Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis

OBJECTIVE: To describe currently accepted methods for managing the term breech pregnancy, and to predict the delivery outcomes and costs of each method.

METHODS: Literature review was used to derive four options for the peripartum management of the term breech pregnancy. Using decision-analysis techniques, we calculated the predicted delivery outcomes and costs associated with each option.

RESULTS: Applying external cephalic version to all term breech pregnancies without contraindications to labor or version, and allowing a trial of labor for eligible women who fail version, results in a 25% cesarean rate, at a cost of $8071 per case. Delivering unsuccessful versions by scheduled cesarean results in a 32% cesarean rate, at a cost of $8276 per case. In contrast, a strategy not using external version but allowing a trial of labor for those mothers who meet eligibility criteria results in a 63% cesarean rate, at a cost of $8755 per case. Routinely scheduling a cesarean when a breech is identified at term results in an 89% cesarean rate, at a cost of $9544 per case.

CONCLUSIONS: Although the liberal use of vaginal delivery for term breech pregnancies has been suggested as one way of lowering the cesarean rate, the addition of routine external cephalic version to the management strategy will result in more vaginal deliveries and lower costs than strategies that allow vaginal delivery but do not include an attempted cephalic version. Routine cesarean without attempted external cephalic version results in excessive operative deliveries.