Re: external cephalic version
From: croure@ibm.net
Sun Apr 30 21:06:34 2000
At Sun, 30 Apr 2000, Ronnie Martinez Brignardello wrote:
>
>good efrain!! all we can say is ........tan-tan.
>
>ronnie
We??????? You probably meant "I"......
Carlos
>
>Efrain Ramirez wrote:
>
>> "What are the success rates for external cephalic version, and what
>> factors are
>> predictive of either success or failure?
>>
>> A review of 20 studies indicates that success rates for ECV range from
>> 35% to 86%, with an
>> average success rate of 58% (4, 6, 9, 12–14, 16–18, 21–25, 27, 29–31).
>> Most authors report a
>> positive association between parity and successful version (4, 6, 13,
>> 21–25, 30, 31). A
>> transverse or oblique lie is associated with higher immediate success
>> rates (13, 29, 30).
>> Opinion is divided about the predictiveness of other factors, including
>> amniotic fluid volume,
>> location of placenta, and maternal weight. Some reports indicate an
>> association between
>> normal or increased amounts of amniotic fluid and successful ECV (12,
>> 13, 24, 32), whereas
>> other reports do not (20). Two authors reported an association between
>> successful ECV and
>> placenta location (20, 24), whereas others failed to find an association
>> (12, 13, 29). Two authors
>> found obesity to be associated with a higher failure rate (23, 30),
>> whereas others found maternal
>> weight not to be a significant predictor of success (12, 13, 19, 20).
>>
>> Although scoring systems have been developed to predict which candidates
>> will have a
>> successful version attempt, these have not been validated by multiple
>> studies. One system
>> considered parity, dilatation, estimated fetal weight, placenta
>> location, and station. Nulliparity,
>> advanced dilatation, fetal weight of less than 2,500 g, anterior
>> placenta, and low station were
>> less likely to be associated with success (20). Such variables may
>> provide useful clinical
>> information for obtaining informed consent from individuals for ECV; no
>> single system, however,
>> has been shown to have complete accuracy.
>>
>> How does the use of tocolysis affect the success rate of external
>> cephalic version?
>>
>> Two of six randomized controlled trials failed to find a significant
>> advantage in using tocolytics
>> during ECV attempts (19, 27). One third reported significantly greater
>> success associated with
>> hexoprenaline but not with ritodrine (33). An additional randomized
>> study reported an initial
>> advantage associated with the use of ritodrine, specifically among
>> nulliparous women. However,
>> as the physicians became proficient at the ECV technique, the advantage
>> diminished (34). The
>> largest randomized study using a ritodrine infusion found significant
>> improvement only among
>> nulliparous patients (35). Finally, a randomized study of terbutaline
>> found the success rate of
>> version associated with use of this tocolytic to be almost double the
>> rate without its use (36). In
>> the vast majority of published studies, a tocolytic agent was used
>> routinely (6, 11–18, 20–23,
>> 27–29, 37). Several studies used tocolytics selectively (5, 7, 9, 34),
>> and some used no tocolytic
>> agents (4, 25). Existing evidence may support the use of a tocolytic
>> agent during ECV attempts,
>> particularly in nulliparous patients.
>>
>> How does the use of anesthesia affect the success rate of external
>> cephalic version?
>>
>> A randomized study found a significantly greater success rate associated
>> with the use of
>> epidural anesthesia, although the success rate was unusually low for the
>> women who did not
>> receive epidural anesthesia (32%) (38). Two studies reported results
>> for women in whom ECV
>> was performed while using epidural anesthesia (10, 15). In one study,
>> use of epidural
>> anesthesia was associated with a significantly greater success rate
>> compared with no use of
>> epidural anesthesia (15). However, the procedure was administered
>> selectively to patients
>> according to physician preference, raising the potential for selection
>> bias. The other study merely
>> noted that ECV was performed without difficulty on three women
>> undergoing epidural anesthesia
>> (10). It also has been suggested that epidural anesthesia be considered
>> for women who failed a
>> previous version attempt (39). Another randomized trial addressed the
>> use of spinal anesthesia
>> before the version attempt and found no significant difference between
>> treatment groups (40).
>> Currently, there is not enough consistent evidence to make a
>> recommendation favoring spinal or
>> epidural anesthesia during ECV attempts.
>>
>> Summary
>>
>> The following recommendation is based on good and consistent scientific
>> evidence (Level
>> A):
>>
>> Because the risk of an adverse event occurring as a result of ECV is
>> small and the
>> cesarean delivery rate is significantly lower among women who have
>> undergone
>> successful version, all women near term with breech presentations should
>> be offered a
>> version attempt.
>>
>> The following recommendations are based on limited or inconsistent
>> scientific evidence
>> (Level B):
>>
>> Patients should have completed 36 weeks of gestation before attempting
>> ECV.
>> Previous cesarean delivery is not associated with a lower rate of
>> success; however, the
>> magnitude of the risk of uterine rupture is not known.
>> There is insufficient evidence to recommend routine tocolysis for ECV
>> attempts for all
>> patients, but it may particularly benefit nulliparous patients.
>> Evidence is inconsistent regarding the benefits of anesthesia use during
>> ECV attempts.
>> Cost-effectiveness depends upon utilization of vaginal breech deliveries
>> and costs of the
>> version protocol at a particular institution, but at least one decision
>> analysis suggests the
>> policy is cost effective.
>>
>> The following recommendations are based primarily on consensus and
>> expert opinion (Level
>> C):
>>
>> Fetal assessment before and after the procedure is recommended.
>> External cephalic version should be attempted only in settings in which
>> cesarean delivery
>> services are readily available."
>>
>> At Sat, 29 Apr 2000, Steve & Eryl Raymond wrote:
>> >
>> >On 27 Apr 2000, at 21:35, Kevin D. Dew MD wrote:
>> >
>> >> 1. What gestational age?
>> >> 2. How soon afterward do you deliver?
>> >> 3. What do you use to relax the uterus?
>> >>
>> >> Trying to get an idea of what people are doing.
>> >>
>> >The WHO Reproductive Health Library states the following in a
>> >meta-analysis of trials involving ECV:
>> >
>> >Conclusions: There is compelling evidence that ECV attempt at
>> >term materially reduces the chance of non-cephalic birth and
>> >Caesarean section. The randomised trials to date are too small to
>> >address the question of the risk of ECV at term, though published
>> >uncontrolled series indicate that this is small. In individual cases,
>> >the risk of ECV needs to be weighed against the current and future
>> >risks of continued breech presentation to mother and fetus.
>> >
>>
>> >As a result of reading this our policy has been established as
>> >follows:
>> >1. Attempt ECV only if breech presentation at 37/40.
>> >2. If unsuccessful then take to a CTG machine and give Ipradol
>> >5mcg. (or another tocolytic) i.v. Within three to five minutes
>> >attempt ECV again.
>> >3. Run CTG for five minutes if unsuccessful, 20 minutes if
>> >successful.
>> >
>> >My experience has been that a more than 50 % success rate can
>> >be achieved with this procedure. It is true that there are occasions
>> >where the procedure results in profound distress in the baby. You
>> >need to be ready to do a C/S if the FH doesn't respond to turning
>> >on the side and/or oxygen administration. This is excessively rare.
>> >Had to do it once in 20 years. Timing of delivery is no different then
>> >from your standard cephalic presentation.
>> >
>> >Steve Raymond
>>
>> --
>> "The things you learn after you know everything are the important ones"
