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Experiences with High Success Rate of External Cephalic Version And Experiences with High Success Rate of External Cephalic Version and Comparisons of Different Tocolysis for Risk-effective version based on a bayesian network meta-analysis Xiao Yunyun Dalian Hospital of Obstetrics and Gynaecology https://orcid.org/0000-0002-3824-3716 Ma Si Yu Dalian Hospital of Obstetrics and Gynaecology Li Jing Dalian Hospital of Obstetrics and Gynaecology Zhao Wei Dalian Hospital of Obstetrics and Gynaecology Dong Yan ( [email protected] ) Dalian Obstetrics and Gynecology Hospital Aliated to Dalian Medical University & Dalian Maternal and Child Health Care Hospital https://orcid.org/0000-0002-7358-7899 Research article Keywords: Breech, External cephalic version, Tocolysis, Network meta-analysis Posted Date: July 27th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-39838/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/20 Abstract Background: External cephalic version (ECV) has been proved effectively in reducing the cesarean section rates, but the success rates of the procedure are uneven. Experiences of ECV with high success rate were concluded in this paper. And in order to evaluate the eciency of the applied tocolytic agents, a corresponding bayesian-network meta-analysis was conducted. Methods: Through retrospective analysis of eighty-four single pregnant women with breech presentation near or at term who received ECV from Dalian Maternal and Child Health Care Hospital from April 2017 to November 2019, inuence factors associated with the success rate of ECV were analyzed. Meanwhile, a bayesian-network meta-analysis including sixteen eligible randomized controlled trials (RCTs) about comparisons of ve common tololytic agents and placebo with 3468 participants searched from Pubmed, Cochrane library and Embase databases until May 20, 2019 was conducted to identify the eciency of ritodrine and terbutaline applied in the authors’ procedures. Results: The ECV procedures were conducted by a skilled obstetrician through strict selection of the candidates. Oral ritodrine, intravenous terbutaline in combination with epidual analgesia were applied as interventions. Success rate of ECV reached 90.48% (76/84) and the overall vaginal delivery rate is up to 88.16% (67/76). Only one patient reverted to breech presentation due to loose of the bellyband. Among the possible variables, amniotic uid index were identied to have signicantly relationship with the success rate of ECV. As the bayesian network meta-analysis proved: terbutaline, salbutamol and ritodrine played more important roles than nitroglycerine and nifedipine on the success rate of ECV. But salbutamol was found to have more common side effects than terbutaline and ritodrine. Conclusions: We conclude that factors inuencing the success rate of ECV mainly include: 1. characteristics of the mothers and fetuses, 2. interventions, 3. skills of the surgeon. During ECV process, selection of patients with enough amniotic uid and proper stature with no contraindications is essential. And a more detailed scoring standard according to the possible inuence indicators of the mothers and fetuses for the feasibility of ECV should be set up in the future. Besides, application of terbutaline and ritodrine as tocolytic agents during ECV procedure were considered to be effective for increasing successful versions. Introduction Breech presentation occurs in 3–4% of term pregnancies[1]. It has become a common sense that planned cesarean section(CS) is better than planned vaginal birth for the term breech presentation fetus, since the publication of a RCT on 2000, which could signicantly reduce the perinatal and neonatal mortality[2]. Breech presentation had become the third most frequent indication for CS, and the CS rate of breech presentation patients keeps increasing, up to 93% in certain countries[3–5]. However, the global average CS rate increased 12.4% (from 6.7–19.1%) with an average annual growth rate of 4.4% between 1990 and 2014, on account of trend analysis with the data from 121 countries, especially in China[6]. Chinese Page 2/20 health facilities had the highest CS rate of 46.2% between 2004 and 2008 in a large cross-sectional study conducted in 24 countries[7], and kept increasing from 2008 to 2014 in a descriptive study covering 2865 countries in mainland China’s 31 provinces[3]. Every coin has two sides, overuse of CS increases the risk of deputy injury, severe complications and adverse outcomes of subsequent pregnancy, and incidence of a twice CS at the same time[2, 3, 8]. External cephalic version (ECV) is an operation in which the baby’s head was turned downward with the pressure on the mother's abdominal wall, which increases the chance of cephalic presentation at the onset of labor and decreases the CS rate by almost 40%[8, 9]. ECV had been highly recommended by the American College of Obstetricians and Gynaecologists and the Society for Maternal-Fetal Medicine in 2014, that every women with an uncomplicated breech pregnancy at term should be offered an ECV[10]. Besides, it has been estimated that ECV trial is cost-effective when compared to a scheduled CS for breech presentation if provided the probability of successful ECV is more than 32%[11]. For decades, ECV has been carried out in many medical institutions domastic and overseas, and the reported success rates of ECV ranged from 35–86%[8, 9, 12, 13]. In the present study, a retrospective experiences analysis with high ECV success rate of 90.58% in a tertiary hospital in Northest China was recorded and the variables associated with the success rate of ECV were detailedly analyzed. As reported, many ancillary managements have been used to increase the success rate of ECV, including vibroacoustic stimulation, moxibustion, amnioinfusion, neuraxial analysis and tocolytic agents[6, 14–17]. Among them, beta stimulants and epidual analgesia have been proved to effectively improve the ECV success rate in Cluver’s meta-analysis[11]. However, the data on comparision of the eciency and side effects of the tocolytic agents was still lack. Terbutaline and ritodrine were applied as tocolytic agents during our procedures empirically. In pursuit of rationality, in this study, a bayesian network meta-analysis was conducted to compare the effects of variant tocolytic agents on the success rate and vaginal delivery rate of ECV, along with the common complications of tocolytic agents for the rst time. Material And Methods Retrospective analysis of our ECV experiences A retrospective analysis of 84 patients who underwent ECV at Dalian Maternal and Child Health Care Hospital from April 2017 to November 2019 was conducted. Healthy women near or at term (≥ 36 weeks) without severe complications, who were conrmed as breech presentation through ultrasonography, were considered as candidates for ECV. Patients who have history of placental or cord anomalies, severe pre- eclampsia or HELLP syndrome, premature rupture of membrane, vaginal bleeding less than seven days before ECV, prior uterine operation, intrauterine growth restriction or other fetal anomaly, oligoamnios, hyperextended fetal head and non-reassuring fetal monitoring were excluded. Oligoamnios was dened as amniotic uid index less than eighty centimeter. And successful external cephalic version was dened as fetal cephalic presentation immediately following the procedure. Informed, ethic consents were obtained for all of the included patients. Page 3/20 Basic information was recorded, including the patients’ age, operation time, gestational weeks at operation, parity, height, weight, tocolytic agents and doses, anaesthetic drugs and doses, placental location, breech type, presence of cord neck and amniotic uid index. Electric fetal monitoring was used to check fetal condition. We informed the risks of the operation, including fetal distress, failure of the procedure and possibility of emergency cesarean section to the candidates of ECV. Then the patients who signed the informed consents were prepared for ECV. It is noteworthy that all the included women were prepared for emergency surgery and remained fasting state before the procedure. ECV was all performed by a single chief obstetrician in our hospital. The patients were in supine position. Electric fetal monitoring and ultrasonography were performed before and after the ECV procedure to monitor fetal condition and position. All patients accepted continuous epidural anesthesia (CEA). Besides, patients were all infused with terbutaline (0.25 mg, intravenously) as the tocolytic agent before the procedure. The obstetrician push fetal buttock toward maternal head by the right hand and the left hand pull the fetal head downward when the patients’ heart rate increased about 20 bpm. If fetal bradycardia was discovered, the operation was stopped until fetal heart rate recovered, otherwise, emergency cesarean section was performed. And the operation was considered as successful if the fetal head was located in the maternal pelvis after the procedure. Bellybands were used to maintain the fetal position until delivery. Only after conrming maternal and fetal condition with electric fetal monitoring and ultrasonography, patients were discharged. If not, patients were kept in hospital or emergency cesarean section was performed. The delivery information of patients undergoing ECV were also collected, including gestational age at delivery, way of induced labor, delivery mode, vaginal bleeding volume, amniotic uid volume, umbilical condition, maternal complications,
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