**16. ECV: Alternatives**

Other methods used to correct the fetal position are acupuncture, homeopathy and postural methods. There is an awakening interest in exploring alternative medicines during pregnancy and labour. This interest is especially important in the case of external version alternatives since this is considered as s "dangerous" manoeuvre by pregnant women. The alternative medicine has become so important that *Cochrane* has carried out some reviews on the effectiveness of these methods, in particular, those referring to postural methods and the moxibustion use in cephalic version.

Pregnant women should be informed of the possible (although in a low rate) complications

Percentage of patients with breech presentation who are offered the external version.

A 2001 British project analyses the hospital costs derived from the external version. The purpose was to determine the difference of costs between performing an external version, a vaginal delivery or a caesarean delivery for the breech presentations. The costs were calculated for the "accepted ECV" vs. "non-accepted ECV" option. Both options included the probable emergence of adverse effects, as well as the different deliveries (breech presentation, cephalic, planned caesarean, emergency caesarean, etc.) The results proved £248-£376 saving per patient. Therefore, offering ECV implies lower hospital costs than if it was not offered. An obstetrics service offering daily ECV will be cheaper than a service

A cost-benefit analysis was also carried out including the *The Term Breech Trial* data. Surprisingly, it demonstrated that healthcare costs in the caesarean group were less than those produced in the vaginal delivery group. It also proved that there were not any differences regarding parity. Even though the caesarean intrapartum costs were higher, the vaginal delivery patients need more antepartum and intrapartum care as well as the babies, who need more intensive and intermediate cares, apart from the costs related to the epidural analgesia. Many studies expressing higher healthcare costs in induced labor or oxytocin stimulation have been published (Bost, 2003). These results show that the caesarean in breech presentation at term, despite being safer, it is also cheaper than vaginal labour (Palencia et al, 2006). However, this statement cannot be taken for granted, since the analysis did not take into account the long term costs (in prospective pregnancies, for instance) as

Other methods used to correct the fetal position are acupuncture, homeopathy and postural methods. There is an awakening interest in exploring alternative medicines during pregnancy and labour. This interest is especially important in the case of external version alternatives since this is considered as s "dangerous" manoeuvre by pregnant women. The alternative medicine has become so important that *Cochrane* has carried out some reviews on the effectiveness of these methods, in particular, those referring to postural methods and the

of the external version (recommendation level B).

The auditable standards for the external version are: Detection of antepartum breech presentation.

Complications occurring during or after the maneuver.

**14. ECV: Quality indicators** 

Version success figures.

**15. ECV: Associated costs** 

Maternal experience of the version.

which does not offer it (James et al, 2001).

well as the maternal risks.

**16. ECV: Alternatives** 

moxibustion use in cephalic version.

Throughout the history, midwives and doctors have used many different techniques referring to the best position to facilitate the cephalic version. However, few articles have been published about this topic in the medical literature. The knee-chest position and the supine position with the pelvis elevated with a wedge-shaped cushion are the most common techniques. The available evidence from the controlled clinical trials is so far insufficient to uphold the use of postural methods (Hofmeyr et Kulier, 2000).

Moxibustion is a type of Chinese medicine which involves burning a herb close to the skin in order to cause a heating sensation. It has also been stated that the acupuncture point called Bladder 67 (BL67) (or *Zhiyin,* according to its Chinese name) placed on the top of the fifth toe can correct breech presentations. How it works is totally unknown, but it seems to stimulate the production of maternal hormones (placental estrogens and prostaglandin) and the uterine contractions, as well as the fetal activity. In spite of not having found any adverse effects, Cochrane did not find enough evidence to prove that the moxibustion might be useful for correcting a breech presentation. The results suggest that moxibustion may be effective to reduce the external cephalic version need and caused a reduction in the use of oxytocin. However, some additional evidence is needed to confirm (or to reject) a benefit with respect to the breech presentation correction (Coyle et al, 2005; Hutton & Hofmeyr, 2006).

Therefore, there is not enough scientific evidence to recommend neither postural methods nor moxibustion to facilitate the spontaneous cephalic version (recommendation level A).

### **17. Conclusions**

The ECV is safe and useful for reducing caesarean rates. The external version success goes from 30% to 80%. The experience of the obstetrician who performed the technique plays a key role in ensuring success (Fandino et al, 2010). An obstetrics service offering daily ECV will be cheaper than a service which does not offer it (James et al, 2001). Tocolycs are recommended to be used during the manoeuvre to reduce adverse effects and increase the success rate.
