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Yaouzis Olsson N, Bartfai ED, Åmark H, Wallström T. Outcomes in term breech birth according to intended mode of delivery-A Swedish prospective single-center experience of a dedicated breech birth team. Acta Obstet Gynecol Scand 2024. [PMID: 39129446 DOI: 10.1111/aogs.14945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/22/2024] [Accepted: 07/24/2024] [Indexed: 08/13/2024]
Abstract
INTRODUCTION The appropriate mode of delivery for breech babies is a topic of ongoing debate. After the publication of the Term Breech Trial in 2000, the proportion of breech babies delivered vaginally in Sweden rapidly dropped to 7% from 26%. In 2015, international guidelines changed to once again recommend offering vaginal breech deliveries in select cases. In 2017, a Swedish hospital established a dedicated Breech Team to provide safe vaginal breech deliveries according to the new guidelines. The aim of this study is to compare neonatal morbidity in the group planned for cesarean breech delivery with the group planned for vaginal breech delivery treated in accordance with the new guidelines. The study adds to the literature by providing insights into the consequences of reintroducing vaginal breech births in a high-resource health-care setting. MATERIAL AND METHODS A prospective observational study was conducted at Södersjukhuset's maternity ward with 1067 women who gave birth to a single breech fetus at term. Outcomes were compared between the planned vaginal and planned cesarean delivery groups using intention-to-treat analysis and multivariate analysis to control for confounders. RESULTS Out of the 1067 women, 78.9% were planned for cesarean delivery and 21.1% were planned for vaginal delivery. The planned vaginal group had a significantly greater risk for neonatal morbidity compared to the planned cesarean group (3.1% vs. 0.7%; OR 4.44, 95% CI 1.48-13.34). The risk difference remained significant after controlling for confounders. CONCLUSIONS Planned vaginal breech delivery was associated with an increased risk of neonatal mortality and short-term morbidity compared to planned cesarean breech delivery in accordance with the new guidelines. The potential risks and benefits of planned vaginal breech delivery should be carefully weighed against those of planned cesarean delivery.
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Affiliation(s)
- Nicolas Yaouzis Olsson
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Emma Debora Bartfai
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Hanna Åmark
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
| | - Tove Wallström
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, Karolinska Institutet, Stockholm, Sweden
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Schafer R, Bovbjerg ML, Cheyney M, Phillippi JC. Maternal and neonatal outcomes associated with breech presentation in planned community (home and birth center) births in the United States: A prospective observational cohort study. PLoS One 2024; 19:e0305587. [PMID: 39037977 PMCID: PMC11262641 DOI: 10.1371/journal.pone.0305587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 06/01/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVE Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States, including outcomes associated with types of breech presentation (i.e., frank, complete, footling/kneeling). DESIGN Secondary analysis of prospective cohort data from a national perinatal data registry (MANA Stats). SETTING Planned community birth (homes and birth centers), United States. SAMPLE Individuals with a term, singleton gestation (N = 71,943) planning community birth at labor onset. METHODS Descriptive statistics to calculate associations between types of breech presentation and maternal and neonatal outcomes. MAIN OUTCOME MEASURES Maternal: intrapartum/postpartum transfer, hospitalization, cesarean, hemorrhage, severe perineal laceration, duration of labor stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death. RESULTS One percent (n = 695) of individuals experienced breech birth (n = 401, 57.6% vaginally). Most fetuses presented frank breech (57%), with 19% complete, 18% footling/kneeling, and 5% unknown type of breech presentation. Among all breech labors, there were high rates of intrapartum transfer and cesarean birth compared to cephalic presentation (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of care integration into the health system. For all types of breech presentations, there was increased risk for nearly all assessed neonatal outcomes including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after congenital anomalies were excluded. CONCLUSIONS All types of breech presentations in community birth settings are associated with increased risk of adverse neonatal outcomes. These research findings contribute to informed decision-making and reinforce the need for breech training and research and an increase in accessible, high-quality care for planned vaginal breech birth in US hospitals.
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Affiliation(s)
- Robyn Schafer
- Division of Advanced Nursing Practice, School of Nursing, Rutgers University, Newark, NJ, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States of America
| | - Marit L. Bovbjerg
- Epidemiology Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, United States of America
| | - Melissa Cheyney
- Department of Anthropology, Oregon State University, Corvallis, OR, United States of America
| | - Julia C. Phillippi
- School of Nursing, Vanderbilt University, Nashville, TN, United States of America
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Ho AK, Zamperoni KE, Ho AMH, Mizubuti GB. Introducing the fragility index-A case study using the Term Breech Trial. Birth 2023; 50:11-15. [PMID: 36576726 DOI: 10.1111/birt.12698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 12/29/2022]
Abstract
The fragility index (FI) is a sensitivity analysis of the statistically significant result of a clinical study. It is the number of hypothetical changes in the primary event of one of the two cohorts in a 1-to-1 comparative trial to render the statistically significant result non-significant (ie, to alter the P-value from ≤0.05 to >0.05). The FI can be compared with the patient drop-out rates and protocol violations, which, if much higher than the FI, may arguably suggest less robustness/stability of the trial's results. To illustrate the concept, we have chosen the Term Breech Trial (TBT) as a case study. The TBT results favor planned cesarean birth, as opposed to planned vaginal delivery, in the term singleton fetus with breech presentation. Our analysis shows that the FI of the TBT is 21, which is small in comparison to the number (hundreds) of protocol violations present. Some experts have suggested the inclusion of the FI in data analysis and subsequent discussion of clinical trial data. Routine use of such a metric may be valuable in encouraging readers to maintain a healthy degree of skepticism, especially when interpreting trial results which may directly influence clinical practice.
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Affiliation(s)
- Adrienne K Ho
- Department of Public Health Sciences (Epidemiology), Queen's University School of Medicine, Kingston, Ontario, Canada
| | | | - Anthony M H Ho
- Department of Anesthesiology and Perioperative Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Glenio B Mizubuti
- Department of Anesthesiology and Perioperative Medicine, Queen's University School of Medicine, Kingston, Ontario, Canada
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Panda S, Begley C, Daly D. Clinicians' views of factors influencing decision-making for CS for first-time mothers-A qualitative descriptive study. PLoS One 2022; 17:e0279403. [PMID: 36576912 PMCID: PMC9797090 DOI: 10.1371/journal.pone.0279403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 12/07/2022] [Indexed: 12/29/2022] Open
Abstract
Clinicians' perspectives of the reasons for performing caesarean section (CS) are fundamental to deepening knowledge and understanding of factors influencing decision-making for CS. The aim of this study was to explore midwives' and obstetricians' views of factors influencing decision-making for CS for first-time mothers. A qualitative descriptive study with semi-structured one-to-one audio-recorded interviews was used to gather data from clinicians (15 midwives and 20 senior obstetricians). Following research ethics committee approval, clinicians, who were directly involved in the decision-making process for CS during the period of data collection, were purposively selected from three maternity units in the Republic of Ireland between June 2016 to July 2017. The interviews were transcribed verbatim and analysed thematically. Three interrelated themes with several subthemes reflective of clinicians' views and experiences emerged following data analysis. These were: 'A fear factor' describing clinicians' fear of adverse outcomes and subsequent litigation, 'Personal preferences versus a threshold-clinician driven factors emphasising the influence of clinicians' personal beliefs, and 'Standardised versus individualised care-a system perspective' explaining the effects of, or lack of, organisational policy and its direct and indirect impact on the decision-making process. Findings show that decisions to perform a CS are, on occasion, based on clinicians' personal beliefs and interpretation, similar to findings from other published literature. Consideration of broader issues related to organisational, socio-cultural and political context is essential when seeking solutions to the rising CS rates. The findings will enable clinicians to reflect on their day-to-day practice, in order to look for modifiable factors that influence their decision-making, and help women understand the multitude of factors that can lead to a decision to perform a CS. Findings will also contribute to the development of the 'next step action' and assist in devising future intervention studies to reduce any unnecessary CSs.
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Affiliation(s)
- Sunita Panda
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
- * E-mail:
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Deirdre Daly
- School of Nursing and Midwifery, Trinity College Dublin, Dublin, Ireland
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Panda S, Begley C, Corcoran P, Daly D. Factors associated with cesarean birth in nulliparous women: A multicenter prospective cohort study. Birth 2022; 49:812-822. [PMID: 35695041 PMCID: PMC9796356 DOI: 10.1111/birt.12654] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/28/2021] [Accepted: 05/09/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND There is widespread concern around the rising rates of cesarean births (CBs), especially among first-time mothers, despite evidence suggesting increased morbidities after birth by cesarean. There are uncertainties around factors associated with rising rates of CBs among first-time mothers in Ireland, and insight into these is essential for understanding the rising trend in CBs. Therefore, this study aimed to identify the factors associated with CBs in nulliparous women. METHODS A prospective cohort study was conducted in three maternity hospitals in the Republic of Ireland between 2012 and 2017. Data were collected from 3047 nulliparous women using self-administered surveys antenatally and at 3 months postpartum and from consenting women's hospital records (n = 2755) and analyzed using the Poisson regression to assess associations between demographic and clinical factors and the main outcome measures, planned and unplanned CBs. RESULTS Common risk factors for planned and unplanned CBs were being aged ≥40 years, being in private care, multiple pregnancy, and fetus in breech or other malpresentations. An unplanned CB occurred for 22.43% (n = 377/1681) of women who did not have induction of labor (IOL) or who had IOL with no epidural, but the risk was about twice as high for women who had IOL and epidural. CONCLUSIONS Findings confirm multifactorial reasons for CB and the challenge of reversing the increasing CB rate if maternal age, overweight/obesity, infertility treatment, multiple pregnancy, and preexisting hypertension in Ireland continue to increase. There is a need to address prelabor interventions, especially IOL combined with epidural analgesia with respect to unplanned CB.
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Affiliation(s)
- Sunita Panda
- School of Nursing and MidwiferyTrinity College DublinDublinIreland
| | - Cecily Begley
- School of Nursing and MidwiferyTrinity College DublinDublinIreland
| | - Paul Corcoran
- National Perinatal Epidemiology CentreUniversity College CorkCorkIreland
| | - Deirdre Daly
- School of Nursing and MidwiferyTrinity College DublinDublinIreland
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Fruscalzo A, Londero AP, Gerleve H, Riedel N, Jaspers KD. Short-term neonatal outcomes in vaginal breech delivery: Results of a retrospective single-centre study. Eur J Obstet Gynecol Reprod Biol 2022; 279:122-129. [DOI: 10.1016/j.ejogrb.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/06/2022] [Accepted: 10/25/2022] [Indexed: 11/25/2022]
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Bevilacqua E, Jani JC, Meli F, Carlin A, Bonanni G, Rimbault M, Ruggiano I, Quenon C, Romanzi F, Lanzone A, Badr DA. Pregnancy outcomes in breech presentation at term: a comparison between 2 third level birth center protocols. AJOG GLOBAL REPORTS 2022; 2:100086. [DOI: 10.1016/j.xagr.2022.100086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Wängberg Nordborg J, Svanberg T, Strandell A, Carlsson Y. Term breech presentation-Intended cesarean section versus intended vaginal delivery-A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2022; 101:564-576. [PMID: 35633052 DOI: 10.1111/aogs.14333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 12/24/2021] [Accepted: 01/07/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Three per cent of all infants are born in breech presentation, still the preferred way to deliver them remains controversial. The objective of this systematic review was to assess the safety for the mother and child depending on intended mode of delivery when the baby is in breech position at term. MATERIAL AND METHODS The population (P) was pregnant women with a child in breech presentation, from gestational week 34+0 . The intervention (I) was the intention to deliver by cesarean section, the comparison (C) was the intention to deliver vaginally. Outcomes (O) were perinatal mortality, perinatal morbidity, maternal mortality, maternal morbidity, conversion of delivery mode, and the mother's experience. Systematic literature searches were performed. We included randomized trials, cohort studies with more than 500 women/group and case series for more than 15 000 women published between 1990 and October 2021, written in English or the Nordic languages. The certainty of evidence was assessed using the GRADE approach and data were pooled in meta-analyses. PROSPERO registration number: CRD42020209546. RESULTS Thirty-two articles were included (with 530 604 women). The certainty of evidence was moderate or low because the study designs were mostly retrospective cohort studies. The only randomized trial showed reduced risk of perinatal mortality for planned cesarean section, risk ratio (RR) 0.27 (95% confidence interval [CI] 0.08-0.97, 2078 women, low certainty of evidence), stillbirths excluded. A meta-analysis of cohort studies resulted in a similar estimate, RR 0.36 (95% CI 0.25-0.51, 21 studies, 388 714 women, low certainty of evidence). We also found reduced risk for outcomes representing perinatal morbidity 0-28 days: 5-min Apgar score less than 7 in one randomized controlled trial: RR 0.27 (95% CI 0.12-0.58, 2033 women, moderate certainty of evidence), and in a meta-analysis: RR 0.1 (95% CI 0.14-0.26, 18 studies, 217 024 women, moderate certainty of evidence); APGAR score less than 4 at 5 min: RR 0.39 (95% CI 0.19-0.81, five studies, 44 498 women, low certainty of evidence); and pH less than 7.0: RR 0.23 (95% CI 0.12-0.43, four studies, 13 440 women, low certainty of evidence). Outcomes for the mother were similar in the groups except for reduced risk for experience of urinary incontinence in the group of planned cesarean section: RR 0.62 (95% CI 0.41-0.93, one study, 1940 women, low certainty of evidence). The conversion rate from planned vaginal delivery to emergency cesarean section ranged from 16% to 51% (median 41.8%, 10 studies, 50 763 women, moderate certainty of evidence). CONCLUSIONS Intended cesarean section may reduce the risk of perinatal mortality and perinatal as well as some maternal morbidity compared with intended vaginal delivery. It is uncertain whether there is any difference in maternal mortality. The conversion rate from intended vaginal delivery to emergency cesarean section is high.
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Affiliation(s)
- Julia Wängberg Nordborg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Therese Svanberg
- HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Medical Library, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annika Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,HTA-centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Ylva Carlsson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Gothenburg Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Zamstein O, Glusman Bendersky A, Sheiner E, Landau D, Levy A. Association Between Mode of Delivery of the Breech Fetus and Hospitalizations Due to Inflammatory Bowel Disease During Childhood. J Clin Gastroenterol 2022; 56:e161-e165. [PMID: 34049380 DOI: 10.1097/mcg.0000000000001565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/11/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND GOALS While evidence suggests short-term benefits in neonatal morbidity and mortality from cesarean delivery of the fetus in breech presentation, the long-term implications for the offspring are less clear. To assess the implications of the mode of delivery on offspring's health, we have evaluated the long-term gastrointestinal (GI) morbidity of offspring with a breech presentation delivered in either way. MATERIALS AND METHODS A population-based retrospective cohort study including singleton deliveries in breech presentation occurring between 1991 and 2014 at a tertiary referral hospital. Incidence of hospitalizations of the offspring up to the age of 18 years involving GI morbidity was compared between those delivered via cesarean section or vaginally. A Kaplan-Meier survival curve compared cumulative GI morbidity. A Weibull parametric survival model controlled for confounders while accounting for repeated occurrence of mothers and dependence among siblings. RESULTS Overall, 86.9% (n=6376) of the 7337 fetuses in breech presentation, were delivered abdominally. Hospitalizations involving GI morbidity were higher in offspring delivered by cesarean section, specifically due to inflammatory bowel disease (IBD). Kaplan-Meier survival curve revealed the higher cumulative incidence of total GI morbidity and IBD specifically in the cesarean delivery group (P<0.001 and P=0.004, respectively). Using a Weibull parametric while controlling for relevant confounders, cesarean delivery emerged as an independent risk factor for long-term IBD-related morbidity of the offspring delivered in breech presentation (adjusted hazard ratio=3.18, 95% confidence interval: 1.47-6.87, P=0.003). CONCLUSION Cesarean delivery is associated with higher rates of hospitalizations due to IBD and total GI morbidity during childhood in term singleton in breech presentation.
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Affiliation(s)
| | - Ahinoam Glusman Bendersky
- The Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | | | | | - Amalia Levy
- The Department of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Morris SE, Sundin D, Geraghty S. Women’s experiences of breech birth decision making: An integrated review. Eur J Midwifery 2022; 6:2. [PMID: 35118350 PMCID: PMC8784975 DOI: 10.18332/ejm/143875] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Currently, caesarean section is the primary mode of birth for a breech presenting fetus, leading to a deskilling of clinicians and limitation of birth choices for women. The aim of this review is to present a synthesized summary of existing literature related to women’s experiences of breech birth mode decision-making. METHODS A systematic search of the literature was conducted in April 2021, utilizing five databases to identify and obtain peer-reviewed articles meeting the predetermined selection criteria. RESULTS Four major categories were synthesized from the integrated review: 1) Women who desire a vaginal birth may experience a range of negative emotions such as feelings of disempowerment, loss, uncertainty and a sense of isolation; 2) Women who experience a breech presentation at term experience significant pressures to conform to expectations of medical professionals and their families due to perceptions of risk related to breech birth; 3) Breech birth decision-making in a limiting system; and 4) Overall satisfaction with the decision to plan a vaginal breech birth. CONCLUSION Women with a breech presenting fetus at term experience a complex range of emotions and internal and external pressures due to perceptions of risk around breech birth. Midwives were seen as helpful throughout the breech experience. The reduced caesarean section rate for breech, observed in studies exploring specialized care pathways or dedicated services, could reduce the incidence of Severe Acute Maternal Morbidity.
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Affiliation(s)
- Sara E. Morris
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
- King Edward Memorial Hospital, Perth, Australia
| | - Deborah Sundin
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
| | - Sadie Geraghty
- School of Nursing and Midwifery, Edith Cowan University, Perth, Australia
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Morris S, Geraghty S, Sundin D. Breech presentation management: A critical review of leading clinical practice guidelines. Women Birth 2021; 35:e233-e242. [PMID: 34253466 DOI: 10.1016/j.wombi.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/23/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
PROBLEM Clinical practice guidelines are designed to guide clinicians and consumers of maternity services in clinical decision making, but recommendations are often consensus based and differ greatly between leading organisations. BACKGROUND Breech birth is a divisive clinical issue, however vaginal breech births continue to occur despite a globally high caesarean section rate for breech presenting fetuses. Inconsistencies are known to exist between clinical practice guidelines relating to the management of breech presentation. AIM The aim of this review was to critically evaluate and compare leading obstetric clinical practice guidelines related to the management of breech presenting fetuses. METHODS Leading obstetric guidelines were purposively obtained for review. Analysis was conducted using the International Centre for Allied Health Evidence (iCAHE) Guideline Quality Checklist and reviewing the content of each guideline. FINDINGS Antenatal care recommendations and indications for Caesarean Section were relatively consistent between clinical guidelines. However, several inconsistencies were found among the other recommendations in terms of birth mode counselling, intrapartum management and the basis for recommendations. DISCUSSION Inconsistencies noted in the clinical practice guidelines have the potential to cause issues related to valid consent and create confusion among clinicians and maternity consumers. CONCLUSION Clinical practice guidelines, which focus on the risks of a Vaginal Breech Birth without also discussing the risks of a Caesarean Section when a breech presentation is diagnosed, has the potential to sway clinician attitudes and impact birth mode decision-making in maternity consumers. To respect pregnant women's autonomy and fulfil the legal requirements of consent, clinicians should provide balanced counselling.
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Affiliation(s)
- Sara Morris
- Edith Cowan University; King Edward Memorial Hopsital.
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Morris S, Geraghty S, Sundin D. Women’s experiences of breech birth and disciplinary power. J Adv Nurs 2021; 77:3116-3131. [DOI: 10.1111/jan.14832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/25/2021] [Accepted: 03/07/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sara Morris
- Edith Cowan University Joondalup Western Australia
- King Edward Memorial Hospital Subiaco Western Australia
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13
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Morris S, Geraghty S, Sundin D. Development of a Breech-Specific Integrated Care Pathway for Pregnant Women: Protocol for a Mixed Methods Study. JMIR Res Protoc 2021; 10:e23514. [PMID: 33620329 PMCID: PMC7943339 DOI: 10.2196/23514] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 01/19/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section. OBJECTIVE This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women's experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback. METHODS A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals' knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time. RESULTS Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete. CONCLUSIONS The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/23514.
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Affiliation(s)
- Sara Morris
- King Edward Memorial Hospital, Subiaco, Australia.,Edith Cowan University, Joondalup, Australia
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Lawrence ER, Appiah-Kubi A, Konney TO, Bell SG, Tawiah A, Compton SD. Preferences and perspectives on vaginal breech delivery in Ghana. Int J Gynaecol Obstet 2020; 153:307-314. [PMID: 33188705 DOI: 10.1002/ijgo.13478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/08/2020] [Accepted: 11/11/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate obstetrician/gynecologist and midwife perspectives and experiences with vaginal breech deliveries in Ghana. METHODS Respondents completed a survey on their experiences, training, comfort levels, and decision making about vaginal breech deliveries. Comparisons were made across obstetricians/gynecologists and midwives. Multiple logistic regression explored predictors of comfort performing vaginal breech deliveries. RESULTS Respondents comprised 93 (36.5%) obstetricians/gynecologists and 162 (63.5%) midwives. Most believed that some breech fetuses should be delivered vaginally, with higher agreement from obstetricians/gynecologists than from midwives (n = 86, 97.7% versus n = 207, 80.8%, P = 0.001). Midwives were more likely to strongly agree that training was adequate for obstetricians/gynecologists (n = 65, 55.6% versus n = 8, 9.8%, P < 0.001) and midwives (n = 60, 49.6% versus n = 6, 7.4%, P < 0.001). Most (n = 192, 94%) respondents wanted more experience and/or training. Despite most providers performing only one ot five breech vaginal deliveries yearly, 77.4% (n = 199) were comfortable performing them and 79.5% (n = 202) were comfortable supervising them. Significant predictors of comfort performing vaginal breech delivery were perceived adequacy of training (odds ratio 8.74, 95% CI 3.39-22.52) and belief that vaginal breech deliveries should be performed (odds ratio 4.28, 95% CI 1.33-13.72). CONCLUSION Respondents were more likely to feel comfortable performing breech vaginal deliveries if they felt that their training was adequate. Vaginal breech deliveries can only be offered as safe alternatives to cesarean delivery if training and experience are maintained in low-resource settings.
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Affiliation(s)
- Emma R Lawrence
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Adu Appiah-Kubi
- School of Medicine Department of Obstetrics and Gynecology, University of Health and Allied Sciences, Ho, Ghana
| | - Thomas O Konney
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Sarah G Bell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - Augustine Tawiah
- Department of Obstetrics and Gynecology, Gynecologic Oncology Unit, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Sarah D Compton
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Al Naimi A, Mouzakiti N, Hondrich M, Louwen F, Bahlmann F. The B-mode sonographic evaluation of the post-caesarean uterine wall and its methodology: A study protocol. J Obstet Gynaecol Res 2020; 46:2547-2551. [PMID: 33094538 DOI: 10.1111/jog.14492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/06/2020] [Accepted: 09/02/2020] [Indexed: 12/20/2022]
Abstract
AIM The aim of this study is to utilize the niche measurement guidelines outlined by Jordans et al. in order to establish normal values and accurate description of caesarean section scars in a normal population. After defining the normal distribution, abnormal pregestational scar characteristics will be identified for predicting adverse pregnancy outcomes. METHODS This is a prospective observational multicenter clinical study where women with a history of only one caesarean section and yet open family planning are enrolled. The uterine length, cervical length, niche length, niche depth, niche width, residual myometrial thickness, endometrial thickness, scar to internal os distance, anterior myometrial thickness superior and inferior to the scar and the posterior myometrial thickness opposite the scar, superior and inferior to it are measured in a pregestational uterus. The lower uterine segment is measured over a length of 3 cm during subsequent pregnancy and followed up until delivery. RESULTS Data from 500 patients will yield normal distribution curves for all predefined measurements. Establishing a correlation between deviations from the normal measures and adverse events would be instrumental for counseling women regarding subsequent pregnancy and mode of delivery. CONCLUSION This study will demonstrate the changes of the post-caesarean scar from a non-pregnant uterus until delivery and can confirm the importance of the scar characteristics in predicting pregnancy outcome.
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Affiliation(s)
- Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
- Goethe University of Frankfurt, Frankfurt, Hessen, Germany
| | - Niki Mouzakiti
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
| | - Marie Hondrich
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
| | - Frank Louwen
- Goethe University of Frankfurt, Frankfurt, Hessen, Germany
| | - Franz Bahlmann
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenbergische Stiftung, Frankfurt, Hessen, Germany
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Bautista-Charry AA, Grillo-Ardila CF. VAGINAL TERM BREECH DELIVERY, A FOOLHARDY OPTION OR AN OPPORTUNITY? REVISTA COLOMBIANA DE OBSTETRICIA Y GINECOLOGÍA 2020; 70:215-218. [PMID: 32142236 DOI: 10.18597/rcog.3483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Carlos Fernando Grillo-Ardila
- Profesor Asistente, Departamento de Obstetricia y Ginecología, Facultad de Medicina, Universidad Nacional de Colombia
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Partridge B. Conceptual and ethical problems underpinning calls to abandon vaginal breech birth. Women Birth 2020; 34:e210-e215. [PMID: 31924567 DOI: 10.1016/j.wombi.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 11/25/2022]
Abstract
The view that vaginal breech birth is unjustifiable due to neonatal safety concerns has resulted in continued calls for breech pregnancies to be managed via a policy of planned caesarean birth. Vaginal breech birth has of course always occurred, but women with term breech pregnancies who seek to have a vaginal birth often face coercive pressures to have a caesarean birth instead. In this paper I argue that even if there is population level evidence that vaginal birth is relatively riskier for the breech presenting fetus, implementing a policy of planned caesarean birth would essentially be an unjustified attempt at forced medical intervention upon women. Advocates of a policy of planned caesarean birth often conflate the acceptability of allocating participants to a treatment group (policy) within the context of a randomized controlled trial with the justifiability of doing that as part of individual health care. Calls for obstetricians to "abandon vaginal breech birth" mistakenly position vaginal breech birth itself as a form of medical intervention that can simply be removed as an option for women by obstetricians. In reality, abandoning vaginal breech birth would entail abandoning women by denying them access to healthcare options that are otherwise available to any woman having a vaginal birth.
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Affiliation(s)
- Bradley Partridge
- School of Clinical Medicine - TPCH Northside, The University of Queensland, Rode Road, Chermside, Queensland, 4032, Australia.
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18
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Hipsher C, Fineberg A. Up against a wall: A patient and obstetrician's perspective on the mode of breech delivery. Birth 2019; 46:543-546. [PMID: 31119789 DOI: 10.1111/birt.12432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 01/14/2023]
Affiliation(s)
| | - Annette Fineberg
- Department of Women's Health, Sutter Medical Group, Davis, California
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[Breech Presentation: CNGOF Guidelines for Clinical Practice - Benefits and Risks for the Neonate and Child of Planned Vaginal Delivery versus Elective Cesarean Section]. ACTA ACUST UNITED AC 2019; 48:95-108. [PMID: 31678508 DOI: 10.1016/j.gofs.2019.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To provide guidelines regarding the benefits and risks for the neonate and the child of planning vaginal delivery versus planning elective cesarean section in case of term breech presentation. METHODS MedLine and Cochrane Library databases search and review of the main foreign guidelines. RESULTS In case of term breech presentation, planned vaginal delivery might be associated with an increased composite risk of perinatal mortality or occurrence of a combined outcome of serious neonatal morbidity in comparison to elective cesarean section (LE2). In case of planned vaginal delivery of term breech presentation, the risk of perinatal mortality is around 1‰ (LE3). It is potentially less but still exists in case of elective cesarean section (LE2). Risks of neonatal trauma - especially fracture of clavicle and breech hematoma -, Apgar score lower than 7 at 5minutes, and need for neonatal intubation and ventilation, are increased in case of planned vaginal delivery (LE2) and are around 1% (LE3). However, no difference has been demonstrated between planned vaginal and planned cesarean delivery regarding neurodevelopmental outcomes at 2 years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). CONCLUSIONS In case of term breech presentation, risks of severe complications for neonate and child are low in case of planned vaginal delivery or elective cesarean section. Short-term benefit/risk balance for the neonate might favor elective cesarean section but long-term morbidity seems to be similar whatever the delivery route (Professional consensus).
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20
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Yeoh SGJ, Rolnik DL, Regan JA, Lee PYA. Experience and confidence in vaginal breech and twin deliveries among obstetric trainees and new specialists in Australia and New Zealand. Aust N Z J Obstet Gynaecol 2018; 59:545-549. [DOI: 10.1111/ajo.12931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/14/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Sara G. J. Yeoh
- Department of Obstetrics and Gynaecology; Monash Health; Melbourne Victoria Australia
| | - Daniel L. Rolnik
- Department of Obstetrics and Gynaecology; Monash Health; Melbourne Victoria Australia
| | - John A. Regan
- Department of Obstetrics and Gynaecology; Monash Health; Melbourne Victoria Australia
| | - Peter Y. A. Lee
- Department of Obstetrics and Gynaecology; Eastern Health; Melbourne Victoria Australia
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Fischbein SJ, Freeze R. Breech birth at home: outcomes of 60 breech and 109 cephalic planned home and birth center births. BMC Pregnancy Childbirth 2018; 18:397. [PMID: 30305050 PMCID: PMC6180643 DOI: 10.1186/s12884-018-2033-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 09/27/2018] [Indexed: 01/17/2023] Open
Abstract
Background Research on outcomes of out-of-hospital breech birth is scarce. This study evaluates the outcomes of singleton term breech and cephalic births in a home or birth center setting. Methods This is a retrospective observational cohort study of 60 breech and 109 cephalic planned out-of-hospital term singleton births during a 6 year period with a single obstetrician. Outcomes measured included mode of delivery; birth weights; 1 & 5-min Apgar scores; ante-, intra-, and post-partum transports; perineal integrity; and other maternal and neonatal morbidity. Results 50 breech and 102 cephalic presentations were still in the obstetrician’s care at the onset of labor; of those, 10 breech and 11 cephalic mothers required transport during labor. 76% of breech and 92.2% of cephalic births were planned to occur at home, with the remainder at a freestanding birth center. When compared to the cephalic group, the breech group had a higher rate of antepartum and in-labor transfer of care and cesarean section. Among completed out-of-hospital births, the breech group had a significantly higher rate of 1-min Apgar scores < 7 but no significant difference at 5 min. Rates of vaginal birth for both groups were high, with 84% of breech and 97.1% of cephalic mothers giving birth vaginally in this series. Compared to primiparas, multiparas in both groups had less perineal trauma and higher rates of out-of-hospital birth, vaginal birth, and spontaneous vaginal birth. No breech infant or mother required postpartum hospital transport, while one cephalic infant and one cephalic mother required postpartum transport. Of the babies born out-of-hospital, there was one short-term and one longer-term birth injury among the breech group and one short-term brachial plexus injury in the cephalic group. Conclusions A home or birth center setting leads to high rates of vaginal birth and good maternal outcomes for both breech and cephalic term singleton presentations. Out-of-hospital vaginal breech birth under specific protocol guidelines and with a skilled provider may be a reasonable choice for women wishing to avoid a cesarean section—especially when there is no option of a hospital breech birth. However, this study is underpowered to calculate uncommon adverse neonatal outcomes.
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Affiliation(s)
| | - Rixa Freeze
- Wabash College, 211 Center Hall, Crawfordsville, IN, 47933, USA.
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Morris S, Geraghty S, Sundin D. Moxibustion: An alternative option for breech presentation. ACTA ACUST UNITED AC 2018. [DOI: 10.12968/bjom.2018.26.7.440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sara Morris
- PhD candidate, Edith Cowan University, Perth, Australia
| | - Sadie Geraghty
- Senior lecturer Midwifery, Edith Cowan University, Perth, Australia
| | - Deborah Sundin
- Clinical Director, School of Nursing and Midwifery Edith Cowan University, Perth, Australia
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Dohbit JS, Foumane P, Tochie JN, Mamoudou F, Temgoua MN, Tankeu R, Aletum V, Mboudou E. Maternal and neonatal outcomes of vaginal breech delivery for singleton term pregnancies in a carefully selected Cameroonian population: a cohort study. BMJ Open 2017; 7:e017198. [PMID: 29170287 PMCID: PMC5719268 DOI: 10.1136/bmjopen-2017-017198] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Vaginal breech delivery (VBD) is known to be associated with more perinatal and maternal complications. Very few studies on the subject have been carried out in poor-resource settings. The aim of this study was to determine maternal and neonatal outcomes in carefully selected cases of VBD for singleton term pregnancies in a tertiary centre in Cameroon. DESIGN A retrospective cohort study. SETTING A tertiary hospital in Yaounde, Cameroon. PARTICIPANTS Cases of VBD of newborns weighing 2500-3500 g were matched in a ratio of 1:4 to consecutive vaginal cephalic deliveries (VCDs) of newborns weighing 2500-3500 g over a 5-year period. Both groups were matched for maternal age and parity. We excluded cases of multiple gestations, footling breech, clinically inadequate maternal pelvis, preterm delivery, post-term pregnancies, fetal demise prior to the onset of labour, placenta praevia and fetal anomaly incompatible with vaginal delivery. OUTCOME MEASURES Neonatal and maternal adverse outcomes of VBD observed till 6 weeks after delivery analysed using Bonferroni correction. RESULTS Fifty-three (53) VBDs were matched against 212 VCD. Unlike women who had VCD, those who underwent VBD were more likely to have prolonged labour (OR 8.05; 95% CI 3.00 to 11.47; P<0.001), and their newborns were more likely to suffer from birth asphyxia (OR 10.24; 95% CI 4.92 to 21.31; P<0.001). CONCLUSION The study infers a strong association between VBD of singleton term pregnancies and maternofetal morbidity when specific protocols are applied. This, however, failed to translate into higher differences in perinatal mortality. This finding does not discount the role of VBD in low-income countries, but we emphasise the need for specific precautions like close monitoring of labour and adequate anticipation for neonatal resuscitation in order to reduce these complications.
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Affiliation(s)
- Julius Sama Dohbit
- Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Yaounde, Cameroon
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Pascal Foumane
- Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Yaounde, Cameroon
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Joel Noutakdie Tochie
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Fadimatou Mamoudou
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Mazou N Temgoua
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Ronni Tankeu
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
| | - Veronica Aletum
- Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
- Department of Obstetrics and Gynaecology, Elig-Mfomo District Hospital, Centre Region, Cameroon
| | - Emile Mboudou
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon
- Department of Obstetrics and Gynaecology, Gynaeco-Obstetric and Paediatric Hospital, Douala, Cameroon
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Petrovska K, Sheehan A, Homer CSE. Media Representations of Breech Birth: A Prospective Analysis of Web-Based News Reports. J Midwifery Womens Health 2017; 62:434-441. [PMID: 28703897 DOI: 10.1111/jmwh.12609] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 01/08/2017] [Accepted: 01/13/2017] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Recent research has demonstrated that the media presentation of childbirth is highly medicalized, often portraying birth as risky and dramatic. Media representation of breech presentation and birth is unexplored in this context. This study aimed to explore the content and tone of news media reports relating to breech presentation and breech birth. METHODS Google alerts were created using the terms breech and breech birth in online English-language news sites over a 3-year period from January 1, 2013, to December 31, 2015. Alerts were received daily and filed for analysis, and data were analyzed to generate themes. RESULTS A total of 138 web-based news reports were gathered from 9 countries. Five themes that arose from the data included the problem of breech presentation, the high drama of vaginal breech birth, the safe option of cesarean birth versus dangers of vaginal breech birth, the defiant mother versus the saintly mother, and vaginal breech birth and medical misadventure. DISCUSSION Media reports in this study predominantly demonstrated negative views toward breech presentation and vaginal breech birth. Cesarean birth was portrayed as the safe option for breech birth, while vaginal breech birth was associated with poor outcomes. Media presentations may impact decision making about mode of birth for pregnant women with a breech fetus. Health care providers can play an important role in balancing the media depiction of planned vaginal breech birth by providing nonjudgmental, evidence-based information to such women to facilitate informed decision making for birth.
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Seeho SK, Nippita TA. Term breech delivery: Is recommending vaginal birth a breach of best practice? Aust N Z J Obstet Gynaecol 2017; 57:375-377. [DOI: 10.1111/ajo.12644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 04/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Sean K.M. Seeho
- Clinical and Population Perinatal Health Research; Kolling Institute; Sydney New South Wales Australia
- Sydney Medical School - Northern, University of Sydney; Sydney New South Wales Australia
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Tanya A. Nippita
- Clinical and Population Perinatal Health Research; Kolling Institute; Sydney New South Wales Australia
- Sydney Medical School - Northern, University of Sydney; Sydney New South Wales Australia
- Department of Obstetrics and Gynaecology; Royal North Shore Hospital; Sydney New South Wales Australia
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Bisits A. There is a place in current obstetric practice for planned vaginal breech birth. Aust N Z J Obstet Gynaecol 2017; 57:372-374. [DOI: 10.1111/ajo.12643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Andrew Bisits
- Department of Maternity; Royal Hospital for Women; Sydney New South Wales Australia
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Lorthe E, Quere M, Sentilhes L, Delorme P, Kayem G. Incidence and risk factors of caesarean section in preterm breech births: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 212:37-43. [DOI: 10.1016/j.ejogrb.2017.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/08/2017] [Indexed: 11/26/2022]
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Petrovska K, Sheehan A, Homer CS. The fact and the fiction: A prospective study of internet forum discussions on vaginal breech birth. Women Birth 2017; 30:e96-e102. [DOI: 10.1016/j.wombi.2016.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 09/13/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
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‘Stress, anger, fear and injustice’: An international qualitative survey of women's experiences planning a vaginal breech birth. Midwifery 2017; 44:41-47. [DOI: 10.1016/j.midw.2016.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/09/2016] [Accepted: 11/20/2016] [Indexed: 11/24/2022]
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Petrovska K, Watts NP, Catling C, Bisits A, Homer CSE. Supporting Women Planning a Vaginal Breech Birth: An International Survey. Birth 2016; 43:353-357. [PMID: 27549572 DOI: 10.1111/birt.12249] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The aim of this study was to explore the experiences of women who planned a vaginal breech birth. METHOD An online survey was developed consisting of questions regarding women's experiences surrounding planned vaginal breech birth. The survey was distributed between April 2014 and January 2015 to closed membership Facebook groups that had a consumer focus on vaginal breech birth. RESULTS In total, 204 unique responses to the survey were obtained from women who had sought the option of a vaginal breech birth in a previous pregnancy. Most women (80.8%) stated that they were happy with the birth choices they made, and a significant proportion (89.4%) would attempt a vaginal breech birth in subsequent pregnancies. Less than half of women were formally referred to a clinician skilled in vaginal breech birth when their baby was diagnosed breech (41.8%), while the remainder sourced a clinician themselves. Half of the women felt supported by their care provider (56.7%) and less than half (42.3%) felt supported by family and friends. CONCLUSION The women who responded to this international survey sought the option of a vaginal breech birth, were subsequently happy with this decision, and would attempt a vaginal breech birth in their next pregnancy. Access to vaginal breech birth is important for some women; however, this choice may be challenging to achieve. Consistent information and support from clinicians is important to assist decision-making.
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Affiliation(s)
| | | | | | - Andrew Bisits
- University of Technology Sydney, Sydney, NSW, Australia.,Director of Obstetrics at the Royal Hospital for Women, Randwick, NSW, Australia
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Petrovska K, Watts N, Sheehan A, Bisits A, Homer C. How do social discourses of risk impact on women’s choices for vaginal breech birth? A qualitative study of women’s experiences. HEALTH RISK & SOCIETY 2016. [DOI: 10.1080/13698575.2016.1256378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Karolina Petrovska
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Nicole Watts
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Athena Sheehan
- School of Nursing and Midwifery, Western Sydney University, Penrith, Australia
| | - Andrew Bisits
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal Hospital for Women, Randwick, Australia
| | - Caroline Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
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Catling C, Petrovska K, Watts N, Bisits A, Homer C. Barriers and facilitators for vaginal breech births in Australia: Clinician's experiences. Women Birth 2016; 29:138-43. [DOI: 10.1016/j.wombi.2015.09.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/14/2015] [Accepted: 09/21/2015] [Indexed: 11/27/2022]
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Catling C, Petrovska K, Watts N, Bisits A, Homer C. Care during the decision-making phase for women who want a vaginal breech birth: Experiences from the field. Midwifery 2016; 34:111-116. [DOI: 10.1016/j.midw.2015.12.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 12/09/2015] [Accepted: 12/20/2015] [Indexed: 10/22/2022]
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Berhan Y, Haileamlak A. The risks of planned vaginal breech delivery versus planned caesarean section for term breech birth: a meta-analysis including observational studies. BJOG 2015; 123:49-57. [DOI: 10.1111/1471-0528.13524] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Y Berhan
- Hawassa University College of Medicine and Health Sciences; Hawassa Ethiopia
| | - A Haileamlak
- Jimma University College of Public Health and Medicine; Jimma Ethiopia
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Abstract
BACKGROUND Poor outcomes after breech birth might be the result of underlying conditions causing breech presentation or due to factors associated with the delivery. OBJECTIVES To assess the effects of planned caesarean section for singleton breech presentation at term on measures of pregnancy outcome. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015). SELECTION CRITERIA Randomised trials comparing planned caesarean section for singleton breech presentation at term with planned vaginal birth. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. MAIN RESULTS Three trials (2396 participants) were included in the review. Caesarean delivery occurred in 550/1227 (45%) of those women allocated to a vaginal delivery protocol and 1060/1169 (91%) of those women allocated to planned caesarean section (average risk ratio (RR) random-effects, 1.88, 95% confidence interval (CI) 1.60 to 2.20; three studies, 2396 women, evidence graded low quality). Perinatal or neonatal death (excluding fatal anomalies) or severe neonatal morbidity was reduced with a policy of planned caesarean section in settings with a low national perinatal mortality rate (RR 0.07, 95% CI 0.02 to 0.29, one study, 1025 women, evidence graded moderate quality), but not in settings with a high national perinatal mortality rate (RR 0.66, 95% CI 0.35 to 1.24, one study, 1053 women, evidence graded low quality). The difference between subgroups was significant (Test for subgroup differences: Chi² = 8.01, df = 1 (P = 0.005), I² = 87.5%). Due to this significant heterogeneity, a random-effects analysis was performed. The average overall effect was not statistically significant (RR 0.23, 95% CI 0.02 to 2.44, one study, 2078 infants). Perinatal or neonatal death (excluding fatal anomalies) was reduced with planned caesarean section (RR 0.29, 95% CI 0.10 to 0.86, three studies, 2388 women). The proportional reductions were similar for countries with low and high national perinatal mortality rates.The numbers studied were too small to satisfactorily address reductions in birth trauma and brachial plexus injury with planned caesarean section. Neither of these outcomes reached statistical significance (birth trauma: RR 0.42, 95% CI 0.16 to 1.10, one study, 2062 infants (20 events),evidence graded low quality; brachial plexus injury: RR 0.35, 95% CI 0.08 to 1.47, three studies, 2375 infants (nine events)).Planned caesarean section was associated with modestly increased short-term maternal morbidity (RR 1.29, 95% CI 1.03 to 1.61, three studies, 2396 women,low quality evidence). At three months after delivery, women allocated to the planned caesarean section group reported less urinary incontinence (RR 0.62, 95% CI 0.41 to 0.93, one study, 1595 women); no difference in 'any pain' (RR 1.09, 95% CI 0.93 to 1.29, one study, 1593 women,low quality evidence); more abdominal pain (RR 1.89, 95% CI 1.29 to 2.79, one study, 1593 women); and less perineal pain (RR 0.32, 95% CI 0.18 to 0.58, one study, 1593 women).At two years, there were no differences in the combined outcome 'death or neurodevelopmental delay' (RR 1.09, 95% CI 0.52 to 2.30, one study, 920 children,evidence graded low quality); more infants who had been allocated to planned caesarean delivery had medical problems at two years (RR 1.41, 95% CI 1.05 to 1.89, one study, 843 children). Maternal outcomes at two years were also similar. In countries with low perinatal mortality rates, the protocol of planned caesarean section was associated with lower healthcare costs, expressed in 2002 Canadian dollars (mean difference -$877.00, 95% CI -894.89 to -859.11, one study, 1027 women).All of the trials included in this review had design limitations, and the GRADE level of evidence was mostly low. No studies attempted to blind the intervention, and the process of random allocation was suboptimal in two studies. Two of the three trials had serious design limitations, however these studies contributed to fewer outcomes than the large multi-centre trial with lower risk of bias. AUTHORS' CONCLUSIONS Planned caesarean section compared with planned vaginal birth reduced perinatal or neonatal death as well as the composite outcome death or serious neonatal morbidity, at the expense of somewhat increased maternal morbidity. In a subset with 2-year follow up, infant medical problems were increased following planned caesarean section and no difference in long-term neurodevelopmental delay or the outcome "death or neurodevelopmental delay" was found, though the numbers were too small to exclude the possibility of an important difference in either direction.The benefits need to be weighed against factors such as the mother's preference for vaginal birth and risks such as future pregnancy complications in the woman's specific healthcare setting. The option of external cephalic version is dealt with in separate reviews. The data from this review cannot be generalised to settings where caesarean section is not readily available, or to methods of breech delivery that differ materially from the clinical delivery protocols used in the trials reviewed. The review will help to inform individualised decision-making regarding breech delivery. Research on strategies to improve the safety of breech delivery and to further investigate the possible association of caesarean section with infant medical problems is needed.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Mary Hannah
- University of TorontoDepartment of Obstetrics and Gynaecology790 Bay StreetSuite 751TorontoONCanadaM5G 1N8
| | - Theresa A Lawrie
- Evidence‐Based Medicine ConsultancyThe Old BarnPipehouse, FreshfordBathUKBA2 7UJ
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Sharoni L, Lyell DJ, Weiniger CF. Too late to back out? Options for breech presentation management. J Epidemiol Community Health 2015; 69:1135-8. [PMID: 26139643 DOI: 10.1136/jech-2015-205528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Limor Sharoni
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Deirdre J Lyell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Lucile Packard Children's Hospital at Stanford, Palo Alto, California, USA
| | - Carolyn F Weiniger
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Homer CS, Watts NP, Petrovska K, Sjostedt CM, Bisits A. Women's experiences of planning a vaginal breech birth in Australia. BMC Pregnancy Childbirth 2015; 15:89. [PMID: 25885035 PMCID: PMC4396595 DOI: 10.1186/s12884-015-0521-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background In many countries, planned vaginal breech birth (VBB) is a rare event. After the Term Breech Trial in 2000, VBB reduced and caesarean section for breech presentation increased. Despite this, women still request VBB. The objective of this study was to explore the experiences and decision-making processes of women who had sought a VBB. Methods A qualitative study using descriptive exploratory design was undertaken. Twenty-two (n = 22) women who planned a VBB, regardless of eventual mode of birth were recruited. The women had given birth at one of two maternity hospitals in Australia that supported VBB. In-depth, semi-structured interviews using an interview guide were conducted. Interviews were analysed thematically. Results Twenty two women were interviewed; three quarters were primiparous (n = 16; 73%). Nine (41%) were already attending a hospital that supported VBB with the remaining women moving hospitals. All women actively sought a vaginal breech birth because the baby remained breech after an external cephalic version – 12 had a vaginal birth (55%) and 10 (45%) a caesarean section after labour commenced. There were four main themes: Reacting to a loss of choice and control, Wanting information that was trustworthy, Fighting the system and seeking support for VBB and The importance of ‘having a go’ at VBB. Conclusions Women seeking a VBB value clear, consistent and relevant information in deciding about mode of birth. Women desire autonomy to choose vaginal breech birth and to be supported in their choice with high quality care.
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Affiliation(s)
- Caroline Se Homer
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Nicole P Watts
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Karolina Petrovska
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Chauncey M Sjostedt
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia.
| | - Andrew Bisits
- Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Sydney, Australia. .,Royal Hospital for Women, Barker St, Randwick, NSW 2031, Australia.
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Affiliation(s)
- Jos van Roosmalen
- VU University Medical Centre, Amsterdam, the Netherlands; Leiden University Medical Centre, 2300 RC Leiden, the Netherlands.
| | - Tarek Meguid
- Mnazi Mmoja Hospital, Zanzibar, Tanzania; School of Health and Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania; Helse Bergen, Haukeland University Hospital, Bergen, Norway
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Sanders R, Steele D. Re-engaging with vaginal breech birth: A philosophical discussion. ACTA ACUST UNITED AC 2014. [DOI: 10.12968/bjom.2014.22.5.326] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ruth Sanders
- Student Midwife School of Nursing Sciences, University of East Anglia, Norwich, Norfolk
| | - Dianne Steele
- Lecturer in Midwifery School of Nursing Sciences, University of East Anglia, Norwich, Norfolk
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Hunter LA. Vaginal Breech Birth: Can We Move Beyond the Term Breech Trial? J Midwifery Womens Health 2014; 59:320-7. [DOI: 10.1111/jmwh.12198] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Borbolla Foster A, Bagust A, Bisits A, Holland M, Welsh A. Lessons to be learnt in managing the breech presentation at term: An 11-year single-centre retrospective study. Aust N Z J Obstet Gynaecol 2014; 54:333-9. [DOI: 10.1111/ajo.12208] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 03/08/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Ailsa Borbolla Foster
- Department of Obstetrics and Gynaecology; John Hunter Hospital; New Lambton New South Wales Australia
| | - Annalise Bagust
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
| | - Andrew Bisits
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Obstetrics & Gynaecology; Royal Hospital for Women; Randwick Sydney New South Wales Australia
| | - Matthew Holland
- Department of Obstetrics and Gynaecology; John Hunter Hospital; New Lambton New South Wales Australia
| | - Alec Welsh
- Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
- Department of Obstetrics & Gynaecology; Royal Hospital for Women; Randwick Sydney New South Wales Australia
- Australian Centre for Perinatal Science; University of New South Wales; Sydney New South Wales Australia
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Comparison of fetal outcome in premature vaginal or cesarean breech delivery at 24-37 gestational weeks. Arch Gynecol Obstet 2014; 290:271-81. [PMID: 24668252 DOI: 10.1007/s00404-014-3203-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/28/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE To compare the fetal outcome of preterm breech infants delivered vaginally (VD) or by cesarean section (CS). METHODS A monocentric, retrospective consecutive case series of preterm breech deliveries between 24-37 gestational weeks over 10 years from 1/2000 to 12/2009 was performed in a perinatal care center (Level 1) at the University Clinic of Salzburg, Austria. Data from hospital database were statistically analyzed and compared regarding birth weight, head circumference, parity, transfer rate to neonatal intensive care unit (NICU), arterial and venous cord blood pH and base excess (BE), arterial cord blood pH ≤ 7.10 and BE ≤ -11. Special focus was on fetal outcome of elective CS preterm breech deliveries with a non-urgent medical indication compared to VD. RESULTS Among 22.115 deliveries, there were 346 live-born preterm singletons and twins in breech presentation (1.56 %), born between 24 + 0 and 37 + 0 gestational weeks. 180 CS and 36 vaginally delivered preterm breech infants were statistically evaluated. On comparing CS vs. VD for premature breech singletons, arterial cord blood pH and BE were lower in the VD group. VD twins had a lower arterial cord blood pH than CS twins. All other parameters were comparable. In preterm breech singletons with non-urgent CS, a statistical analysis was not possible due to small numbers. The VD twin group revealed lower values in birth weight, head circumference, arterial cord blood pH and BE, but no significant difference in venous cord blood pH and BE and transfer rate to NICU. CONCLUSIONS Although general recommendations regarding a superior mode of delivery for improved fetal outcome of preterm breech infants cannot be given, these data do not support a policy of routine CS.
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External cephalic version – the bad, the good and the what now? Int J Obstet Anesth 2014; 23:4-7. [DOI: 10.1016/j.ijoa.2013.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 11/23/2022]
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Gannard-Pechin E, Ramanah R, Desmarets M, Maillet R, Riethmuller D. La présentation du siège singleton à terme. À propos d’une série continue de 418 cas. ACTA ACUST UNITED AC 2013; 42:685-92. [DOI: 10.1016/j.jgyn.2013.01.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 01/10/2013] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
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Affiliation(s)
- Shawn Walker
- Shawn Walker Breech Specialist Midwife James Paget University Hospital NHS Foundation Trust
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Welsh AW. Randomised controlled trials and clinical maternity care: moving on from intention-to-treat and other simplistic analyses of efficacy. BMC Pregnancy Childbirth 2013; 13:15. [PMID: 23324442 PMCID: PMC3554494 DOI: 10.1186/1471-2393-13-15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/10/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The obstetrical literature is dominated by Randomised Controlled Trials (RCTs), with the vast majority being analysed using an intention-to-treat (ITT) approach. Whilst this approach may reflect well the consequence of assignment to therapy and hence the 'trialists'perspective', it may fail to address the consequence of actually receiving therapy (the patient's perspective). DISCUSSION This review questions the ubiquitous adherence to the ITT approach, and gives examples of where this may have misled the maternity care professions. It gives an overview of techniques to overcome potential deficiencies in result presentation, using method effectiveness models such as 'Per Protocol' (PP) or 'As-Treated' (AT) that may give more accurate clinical meaning to the presentation of obstetrical results. It then proceeds to cover the added benefits, considerations and potential pitfalls of the use of Instrumental Variable (IV) models in order to better reflect the clinical context. SUMMARY While ITT may achieve statistical purity, it frequently fails to address the true clinical or patient's perspective. Though more complex and potentially beset by problems of their own, alternative methods of result presentation may better serve the latter aim. Each of the other methods may rely on untestable assumptions and therefore it is wisest that study results are presented in multiple formats to allow for informed reader evaluation.
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Affiliation(s)
- A W Welsh
- Division of Obstetrics and Gynaecology, School of Women's & Children's Health, University of New South Wales, Randwick, NSW, 2031, Australia.
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Abstract
Since the concept of "evidence-based medicine" was first launched 20 years ago as a new method of teaching the practice of medicine, it has had an enormous impact on practice in many fields of health care. From the very start, professionals in pregnancy and perinatal care were at the forefront of attempts to collect good evidence systematically on the benefits and harms of health care interventions during pregnancy and in and around childbirth. Perinatal practice has largely benefitted from that endeavor. However, it has also suffered from the ill-effects of the narrow view that evidence, to be good evidence, needs to be randomized evidence. Twenty years on, it may be time to reflect on what is meant by evidence and how to use it, not as a doctrine or dogma, but as a valuable tool and a tremendous asset to improve outcomes for mothers and babies.
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Affiliation(s)
- Marc J N C Keirse
- Obstetrics, Flinders University, Adelaide, South Australia, Australia
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