Outcomes after attempted external cephalic version with two prior cesarean deliveries

American college of obstetricians and gynecologists (ACOG) considers patients with two prior cesarean deliveries (CDs) to be candidates for a trial of labor and separately recommends that external cephalic version (ECV) be offered for malpresentation. However, little is known about the safety, success rate, or effect on maternal and neonatal outcomes of ECV among patients with two prior CDs. This study aimed to evaluate obstetric outcomes after ECV in patients with two prior CDs to guide counseling.

This was a retrospective cohort study of patients with two prior CDs with non-anomalous, singleton births after 36 weeks' gestation utilizing the US Natality Database from 2018 to 2023. Pregnant patients with breech pregnancies who had an ECV attempt were compared with those who did not. The adverse maternal outcomes included blood transfusion, uterine rupture, unplanned hysterectomy, and intensive care unit (ICU) admission. Adverse neonatal outcomes included 5-minute Apgar score < 7, immediate or prolonged assisted ventilation, neonatal ICU (NICU) admission, seizure, and death. ECV success rate and mode of delivery were also assessed. Univariable and multivariable analyses were performed.

Among the 16,293 included births, 15,965 (98.0%) had a repeat CD (rCD) for malpresentation without an ECV attempt and 328 (2.0%) had an ECV attempt. Of these 328 ECVs, 223 (68.0%) were successful. Adverse maternal composite outcomes did not differ between births after an ECV attempt and those without (1.8% vs. 1.5%; adjusted odds ratio [aOR], 1.20; 95% confidence interval [CI], 0.53-2.71). Those who had an ECV attempt had a lower risk of adverse neonatal composite outcomes compared to those who did not (9.5% vs. 18.2%; aOR, 0.54; 95% CI, 0.37-0.79). Of the 223 who had a successful ECV, 152 (68.2%) underwent rCD without trial of labor after cesarean (TOLAC) and 71 (31.8%) underwent TOLAC. Among those with a successful ECV, there was no difference in adverse maternal or neonatal morbidities between those who had a TOLAC after successful ECV and those who did not.

These data suggest that among patients with two prior CDs, an ECV had a success rate similar to the published rate in the general obstetric population and may be associated with decreased neonatal morbidity compared to patients with no attempted ECV.