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Introduction Material and Methods Results Conclusions One of the key challenges regarding the management of twins involves choosing the optimal mode of delivery, which is strongly influenced by the final presentation of both fetuses. In cases of vertex–nonvertex pregnancies attempting the trial of vaginal delivery, external cephalic version (ECV) is one of possible management options. The main objective of this review was to collect and summarize available data in terms of the application of ECV in the population of nonvertex second twins.Using the PRISMA guidelines, we searched for original, English‐language studies investigating ECV in nonvertex second twins. The PubMed/MEDLINE, SCOPUS, and COCHRANE databases were searched until May 2024. Reviews, case reports, editorials, and conference papers were excluded from further analysis. Out of 260 papers retrieved, 10 were subjected to the final analysis in terms of success rates, modes of delivery, and adverse outcomes.The total number of ECVs was 289, with an overall success rate of 64.4%. In the group of successful versions, vertex vaginal delivery was achieved in 171 cases (91.9%). The incidence of adverse maternal and neonatal outcomes was low.The purpose of this review was to consolidate and update the current knowledge regarding ECV in nonvertex second twins. Based on the results of this series of studies, ECV appears to be a reasonable management option. However, it is important to highlight several significant limitations. The primary concern is the lack of recent research in this field over the past three decades, with the most recent study in our review being published in 1998. Furthermore, the actual number of studies addressing this topic is relatively low, characterized by a retrospective nature and questionable methodologies. These limitations make it challenging to draw definitive conclusions for clinical practice. This is an important message for our community, emphasizing the need for further studies in this area, particularly randomized controlled trials, to evaluate the safety and success rate of vaginal twin delivery after ECV when the second twin presents in a nonvertex position. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to evaluate the impact of women's body mass index (BMI) on the probability of a successful external cephalic version (ECV).Material and Methods: A retrospective population-based observational study including all women that underwent an ECV in the southeast region of Sweden from January 2014 to December 2019. Data were collected from electronic medical records, Obstetrix, Cerner. The women were divided into BMI categories according to the World Health Organization classification. Women with a BMI below 25 kg/m2 formed the reference group. Crude and adjusted odds ratios for unsuccessful ECV in each BMI group were calculated using binary logistic regression. Furthermore, the association between maternal characteristics and clinical and ultrasound variables at the time of the ECV and unsuccessful ECV was evaluated.Results: A total of 2331 women were included. The overall success rate of ECV was 53.4%. Women with a BMI below 25 kg/m2 had a success rate of 51.3% whereas obese women had a success rate of 58.6%. The risk of an unsuccessful ECV among obese women (BMI ≥30 kg/m2 ) had an OR of 0.74 (95% CI 0.59-0.94) compared with women with a BMI below 25 kg/m2 . After adjusting for suitable confounding factors, the association was no longer significant. Higher maternal age, multiparity, higher gestational age, posterior placenta position, polyhydramnios and higher estimated weight of the fetus at the ECV significantly decreased the risk of an unsuccessful ECV.Conclusions: Maternal obesity does not seem to negatively influence the success rate of ECV. This is a finding that may encourage both caregivers and obese pregnant women to consider an ECV and so avoid a planned cesarean section for breech presentation in this group. [ABSTRACT FROM AUTHOR]

Introduction: Approximately 4% of singleton pregnancies at term are in breech presentation. External cephalic version (ECV) can reduce the risks of noncephalic birth and cesarean delivery, but this maneuver can be painful. Our aim was to analyze the effect of administering inhaled nitrous oxide for analgesia on the ECV success rate.Material and Methods: This prospective, randomized, single-blind, controlled trial included women with singleton pregnancies in breech presentation at term who were referred for ECV in a tertiary care center. Women were assigned according to a balanced (1:1) restricted randomization design to inhale either nitrous oxide (N2 O) in a 50:50 mix with oxygen or medical air during the procedure. The main outcomes reported are the ECV success rate, degree of pain, adverse event rate, and women's satisfaction.Trial Registration: ClinicalTrials.gov Identifier: NCT01948115.Results: The study included 150 women (nitrous oxide group: n = 74; medical air: n = 76). Inhaled nitrous oxide was not associated with a higher ECV success rate than medical air (24.3 vs 19.7%, P = 0.51). Among parous women (n = 34 in each group), the ECV success rate appeared higher in the nitrous oxide group, respectively 47.1% (n = 16) vs 23.5% (n = 8) (P = 0.042). Neither the median pain level nor adverse event rates differed significantly in women with inhaled nitrous oxide compared with medical air.Conclusions: Use of an equimolar mixture of oxygen and nitrous oxide during ECV appears safe. Although it does not seem to change the overall success rate, it may increase success in parous women. [ABSTRACT FROM AUTHOR]

Introduction: Among women with a fetus with a non-cephalic presentation, external cephalic version (ECV) has been shown to reduce the rate of breech presentation at birth and cesarean birth. Compared with ECV at term, beginning ECV prior to 37 weeks' gestation decreases the number of infants in a non-cephalic presentation at birth. The purpose of this secondary analysis was to investigate factors associated with a successful ECV procedure and to present this in a clinically useful format.Material and Methods: Data were collected as part of the Early ECV Pilot and Early ECV2 Trials, which randomized 1776 women with a fetus in breech presentation to either early ECV (34-36 weeks' gestation) or delayed ECV (at or after 37 weeks). The outcome of interest was successful ECV, defined as the fetus being in a cephalic presentation immediately following the procedure, as well as at the time of birth. The importance of several factors in predicting successful ECV was investigated using two statistical methods: logistic regression and classification and regression tree (CART) analyses.Results: Among nulliparas, non-engagement of the presenting part and an easily palpable fetal head were independently associated with success. Among multiparas, non-engagement of the presenting part, gestation less than 37 weeks and an easily palpable fetal head were found to be independent predictors of success. These findings were consistent with results of the CART analyses.Conclusions: Regardless of parity, descent of the presenting part was the most discriminating factor in predicting successful ECV and cephalic presentation at birth. [ABSTRACT FROM AUTHOR]

Introduction: While evidence suggests that beginning an external cephalic version (ECV) before term (340/7 to 366/7 weeks) compared with after term may be associated with an increase in late preterm birth (340/7 to 366/7 weeks), it remains unknown what might account for this risk. The objective of the present study is to further investigate the association between ECV before term and late preterm birth.Material and Methods: Secondary analysis of data collected from the international, multicenter Early ECV trials. We evaluated the relation between ECV exposure and late preterm birth (340/7 to 366/7 weeks), as well as whether additional risk factors for preterm birth (such as maternal age, height, body mass index, parity, placental location, and perinatal mortality rate) moderated this relation. Generalized linear mixed methods were used to account for center effect and adjust for covariates.Result: Among 1765 women with breech pregnancies and without a prior preterm birth, 749 (42.4%) received at least one ECV before term. Exposure to an ECV before term was not associated significantly independently with odds of preterm birth. However, placenta location moderated the association between early ECV exposure and late preterm birth. The odds of preterm birth in women who were exposed to an ECV before term and who also had an anterior placenta were doubled (OR 2.05; 95% CI 1.12-3.71; p = 0.02).Conclusion: In a large cohort of women without known risks for preterm birth, those with an anterior placenta who undergo an ECV before term constitute a subgroup at particular risk for late preterm birth. [ABSTRACT FROM AUTHOR]

Objective To determine the effectiveness of a client or care-provider strategy to improve the implementation of external cephalic version. Design Cluster randomized controlled trial. Setting Twenty-five clusters; hospitals and their referring midwifery practices randomly selected in the Netherlands. Population Singleton breech presentation from 32 weeks of gestation onwards. Methods We randomized clusters to a client strategy (written information leaflets and decision aid), a care-provider strategy (1-day counseling course focused on knowledge and counseling skills), a combined client and care-provider strategy and care-as-usual strategy. We performed an intention-to-treat analysis. Main outcome measures Rate of external cephalic version in various strategies. Secondary outcomes were the percentage of women counseled and opting for a version attempt. Results The overall implementation rate of external cephalic version was 72% (1169 of 1613 eligible clients) with a range between clusters of 8-95%. Neither the client strategy ( OR 0.8, 95% CI 0.4-1.5) nor the care-provider strategy ( OR 1.2, 95% CI 0.6-2.3) showed significant improvements. Results were comparable when we limited the analysis to those women who were actually offered intervention ( OR 0.6, 95% CI 0.3-1.4 and OR 2.0, 95% CI 0.7-4.5). Conclusions Neither a client nor a care-provider strategy improved the external cephalic version implementation rate for breech presentation, neither with regard to the number of version attempts offered nor the number of women accepting the procedure. [ABSTRACT FROM AUTHOR]

Objective. External cephalic version (ECV) is a safe and effective intervention that can prevent breech delivery, thus reducing the need for cesarean delivery. It is recommended in national guidelines. These guidelines also mention contraindications for ECV, and thereby restrict the application of ECV. We assessed whether the formulation of these contraindications in guidelines are based on empiric data. Design. Systematic review. Population. Pregnant women with a singleton breech presentation from 34 weeks. Methods. We searched the National Guideline Clearinghouse, the Cochrane Central Register of Controlled Trials, MEDLINE (1953-2009), EMBASE (1980-2009), TRIP database (until 2011), NHS (National Health Services, until 2011), Diseases database (until 2011) and NICE guidelines (until 2011) for existing guidelines on ECV and studied the reproducibility of the contraindications stated in the guidelines. Furthermore, we systematically reviewed the literature for contraindications and evidence on these contraindications. Main outcome measures. Contraindications of ECV. Results. We found five guidelines mentioning 18 contraindications, varying from five to 13 per guideline. The contraindications were not reproducible between the guidelines with oligohydramnios as the only contraindication mentioned in all guidelines. The literature search yielded 60 studies reporting on 39 different contraindications, of which we could only assess evidence of six of them. Conclusion. The present study shows that there is no general consensus on the eligibility of patients for ECV. Therefore we propose to limit contraindications for ECV to clear empirical evidence or to those with a clear pathophysiological relevance. [ABSTRACT FROM AUTHOR]

Background. External cephalic version (ECV) is accepted as a means of reducing the rate of breech presentation at term. Routine use of tocolysis prior to an ECV has been described to increase its success rate. The study's objective was to evaluate the efficacy of oral nifedipine as a tocolytic agent prior to ECV, and to compare it with intravenous ritodrine (IR). Methods. Women with breech presentation at term considered suitable for ECV were given nifedipine prior to the procedure. The success rate was compared to a cohort of women who underwent an ECV attempt at our department during the years 1999-2002 using IR prior to the procedure. Power analysis indicated that 70 women were needed in each group to detect a difference of 25% from our baseline success rate of 50%. Results. Seventy-six women receiving nifedipine before their ECV attempt were compared to 90 women who received IR. Age, parity, gestational age at ECV, type of breech, placental location, fetal weight, and gestational age at delivery were not different between the groups. The overall success rate was 54% and 50% in the nifedipine and ritodrine groups respectively (p=0.6). The success rate among primiparous women was 35% and 29% respectively (p=0.8). The success rate among multiparous women was 64% and 63% respectively (p=1.0). The success rate was statistically different between primiparous and multiparous women in each group (p<0.05). Conclusion. Oral nifedipine may be as effective as IR when administered before ECV. [ABSTRACT FROM AUTHOR]

Objective. To assess the clinical factors that influence the estimates of clinicians of the success of an external cephalic version (ECV), and the subsequent management decisions made by clinicians. Design. We constructed 16 fictional vignettes of women with a term fetus in breech position eligible for ECV. Setting. Secondary and tertiary clinics in The Netherlands. Population. Thirty-seven gynaecologists, residents and midwifes. Methods. Sixteen case summaries concerning a hypothetical patient eligible for ECV. Potential prognostic factors that varied between the cases were parity, maternal body mass index, engagement of the fetus, amniotic fluid, fetal growth, fetal presentation and placental localisation. For each case presentation, the clinicians were asked for their inclination to perform an ECV, and whether or not they would use tocolysis. Results. The estimated probabilities of success varied between 20 and 60%. The number of clinicians that would attempt an ECV varied per case between 32 and 97%. Amniotic fluid and engagement contributed 80% of the variation in the decision to perform ECV. In the case of oligohydramnios or an engaged breech, the clinicians tended not to perform an ECV. Conclusion. Amniotic fluid and engagement seem to be the main factors in the clinical decision-making of clinicians in ECV. This decision-making is probably experience based. Systematic knowledge of clinical prognosticators and subsequent assessment of their prognostic capacity is needed. [ABSTRACT FROM AUTHOR]

Background. Probabilistic information on outcomes of breech presentation is important for clinical decision-making. We aim to quantify adverse maternal and fetal outcomes of breech presentation at term. Methods. We conducted an audit of 1,070 women with a term, singleton breech presentation who were classified as eligible or ineligible for external cephalic version or diagnosed in labor at a tertiary obstetric hospital in Australia, 1997–2004. Maternal, delivery and perinatal outcomes were assessed and frequency of events quantified. Results. Five hundred and sixty (52%) women were eligible and 170 (16%) were ineligible for external cephalic version, 211 (20%) women were diagnosed in labor and 134 (12%) were unclassifiable. Seventy-one percent of eligible women had an external cephalic version, with a 39% success rate. Adverse outcomes of breech presentation at term were rare: immediate delivery for prelabor rupture of membranes (1.3%), nuchal cord (9.3%), cord prolapse (0.4%), and fetal death (0.3%); and did not differ by clinical classification. Women who had an external cephalic version had a reduced risk of onset-of-labor within 24 h (RR 0.25; 95%CI 0.08, 0.82) compared with women eligible for but who did not have an external cephalic version. Women diagnosed with breech in labor had the highest rates of emergency cesarean section (64%), cord prolapse (1.4%) and poorest infant outcomes. Conclusions. Adverse maternal and fetal outcomes of breech presentation at term are rare and there was no increased risk of complications after external cephalic version. Findings provide important data to quantify the frequency of adverse outcomes that will help facilitate informed decision-making and ensure optimal management of breech presentation. [ABSTRACT FROM AUTHOR]

Background . To compare the degree of force applied during external cephalic version, between different patients’ characteristic and outcomes of version. Methods . It is a prospective observational study in a cohort of patients undergoing external cephalic version at or above 36 weeks of gestation. During external cephalic version, the operator wore a pair of pressure-sensing gloves which had ultra-thin piezo-resistive pressure sensors positioned on the palmer surface. Readings from each of the sensors were recorded in real time throughout each version attempt and analyzed by a computer program. The pressure exerted on individual sensors over time, the pressure–time integral (PTI; mmHg s), was calculated for each sensor from the start to the end of each version attempted. The degree of force applied for each attempt (PTI-A) was represented by the sum of pressure–time integrals across all sensors. PTI-A was analyzed in relation to different patients’ characteristics and outcome of version. Results . Ninety-two patients were recruited, 73% of whom had a successful external cephalic version. The median PTI-A of the successful attempt in women who completed version after 1 and 2 attempts were 17,180 and 17,736?mmHg s, respectively. They were significantly lower than that of the women who required 3 or more attempts for a successful version (32,351?mmHg s), as well as the highest PTI-A among all attempts received by women who finally had a failed version (31,638?mmHg s) ( p [ABSTRACT FROM AUTHOR]

The Term Breech Trial has considerably increased the number of cesareans. External cephalic version (ECV) might be an effective method of lowering the rate of cesareans; its efficacy has been well established. However, although in the absence of anesthesia the risks are thought to be low, most studies have used populations too small to allow definite conclusions on version-related risks. In an attempt to make an inventory of these risks, we have systematically analyzed 44 studies, covering a total of 7377 patients from 1990 to 2002. The studies used were derived from a Medline and Embase search. The most frequently reported complications were transient abnormal cardiotocography (CTG) patterns (5.7%). Persisting pathological CTG readings (0.37%) and vaginal bleeding occur rarely (0.47%). The incidence of placental abruption was even lower, at 0.12%. Fetomaternal transfusion was absent in five out of seven studies, with a mean incidence of 3.7%. Emergency cesareans were performed in 0.43% of all versions. Perinatal mortality was 0.16%. External cephalic version seems to be a safe procedure. [ABSTRACT FROM AUTHOR]

Objective. To compare the efficacy of atosiban and ritodrine as tocolytic agents for successful external cephalic version (ECV). Factors affecting the success of ECV, as well as maternal and perinatal outcomes are reviewed. Method. A retrospective review of women who underwent ECV with either atosiban (2004) or ritodrine (2002). Results. Atosiban and ritodrine were similarly effective (28 versus 41%, p>0.05). Side effects were more common with ritodrine. No significant adverse maternal and perinatal outcomes were recorded following procedures with either tocolytic. Conclusion. Atosiban is a safe choice for ECV with less maternal side effects. However, it is no more effective than ritodrine and the benefit of safety has to be balanced against that of cost. [ABSTRACT FROM AUTHOR]