequences associated with cesarean section (CS) for breech presentation.[3],[4] The procedure is recommended as first-line treatment in the management of uncomplicated breech presentation at term.[1],[5],[6],[7]

ECV has enjoyed remarkable acceptance among women over the years leading to a significant reduction in the proportion of women who declined the procedure.[8] The increasing popularity of ECV in the past 10 years can be linked to the desire to avoid the risks of vaginal breech delivery, the demand for reduction of CS rates across the globe, good safety profile of the procedure, and its high success rate of up to 70%.[9] The procedure also results in considerable cost savings especially for places where health care payment is borne out of pocket.[10],[11]

Despite the importance and success of ECV, there is wide variation in the application of ECV across the world. A survey of 165 obstetricians in Nigeria showed that only 47.6% of them have ever performed ECV for breech presentation.[12]

Careful selection of eligible patients is essential for the success of ECV. Previous delivery, adequate amniotic fluid, nonfrank breech, gestational age of less than 38 weeks, and posterior placenta have been linked with success of the procedure, whereas nulliparity, firm anterior abdominal walls, engaged presenting part, ruptured membranes, none palpable fetal head, posterior fetal spine, oligohydramnios, and tense or contracting uterus are associated with reduced likelihood of success.[13],[14],[15],[16],[17],[18] ECV has been safely offered to women with previous CS[19] and a high success rate has been reported among them.[20] Even though the procedure is generally safe and associated with favorable obstetrics outcomes, it is associated with 0.5% risk of emergency cesarean delivery due to grave complications like placental abruption.[21]

Model for predicting the success of ECV has been proposed by Kok et al.[18] for breech after 36 weeks. The model has a fair discriminatory ability with the area under the curve of 0.71. However, the model could only differentiate reliably between women with poor chance of successful ECV (less than 20%) and good chance of success (greater than 60%) and it has not been externally validated.[18]

Our center has a breech delivery rate of 1.7%[22] and it is responsible for 4.7%[23] of our CS. However, ECV is sparingly done despite the purported reports of its safety. Hence, we conceived this study to determine the success rate of ECV for breech presentation at term, determine clinical as well as ultrasound factors that are associated with success of the procedure, and the obstetric outcome at the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Also, the maternal and perinatal outcomes of women who had a successful ECV were compared with those who had spontaneous vertex presentation at delivery. The outcome of the study will guide our practice and counseling of women with breech presentation.


  Patients and Methods Top


This was a 2-year longitudinal interventional study to determine the success rate, factors associated with success, and the obstetric outcome of ECV for breech presentation at term at the University of Maiduguri Teaching Hospital, Maiduguri, Borno State, North-eastern, Nigeria. The study was conducted between January 1, 2017 and December 31, 2018.

The study population was booked patients with uncomplicated singleton pregnancy with breech presentation at term. All patients with breech were counseled and informed of the study and written informed consent was obtained from those that agreed to participate in the study. The counseling given included the description of procedure (manipulating the fetus through the abdominal wall to turn it to cephalic presentation) and that they might suffer mild pains or abdominal discomfort. They were also informed about the occasionally grave complications like abruptio placenta that will necessitate immediate cesarean delivery. Also, all the patients were informed that participation was voluntary and refusal to participate would not affect their care in any way and that they could withdraw the consent at any time without any consequences.

Eligible patients were those who gave informed written consent and had no contraindication for ECV and vaginal delivery. They were admitted into the antenatal ward and interviewed using a provider-administered pretested questionnaire to obtain information on their sociodemographic characteristics, previous pregnancies, and previous uterine surgeries/abnormalities. The antenatal records of the patients were also reviewed to obtain information on the index pregnancy (including anomaly scan). Gestational age was calculated using last menstrual period and/or early ultrasound scan.

An ultrasound scan was also repeated prior to the procedure to confirm the fetal presentation, the position and nature of breech, placental location, amniotic fluid index, presence of any contraindication to ECV, and estimate fetal weight. A 20-min cardiotocography (CTG) was performed on each patient to ascertain fetal well-being prior to the procedure.

Patients with multiple gestation, intrauterine growth restriction, fetal congenital abnormalities, fetal distress, intrauterine fetal death (IUFD), uterine anomaly, placenta praevia, severe oligohydramnios, placental abruption, uterine contractions, labor, premature rupture of membranes, antepartum hemorrhage, suspected chorioamnionitis, pre-eclampsia, abnormal CTG, and any contraindications to vaginal delivery were excluded from the study.

The procedure was performed by the patient’s consultant or a senior resident of the managing team under the supervision of the consultant. The patients were placed in supine position with a pillow to prop up their heads. They were reassured and their cooperation sorted for in order to maintain a relaxed abdomen. They were also asked to stop the doctor anytime they feel intense pain or the procedure is unduly uncomfortable. A gentle but firm pressure was applied on the fetal buttocks to lift it out of the pelvis and displace it laterally using the dominant hand. Constant firm pressure was then applied to the fetal buttocks with the other hand guiding the fetal head to rotate it to cephalic presentation. A forward roll was usually attempted first, and a backward roll was attempted if the forward roll was not successful.

The ECV was adjudged successful if the fetus was turned to cephalic presentation at the end of the procedure. Only two attempts were offered and the procedure was usually abandoned after two unsuccessful attempts. A third attempt was only made with the mother’s consent in a few cases where the operator (consultant) considered that there was a chance of success with a third attempt. The decision to undertake a third attempt was made based on significant progress with the initial two attempts, or when one of the initial attempts was made by a less experienced operator.

The procedure was abandoned at any point if it was not well tolerated by the patient or if there were concerns about maternal or fetal well-being. At the end of the procedure, patients were asked whether the procedure was painful or not and also rate the pain associated with it using a numeric pain score rating with 0 as no pain and 10 as the most severe pain. For the purpose of this study, women that gave a pain score of 0–3 were classified as painless, whereas those that gave a pain score of 4 or more were classified as painful. A postprocedure CTG was offered to determine the fetal status. All patients were observed for 24 h after ECV and subsequently discharged to continue routine antenatal care. They were all followed up to delivery.

For successful cases, subsequent management was the same as that of cephalic presenting pregnancies.

For unsuccessful cases, patients were counseled on the option of delivery via elective CS (at 38–39 weeks) or assisted vaginal breech delivery for those with no contraindication for it. All the patients included in the study were observed for maternal, fetal, and delivery outcomes. The delivery outcomes of women that had successful ECV were compared with the women that presented in spontaneous labor with a cephalic presentation during the period of the study.

Data analysis was performed using the Statistical Package for Social Sciences version 25.0 (IBM SPSS, 2017) and presented as frequency and percentages. Associations were assessed using chi-square or Fisher exact test for categorical data as appropriate, and multinomial logistic regression was computed to find factors independently associated with ECV success. A value of P < 0.05 was considered statistically significant.


  Results Top


During the study period, 119 booked patients with breech presentation at term were seen at the antenatal clinic; 98 met the criteria for ECV and were counseled for the study. Eighty-seven women consented to take part in the study; eight had transverse or oblique lie at the time of ECV and were also excluded. The remaining 79 women had ECV and were followed up to delivery.

The success rate of the ECV was 78.5% (62/79) as shown in [Figure 1]. All the women were term at the time of ECV with a mean gestational age of 38.5 ± 2.0 weeks and 77.4% (48/62) of them were successful at the first attempt. There were no maternal or fetal complications recorded after the procedure as all women (both successful and unsuccessful ECV) were discharged with reactive antenatal cardiotocograph after 24 h of observation.
Figure 1: Success of ECV

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The mean age and parity of the patients studied were 29.2 ± 6.2 years and 2.8 ± 2.7, respectively. There were no statistically significant differences in the mean age, parity, and gestational age at ECV between the successful and the unsuccessful groups with P = 0.19, 0.79, and 0.36, respectively. Approximately two-thirds (75.9%) of the women studied have had at least secondary-school education but 60.8% (48/79) of them were not gainfully employed as shown in [Table 1].
Table 1: Sociodemographic characteristics of the patients studied

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[Table 2] shows the factors associated with successful ECV. The procedure was more likely to be successful in parous women and women who weighed 80 kg or less with P = 0.02 and 0.01, respectively. Women with an estimated fetal weight of less than 3.5 kg were more likely to have a successful ECV with odds ratio (OR) = 6.79 and 95% CI: 1.39–18.74, whereas normal amniotic fluid index increased the success of ECV by at least threefolds, 95% CI = 1.41–7.10. Pains during the procedure negatively affected the success of the ECV and women who did not complain of pains and those with pain scores of 3 or less were at least four times more likely to have successful ECV than women who had pain scores of 4 and above, as shown in [Table 2]. Similarly, women with soft uterus during the procedure were more likely to have a successful ECV compared to women with tensed uterus (P = 0.001). Other factors such as type of breech, position, and placental location did not affect the success of ECV significantly.
Table 2: Factors associated with success of ECV

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Multinomial logistic regression analysis showed that parous women, women who did not complain of pain during the procedure, women who weighed 80 kg or less, and women with an estimated fetal weight of <3.5 kg were significantly associated with successful ECV, as shown in [Table 3].
Table 3: Multinomial logistic regression analysis of factors associated with successful ECV

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During antenatal follow-up, 10 of the women with successful ECV had prolonged pregnancies and 4 had fetuses that reverted back to breech, giving a revert rate of 6.4% (4/62). Of the remaining 58 with cephalic babies, 49 had vaginal deliveries, giving a vaginal delivery rate of 79.0% (49/62). The remaining nine were delivered via CS for various indications. The CS rate among the successful ECV group was 21.0% (13/62). Fifteen of the 17 women with unsuccessful ECV had CS, whereas the remaining two had assisted breech deliveries. The CS rate was 88.2% (15/17) among women with unsuccessful ECV.

Ten women with successful ECV went postterm and eight had induction of labor. The other two declined intervention and presented with intrauterine fetal death at 43 weeks each. One of the women who had induction of labor with misoprostol had uterine rupture and developed postpartum hemorrhage, which necessitated subtotal hysterectomy. There were three other three stillbirths (due to severe abruptio placenta, chorioamnionitis, and fetal distress). The perinatal mortality rate was 97 per 1000 births and was comparable with that of the other women that delivered during the period of the study, 63/1000 (χ2 = 1.34, P = 0.243). Three of the women with successful ECV had antepartum hemorrhage and three babies were admitted to special baby care unit on account of birth asphyxia. Two women had postpartum hemorrhage, as shown in [Table 4].
Table 4: Maternal and perinatal complications among 62 women that had successful ECV

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  Discussion Top


Breech presentation at term as an indication for CS can be abated by successful ECV and most obstetricians and midwives agree with this assertion; the only impediment to its widespread implementation and adherence to the practice is self-efficacy, skills of performing the procedure, and assurance of its safety.

This study showed an encouraging success rate of ECV of 78.5%. This rate is higher than the 60%–71% reported by other workers.[16],[24],[25] The high success rate could be attributed to proper counseling of the women coupled with their heightened cooperation during the procedure. ECV was more likely to be successful among women that considered the procedure to be painless and gave low pain score of less than 3 (75.8% versus 24.2%). Counseling allays anxiety and also encourages relaxation of the anterior abdominal wall during the procedure. Sultan and Carvalho[26] reported that the relaxation of the anterior abdominal wall as the reason behind the high success of ECV when epidural or spinal anesthesia or analgesia is used for ECV and use of anesthesia or analgesia has been proven to be cost-effective when compared with CS.[10] Even though analgesia was not used in our study, we believed that proper counseling resulted in many of the women being relaxed and cooperative during the procedure and that increased the success rate.

Other factors that are independently associated with success of the ECV are previous delivery, maternal weight of 80 kg or less, estimated fetal weight of less than 3.5 kg, and amniotic fluid index of 8 cm or more. Parous women often have lax anterior abdominal wall and the increased success of ECV among parous women has been collaborated by El-Toukhy et al.[27] The procedure is less successful among nulliparous women who in addition to having tensed anterior abdominal wall are more likely to be anxious and less cooperative during the procedure. Efforts should be geared towards improving the success of the procedure among the nulliparous woman because CS in them is a panacea for more cesarean deliveries in their subsequent pregnancies.[28]

Our study showed that soft uterus is associated with successful ECV and this agrees with the findings of Rodriquez et al.[29] and Naveira and Cajal.[30] The soft uterus is associated with easier maneuvering of the fetus per abdomen and some workers have used tocolytic to achieved uterine relaxation during the ECV.[29],[30],[31] In this study, ECV was not successful in any woman with irritable and tensed uterus. This calls for the use of tocolytic in selected women in order to encourage uterine relaxation and reduced contractions during the procedure. Studies have shown the increased success of ECV when tocolytics are used[29],[30],[31]

We found ECV to be more successful in women who weighed 80 kg or less. Heavier and obese women have a thicker anterior abdominal wall that will interfere with manipulation of the fetus through the abdomen. The thinner abdominal wall allows better grip of the fetus during the procedure and will allow an easier and a more comfortable manipulation. In this study, we used the absolute maternal weight at the time of ECV because of paucity of information on the pre-pregnancy maternal body mass index (BMI) of the women. Both Isakov et al.[15] and Correia Costa et al.[29] in their separate works found low BMI to be associated with successful ECV. Women should be encouraged to live a healthy lifestyle in order to achieve and maintain a normal BMI during pregnancy to improve their chances of avoiding CS due to unsuccessful ECV for breech at term. In this study, 88.2% of the women with unsuccessful ECV had cesarean delivery. Bin et al.,[32] in their study on ECV in Sidney, Australia, reported a slightly higher CS rate of 95.6% among women with failed ECV. Despite the obvious risks of vaginal breech delivery and relative safety of elective CS, up to 40% of women with breech at term attempt will vaginal delivery.[33] It is therefore necessary that obstetricians be acquainted with the skills of assisted vaginal breech delivery for the women that will prefer to take the slight neonatal risk in exchange for reduced maternal morbidities.[34]

A normal amniotic fluid index is associated with successful ECV[16],[18] and our study also affirmed this finding. The amniotic fluid serves as a lubricating medium and allows easy movement of the fetus during ECV. Conversely, reduced AFI and fetuses that weighted 3.5 kg or more may choke up the uterus and hinder mobility of the fetus during ECV, thereby thwarting the success of the procedure. Both reduced AFI and fetus weighing 3.5 kg or more are associated with unsuccessful ECV in this study.

The best chance of success of the ECV is during the first attempt as shown in this study. Even though more attempts may be required in some women and those that revert after an initial successful ECV, it is necessary to counsel the women on the success rate of the subsequent attempts. The low success in subsequent attempts may be due to increased anxiety and discomfort. Analgesia and tocolytic may be used after the first attempt as they have been found to be associated with higher success rates by other researchers.[29],[31]

One previous CS, type of breech, position of the fetus, and placental location are found not to significantly affect the success of ECV. Women with one previous CS scar can be offered ECV when trial of scar is being considered. We found no increased morbidity among the women with previous CS that had ECV.

We found a revert rate of 6.5% (4/62) among women with successful ECV. This calls for regular follow-up during the antenatal period in order to avoid unsuspected breech presentation in labor which may necessitate an emergency CS with its consequent risks.[35] Our revert rate is higher than 2.2% reported by Melo et al.,[36] but lower than 7.46% reported by Lim et al.[14] in Malaysia. However, because of a small number of cases we could not find a specific risk factor associated with it.

All the women both successful and unsuccessful had stable fetuses at discharge. This goes to affirm the safety of the procedure for uncomplicated breech at term. Collins et al.[21] reported a complication rate of 0.5% necessitating emergency cesarean section among 805 consecutive ECV. Also, a systematic review of risk of ECV showed a transient fetal heart rate changes of 5.7%, persistent fetal heart rate abnormalities of 0.37%, and vaginal bleeding in 0.4% of women that had ECV.[37] We recorded none of the abovementioned complications.

Ten (15.1%) of the women who had successful ECV had prolonged pregnancy and eight of them had induction of labor. The rate of prolonged pregnancy among the women with successful ECV was significantly higher than 5.6% in the unit during the period of the study (χ2 = 11.61, P = 0.001). The cause of the prolonged pregnancy in them is not obvious but it signifies an increased risk of intervention in women after successful ECV. A similar finding has also been reported by Lim et al.[16] and Jain et al.[38] Induction of labor is perceived by most women as a very painful procedure especially those that demand natural labor and two out of the 10 declined the procedure and later presented with IUFD. Also, one of the women with prolonged pregnancy had misoprostol for cervical ripening and ended up with uterine rupture and subtotal hysterectomy. These complications occurred weeks after the ECV and are therefore not specific to the procedure. This information is crucial in counseling women after ECV for a realistic expectation and the need for continuous follow-up until delivery.[38],[39]

The CS rate for spontaneous labor with cephalic presentation during the period under review was 17.6% (993/5632) and it is comparable to 21.0% (9/62) among the women with successful ECV with χ2= 0.126 and P = 0.722. Similarly, the perinatal mortality rate in the unit during the period of the study was 62.8/1000 (405/6450) which is comparable to the 97/1000 (6/62) recorded among women that had successful ECV with χ2 = 1.364 and P = 0.243. Our finding showed no increased CS rate or perinatal mortality rates in the women with successful ECV and a similar finding has also been reported by Correia Costa et al.[14]

In conclusion, ECV in our setting is highly successful, tolerable, and safe. We recommend that the procedure be adopted as routine for all eligible women with breech at term after due counseling.

A multicenter study with the use of analgesia and/or tocolysis especially for primigravida and subsequent attempts after a failed first attempt in selected cases is recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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