External Cephalic Version for breech presenting fetus does not hike the cesarean section rates.

Women who had a successful External Cephalic Version (ECV) are not at increased risk of cesarean section as compared to women who had Spontaneous Cephalic Version (SCV) says the results of a study published ahead of print on August 2, 2017 in Journal of Obstetrics and Gynecology Canada. 

  

This is first study conducted to compare the outcome between spontaneous and external version in breech presenting fetuses.

It is estimated that term fetal malpresentation occurs in about 3% of pregnancies—and is a common indication for cesarean. External Cephalic version is an important tool to reduce the rate of cesarean births in breech presentation.

This secondary analysis of Early External Cephalic Version Trial data identified 931 women who had breech presenting fetuses between 34-36 weeks of pregnancy, but cephalic presentation at term.

Out of these study subjects, 557 women have undergone successful ECV while in 374 women the fetus reverted spontaneously.

Obstetric outcomes between the two groups were comparable: 96 women in ECV arm had Cesarean section as compared to 76 in the SCV group. (adjusted OR [aOR] 0.89; 95% CI 0.63-1.26); 393 had vaginal delivery in ECV arm vs 268 in SCV arm. (aOR 0.92; 95% CI 0.68-1.24).

Women in the ECV had 45% increased odds of undergoing instrumental intervention as compared to women in SCV group. (aOR 1.55; 95% CI 0.96-2.50).

Multiparous women with ECV were half as likely to require a cesarean section as compared to women with spontaneous version or no version at all. ( aOR 0.45; 95% CI 0.26-0.80).

The authors concluded, “Women with a cephalic-presenting fetus at birth as a result of successful ECV are not at greater risk of obstetrical interventions at birth when compared with women with fetuses who spontaneously turn to a cephalic presentation in the third trimester.”

Media Courtesy: American Association of Family Physicians 

Monoamniotic Monochorionic Twins can be delivered safely by vaginal route-- News from ACOG Annual Clinical and Scientific Meeting 2016.

In 2014, ACOG technical bulletin states "Women with monoamniotic twin gestations should undergo cesarean delivery to avoid an umbilical cord complication of the nonpresenting twin at the time of the initial twin's delivery."

New research findings from investigators at the Cooper Medical School of Rowan University, Camden, NJ, led by Dr. Khandelwal, Professor of Obstetrics and Gynecology have shown that vaginal delivery is feasible in monamniotic monochorionic (MoMo) twins who are appropriately identified.

Dr. Khandelwal opined that while theoretical risks form the basis of current guidelines and recommendations, the current study offers important data on safety of vaginal deliveries as an alternative to Cesarean section. A large study recently found that cord entanglement occurs in almost all the cases, but it contributes very little to the neonatal morbidity and mortality.

This award-winning paper was presented at the American College of Obstetricians and Gynecologists (ACOG) 2016 annual meeting at Washington D.C. The study was also published in  Obstet Gynecol. 2016 May; (127 Suppl 1:3S. doi: 10.1097/01.AOG.0000483625.92567.88.)

It was a retrospective cohort study at two tertiary care hospitals. The researchers reviewed data for all viable twins delivered beyond 24 weeks for the last 15 years at these centers.

Outcomes were compared between attempted vaginal delivery and planned cesarean delivery.

A total of 29 patients with MoMo twins were included in the study, out of which 15 underwent planned Cesarean Delivery and in 14 patients’ vaginal delivery was attempted, out of which 6 patient had Induction of labor(IOL). 10 patients had successful vaginal deliveries of both neonates with median interval of 3 minutes between the twins; 3 had to undergo cesarean section for non-reassuring fetal CTG tracing and one had to undergo cesarean section for 2^nd   of the twin. 

It was also seen that despite being nearly delivered at the same gestational age (32.7 vs 33.3 weeks) incidence of intracranial hemorrhage and respiratory complication was much lower in vaginally delivered neonates.

Three fetuses died before birth – one in the planned vaginal delivery group (7%) and two in the planned cesarean delivery group (13%). In 28 of all 29 pregnancies, entangled umbilical cords were observed at birth. Apgar at 5 minutes was 6.6 in the vaginal delivery group and 8.3 in the cesarean group.

It was observed that patients who had prior CD, opted out for repeat CD more often. But, the composite maternal outcome was similar in both the groups.

Successful vaginal delivery of both twins occurred in 71% of patients who chose to attempt it.

 “This is a small study but it does add valuable data on the safety of vaginal delivery in [monoamniotic-monochorionic] twins,” Dr. Khandelwal said. “Vaginal delivery can be considered a safe option in tertiary care centers.

She further added “ACOG guidelines are used as ‘standard of care’ by most practitioners; so it is important that they discourage ‘expert opinion’ statements in their guidelines and encourage evidence-based medicine.”

References:

http://www.ncbi.nlm.nih.gov/pubmed/27176162

http://www.acog.org/About-ACOG/ACOG-Departments/Annual-Meeting