Introduction: Breech presentation occurs in approximately 3–4% of term pregnancies and is associated with high cesarean delivery rates, which contribute to increased perinatal morbidity and mortality. External Cephalic Version (ECV) is an obstetric procedure involving the application of external pressure to the abdomen to turn the fetus to a vertex presentation. ECV is considered a safe and effective method for reducing breech presentations and decreasing cesarean delivery rates. This study aims to evaluate the success rate of ECV and identify factors associated with its success in pregnant women at the University of Gondar Specialized Hospital.

Objective: The objective of this study was to determine the success rate of ECV and the factors associated with its success among pregnant women with breech or other malpresentations at the University of Gondar Specialized Hospital, Northwest Ethiopia, in 2022.

Methods: An institution-based cross-sectional study was conducted from December 2021 to September 2022 at the University of Gondar Specialized Hospital. A total of 174 pregnant women with breech or malpresentation after 36 weeks of gestation who met the inclusion criteria were included. Data was collected and verified for completeness and accuracy, then entered into EpiData version 4.6 for coding and analysis. The data analysis was performed using SPSS version 25, with both bivariate and multivariate logistic regression models employed to assess associations between independent and dependent variables. Adjusted Odds Ratios (AOR) with 95% confidence intervals were calculated, and a p-value of <0.05 was considered statistically significant.

Results: The success rate of ECV was 58.6%. Factors significantly associated with a successful ECV included:

• 1. A lax or thin abdominal wall (AOR 0.039, 95% CI: 0.003–0.453).
• 2. Palpability of the fetal head during the procedure (AOR 0.139, 95% CI: 0.024–0.794).
• 3. An anterior placental location was associated with ECV failure (AOR 6.94, 95% CI: 1.404–34.318).
• 4. The forward roll technique (AOR 0.149, 95% CI: 0.048–0.460) was found to increase the likelihood of success.

Discussion

The success rate of ECV in this study (58.6%) is consistent with similar studies conducted in other regions. Factors such as a lax or thin abdominal wall, posterior placental location, and fetal head palpability were found to positively influence the success of ECV, as similarly reported in the literature. The forward roll technique, which was associated with higher success rates, may be recommended for use in clinical practice. The presence of an anterior placenta, on the other hand, was a significant predictor of ECV failure. These findings underline the importance of assessing these factors prior to attempting ECV.

Conclusion

The success rate of ECV in this study was 58.6%, which is comparable to previous research and standard medical literature. Factors significantly associated with successful ECV include a lax or thin abdominal wall, posterior placental location, fetal head palpability, and the forward roll technique. These findings can guide clinicians in improving the outcomes of ECV procedures for breech and malpresentation pregnancies.

Keywords

Acronyms and Abbreviations

AF: Amniotic fluid, ACOG: American College of Obstetricians and Gynecologists, AFI: Amniotic Fluid Index, ANC: Antenatal care, CD: Cesarean delivery, CI: Confidence interval, CM: Centimeter, CS: Cesarean section, CST: Contraction stress test, CTG: Cardiotocography, ECV: External cephalic version, DM: Diabetes mellitus, EFM: Electronic fetal monitoring, ETB: Ethiopian birr, FHR: Fetal heart rate, FHRP: Fetal heart rate pattern, IUFD: Intrauterine fetal death, IUGR: Intrauterine growth restriction, KG: Kilogram, BMI: Body mass index, RCOG: Royal College of Obstetricians and Gynecologists.

Background

The Cesarean Section (CS) rate has been steadily increasing worldwide, exceeding 50% of all births in some countries. Given that CS is associated with severe complications, the rising rates contribute to an increase in maternal mortality. In low- and middle-income countries, the maternal mortality rate related to cesarean sections is 8 per 1,000 procedures, while in more developed countries, the rate is 16 per 100,000 births. Breech presentation occurs in approximately 3–4% of term pregnancies, and breech presentations are associated with higher cesarean birth rates. Breech delivery increases the incidence of perinatal morbidity and mortality, posing significant challenges to obstetric management. External Cephalic Version (ECV) is an obstetric procedure that involves applying external pressure to the woman’s abdomen to rotate the fetus into a vertex presentation, either through a forward or backward roll. ECV is a safe and effective method for reducing the occurrence of breech presentations at term, thereby lowering the cesarean delivery rate for this indication. ECV is considered a safe procedure, with a reported risk for emergency cesarean section within 24 hours being as low as 0.5%. It can be performed for various malpresentations of the fetus, such as breech, transverse, and oblique presentations. ECV was first described in 1807 by Wigand and later popularized by Tarnier and Pinard in 1878. One ECV technique involves lifting the breech upward from the pelvis with one hand while applying pressure on the fetal head with the other hand to achieve a forward roll. If the forward roll fails, a backward roll may be attempted. ECV can be performed by one or two practitioners, and intermittent use of ultrasonography during the procedure allows for real-time evaluation of fetal heart rate and position. The procedure should be abandoned if there is prolonged fetal bradycardia, patient discomfort, or difficulty in completing the maneuver. After attempting ECV, the fetus should be reevaluated, and the patient should be monitored for at least 30 minutes, or longer if clinically necessary. For Rh-negative patients, Anti-D immunoglobulin is administered if delivery is not anticipated within the next 72 hours. There is no evidence supporting the routine practice of inducing labor immediately after an ECV attempt to prevent reversion [1].

Statements of the Problem

Breech presentation occurs in approximately 3–4% of term pregnancies, and there is a high cesarean delivery rate for breech presentation. Most of these patients will be delivered by cesarean section. It is believed that the overall cesarean delivery rate is higher than necessary, and efforts to prevent the first cesarean section often present obstetricians with the challenge of reducing the number of cesareans they perform. Over the last decade, cesarean deliveries have increased from approximately 23% to 34%, with malpresentation being the third most common indication (approximately 17%). External cephalic version (ECV) is an important intervention that can help reduce this rate. Breech delivery is associated with higher rates of perinatal morbidity and mortality, and it presents a significant challenge to obstetric management. In 2000, the Term Breech Trial (TBT) reported a significant reduction in perinatal morbidity and mortality for breech babies delivered by planned cesarean, estimating an excess mortality of 1% with planned vaginal breech birth. The trial also found little alteration in maternal morbidity and concluded that perinatal outcomes were worse for babies delivered vaginally compared to those delivered by cesarean section. As a result, ECV is widely advocated. However, its implementation varies, with an estimated 20–30% of eligible women not being offered the procedure. Attempting ECV reduces the number of non-cephalic births and cesarean deliveries, thereby decreasing complications associated with breech births and the maternal and fetal morbidity linked to abdominal deliveries. This is particularly important in women with an unscarred uterus, as avoiding a first cesarean birth reduces the likelihood of requiring repeat cesareans and lowers the risk of complications such as abnormally invasive placenta in future pregnancies. The reported success rates of External Cephalic Version (ECV) vary widely in the literature, ranging from 17% to 86%. This variability may be attributed to differences in geographic settings, study designs, and sample sizes. Many of the studies were clinical trials, and most population-based studies had small sample sizes. The uncertainty around success rates, coupled with the perception of ECV as a painful and potentially hazardous procedure, has led up to 76% of patients to decline the procedure. Identifying factors associated with successful ECV outside of clinical trial settings could help improve the decision-making process by providing women with more realistic expectations of success. Women who underwent successful ECV had lower hospital charges, shorter lengths of stay, and reduced odds of developing complications such as endometritis, sepsis, and prolonged hospital stays (i.e., >7 days) compared with women with persistent breech presentations. Despite the benefits, ECV has physical, emotional, and financial costs. Studies have reported complications associated with the procedure, including abnormal fetal cardiotocography in 6% of cases. Additionally, 35% of women who underwent ECV found the procedure painful. The emotional impact on women should not be underestimated, as many report feeling anxious prior to the procedure. The most common complications associated with External Cephalic Version (ECV) are fetal heart rate abnormalities, which occur in 4.7% of cases. However, these are usually transient and resolve upon completion or abandonment of the procedure. More severe complications occur in less than 1%. Cases and include emergency cesarean section, premature rupture of membranes, cord prolapse, vaginal bleeding, placental abruption, fetomaternal hemorrhage, stillbirth, and premature labor [3]. While ECV is routinely offered in some developed countries, it is less commonly practiced in developing regions, particularly among younger obstetricians. This is mainly due to an inordinate fear of the procedure’s risks, compounded by a lack of necessary skills and experience. Consequently, there is limited published literature on ECV from developing countries [7]. Although complications are rare, ECV should only be attempted in settings where emergency cesarean section facilities are readily available. For this reason, some practitioners prefer to perform ECV in the operating room, though this is not universally required [3]. The American College of Obstetricians and Gynecologists (ACOG) recommends offering ECV to women with breech fetuses who have no contraindications to the procedure and have reached 36 weeks of gestation. This timing helps avoid complications related to prematurity if an urgent cesarean section is necessary [2]. With the restrictive practice of breech vaginal delivery over the past 15 years, national organizations like the Royal College of Obstetricians and Gynecologists (RCOG), the Society of Obstetricians and Gynecologists of Canada (SOGC), the Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG), and the International Federation of Gynecology and Obstetrics (FIGO) have updated their guidelines. These organizations now recommend ECV at term to help limit the rise in elective cesarean sections for term breech presentations (4). Despite being routinely offered in developed countries, ECV remains underutilized in regions like Sub-Saharan Africa, where data on its success rate is also scarce. Therefore, this research is aimed to determine the success rate of ECV and its associated factors among pregnant women with malpresentation after 36 weeks of gestation.

Literature Review

Success rate of ECV

Different researches have been conducted to discover the success rate of External Cephalic Version (ECV) and the associated factors influencing its success. According to the updated ACOG practice guidelines for ECV, and based on a recent meta-analysis, the success rate of this procedure ranged from 16% to 100%, with a pooled success rate of 58%. Similarly, the RCOG recommends that about 50% of ECV attempts will be successful [1]. According to the SOGC guidelines, the procedure results in a cephalic presentation in approximately 60% of cases [8]. In studies conducted in Germany, 1,379 women underwent an ECV attempt, with 895 (64.9%) being successful. A recent study in Israel involving 250 pregnant women opting for a trial of ECV by a single operator reported a success rate of 64.8% [9]. A 10-year retrospective study at the Coombe Women and Infants University Hospital (CWIUH), one of the largest maternity hospitals in Ireland and Europe, reviewed 604 women who underwent an ECV, and 329 (54.5%) had a successful ECV [2]. A study conducted in the Czech Republic involving 478 cases showed a 48.7% success rate [11]. In a study conducted in the Netherlands in 2015, among 2,318 women who underwent the ECV procedure, 1,093 (47.2%) had a successful ECV [8]. One of the largest data sets on the success of ECV comes from the USA, where a cross-sectional analysis of 51,001 ECV cases (2010–2014) documented a 58.5% success rate [8]. A large prospective study from the UK analyzing 2,614 women who underwent ECV showed a 47% success rate [12]. A Malaysian study, reviewing 142 cases, reported a 51.4% success rate [13]. Studies conducted in Washington State between 2003 and 2014, involving 4,981 ECV attempts, found a success rate of 57.2% [6]. Similar results were seen in Sweden, where a study involving 2,331 women reported a success rate of 53.4% [14]. In Spain, however, a study involving 320 patients found a significantly higher success rate of 82.5% [15]. In Africa, a study conducted at a Nigerian hospital involving 111 mothers undergoing ECV found a success rate of 66.7% [7]. Additionally, a study conducted in Ethiopia at Saint Paul’s Medical College, involving 152 mothers, reported a success rate of 71.1% [8]. Overall, the success rates of ECV vary globally, with rates ranging from as low as 47% to as high as 82.5%, depending on geographic location, sample size, and procedural factors.

Associated factors for successful ECV

Success rates depend on multiple variables like sociodemographic factors, maternal characteristics and current obstetric conditions. It is likely that case selection considerably affects success rates.

Sociodemographic factors

There was no statistically significant difference in socio-demographic characteristics distribution between those mothers who had successful ECV and those who had unsuccessful ECV [2, 6–9, 11, 16–25]. A retrospective study done in Israel Sourasky medical center which involves around 250 ECV shows that the mean maternal age was higher in the successful ECV group compared with the unsuccessful ECV group [9].

Maternal Characteristic

A cross-sectional study done at University of Minnesota, USA, which involved a total of 51,002 ECV attempts, showed that the ECV success rate for the entire study population was 65.3%. There was a decreasing success rate for ECV as BMI increased. Women with a normal BMI had a 65.0% success rate of ECV, while women with a BMI >29.9 kg/m² had a lower success rate.

Current Obstetric Conditions

In a meta-analysis, RCOG showed that multiparity, non-engagement of the breech, use of tocolysis, a palpable fetal head, posterior placental location, complete breech position, and an amniotic fluid index greater than 10 are predictors of successful ECV. In the literature, various factors have been identified as predictors of ECV success. A study in France and Hong Kong found that an unengaged breech presentation is an important predictor of successful ECV. A Randomized Controlled Trial (RCT) conducted at McMaster University in Hamilton, ON, showed that having a very or moderately mobile fetus, relaxed uterine tone, a fetal head that was easy to palpate, multiparity, and a non-engaged presenting part were associated with ECV success. A secondary analysis of a multicenter, open-label randomized controlled trial conducted at the Academic Medical Center in Amsterdam, The Netherlands, involving 818 women who underwent ECV, found that the administration of tocolysis, posterior placenta, and adequate amniotic fluid were the most important predictors positively affecting the success of the procedure. A prospective study conducted at the Nigerian University Teaching Hospital, involving 183 singleton breech presentations at term, identified favorable factors for success, including multiparity, flexed breech, unengaged breech, normal liquor volume, and a posterior placenta. A study at St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia, involving 152 ECVs, showed that multiparity, absence of pain during the procedure, posterior placenta, unengaged breech, soft uterine tone, and a thin abdominal wall were significantly associated with ECV success.

Conceptual Frame Work

See Figure 1

Justifications

In a meta-analysis, RCOG showed that multiparity, non-engagement of the breech, use of tocolysis, a palpable fetal head, posterior placental location, complete breech position, and an amniotic fluid index greater than 10 are predictors of successful ECV [29]. In the literature, various factors have been identified as predictors of ECV success. A study in France and Hong Kong found that an unengaged breech presentation is an important predictor of successful ECV [2]. A Randomized Controlled Trial (RCT) conducted at McMaster University in Hamilton, ON, showed that having a very or moderately mobile fetus, relaxed uterine tone, a fetal head that was easy to palpate, multiparity, and a non-engaged presenting part were associated with ECV success [21]. A secondary analysis of a multicenter, open-label randomized controlled trial conducted at the Academic Medical Center in Amsterdam, The Netherlands, involving 818 women who underwent ECV, found that the administration of tocolysis, posterior placenta, and adequate amniotic fluid were the most important predictors positively affecting the success of the procedure [30]. A prospective study conducted at the Nigerian University Teaching Hospital, involving 183 singleton breech presentations at term, identified favorable factors for success, including multiparity, flexed breech, unengaged breech, normal liquor volume, and a posterior placenta [7]. A study at St. Paul’s Hospital Millennium Medical College in Addis Ababa, Ethiopia, involving 152 ECVs, showed that multiparity, absence of pain during the procedure, posterior placenta, unengaged breech, soft uterine tone, and a thin abdominal wall were significantly associated with ECV success [8].

Objectives

General objectives

To determine the success rate of ECV and its associated factors among pregnant women with malpresentation after 36 weeks of gestation in University of Gondar specialized hospital, Gondar, Ethiopia, 2022.

Specific objectives

• To determine success rate of external cephalic version.
• To assess factors associated with successful external cephalic version.

Materials and Methods

Study Area and Period

The study was conducted in University of Gondar specialized hospital, found in Gondar town, which is the capital town of the central Gondar administrative zone, located 743 kms northwest of Addis Ababa. University of Gondar specialized hospital is one of the biggest tertiary level referral and teaching hospitals in the Amhara Regional State. According to records from the hospital’s information center, every year more than 200,000 people visit the hospital which serves as referral hospital for more than 7 million people in the surrounding catchment area. University of Gondar comprehensive specialized hospital department of gynecology and obstetrics run one labor and delivery ward, three postpartum maternity ward, one high risk ward, one gynecology ward, one urogynecologic ward, four gynecologic OPD, four antenatal clinics and Michu clinic. The study was conducted from December 2021 to September, 2022.

Study Design

An institutional based cross-sectional study design was used to assess success rate of ECV and its associated factors in an Ethiopian setting among women at University of Gondar specialized hospital, northwest Ethiopia, 2022.

Source Population

All pregnant women who visited University of Gondar comprehensive specialized hospital and the three affiliated health centers (Poly health center, Maraki Health center and Mulu maternity).

Study Population

The study population consisted of pregnant women with breech presentation or transverse lie at ≥ 36-week gestation seeking obstetric services at the University of Gondar Referral Hospital and three health centers working in collaboration with University of Gondar.

Eligibility Criteria

Inclusion Criteria

• All pregnant women with singleton fetus with malpresentation at or near term with gestational age ≥ 36 and no contraindications to ECV.

Exclusion Criteria

1. Multiple pregnancy
2. Clotting disorders
3. Previous cesarean section
4. RH isoimmunization
5. Obstetric complications (preeclampsia, GDM, APH…)
6. Other medical illness (diabetes, hypertension…)

Sample Size Determination and Sampling Procedure

The sample size was estimated using single population proportion formula. By considering a 95% confidence level, 5% margin of error, and the success rate of ECV (71.7%) in a study done at Saint Paulos Medical College, Addis Ababa, Ethiopia, four years back and 10% of non-response rate, a total of 342 participants were selected.