Current Approach for External Cephalic Version in Germany

Abstract

Introduction Fetal breech presentation at terms occurs in 3 – 6% of pregnancies. External cephalic version can reduce the number of cesarean sections and vaginal breech deliveries. Different approaches are used to carry out external cephalic version. This study looked at the different approaches used in Germany and compared the approach used with the recommendations given in German and international guidelines. Material and Methods An anonymized online survey of 234 hospitals in Germany was carried out in 2018. In addition to asking about hospital structures, questions also focused on how external version was carried out in practice (preparations, tocolysis, anesthetics, etc.), on relative and absolute contraindications and on the success rate. Results 37.2% of the hospitals approached for the survey participated in the study. Of these, 98.8% performed external version procedures. The majority of participating hospitals were university hospitals (26.4%) and maximum care hospitals (35.6%) with an average number of more than 2000 births per year (60.9%). External cephalic version is the preferred (61.7%) obstetrical procedure to deal with breech presentation, rather than vaginal breech birth or primary cesarean section. 45.8% of respondents carry out external version procedures on an outpatient basis, and 42.1% of hospitals perform the procedure as an inpatient intervention, especially from the 37th week of gestation. Prior to performing an external version procedure, 21.6% of surveyed institutions carry out a vaginal examination to evaluate possible fixation of the fetal rump. 95.5% of institutions used fenoterol for tocolytic therapy; the majority using it for continuous tocolysis (70.2%). 1 – 3 attempts at external version (8.4%) were usually carried out by a specific senior physician. In most cases, no analgesics were administered. The reported rate of emergency cesarean sections was very low. The most common indication for emergency C-section was pathological CTG (56,7%). The assessment of relative and absolute contraindications varied, depending on the surveyed hospital. 67.5% asked patients to empty their bladders before carrying out external version, while 10.8% carried out external version when the bladder was filled. The reported success rate was more than 45%. After successful version, only 14.8% of hospitals arranged for patients to wear an abdominal binder. For 32.4%, the decision to apply an abdominal binder was taken on a case-by-case basis. Conclusion The approach used in Germany to carry out external cephalic version is based on the (expired) German guideline on breech presentation. Based on the evidence obtained, a number of individual recommendations should be re-evaluated. More recent international guidelines could be useful to update the standard procedure.

Die äußere Wendung – sanft und sicher

“…Der Versuch einer äußeren Wendung ("external cephalic version" [ECV]) des Feten reduziert auf sichere Art und Weise die Anzahl an vaginalen BEL-und Schnittentbindungen [15]. Trotz Empfehlung nationaler und internationaler Leitlinien [1,29] wird den infrage kommenden Schwangeren in 20-30 % keine ECV angeboten [22,34]. Obwohl das Manöver seit Jahrzenten etabliert und seit vielen Jahrhunderten bekannt ist, besteht kein einheitliches Vorgehen in der Vorbereitung und Durchführung der ECV.…”

“…Eine 2020 in Deutschland durchgeführte Umfrage ergab, dassmit98,8 % nahezu alle teilnehmenden Krankenhäuser (Rücklaufrate 37,2 %) eine äußere Wendung anbieten. Bei 61,7 % der Schwangeren mit BEL wurde eine ECV versucht [22]. Ziel dieses Artikels ist es, einen Überblick zum aktuellen Wissenstand zu geben, nicht evidente Fehlinformationen zu reduzieren und die Akzeptanz gegenüber der äußeren Wendung weiter zu steigern.…”

External cephalic version at 38 weeks’ gestation at a specialized German single center

“…The aim of ECV is to rotate the fetus, resulting in a vertex position, by manipulation through the maternal abdomen. Even though ECV is recommended based on current gynaecologic guidelines, it is not always offered in Germany or is refused by pregnant women [ 11 , 12 ]. Little information is available regarding the demographics and implementation rates in Germany.…”

“…In a recently published multicenter observational study in Germany, hospitals were questioned about breech birth and the ECV approach. Unfortunately, the response rate was low (37.2%) [ 12 ].…”

“…The American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists guidelines recommend that ECV should be performed beginning at 37+0 weeks to decrease the rate of reversion and increase the rate of spontaneous version [ 8 , 19 ]. To the best of our knowledge, many obstetrics departments in Germany offer ECV before 37 weeks of gestation [ 12 , 20 ].…”