Interventions to help external cephalic version for breech presentation at term

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Abstract
Breech presentation places a fetus at increased risk. The outcome for the baby is improved by planned caesarean section compared with current medical practice for planned vaginal birth. External cephalic version (turning the fetus to the vertex position by external manipulation) attempts to reduce the chances of breech presentation at birth, and thus reduce the adverse effects of caesarean section, but is not always successful. Tocolytic drugs to relax the uterus, as well as other methods, have been used in an attempt to facilitate external cephalic version at term. 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. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2004). We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 1 October 2009 and added the results to the awaiting classification section. Randomised and quasi‐randomised trials comparing routine tocolysis; selective tocolysis; fetal acoustic stimulation in midline fetal spine positions; epidural or spinal analgesia; or transabdominal amnioinfusion; with alternative methods or no intervention to facilitate external cephalic version at term. We assessed eligibility and trial quality. Sixteen studies were included. Routine tocolysis with beta‐stimulants was associated with fewer failures of external cephalic version (6 trials, 617 women, relative risk (RR) 0.74, 95% confidence interval (CI) 0.64 to 0.87). The reduction in non‐cephalic presentations at birth was not statistically significant. Caesarean sections were reduced (3 trials, 444 women, RR 0.85, 95% CI 0.72 to 0.99). In four small trials, sublingual nitroglycerine was associated with significant side‐effects, and was not found to be effective. Fetal acoustic stimulation in midline fetal spine positions was associated with fewer failures of external cephalic version at term (1 trial, 26 women, RR 0.17, 95% CI 0.05 to 0.60). External cephalic version failure, non‐cephalic births and caesarean sections were reduced in two trials with epidural but not in three with spinal analgesia. We postulate that large volume preloading with epidural may have increased the amniotic fluid volume. No randomised trials of transabdominal amnioinfusion for external cephalic version at term were located. Although the methodological quality of the trials was not ideal, routine tocolysis appears to increase the success rate of external cephalic version at term. There is not enough evidence to evaluate the use of fetal acoustic stimulation in midline fetal spine positions, nor of epidural or spinal analgesia. [Note: The 19 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

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