Risk factors and outcomes of abnormal bleeding after external cephalic version.

OBJECTIVES: To present the consequences of and risk factors for abnormal bleeding after ECV (external cephalic version). METHODS: We conducted a retrospective chart review at a single center in Japan. Abnormal bleeding was defined as vaginal bleeding and/or intrauterine hemorrhage. We descriptively assessed birth outcomes among women with abnormal bleeding, and investigated the risk factors using a logistic regression analysis. RESULTS: Of 477 women who received ECV, 39 (8.2%) showed abnormal bleeding, including 16 (3.4%) with intrauterine hemorrhage. Of the 16 women with intrauterine hemorrhage, 14 required emergency cesarean section; none experienced placental abruption, a low Apgar score at 5 min (<7), or low umbilical cord artery pH (<7.1). Among 23 women who had vaginal bleeding without intrauterine hemorrhage, four cases underwent emergency cesarean section and one case of vaginal delivery involved placental abruption. The risk of abnormal bleeding was higher in women with a maximum vertical pocket (MVP) of <40 mm in comparison to those with an MVP of >50 mm (adjusted odds ratio [OR]: 3.48, 95% confidence interval [CI]: 1.23-9.90), as was higher in women with unsuccessful ECV than in those with successful ECV (aOR: 4.54, 95% CI: 1.95-10.6). CONCLUSIONS: A certain number of women who underwent ECV had abnormal bleeding, including vaginal bleeding and/or intrauterine hemorrhage, many of them resulted in emergency cesarean section. Although all of cases with abnormal bleeding had good birth outcomes, one case of vaginal bleeding was accompanied by placental abruption. Small amniotic fluid volume and unsuccessful ECV are risk factors for abnormal bleeding.

Comparison of Nitroglycerin and Terbutaline for External Cephalic Version in Women Who Received Neuraxial Anesthesia: A Retrospective Analysis.

External cephalic version is a technique that decreases the need for cesarean delivery in patients with breech presentation. Several techniques exist to increase the success of external cephalic version; however, there are no studies comparing different tocolytics in patients who also received neuraxial anesthesia. We, therefore, performed a review of 198 patients who presented for external cephalic version and compared their success rates based on the tocolytic medication utilized. The external cephalic version success rate for patients who received terbutaline was significantly higher than for those who received nitroglycerin (N [%]: 57 [65.6] terbutaline group versus 40 [36.0] nitroglycerin group; P < .001).

Patient opinion of analgesia during external cephalic version at term in singleton pregnancy.

To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it.

Maternal and perinatal outcomes in external cephalic version: prognostic factors for the success of the technique.

Background We aimed to analyze the success rate of external cephalic version (ECV) for breech presentations performed in our center between March 2011 and March 2016. We evaluated factors related to a successful ECV, delivery mode, complications and newborn status after ECV. Methods Analysis of assembled data of 327 consecutive ECVs in the third trimester was done. Results The total success rate was 56.6%. After a successful ECV, 85.9% of the fetuses were delivered vaginally. Logistic regression analysis of background factors leading to a successful ECV showed that tocolysis with ritodrine and anterior placenta were each significantly correlated with the rate of successful version. No severe complications were registered during the ECVs, and all babies had normal Apgar scores at delivery. Conclusion These findings suggest that attempting an ECV in breech presentations, once or even twice, seems to be an appropriate management given that a successful ECV decreases the rate of cesarean section in this group of patients and by doing so, it might also decrease the risk of cesarean sections in future pregnancies.

Complications of external cephalic version: a retrospective analysis of 1121 patients at a tertiary hospital in Sydney.

OBJECTIVE: To report the complication rate associated with external cephalic version (ECV) at term. DESIGN: Single-centre retrospective study. SETTING: A major tertiary hospital in Sydney, Australia. POPULATION OR SAMPLE: All women who underwent an ECV at Royal Prince Alfred Hospital from 1995-2013 were included. METHODS: ECV was attempted on all consenting women with a breech presentation at term in the absence of contraindications. Complications were classified as minor (transient cardiotocography abnormalities, ruptured membranes, small antepartum haemorrhage) or serious (fetal death, placental abruption, fetal distress requiring emergency caesarean section, fetal bone injury, cord prolapse). ECV success rates and rate of reversion to breech were recorded. MAIN OUTCOME MEASURES: The primary outcome was the incidence of serious complications. Secondary outcome measures were the rate of minor complications and reversion to breech. RESULTS: Of 1121 patients that underwent ECV, five (0.45%) experienced a serious complication. There was one placental abruption, one emergency caesarean section for fetal distress and two cord prolapses. There was one fetal death attributable to a successful ECV. Forty-eight women (4.28%) experienced a minor complication. Reversion to the breech occurred in sixteen patients (3.32%). CONCLUSION: ECV at term is associated with a low rate of serious complications. TWEETABLE ABSTRACT: Study of 1121 consecutive ECV attempts shows low rate of complications although one fetal death reported.

Fetal heart rate abnormalities during and after external cephalic version: Which fetuses are at risk and how are they delivered?

BACKGROUND: Fetal heart rate abnormalities (FHR) during and after external cephalic version (ECV) are relatively frequent. They may raise concern about fetal wellbeing. Only occasionally they may lead to an emergency cesarean section. METHODS: Prospective cohort study in 980 women (> 34 weeks gestation) with a singleton fetus in breech presentation. During and after external cephalic version (ECV) FHR abnormalities were recorded. Obstetric variables and delivery outcome were evaluated. Primary outcome was to identify which fetuses are at risk for FHR abnormalities. Secondary outcome was to identify a possible relationship between FHR abnormalities during and after ECV and mode of delivery and fetal distress during subsequent labor. RESULTS: The overall success rate of ECV was 60% and in 9% of the attempts there was an abnormal FHR pattern. In two cases FHR abnormalities after ECV led to an emergency CS. Estimated fetal weight per 100 g (OR 0.90, CI: 0.87-0.94) and longer duration of the ECV-procedure (OR 1.13, CI: 1.05-1.21) were factors significantly associated with the occurrence of FHR abnormalities. FHR abnormalities were not associated with the mode of delivery or the occurrence of fetal distress during subsequent labor. CONCLUSIONS: FHR abnormalities during and after ECV are more frequent with lower estimated fetal weight and longer duration of the procedure. FHR abnormalities during and after ECV have no consequences for subsequent mode of delivery. They do not predict whether fetal distress will occur during labor. TRIAL REGISTRATION: The Eindhoven Breech Intervention Study, NCT00516555 . Date of registration: August 13, 2007.

What is the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs? A systematic review and meta-analyses.

BACKGROUND: Given the controversy around mode of delivery, our objective was to assess the evidence regarding the safest mode of delivery for actively resuscitated extremely preterm cephalic/non-cephalic twin pairs before 28 weeks of gestation. METHODS: We searched Cochrane CENTRAL, MEDLINE, EMBASE and  http://clinicaltrials.gov from January 1994 to January 2017. Two reviewers independently screened titles, abstracts and full text articles, extracted data and assessed risk of bias. We included randomized controlled trials and observational studies. Our primary outcome was a composite of neonatal death (<28 days of life) and severe brain injury in survivors (intraventricular hemorrhage grade ≥ 3 or periventricular leukomalacia). We performed random-effects meta-analyses, generating odds ratios with 95% confidence intervals for the first and second twin separately, and for both twins together. We assessed the risk of bias using a modified Newcastle Ottawa Scale (NOS) for observational studies and used Grading of Recommendations Assessment, Development and Evaluation approach (GRADE). RESULTS: Our search generated 2695 articles, and after duplicate removal, we screened 2051 titles and abstracts, selecting 113 articles for full-text review. We contacted 36 authors, and ultimately, three observational studies met our inclusion criteria. In cephalic/non-cephalic twin pairs delivered by caesarean section compared to vaginal birth at 24+0-27+6 weeks the odds ratio for our composite outcome of neonatal death and severe brain injury for the cephalic first twin was 0.35 (95% CI 0.00-92.61, two studies, I2 = 76%), 1.69 for the non-cephalic second twin (95% CI 0.04-72.81, two studies, I2 = 55%) and 0.83 for both twins (95% CI 0.05-13.43, two studies, I2 = 56%). According to the modified Newcastle Ottawa Scale we assessed individual study quality as being at high risk of bias and according to GRADE the overall evidence for our primary outcomes was very low. CONCLUSION: Our systematic review on the safest mode of delivery for extremely preterm cephalic/non-cephalic twin pairs found very limited existing evidence, without significant differences in neonatal death and severe brain injury by mode of delivery.

An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives.

OBJECTIVE: To evaluate the success of an external cephalic version (ECV) training programme, and to determine the rates of successful ECV, complications, and caesarean birth in a low-risk population. DESIGN: Prospective observational study. SETTING: Primary health care and hospital settings throughout the Netherlands (January 2008-September 2011). POPULATION: Low-risk women with a singleton fetus in breech presentation, without contraindications to ECV, were offered ECV at approximately 36 weeks of gestation. METHODS: Data were collected for all ECVs performed by midwives, and were entered into a national online database. MAIN MEASURES: Successful ECV was defined as the fetus having a cephalic presentation immediately following the procedure and at birth. Complications were observed at ≤ 30 minutes and between 30 minutes and 48 hours after the ECV procedure. All serious pregnancy outcomes that occurred after the ECV procedure until birth were reported. RESULTS: A total of 47% had a successful ECv and a cephalic at the time of birth: 34% of nulliparous and 66% of multiparous women. After ECV, 57% of women gave birth vaginally: 45% of nulliparous women and 76% of multiparous women. Within 30 minutes after ECV, and between 30 minutes and 48 hours after ECV, the proportion of women experiencing a complication or serious pregnancy outcome was 0.9% and 1.8%, respectively. Serious pregnancy outcome at any time following ECV until birth was experienced by 58 (2.5%) of the women. CONCLUSIONS: The success rate of ECVs performed by trained midwives in primary health care or hospital settings is comparable with that of other providers, and the procedure is safe for low-risk women.

Shoulder dystocia and associated manoeuvres as risk factors for perineal trauma.

INTRODUCTION AND HYPOTHESIS: Shoulder dystocia (SD) is an obstetric emergency that can be associated with serious neonatal morbidity and mortality. The aim of this study was to identify the incidence and risk factors for obstetric anal sphincter injuries (OASIS) in women who sustained SD at birth. METHODS: This was a retrospective observational study over a 5-year period whereby 403 cases of SD were identified. The primary outcome measure was to identify the incidence of OASIS in women with SD. We also evaluated the role of the manoeuvres used for the management of SD and aimed to identify possible correlations between specific manoeuvres and OASIS by univariate and multivariate regression analysis. RESULTS: Shoulder dystocia was associated with a three-fold increase in the risk of OASIS in our population. The use of internal manoeuvres (OR 2.182: 95 % CI 1.173-4.059), an increased number of manoeuvres ≥ 4 (OR 4.667: 95 % CI 1.846-11.795), Woods' screw manoeuvre (OR 3.096: 95 % CI 1.554-6.169), reverse Woods' screw manoeuvre (OR 4.848: 95 % CI 1.647-14.277) and removal of the posterior arm (OR 2.222: 95 % CI 1.117-4.421) were all associated with a significant increase in the likelihood of OASIS. CONCLUSIONS: In our study, instrumental deliveries, the use of internal manoeuvres (Woods' screw and reverse Woods' screw) and four or more manoeuvres for the management of SD were independently associated with a higher incidence of OASIS. To effectively manage shoulder dystocia with lower risks of perineal trauma, these factors could be considered when designing further prospective studies and developing management protocols.

External cephalic version for breech presentation before term.

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 METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) of ECV attempted before term (37 weeks' gestation) or commenced before term, compared with a control group of women (in breech presentation) in which either no ECV attempted or ECV was attempted at term. Cluster-randomised trials were eligible for inclusion but none were identified. Quasi-RCTs or studies using a cross-over design were not eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. Studies were assessed for risk of bias and for important outcomes the overall quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: Five studies are included (2187 women). It was not possible for the intervention to be blinded, and it is not clear what impact lack of blinding would have on the outcomes reported. For other 'Risk of bias' domains studies were either at low or unclear risk of bias.One study reported on ECV that was undertaken and completed before 37 weeks' gestation compared with no ECV. No difference was found in the rate of non-cephalic presentation at birth (risk ratio (RR) 1.04, 95% confidence interval (CI) 0.64 to 1.69; participants = 102). 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 with no ECV. This study showed a decrease in the rate of non-cephalic presentation at birth (RR 0.59, 95% CI 0.45 to 0.77; participants = 179).Three studies reported on ECV started at between 34 to 35 weeks' gestation compared with beginning at 37 to 38 weeks' gestation. Pooled results suggested that early ECV reduced the risk of non-cephalic presentation at birth (RR 0.81, 95% CI 0.74 to 0.90; participants = 1906; studies = three; I² = 0%, evidence graded high quality), failure to achieve vaginal cephalic birth (RR 0.90, 95% CI 0.83 to 0.97; participants = 1888; studies = three; I² = 0%, evidence graded high quality), and vaginal breech delivery (RR 0.44, 95% CI 0.25 to 0.78; participants = 1888; studies = three; I² = 0%, evidence graded high quality). The difference between groups for risk of caesarean was not statistically significant (RR 0.92, 95% CI 0.85 to 1.00; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was evidence that risk of preterm labour was increased with early ECV compared with ECV after 37 weeks (6.6% in the ECV group and 4.3% for controls) (RR 1.51, 95% CI 1.03 to 2.21; participants = 1888; studies = three; I² = 0%, evidence graded high quality). There was no clear difference between groups for low infant Apgar score at five minutes or perinatal death (stillbirth plus neonatal mortality up to seven days) (evidence graded as low quality for both outcomes). AUTHORS' CONCLUSIONS: Compared with no ECV attempt, ECV commenced before term reduces non-cephalic presentation at birth. 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 risk of vaginal breech birth. However, early ECV may increase risk of late preterm birth, and it is important that any future research reports infant morbidity outcomes. Results of the review suggest that there is a need for careful discussion with women about the timing of the ECV procedure so that they can make informed decisions.

Neuraxial blockade for external cephalic version: Cost analysis.

AIM: Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates. METHODS: A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness. RESULTS: Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted. CONCLUSIONS: Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

Maternal and neonatal morbidity in relation to the instrument used for mid-cavity rotational operative vaginal delivery: a prospective cohort study.

OBJECTIVE: To compare the maternal and neonatal morbidity associated with alternative instruments used to perform a mid-cavity rotational delivery. DESIGN: A prospective cohort study. SETTING: Two university teaching hospitals in Scotland and England. POPULATION: Three hundred and eighty-one nulliparous women who had a mid-cavity rotational operative vaginal delivery. METHODS: A data collection sheet was completed by the research team following delivery. MAIN OUTCOME MEASURES: Postpartum haemorrhage, third- and fourth-degree perineal tears, low cord pH, neonatal trauma, and failed or sequential operative vaginal delivery. RESULTS: One hundred and sixty-three women (42.8%) underwent manual rotation followed by non-rotational forceps delivery, 73 (19.1%) had a rotational vacuum delivery, and 145 (38.1%) delivered with the assistance of rotational (Kielland) forceps. The rates of postpartum haemorrhage were similar when comparing manual rotation with rotational vacuum (adjusted OR 1.42, 95% CI 0.66-3.98), and when comparing manual rotation with Kielland forceps (adjusted OR 1.22, 95% CI 0.71-2.88). The results were comparable for third- and fourth-degree perineal tears (adjusted OR 0.85, 95% CI 0.13-1.89; adjusted OR 0.94, 95% CI 0.39-1.82), low cord pH (adjusted OR 1.76, 95% CI 0.44-6.91; adjusted OR 1.12, 95% CI 0.44-2.83), neonatal trauma (adjusted OR 0.50, 95% CI 0.16-1.55; adjusted OR 3.25, 95% CI 0.65-16.17), and admission to the neonatal intensive care unit (adjusted OR 1.47, 95% CI 0.45-4.81; adjusted OR 1.04, 95% CI 0.49-2.19). The sequential use of instruments was less likely with manual rotation and forceps than with rotational vacuum delivery (0.6 versus 36.9%, OR 0.01, 95% CI 0.002-0.090). CONCLUSIONS: Maternal and perinatal outcomes are comparable with Kielland forceps, vacuum extraction, and manual rotation, with few serious adverse outcomes. With appropriate training mid-cavity rotational delivery can be practiced safely, including the use of Kielland forceps.

Analgesia/anesthesia for external cephalic version.

PURPOSE OF REVIEW: Professional society guidelines recommend that women with breech presentation be delivered surgically due to a higher incidence of fetal risks compared with vaginal delivery. An alternative is attempted external cephalic version, which if successful, enables attempted vaginal delivery. Attitudes towards external cephalic version (ECV) will be considered in this review, along with pain relief methods and their impact on ECV success rates. RECENT FINDINGS: Articles suggest that ECV is infrequently offered, due to both physician and patient factors. Success of ECV is higher in multiparous women, complete breech, posterior placenta, or smaller fetus. Preterm ECV performance does not increase vaginal delivery rates. Neuraxial techniques (spinal or epidural) significantly increase ECV success rates, as do moxibustion and hypnosis. Four reviews summarized studies considering ECV and neuraxial techniques. These reviews suggest that neuraxial techniques using high (surgical) doses of local anesthetic are efficacious compared with control groups not using anesthesia, whereas techniques using low-doses are not. Low-dose versus high-dose neuraxial analgesia/anesthesia has not been directly compared in a single study. Based on currently available data, the rate of cephalic presentation is not increased using neuraxial techniques, but vaginal delivery rates are higher. ECV appears to be a low-risk procedure. SUMMARY: The logistics of routine ECV and provision of optimal neuraxial techniques for successful ECV require additional research. Safety aspects of neuraxial anesthesia for ECV require further investigation.

Evaluating the effectiveness of lateral postural management for breech presentation: study protocol for a randomized controlled trial (BRLT study).

BACKGROUND: Breech presentation is observed in 3-4% at term of pregnancy and is one of the leading causes of cesarean section. There is no established treatment for breech presentation before 36 weeks. A retrospective cohort study was conducted to demonstrate that the lateral position is effective for breech presentation. However, there are no randomized controlled trials evaluating lateral position management for breech presentation. Here, we described the methodology of a randomized controlled trial of a cephalic version for breech presentation in the third trimester by lateral postural management (BRLT study). METHODS: The BRLT study is an open-label, randomized controlled trial with two parallel groups allocated in a 1:1 ratio to examine the lateral position management for breech presentation, as compared with expectant management care. An academic hospital in Japan will enroll 200 patients diagnosed with a breech presentation by ultrasonography between 28 + 0 weeks and 30 + 0 weeks. Participants in the intervention group will be instructed to lie on their right sides for 15 min three times per day if the fetal back was on the left side or lie on their left sides if the fetal back was on the right side. The instruction will be given every 2 weeks after confirmation of fetal position, and the lateral position will be instructed until the cephalic version, and after the cephalic version, the reverse lateral position will be instructed until delivery. The primary outcome is cephalic presentation at term. The secondary outcomes are cesarean delivery, cephalic presentation 2, 4, and 6 weeks after the instruction, and at delivery, recurrent breech presentation after cephalic version, and adverse effects. DISCUSSION: This trial will answer whether the lateral positioning technique is effective in treating breech presentation and, depending on the results, may provide a very simple, less painful, and safe option for treating breech presentation before 36 weeks, and it may impact breech presentation treatment. TRIAL REGISTRATION: UMIN Clinical Trials Registry UMIN000043613. Registered on 15 March 2021 https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000049800 .

Clinical hypnosis before external cephalic version.

Three to four percent of full-term singleton pregnancies present themselves as breech deliveries. External cephalic version (ECV) is a procedure to try to turn a breech fetus to cephalic by externally maneuvering the fetus through the maternal abdomen. This trial examines a clinical hypnosis intervention against standard medical care of women before ECV. A total of 78 women, who received a hypnosis intervention prior to ECV, had a 41.6% (n = 32) successful ECV, whereas the control group of 122, who had similar baseline characteristics, had a 27.3% (n = 33) successful ECV procedure (p < 0.05). This trial found that a relaxation technique with the help of clinical hypnosis was successful at increasing the likelihood of a successful ECV procedure.

External cephalic version of the non-cephalic presenting twin: a systematic review.

OBJECTIVE: Decreasing the primary cesarean delivery rate and associated maternal and fetal complications is a priority for obstetric care providers. External cephalic version (ECV) is a procedure recommended for women with singleton pregnancies where the fetus is malpresenting to avoid vaginal breech delivery, which is inherently riskier than cesarean delivery. However, little is known about this procedure in the context of twin gestations. Scheduled cesarean delivery is instead recommended for women with twin gestations where the presenting twin is not cephalic. Our aim is to evaluate the safety and efficacy of ECV in the setting of twin pregnancy where the presenting twin is not cephalic. We also present two patients with twin pregnancy at our institution that attempted ECV. DATA SOURCES: A systematic review of the following electronic databases was performed, searching from their inception until September 2019: Pubmed, Ovid, Scopus, and clinicaltrials.gov. STUDY ELIGIBILITY CRITERIA: All reported cases of ECV for a non-cephalic presenting twin were included. Studies were excluded if patients had contraindications to vaginal delivery and if they described ECV of the second twin only. Maternal demographics, procedure details, and outcomes data were collected. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was a successful version of the presenting twin to the cephalic presentation following ECV. Statistical analysis involved calculating means, standard deviations, frequencies and percentages as appropriate. RESULTS: Two case reports and one case series, totaling 22 patients, met inclusion criteria. Two additional patients attempted ECV at our institution. One completed ECV (for a total of 23 patients) while the other did not. This patient consented for ECV as Twin A was noted to be breeched upon presentation to labor and delivery but after receiving regional anesthesia, twin A was cephalic. No randomized controlled trials were identified. All were dichorionic pregnancies. Successful ECV of twin A occurred in 57% (13/23) of women and 48% (11/23) had a successful vaginal delivery. The majority were performed using regional anesthesia and a uterine relaxant (20/23). No serious adverse events occurred in any of the reports. CONCLUSIONS: ECV is insufficiently studied in twin pregnancy. Based on very limited data, it appears feasible to turn the non-cephalic presenting twin. Additional randomized controlled trials are needed to further evaluate the safety and efficacy of this procedure for a non-cephalic presenting twin.

Spontaneous cephalic version and risk factors for persistent breech presentation: a longitudinal retrospective cohort study.

AIMS: To address the rate of spontaneous version in breech presentation until term and explore the risk factors for persistent breech presentation diagnosed by the second-trimester ultrasound examination. METHODS: This is a retrospective cohort study of pregnant women with a singleton pregnancy who had their ultrasound examination conducted at the time of 22-26 weeks of gestation in the Guangzhou Women and Children's Medical Center. Cox regressions were applied to determine the strength of association between selected risk factors and persistent breech presentation. RESULTS: Among 25,313 pregnant women eligible for analysis, the prevalence of breech presentation was 36.8% (9,306/25,313) at 22-26 weeks of gestation, 4.2% (376/8,876) of which would remain in the breech presentation at the onset of labor (adjusted odds ratio [aOR], 0.39, 95% confidence interval [CI], 0.17-0.88). Multiparity (aOR, 0.39, 95% CI, 0.30-0.52) and longer gestational weeks at delivery (aOR, 0.50, 95% CI, 0.44-0.56) were associated with a lower risk of persistent breech presentation (PBP). Female fetus, lateral or fundal placenta, and known uterine malformation was each associated with an increased odd of 1.4 (aOR, 95% CI, 1.11-1.70), 2.4 (aOR, 95% CI,1.50-3.73), 3.1 (aOR, 95% CI, 1.71-5.53) and 8.7 (aOR, 95% CI, 3.84-19.84) times in the persistent breech presentation, respectively. CONCLUSION: The prevalence of the breech presentation was 36.8% between 22 and 26 weeks of gestation, and approximately 4% would have been in the persistent breech presentation until the onset of labor. Higher educational attainment, multiparity and longer gestational weeks at delivery were significantly decreasing the risk of persistent breech presentation. While the pregnant women with age >40 years, female fetus, lateral or fundal placenta and known uterine malformation were associated increased risk of persistent breech presentation.

Manipulative Reduction for Abnormal Uterine Inclination in Vaginal Delivery.

OBJECTIVE: To investigate the manipulative reduction in abnormal uterine inclination in vaginal delivery. METHODS: With the independently developed uterine inclination surveyor, 40 primiparas with abnormal uterine inclination were randomly divided into two groups: treatment group (Group A, 20 cases) and control group (Group B, 20 cases). The general condition of the primipara, the labor stages, the changes in uterine inclination after treatment, postpartum hemorrhage at 2 hours, and the general condition of fetuses were observed to study the therapeutic value of manual reduction in abnormal uterine inclination. RESULT: In the control group, one uterine inclination was not corrected with the change in labor process, and the pregnancy was terminated due to stagnation of the active phase. In the first stage of labor, the time spent in the treatment group (393.4 ± 31.3 mins) was significantly lower than that in the control group (440.7 ± 34.9 mins) (P = 0.001). Compared with the control group (49.8 ± 6.5 mins), the treatment group (42.6 ± 7.2 mins) also exhibited a significantly shortened second stage of labor (P = 0.02). Sixteen cases (16/20) in the treatment group returned to normal after manual reduction, and 9 cases (9/20) in the control group returned to normal with the progression of natural labor. Manual reduction could be used as an option to treat abnormal uterine inclination (P = 0.01). There was no significant difference in the third stage of labor (P = 0.2), 2-hour postpartum hemorrhage (P = 0.35), Apgar score (P = 0.64), or body weight (P = 0.76) between the two groups. CONCLUSION: Manual reduction in the treatment of abnormal uterine inclination has obvious effects, shortens the birth process, and is safe for the fetus.

Moxibustion for cephalic version: a feasibility randomised controlled trial.

BACKGROUND: Moxibustion (a type of Chinese medicine which involves burning a herb close to the skin) has been used to correct a breech presentation. Evidence of effectiveness and safety from systematic reviews is encouraging although significant heterogeneity has been found among trials. We assessed the feasibility of conducting a randomised controlled trial of moxibustion plus usual care compared with usual care to promote cephalic version in women with a breech presentation, and examined the views of women and health care providers towards implementing a trial within an Australian context. METHODS: The study was undertaken at a public hospital in Newcastle, New South Wales, Australia. Women at 34-36.5 weeks of gestation with a singleton breech presentation (confirmed by ultrasound), were randomised to moxibustion plus usual care or usual care alone. The intervention was administered over 10 days. Clinical outcomes included cephalic presentation at birth, the need for ECV, mode of birth; perinatal morbidity and mortality, and maternal complications. Feasibility outcomes included: recruitment rate, acceptability, compliance and a sample size for a future study. Interviews were conducted with 19 midwives and obstetricians to examine the acceptability of moxibustion, and views on the trial. RESULTS: Twenty women were randomised to the trial. Fifty one percent of women approached accepted randomisation to the trial. A trend towards an increase in cephalic version at delivery (RR 5.0; 95% CI 0.7-35.5) was found for women receiving moxibustion compared with usual care. There was also a trend towards greater success with version following ECV. Two babies were admitted to the neonatal unit from the moxibustion group. Compliance with the moxibustion protocol was acceptable with no reported side effects. Clinicians expressed the need for research to establish the safety and efficacy of moxibustion, and support for the intervention was given to increase women's choices, and explore opportunities to normalise birth. The sample size for a future trial is estimated to be 381 women. CONCLUSION: Our findings should be interpreted with caution as the study was underpowered to detect statistical differences between groups. Acceptance by women and health professionals towards moxibustion suggest further research is warranted. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000985280.