- Design
- Systematic review and meta-analysis of 10 randomised trials
- Population
- 2,745 women with breech presentation undergoing external cephalic version
- Primary outcome
- Successful version
- Effect
- RR 1.53 (1.15–2.04), I² 87%; tocolysis RR 2.39 (1.39–4.11)
A systematic review pooled ten randomised trials (2,745 women with breech presentation) testing adjuncts to external cephalic version: tocolysis, neuraxial anaesthesia or analgesia, systemic analgesia and procedural protocols.
Overall, adjuncts were associated with more successful versions (RR 1.53, 95% CI 1.15 to 2.04), but heterogeneity was very high (I² = 87%). Tocolysis showed 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 changes alone did not help. Caesarean delivery fell, but not significantly (RR 0.88, 0.76 to 1.02). Serious complications were uncommon.
Tocolysis with a beta-agonist is already standard in many units; this supports offering it routinely and considering neuraxial block, particularly after a failed first attempt. The missing piece is the outcome women care about: fewer caesareans was not shown.
- Offer tocolysis with external cephalic version unless contraindicated.
- Consider neuraxial anaesthesia, especially for a repeat attempt after failure.
- Counsel that a successful version does not guarantee a vaginal birth.
- Keep version in a setting with continuous monitoring and access to theatre.
Why it matters
A version that turns the baby is only worth the effort if adjuncts make success likely enough to offer it confidently.
Don't overread it
Caesarean rates did not fall significantly, and the pooled effect hides very different trials.
The statistics, in plain English
A risk ratio of 2.39 for tocolysis means success was more than twice as likely with it. I² of 87% means most of the variation between trials reflects real differences in drugs, settings and technique rather than chance, so the single pooled number is a rough average. The caesarean interval runs from a 24% reduction to a 2% increase, so no effect cannot be excluded.
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