Download PDF
Am J Perinatol 2025; 42(06): 751-757
DOI: 10.1055/a-2419-9146
Original Article

The Optimal Prediction Model for Successful External Cephalic Version

Rahul S. Yerrabelli 
1   Carle Illinois College of Medicine, The University of Illinois at Urbana-Champaign, Champaign, Illinois
2   Department of Obstetrics and Gynecology, Reading Hospital, Tower Health, West Reading, Pennsylvania
,
Peggy K. Palsgaard 
1   Carle Illinois College of Medicine, The University of Illinois at Urbana-Champaign, Champaign, Illinois
3   Department of Obstetrics and Gynecology, Western Michigan University, Kalamazoo, Michigan
,
Priya Shankarappa
1   Carle Illinois College of Medicine, The University of Illinois at Urbana-Champaign, Champaign, Illinois
4   Department of Internal Medicine, Brown University, Providence, Rhode Island
,
Valerie Jennings
1   Carle Illinois College of Medicine, The University of Illinois at Urbana-Champaign, Champaign, Illinois
5   Department of Obstetrics and Gynecology, Carle Foundation Hospital, Urbana, Illinois
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Objective

The majority of breech fetuses are delivered by cesarean birth as few physicians are trained in vaginal breech birth. An external cephalic version (ECV) can prevent cesarean delivery and the associated morbidity in these patients. Current guidelines recommend that all patients with breech presentation be offered an ECV attempt. Not all attempts are successful, and an attempt does carry some risks, so shared decision-making is necessary. To aid in patient counseling, over a dozen prediction models to predict ECV success have been proposed in the last few years. However, very few models have been externally validated, and thus, none have been adopted into clinical practice. This study aims to use data from a U.S. hospital to provide further data on ECV prediction models.

Study Design

This study retrospectively gathered data from Carle Foundation Hospital and used it to test six models previously proposed to predict ECV success. These models were Dahl 2021, Bilgory 2023, López Pérez 2020, Kok 2011, Burgos 2010, and Tasnim 2012 (GNK-PIMS score).

Results

A total of 125 patients undergoing 132 ECV attempts were included. A total of 69 attempts were successful (52.2%). Dahl 2021 had the greatest predictive value (area under the curve [AUC]: 0.779), whereas Tasnim 2012 performed the worst (AUC: 0.626). The remaining models had similar predictive values as each other (AUC: 0.68–0.71). Bootstrapping confirmed that all models except Tasnim 2012 had confidence intervals not including 0.5. The bootstrapped 95% AUC confidence interval for Dahl 2021 was 0.71 to 0.84. In terms of calibration, Dahl 2021 was well calibrated with predicted probabilities matching observed probabilities. Bilgory 2023 and López Pérez were poorly calibrated.

Conclusion

Multiple prediction tools have now been externally validated for ECV success. Dahl 2021 is the most promising prediction tool.

Key Points

  • Prediction models can be powerful tools for patient counseling.

  • The odds of ECV success can estimated based on patient factors and clinical findings.

  • Of the six tested models, only Dahl 2021 appears to have good predictive value and calibration.

Keywords

breech presentation - cesarean section - clinical prediction rule - logistic regression - machine learning - nomogram - obstetrics - prognostic score

Availability of Data and Materials

The data are published in the supplemental data. The code and data are also hosted in a public GitHub repository and are available at https://github.com/ryerrabelli/ECV-Analysis-Public or https://doi.org/10.5281/zenodo.13917274 .


Supplementary Material



Publication History

Received: 30 June 2024

Accepted: 23 September 2024

Accepted Manuscript online:
24 September 2024

Article published online:
21 October 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Richmond AK, Ashworth JR. Management of malposition and malpresentation in labour. Obstet Gynaecol Reprod Med 2023; 33 (11) 325-333
    CrossrefPubMedSearch in Google Scholar
  • 2 External Cephalic Version. External cephalic version: ACOG practice bulletin, number 221. Obstet Gynecol 2020; 135 (05) e203-e212
    CrossrefPubMedSearch in Google Scholar
  • 3 Hill LM. Prevalence of breech presentation by gestational age. Am J Perinatol 1990; 7 (01) 92-93
    Thieme ConnectPubMedSearch in Google Scholar
  • 4 ACOG committee opinion no. 745: mode of term singleton breech delivery. Obstet Gynecol 2018; 132 (02) e60-e63
    CrossrefPubMedSearch in Google Scholar
  • 5 External cephalic version and reducing the incidence of term breech presentation. BJOG 2017; 124 (07) e178-e192
    CrossrefPubMedSearch in Google Scholar
  • 6 Nalam RL, Chinnachamy P, Emmanuel P. External cephalic version: a dying art worth reviving. J Obstet Gynecol India 2018; 68 (06) 493-497
    CrossrefPubMedSearch in Google Scholar
  • 7 Grootscholten K, Kok M, Oei SG, Mol BWJ, van der Post JA. External cephalic version-related risks: a meta-analysis. Obstet Gynecol 2008; 112 (05) 1143-1151
    CrossrefPubMedSearch in Google Scholar
  • 8 Ben-Meir A, Erez Y, Sela HY, Shveiky D, Tsafrir A, Ezra Y. Prognostic parameters for successful external cephalic version. J Matern Fetal Neonatal Med 2008; 21 (09) 660-662
    CrossrefPubMedSearch in Google Scholar
  • 9 Ebner F, Friedl TWP, Leinert E. et al. Predictors for a successful external cephalic version: a single centre experience. Arch Gynecol Obstet 2016; 293 (04) 749-755
    CrossrefPubMedSearch in Google Scholar
  • 10 Kok M, Cnossen J, Gravendeel L, van der Post J, Opmeer B, Mol BW. Clinical factors to predict the outcome of external cephalic version: a metaanalysis. Am J Obstet Gynecol 2008; 199 (06) 630.e1-630.e7 , discussion e1–e5
    CrossrefPubMedSearch in Google Scholar
  • 11 Chaudhary S, Contag S, Yao R. The impact of maternal body mass index on external cephalic version success. J Matern Fetal Neonatal Med 2019; 32 (13) 2159-2165
    CrossrefPubMedSearch in Google Scholar
  • 12 López-Pérez R, Lorente-Fernández M, Velasco-Martínez M, Martínez-Cendán JP. Prediction model of success for external cephalic version. Complications and perinatal outcomes after a successful version. J Obstet Gynaecol Res 2020; 46 (10) 2002-2009
    CrossrefPubMedSearch in Google Scholar
  • 13 Yerrabelli RS, Lee C, Palsgaard PK, Lauinger AR, Abdelsalam O, Jennings V. Prediction models for successful external cephalic version: an updated systematic review. Am J Perinatol 2024; 41 (S 01): e3210-e3240
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Dahl CM, Zhang Y, Ong JX. et al. A multivariable predictive model for success of external cephalic version. Obstet Gynecol 2021; 138 (03) 426-433
    CrossrefPubMedSearch in Google Scholar
  • 15 Burgos J, Melchor JC, Pijoán JI, Cobos P, Fernández-Llebrez L, Martínez-Astorquiza T. A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term. Int J Gynaecol Obstet 2011; 112 (01) 48-51
    CrossrefPubMedSearch in Google Scholar
  • 16 Burgos J, Cobos P, Rodriguez L. et al. Clinical score for the outcome of external cephalic version: a two-phase prospective study. Aust N Z J Obstet Gynaecol 2012; 52 (01) 59-61
    CrossrefPubMedSearch in Google Scholar
  • 17 Reddy UM, Abuhamad AZ, Levine D, Saade GR. Fetal Imaging Workshop Invited Participants*. Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop. Obstet Gynecol 2014; 123 (05) 1070-1082
    CrossrefPubMedSearch in Google Scholar
  • 18 Dashe JS, Pressman EK, Hibbard JU. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org. SMFM consult series #46: evaluation and management of polyhydramnios. Am J Obstet Gynecol 2018; 219 (04) B2-B8
    CrossrefPubMedSearch in Google Scholar
  • 19 Kiserud T, Piaggio G, Carroli G. et al. The World Health Organization fetal growth charts: a multinational longitudinal study of ultrasound biometric measurements and estimated fetal weight. PLoS Med 2017; 14 (01) e1002220
    CrossrefPubMedSearch in Google Scholar
  • 20 Kiserud T, Benachi A, Hecher K. et al. The World Health Organization fetal growth charts: concept, findings, interpretation, and application. Am J Obstet Gynecol 2018; 218 (2S): S619-S629
    CrossrefPubMedSearch in Google Scholar
  • 21 Bilgory A, Minich O, Shvaikovsky M, Gurevich G, Lessing JB, Olteanu I. Predictive factors for successful vaginal delivery after a trial of external cephalic version: a retrospective cohort study of 946 women. Am J Perinatol 2023; 40 (15) 1679-1686
    Thieme ConnectPubMedSearch in Google Scholar
  • 22 Bilgory A, Minich O, Shvaikovsky M, Gurevich G, Lessing JB, Olteanu I. Erratum: predictive factors for successful vaginal delivery after a trial of external cephalic version: a retrospective cohort study of 946 women. Am J Perinatol 2023; 40 (15) e1
    Thieme ConnectPubMedSearch in Google Scholar
  • 23 De Hundt M, Vlemmix F, Kok M. et al. External validation of a prediction model for successful external cephalic version. Am J Perinatol 2012; 29 (03) 231-236
    Thieme ConnectPubMedSearch in Google Scholar
  • 24 Tasnim N, Mahmud G, Javaid K. GNK-PIMS Score: a predictive model for success of external cephalic version. J South Asian Fed Obstet Gynecol 2012; 4 (02) 99-102
    PubMedSearch in Google Scholar
  • 25 Van Calster B, Nieboer D, Vergouwe Y, De Cock B, Pencina MJ, Steyerberg EW. A calibration hierarchy for risk models was defined: from utopia to empirical data. J Clin Epidemiol 2016; 74: 167-176
    CrossrefPubMedSearch in Google Scholar
  • 26 Anand K, Keepanasseril A, Amala R, Nair NS. Development and validation of a clinical score to predict the probability of successful procedure in women undergoing external cephalic version. J Matern Fetal Neonatal Med 2021; 34 (18) 2925-2931
    CrossrefPubMedSearch in Google Scholar
  • 27 Wong WM, Lao TT, Liu KL. Predicting the success of external cephalic version with a scoring system. A prospective, two-phase study. J Reprod Med 2000; 45 (03) 201-206
    PubMedSearch in Google Scholar
  • 28 Zheng LG, Zhang HL, Chen RX. et al. Scoring system to predict the success rate of external cephalic versions and determine the timing of the procedure. Eur Rev Med Pharmacol Sci 2021; 25 (01) 45-55
    PubMedSearch in Google Scholar
  • 29 Hutton EK, Simioni JC, Thabane L. Predictors of success of external cephalic version and cephalic presentation at birth among 1253 women with non-cephalic presentation using logistic regression and classification tree analyses. Acta Obstet Gynecol Scand 2017; 96 (08) 1012-1020
    CrossrefPubMedSearch in Google Scholar
  • 30 Newman RB, Peacock BS, VanDorsten JP, Hunt HH. Predicting success of external cephalic version. Am J Obstet Gynecol 1993; 169 (2 Pt 1): 245-249 , discussion 249–250
    CrossrefPubMedSearch in Google Scholar
  • 31 Isakov O, Reicher L, Lavie A, Yogev Y, Maslovitz S. Prediction of success in external cephalic version for breech presentation at term. Obstet Gynecol 2019; 133 (05) 857-866
    CrossrefPubMedSearch in Google Scholar