In addition to these evidence-based recommendations, the guideline development group also identifies points of best clinical practice in the original guideline document.
Levels of evidence (Ia-IV) and grading of recommendations (A-C) are defined at the end of the "Major Recommendations" field.
External Cephalic Version (ECV)
What Is the Impact of ECV on the Incidence of Breech Presentation at Delivery?
A - Women should be counselled that ECV reduces the chance of breech presentation at delivery.
What is the Effect of ECV on the Caesarean Section Rate?
A - Women with a breech baby should be informed that attempting ECV lowers their chances of having a caesarean section.
B - Labour with a cephalic presentation following ECV is associated with a higher rate of obstetric intervention than when ECV has not been required.
What is the Success Rate of ECV and What Influences It?
B - Women should be counselled that, with a trained operator, about 50% of ECV attempts will be successful but this rate can be individualised for them.
Does the Use of Tocolysis Improve the Success Rate of ECV?
A - The use of tocolysis with beta-sympathomimetics may be offered to women undergoing ECV as it has been shown to increase the success rate.
A simple protocol is to offer a slow intravenous or subcutaneous bolus of salbutamol or terbutaline either routinely or if an initial ECV attempt has failed. Women should be advised of the adverse effects of tocolysis with beta-2 agonists. (Evidence level Ia)
When Should ECV Be Offered?
B - ECV should be offered from 36 weeks in nulliparous women and from 37 weeks in multiparous women.
Is ECV safe?
B - Women should be counselled that ECV has a very low complication rate.
ECV should be performed where ultrasound to enable fetal heart rate visualisation, cardiotocography and theatre facilities are available. Cardiotocography should be performed after the procedure. Kleihauer testing is unnecessary but anti-D immunoglobulin is normally offered to rhesus-negative women. Given the low complication rate, particularly when compared with labour, starvation, anaesthetic premedication, and intravenous access are all unnecessary.
Is ECV Painful?
ECV can be painful, with few women experiencing no discomfort and around 5% reporting high pain scores. The procedure may need to be stopped because of this.
What Are Contraindications to ECV?
C - There are few absolute contraindications to ECV.
Absolute contraindications for ECV that are likely to be associated with increased mortality or morbidity:
- Where caesarean delivery is required
- Antepartum haemorrhage within the last 7 days
- Abnormal cardiotocography
- Major uterine anomaly
- Ruptured membranes
- Multiple pregnancy (except delivery of second twin)
Relative contraindications where ECV might be more complicated:
- Small-for-gestational-age fetus with abnormal Doppler parameters
- Proteinuric pre-eclampsia
- Oligohydramnios
- Major fetal anomalies
- Scarred uterus
- Unstable lie
Increasing the Uptake of ECV
B - Local policies should be implemented to actively increase the number of women offered and undergoing ECV.
Alternatives To ECV
A - There is insufficient evidence to support the use of postural management as a method of promoting spontaneous version over ECV.
A - Moxibustion should not be recommended as a method of promoting spontaneous version over ECV.
Developing An ECV Service
C - An ECV service, provided by appropriately trained clinicians, should be available to all women with a breech presentation at term.
Definitions:
Grading of Recommendations
Grade A - Requires at least one randomised controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation. (Evidence levels Ia, Ib)
Grade B - Requires the availability of well controlled clinical studies but no randomised clinical trials on the topic of recommendations. (Evidence levels IIa, IIb, III)
Grade C - Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. (Evidence level IV)
Levels of Evidence
Ia: Evidence obtained from meta-analyses of randomised controlled trials
Ib: Evidence obtained from at least one randomised controlled trial
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities
