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External Cephalic Version()

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2016 5 28 () () (ECV) . 100 , ECV 1 . ECV . . 1

ECV?

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ECV : learning curve ?

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CONTENTS

ECV , , ECV learning curve , ECV ? ? . 2

External Cephalic Version(ECV)? Breech presentation : 34% of all term pregnancies

External cephalic version (ECV)

Success rate: 35-86 %

ECV ( ) . 35-86%. 3

Since the time of Hippocrates

1960s : Several reports suggested high fetal complication rates associated with version maneuvers (Brosset 1956)

1970s : ECV performed under tocolysis after 37 weeks gestation and after screening with ultrasound and fetal cardiotocography(CTG) (Salinger & Mller-Holve 1974)

1980s : successful ECV could be achieved in a substantial proportion of term breech pregnancies with a low risk of complications.

Recent randomized controlled trials : ECV at or near term effectively reduces the risk of noncephalic births and caesarean delivery for malpresentation

History of ECV

ECV . 1960 1970 . ECV (noncephalic) . 4

ECV ?

A review of strategies to reduce C/S rates :

Identified ECV as only clinical intervention with demonstrated Level 1 evidence for reducing primary C/S rates overall(Walker 2002)

ECV () Level I ( ) . 5

American College of Obstetricians and Gynecologists (ACOG)Royal College of Obstetricians and Gynaecologists (RCOG)Royal Australian and New Zealand College of Obstetricians and GynaecologistsDutch association of Obstetricians and Gynaecologists (NVOG) Recommends ECV

For breech fetuses near term

ECV , , , , . . , ECV . 6

ECV ?

ECV ? ECV . ECV . 7

Woman who has reached 36 weeks gestation with breech presentationBefore laborECV

ECV , ?(Williams) 36 . 36 36 ECV . 8

ECV Placenta previaNon-reassuring fetal statusRupture of membranesKnown uterine malformationsMultifetal gestationRecent uterine bleedingPrior uterine incision

ECV , ,, , , . VBAC . 9

ECV ? ECV ()

1. USG

USG : , , , Nuchal cord

: elasticity, floating

2. NST with size

ECV ? , , . . , NST with size . 10

ECV ?

3. ? 35-86 % ( 58%)

Favorable factors : Multiparity, Abundant amniotic fluid Unengaged presenting part, Fetal size 2500 to 3000g Posterior placenta, Nonobese patientBushimschi, 2011; de Hundt, 2012; Kok, 2008, 2009, 2011

ECV 58% , , , . , , 12cm, 90% . 11

4. Adverse events after ECV

S. Collins 2007

ECV . , , , . 0.5%. . 12

ECV Midnight 8

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Fetal monitoring

Epidural anesthesia

Tocolytics

ECV . daytime 8 . ( ) 2-3 . . 13

Discouraged the use of neuraxial techniques out of fear of injuringthe fetus by applying too much force

Fall in blood pressure and headache

Increased success rates of version with epidural anesthesia

(Mancuso, 2000; Schorr, 1997)

Not enough consistent evidence to recommend conduction analgesia routinely for external version. (ACOG 2012)

Epidural anesthesia

ECV () . , ECV . , 2012 ECV . 14

Epidural anesthesia

Randomized trial of anaesthetic interventions inexternal cephalic version for breech presentation

British Journal of Anaesthesia 114 (6): 94450 (2015)

2015 ECV . 15

British Journal of Anaesthesia 114 (6): 94450 (2015)

189 3 : ( ), , , 2 ECV. . 16

Epidural anesthesia

British Journal of Anaesthesia 114 (6): 94450 (2015)

3 ECV ( ) 64%, 64%, 83% . ECV (Visual Pain Score( ) 50, 35 0 ., 2 ECV 0% 78% . ECV . 17

Epidural anesthesia

In this study, success at ECV was higher using spinal anaesthesia compared with remifentanil infusion or no intervention Pain was also reduced in the remifentanil group but success at ECV was no different to the no intervention group The effect of spinal anaesthesia in ECV may relate to relaxation of the abdominal musculatureBritish Journal of Anaesthesia 114 (6): 94450 (2015)

ECV . , . 18

Tocolytics increase the success rate of the procedure with minimal risks from adverse effects

Existing evidence may support the use of tocolytic agents during external version attempts

(ACOG 2012)Tocolytics

(tocolytics) ECV . . 19

ECV

ECV : . ECV .

ECV : 1( ), 1( ), 1( ), 1( )

ECV: . 2-3 . 2-3 . 8% .

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ECV Fetal Monitoring

ECV 3

NST

ECV . . 21

2014-2015 ECV 2014ECV9647869911108996Success53163255265548(50)2015ECV149699899367897Success55388555335762(63.9)

Cheil General Hospital and Women's Healthcare Center, Dankook University College of Medicine, Seoul, Korea(2014-2015)

ECV 2014 96 50%. 2015 97 64% . . 22

ECV : learning curve ?

Learning curve : showing how learning improves with experience

ECV (Experience) Learning curve . . 23

2014.1-32014.4-62014.7-92014.10-122015.1-32015.4-62015.7-92015.10-122016.1-3ECV192129272926212117Success91112161321131514(%)47.3752.3841.3859.2644.8380.7761.9071.4382.35

ECV : 3 %

2014 2016 382% . 24

ECV : 3 with Parity 36.8% 38.0% 48.2% 33.3% 34.4% 50.0% 38.0% 33.3% 58.8% Multiparity %

2014 2015 . , 33.3% 2015 2014 12% . . 25

ECV : 3 with Parity 36.8% 38.0% 48.2% 33.3% 34.4% 50.0% 38.0% 33.3% 58.8% Multiparity %

Learning curve

curve S . (plateau) . 26

Learning curveThe learning curve for ECV is very sharp

The success rate of external cephalic version plateau after the first 20 cases from 45% to about 60%.

Only parity and type of breech have a significant effect on the outcome.

Teoh TG. Singapore Med J. 1997

learning curve 20 15% . . 27

ECV ?

ECV . . , . 100% . ? 28

Bnifla JL et al. Journal de Gynecologie, 1995Transabdominal amnio-infusion facilitates external version maneuver after initial failure. Six successful attempts External version was successful after initial failure in 6 cases after transabdominal amnio-infusion. Filling the uterine cavity by amnio-infusion with 700 to 900 ml saline solution at 37 degrees C facilitated cephalic presentation in these 6 cases. In each case, a prior version attempt had been unsuccessful.

1995 700-900cc 6 6 . 29

Amnioinfusion to facilitate ECVafter initial failure

Adama van Scheltema PN et al. Obstet Gynecol. 2006

A median amount of 1,000 mL Ringers solution (range 700-1,000 mL) was infused per procedure. The repeat external cephalic versions after amnioinfusion were not successful in any of the patients.Seven women participated in the study.

CONCLUSION: In our experience, amnioinfusion does not facilitate external cephalic version.

, 2006 700-1000ccfmf 7 . 30

Adama van Scheltema PN et al. Obstet Gynecol. 2006

7 (AFI) 10-15cm . 5 2 . ( ) 31

(Initial failure) :

ECV ? :

ECV 3 . 32

: ECV with amnioinfusion 32 G2P1

2010 NSVD 2.76kg

2015. 11 37+4 weeks of gestation Breech presentation 2.3Kg AFI=7cm Operation history

19 ovarian cystectomy

26 Panperitonitis

29 Adhesion-

ECV 32 2.76kg . 37 3 (19 , 26 , 29 ) . ECV 10 . 33

36.5 0.9%

8.9 cm 22G (Hakko Co., Chikuma, Japan)

15cm 1 ECV ? :

ECV . (AFI) 15cm 1 . 34

Successful rate : 70.5% (12/17) ECV ?

70% . 6 7 100% 0% 17 70% . , . 35

Factors associated with successful ECV with amnioinfusion

ECV . 12 9 81% 1 . 36

ECV (ACOG 2012)

ECV : Positive ,

ECV learning curve : S ?

Initial failure ECV with amnioinfusion : 70%

ECV .

ECV 80% , ECV . , ECV learning curve 100 10% . 70% ECV . 37

Thank you ~~^^