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Versión cefálica externa para la presentación podálida a término

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Referencias

Referencias de los estudios incluidos en esta revisión

Akhtar 2013 {published data only}

Akhtar N. Early versus late external cephalic version. Journal of Postgraduate Medical Institute 2013;27(2):164‐9.

Hutton 2003 {published data only}

Hutton EK, Kaufman K, Hodnett E, Amankwah K, Hewson SA, McKay D, et al. External cephalic version beginning at 34 weeks' gestation versus 37 weeks' gestation: a randomized multicenter trial. American Journal of Obstetrics and Gynecology 2003;189(1):245‐54.
Hutton EK, Saunders CA, Tu M, Stoll K, Berkowitz J, for the Early External Cephalic Version Trial Collaborators Group. Factors associated with a successful external cephalic version in the early ECV trial. JOGC: Journal of Obstetrics and Gynaecology Canada 2008;30(1):23‐8.

Hutton 2011 {published data only}

Hutton E. The Early External Cephalic Version 2 Trial. www.utoronto.ca/MIRU/eecv2 (accessed 19 July 2005).
Hutton E. The early ECV trial. JOGC: Journal of Obstetrics and Gynaecology Canada 2007;29(6 Suppl 1):S47.
Hutton EK. The early ECV‐2 Trial Group. The early external cephalic version ‐ 2 trial. Perinatal Society of Australia and New Zealand 7th Annual Congress; 2003 March 9‐12; Tasmania, Australia2003:A33.
Hutton EK. The early ECV‐2 Trial Group. The early external cephalic version ‐ 2 trial. Perinatal Society of Australia and New Zealand 7th Annual Congress; 2003 March 9‐12; Tasmania, Australia2003:P97.
Hutton EK, Hannah ME, Ross SJ, Delisle MF, Carson GD, Windrim R, et al. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG: an international journal of obstetrics and gynaecology 2011;118(5):564‐77.
Hutton EK, Phipps H. Early ECV 2 trial. Perinatal Society of Australia and New Zealand 10th Annual Congress; 2006 April 3‐6; Perth, Australia. 2006:369.
Hutton EK, for the EECV2 Trial Collaborative Group. Early ECV 2 trial [abstract]. Journal of Paediatrics and Child Health 2007;43(Suppl 1):A117‐8.
Murray‐Davis B, Marion A, Malott A, Reitsma A, Hutton EK, Early ECV2G. Women's experiences of participating in the early external cephalic version 2 trial. Birth 2012;39(1):30‐8.

Mensink 1980 {published data only}

Mensink WFA, Huisjes HJ. Is external version useful in breech presentation?. Nederlands Tijdschrift voor Geneeskunde 1980;124:1828‐31.

Van Veelen 1989 {published data only}

Van Veelen AJ, Van Cappellen AW, Flu PK, Straub MJPF, Wallenburg HCS. Effect of external cephalic version in late pregnancy on presentation at delivery: a randomized controlled trial. British Journal of Obstetrics and Gynaecology 1989;96(8):916‐21.

Referencias de los estudios excluidos de esta revisión

Brosset 1956 {published data only}

Brosset A. The value of prophylactic external version in cases of breech presentation. Acta Obstetricia et Gynecologica Scandinavica 1956;35(4):555‐62.

Dafallah 2004 {published data only}

Dafallah SE, Elhag SM. The role of external cephalic version on the presentation at delivery. Saudi Medical Journal 2004;25(3):386‐8.

El‐Muzaini 2008 {published data only}

El‐Muzaini MF, Felimban HM, Al‐Hazmi NM, Shabaan LA, Namankani FY, Fathudein MA. Breech with previous scar, is ECV a good option?. BJOG: an international journal of obstetrics and gynaecology 2008;115(s1):77‐8.

Kasule 1985 {published data only}

Kasule J, Chimbira TH, Brown I. Controlled trial of external cephalic version. British Journal of Obstetrics and Gynaecology 1985;92(1):14‐8.

Rust 2005 {published data only}

Rust O, Atlas R, Gersbach E, Roberts W, Larkin R, Hess LW. A randomized trial of late versus early external cephalic version for the treatment of abnormal presentation at term [abstract]. American Journal of Obstetrics and Gynecology 2005;193(6 Suppl):S129.

Belizan 1989 {published data only}

Belizan JM. Early external cephalic version in antenatal care. A randomized trial. Personal communication1989.

Bradley‐Watson 1975

Bradley‐Watson PJ. The decreasing value of external cephalic version in modern obstetric practice. American Journal of Obstetrics and Gynecology 1975;123(3):237‐40.

Cluver 2015

Cluver C, Gyte GML, Sinclair M, Dowswell T, Hofmeyr GJ. Interventions for helping to turn term breech babies to head first presentation when using external cephalic version. Cochrane Database of Systematic Reviews 2015, Issue 2. [DOI: 10.1002/14651858.CD000184.pub4]

Cooper 2002

Cooper GM, Lewis G, Neilson J. Editorial: confidential enquiries into maternal deaths. British Journal of Anaesthesia2002; Vol. 89, issue 3:369‐72.

Dashe 2002

Dashe JS, McIntire DD, Ramus RM, Santos‐Ramos R, Twickler DM. Persistence of placenta previa according to gestational age at ultrasound. Obstetrics & Gynecology 2002;99(5 Pt 1):692‐7.

Gamble 2000

Gamble JA, Creedy DK. Women's request for a cesarean section: a critique of the literature. Birth 2000;27(4):256‐63.

Geary 1997

Geary M, Fanagan M, Boylan P. Maternal satisfaction with management of labour and preference for mode of delivery. Journal of Perinatal Medicine 1997;25(5):433‐9.

Gilliam 2002

Gilliam M, Rosenberg D, Davis F. The likelihood of placenta previa with greater number of cesarean deliveries and higher parity. Obstetrics & Gynecology 2002;99(6):976‐80.

GRADEpro 2014 [Computer program]

GRADEpro. [Computer program on www.gradepro.org]. GRADEpro. [Computer program on www.gradepro.org]. Version 2015. GRADEpro. [Computer program on www.gradepro.org], 2014.

Hall 1999

Hall MH, Bewley S. Maternal mortality and mode of delivery. Lancet 1999;354(1180):776.

Hannah 2000

Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for the term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356(9239):1375‐83.

Higgins 2011

Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐handbook.org.

Hildingsson 2002

Hildingsson I, Radestad I, Rubertsson C. Waldenstrom U. Few women wish to be delivered by caesarean section. BJOG: an international journal of obstetrics and gynaecology 2002;109(6):618‐23.

Hofmeyr 1986

Hofmeyr GJ, Sadan O, Myer IG, Galal KC, Simko G. External cephalic version and spontaneous version rates: ethnic and other determinants. British Journal Obstetrics Gynaecology 1986;93(1):13‐6.

Hofmeyr 1989

Hofmeyr GJ. Breech presentation and abnormal lie in late pregnancy. In: Chalmers I, Enkin MW, Keirse MJNC editor(s). Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:653‐65.

Hofmeyr 1991

Hofmeyr GJ. External cephalic version at term: how high are the stakes?. BJOG: an international journal of obstetrics and gynaecology 1991;98(1):1‐3.

Hofmeyr 1992

Hofmeyr GJ. Breech presentation and shoulder dystocia in childbirth. Current Opinion in Obstetrics and Gynecology 1992;4(6):807‐12.

Hofmeyr 1993

Hofmeyr GJ. External cephalic version at term. Fetal Maternal Medicine Review 1993;5:213‐22.

Hofmeyr 2003

Hofmeyr GJ, Hannah M, Lawrie TA. Planned caesarean section for term breech delivery. Cochrane Database of Systematic Reviews 2003, Issue 2. [DOI: 10.1002/14651858.CD000166]

Hofmeyr 2012

Hofmeyr GJ, Kulier R. Cephalic version by postural management for breech presentation. Cochrane Database of Systematic Reviews 2012, Issue 10. [DOI: 10.1002/14651858.CD000051.pub2]

Hofmeyr 2015

Hofmeyr GJ, Kulier R, West HM. External cephalic version for breech presentation at term. Cochrane Database of Systematic Reviews 2015, Issue 4. [DOI: 10.1002/14651858.CD000083.pub3]

Hutton 1999

Hutton EK, Hannah ME, Amankwah K, Kaufman K, Hodnett ED. External cephalic version (ECV) and the Early ECV Trial. Journal of the Society of Obstetricians and Gynaecologists of Canada 1999;21(14):1316‐26.

Hutton 2011b

Hutton EK, Hannah ME, Ross SJ, Delisle MF, Carson GD, Windrim R, et al. The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies. BJOG: an international journal of obstetrics and gynaecology 2011;118(5):564‐77.

LaSala 1987

LaSala AP, Berkeley AS. Primary cesarean section and subsequent fertility. American Journal of Obstetrics and Gynecology 1987;157(2):379‐83.

Liu 2007

Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, Kramer MS, for the Maternal Health Study Group of the Canadian Perinatal Surveillance System. Maternal mortality and severe morbidity associated with low‐risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ: Canadian Medical Association Journal 2007;176(4):455‐60.

Lydon‐Rochelle 2001

Lydon‐Rochelle M, Holt VL, Easterling TR, Martin DP. First‐birth cesarean and placental abruption or previa at second birth. Obstetrics & Gynecology 2001;97(5 Pt 1):765‐9.

Minkoff 2003

Minkoff H, Chervenak FA. Elective primary cesarean delivery. New England Journal of Medicine 2003;384(10):946‐50.

RevMan 2014 [Computer program]

The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

Schunemann 2009

Schunemann HJ. GRADE: from grading the evidence to developing recommendations. A description of the system and a proposal regarding the transferability of the results of clinical research to clinical practice [GRADE: Von der Evidenz zur Empfehlung. Beschreibung des Systems und Losungsbeitrag zur Ubertragbarkeit von Studienergebnissen]. Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen 2009;103(6):391‐400. [PUBMED: 19839216]

Schutte 1985

Schutte MF, van Hemel OJS, van de Berg C, van de Pol A. Perinatal mortality in breech presentation as compared with vertex presentation in singleton pregnancies: an analysis based on 57819 computer‐registered pregnancies in The Netherlands. European Journal of Obstetrics, Gynecology, and Reproductive Biology 1985;19:391‐400.

Turnbull 1999

Turnbull DA, Wilkinson C, Yaser A, Carty V, Svigos JM, Robinson JS. Women's role and satisfaction in the decision to have a caesarean section. Medical Journal of Australia 1999;170(12):580‐3.

Walker 2002

Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth 2002;29(1):28‐39.

Referencias de otras versiones publicadas de esta revisión

Hofmeyr 1995

Hofmeyr GJ. External cephalic version before term. [revised 04 October 1993]. In: Enkin MW, Keirse MJNC, Renfrew MJ, Neilson JP, Crowther C (eds.) Pregnancy and Childbirth Module. In: The Cochrane Pregnancy and Childbirth Database [database on disk and CDROM]. The Cochrane Collaboration; Issue 2, Oxford: Update Software; 1995.

Hofmeyr 1996b

Hofmeyr GJ. External cephalic version for breech presentation before term. Cochrane Database of Systematic Reviews 1996, Issue 1. [DOI: 10.1002/14651858.CD000084]

Hutton 2006

Hutton EK, Hofmeyr GJ. External cephalic version for breech presentation before term. Cochrane Database of Systematic Reviews 2006, Issue 1. [DOI: 10.1002/14651858.CD000084.pub2]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Akhtar 2013

Methods

Single centre, parallel‐group randomised controlled trial. 2‐arm trial with individual randomisation.

Participants

Setting: Mardan Medical Complex, Pakistan. July 2010 to 31st Dec 2011.

Inclusion criteria: singleton fetus in a breech presentation confirmed by ultrasound, between 33 weeks and 35 weeks' gestation. N = 123 women.

Exclusion criteria: women with contraindication to ECV; contraindications to early ECV or contraindications to labour or vaginal birth (e.g. fetal heart rate abnormalities, vaginal bleeding, rupture of membranes, placental abruption, fetal growth restriction, previous caesarean section, low amniotic fluid index, fetal weight > 4 kg) or woman unwilling to undergo ECV.

Interventions

Early ECV: ECV carried out between 34 (238 days) and 35 weeks of gestation. No tocolytics were used. Women were monitored for 3 hours before and 1 hour after the procedure. Up to 2‐3 attempts were allowed. The procedure was discontinued if there was excessive maternal discomfort or fetal heart rate irregularities. N = 63.

Control: ECV carried out at or after 37 weeks. No tocolytics were used. Women were monitored for 3 hours before and 1 hour after the procedure. Up to 2‐3 attempts were allowed. The procedure was discontinued if there was excessive maternal discomfort or fetal heart rate irregularities. N = 60.

Outcomes

Reported number of attempts at ECV, reasons for discontinuing ECV, maternal and fetal complications, presentation at delivery, mode of delivery.

Notes

It was reported that methods and allocation was "in accordance with the two major multicenter trials conducted on the same subject". There was no further description of methods used. We contacted the author for more information but have not yet had a response.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Reported that this was the same as methods used in published multicentre randomised controlled trials.

Allocation concealment (selection bias)

Unclear risk

Not described. "Patients were randomly divided into two groups".

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding mentioned.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

No blinding mentioned.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

All women appeared to be accounted for in the analysis.

Selective reporting (reporting bias)

Unclear risk

Assessment from published report. We requested a copy of the protocol but this was not made available to us.

Other bias

Unclear risk

It was reported that methods and allocation was "in accordance with the two major multicenter trials conducted on the same subject". There was no further description of methods used. We contacted the author for more information but have not yet had a response.

Hutton 2003

Methods

An international multicentre randomised controlled trial with randomisation stratified by parity using a centralised telephone randomisation system. Breech verified within 4 days of randomisation, and confirmed prior to ECV attempt.

Participants

All nulliparous women with any breech presentation and multiparous women with a frank breech presentation were eligible for the trial if they had a live singleton fetus and a gestational age of between 34 weeks, 0 days and 36 weeks 0 days. Women were excluded if they had a parity > 4, if they planned to move to a non‐trial centre, or if there was any contraindication to labour or vaginal birth (such as placenta previa, or previous classical caesarean section), to ECV (such as fetal heart rate abnormalities, abruptio placenta, fetal anomalies, uterine anomalies, oligohydramnios, rupture of membranes, over distended uterus) or to early ECV (such as fetus engaged in the pelvis, an increased risk of preterm labour, increased risk of abruptio placenta).

Interventions

ECV was begun between 34 weeks 0 days and 36 weeks 0 days in the early group (n = 117); and between 37 weeks 0 days and 38 weeks 0 days in the delayed group (n = 116). Tocolysis recommended either routinely or selectively in both groups; analgesia permitted.

Outcomes

Primary: presentation at delivery.
Other: caesarean section rate; serious fetal complication; preterm birth < 37 weeks; women's view's about ECV.

Notes

n = 233.
Funded by Canadian Institutes of Health Research; coordinated through the Maternal Infant and Reproductive Health Research Unit (MIRU) at the University of Toronto, Canada.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Stratification by parity, random block sizes. External randomisation service.

Allocation concealment (selection bias)

Low risk

External telephone randomisation service.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Unblinded intervention.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Interim analysis was carried out by blinded assessors.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Analysis by intention‐to‐treat. 233 women randomised, outcome data available for 132 women and babies.

Selective reporting (reporting bias)

Low risk

Protocol provided by the authors. Outcome reporting bias not apparent.

Other bias

Low risk

Other bias not apparent.

Hutton 2011

Methods

2‐arm, unblinded, multicentre, parallel‐group randomised controlled trial. Stratification for parity and centre. Individual randomisation.

Participants

Setting: 68 centres in 21 countries. Hospital setting, with clinicians who were experienced in ECV and birth facilities that were deemed to meet Canadian standards.

1543 women randomised.

Inclusion criteria: women with singleton fetus in a breech presentation who had a recent screening ultrasound, between 33+0/7 weeks' and 35+6/7 weeks' gestation.

Exclusion criteria: women with contraindications to ECV (e.g. fetal heart rate abnormalities, placental abruption, major life‐threatening fetal anomalies, uterine anomalies, hyper‐extended fetal head, rupture of fetal membranes, severe oligohydramnios or hydramnios); contraindications to early ECV (e.g. increased risk of preterm labour or placental abruption); or contraindications to labour or vaginal birth (e.g. placenta praevia, previous classical caesarean section); or if they had been prior participants in the trial; were at increased risk of unstable lie (such as grand multiparity); or if they planned to give birth by caesarean section even if the fetus turned to a cephalic position, or if they planned a vaginal birth if the fetus remained breech.

Interventions

Early ECV: (n = 767) ECV carried out between 34+0/7 and 35+6/7 weeks of gestation, and within 7 days of randomisation. Fetal presentation was confirmed by ultrasound immediately before the ECV procedure. Fetal heart rate was monitored before, during and after the procedure. The use of tocolytics and analgesia was left to the discretion of the clinician, and they were directed to use the same approach for women in both arms of the trial. If the procedure was unsuccessful, or if a fetus later reverted to non‐cephalic, a repeat ECV procedure could be performed at a later date at the discretion of the care provider in consultation with the woman.

Delayed ECV: (n = 774) ECV carried out at or after 37+0/7. Fetal presentation was confirmed by ultrasound immediately before the ECV procedure. Fetal heart rate was monitored before, during and after the procedure. The use of tocolytics and analgesia was left to the discretion of the clinician, and they were directed to use the same approach for women in both arms of the trial. If the procedure was unsuccessful, or if a fetus later reverted to non‐cephalic, a repeat ECV procedure could be performed at a later date at the discretion of the care provider in consultation with the woman.

(Overall, tocolytics were used during all ECV attempts in 68% of cases.)

Outcomes

Primary: rate of caesarean section.

Secondary: rate of preterm birth (< 37 weeks), non‐cephalic presentation at birth, admission to NICU for more than 24 hours, serious neonatal morbidity or death, maternal morbidity or death, pain and maternal satisfaction.

Notes

1 of the review authors was an investigator on this trial. Data extraction and assessment of risk of bias were carried out by 2 independent review authors.

This study was funded by Canadian institutes of Health Research.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Randomisation with a computerised randomisation program, using computer‐generated random block sizes and 1:1 allocation.

Allocation concealment (selection bias)

Low risk

Central randomisation by telephone.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

“The nature of the intervention did not lend itself to blinding of either participants or clinicians.”

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

Some efforts were made to avoid detection bias. Blinding of initial assessment and recording of outcomes is not described. An independent Data Safety and Monitoring Board “reviewed all stillbirths and neonatal deaths, blinded to allocation group, for the existence of any anomaly considered incompatible with life and to make a determination regarding exclusion of any women from the analysis of perinatal/neonatal outcomes”.

An interim analysis of results was also carried out by the independent Data Safety and Monitoring Board, blinded to group assignment.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

2 women, 1 in each group, asked to be removed from the study. 8 women were lost to follow‐up (2 assigned to early ECV, 6 to delayed ECV). This left 1533 women (99.4%), so although the losses to follow‐up were unequal the numbers were small in the context of the whole study. A small amount of missing data (2 early ECV, 1 delayed ECV) accounted for in table 5.

An intention‐to‐treat analysis was conducted. Perinatal and neonatal deaths were excluded from the analyses of measures of neonatal morbidity.

Selective reporting (reporting bias)

Low risk

All relevant outcomes appear to have been reported, including those showing no differences between groups. Multiple reports available for this study including trial registration.

Other bias

Low risk

Baseline characteristics were similar in the 2 groups. No other bias apparent.

Mensink 1980

Methods

Allocation at 32 weeks' gestation by randomised sealed envelopes, stratified by parity. Breech verified by ultrasound.

Participants

Singleton breech presentation before term (from 32 weeks).

Exclusion criteria: contraindication to external version.

Interventions

External cephalic version attempt without tocolysis (n = 50) compared with no ECV attempt (n = 52).

ECV was attempted by an assistant in training. If failed, a further attempt was made by an obstetrician 1 week later.

Outcomes

Non‐cephalic births; caesarean section; 1 minute Apgar score < 7; Umbilical vein pH < 7.2; neurological deficit in newborn; perinatal mortality. The perinatal death was due to placental abruption.

Notes

Groningen, The Netherlands.

The authors ascribe the low success rate to the gentleness with which external cephalic version was attempted.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not described.

Allocation concealment (selection bias)

Unclear risk

Allocations were concealed in sealed envelopes. It was not clear whether all envelopes were used in sequential order and that all were accounted for.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Unblinded trial.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

It was not possible to blind the intervention. It was not clear whether outcomes were recorded by blinded assessors.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

102 women were randomised. All appear to be accounted for in the analysis.

Selective reporting (reporting bias)

Unclear risk

Assessment from original paper, translated notes and correspondence. It was not clear whether all outcomes were fully reported.

Other bias

Unclear risk

The description of study methods was very brief. Other bias was not apparent.

Van Veelen 1989

Methods

Random allocation of women using sealed envelopes, stratified by parity.

Participants

Healthy white Dutch women with uncomplicated pregnancy of 33‐40 weeks' gestation and a live singleton breech fetus attending antenatal clinic of Ikazia Hospital, Rotterdam, The Netherlands.

Interventions

Repeated ECV performed between 33 and 40 weeks' gestation with no tocolysis, analgesia or anaesthesia compared to no ECV.

Outcomes

Presentation at delivery; mode of delivery; neonatal outcome.

Notes

n = 180.
Rotterdam, The Netherlands.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Not described. Randomisation stratified by parity.

Allocation concealment (selection bias)

Unclear risk

"by means of drawing a sealed envelope." Othe information not provided.

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No blinding.

Blinding of outcome assessment (detection bias)
All outcomes

Unclear risk

There was no mention of whether or not outcome assessors were blinded.

Incomplete outcome data (attrition bias)
All outcomes

Low risk

180 women were randomised. 1 was lost to follow‐up.

Selective reporting (reporting bias)

Unclear risk

Assessment from published report.

Other bias

Unclear risk

Little information on study methods was provided. Other bias was not apparent.

ECV: external cephalic version
NICU: neonatal intensive care unit

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Brosset 1956

Method to group allocation is described as "dividing the cases up into two groups". It is highly unlikely that randomisation was used and there is risk of enrolment bias. This study is of historical interest in that it is an early example of a controlled trial.

Dafallah 2004

The methods of randomisation were not described for this study. Participants recruited included women between 36 to 38 weeks' gestation, some of the women were ≥ 37 weeks' gestation; separate data were not reported for women before term.

El‐Muzaini 2008

It was not clear that this was a randomised controlled trial and participants recruited to the study were women with singleton pregnancies with breech presentation at term (≥ 37 weeks).

Kasule 1985

Method to group allocation is described as being dependant on the day that women attended at antenatal clinic (on Monday and Wednesday ECV was performed, whereas on Tuesday and Thursday it was not), and there is significant risk of enrolment bias. It is also unclear in this study how the breech pregnancies were confirmed. In addition, 25% of the study population were grand‐multiparous women who are at increased risk of unstable lie, and are at an increased risk of encountering complications.

Rust 2005

In this trial women were recruited from 36 up to 386/7 weeks. Most included women were at term and separate data were not reported for women less than 37 weeks' gestation.

ECV: external cephalic version

Characteristics of ongoing studies [ordered by study ID]

Belizan 1989

Trial name or title

Early external cephalic version in antenatal care. A randomized trial.

Methods

Participants

Women with breech presentation at 31 weeks' pregnancy.

Interventions

ECV for breech presentation versus no ECV.

Outcomes

Caesarean section; length of postpartum stay.

Starting date

June 1989.

Contact information

Belizan JM. Centro Rosarino de Estudios Perinatales, Bv OroNo 500, 2000 Rosario, Argentina.
Tel +54 41 63745

Notes

It is not clear whether or not this trial was completed.

ECV: external cephalic version

Data and analyses

Open in table viewer
Comparison 1. External cephalic version (ECV) before term versus no ECV

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.64, 1.69]

Analysis 1.1

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

2 Vaginal cephalic birth not achieved (CS + breech vaginal birth) Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.67, 1.62]

Analysis 1.2

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

3 Caesarean section Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.82 [0.57, 5.84]

Analysis 1.3

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 3 Caesarean section.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 3 Caesarean section.

4 Vaginal breech birth Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.49, 1.52]

Analysis 1.4

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 4 Vaginal breech birth.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 4 Vaginal breech birth.

5 Apgar score < 7 at 1 minute Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.25, 1.59]

Analysis 1.5

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 5 Apgar score < 7 at 1 minute.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 5 Apgar score < 7 at 1 minute.

6 Perinatal mortality Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.04, 3.22]

Analysis 1.6

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 6 Perinatal mortality.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 6 Perinatal mortality.

Open in table viewer
Comparison 2. External cephalic version (ECV) commenced before term versus no ECV

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.45, 0.77]

Analysis 2.1

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

2 Vaginal cephalic birth not achieved (CS + breech vaginal birth) Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.49, 0.80]

Analysis 2.2

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

3 Caesarean section Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.27, 1.43]

Analysis 2.3

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 3 Caesarean section.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 3 Caesarean section.

4 Vaginal breech birth Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.46, 0.85]

Analysis 2.4

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 4 Vaginal breech birth.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 4 Vaginal breech birth.

5 Apgar score < 7 at 5 minutes Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

3.03 [0.13, 73.48]

Analysis 2.5

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 5 Apgar score < 7 at 5 minutes.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 5 Apgar score < 7 at 5 minutes.

6 Stillbirth and neonatal mortality < 7 days Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.34 [0.01, 8.16]

Analysis 2.6

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 6 Stillbirth and neonatal mortality < 7 days.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 6 Stillbirth and neonatal mortality < 7 days.

Open in table viewer
Comparison 3. External cephalic version (ECV) commenced before term versus ECV at term

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

3

1906

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.74, 0.90]

Analysis 3.1

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 1 Non‐cephalic presentation at the birth.

2 Vaginal cephalic birth not achieved (CS + vaginal breech birth) Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.83, 0.97]

Analysis 3.2

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 2 Vaginal cephalic birth not achieved (CS + vaginal breech birth).

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 2 Vaginal cephalic birth not achieved (CS + vaginal breech birth).

3 Caesarean section Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.85, 1.00]

Analysis 3.3

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 3 Caesarean section.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 3 Caesarean section.

4 Vaginal breech birth Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.44 [0.25, 0.78]

Analysis 3.4

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 4 Vaginal breech birth.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 4 Vaginal breech birth.

5 Apgar score < 7 at 5 minutes Show forest plot

2

1759

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.39, 3.44]

Analysis 3.5

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 5 Apgar score < 7 at 5 minutes.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 5 Apgar score < 7 at 5 minutes.

6 Stillbirth or neonatal mortality < 7 days Show forest plot

3

1887

Risk Ratio (M‐H, Fixed, 95% CI)

0.23 [0.04, 1.34]

Analysis 3.6

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 6 Stillbirth or neonatal mortality < 7 days.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 6 Stillbirth or neonatal mortality < 7 days.

7 Preterm birth < 37 weeks Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

1.51 [1.03, 2.21]

Analysis 3.7

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 7 Preterm birth < 37 weeks.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 7 Preterm birth < 37 weeks.

8 One or more serious fetal complications following randomisation Show forest plot

2

1761

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.42, 1.79]

Analysis 3.8

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 8 One or more serious fetal complications following randomisation.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 8 One or more serious fetal complications following randomisation.

9 NICU stay 4 days or longer Show forest plot

1

232

Risk Ratio (M‐H, Fixed, 95% CI)

2.5 [0.49, 12.63]

Analysis 3.9

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 9 NICU stay 4 days or longer.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 9 NICU stay 4 days or longer.

10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain) Show forest plot

1

1533

Mean Difference (IV, Fixed, 95% CI)

‐4.60 [‐7.74, ‐1.46]

Analysis 3.10

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain).

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain).

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figuras y tablas -
Figure 1

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.
Figuras y tablas -
Analysis 1.1

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).
Figuras y tablas -
Analysis 1.2

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 3 Caesarean section.
Figuras y tablas -
Analysis 1.3

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 3 Caesarean section.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 4 Vaginal breech birth.
Figuras y tablas -
Analysis 1.4

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 4 Vaginal breech birth.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 5 Apgar score < 7 at 1 minute.
Figuras y tablas -
Analysis 1.5

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 5 Apgar score < 7 at 1 minute.

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 6 Perinatal mortality.
Figuras y tablas -
Analysis 1.6

Comparison 1 External cephalic version (ECV) before term versus no ECV, Outcome 6 Perinatal mortality.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.
Figuras y tablas -
Analysis 2.1

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).
Figuras y tablas -
Analysis 2.2

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 2 Vaginal cephalic birth not achieved (CS + breech vaginal birth).

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 3 Caesarean section.
Figuras y tablas -
Analysis 2.3

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 3 Caesarean section.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 4 Vaginal breech birth.
Figuras y tablas -
Analysis 2.4

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 4 Vaginal breech birth.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 5 Apgar score < 7 at 5 minutes.
Figuras y tablas -
Analysis 2.5

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 5 Apgar score < 7 at 5 minutes.

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 6 Stillbirth and neonatal mortality < 7 days.
Figuras y tablas -
Analysis 2.6

Comparison 2 External cephalic version (ECV) commenced before term versus no ECV, Outcome 6 Stillbirth and neonatal mortality < 7 days.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 1 Non‐cephalic presentation at the birth.
Figuras y tablas -
Analysis 3.1

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 1 Non‐cephalic presentation at the birth.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 2 Vaginal cephalic birth not achieved (CS + vaginal breech birth).
Figuras y tablas -
Analysis 3.2

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 2 Vaginal cephalic birth not achieved (CS + vaginal breech birth).

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 3 Caesarean section.
Figuras y tablas -
Analysis 3.3

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 3 Caesarean section.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 4 Vaginal breech birth.
Figuras y tablas -
Analysis 3.4

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 4 Vaginal breech birth.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 5 Apgar score < 7 at 5 minutes.
Figuras y tablas -
Analysis 3.5

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 5 Apgar score < 7 at 5 minutes.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 6 Stillbirth or neonatal mortality < 7 days.
Figuras y tablas -
Analysis 3.6

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 6 Stillbirth or neonatal mortality < 7 days.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 7 Preterm birth < 37 weeks.
Figuras y tablas -
Analysis 3.7

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 7 Preterm birth < 37 weeks.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 8 One or more serious fetal complications following randomisation.
Figuras y tablas -
Analysis 3.8

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 8 One or more serious fetal complications following randomisation.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 9 NICU stay 4 days or longer.
Figuras y tablas -
Analysis 3.9

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 9 NICU stay 4 days or longer.

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain).
Figuras y tablas -
Analysis 3.10

Comparison 3 External cephalic version (ECV) commenced before term versus ECV at term, Outcome 10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain).

Summary of findings for the main comparison. External cephalic version (ECV) commenced before term versus ECV at term for breech presentation before term

External cephalic version (ECV) commenced before term versus ECV at term for breech presentation before term

Population: women with breech presentation before term
Settings: 3 trials, 2 multicentre and 1 in Pakistan
Intervention: external cephalic version (ECV) commenced before term
Comparison: external cephalic version at term

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

External cephalic version at term

External cephalic version (ECV) commenced before term

Non‐cephalic presentation at the birth

Study population

RR 0.81
(0.74 to 0.9)

1906
(3 studies)

⊕⊕⊕⊕
high

523 per 1000

424 per 1000
(387 to 471)

Moderate

517 per 1000

419 per 1000
(383 to 465)

Vaginal cephalic birth not achieved (caesarean section + vaginal breech birth)

Study population

RR 0.9
(0.83 to 0.97)

1888
(3 studies)

⊕⊕⊕⊕
high

600 per 1000

540 per 1000
(498 to 582)

Moderate

633 per 1000

570 per 1000
(525 to 614)

Caesarean section

Study population

RR 0.92
(0.85 to 1)

1888
(3 studies)

⊕⊕⊕⊕
high

565 per 1000

519 per 1000
(480 to 565)

Moderate

560 per 1000

515 per 1000
(476 to 560)

Vaginal breech birth

Study population

RR 0.44
(0.25 to 0.78)

1888
(3 studies)

⊕⊕⊕⊕
high

35 per 1000

15 per 1000
(9 to 27)

Moderate

26 per 1000

11 per 1000
(6 to 20)

Apgar score < 7 at 5 minutes

Study population

RR 1.16
(0.39 to 3.44)

1759
(2 studies)

⊕⊕⊝⊝
low1

7 per 1000

8 per 1000
(3 to 23)

Moderate

11 per 1000

13 per 1000
(4 to 38)

Perinatal mortality (Stillbirth or neonatal mortality < 7 days)

Study population

RR 0.23
(0.04 to 1.34)

1887
(3 studies)

⊕⊕⊝⊝
low1

5 per 1000

1 per 1000
(0 to 7)

Moderate

9 per 1000

2 per 1000
(0 to 12)

Preterm birth < 37 weeks

Study population

RR 1.51
(1.03 to 2.21)

1888
(3 studies)

⊕⊕⊕⊕
high

43 per 1000

66 per 1000
(45 to 96)

Moderate

44 per 1000

66 per 1000
(45 to 97)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Wide 95% CI crossing the line of no effect and low event rate.

Figuras y tablas -
Summary of findings for the main comparison. External cephalic version (ECV) commenced before term versus ECV at term for breech presentation before term
Comparison 1. External cephalic version (ECV) before term versus no ECV

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.64, 1.69]

2 Vaginal cephalic birth not achieved (CS + breech vaginal birth) Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.04 [0.67, 1.62]

3 Caesarean section Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

1.82 [0.57, 5.84]

4 Vaginal breech birth Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.49, 1.52]

5 Apgar score < 7 at 1 minute Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.25, 1.59]

6 Perinatal mortality Show forest plot

1

102

Risk Ratio (M‐H, Fixed, 95% CI)

0.35 [0.04, 3.22]

Figuras y tablas -
Comparison 1. External cephalic version (ECV) before term versus no ECV
Comparison 2. External cephalic version (ECV) commenced before term versus no ECV

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.45, 0.77]

2 Vaginal cephalic birth not achieved (CS + breech vaginal birth) Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.49, 0.80]

3 Caesarean section Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.27, 1.43]

4 Vaginal breech birth Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.46, 0.85]

5 Apgar score < 7 at 5 minutes Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

3.03 [0.13, 73.48]

6 Stillbirth and neonatal mortality < 7 days Show forest plot

1

179

Risk Ratio (M‐H, Fixed, 95% CI)

0.34 [0.01, 8.16]

Figuras y tablas -
Comparison 2. External cephalic version (ECV) commenced before term versus no ECV
Comparison 3. External cephalic version (ECV) commenced before term versus ECV at term

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Non‐cephalic presentation at the birth Show forest plot

3

1906

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.74, 0.90]

2 Vaginal cephalic birth not achieved (CS + vaginal breech birth) Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.83, 0.97]

3 Caesarean section Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.85, 1.00]

4 Vaginal breech birth Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

0.44 [0.25, 0.78]

5 Apgar score < 7 at 5 minutes Show forest plot

2

1759

Risk Ratio (M‐H, Fixed, 95% CI)

1.16 [0.39, 3.44]

6 Stillbirth or neonatal mortality < 7 days Show forest plot

3

1887

Risk Ratio (M‐H, Fixed, 95% CI)

0.23 [0.04, 1.34]

7 Preterm birth < 37 weeks Show forest plot

3

1888

Risk Ratio (M‐H, Fixed, 95% CI)

1.51 [1.03, 2.21]

8 One or more serious fetal complications following randomisation Show forest plot

2

1761

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.42, 1.79]

9 NICU stay 4 days or longer Show forest plot

1

232

Risk Ratio (M‐H, Fixed, 95% CI)

2.5 [0.49, 12.63]

10 (Non‐prespecified outcome) Maternal pain score (0‐100; 0 = no pain) Show forest plot

1

1533

Mean Difference (IV, Fixed, 95% CI)

‐4.60 [‐7.74, ‐1.46]

Figuras y tablas -
Comparison 3. External cephalic version (ECV) commenced before term versus ECV at term