External cephalic version for breech presentation at term

Retrospective Analysis of Pregnancy Outcomes Following External Cephalic Version for Breech Presentation

Objective

We explored the feasibility and safety of external cephalic version (ECV) for cases of breech presentation.

Methods

We retrospectively analyzed data from 158 singleton pregnant women with breech presentation at 36 weeks gestation, admitted to Guangzhou Hospital of Integrated Traditional and Western Medicine from January 2018 to March 2022. 42 underwent ECV, categorized as the ECV group, while 116 without ECV comprised the control group. Systematic collection and evaluation of pregnancy outcomes were conducted for both groups.

Results

Within the control group, 16 cases experienced a spontaneous transition to head presentation, among which 14 cases resulted in successful vaginal deliveries. In 2 cases, cesarean deliveries were performed due to fetal macrosomia and persistent posterior occipital presentation. Furthermore, 2 cases of breech presentation in pregnant women were successfully delivered vaginally through breech traction, necessitating an emergency procedure due to the wide opening of the uterus. Within the ECV group, 28 cases were successfully inverted to the cephalic presentation. Among them, 1 case underwent an emergency cesarean delivery due to fetal distress during cephalic delivery, 3 cases required cesarean deliveries due to abnormal labor, and 24 cases were successfully delivered vaginally. The comparative analyses showed that the cesarean section rate (18/42 vs 100/116) and non-cephalic delivery rate (14/42 vs 100/116) in the ECV group were significantly lower than those in the control group (P < 0.001). There was no statistically significant differences between the two groups with respect to the rate of newborns with Apgar score < 7 (1/42 vs 3/116), premature rupture of membrane (3/42 vs 20/116), acute fetal distress (2/42 vs 2/116), and cord prolapse (0/42 vs 1/116) (P > 0.05).

Conclusion

ECV can effectively reduce the rate of cesarean delivery and non-cephalic deliveries. However, it but requires strict adherence to indications and continuous monitoring.

Flat trend of high caesarean section rates in Peru: A pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020

Background

Methods

Findings

Interpretation

Funding

Rebozo and External Cephalic Version in breech presentation (RECEIVE): A randomised controlled study

OBJECTIVE

To investigate if a hospital-initiated home-based rebozo intervention performed by the pregnant woman and her partner before external cephalic version (ECV) would increase the rate of cephalic presentations at birth.

DESIGN

A multicentre randomised controlled trial.

SETTING

Three university hospitals in Copenhagen, Denmark.

POPULATION

Pregnant women with a breech or transverse presentation at 35 weeks or more of gestation eligible for ECV.

METHODS

We compared rebozo before ECV with ECV alone. The randomisation was computer-generated in blocks and stratified by parity. The woman and her partner were instructed in the technique by a project midwife and performed the technique at home three times daily for 3-5 days before the scheduled ECV. Analyses were by intention-to-treat.

MAIN OUTCOME MEASURE

The number of cephalic presentations at the time of birth. Odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

A total of 372 women were randomly assigned (1:1) to either rebozo intervention (n = 187) or control (n = 185). At birth, 95 (51%) in the intervention group versus 112 (62%) in the control group had a fetus in cephalic presentation (OR 0.61; 95% CI 0.40-0.95). No adverse events were observed in relation to the intervention.

CONCLUSIONS

In breech or transverse presentation, home-based rebozo exercise before ECV lowered the overall rate of cephalic presentation at birth.

Management of external cephalic version in France: A national practice survey

INTRODUCTION

The breech presentation represents 4,7% of deliveries at term. There is a method of external cephalic version (ECV) performed from 36 weeks of gestation. French guidelines for the clinical practice of ECV were published in 2020.

OBJECTIVE

To evaluate the national practices of ECV in French maternity units, especially on the use of tocolysis, 1 year after publication of the French clinical recommendations guidelines by the French national college of obstetricians and gynecologists (CNGOF).

METHODS

Data self-reported for this national descriptive study were collected from March to May 2021 by an online questionnaire distributed to all French maternities. The 25 items of the questionnaire collected information of maternity units, the general practice of ECV, use or not of tocolysis for ECV attempt and the relevance of a prospective study.

RESULTS

Of the 517 French maternity units, 150 (29%) responded to the online survey.  95,3% systematically performed ECV. A Kleihauer test was routinely performed in 71 units (49.7%). A tocolysis was associated with ECV attempt in 52.4% of cases. The drugs used were intravenous atosiban (30,7%), mainly in levels 2b and 3 maternity units, intravenous salbutamol (24%), other mode of administration of salbutamol (14,7%) and oral nifedipine (22,6%) mainly in levels 1 and 2a maternity units. Adverse effects were described in 20%, mainly with the use of salbutamol (73,3%).

CONCLUSIONS

52.4% of the French maternity units surveyed used tocolysis for the ECV attempt, although it is systematically recommended. The choice of tocolytic drug differed according to the maternity units.

Development of prediction models for successful external cephalic version and delivery outcome

OBJECTIVE

To develop prediction models for the chance of successful external cephalic version (ECV) and delivery outcome.

STUDY DESIGN

This is a single-center retrospective study including 350 pregnant women with a singleton non-cephalic pregnancy at or after 36 weeks of gestational age. We selected 22 factors for ECV prediction and 21 for delivery outcome after successful ECV prediction as candidate predictors. Multivariable logistic regression with a stepwise backward selection procedure was used to construct a prediction model for the chance of successful ECV and the other for the delivery outcome. The discrimination and calibration of the models were assessed and internal validation was done with bootstrapping.

RESULTS

ECV was successfully performed in 232 cases (66.3%) among 343 women. Eight predictive factors were identified to be associated with a successful ECV: Gestational week at ECV < 39 weeks, multiparous, BMI before pregnancy < 22 kg/m³, palpable fetal head, breech engagement, larger AFI, larger BPD and posterior placenta. This model showed good calibration and good discrimination (c-statistic = 0.82, 95% CI 0.76-0.88). Six predictive factors were identified to be associated with vaginal delivery after successful ECV: age < 35, multiparous, BMI before pregnancy < 22 kg/m³, anterior placenta, lateral placenta and none-front fetal spine position. This model showed fair discrimination (c-statistic = 0.79, 95% CI 0.72-0.85). However, its calibration was not so satisfactory especially when the predicted probability was low.

CONCLUSION

We validated a prediction model for ECV and delivery outcome, showing that the model's overall performance is good. This can be used in clinical practice after external validation.

The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study

BACKGROUND

Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation.

METHODS AND FINDINGS

We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists.

CONCLUSIONS

In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.

Effects of external cephalic version for breech presentation at or near term in high-resource settings: A systematic review of randomized and non-randomized studies

INTRODUCTION

External cephalic version (ECV) for breech presentation involves manual manipulation of the fetus from breech to cephalic presentation at or near term, in an attempt to avoid breech birth. This systematic review summarizes the literature on the effects of ECV at or near term on pregnancy outcomes in high-resource settings.

METHODS

The MEDLINE, Embase, CINAHL, Cochrane Library, MIDIRS, and SweMED+ databases were searched for relevant articles published through April 2019, with no limitation on publication date. Clinical trials comparing the effects of ECV at ≥36 weeks, with or without tocolysis, with that of no ECV, conducted in northern, western, and central Europe, the USA, Canada, Australia, and New Zealand were eligible for inclusion.

RESULTS

Nine articles reporting on 184704 breech pregnancies were included. Pooled data showed that ECV attempts reduced the failure to achieve vaginal cephalic birth (risk ratio, RR=0.56; 95% CI: 0.45–0.71), caesarean section performance (RR=0.57; 95% CI: 0.50–0.64), and non-cephalic presentation at birth (RR=0.45; 95% CI: 0.29–0.68) compared with no ECV. ECV attempts also increased the incidence of Apgar score <7 at 5 minutes (RR=1.29; 95% CI: 1.10–1.52).

CONCLUSIONS

Women for whom ECV is attempted at or near term are at reduced risk of caesarean section, non-cephalic presentation at term, and failure to achieve vaginal cephalic birth. Compared with no ECV, attempted ECV was also associated with a slightly increased risk of a low Apgar score at 5 minutes. The evidence is limited by the scarcity of high-quality research and the presence of risks of bias.

Breech presentation delivery care: A review of childbirth semiology, mechanism and care

Objective

To review the concepts underlying breech presentation delivery as well as the semiology and the obstetric maneuvers contributing to a successful perinatal maternal outcome.

Materials and methods

Based on a hypothetical scenario to set the stage for a practical approach to the topic, an explanatory paper built on a narrative review is created in order to examine the principles related to diagnosis, mechanism of delivery and maternal care, emphasizing maneuvers to ease fetal extraction.

Results

Breech presentation delivery must be managed through the vaginal canal when already in the expulsion phase with fetal engagement. For diagnosis and care, it is essential to know the unique semiology and physiology of this condition as well as the obstetric maneuvers to facilitate an uncomplicated delivery.

Results

The mechanism of childbirth in breech presentation is complex and requires knowledge of its physiology and multiple obstetric maneuvers on the part of the obstetrician as well as the general practitioner, in order to ensure adequate care when there is no other option.

External Cephalic Version: A Dying Art Worth Reviving

Purpose

Breech presentation is the most common abnormal presentation occurring in 3-4% of all deliveries. Incidence of caesarean section for breech presentation has increased markedly in the last few decades. Attempting external cephalic version (ECV) reduces the chance of non-cephalic presentation at term, thus reducing the rate of caesarean sections.

Methods

Prospective study was conducted in secondary healthcare centre, in rural set-up from August 2013 to August 2015. A total of 52 patients were enrolled into the study.

Results

ECV was successful in 32 out of 52 patients with overall success of 61.5%. Out of the 32 successful ECVs, 24 patients delivered vaginally (75%) (p value 0.00), 6 patients delivered by caesarean section, and 2 patients were lost to follow-up. Transverse lie had 100% success rate for ECV (p value 0.005). Gravidity, placental position, gestational age and use of tocolytics did not influence the success rate of ECV. Most common problem observed during the procedure was abdominal discomfort.

Conclusion

ECV is a safe procedure with high percentage of patients delivering vaginally after successful version. Hence, acquiring skills in ECV should be considered mandatory in the postgraduate training of future obstetricians.

Robson 10-groups classification system to access C-section in two public hospitals of the Federal District/Brazil

BACKGROUND

The global increase in C-section rates is real. In Brazil, these indices correspond to 58.94% in the Midwest region and 52.77% in the Federal District.

OBJECTIVE

To evaluate the C-section rates and identify the groups with the greatest risk at two reference hospitals in the public network of Federal District/Brazil, using 10-Group Robson System.

METHOD

A cross-sectional study of 6579 births assisted at the Hospital A (HA) and the Hospital B (HB) during 2013. The C-section rates in each group and its respective contribution to the total hospital C-sections was compared between HA and HB. To this, was used the proportion difference test (similar to chi-square test), with RR and 95% CI, and the logistic regression analysis (OR; 95% CI) among the groups with higher C-section/total C-section. The significance limit of p < 0.05 was defined for all tests.

RESULTS

The C-section rates were 50.8% at the HA and 42.3% at the HB, with 1.20 RR (95%CI = 1.13-1.28) at the HA. The highest rates were observed in Robson groups G5, G1, and G2. At the HA, G1 had a 21.5% C-section rate, which was greater than at the HB (13.8%; p < 0.05); the cesarean rates for groups G2 and G5 were higher at the HB (respectively, 18.6 and 38.1%) than at the HA (14.8 and 32.5%, respectively; p < 0.05).

CONCLUSION

These results point out specific goals to be achieved in order to reduce abusive cesarean rates in both A and B hospitals, especially in the primigravida and in those with previous C-section.

External cephalic version experiences in Korea

Objective

The aim of this study was to evaluate obstetric outcomes of external cephalic version (ECV) performed at or near term.

Methods

Single pregnant woman with breech presentation at or near term (n=145), who experienced ECV by one obstetrician from November 2009 to July 2014 in our institution were included in the study. Maternal baseline characteristic and fetal ultrasonographic variables were checked before the procedure. After ECV, the delivery outcomes of the women were gathered. Variables affecting the success or failure of ECV were evaluated.

Results

Success rate of ECV was 71.0% (n=103). Four variables (parity, amniotic fluid index, fetal spine position and rotational direction) were observed to be in correlation with success or failure of ECV. In contactable 83 individuals experienced successful ECV, cesarean delivery rates were 18.1%, 28.9%, and 5.3% in total, nulliparas, and multiparas, respectively.

Conclusion

Based on the results, ECV is proposed to be safe for both mother and her fetus. In addition, it is a valuable procedure that increases probability of vaginal delivery for women with breech presentation.

Interventions to Improve Neonatal Health and Later Survival: An Overview of Systematic Reviews

BACKGROUND

Evidence-based interventions and strategies are needed to improve child survival in countries with a high burden of neonatal and child mortality. An overview of systematic reviews can focus implementation on the most effective ways to increase child survival.

METHODS

In this overview we included published Cochrane and other systematic reviews of experimental and observational studies on antenatal, childbirth, postnatal and child health interventions aiming to prevent perinatal/neonatal and child mortality using the WHO list of essential interventions. We assessed the methodological quality of the reviews using the AMSTAR criteria and assessed the quality of the outcomes using the GRADE approach. Based on the findings from GRADE criteria, interventions were summarized as effective, promising or ineffective.

FINDINGS

The overview identified 148 Cochrane and other systematic reviews on 61 reproductive, maternal, newborn and child health interventions. Of these, only 57 reviews reported mortality outcomes. Using the GRADE approach, antenatal corticosteroids for preventing neonatal respiratory distress syndrome in preterm infants; early initiation of breastfeeding; hygienic cord care; kangaroo care for preterm infants; provision and promotion of use of insecticide treated bed nets (ITNs) for children; and vitamin A supplementation for infants from six months of age, were identified as clearly effective interventions for reducing neonatal, infant or child mortality. Antenatal care, tetanus immunization in pregnancy, prophylactic antimalarials during pregnancy, induction of labour for prolonged pregnancy, case management of neonatal sepsis, meningitis and pneumonia, prophylactic and therapeutic use of surfactant, continuous positive airway pressure for neonatal resuscitation, case management of childhood malaria and pneumonia, vitamin A as part of treatment for measles associated pneumonia for children above 6 months, and home visits across the continuum of care, were identified as promising interventions for reducing neonatal, infant, child or perinatal mortality.

INTERPRETATION

Comprehensive adoption of the above six effective and 11 promising interventions can improve neonatal and child survival around the world. Choice of intervention and degree of implementation currently depends on resources available and policies in individual countries and geographical settings.

FUNDING

This review was part of doctoral thesis which was funded by University of Adelaide, Australia.

Expedited versus conservative approaches for vaginal delivery in breech presentation

BACKGROUND

In a vaginal breech birth there may be benefit from rapid delivery of the baby to prevent progressive acidosis. However, this needs to be weighed against the potential trauma of a quick delivery.

OBJECTIVES

The objective of this review was to assess the effects of expedited vaginal delivery (breech delivery from umbilicus to delivery of the head within one contraction) on perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of expedited vaginal breech delivery compared with delivery not routinely expedited in women undergoing vaginal breech delivery.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the one identified trial for inclusion.If studies are included in future updates, two review authors will assess risk of bias, extract data and check data for accuracy.

MAIN RESULTS

No studies were included.

AUTHORS' CONCLUSIONS

There is not enough evidence to evaluate the effects of expedited vaginal breech delivery.

Neuraxial blockade for external cephalic version: Cost analysis

AIM

Neuraxial blockade (epidural or spinal anesthesia/analgesia) with external cephalic version increases the external cephalic version success rate. Hospitals and insurers may affect access to neuraxial blockade for external cephalic version, but the costs to these institutions remain largely unstudied. The objective of this study was to perform a cost analysis of neuraxial blockade use during external cephalic version from hospital and insurance payer perspectives. Secondarily, we estimated the effect of neuraxial blockade on cesarean delivery rates.

METHODS

A decision-analysis model was developed using costs and probabilities occurring prenatally through the delivery hospital admission. Model inputs were derived from the literature, national databases, and local supply costs. Univariate and bivariate sensitivity analyses and Monte Carlo simulations were performed to assess model robustness.

RESULTS

Neuraxial blockade was cost saving to both hospitals ($30 per delivery) and insurers ($539 per delivery) using baseline estimates. From both perspectives, however, the model was sensitive to multiple variables. Monte Carlo simulation indicated neuraxial blockade to be more costly in approximately 50% of scenarios. The model demonstrated that routine use of neuraxial blockade during external cephalic version, compared to no neuraxial blockade, prevented 17 cesarean deliveries for every 100 external cephalic versions attempted.

CONCLUSIONS

Neuraxial blockade is associated with minimal hospital and insurer cost changes in the setting of external cephalic version, while reducing the cesarean delivery rate.

External cephalic version for breech presentation at term

BACKGROUND

Management of breech presentation is controversial, particularly in regard to manipulation of the position of the fetus by external cephalic version (ECV). ECV may reduce the number of breech presentations and caesarean sections, but there also have been reports of complications with the procedure.

OBJECTIVES

The objective of this review was to assess the effects of ECV at or near term on measures of pregnancy outcome. Methods of facilitating ECV, and ECV before term are reviewed separately.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Trials Register (28 February 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised trials of ECV at or near term (with or without tocolysis) compared with no attempt at ECV in women with breech presentation.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality, and extracted the data.

MAIN RESULTS

We included eight studies, with a total of 1308 women randomised. The pooled data from these studies show a statistically significant and clinically meaningful reduction in non-cephalic presentation at birth (average risk ratio (RR) 0.42, 95% confidence interval (CI) 0.29 to 0.61, eight trials, 1305 women); vaginal cephalic birth not achieved (average RR 0.46, 95% CI 0.33 to 0.62, seven trials, 1253 women, evidence graded very low); and caesarean section (average RR 0.57, 95% CI 0.40 to 0.82, eight trials, 1305 women, evidence graded very low) when ECV was attempted in comparison to no ECV attempted. There were no significant differences in the incidence of Apgar score ratings below seven at one minute (average RR 0.67, 95% CI 0.32 to 1.37, three trials, 168 infants) or five minutes (RR 0.63, 95% CI 0.29 to 1.36, five trials, 428 infants, evidence graded very low), low umbilical vein pH levels (RR 0.65, 95% CI 0.17 to 2.44, one trial, 52 infants, evidence graded very low), neonatal admission (RR 0.80, 95% CI 0.48 to 1.34, four trials, 368 infants, evidence graded very low), perinatal death (RR 0.39, 95% CI 0.09 to 1.64, eight trials, 1305 infants, evidence graded low), nor time from enrolment to delivery (mean difference -0.25 days, 95% CI -2.81 to 2.31, two trials, 256 women).All of the trials included in this review had design limitations, and the level of evidence was graded low or very low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in several studies. Three of the eight trials had serious design limitations, however excluding these studies in a sensitivity analysis for outcomes with substantial heterogeneity did not alter the results.

AUTHORS' CONCLUSIONS

Attempting cephalic version at term reduces the chance of non-cephalic presentation at birth, vaginal cephalic birth not achieved and caesarean section. There is not enough evidence from randomised trials to assess complications of ECV at term. Large observational studies suggest that complications are rare.

Interventions for helping to turn term breech babies to head first presentation when using external cephalic version

BACKGROUND

Breech presentation is associated with increased complications. Turning a breech baby to head first presentation using external cephalic version (ECV) attempts to reduce the chances of breech presentation at birth so as to avoid the adverse effects of breech vaginal birth or caesarean section. Interventions such as tocolytic drugs and other methods have been used in an attempt to facilitate ECV.

OBJECTIVES

To assess, from the best evidence available, the effects of interventions such as tocolysis, acoustic stimulation for midline spine position, regional analgesia (epidural or spinal), transabdominal amnioinfusion, systemic opioids and hypnosis, or the use of abdominal lubricants, on ECV at term for successful version, presentation at birth, method of birth and perinatal and maternal morbidity and mortality.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014) and the reference lists of identified studies.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing the above interventions with no intervention or other methods to facilitate ECV at term.

DATA COLLECTION AND ANALYSIS

We assessed eligibility and trial quality. Two review authors independently assessed for inclusion all potential studies identified as a result of the search strategy and independently extracted the data using a specially designed data extraction form.

MAIN RESULTS

We included 28 studies, providing data on 2786 women. We used the random-effects model for pooling data because of clinical heterogeneity between studies. A number of trial reports gave insufficient information to allow clear assessment of risk of bias. We used GradePro software to carry out formal assessments of quality of the evidence for beta stimulants versus placebo and regional analgesia with tocolysis versus tocolysis alone.Tocolytic parenteral beta stimulants were effective in increasing cephalic presentations in labour (average risk ratio (RR) 1.68, 95% confidence interval (CI) 1.14 to 2.48, five studies, 459 women, low-quality evidence) and in reducing the number of caesarean sections (average RR 0.77, 95% CI 0.67 to 0.88, six studies, 742 women, moderate-quality evidence). Failure to achieve a cephalic vaginal birth was less likely for women receiving a parenteral beta stimulant (average RR 0.75, 95% CI 0.60 to 0.92, four studies, 399 women, moderate-quality evidence). No clear differences in fetal bradycardias were identified, although this was reported for only one study, which was underpowered for assessing this outcome. Failed external cephalic version was reported in nine studies (900 women), and women receiving parenteral beta stimulants were less likely to have failure compared with controls (average RR 0.70, 95% CI 0.60 to 0.82, moderate-quality evidence). Perinatal mortality and serious morbidity were not reported. Sensitivity analysis by study quality was consistent with overall findings.For other classes of tocolytic drugs (calcium channel blockers and nitric oxide donors), evidence was insufficient to permit conclusions; outcomes were reported for only one or two studies, which were underpowered to demonstrate differences between treatment and control groups. Little evidence was found regarding adverse effects, although nitric oxide donors were associated with increased risk of headache. Data comparing different tocolytic drugs were insufficient.Regional analgesia in combination with a tocolytic was more effective than the tocolytic alone for increasing successful versions (assessed by the rate of failed ECVs; average RR 0.61, 95% CI 0.43 to 0.86, five studies, 409 women, moderate-quality evidence), and no difference was identified in cephalic presentation in labour (average RR 1.63, 95% CI 0.75 to 3.53, three studies, 279 women, very low-quality evidence), caesarean sections (average RR 0.74, 95% CI 0.40 to 1.37, three studies, 279 women, very low-quality evidence) nor fetal bradycardia (average RR 1.48, 95% CI 0.62 to 3.57, two studies, 210 women, low-quality evidence), although studies were underpowered for assessing these outcomes. Studies did not report on failure to achieve a cephalic vaginal birth (breech vaginal deliveries plus caesarean sections) nor on perinatal mortality or serious infant morbidity.Data were insufficient on the use of regional analgesia without tocolysis, vibroacoustic stimulation, amnioinfusion, systemic opioids and hypnosis, and on the use of talcum powder or gel to assist external cephalic version, to permit conclusions about their effectiveness and safety.

AUTHORS' CONCLUSIONS

Parenteral beta stimulants were effective in facilitating successful ECV, increasing cephalic presentation in labour and reducing the caesarean section rate, but data on adverse effects were insufficient. Data on calcium channel blockers and nitric acid donors were insufficient to provide good evidence.The scope for further research is clear. Possible benefits of tocolysis in reducing the force required for successful version and possible risks of side effects need to be addressed further. Further trials are needed to compare the effectiveness of routine versus selective use of tocolysis and the role of regional analgesia, fetal acoustic stimulation, amnioinfusion and abdominal lubricants, and the effects of hypnosis, in facilitating ECV. Although randomised trials of nitric oxide donors are small, the results are sufficiently negative to discourage further trials. Intervention fidelity for ECV can be enhanced by standardisation of the techniques and processes used for clinical manipulation of the fetus in the abdominal cavity and ought to be the subject of further research.

Accounting for center in the Early External Cephalic Version trials: an empirical comparison of statistical methods to adjust for center in a multicenter trial with binary outcomes

Background

Clustering of outcomes at centers involved in multicenter trials is a type of center effect. The Consolidated Standards of Reporting Trials Statement recommends that multicenter randomized controlled trials (RCTs) should account for center effects in their analysis, however most do not. The Early External Cephalic Version (EECV) trials published in 2003 and 2011 stratified by center at randomization, but did not account for center in the analyses, and due to the nature of the intervention and number of centers, may have been prone to center effects. Using data from the EECV trials, we undertook an empirical study to compare various statistical approaches to account for center effect while estimating the impact of external cephalic version timing (early or delayed) on the outcomes of cesarean section, preterm birth, and non-cephalic presentation at the time of birth.

Methods

The data from the EECV pilot trial and the EECV2 trial were merged into one dataset. Fisher’s exact method was used to test the overall effect of external cephalic version timing unadjusted for center effects. Seven statistical models that accounted for center effects were applied to the data. The models included: i) the Mantel-Haenszel test, ii) logistic regression with fixed center effect and fixed treatment effect, iii) center-size weighted and iv) un-weighted logistic regression with fixed center effect and fixed treatment-by-center interaction, iv) logistic regression with random center effect and fixed treatment effect, v) logistic regression with random center effect and random treatment-by-center interaction, and vi) generalized estimating equations.

Results

For each of the three outcomes of interest approaches to account for center effect did not alter the overall findings of the trial. The results were similar for the majority of the methods used to adjust for center, illustrating the robustness of the findings.

Conclusions

Despite literature that suggests center effect can change the estimate of effect in multicenter trials, this empirical study does not show a difference in the outcomes of the EECV trials when accounting for center effect.

Trial registration

The EECV2 trial was registered on 30 July 30 2005 with Current Controlled Trials: ISRCTN%2056498577.

Midwifery and quality care: findings from a new evidence-informed framework for maternal and newborn care

In this first paper in a series of four papers on midwifery, we aimed to examine, comprehensively and systematically, the contribution midwifery can make to the quality of care of women and infants globally, and the role of midwives and others in providing midwifery care. Drawing on international definitions and current practice, we mapped the scope of midwifery. We then developed a framework for quality maternal and newborn care using a mixed-methods approach including synthesis of findings from systematic reviews of women's views and experiences, effective practices, and maternal and newborn care providers. The framework differentiates between what care is provided and how and by whom it is provided, and describes the care and services that childbearing women and newborn infants need in all settings. We identified more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery; reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth, decreased number of unnecessary interventions, and improved psychosocial and public health outcomes. Midwifery was associated with more efficient use of resources and improved outcomes when provided by midwives who were educated, trained, licensed, and regulated. Our findings support a system-level shift from maternal and newborn care focused on identification and treatment of pathology for the minority to skilled care for all. This change includes preventive and supportive care that works to strengthen women's capabilities in the context of respectful relationships, is tailored to their needs, focuses on promotion of normal reproductive processes, and in which first-line management of complications and accessible emergency treatment are provided when needed. Midwifery is pivotal to this approach, which requires effective interdisciplinary teamwork and integration across facility and community settings. Future planning for maternal and newborn care systems can benefit from using the quality framework in planning workforce development and resource allocation.

Essential pre-pregnancy and pregnancy interventions for improved maternal, newborn and child health

The statistics related to pregnancy and its outcomes are staggering: annually, an estimated 250000-280000 women die during childbirth. Unfortunately, a large number of women receive little or no care during or before pregnancy. At a period of critical vulnerability, interventions can be effectively delivered to improve the health of women and their newborns and also to make their pregnancy safe. This paper reviews the interventions that are most effective during preconception and pregnancy period and synergistically improve maternal and neonatal outcomes. Among pre-pregnancy interventions, family planning and advocating pregnancies at appropriate intervals; prevention and management of sexually transmitted infections including HIV; and peri-conceptual folic-acid supplementation have shown significant impact on reducing maternal and neonatal morbidity and mortality. During pregnancy, interventions including antenatal care visit model; iron and folic acid supplementation; tetanus Immunisation; prevention and management of malaria; prevention and management of HIV and PMTCT; calcium for hypertension; anti-Platelet agents (low dose aspirin) for prevention of Pre-eclampsia; anti-hypertensives for treating severe hypertension; management of pregnancy-induced hypertension/eclampsia; external cephalic version for breech presentation at term (>36 weeks); management of preterm, premature rupture of membranes; management of unintended pregnancy; and home visits for women and children across the continuum of care have shown maximum impact on reducing the burden of maternal and newborn morbidity and mortality. All of the interventions summarized in this paper have the potential to improve maternal mortality rates and also contribute to better health care practices during preconception and periconception period.

Essential interventions: implementation strategies and proposed packages of care

In an effort to accelerate progress towards achieving Millennium Development Goal (MDG) 4 and 5, provision of essential reproductive, maternal, newborn and child health (RMNCH) interventions is being considered. Not only should a state-of-the-art approach be taken for services delivered to the mother, neonate and to the child, but services must also be deployed across the household to hospital continuum of care approach and in the form of packages. The paper proposed several packages for improved maternal, newborn and child health that can be delivered across RMNCH continuum of care. These packages include: supportive care package for women to promote awareness related to healthy pre-pregnancy and pregnancy interventions; nutritional support package for mother to improve supplementation of essential nutrients and micronutrients; antenatal care package to detect, treat and manage infectious and noninfectious diseases and promote immunization; high risk care package to manage preeclampsia and eclampsia in pregnancy; childbirth package to promote support during labor and importance of skilled birth attendance during labor; essential newborn care package to support healthy newborn care practices; and child health care package to prevent and manage infections. This paper further discussed the implementation strategies for employing these interventions at scale.

Talcum powder or aqueous gel to aid external cephalic version: a randomised controlled trial

BACKGROUND

External cephalic version (ECV) is offered to reduce the number of Caesarean delivery indicated by breech presentation which occurs in 3-4% of term pregnancies. ECV is commonly performed aided by the application of aqueous gel or talcum powder to the maternal abdomen. We sought to compare gel with powder during ECV on achieving successful version and increasing tolerability.

METHOD

We enrolled 95 women (≥ 36 weeks gestation) on their attendance for planned ECV. All participants received terbutaline tocolysis. Regional anaesthesia was not used. ECV was performed in the standard fashion after the application of the allocated aid. If the first round (maximum of 2 attempts) of ECV failed, crossover to the opposing aid was permitted.

RESULTS

48 women were randomised to powder and 47 to gel. Self-reported procedure related median [interquartile range] pain scores (using a 10-point visual numerical rating scale VNRS; low score more pain) were 6 [5-9] vs. 8 [7-9] P = 0.03 in favor of gel. ECV was successful in 21/48 (43.8%) vs. 26/47 (55.3%) RR 0.6 95% CI 0.3-1.4 P = 0.3 for powder and gel arms respectively. Crossover to the opposing aid and a second round of ECV was performed in 13/27 (48.1%) following initial failure with powder and 4/21 (19%) after failure with gel (RR 3.9 95% CI 1.0-15 P = 0.07). ECV success rate was 5/13 (38.5%) vs. 1/4 (25%) P = 0.99 after crossover use of gel or powder respectively. Operators reported higher satisfaction score with the use of gel (high score, greater satisfaction) VNRS scores 6 [4.25-8] vs 8 [7-9] P = 0.01.

CONCLUSION

Women find gel use to be associated with less pain. The ECV success rate is not significantly different.

TRIAL REGISTRATION

The trial is registered with ISRCTN (identifier ISRCTN87231556).

Anesthetic management of external cephalic version

Breech presentation is common at term and its reduction through external cephalic version represents a noninvasive opportunity to avoid cesarean delivery and the associated maternal morbidity. In addition to uterine relaxants, neuraxial anesthesia is associated with increased success of version procedures when surgical anesthetic dosing is used. The intervention is likely cost effective given the effect size and the avoided high costs of cesarean delivery.

Why We Do Caesars: A Comparison of the Trends in Caesarean Section Delivery over a Decade

Introduction: In the United Kingdom, caesarean section (CS) rates have increased from 9% of deliveries in 1980 to 21% in 2001. A similar increase in CS rates has been seen in many developed countries. This is beyond the World Health Organisation’s (WHO’s) recommended level of 15%. This is a worrying trend as the risks of placenta previa, placenta accreta, hysterectomies, bladder and bowel injuries are increased with subsequent CS. We aim to ascertain the commonest indications for CS in a tertiary hospital and make recommendations to decrease future CS rates. Materials and Methods: This retrospective analysis compares the 5 most common indications for CS in 1999 and 2009. CS rates in the 2 study periods are tabulated and analysed as well. Results: In the first study period between January and December 1999, there were 2048 deliveries of which 365 were via CS. In the second study period of a decade later from January to December 2009, there were 1572 deliveries of which 531 were via CS. This gives an increase in CS rate from 17.8% in 1999 to 34% in 2009. The main indications for CS in 1999 were: cephalopelvic disproportion (18.6%), breech (14.2%), non-reassuring fetal status (11.8%), 1 previous CS (11.2%) and pregnancy-induced hypertension/pre-eclampsia/eclampsia (6.6%). The main indications for CS in 2009 were: 1 previous CS (18.1%), non-reassuring fetal status (12.2%), cephalopelvic disproportion (10.5%), 2 or more previous CS (7.9%) and breech (7.7%). Conclusion: There is a significant increase in CS rates over the last decade with an increased percentage of CS done because of a previous CS. This is associated with increased risk of complications as well. Recommendations are suggested with the view to decrease future CS rates. Key words: Breech, Cephalopelvic disproportion, Non-reassuring fetal status, Previous caesarean section

Development of quality of care indicators from systematic reviews: the case of hospital delivery

BACKGROUND

The objective of this research is to generate quality of care indicators from systematic reviews to assess the appropriateness of obstetric care in hospitals.

METHODS

A search for systematic reviews about hospital obstetric interventions, conducted in The Cochrane Library, clinical evidence and practice guidelines, identified 303 reviews. We selected 48 high-quality evidence reviews, which resulted in strong clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The 255 remaining reviews were excluded, mainly due to a lack of strong evidence provided by the studies reviewed.

RESULTS

A total of 18 indicators were formulated from these clinical recommendations, on antepartum care (8), care during delivery and postpartum (9), and incomplete miscarriage (1). Authors of the systematic reviews and specialists in obstetrics were consulted to refine the formulation of indicators.

CONCLUSIONS

High-quality systematic reviews, whose conclusions clearly claim in favour or against an intervention, can be a source for generating quality indicators of delivery care. To make indicators coherent, the nuances of clinical practice should be considered. Any attempt made to evaluate the extent to which delivery care in hospitals is based on scientific evidence should take the generated indicators into account.

A qualitative interview study exploring pregnant women's and health professionals' attitudes to external cephalic version

Background

Women who have a breech presentation at term have to decide whether to attempt external cephalic version (ECV) and how they want to give birth if the baby remains breech, either by planned caesarean section (CS) or vaginal breech birth. The aim of this study was to explore the attitudes of women with a breech presentation and health professionals who manage breech presentation to ECV.

Methods

We carried out semi-structured interviews with pregnant women with a breech presentation (n=11) and health professionals who manage breech presentation (n=11) recruited from two hospitals in North East England. We used purposive sampling to include women who chose ECV and women who chose planned CS. We analysed data using thematic analysis, comparing between individuals and seeking out disconfirming cases.

Results

Four main themes emerged from the data collected during interviews with pregnant women with a breech presentation: ECV as a means of enabling natural birth; concerns about ECV; lay and professional accounts of ECV; and breech presentation as a means of choosing planned CS. Some women’s attitudes to ECV were affected by their preferences for how to give birth. Other women chose CS because ECV was not acceptable to them. Two main themes emerged from the interview data about health professionals’ attitudes towards ECV: directive counselling and attitudes towards lay beliefs about ECV and breech presentation.

Conclusions

Women had a range of attitudes to ECV informed by their preferences for how to give birth; the acceptability of ECV to them; and lay accounts of ECV, which were frequently negative. Most professionals described having a preference for ECV and reported directively counselling women to choose it. Some professionals were dismissive of lay beliefs about ECV. Some key challenges for shared decision making about breech presentation were identified: health professionals counselling women directively about ECV and the differences between evidence-based information about ECV and lay beliefs. To address these challenges a number of approaches will be required.