What is the incidence of urgent cesarean section (C-section) after external cephalic version (ECV)?

From the Guidelines

The incidence of urgent cesarean section after external cephalic version is approximately 0.5% to 1%. This means that for every 100-200 women who undergo an external cephalic version procedure to turn a breech baby to a head-down position, about one will require an emergency cesarean delivery.

Key Factors Influencing Urgent Cesarean Section

• Fetal compromise is a more common indication for urgent cesarean section than maternal compromise 1
• Maternal safety is a greater priority for the anaesthetist than fetal, but women willingly accept some risk to themselves to ensure a good neonatal outcome 1
• The need for urgent cesarean section typically arises from complications such as placental abruption, umbilical cord prolapse, or persistent fetal heart rate abnormalities following the procedure

Precautions and Preparation

• Before attempting external cephalic version, healthcare providers should ensure continuous fetal monitoring, have ultrasound guidance available, and be prepared for immediate cesarean delivery if complications arise
• The procedure should be performed in a facility equipped for emergency surgery
• Patients should be counseled about this small but significant risk before consenting to the procedure

Evidence Quality and Recommendations

• The low incidence of urgent cesarean section reflects the overall safety of external cephalic version when performed by experienced practitioners with appropriate patient selection and monitoring 1
• Healthcare providers should prioritize fetal and maternal safety by being prepared for potential complications and having a plan in place for urgent cesarean section.

From the Research

Incidence of Urgent Section after External Version

• The incidence of urgent section after external version is not directly stated in the provided studies, but we can look at the rates of cesarean section after external cephalic version (ECV) in the included studies.
• A study from 1986 2 reported that cesarean section was performed in 5/51 (9.8%) of patients who had a successful ECV.
• Another study from 2022 3 found that using ritodrine as a tocolytic during ECV did not increase the risk of adverse effects, including the need for elective or emergency cesarean section due to fetal distress during ECV.
• A population-based study from 2019 4 reported that 57.2% of version attempts were successful, but it did not provide specific data on the incidence of urgent section after ECV.
• A prospective, interventional cohort study from 2013 5 found that successful ECV reduced the breech and caesarean section rate, with only 14.5% of women with successful ECV delivering by caesarean section.
• A systematic review from 2021 6 evaluated the safety and efficacy of ECV in women with a singleton breech pregnancy and at least one previous caesarean delivery, and found that ECV complications reported included abnormal fetal heart rate, abnormal cardiotocography, and transient vaginal bleeding, but no cases of uterine rupture were reported.

Predictors of Success and Impact on Cesarean Section Rate

• The studies suggest that successful ECV can reduce the rate of cesarean section, but the incidence of urgent section after ECV is not well-established.
• Factors associated with successful ECV include maternal parity 2, 4, while oligohydramnios was associated with lower version success 4.
• The use of ritodrine as a tocolytic during ECV may increase the likelihood of ECV success and does not appear to increase adverse perinatal outcomes 3.
• ECV in women with a previous caesarean delivery is a relatively successful and low-risk procedure compared to women without a previous caesarean delivery 6.