Tocolysis and neuraxial block were linked to more successful version

Design

Systematic review and meta-analysis of 10 randomised trials

Population

2,745 women with breech presentation undergoing ECV

Primary outcome

Successful ECV

Effect

RR 1.53 (95% CI 1.15–2.04), I² 87%; tocolysis RR 2.39 (1.39–4.11)

A systematic review pooled ten randomised trials of 2,745 women with breech presentation, comparing adjuncts to external cephalic version (ECV) with standard care or placebo. Adjuncts as a group were associated with higher success (RR 1.53, 95% CI 1.15 to 2.04), but heterogeneity was very high (I² = 87%).

By type, pharmacological tocolysis had the largest effect (RR 2.39, 1.39 to 4.11), then neuraxial anaesthesia (RR 1.75, 1.07 to 2.85) and systemic analgesia (RR 1.39, 1.15 to 1.69). Protocol or timing changes did not significantly improve success. Caesarean delivery was not significantly reduced (RR 0.88, 0.76 to 1.02), and serious complications were uncommon.

The practical reading is that a version attempt is more likely to succeed with uterine relaxation on board, and that a neuraxial block is a reasonable option where it is available and the woman wants it. The caesarean result is the one that matters most to women and it remains uncertain.

• Offer ECV from 36–37 weeks to suitable women with an uncomplicated breech pregnancy.
• Consider a tocolytic before the attempt, in line with your unit protocol and contraindications.
• Discuss neuraxial anaesthesia where the service can provide it, especially after a failed first attempt.
• Tell women that success becomes more likely with these adjuncts, but a lower caesarean rate is not yet shown.
• Monitor the fetal heart before and after every attempt, and give anti-D where the woman is RhD negative.

Why it matters

Version success is not fixed — what you give beforehand changes the odds.

Don't overread it

Higher version success did not translate into a significantly lower caesarean rate in this pooled analysis.

The statistics, in plain English

An RR of 2.39 means success was more than twice as likely with tocolysis. The I² of 87% means the trials disagreed a great deal on the size of the effect, so the pooled number is an average over quite different settings. The caesarean interval runs from 0.76 to 1.02 — it crosses 1.0, so no reduction is established.

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