Interventions to help external cephalic version for breech presentation at term

Breech presentation places a fetus at increased risk. The outcome for the baby is improved by planned caesarean section compared with planned vaginal delivery. External cephalic version attempt reduces the chance of breech presentation at birth, but is not always successful. Tocolytic drugs to relax the uterus as well as other methods have been also used in an attempt to facilitate external cephalic version at term.

The objective of this review is to assess the effects of routine tocolysis, fetal acoustic stimulation, epidural or spinal analgesia and transabdominal amnioinfusion for external cephalic version at term on successful version and measures of pregnancy outcome.

The Cochrane Pregnancy and Childbirth Group Trials Register (searched December 2001) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001) were searched.

Randomised and quasi-randomised trials comparing routine versus selective or no tocolysis; fetal acoustic stimulation in midline fetal spine positions versus dummy or no stimulation; epidural or spinal analgesia versus no regional analgesia; or transabdominal amnioinfusion versus no amnioinfusion for external cephalic version at term.

Eligibility and trial quality were assessed by the reviewer.

In six trials, routine tocolysis was associated with fewer failures of external cephalic version (relative risk 0.74, 95% confidence interval 0.64 to 0.87). The reduction in non-cephalic presentations at birth was not statistically significant. Caesarean sections were reduced (relative risk 0.85, 95% confidence interval 0.72 to 0.99). Fetal acoustic stimulation in midline fetal spine positions was associated with fewer failures of external cephalic version at term (relative risk 0.17, 95% confidence interval 0.05 to 0.60). With epidural or spinal analgesia, external cephalic version failure, non-cephalic births and caesarean sections were reduced in two trials but not the other. The overall differences were not statistically significant. No randomised trials of transabdominal amnioinfusion for external cephalic version at term were located.

Routine tocolysis appears to reduce the failure rate of external cephalic version at term. Although promising, there is not enough evidence to evaluate the use of fetal acoustic stimulation in midline fetal spine positions, nor of epidural or spinal analgesia. Large volume intravenous preloading may have contributed to the effectiveness demonstrated in two of the latter trials. No randomised trials of transabdominal amnioinfusion for external cephalic version at term were found.