Tugas

Nama : Fadhlullah Latama

NIM : C111 08 169
External Cephalic Version for Breech Presentation at Term

Critical appraisal
Berdasarkan jurnal penelitian yang diterbitkan oleh John Wiley&sons, Ltd pada tahun 2012
dengan judul external cephalic version for breech presentation at term dilakukan critical
appraisal dengan cara berikut :
P Patient with breech presentation
I External cephalic version
C Non cephalic births
O prognosis

Are the result of the trial valid (internal validity)
Was the assignment of patients to treatments randomised?
yes Pregnant women with babies in the breech presentation at or near term and no
contraindications to ECV. ECV attempt at term, with or without the use of tocolysis,
compared with no ECV attempt.
Were the groups similar at the start of the trial?
no Because of significant heterogeneity, results for the first two outcomes were pooled
using the random-effects model. For all other data we used the fixed-effect model.
Sensitivity analyses showed overall results not to be greatly influenced by the inclusion
of the two high risk of bias studies and so they are included in the results. Overall, the
pooled data from included studies show a statistically significant and clinically
meaningful reduction in non-cephalic birth (seven trials, 1245 women; risk ratio (RR)
0.46, 95% confidence interval (CI) 0.31 to 0.66); and caesarean section (seven trials,
1245 women; RR 0.63, 95% CI 0.44 to 0.90) when ECV was attempted. Data were not
available from all the trials for the remaining outcomes. There were no significant
differences in the incidence of Apgar score ratings below seven at one minute (two
trials, 108 women; RR 0.95, 95% 0.47 to 1.89) or five minutes (four trials, 368
women; RR 0.76, 95%32 to 1.77), low umbilical artery pH levels (one trial, 52 women
No Keywords Hasil penelusuran
1 Breech presentation 8562
2 External cephalic versioin 8562
3 Non cephalic births 8562
4 1, 2 and 3 8562
RR 0.65; 0.17 to 2.44), neonatal admission (one trial, 52 women; RR 0.36, 95% 0.04 to
3.24), perinatal death (six trials, 1053 women; RR 0.34, 95% CI 0.05 to 2.12), nor time
from enrolment to delivery (2 trials, 256 women; weighted mean difference -0.25 days,
95% -2.81 to 2.31).
Aside from the allocated treatment, were groups treated equally?
yes ECV attempt at term, with or without the use of tocolysis, compared with no ECV
attempt. Perinatal outcomes including non-cephalic presentation at delivery, method of
delivery and perinatal and maternal morbidity and mortality. Outcomes included if
clinically meaningful; reasonable measures taken tominimise observer bias;missing
data insufficient to materially influence conclusions; data available for analysis
according to original allocation, irrespective of protocol violations; data available in
format suitable for analysis.
Were all patients who entered the trial accounted for? And were they analyzed in the groups to
which they were randomised?
yes Because of significant heterogeneity, results for the first two outcomes were pooled
using the random-effects model. For all other data we used the fixed-effect model.
Sensitivity analyses showed overall results not to be greatly influenced by the inclusion
of the two high risk of bias studies and so they are included in the results.
Were measures objective or were the patients and clinicians kept blind to which treatment was
being received?
no ECV attempt at term, with or without the use of tocolysis, compared with no ECV
attempt. Perinatal outcomes including non-cephalic presentation at delivery, method of
delivery and perinatal and maternal morbidity and mortality. Outcomes included if
clinically meaningful; reasonable measures taken tominimise observer bias;missing
data insufficient to materially influence conclusions; data available for analysis
according to original allocation, irrespective of protocol violations;
data available in format suitable for analysis.

What were the results?
How large was the treatment effect?
We included seven studies. The pooled data from these studies show a statistically significant
and clinically meaningful reduction in non-cephalic birth (seven trials, 1245 women; risk ratio
(RR) 0.46, 95% confidence interval (CI) 0.31 to 0.66; and caesarean section (seven trials, 1245
women; RR 0.63, 95% CI 0.44 to 0.90) when ECV was attempted. There were no significant
differences in the incidence of Apgar score ratings below seven at one minute (two trials, 108
women; RR 0.95, 95% CI 0.47 to 1.89) or five minutes (four trials, 368 women; RR 0.76, 95%
CI 0.32 to 1.77), low umbilical artery pH levels (one trial, 52 women; RR 0.65, 95% CI 0.17
to 2.44), neonatal admission (one trial, 52 women; RR 0.36, 95% CI 0.04 to 3.24), perinatal
death (six trials, 1053 women; RR 0.34, 95% CI 0.05 to 2.12), nor time from enrolment to
delivery (2 trials, 256 women; weighted mean difference -0.25 days, 95% CI -2.81 to 2.31).
What is the measure?
Relative risk
(RR)
non-cephalic birth (RR) 0.46
caesarean section RR 0.63
Apgar score ratings below seven at one minute RR 0.95
low umbilical artery pH levels RR 0.65
neonatal admission RR 0.36
perinatal death RR 0.34
How precise was the estimate of the treatment effect?
non-cephalic birth (seven trials, 1245 women; risk ratio (RR) 0.46, 95% confidence interval (CI)
0.31 to 0.66; and caesarean section (seven trials, 1245 women; RR 0.63, 95% CI 0.44 to 0.90)
when ECV was attempted. There were no significant differences in the incidence of Apgar score
ratings below seven at one minute (two trials, 108 women; RR 0.95, 95% CI 0.47 to 1.89) or five
minutes(four trials, 368 women; RR 0.76, 95% CI 0.32 to 1.77), low umbilical artery pH levels
(one trial, 52 women; RR 0.65, 95% CI 0.17 to 2.44), neonatal admission (one trial, 52 women;
RR 0.36, 95% CI 0.04 to 3.24), perinatal death (six trials, 1053 women; RR 0.34, 95% CI 0.05 to
2.12), nor time from enrolment to delivery (2 trials, 256 women; weighted mean difference -0.25
days, 95% CI -2.81 to 2.31)

Will the results help me in caring for my patient? (external validity/applicability)
Is my patient so different to those in the study that the result cannot apply?
No
Is the treatment feasible in my setting?
There is less risk to the baby andmother when the baby is head-down at the time of birth.
External cephalic version (ECV) is a procedure by which the baby, who is lying bottom first, is
manipulated through the mothers abdominal wall to the head-down position. The review of
seven studies, 1245 women, found that If the baby is not head down after about 36 weeks of
pregnancy, ECV reduces the chance that the baby will present as breech at the time of birth, and
reduces the chance of caesarean birth.
Will the potential benefits of the treatment outweight the potential harms of the treatment for my
patient?
With the trial result, the preferred approach for breech presentation is extra cephalic version.
With RR 0,46 in non cephalic birth