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Evaluation of the Learning Curve for External Cephalic Version Using Original Article Obstet Gynecol Sci 2017;60(4):343-349 https://doi.org/10.5468/ogs.2017.60.4.343 pISSN 2287-8572 · eISSN 2287-8580 Evaluation of the learning curve for external cephalic version using cumulative sum analysis So Yun Kim, Jung Yeol Han, Eun Hye Chang, Dong Wook Kwak, Hyun Kyung Ahn, Hyun Mi Ryu, Moon Young Kim Department of Obstetrics and Gynecology, Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea Objective We evaluated the learning curve for external cephalic version (ECV) using learning curve-cumulative sum (LC-CUSUM) analysis. Methods This was a retrospective study involving 290 consecutive cases between October 2013 and March 2017. We evaluated the learning curve for ECV on nulli and over para 1 group using LC-CUSUM analysis on the assumption that 50% and 70% of ECV procedures succeeded by description a trend-line of quadratic function with reliable R2 values. Results The overall success rate for ECV was 64.8% (188/290), while the success rate for nullipara and over para 1 groups was 56.2% (100/178) and 78.6% (88/112), respectively. ‘H’ value, that the actual failure rate does not differ from the acceptable failure rate, was -3.27 and -1.635 when considering ECV success rates of 50% and 70%, respectively. Consequently, in order to obtain a consistent 50% success rate, we would require 57 nullipara cases, and in order to obtain a consistent 70% success rate, we would require 130 nullipara cases. In contrast, 8 to 10 over para 1 cases would be required for an expected success rate of 50% and 70% on over para 1 group. Conclusion Even a relatively inexperienced physician can experience success with multipara and after accumulating experience, they will manage nullipara cases. Further research is required for LC-CUSUM involving several practitioners instead of a single practitioner. This will lead to the gradual implementation of standard learning curve guidelines for ECV. Keywords: Amniotic fluid; Breech presentation; Learning curve; Version, fetal Introduction few physicians with the skills required to carry out this tech- nique [1]. This skill depends on a range of factors, including Breech presentation occurs in 3% to 4% of single pregnan- cies, reaching term. In 2012, the cesarean delivery rate in the United States of America was 32.8%, compared to 36.0% Received: 2017.3.29. Revised: 2017.5.5. Accepted: 2017.6.16. Corresponding author: Jung Yeol Han in Korea [1]. External cephalic version (ECV) is an obstetric Department of Obstetrics and Gynecology, Cheil General Hospital and procedure, which aims to turn a fetus into a cephalic presen- Women’s Healthcare Center, Dankook University College of Medicine, 17 tation by moving the maternal abdomen. A Cochrane review Seoae-ro 1-gil, Jung-gu, Seoul 04619, Korea reported that ECV at full-term gestation (>37 weeks) reduces Tel: +82-2-2000-5633 Fax: +82-2-2000-7477 the likelihood of a non-cephalic presentation at birth and E-mail: [email protected] http://orcid.org/0000-0001-5611-2392 thus, the need for a cesarean section [2]. On this basis, ECV should be recommended for all women with a breech fetus at Articles published in Obstet Gynecol Sci are open-access, distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. term when there are no contraindications [3]. org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, In some countries, including Korea, however, ECV has been and reproduction in any medium, provided the original work is properly cited. a relatively unfamiliar procedure until recently and there are Copyright © 2017 Korean Society of Obstetrics and Gynecology www.ogscience.org 343 Vol. 60, No. 4, 2017 individual skills, environmental circumstances and institutional part, whether any other procedure was involved (e.g., amniot- factors and the time taken to achieve the required level of ic fluid infusion), contraction status in admission, presence of skill can thus influence the clinical outcomes of patients [4]. myoma, and buttock elevation status. Our contraindications Although there have been numerous studies investigating for ECV were multiple pregnancy, oligohydramnios, antepar- factors which might influence success rate of ECV, such as tum hemorrhage, rupture of membranes, any contraindica- amniotic fluid index, parity, and type of breech but very few tion to vaginal delivery, utero-placental insufficiency, intrauter- of these have specifically investigated the learning curve ECV; ine growth restriction, preeclampsia, and non-reassuring fetal only one paper published involving 80 cases, has investigated monitoring pattern. ECV [5]. All patients agreed to undergo the procedure, and they The ‘learning curve’ is defined as an improvement in per- were informed of the probability of failure and the risks as- formance over time or with increasing experience or training. sociated with the procedure, including fetal distress and We considered the possibility of the existence of a learning emergency cesarean delivery. Patients were admitted after curve when we first started using a simple ‘moving average fasting for eight hours and laboratory tests were conducted in curve’ when our experience reached approximately 200 cases. preparation for cesarean sections, including complete blood But because of limitation its objectivity and quantification, we cell count, blood typing, electrolytes, liver function test, and proposed ‘cumulative sum (CUSUM) analysis’ that is a sequen- urinalysis. We also arranged the preventive mutual coopera- tial analysis tool that was initially used in industrial settings for tion between an anesthesiologist and the operation team. quality control purposes. It can allow one to judge when an The ECV procedure was discontinued immediately if the fetal individual’s performance has achieved a predefined level of heart rate showed a non-reassuring pattern, or if the patient competence [4]. More recently, various fields, including medi- complained of an intolerable discomfort, despite the use of cal fields, have applied quality control procedures to assess epidural anesthesia. the learning curves of trainees and monitor the introduction All ECVs were performed in the delivery unit of Cheil Gen- of innovative technologies [6]. The slope of CUSUM expresses eral Hospital & Women’s Healthcare Center with the patient the tendency of the learning achievement while the aspect lying horizontally on a bed. Just before the ECV, we assessed of the slope showing stabilization represents a breakthrough the contraction pattern and fetal heart beat variability by con- in learning. This system has the advantage of allowing for tinuous fetal heart rate monitoring for more than 30 minutes. easier visual verification of when the evaluation of a specific We then administered more than 30 minutes of tocolysis us- technique reaches a certain level [7]. Furthermore, this allows ing an intravenous infusion of ritodrine hydrochloride (Lavopa) us to convey to patients our consistent proficiency in ECV suc- and epidural anesthesia. Fetal presentation was confirmed by cess during counseling sessions in the clinic. Therefore, in this performing transabdominal ultrasonography of the fetal spi- paper, we aimed to evaluate the learning curve for ECV using nous side. The ECV procedure team consisted of a maximum CUSUM and to determine consistent proficiency for the ECV of four members, including a main supervisor (clinical opera- for nullipara and over para 1. tor), sonographer (resident), and two helpers, including one nurse. As starting this procedure, the sonographer (resident) checked the location of fetal head, spine and fetal heart beat. Materials and methods Main clinical operator stood the other side from ultrasonog- raphy to gaze the patient’s foot side. And in the process, if This retrospective observational study was gone through by the fetus is descending or engaging too much in pelvic cavity, the institutional review board of Cheil General Hospital (CGH- one team member stood the same side besides to operator to IRB-2017-14). The study involved 290 consecutive cases of gaze the patient’s face and push to upward from symphysis ECV, performed between October 2013 and March 2017 pubis for free float the fetus. And one other member, if nec- by a single practitioner. Demographic factors were collected essary, stood the opposite side from operator and push for for each subject from medical records, including age, parity, prevent to oust of fetus. Sonographer moved the probe along maternal body weight, fetal estimated weight, AFI, type of with the fetal head moving and checked the fetal heart beat breech, location of placenta, fixation status of the presenting when finishing one time trial of ECV. 344 www.ogscience.org So Yun Kim, et al. ECV and LC-CUSUM Table 1. Demographic factors of the patients involved in this study Success (n=188) Fail (n=102) P-value Age (yr) 34.1 32.3 <0.001 Gravida 2.1 1.6 0.001 Parity 0.5 0.3 0.001 Gestational age (wk) 37.4 37.4 0.529 Amniotic fluid index (cm) 11.0 10.3 0.092 Body mass index (kg/m2) 24.8 25.7 0.063 after the recommendation of amnioinfusion only after with Table 2. Formulas and values involved in plotting the LC-CUSUM the patient’s agreement. After a successful procedure, the pa- curve with an acceptable ECV failure rate of 50% tient was placed in a lateral decubitus position and continu- Variable Value ous fetal monitoring was continued for an additional 3 hours; p0—unacceptable ECV failure rate 0.7 ritodrine and anesthesia infusion were stopped. After confir- p1—acceptable ECV failure rate 0.5 mation of a reassuring fetal heartbeat and the lack of regular α—probability of the type I error 0.05 contractions, the patient was discharged to their home. The β—probability of the type II error 0.20 following day, non-stress test and an official general checkup P=ln (p1/p0) -0.3365 was performed.
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