ECV and Reducing Term Breech

Question 1

What proportion of babies are breech at term?

Answer 1

3-4%
(more common in pre-term and primips).

Question 2

What is the re-occurence rate for breech presentation?

Answer 2

10%

Question 3

What is the success rate of ECV?
(overall, in multips and in nullips)

Answer 3

Overall success = 50%
Multips success = 60%
Nullips success = 40%

Question 4

What is the rate of spontaneous cephalic version in primips, after 36/40?

Answer 4

8%

Question 5

5 factors that increase the success rate of ECV

Answer 5

1. Multiparity
2. Non-engagement of the breech
3. Use of tocolysis
4. Palpable foetal head
5. Malternal weight <65kg

Question 6

What is the rate of spontaneous cephalic version after an unsuccessful ECV?

Answer 6

3-7%

Question 7

What is the chance of babies reverting to breech presentation after a successful ECV?

Answer 7

3%

Question 8

What tocolysis is used during an ECV?

What are the contra-indications to this type of tocolysis?

Answer 8

Betamimetics (250microg salbutamol or 250microg terbutaline).

CI if significant cardiac disease and not effective if taking beta blockers.

Question 9

Can Nifedipine or Atosiban be used as tocolysis for ECV?

Answer 9

There is no evidence for use of Nifedipine.
There is insufficient data for Atosiban.

Question 10

What is the role of anasthetic and neuroaxial blocks in ECV?

Answer 10

Routine use should be avoided, but if re-attempting ECV, both of these can be considered.

Question 11

When should ECV be offered?

Answer 11

From 36/40 in nullips.
From 37/40 in multips.

Question 12

What are the contra - indications for ECV?

Answer 12

Known abruption
Severe PET
Abnormal CTG Doppler
Absolute reason patient should have LSCS (e.g. previa)
Rhesis immunisation (<1 week ago)
PVB
PROM/SROM

Previous LSCS (after 1LSCS there appears to be the same risk as unscared uterus, but only one small scale study).

Caution in HTN and Oligohydramnios.

Question 13

What are the risks of ECV?

Answer 13

2.4% risk of foeto-maternal haemorrhage of 1-30mls.
0.5% risk of EmLSCS within 24 hours (90% of those due to PVB or abnormal CTG).

Placental abruption/ large fetomaternal haemorrhage (only case reports).

Question 14

What measures should be taken before carrying out an ECV?

Answer 14

1. Anti-D if Rh negative (max 500IU within 72 hours, depending on Kleihauer).
2. EFM before and after procedure.
3. USS before and after to asses FH (note that transient 3 minute bradycarida is common, but LSCS if 6+ mins).

Question 15

What is the difference in APGAR scores between babies who have had an ECV vs ElLSCS?

Answer 15

No difference in APGAR scores.

Question 16

What is the maximum time / number of attempts that an ECV should be carried out?

Answer 16

10 minutes
4 attempts

Question 17

What proportion of women decline an ECV?

Answer 17

9%
Increased uptake if early identification and time to discuss/understand options.

Question 18

What proportion of women report significant pain during an ECV?

Answer 18

33%

Question 19

What is the sensitivity of abdominal palpation in detecting breech presentation?

Answer 19

70%

Question 20

What is the alternative to ECV?

Answer 20

1. ElLSCS
2. Moxibustion (burning Mugwort leaves at 33-35/40 under professional supervision).

(no evidence for changing maternal position)

Question 21

What are the effects of ECV on labour?

Answer 21

1. Reduces risk of LSCS (higher chance if shorter ECV to delivery time).
2. Overall slightly higher risk of instrumental or LSCS (obstructed labour or foetal distress).

Question 22

What is the maximum time in which a vaginal breech baby should be delivered from the breech on the perineum to the head?

Answer 22

Total 7 minutes.

3 minutes from scapulae to head delivery.

Question 24

What factors increase risk during planned vaginal breech delivery?

Answer 24

Hyperextended neck
EFW>3.8kg
EFW<10th centile
Footling presentation
Evidence of antenatal foetal compromise.

Question 25

What is the perinatal mortality associated with:
- breech vaginal delivery?
- cephalic vaginal delivery?
- LSCS delivery (from 39/40)?

Answer 25

Breech - 2 / 1,000
Cephalic - 1 / 1, 000
LSCS - 0.5 / 1, 000