External cephalic version for breech presentation before term

Hutton EK, Hofmeyr GJ

Published Online:

January 20, 2010

Not enough evidence to say if turning a breech baby to head first early in the last months of pregnancy reduces breech position at term.

Babies born bottom first (in the breech position) may have more problems during birth than those who are born head first (in the cephalic position). During an external cephalic version (ECV) a breech baby is turned to the head down position by gently pushing on the mother's abdomen. Other research shows that ECV after 37 weeks reduces the number of babies in the breech position at full term, and the number of caesarean sections. This review of trials found that if ECV is done very early in the third trimester (32 to 34 weeks) it does not affect how the baby is lying at full term nor was there any change in the number of babies born by caesarean delivery. However, there are insufficient data to say if beginning ECV between 34 and 36 weeks compared to beginning ECV after 37 weeks would result in fewer breech babies at birth and fewer caesarean sections. Further research is underway.

Abstract (click to read)

Background:

External cephalic version (ECV) of the breech fetus at term (after 37 weeks) has been shown to be effective in reducing the number of breech presentations and caesarean sections, but the rates of success are relatively low. This review examines studies initiating ECV prior to term (before 37 weeks' gestation).

Objectives:

To assess the effectiveness of a policy of beginning ECV before term (before 37 weeks' gestation) for breech presentation on fetal presentation at birth, method of delivery, and the rate of preterm birth, perinatal morbidity, stillbirth or neonatal mortality.

Search strategy:

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2005), MEDLINE (1965 to April 2005), EMBASE (1988 to April 2005), and Controlled Clinical Trials randomised controlled trials registry (April 2005). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section.

Selection criteria:

Randomised trials of ECV beginning before term (before 37 weeks' gestation) compared with a control group in women with breech presentation before term.

Data collection and analysis:

Two review authors independently assessed eligibility and trial quality and extracted data.

Main results:

Three studies are included. One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared to no ECV. No difference was found in the rate of non-cephalic presentation at birth. One study reported on a policy of ECV that was initiated before term (33 weeks) and up until 40 weeks' gestation and which could be repeated up until delivery compared to no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (relative risk 0.59, 95% confidence interval 0.45 to 0.77). One study reported on ECV started at between 34 to 35 weeks' gestation compared to beginning at 37 to 38 weeks' gestation. Although findings were not statistically significant, a 9.5% decrease in the rate of non-cephalic presentation at birth and a 7% decrease in the caesarean section rate were reported when ECV was started early.

Authors' conclusions:

Compared with no ECV attempt, ECV commenced before term reduces non-cephalic births. Compared with ECV at term, beginning ECV at between 34 to 35 weeks may have some benefit in terms of decreasing the rate of non-cephalic presentation, and caesarean section. Further trials are needed to confirm this finding and to rule out increased rates of preterm birth, or other adverse perinatal outcomes. A large pragmatic trial is ongoing (www.utoronto.ca/miru/eecv2).

[Note: The citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

This record should be cited as:

Hutton EK, Hofmeyr GJ. External cephalic version for breech presentation before term. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD000084. DOI: 10.1002/14651858.CD000084.pub2

Assessed as up to date:

October 18, 2005

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Primary Review Group:

Pregnancy and Childbirth Group

Health topics:

Pregnancy & childbirth > Fetal malpresentation

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

External cephalic version for breech presentation before term

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