External cephalic version. Is it an effective and safe procedure? External cephalic version is a procedure for modifying fetal position and achieving a cephalic presentation.
The aim of ECV is to offer an opportunity to have a cephalic delivery with less risk than a breech or cesarean delivery. ECV is usually done before active labor period begins. The aim of this study was to show how to do the ECV and describe key actions that could contribute to improve the success of this procedure.
Our secondary objective was to analyze the results of ECV with our specific protocol with tocolysis and analgesia and compare with those in the literature. This study was approved by the Clinical Research Committee of the Virgen de la Arrixaca at the University Clinical Hospital. Written informed consent was obtained from all participants.
A descriptive retrospective analysis of ECV performed in Hospital Clinico Universitario Virgen de la Arrixaca in Murcia between 1st of January of 2014 and 31st of December of 2018 has been carried out. Procedure was performed by two of the four experienced obstetricians of Maternal-Fetal Unit. A midwife and anesthesiologist were present during the ECV.
During third trimester ultrasound scan fetal presentation is checked. If non-cephalic presentation is assessed, the patient is seated the next week. During that consult, ECV is offered to every pregnant with non-cephalic presentation and no absolute contraindication for vaginal delivery.
Then, procedure is scheduled for the following week. Offer external cephalic version at consult. Identify fetal position with ultrasound offer the external cephalic version, sign informed consent.
Admit in obstetric emergency room. Identify fetal position with ultrasound. Prepare the patient and take requirements with test and informed consent.
Admit in obstetric delivery room. Perform cardiotocography assessment for fetal well-being. Prepare ritodrine solution.
Administer six milligrams of ritodrine at 60 milliliter per hour during 30 minutes before the procedure. Invite the patient to empty her bladder. Stop ritodrine perfusion before moving to obstetric operating room.
External cephalic version procedure in obstetric operating room. Move to obstetric operating room. Monitor maternal vital signs.
Position the patient in Trendelenburg. There are two options for performing analgesia. Sedate patient with propofol or alternatively spinal anesthesia.
External cephalic version procedure following National guidelines, two attempts are done. No more. Obstetrician A elevate fetal buttocks.
Then when it is achieved, obstetrician A guide fetal buttocks to the fundus. And when it is achieved, obstetrician B direct fetal head to the pelvis. Identify fetal well-being with ultrasound.
Check vaginal bleeding and perform cardiotocography assessment for fetal well-being. Later moved to obstetric delivery room. Perform cardiotocography assessment for fetal well-being during at least four hours.
And discharge the patient. Cardiotocography assessment for fetal well-being should be repeated in 24 hours. 320 patients were recruited between 1st of January of 2014 and 31st of December of 2018.
Three patients were lost. The ECV were performed in 37 plus three weeks of gestation as an average. ECV was successful in 82.5%Intraversion complication occurred in almost 6%Nine fetal bradycardia more than six minutes, eight vaginal bleeding, one cord prolapse and one preterm rupture of the membranes during the following 24 hours.
No newborns were hospitalization in neonatal unit neither neonatal intensive care unit. These are the results and the characteristic of ECV. It should be noted that nulliparity was more prevalent in patient in fail group.
It should be highlighted that there was no difference between BMI. It should be emphasized that sedation was the most frequent method for analgesia during ECV and only in three patients spinal anesthesia was performed for ECV. These are the results and delivery depending on ECV result.
It should be remarked that almost 78%of patients with successful ECV had vaginal delivery. 52%have eutocic delivery and 26 instrumented delivery. This is the multivariate logistic regression model for predicting ECV result.
It should be highlighted that previous vaginal delivery improved the possibilities of success with an adjusted odds ratio of three. And maternal body mass index reduced the possibilities of success with an adjusted odds ratio of 0.94. This is the multivariate logistic regression model for predicting ECV results depending on the BMI.
It should be noted that patients with BMI above 40 had far less possibilities of success with an odds ratio of 0.09. This is the comparisons of the type of delivery. It should be note that there were no difference in cesarean rate and eutocic delivery rate between patients with a successful ECV and general pregnant population.
However, patients with successful ECV had the higher instrumented delivery rate than general pregnant population. After a successful ECV, nulliparity was the only factor statistically associated with instrumented delivery with an adjusted odds ratio of nine. After a successful ECV, BMI was the only factor statistically associated with urgent cesarean section with an adjusted odds ratio of 1.11.
After a successful ECV, instrumented delivery rate increased in 8.56%compared with general population what means an odds ratio of 1.63. ECV procedure rate is higher than literature and Spain. It should be noted that some steps considered as crucial and that may differ from others such as empty the bladder before the procedure, the use of tocolysis only before the ECV, or analgesic with propofol or spinal anesthesia.
Bladder volume plays an important role in the success of ECV. The high procedure success rate maybe explained because of the use of this protocol with tocolysis and analgesia, the experienced team and the presence of a midwife and anesthesiologist. ECV complication rate is 5.94%which is similar to literature.
It should be remarked that the use of tocolysis and analgesia increase the risk of vaginal bleeding and placental abruption. Successful ECV does not modify eutocic delivery rate. Successful ECV does not modify cesarean delivery rate.
Successful ECV increase instrumented delivery rate with an odds ratio 1.63 which is similar to literature.
