Management of breech presentation

National Guideline Alliance (UK)

Management of breech presentation

Antenatal care

Evidence review M

NICE Guideline, No. 201

Authors

National Guideline Alliance (UK).

London: National Institute for Health and Care Excellence (NICE); 2021 Aug.

ISBN-13: 978-1-4731-4227-5

Management of breech presentation

Review question

What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

Introduction

Breech presentation of the fetus in late pregnancy may result in prolonged or obstructed labour with resulting risks to both woman and fetus. Interventions to correct breech presentation (to cephalic) before labour and birth are important for the woman’s and the baby’s health. The aim of this review is to determine the most effective way of managing a breech presentation in late pregnancy.

Summary of the protocol

Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.

Table 1

Summary of the protocol (PICO table).

For further details see the review protocol in appendix A.

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

Clinical evidence

Included studies

Thirty-six randomised controlled trials (RCTs) were identified for this review.

The included studies are summarised in Table 2.

Three studies reported on external cephalic version (ECV) versus no intervention (Dafallah 2004, Hofmeyr 1983, Rita 2011). One study reported on a 4-arm trial comparing acupuncture, sweeping of fetal membranes, acupuncture plus sweeping, and no intervention (Andersen 2013). Two studies reported on postural management versus no intervention (Chenia 1987, Smith 1999).

Seven studies reported on ECV plus anaesthesia (Chalifoux 2017, Dugoff 1999, Khaw 2015, Mancuso 2000, Schorr 1997, Sullivan 2009, Weiniger 2010). Of these studies, 1 study compared ECV plus anaesthesia to ECV plus other dosages of the same anaesthetic (Chalifoux 2017); 4 studies compared ECV plus anaesthesia to ECV only (Dugoff 1999, Mancuso 2000, Schorr 1997, Weiniger 2010); and 2 studies compared ECV plus anaesthesia to ECV plus a different anaesthetic (Khaw 2015, Sullivan 2009).

Ten studies reported ECV plus a β2 receptor agonist (Brocks 1984, Fernandez 1997, Hindawi 2005, Impey 2005, Mahomed 1991, Marquette 1996, Nor Azlin 2005, Robertson 1987, Van Dorsten 1981, Vani 2009). Of these studies, 5 studies compared ECV plus a β2 receptor agonist to ECV plus placebo (Fernandez 1997, Impey 2005, Marquette 1996, Nor Azlin 2005, Vani 2009); 1 study compared ECV plus a β2 receptor agonist to ECV alone (Robertson 1987); and 4 studies compared ECV plus a β2 receptor agonist to no intervention (Brocks 1984, Hindawi 2005, Mahomed 1991, Van Dorsten 1981).

One study reported on ECV plus Ca²⁺ channel blocker versus ECV plus placebo (Kok 2008). Two studies reported on ECV plus β2 receptor agonist versus ECV plus Ca²⁺ channel blocker (Collaris 2009, Mohamed Ismail 2008). Four studies reported on ECV plus a µ-receptor agonist (Burgos 2016, Liu 2016, Munoz 2014, Wang 2017), of which 3 compared against ECV plus placebo (Liu 2016, Munoz 2014, Wang 2017) and 1 compared to ECV plus nitrous oxide (Burgos 2016).

Four studies reported on ECV plus nitroglycerin (Bujold 2003a, Bujold 2003b, El-Sayed 2004, Hilton 2009), of which 2 compared it to ECV plus β2 receptor agonist (Bujold 2003b, El-Sayed 2004) and compared it to ECV plus placebo (Bujold 2003a, Hilton 2009). One study compared ECV plus amnioinfusion versus ECV alone (Diguisto 2018) and 1 study compared ECV plus talcum powder to ECV plus gel (Vallikkannu 2014).

One study was conducted in Australia (Smith 1999); 4 studies in Canada (Bujold 2003a, Bujold 2003b, Hilton 2009, Marquette 1996); 2 studies in China (Liu 2016, Wang 2017); 2 studies in Denmark (Andersen 2013, Brocks 1984); 1 study in France (Diguisto 2018); 1 study in Hong Kong (Khaw 2015); 1 study in India (Rita 2011); 1 study in Israel (Weiniger 2010); 1 study in Jordan (Hindawi 2005); 5 studies in Malaysia (Collaris 2009, Mohamed Ismail 2008, Nor Azlin 2005, Vallikkannu 2014, Vani 2009); 1 study in South Africa (Hofmeyr 1983); 2 studies in Spain (Burgos 2016, Munoz 2014); 1 study in Sudan (Dafallah 2004); 1 study in The Netherlands (Kok 2008); 2 studies in the UK (Impey 2005, Chenia 1987); 9 studies in US (Chalifoux 2017, Dugoff 1999, El-Sayed 2004, Fernandez 1997, Mancuso 2000, Robertson 1987, Schorr 1997, Sullivan 2009, Van Dorsten 1981); and 1 study in Zimbabwe (Mahomed 1991).

The majority of studies were 2-arm trials, but there was one 3-arm trial (Khaw 2015) and two 4-arm trials (Andersen 2013, Chalifoux 2017). All studies were conducted in a hospital or an outpatient ward connected to a hospital.

See the literature search strategy in appendix B and study selection flow chart in appendix C.

Excluded studies

Studies not included in this review with reasons for their exclusions are provided in appendix K.

Summary of clinical studies included in the evidence review

Summaries of the studies that were included in this review are presented in Table 2.

Table 2

Summary of included studies.

See the full evidence tables in appendix D and the forest plots in appendix E.

Quality assessment of clinical outcomes included in the evidence review

See the evidence profiles in appendix F.

Economic evidence

Included studies

A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplementary material 2 for details.

Excluded studies

Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.

Summary of studies included in the economic evidence review

No economic studies were identified which were applicable to this review question.

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Evidence statements

Clinical evidence statements

Comparison 1. Complementary therapy versus control (no intervention)

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Caesarean section

Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.74 (95% CI 0.38 to 1.43).
Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 1.29 (95% CI 0.73 to 2.29).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.19 (95% CI 0.02 to 1.62).
Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.40 (0.08 to 2.01).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.32 (95% CI 0.01 to 7.78).
Very low quality evidence from 1 RCT (N=200) showed that there is no clinically important difference between acupuncture plus membrane sweeping and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.33 (0.01 to 8.09).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 2. Complementary therapy versus Other treatment

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Caesarean section

Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.64 (95% CI 0.34 to 1.22).
Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 0.57 (95% CI 0.30 to 1.07).
Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on the number of caesarean sections in pregnant women with breech presentation: RR 1.13 (95% CI 0.66 to 1.94).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.33 (95% CI 0.03 to 3.12).
Very low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.48 (95% CI 0.04 to 5.22).
Very low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.69 (95% CI 0.12 to 4.02).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=207) showed that there is no clinically important difference between acupuncture and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
Low quality evidence from 1 RCT (N=204) showed that there is no clinically important difference between acupuncture and acupuncture plus membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).
Low quality evidence from 1 RCT (N=203) showed that there is no clinically important difference between acupuncture plus membrane sweeping and membrane sweeping on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 3. ECV versus no ECV

Critical outcomes

Cephalic presentation in labour

Moderate quality evidence from 2 RCTs (N=680) showed that there is clinically important difference favouring ECV over no ECV on cephalic presentation in labour in pregnant women with breech presentation: RR 1.83 (95% CI 1.53 to 2.18).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 3 RCTs (N=740) showed that there is a clinically important difference favouring ECV over no ECV on cephalic vaginal birth in pregnant women with breech presentation: RR 1.67 (95% CI 1.20 to 2.31).

Breech vaginal birth

Very low quality evidence from 2 RCTs (N=680) showed that there is no clinically important difference between ECV and no ECV on breech vaginal birth in pregnant women with breech presentation: RR 0.29 (95% CI 0.03 to 2.84).

Caesarean section

Very low quality evidence from 3 RCTs (N=740) showed that there is no clinically important difference between ECV and no ECV on the number of caesarean sections in pregnant women with breech presentation: RR 0.52 (95% CI 0.23 to 1.20).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=60) showed that there is no clinically important difference between ECV and no ECV on admission to SCBU//NICU in pregnant women with breech presentation: RR 0.50 (95% CI 0.14 to 1.82).

Fetal death after 36⁺⁰ weeks gestation

Very low evidence from 3 RCTs (N=740) showed that there is no statistically significant difference between ECV and no ECV on fetal death after 36⁺⁰ weeks gestation in pregnant women with breech presentation: Peto OR 0.29 (95% CI 0.05 to 1.73) p=0.18.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Very low quality evidence from 2 RCTs (N=120) showed that there is no clinically important difference between ECV and no ECV on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.28 (95% CI 0.04 to 1.70).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 4. ECV + Amnioinfusion versus ECV only

Critical outcomes

Cephalic presentation in labour

Very low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.74 (95% CI 0.74 to 4.12).

Method of birth

Caesarean section

Low quality evidence from 1 RCT (N=109) showed that there is no clinically important difference between ECV plus amnioinfusion and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.95 (95% CI 0.75 to 1.19).

Critical outcomes

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 5. ECV + Anaesthesia versus ECV only

Critical outcomes

Cephalic presentation in labour

Very low quality evidence from 2 RCTs (N=210) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic presentation in labour in pregnant women with breech presentation: RR 1.16 (95% CI 0.56 to 2.41).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 5 RCTs (N=435) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.16 (95% CI 0.77 to 1.74).

Breech vaginal birth

Very low quality evidence from 1 RCT (N=108) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on breech vaginal birth in pregnant women with breech presentation: RR 0.33 (95% CI 0.04 to 3.10).

Caesarean section

Very low quality evidence from 3 RCTs (N=263) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 0.76 (95% CI 0.42 to 1.38).

Admission to SCBU/NICU

Moderate quality evidence from 1 RCT (N=69) showed that there is a clinically important difference favouring ECV plus anaesthesia over ECV alone on admission to SCBU/NICU in pregnant women with breech presentation: MD −1.80 (95% CI −2.53 to −1.07).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus anaesthesia and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 6. ECV + Anaesthesia versus ECV + Anaesthesia

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Cephalic vaginal birth

Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.13 (95% CI 0.73 to 1.74).
Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
Very low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 0.05mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.69 (95% CI 0.37 to 1.28).
Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.81 (95% CI 0.53 to 1.23).
Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 0.96 (95% CI 0.61 to 1.50).
Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on cephalic vaginal birth in pregnant women with breech presentation: RR 1.19 (95% CI 0.79 to 1.79).

Caesarean section

Low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.92 (95% CI 0.68 to 1.24).
Very low evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.08 (95% CI 0.78 to 1.50).
Very low evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 2.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.70 to 1.28).
Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.17 (95% CI 0.86 to 1.61).
Very low quality evidence from 1 RCT (N=120) showed that there is no clinically important difference between ECV plus 5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 1.03 (95% CI 0.77 to 1.37).
Low quality evidence from 1 RCT (N=119) showed that there is no clinically important difference between ECV plus 7.5mg Bupivacaine plus 0.015mg Fentanyl and ECV plus 10mg Bupivacaine plus 0.015mg Fentanyl on the number of caesarean sections in pregnant women with breech presentation: RR 0.88 (95% CI 0.64 to 1.20).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 7. ECV + β2 agonist versus Control (no intervention)

Critical outcomes

Cephalic presentation in labour

Moderate quality evidence from 2 RCTs (N=256) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on cephalic presentation in labour in pregnant women with breech presentation: RR 4.83 (95% CI 3.27 to 7.11).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 3 RCTs (N=265) showed that there no clinically important difference between ECV plus β2 agonist and control (no intervention) on cephalic vaginal birth in pregnant women with breech presentation: RR 2.03 (95% CI 0.22 to 19.01).

Breech vaginal birth

Very low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on breech vaginal birth in pregnant women with breech presentation: RR 0.38 (95% CI 0.20 to 0.69).

Caesarean section

Low quality evidence from 4 RCTs (N=513) showed that there is a clinically important difference favouring ECV plus β2 agonist over control (no intervention) on the number of caesarean sections in pregnant women with breech presentation: RR 0.53 (95% CI 0.41 to 0.67).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=48) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on admission to SCBU/NICU in pregnant women with breech presentation: RD 0.00 (95% CI −0.08 to 0.08).

Fetal death after 36⁺⁰ weeks gestation

Very low quality evidence from 3 RCTs (N=208) showed that there is no statistically significant difference between ECV plus β2 agonist and control (no intervention) on fetal death after 36⁺⁰ weeks gestation in pregnant women with breech presentation: RD −0.01 (95% CI −0.03 to 0.01) p=0.66.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Very low quality evidence from 2 RCTs (N=208) showed that there is no clinically important difference between ECV plus β2 agonist and control (no intervention) on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.80 (95% CI 0.31 to 2.10).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 8. ECV + β2 agonist versus ECV only

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Cephalic vaginal birth

Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on cephalic vaginal birth in pregnant women with breech presentation: RR 1.32 (95% CI 0.67 to 2.62).

Breech vaginal birth

Very low quality evidence from 1 RCT (N=58) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on breech vaginal birth in pregnant women with breech presentation: RR 0.75 (95% CI 0.22 to 2.50).

Caesarean section

Very low quality evidence from 2 RCTs (N=172) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 0.79 (95% CI 0.27 to 2.28).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=114) showed that there is no clinically important difference between ECV plus β2 agonist and ECV only on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.00 (95% CI 0.21 to 4.75).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 9. ECV + β2 agonist versus ECV + Placebo

Critical outcomes

Cephalic presentation in labour

Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.54 (95% CI 0.24 to 9.76).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 1.27 (95% CI 0.41 to 3.89).

Breech vaginal birth

Very low quality evidence from 2 RCTs (N=227) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on breech vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.33 to 2.97).

Caesarean section

Low quality evidence from 4 RCTs (N=532) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.81 (95% CI 0.72 to 0.92)

Admission to SCBU/NICU

Very low quality evidence from 2 RCTs (N=146) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: RR 0.78 (95% CI 0.17 to 3.63).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Very low quality evidence from 1 RCT (N=124) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 10. ECV + Ca²⁺ channel blocker versus ECV + Placebo

Critical outcomes

Cephalic presentation in labour

Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.87 to 1.48).

Method of birth

Cephalic vaginal birth

Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.90 (95% CI 0.73 to 1.12).

Caesarean section

Moderate quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 1.11 (95% CI 0.88 to 1.40).

Admission to SCBU/NICU

High quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on admission to SCBU/NICU in pregnant women with breech presentation: MD −0.20 (95% CI −0.70 to 0.30).

Fetal death after 36⁺⁰ weeks gestation

Moderate quality evidence from 1 RCT (N=310) showed that there is no statistically significant difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on fetal death after 36⁺⁰ weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.01 to 0.01) p=1.00.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=310) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus placebo on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.52 (95% 0.05 to 5.02).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 11. ECV + Ca2+ channel blocker versus ECV + β2 agonist

Critical outcomes

Cephalic presentation in labour

Low quality evidence from 1 RCT (N=90) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca²⁺ channel blocker on cephalic presentation in labour in pregnant women with breech presentation: RR 0.62 (95% CI 0.39 to 0.98).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 2 RCTs (N=126) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 1.26 (95% CI 0.55 to 2.89).

Caesarean section

Very low quality evidence from 2 RCTs (N=132) showed that there is a clinically important difference favouring ECV plus β2 agonist over ECV plus Ca²⁺ channel blocker on the number of caesarean sections in pregnant women with breech presentation: RR 1.42 (95% CI 1.06 to 1.91).

Admission to SCBU/NICU

Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus β2 agonist on admission to SCBU/NICU in pregnant women with breech presentation: Peto OR 0.53 (95% CI 0.05 to 5.22).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Very low quality evidence from 2 RCTs (N=176) showed that there is no clinically important difference between ECV plus Ca²⁺ channel blocker and ECV plus β2 agonist on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 12. ECV + µ-receptor agonist versus ECV only

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Cephalic vaginal birth

High quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on cephalic vaginal birth in pregnant women with breech presentation: RR 1.00 (95% CI 0.80 to 1.24).

Caesarean section

Low quality evidence from 1 RCT (N=80) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on the number of caesarean sections in pregnant women with breech presentation: RR 1.00 (95% CI 0.42 to 2.40).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=126) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV alone on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 13. ECV + µ-receptor agonist versus ECV + Placebo

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Cephalic vaginal birth after successful ECV

High quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on cephalic vaginal birth after successful ECV in pregnant women with breech presentation: RR 1.00 (95% CI 0.86 to 1.17).

Caesarean section after successful ECV

Low quality evidence from 2 RCTs (N=98) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after successful ECV in pregnant women with breech presentation: RR 0.97 (95% CI 0.33 to 2.84).

Breech vaginal birth after unsuccessful ECV

High quality evidence from 3 RCTs (N=186) showed that there is a clinically important difference favouring ECV plus µ-receptor agonist over ECV plus placebo on breech vaginal birth after unsuccessful ECV in pregnant women with breech presentation: RR 0.10 (95% CI 0.02 to 0.53).

Caesarean section after unsuccessful ECV

Moderate quality evidence from 3 RCTs (N=186) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus placebo on caesarean section after unsuccessful ECV in pregnant women with breech presentation: RR 1.19 (95% CI 1.09 to 1.31).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

Low quality evidence from 1 RCT (N=137) showed that there is no statistically significant difference between ECV plus µ-receptor agonist and ECV plus placebo on fetal death after 36⁺⁰ weeks gestation in pregnant women with breech presentation: RD 0.00 (95% CI −0.03 to 0.03) p=1.00.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 14. ECV + µ-receptor agonist versus ECV + Anaesthesia

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Cephalic vaginal birth

Moderate quality evidence from 1 RCT (N=92) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on cephalic vaginal birth in pregnant women with breech presentation: RR 1.04 (95% CI 0.84 to 1.29).

Caesarean section

Very low quality evidence from 2 RCTs (N=212) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on the number of caesarean sections in pregnant women with breech presentation: RR 0.90 (95% CI 0.61 to 1.34).

Admission to SCBU/NICU

Very low quality evidence from 1 RCT (N=129) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on admission to SCBU/NICU in pregnant women with breech presentation: RR 2.30 (95% CI 0.21 to 24.74).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 2 RCTs (N=255) showed that there is no clinically important difference between ECV plus µ-receptor agonist and ECV plus anaesthesia on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RD 0.00 (95% CI −0.02 to 0.02).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 15. ECV + Nitric oxide donor versus ECV + Placebo

Critical outcomes

Cephalic presentation in labour

Very low quality evidence from 3 RCTs (N=224) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic presentation in labour in pregnant women with breech presentation: RR 1.13 (95% CI 0.59 to 2.16).

Method of birth

Cephalic vaginal birth

Low quality evidence from 1 RCT (N=99) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on cephalic vaginal birth in pregnant women with breech presentation: RR 0.78 (95% CI 0.49 to 1.22).

Caesarean section

Low quality evidence from 2 RCTs (N=125) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus placebo on the number of caesarean sections in pregnant women with breech presentation: RR 0.83 (95% CI 0.68 to 1.01).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 16. ECV + Nitric oxide donor versus ECV + β2 agonist

Critical outcomes

Cephalic presentation in labour

Low quality evidence from 1 RCT (N=74) showed that there is no clinically important difference between ECV plus β2 agonist and ECV plus nitric oxide donor on cephalic presentation in labour in pregnant women with breech presentation: RR 0.56 (95% CI 0.29 to 1.09).

Method of birth

Cephalic vaginal birth

Very low quality evidence from 2 RCTs (N=97) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on cephalic vaginal birth in pregnant women with breech presentation: RR 0.98 (95% CI 0.47 to 2.05).

Caesarean section

Very low quality evidence from 1 RCT (N=59) showed that there is no clinically important difference between ECV plus nitric oxide donor and ECV plus β2 agonist on the number of caesarean sections in pregnant women with breech presentation: RR 1.07 (95% CI 0.73 to 1.57).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 17. ECV + Talcum powder versus ECV + Gel

Critical outcomes

Cephalic presentation in labour

Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic presentation in labour in pregnant women with breech presentation: RR 1.02 (95% CI 0.68 to 1.53).

Method of birth

Cephalic vaginal birth

Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on cephalic vaginal birth in pregnant women with breech presentation: RR 1.08 (95% CI 0.67 to 1.74).

Caesarean section

Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on the number of caesarean sections in pregnant women with breech presentation: RR 0.94 (95% CI 0.67 to 1.33).

Admission to SCBU/NICU

Low quality evidence from 1 RCT (N=95) showed that there is no clinically important difference between ECV plus talcum powder and ECV plus gel on admission to SCBU/NICU in pregnant women with breech presentation: RR 1.96 (95% CI 0.38 to 10.19).

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

No evidence was identified to inform this outcome.

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 18. Postural management versus No postural management

Critical outcomes

Cephalic presentation in labour

Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic presentation in labour in pregnant women with breech presentation: RR 1.26 (95% CI 0.70 to 2.30).

Method of birth

Cephalic vaginal birth

Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on cephalic vaginal birth in pregnant women with breech presentation: RR 1.11 (95% CI 0.59 to 2.07).

Breech vaginal delivery

Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on breech vaginal delivery in pregnant women with breech presentation: RR 1.15 (95% CI 0.67 to 1.99).

Caesarean section

Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on the number of caesarean sections in pregnant women with breech presentation: RR 0.69 (95% CI 0.31 to 1.52).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=76) showed that there is no clinically important difference between postural management and no postural management on Apgar score <7 at 5 minutes in pregnant women with breech presentation: RR 0.24 (95% CI 0.03 to 2.03).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Comparison 19. Postural management + ECV versus ECV only

Critical outcomes

Cephalic presentation in labour

No evidence was identified to inform this outcome.

Method of birth

Caesarean section

Moderate quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on the number of caesarean sections in pregnant women with breech presentation: RR 1.05 (95% CI 0.80 to 1.38).

Admission to SCBU/NICU

No evidence was identified to inform this outcome.

Fetal death after 36⁺⁰ weeks gestation

No evidence was identified to inform this outcome.

Infant death up to 4 weeks chronological age

No evidence was identified to inform this outcome.

Important outcomes

Apgar score <7 at 5 minutes

Low quality evidence from 1 RCT (N=100) showed that there is no clinically important difference between postural management plus ECV and ECV only on Apgar score <7 at 5 minutes in pregnant women with breech presentation: Peto OR 0.13 (95% CI 0.00 to 6.55).

Birth before 39⁺⁰ weeks of gestation

No evidence was identified to inform this outcome.

Economic evidence statements

No economic evidence was identified which was applicable to this review question.

The committee’s discussion of the evidence

Interpreting the evidence

The outcomes that matter most

Provision of antenatal care is important for the health and wellbeing of both mother and baby with the aim of avoiding adverse pregnancy outcomes and enhancing maternal satisfaction and wellbeing. Breech presentation in labour may be associated with adverse outcomes for the fetus, which has contributed to an increased likelihood of caesarean birth. The committee therefore agreed that cephalic presentation in labour and method of birth were critical outcomes for the woman, and admission to SCBU/NICU, fetal death after 36⁺⁰ weeks gestation, and infant death up to 4 weeks chronological age were critical outcomes for the baby. Apgar score <7 at 5 minutes and birth before 39⁺⁰ weeks of gestation were important outcomes for the baby.

The quality of the evidence

The quality of the evidence for interventions for managing a longitudinal lie fetal malpresentation (that is breech presentation) in late pregnancy ranged from very low to high, with most of the evidence being of a very low or low quality.

This was predominately due to serious overall risk of bias in some outcomes; imprecision around the effect estimate in some outcomes; indirect population in some outcomes; and the presence of serious heterogeneity in some outcomes, which was unresolved by subgroup analysis. The majority of included studies had a small sample size, which contributed to imprecision around the effect estimate.

No evidence was identified to inform the outcomes of infant death up to 4 weeks chronological age and birth before 39⁺⁰ weeks of gestation.

There was no publication bias identified in the evidence. However, the committee noted the influence pharmacological developers may have in these trials as funders, and took this into account in their decision making.

Benefits and harms

ECV

The committee discussed that in the case of breech presentation, a discussion with the woman about the different options and their potential benefits, harms and implications is needed to ensure an informed decision. The committee discussed that some women may prefer a breech vaginal birth or choose an elective caesarean birth, and that her preferences should be supported, in line with shared decision making.

The committee discussed that external cephalic version is standard practice for managing breech presentation in uncomplicated singleton pregnancies at or after 36+0 weeks. The committee discussed that there could be variation in the success rates of ECV based on the experience of the healthcare professional providing the ECV. There was some evidence supporting the use of ECV for managing a breech presentation in late pregnancy. The evidence showed ECV had a clinically important benefit in terms of cephalic presentations in labour and cephalic vaginal deliveries, when compared to no intervention. The committee noted that the evidence suggested that ECV was not harmful to the baby, although the effect estimate was imprecise relating to the relative rarity of the fetal death as an outcome.

Cephalic (head-down) vaginal birth is preferred by many women and the evidence suggests that external cephalic version is an effective way to achieve this. The evidence suggested ECV increased the chance for a cephalic vaginal birth and the committee agreed that it was important to explain this to the woman during her consultation.

The committee discussed the optimum timing for ECV. Timing of ECV must take into account the likelihood of the baby turning naturally before a woman commences labour and the possibility of the baby turning back to a breech presentation after ECV if it is done too early. The committee noted that in their experience, current practice was to perform ECV at 37 gestational weeks. The majority of the evidence demonstrating a benefit of ECV in this review involved ECV performed around 37 gestational weeks, although the review did not look for studies directly comparing different timings of ECV and their relative success rates.

The evidence in this review excluded women with previous complicated pregnancies, such as those with previous caesarean section or uterine surgery. The committee discussed that a previous caesarean section indicates a complicated pregnancy and that this population of women are not the focus of this guideline, which concentrates on women with uncomplicated pregnancies.

The committee’s recommendations align with other NICE guidance and cross references to the NICE guideline on caesarean birth and the section on breech presenting in labour in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies were made.

ECV combined with pharmacological agents

There were some small studies comparing a variety of pharmacological agents (including β2 agonists, Ca²⁺ channel blockers, µ-receptor agonists and nitric oxide donors) given alongside ECV. Overall the evidence typically showed no clinically important benefit of adding any pharmacological agent to ECV except in comparisons with a control arm with no ECV where it was not possible to isolate the effect of the ECV versus the pharmacological agent. The evidence tended toward benefit most for β2 agonists and µ-receptor agonists however there was no consistent or high quality evidence of benefit even for these agents. The committee agreed that although these pharmacological agents are used in practice, there was insufficient evidence to make a recommendation supporting or refuting their use or on which pharmacological agent should be used.

The committee discussed that the evidence suggesting µ-receptor agonist, remifentanil, had a clinically important benefit in terms reducing breech vaginal births after unsuccessful ECV was biologically implausible. The committee noted that this pharmacological agent has strong sedative effects, depending on the dosage, and therefore studies comparing it to a placebo had possible design flaws as it would be obvious to all parties whether placebo or active drug had been received. The committee discussed that the risks associated with using remifentanil such as respiratory depression, likely outweigh any potential added benefit it may have on managing breech presentation.

There was some evidence comparing different anaesthetics together with ECV. Although there was little consistent evidence of benefit overall, one small study of low quality showed a combination of 2% lidocaine and epinephrine via epidural catheter (anaesthesia) with ECV showed a clinically important benefit in terms of cephalic presentations in labour and the method of birth. The committee discussed the evidence and agreed the use of anaesthesia via epidural catheter during ECV was uncommon practice in the UK and could be expensive, overall they agreed the strength of the evidence available was insufficient to support a change in practice.

Postural management

There was limited evidence on postural management as an intervention for managing breech presentation in late pregnancy, which showed no difference in effectiveness. Postural management was defined as ‘knee-chest position for 15 minutes, 3 times a day’. The committee agreed that in their experience women valued trying interventions at home first which might make postural management an attractive option for some women, however, there was no evidence that postural management was beneficial. The committee also noted that in their experience postural management can cause notable discomfort so it is not an intervention without disadvantages.

Cost effectiveness and resource use

A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question.

The committee’s recommendations to offer external cephalic version reinforces current practice. The committee noted that, compared to no intervention, external cephalic version results in clinically important benefits and that there would also be overall downstream cost savings from lower adverse events. It was therefore the committee’s view that offering external cephalic version is cost effective and would not entail any resource impact.

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Appendices

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

No economic evidence was identified which was applicable to this review question.

Appendix H. Economic evidence tables

Economic evidence tables for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

No economic evidence was identified which was applicable to this review question.

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

No economic evidence was identified which was applicable to this review question.

Appendix J. Economic analysis

Economic evidence analysis for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded clinical and economic studies for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

Clinical studies

Table 24

Excluded studies.

Economic studies

No economic evidence was identified for this review.

Appendix L. Research recommendations

Research recommendations for review question: What is the most effective way of managing a longitudinal lie fetal malpresentation (breech presentation) in late pregnancy?

No research recommendations were made for this review question.

Final

Evidence reviews underpinning recommendation 1.2.38

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK573937PMID: 34524741

Table 1Summary of the protocol (PICO table)

Population	All pregnant women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36⁺⁰ weeks
Intervention	Cephalic version by the following listed interventions will be considered: Complementary therapy Acupressure Acupuncture Moxibustion Reflexology Note: complementary therapy interventions will be analysed separately. External cephalic version (ECV) ECV only ECV + additional component (for example, fetal acoustic stimulation, pharmacological [for example, beta-2 agonist, Ca²⁺ channel blocker, NSAID, oxytocin receptor anatagonist]) Postural management (for example, knee-chest, supine) Any combination of these interventions
Comparison	For all between-intervention comparisons: 1. Any listed intervention vs any other listed intervention 2. Any listed intervention vs control (including no treatment, placebo or sham treatment) 3. Any combination of listed interventions vs one of the interventions For postural management: 4. Specific form of postural management vs another form of postural management 5. Specific form of postural management vs daily walking 6. Specific form of postural management vs no treatment
Outcomes	Critical Cephalic presentation in labour Method of birth Breech vaginal birth Caesarean birth Cephalic vaginal birth Admission to SCBU/NICU Fetal death after 36⁺⁰ weeks gestation Infant death up to 4 weeks chronological age Important Apgar score <7 at 5 minutes Birth before 39⁺⁰ weeks of gestation

: ECV: external cephalic version; NICU: neonatal intensive care unit; NSAID: non-steroidal anti-inflammatory drug; SCBU: special care baby unit.

Table 2Summary of included studies

Study

Population

Intervention

Comparison

Outcomes

Andersen 2013

RCT

Denmark

N=407 pregnant women

Maternal mean age: 30.5 years

Mean maternal gestational age: 41 weeks (±0.7)

Acupuncture

Needles placed bilaterally for at least 30 minutes

Sweeping of fetal membrane

Performed by investigator

Acupuncture + sweeping

Control (no intervention)

Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Brocks 1984

RCT

Denmark

N=65 pregnant women

Maternal mean age: Not reported

Mean maternal gestational age: Not mentioned

ECV + Ritodrine

IV ritodrine, administered for 15 minutes

Control (no intervention)

Method of birth
Fetal death after 36⁺⁰ weeks gestation

Bujold 2003a

RCT

Canada

N=99 pregnant women

Maternal mean age: 29.5 years

Median maternal gestational age: 37.5 weeks (min 36.0, max 40.7)

ECV + Nitroglycerin

Two sublingual sprays of nitroglycerin (400 micrograms)

ECV + Placebo

Sublingual placebo spray

Cephalic presentation in labour
Method of birth

Bujold 2003b

RCT

Canada

N=74 pregnant women

Maternal mean age: 31.6 years

Median maternal gestational age: 37.4 (min 36.1, max 39.3)

ECV + Ritodrine

IV ritodrine (10mg/mL) plus sublingual placebo

ECV + Nitroglycerin

IV placebo plus sublingual nitroglycerin (400 micrograms)

Cephalic presentation in labour
Method of birth

Burgos 2016

RCT

Spain

N=120 pregnant women

Maternal mean age: 34.95 years

Mean maternal gestational age: 37 weeks

ECV + Remifentanil

Injectable solution or infusion of remifentanil (1mg vials)

Note: All ECVs were performed under tocolysis (either ritodrine 200μg/min for 30 minutes or 6.75mg atosiban, given as an IV bolus 2 min before procedure).

ECV + Nitrous oxide

Medicinal gas mixture of 50% nitrous oxide and 50% oxygen

Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Chalifoux 2017

RCT

N=240 pregnant women

Maternal mean age: Not reported

Median maternal gestational age: 37.3 weeks [IQR 37 to 38]

ECV + Bupivacaine 2.5mg + fentanyl 15 micrograms

ECV + Bupivacaine 5.0mg + fentanyl 15 micrograms

ECV + Bupivacaine 7.5mg + fentanyl 15 micrograms

ECV + Bupivacaine 10mg + fentanyl 15 micrograms

Method of birth

Chenia 1987

RCT

N=76 pregnant women

Maternal mean age: 26.1 years

Mean maternal gestational age: 38.4 weeks (±1.74)

Postural management

Knee-chest position for 15 minutes, three times a day, for 1 week

Control (no intervention)

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Collaris 2009

RCT

Malaysia

N=90 pregnant women

Maternal mean age: 30 years

Mean maternal gestational age: 38 weeks (±1.0)

ECV + Nifedipine

Nifedipine tablet (10mg) + placebo injection

ECV + Terbutaline

Placebo tablet + 0.5mL terbutaline injection (500 micrograms/mL)

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Dafallah 2004

RCT

Sudan

N=620 pregnant women

Maternal mean age: Not reported

Mean maternal gestational age: Not mentioned

ECV

Classic forward roll technique used, in slight Trendelenburg. Repeated up to 3 times at subsequent visits but not more than twice in one week.

Control (no intervention)

Cephalic presentation in labour
Method of birth
Fetal death after 36⁺⁰ weeks gestation

Diguisto 2018

RCT

France

N=199 pregnant women

Maternal mean age: 29.5 years

Median maternal gestational age: 37.1 weeks [IQR 36.1 to 37.8]

ECV + Amnioinfusion

Transabdominal amnioinfusion with saline solution (500mL)

ECV

Cephalic presentation in labour
Method of birth

Dugoff 1999

RCT

N=102 pregnant women

Maternal mean age: 25 years

Mean maternal gestational age: 38 weeks (±0.2)

ECV + Sufentanil

Sufentanil (10 micrograms)

0.25% bupivacaine (1mL) administered after lactated Ringer’s solution (500mL) + IV terbutaline (0.25mg)

ECV

Cephalic presentation in labour
Method of birth

El-Sayed 2004

RCT

N=59 pregnant women

Maternal mean age: 31.3 years

Mean maternal gestational age: 38.4 weeks (±0.8)

ECV + Nitroglycerin

IV nitroglycerin (200 micrograms)

ECV + Terbutaline

Subcutaneous terbutaline injection (0.25mg)

Method of birth

Fernandez 1997

RCT

N=103 pregnant women

Maternal mean age: 24 years

Mean maternal gestational age: 38.5 weeks (±1.6)

ECV + Terbutaline

Subcutaneous injection of terbutaline (0.25mg)

ECV + Placebo

Subcutaneous injection of placebo

Method of birth

Hilton 2009

RCT

Canada

Nulliparous women

N=82 pregnant women

Multiparous women

N=44 pregnant women

Maternal mean age: 29.5 and 31.5 years, respectively

Mean maternal gestational age:

Nulliparous

37 weeks (±5.0)

Multiparous

37 weeks (±4.0)

ECV + Nitroglycerin

IV nitroglycerin (100 micrograms/mL)

ECV + Placebo

IV saline (10mL)

Cephalic presentation in labour
Method of birth

Hindawi 2005

RCT

Jordan

N=192 pregnant women

Maternal mean age: 28 years

Mean maternal gestational age: 38 weeks (±2.0)

ECV + Ritodrine

Infusion of ritodrine (0.3mg/minute for 30 minutes)

Control (no intervention)

Cephalic presentation in labour
Method of birth
Fetal death after 36⁺⁰ weeks gestation

Hofmeyr 1983

RCT

South Africa

N=60 pregnant women

Maternal mean age: 24.8 years

Mean maternal gestational age: 37.6 weeks (±1.0)

ECV

ECV attempt initially without tocolysis.

If unsuccessful (7 cases), attempt repeated following hexoprenaline (10 micrograms) by slow IV injection.

Control (no intervention)

Cephalic presentation in labour
Method of birth
Fetal death after 36⁺⁰ weeks gestation
Apgar score <7 at 5 minutes

Impey 2005

RCT

N=124 pregnant women

Maternal mean age: 30.7 years

Mean maternal gestational age: 37.5 weeks (±0.83)

ECV + Ritodrine

17mL ritodrine hydrochloride (3mg/mL)

ECV + Placebo

Dextrose saline (17mL)

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Khaw 2015

RCT

Hong Kong

N=189 pregnant women

Maternal mean age: 32 years

Median maternal gestational age: 36.5 weeks (Range 36.1 to 39.6)

ECV + Bupivacaine

Hyperbaric bupivacaine 0.5% (1.8mL) + fentanyl (15 micrograms)

ECV + Remifentanil

IV remifentanil (0.1 micrograms/kg/mi nute)

ECV alone

Method of birth
Apgar score <7 at 5 minutes

Kok 2008

RCT

The Netherlands

N=320 pregnant women

Maternal mean age: 33.85 years

Mean maternal gestational age: 37 weeks (±6.1)

ECV + Nifedipine

Two nifedipine capsules (10mg)

ECV + Placebo

Two placebo capsules

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Fetal death after 36⁺⁰ weeks gestation
Apgar score <7 at 5 minutes

Liu 2016

RCT

China

N=152 pregnant women

Maternal mean age: 33.95 years

Mean maternal gestational age: 37 weeks

ECV + Remifentanil

Remifentanil (01 micrograms/kg/mi nute) 3 minutes before ECV

ECV + Placebo

Saline placebo

Method of birth

Mahomed 1991

RCT

Zimbabwe

N=208 pregnant women

Maternal mean age: 26.65 years

Mean maternal gestational age: 38 weeks (±1.0)

ECV + Hexoprenaline

IV hexaprenaline (Ipradol 10 micrograms) over 1 minute

Control (no intervention)

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Fetal death after 36⁺⁰ weeks gestation
Apgar score <7 at 5 minutes

Mancuso 2000

RCT

N=108 pregnant women

Maternal mean age: 28.3 years

Mean maternal gestational age: 38.0 weeks (±1.1)

ECV + Lidocaine + Epinephrine + Fentanyl

2% lidocaine epinephrine (3 mL) infused through lumbar epidural catheters.

ECV alone

Cephalic presentation in labour
Method of birth

Marquette 1996

RCT

Canada

N=283 pregnant women

Maternal mean age: 28.9 years

Mean maternal gestational age: 37.4 weeks (±0.08)

ECV + Ritodrine

IV ritodrine (111 micrograms/minute)

ECV + Placebo

Placebo saline

Method of birth

Mohamed Ismail 2008

RCT

Malaysia

N=86 pregnant women

Maternal mean age: 29.2 years

Mean maternal gestational age: 37.7 weeks (±0.6)

ECV + Nifedipine

Oral nifedipine (20mg)

ECV + Terbutaline

IV terbutaline (50 micrograms)

Method of birth
Admission to SCBU/NICU
Apgar score <7 at 5 minutes

Munoz 2014

RCT

Spain

N=63 pregnant women

Maternal mean age: 32.7 years

Mean maternal gestational age: Not mentioned

ECV + Remifentanil

100mL remifentanil (1mg) at 0.1 microgram/kg/min

ECV + Placebo

Placebo saline (100mL)

Method of birth

Nor Azlin 2005

RCT

Malaysia

N=60 pregnant women

Maternal mean age: 28 years

Mean maternal gestational age: Not mentioned

ECV + Ritodrine

IV ritodrine (0.4mg/mL)

ECV + Placebo

IV placebo saline

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU

Rita 2011

RCT

India

N=60 pregnant women

Maternal mean age: 27.2 years

Mean maternal gestational age: 38 weeks (±1.4)

ECV

Control (no intervention)

Method of birth
Admission to SCBU/NICU
Fetal death after 36⁺⁰ weeks gestation
Apgar score <7 at 5 minutes

Robertson 1987

RCT

N=58 pregnant women

Maternal mean age: 23 years

Mean maternal gestational age: 38.6 weeks (±0.2)

ECV + Ritodrine

IV ritodrine (200 micrograms/minute)

ECV alone

Method of birth

Schorr 1997

RCT

N=69 pregnant women

Maternal mean age: 26 years

Mean maternal gestational age: 37.7 weeks (±2.22)

ECV + Lidocaine + Epinephrine

2% lidocaine with epinephrine

ECV alone

Method of birth
Admission to SCBU/NICU

Smith 1999

RCT

Australia

N=100 pregnant women

Maternal mean age: 29 years

Mean maternal gestational age: 36.7 weeks (±0.6)

ECV + Postural management

Knee-chest position, for 15 minutes, three times a day, for one week

ECV alone

Method of birth
Apgar score <7 at 5 minutes

Sullivan 2009

RCT

N=96 pregnant women

Maternal mean age: 32.5 years

Median maternal gestational age: 37 weeks [IQR 37 to 38]

ECV + Bupivacaine + Fentanyl

Bupivacaine (2.5mg) + fentanyl (15 micrograms)

ECV + Fentanyl

IV fentanyl (50 micrograms)

Method of birth

Vallikkannu 2014

RCT

Malaysia

N=95 pregnant women

Maternal mean age: 30.3 years

Median maternal gestational age: 37.7 weeks [IQR 37.4 to 38.2]

ECV + Talcum powder

Subcutaneous terbutaline (250 micrograms) given 5-10 minutes prior to attempting ECV.

ECV + Gel

Subcutaneous terbutaline (250 micrograms) given 5-10 minutes prior to attempting ECV.

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU

Van Dorsten 1981

RCT

N=48 pregnant women

Maternal mean age: 25 years

Mean maternal gestational age: 37.7 weeks (±0.2)

ECV + Terbutaline

Terbutaline (5 micrograms/minut e) given 10-15 minutes before ECV

Control (no intervention)

Cephalic presentation in labour
Method of birth
Admission to SCBU/NICU
Fetal death after 36⁺⁰ weeks gestation
Apgar score <7 at 5 minutes

Vani 2009

RCT

Malaysia

N=144 pregnant women

Maternal mean age: 28.45 years

Mean maternal gestational age: 38 weeks (±0.65)

ECV + Salbutamol

IV salbutamol (0.1mg)

ECV + Placebo

Method of birth
Admission to SCBU/NICU

Wang 2017

RCT

China

N=144 pregnant women

Maternal mean age: 32.05 years

Mean maternal gestational age: 37 weeks

ECV + Remifentanil

Remifentanil (0.1 micrograms/kg/mi n) for 3 minutes

ECV + Placebo

Saline placebo

Method of birth
Fetal death after 36⁺⁰ weeks gestation

Weiniger 2010

RCT

Israel

N=65 pregnant women

Maternal mean age: 28.55 years

Mean maternal gestational age: 38.1 weeks (±1.0)

ECV + Bupivacaine

Bupivacaine (7.5mg)

ECV alone

Method of birth

: ECV: external cephalic version; IV: intravenous; NICU: neonatal intensive care unit; NSAID: non-steroidal anti-inflammatory drug; SCBU: special care baby unit.

Table 24Excluded studies

Study	Reason for exclusion
Ahmed, R. J., Gafni, A., Hutton, E. K., Early, E. C. V.Trial Collaborative Group, The Cost Implications in Ontario, Alberta, and British Columbia of Early Versus Delayed External Cephalic Version in the Early External Cephalic Version 2 (EECV2) Trial, Journal of Obstetrics & Gynaecology Canada: JOGCJ Obstet Gynaecol Can, 38, 235–245.e3, 2016 [PubMed: 27106193]	HE analysis.
Akhtar,N., Early versus late external cephalic version, Journal of Postgraduate Medical Institute, 27, 164–169, 2013	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36 0 weeks.
Albaladejo, M. I., Esquius, N. P., Trabado, C. R., Sabate, G. S., Marmol, R. U., Ventura, C. V., Brito, M. Z., Torres, M. D., Evaluation of the effectiveness of the moxibustion in non-cephalic presentations in pregnant women assisted in Primary Care, Matronas profesion, 18, 27–33, 2017	This study is not available in English.
American College of, Obstetricians, Gynecologists’ Committee on Practice, Bulletins-Obstetrics, Practice Bulletin No. 161 Summary: External Cephalic Version, Obstetrics & GynecologyObstet Gynecol, 127, 412–3, 2016 [PubMed: 26942380]	Duplicate.
Annapoorna,V., Arulkumaran,S., Anandakumar,C., Chua,S., Montan,S., Ratnam,S.S., External cephalic version at term with tocolysis and vibroacoustic stimulation, International Journal of Gynaecology and Obstetrics, 59, 13–18, 1997 [PubMed: 9359440]	Study design is a non-randomised trial.
Bolaji, I., Alabi-Isama, L., Central neuraxial blockade-assisted external cephalic version in reducing caesarean section rate: systematic review and meta-analysis, Obstetrics & Gynecology International, 2009, 718981, 2009 [PMC free article: PMC2798565] [PubMed: 20069044]	Systematic review for ECV anaesthesia. Relevant references examined and included if appropriate.
Bue, L., Lauszus, F. F., Moxibustion did not have an effect in a randomised clinical trial for version of breech position, Danish Medical JournalDan Med J, 63, 2016 [PubMed: 26836801]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
CardiniF, Weixin, H, Moxibustion for correction of breech presentation: a randomized controlled trial, JAMA, 280, 1580–4, 1998 [PubMed: 9820259]	Duplicate.
Cardini, F., Lombardo, P., Regalia, A. L., Regaldo, G., Zanini, A., Negri, M. G., Panepuccia, L., Todros, T., A randomised controlled trial of moxibustion for breech presentation, BJOG, 112, 743–747, 2005 [PubMed: 15924530]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Cardini, F., Weixin, H., Moxibustion for correction of breech presentation: a randomized controlled trial, JamaJama, 280, 1580–4, 1998 [PubMed: 9820259]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Carvalho, B., Tan, J. M., MacArio, A., El-Sayed, Y. Y., Sultan, P., A cost analysis of neuraxial anesthesia to facilitate external cephalic version for breech fetal presentation, Anesthesia and Analgesia, 117, 155–159, 2013 [PubMed: 23592608]	HE analysis.
Chi, Ctr Trc, External cephalic version for breech presentation: a randomised controlled trial of anaesthetic interventions, Http://www.who.int/trialsearch/trial2.aspx?Trialid=chictr-trc-12002644, 2012	No full text available.
Chung, T., Neale, E., Lau, T. K., Rogers, M., A randomized, double blind, controlled trial of tocolysis to assist external cephalic version in late pregnancy, Acta Obstet Gynecol ScandActa obstetricia et gynecologica Scandinavica, 75, 720–4, 1996 [PubMed: 8906005]	The study does not report any outcomes that match our protocol.
Couceiro Naveira, E., Lopez Ramon, Y.CajalC., Atosiban versus ritodrine as tocolytics in external cephalic version, Journal of Maternal-Fetal & Neonatal MedicineJ Matern Fetal Neonatal Med, 1–6, 2020 [PubMed: 31931641]	Study design is a non-randomised trial.
Coulon, C., Poleszczuk, M., Paty-Montaigne, M. H., Gascard, C., Gay, C., Houfflin-Debarge, V., Subtil, D., Version of breech fetuses by moxibustion with acupuncture: A randomized controlled trial, Obstetrics and Gynecology, 124, 32–39, 2014 [PubMed: 24901279]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Coyle,M.E., Smith,C.A., Peat,B., Cephalic version by moxibustion for breech presentation, Cochrane database of systematic reviews (Online), 5, CD003928-, 2012 [PubMed: 22592693]	Systematic review for moxibustion. Relevant references examined and included if appropriate.
Delisle, Marie-France, Kamani, Allaudin, Douglas, Joanne, Bebbington, Michael, 124 Antepartum external cephalic version under spinal anesthesia: A randomized controlled trial, American Journal of Obstetrics & Gynecology, 185, S115, 2001	No full text article available.
Do, C. K., Smith, C. A., Dahlen, H., Bisits, A., Schmied, V., Moxibustion for cephalic version: A feasibility randomised controlled trial, BMC Complementary and Alternative Medicine, 11, 81, 2011 [PMC free article: PMC3192686] [PubMed: 21943180]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Do, C., Smith, C., Dahlen, H., Bissets, A., Schmeid, V., Moxibustion for cephalic version: A feasibility study, Journal of Paediatrics and Child Health, 47, 37, 2011	Duplicate.
Dochez, V., Esbelin, J., Volteau, C., Winer, N., Efficiency of nitrous oxide in external cephalic version on success rate: A randomised controlled trial, BJOG: An International Journal of Obstetrics and Gynaecology, 124 (Supplement 1), 111, 2017	No full text available.
Founds, S. A., Clinical implications from an exploratory study of postural management of breech presentation, Journal of midwifery & women’s health, 51, 292–296, 2006 [PMC free article: PMC3628770] [PubMed: 16814225]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Garcia-Mochon, L., Martin, J. J., Aranda-Regules, J. M., Rivas-Ruiz, F., Vas, J., Cost effectiveness of using moxibustion to correct non-vertex presentation, Acupuncture in Medicine, 33, 136–41, 2015 [PubMed: 25669428]	HE analysis.
Guittier,M.J., Klein,T.J., Dong,H., Andreoli,N., Irion,O., Boulvain,M., Side-effects of moxibustion for cephalic version of breech presentation, Journal of Alternative and Complementary Medicine, 14, 1231–1233, 2008 [PubMed: 19040374]	This article reports on an unfinished trial.
Guittier,M.J., Pichon,M., Dong,H., Irion,O., Boulvain,M., Moxibustion for breech version: a randomized controlled trial, Obstetrics and Gynecology, 114, 1034–1040, 2009 [PubMed: 20168104]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Hofmeyr, G. J., Kulier, R., Cephalic version by postural management for breech presentation, Cochrane Database of Systematic Reviews, 10, CD000051, 2012 [PMC free article: PMC7052740] [PubMed: 23076882]	Cochrane review on postural management. Relevant references examined and included if appropriate.
Hofmeyr, G. J., Kulier, R., West, H. M., External cephalic version for breech presentation at term, Cochrane Database of Systematic Reviews, 2016, CD000083, 2015 [PMC free article: PMC6505738] [PubMed: 25828903]	Cochrane review on ECV. Relevant references examined and included if appropriate.
Hofmeyr, GJ, External cephalic version facilitation for breech presentation at term, Cochrane Database of Systematic Reviews, 2, 2001 [PubMed: 11687071]	Relevant references extracted and added to review.
Hofmeyr, GJ, External cephalic version for breech presentation before term, Cochrane Database of Systematic Reviews, 2, 2001 [PubMed: 10796123]	Relevant references extracted and included in review.
Hofmeyr, GJ, Interventions to help external cephalic version for breech presentation at term, Cochrane Database of Systematic Reviews, 4, 2002 [PubMed: 12076384]	Relevant references extracted and included in review.
Hofmeyr, GJ, Kulier, R, Cephalic version by postural management for breech presentation, Cochrane Database of Systematic Reviews, 1, 2003 [PubMed: 10796105]	Relevant references extracted and included in review.
Hunter, S., Hofmeyr, G. J., Kulier, R., Hands and knees posture in late pregnancy or labour for fetal malposition (lateral or posterior), Cochrane Database of Systematic Reviews, CD001063, 2007 [PMC free article: PMC8407052] [PubMed: 17943750]	Cochrane review for postural management. Relevant references examined and included if appropriate.
Hutton, E. K., Hannah, M. E., Ross, S. J., Delisle, M. F., Carson, G. D., Windrim, R., Ohlsson, A., Willan, A. R., Gafni, A., Sylvestre, G., Natale, R., Barrett, Y., Pollard, J. K., Dunn, M. S., Turtle, P., Early, E. C. V.Trial Collaborative Group, 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 & GynaecologyBjog, 118, 564–77, 2011 [PMC free article: PMC3085121] [PubMed: 21291506]	Duplicate.
Hutton, E. K., Hannah, M. E., Ross, S. J., Delisle, M. F., Carson, G. D., Windrim, R., Ohlsson, A., Willan, A. R., Gafni, A., Sylvestre, G., Natale, R., Barrett, Y., Pollard, J. K., Dunn, M. S., Turtle, P., The early external cephalic version 2 trial: An international multicenter randomized controlled trial of timing of external cephalic version for breech pregnancies, Obstetrical and Gynecological Survey, 66, 469–470, 2011	No full text available.
Hutton, E. K., Hofmeyr, G. J., Dowswell, T., External cephalic version for breech presentation before term, Cochrane Database of Systematic Reviews, 2015 [PMC free article: PMC9188447] [PubMed: 26222245]	Cochrane review on ECV. Relevant references examined and included if appropriate.
Johnson,R.L., Elliott,J.P., Fetal acoustic stimulation, an adjunct to external cephalic version: a blinded, randomized crossover study, American Journal of Obstetrics and Gynecology, 173, 1369–1372, 1995 [PubMed: 7503169]	This study does not focus on breech presentation and instead focuses on fetal mid-line spine position.
Jorge, V., Manuel, A. R. J., Manuela, M., Mercedes, B., Nicolas, B. P., Francisco, R. R., Moxibustion applied at home for non-vertex presentation: A multicentre randomised controlled clinical trial, European Journal of Integrative Medicine, 4, 47, 2012	No full text available.
Jprn, Umin, Utility of acupuncture and moxibustion for repositioning breech presentation. -Randomized Controlled Trial, Http://www.who.int/trialsearch/trial2.aspx?Trialid=jprn-umin000011757, 2013	No full text available.
Kim, S. Y., Chae, Y., Lee, S. M., Lee, H., Park, H. J., The effectiveness of moxibustion: an overview during 10 years, Evidence-Based Complementary & Alternative Medicine: eCAMEvid Based Complement Alternat Med, 2011, 306515, 2011 [PMC free article: PMC3136359] [PubMed: 19825873]	Systematic review on moxibustion. Relevant references examined and included if appropriate.
Langer, B. P., Roth, G. E., Aissi, G., Meyer, N., Bigler, A., Bouschbacher, J. M., Hemlinger, C., Viville, B., Guilpain, M., Gaudineau, A., Akladios, C., Nisand, I., Vayssiere, C., Favre, R., Sananes, N., Acupuncture version of breech presentation: A randomized placebo-controlled single-blinded trial, American Journal of Obstetrics and Gynecology, 214, S65, 2016	No full text available.
Lee, M. S., Are acupuncture-type interventions beneficial for correcting breech presentation?, Complementary Therapies in Medicine, 16, 238–9, 2008 [PubMed: 18638715]	The study does not use RCT study design.
Lee, M. S., Kang, J. W., Ernst, E., Does moxibustion work? An overview of systematic reviews, BMC Research NotesBMC Res Notes, 3, 284, 2010 [PMC free article: PMC2987875] [PubMed: 21054851]	Systematic review on moxibustion. Relevant references examined and included if appropriate.
Li, Q, Clinical observation on correcting malposition of fetus by electro-acupuncture, Journal of Traditional Chinese Medicine, 16, 260–2, 1996 [PubMed: 9389098]	Duplicate.
Li, Q., Wang, L., Clinical observation on correcting malposition of fetus by electro-acupuncture, J Tradit Chin MedJournal of traditional Chinese medicine = Chung i tsa chih ying wen pan, 16, 260–2, 1996 [PubMed: 9389098]	Included in CG62 but is not a RCT-observational study of women with malpresentation at 28 gestational weeks and more.
Li, X., Hu, J., Wang, X., Zhang, H., Liu, J., Moxibustion and other acupuncture point stimulation methods to treat breech presentation: A systematic review of clinical trials, Chinese Medicine, 4 (no pagination), 2009 [PMC free article: PMC2663768] [PubMed: 19245719]	Systematic review on moxibustion. Relevant references examined and included if appropriate.
Liu, M. L., Lan, L., Tang, Y., Liang, F. R., Acupuncture and moxibustion for breech presentation: a systematic review, Chinese journal of evidence-based medicine, 9, 840–843, 2009	This study is not available in English.
Magro-Malosso, E. R., Saccone, G., Di Tommaso, M., Mele, M., Berghella, V., Neuraxial analgesia to increase the success rate of external cephalic version: a systematic review and meta-analysis of randomized controlled trials, American Journal of Obstetrics & Gynecology, 215, 276–86, 2016 [PubMed: 27131581]	Systematic review for ECV anaesthesia. Relevant references examined and included if appropriate.
Massalha, M., Garmi, G., Zafran, N., Carmeli, J., Gimburg, G., Salim, R., Clinical outcomes after external cephalic version with spinal anesthesia after failure of a first attempt without anesthesia, International Journal of Gynecology and Obstetrics, 139, 324–328, 2017 [PubMed: 28842977]	The study does not use RCT study design.
Millereau, M., Branger, B., Darcel, F., Fetal version by acupuncture (moxibustion) versus control group, Journal de Gynecologie, Obstetrique et Biologie de la Reproduction, 38, 481–487, 2009 [PubMed: 19500919]	Study is not written in English.
Morris, S., Geraghty, S., Sundin, D., Moxibustion: An alternative option for breech presentation, British Journal of Midwifery, 26, 440–445, 2018	The study does not use RCT study design.
Muslim, I., Tan, I., Rodriguez, P., Tan, T. L., Cost effectiveness of external cephalic version, BJOG: An International Journal of Obstetrics and Gynaecology, 119, 121, 2012	HE analysis.
Neri, I., De Pace, V., Venturini, P., Facchinetti, F., Effects of three different stimulations (acupuncture, moxibustion, acupuncture plus moxibustion) of BL.67 acupoint at small toe on fetal behavior of breech presentation, American Journal of Chinese Medicine, 35, 27–33, 2007 [PubMed: 17265548]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Nor AzlinMI, MaryasalwatiI, NorzilalwatiMN, ZalehaAM, MohammadAJ, ZainulRMR, Nifedipine versusterbutaline for tocolysis in external cephalic version, International Journal of Gynecology & Obstetrics, 102, 263–266, 2008 [PubMed: 18554601]	Duplicate.
Nor Azlin,, M. I., Ibrahim, M., Mohd Naim, N., Mahdy, Z. A., Jamil, M. A., Mohd Razi, Z. R., Nifedipine versus terbutaline for tocolysis in external cephalic version, Int J Gynaecol ObstetInternational journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 102, 263–6, 2008 [PubMed: 18554601]	Duplicate.
O’Brien, J. A., Adashi, E. Y., Coming out ahead: the cost effectiveness of external cephalic version using spinal anesthesia, Israel Journal of Health Policy ResearchIsr J Health Policy Res, 3, 6, 2014 [PMC free article: PMC3936830] [PubMed: 24565024]	HE analysis.
Paraiso Torras, B., Rodriguez Martin, N., Lazaro Carrasco Delgado, C., Jimenez Fournier, M. C., Canete Palomo, M. L., Economic impact of the introduction of the cephalic external version in a tertiary Hospital, Journal of Perinatal Medicine, 43, 2015	HE analysis.
Predanic,M., External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial, Obstetrics and Gynecology, 111, 776–777, 2008 [PubMed: 18310385]	The study does not use RCT study design.
Preston, R., Jee, R., Anesthesia-facilitated external cephalic version: pennywise or pound-foolish?, Canadian Journal of AnaesthesiaCan J Anaesth, 60, 6–13, 2013 [PubMed: 23224669]	Systematic review for ECV anaesthesia. Relevant references examined and included if appropriate.
Reinhard, J., Peiffer, S., Reichenbach, L., Tottel, E., Reitter, A., Sinanovic, B., Yuan, J., Louwen, F., The effects of clinical hypnosis versus Neuro-Linguistic Programming (NLP) before External Cephalic Version (ECV)-A prospective off-centre randomised double blind controlled trial, Archives of Gynecology and Obstetrics, 1), S213–S214, 2012 [PMC free article: PMC3388481] [PubMed: 22778774]	No full text available.
Reinhard, J., Peiffer, S., Sanger, N., Herrmann, E., Yuan, J., Louwen, F., The Effects of Clinical Hypnosis versus Neurolinguistic Programming (NLP) before External Cephalic Version (ECV): A Prospective Off-Centre Randomised, Double-Blind, Controlled Trial, Evidence-Based Complementary & Alternative Medicine: eCAMEvid Based Complement Alternat Med, 2012, 626740, 2012 [PMC free article: PMC3388481] [PubMed: 22778774]	Duplicate.
Rosim, R. P., Carmo, E. V., Cost-effectiveness of breech version by moxibustion associated with acupuncture for women at 33 weeks gestation: A modeling approach by the brazilian public health care system perspective, Value in Health, 20, A924, 2017	HE analysis.
Rosman, Ageeth, Vlemmix, Floortje, Fleuren, Margot, Rijnders, Marlies, Beuckens, Antje, Opmeer, Brent, Hardeman, Rob, Kok, Olga, Mol, Ben Willem, Kok, Marjolein, Implementation of external cephalic version: A multicentre cluster randomised controlled trial, Women & Birth, 26, S16–S16, 2013	No full text available.
Sananes, N., Roth, G. E., Aissi, G. A., Meyer, N., Bigler, A., Bouschbacher, J. M., Helmlinger, C., Viville, B., Guilpain, M., Gaudineau, A., Akladios, C. Y., Nisand, I., Langer, B., Vayssiere, C., Favre, R., Acupuncture version of breech presentation: a randomized sham-controlled single-blinded trial, European Journal of Obstetrics, Gynecology, & Reproductive BiologyEur J Obstet Gynecol Reprod Biol, 204, 24–30, 2016 [PubMed: 27521594]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Sloos, J. H., [The value of external version in at-term breech presentation], Ned Tijdschr GeneeskdNederlands tijdschrift voor geneeskunde, 135, 241–2, 1991 [PubMed: 2005990]	Not available in English.
Smith, C. A., Cochrane, S., Does acupuncture have a place as an adjunct treatment during pregnancy? A review of randomized controlled trials and systematic reviews, Birth, 36, 246–253, 2009 [PubMed: 19747272]	Systematic review on acupuncture. Relevant references examined and included if appropriate.
Sonia, B., Alessandro, B., Sylvie, B., Enrica, B., Filippa, T., Antonella, T., Federica, S., Catia, V., Valeria, M. M., Breech presentation of the foetus and traditional Chinese medicine, European Journal of Integrative Medicine, 4, 56, 2012	No full text available.
Stock, A., Chung, T., Rogers, M., Ming, W. W., Randomized, double blind, placebo controlled comparison of ritodrine and hexoprenaline for tocolysis prior to external cephalic version at term, Aust N Z J Obstet GynaecolThe Australian & New Zealand journal of obstetrics & gynaecology, 33, 265–8, 1993 [PubMed: 8304889]	The study does not report any outcomes that match our protocol.
Sullivan, J. T., Scavone, B. M., Patel, R., Robles, C., McCarthy, R. J., Wong, C. A., A randomized controlled trial of the impact of combined spinal-epidural analgesia on the success of external cephalic version for breech presentation, Anesthesiology, 104, 10, 2006 [PubMed: 19682886]	Duplicate.
Sultan, P., Carvalho, B., Neuraxial blockade for external cephalic version: a systematic review, International Journal of Obstetric Anesthesia, 20, 299–306, 2011 [PubMed: 21925869]	Systematic review for ECV anaesthesia. Relevant references examined and included if appropriate.
Tan,J.M., Macario,A., Carvalho,B., Druzin,M.L., El-Sayed,Y.Y., Cost-effectiveness of external cephalic version for term breech presentation, BMC Pregnancy and Childbirth, 10, 3-, 2010 [PMC free article: PMC2826287] [PubMed: 20092630]	HE analysis.
van den Berg, I., Bosch, J. L., Jacobs, B., Bouman, I., Duvekot, J. J., Hunink, M. G., Effectiveness of acupuncture-type interventions versus expectant management to correct breech presentation: a systematic review, Complementary Therapies in Medicine, 16, 92–100, 2008 [PubMed: 18514911]	Systematic review on acupuncture. Relevant references examined and included if appropriate.
van den Berg, I., Kaandorp, G. C., Bosch, J. L., Duvekot, J. J., Arends, L. R., Hunink, M. G., Cost-effectiveness of breech version by acupuncture-type interventions on BL 67, including moxibustion, for women with a breech foetus at 33 weeks gestation: a modelling approach, Complementary Therapies in Medicine, 18, 67–77, 2010 [PubMed: 20430289]	HE analysis.
van den Berg, I., Kaandorp, G., Bosch, J. L., Duvekot, J. J., Hunink, M. G. M., The effectiveness and cost-effectiveness of Breech Version Acumoxa compared to standard care to correct breech presentation…13th Annual Symposium on Complementary Health Care, 12th-14th December, 2006, University of Exeter, UK, Focus on Alternative & Complementary Therapies, 11, 5–5, 2006	HE analysis.
van Loon, AJ, Mantingh, A, Serlier, EK, Kroon, G, Mooyaart, EL, Huisjes, HJ, Randomised controlled trial of magnetic-resonance pelvimetry in breech presentation at term, Lancet, 350, 1799–804, 1997 [PubMed: 9428250]	This study does not focus on interventions for breech management but rather on breech identification.
Vas, J., Aranda-Regules, J. M., Modesto, M., Ramos-Monserrat, M., Baron, M., Aguilar, I., Benitez-Parejo, N., Ramirez-Carmona, C., Rivas-Ruiz, F., Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial, Acupuncture in Medicine, 31, 31–8, 2013 [PubMed: 23249535]	Population did not include women with a longitudinal lie fetal malpresentation (breech presentation) confirmed by ultrasound scan at ≥36+0 weeks.
Vas, J., Aranda-Regules, J. M., Modesto, M., Ramos-Monserrat, M., Baron, M., Aguilar, I., Benitez-Parejo, N., Ramirez-Carmona, C., Rivas-Ruiz, F., Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial, Revista Internacional de Acupuntura, 8, 41–49, 2014	Duplicate.
Vas, J., Aranda-Regules, J. M., Modesto, M., Ramos-Monserrat, M., Barón, M., Aguilar, I., Benítez-Parejo, N., Ramírez-Carmona, C., Rivas-Ruiz, F., Using moxibustion in primary healthcare to correct non-vertex presentation: a multicentre randomised controlled trial, Acupuncture in Medicine, 31, 31–38, 2013 [PubMed: 23249535]	Duplicate.
Vas,J., Aranda,J.M., Nishishinya,B., Mendez,C., Martin,M.A., Pons,J., Liu,J.P., Wang,C.Y., Perea-Milla,E., Correction of nonvertex presentation with moxibustion: a systematic review and metaanalysis, American Journal of Obstetrics and Gynecology, #201, 241–259, 2009 [PubMed: 19733275]	Systematic review on moxibustion. Relevant references examined and included if appropriate.
Velzel, J., Vlemmix, F., Opmeer, B. C., Mol, B. W., Kok, M., Atosiban versus fenoterol as a uterine relaxant for external cephalic version: A randomized controlled trial, Journal of Paediatrics and Child Health, 51, 53, 2015 [PMC free article: PMC5421458] [PubMed: 28126898]	No full text available.
Velzel, J., Vlemmix, F., Opmeer, B. C., Molkenboer, J. F., Verhoeven, C. J., van Pampus, M. G., Papatsonis, D. N., Bais, J. M., Vollebregt, K. C., van der Esch, L., Van der Post, J. A., Mol, B. W., Kok, M., Atosiban versus fenoterol as a uterine relaxant for external cephalic version: randomised controlled trial, BMJ, 356, i6773, 2017 [PMC free article: PMC5421458] [PubMed: 28126898]	Duplicate.
Vlemmix, F., Rosman, A., Fleuren, M., Rijnders, M., Beuckens, A., Opmeer, B., Hardeman, R., Dirken, J., De Vaan, M., Kok, O., Bazairi, M., Cikot, R., Renes, C., Mol, B., Kok, M., Implementation of external cephalic version; A multicentre cluster randomised controlled trial, American Journal of Obstetrics and Gynecology, 208, S320, 2013	No full text available.
Weiniger, C. F., Ginosaur, Y., Elchalal, U., Einav, S., Nucrietin, M., Guage, P., Ezra, Y., Prospective randomised study of external cephalic version for breech presentation at term in nulliparous women: spinal analgesia versus no analgesia, International Journal of Obstetric Anesthesia, 16, S21, 2007	Duplicate.
Weiniger,C.F., Ginosar,Y., Elchalal,U., Sharon,E., Nokrian,M., Ezra,Y., External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial, Obstetrics and Gynecology, 110, 1343–1350, 2007 [PubMed: 18055730]	The study does not report any outcomes that match our protocol.
Weomoger, C. F., Ginosar, Y., Elchalal, U., Sharon, E., Nokrian, M., Ezra, Y., External cephalix version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial, Obstetrics & GynecologyObstet Gynecol, 110, 1343–1350, 2007 [PubMed: 18055730]	Duplicate.
Wilcox, C. B., Nassar, N., Roberts, C. L., Effectiveness of nifedipine tocolysis to facilitate external cephalic version: A systematic review, BJOG: An International Journal of Obstetrics and Gynaecology, 118, 423–428, 2011 [PubMed: 21199292]	Systematic review on ECV pharmaceutical component. Relevant references examined and included if appropriate.
Y. K.Yang, M.Mao, Y. P.Huet al, Effect of moxibustion at zhiyin (BL67) to correct the fetus malposition: multi-center randomized controlled clinical study, Journal of Traditional Chinese Medicine, 48, 1097–1110, 2007	Not available in English.
Yamasato, K., Kaneshiro, B., Salcedo, J., Neuraxial blockade for external cephalic version: Cost analysis, Journal of Obstetrics & Gynaecology Research, 41, 1023–31, 2015 [PMC free article: PMC5637526] [PubMed: 25771920]	HE analysis.
YangYK, MaoM, HuYP, et al., Effect of moxibustion at zhiyin (BL67) to correct the fetus malposition: multi-center randomized controlled clinical study, Journal of traditional Chinese medicine, 48, 1097–1110, 2007	Duplicate.
Yang, F., Comparison of knee-chest plus moxibustion on Zhiyin with knee-chest position for breech position, Journal of sichuan traditional chinese medicine, 24, 106–107, 2006	Not written in English.
Zhang,Q.H., Yue,J.H., Liu,M., Sun,Z.R., Sun,Q., Han,C., Wang,D., Moxibustion for the correction of nonvertex presentation: A systematic review and meta-analysis of randomized controlled trials, Evidence-based Complementary and Alternative Medicine, 2013, 2013. Article Number, -, 2013 [PMC free article: PMC3789399] [PubMed: 24159341]	Systematic review on moxibustion. Relevant references examined and included if appropriate.

Management of breech presentation

Authors

Management of breech presentation

Review question

Introduction

Summary of the protocol

Table 1

Methods and process

Clinical evidence

Included studies

Excluded studies

Summary of clinical studies included in the evidence review

Table 2

Quality assessment of clinical outcomes included in the evidence review

Economic evidence

Included studies

Excluded studies

Summary of studies included in the economic evidence review

Economic model

Evidence statements

Clinical evidence statements

Comparison 1. Complementary therapy versus control (no intervention)

Critical outcomes

Cephalic presentation in labour

Method of birth

Caesarean section

Admission to SCBU/NICU

Fetal death after 36+0 weeks gestation

Infant death up to 4 weeks chronological age

Important outcomes

Apgar score <7 at 5 minutes

Birth before 39+0 weeks of gestation

Comparison 2. Complementary therapy versus Other treatment

Critical outcomes

Cephalic presentation in labour

Method of birth

Caesarean section

Admission to SCBU/NICU

Fetal death after 36+0 weeks gestation

Infant death up to 4 weeks chronological age

Important outcomes

Apgar score <7 at 5 minutes

Birth before 39+0 weeks of gestation

Comparison 3. ECV versus no ECV

Critical outcomes

Cephalic presentation in labour

Method of birth

Cephalic vaginal birth

Breech vaginal birth

Caesarean section

Admission to SCBU/NICU

Fetal death after 36+0 weeks gestation

Infant death up to 4 weeks chronological age

Important outcomes

Apgar score <7 at 5 minutes

Birth before 39+0 weeks of gestation

Comparison 4. ECV + Amnioinfusion versus ECV only

Critical outcomes

Cephalic presentation in labour

Method of birth

Caesarean section

Critical outcomes

Admission to SCBU/NICU

Fetal death after 36+0 weeks gestation

Infant death up to 4 weeks chronological age

Important outcomes

Apgar score <7 at 5 minutes

Birth before 39+0 weeks of gestation

Comparison 5. ECV + Anaesthesia versus ECV only

Critical outcomes

Cephalic presentation in labour

Method of birth

Cephalic vaginal birth

Breech vaginal birth

Caesarean section

Admission to SCBU/NICU

Fetal death after 36+0 weeks gestation

Infant death up to 4 weeks chronological age

Important outcomes

Apgar score <7 at 5 minutes

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation

Comparison 10. ECV + Ca²⁺ channel blocker versus ECV + Placebo

Fetal death after 36⁺⁰ weeks gestation

Birth before 39⁺⁰ weeks of gestation