Implementation of the external cephalic version in breech delivery. Dutch national implementation study of external cephalic version

Use of external cephalic version for breech presentation at term: A national survey of Norwegian birth units

INTRODUCTION

International guidelines recommend that external cephalic version (ECV) be offered to all women with single fetuses in breech presentation at term. In Norway, ECV is not offered routinely; the national clinical guidelines advice that birth units capable of offering ECV for breech pregnancies make their own practice decisions. This study was performed to determine the extent to which Norwegian birth units offer ECV to pregnant women with fetuses in breech presentations at term, and to identify factors that might influence the use of ECV.

MATERIAL AND METHODS

A survey of all 39 obstetric birth units providing ECV in Norway was conducted using a self-reporting questionnaire about ECV availability, attitudes, clinical procedures, perceived competence, and outcome expectations.

RESULTS

Chief obstetricians from all birth units responded. Twenty-six (67%) respondents reported that their units offered ECV for breech presentation at term to a large degree. Thirty-one (80%) respondents reported a large degree of competence in performing ECV. Thirty-three (85%) units followed local ECV procedures. Nineteen (49%) units provided standardized information about the procedure to pregnant women. The respondents had different views about who should be offered ECV, and varying knowledge about ECV outcomes.

CONCLUSIONS

The majority of Norwegian birth units offer ECV to pregnant women with fetuses in breech position to a large extent. However, the survey results reveal challenges related to ECV information provision to pregnant women, determination of women's eligibility for ECV attempts, and familiarity and agreement with the knowledge base regarding ECV.

External cephalic version for breech presentation: The guideline landscape and a quest for an optimal approach

OBJECTIVES

The aim of this study was to illuminate differences in guidelines for external cephalic version (ECV) for breech presentation at or near term and assess their impact on effectiveness of the procedure in order to improve policymaking.

STUDY DESIGN

Guidelines from all Swedish ECV providers (hospitals with labor wards, n = 44) were retrieved in 2019 and assessed for similarities and differences. The scoring system based on the identified differences in timing, contraindications and periprocedural care was created. The hospitals were subsequently classified into either restrictive or liberal with regard to ECV. This classification was verified by comparing selection of patients for ECV attempts between the two groups. Our main outcomes were ECV success rate and effectiveness in reducing the remaining breech births and breech cesarean sections.

RESULTS

Important differences in timing of ECV, contraindications, periprocedural care, and counselling after failed ECV attempt were found. Two thirds of the hospitals were considered liberal and one third restrictive with regard to ECV. ECV success rate was significantly higher in hospitals with a liberal attitude towards ECV compared with restrictive hospitals (54.0 % vs 50.5 %, p = 0.015). Liberal hospitals had a significantly lower proportion of remaining breech births (2.81 % vs 3.01 %, p = 0.009) and breech cesarean sections at or near term (2.49 % vs 2.72 %, p = 0.003).

CONCLUSION

Important differences in ECV guidelines were found. Hospitals with guidelines reflecting a liberal attitude to ECV had a higher ECV success rate, despite a less strict patient selection, and a lower proportion of breech births and breech cesarean sections, which is the aim of ECV. We recommend avoiding routine ill-founded restrictivity in ECV guidelines and support a more nuanced counselling.

Intrapartum intervention rates and perinatal outcomes following successful external cephalic version

OBJECTIVE

To determine intrapartum and perinatal outcomes following successful external cephalic version for breech presentation at term.

STUDY DESIGN

This was a retrospective cohort study of outcomes following successful external cephalic version in 411 women at an Australian tertiary maternity unit between November 2008 and March 2015. The study cohort was compared with a control group of 1236 women with cephalic presentation who underwent spontaneous labor. Intrapartum intervention rates and adverse neonatal outcomes were compared between both groups.

RESULTS

The success rate of external cephalic version (ECV) was 66.4%. The spontaneous vaginal delivery rate in the study cohort was 59.4% (224/411) vs 72.8% (900/1236) in the control cohort (P<0.001). Intrapartum intervention rates (emergency cesarean section (CS) and instrumental delivery) were higher in the ECV group (38% vs 27.2%, P<0.001). Rates of emergency CS for non-reassuring fetal status (9.5%, 39/411 vs 4.4%, 54/1236, P⩽0.001) and failure to progress (13.4%, 55/411 vs 4.1%, 51/1236, P<0.001) were higher in the study cohort. Neonatal outcomes were worse in the study cohort-Apgar score <7 at 5 min (2.2%, 9/411 vs 0.6%, 8/1236, P<0.001) and abnormal cord gases (8.5%, 35/411 vs 0.2%, 3/1236, P<0.001). Rates for resuscitation at birth and admission to the neonatal intensive care unit were higher in the study cohort (6.1% vs 4.1% and 1.9% vs 1.1%, respectively) but these were not statistically significant.

CONCLUSION

Labor following successful ECV is more likely to result in increased intrapartum intervention rates and poorer neonatal outcomes.

The Impact of an ECV Service is Limited by Antenatal Breech Detection: A Retrospective Cohort Study

BACKGROUND

External cephalic version (ECV) reduces the chance of breech presentation at term birth and lowers the chance of a cesarean delivery. ECV services are now in place in many units in the United Kingdom but their effectiveness is unknown. The aim of this study was to investigate the reasons for breech presentation at term birth.

METHODS

We performed a retrospective cohort study of 394 consecutive babies who were in breech presentation at term birth in a large United Kingdom maternity unit that offers ECV. The cohort was analyzed over two time periods 10 years apart: 1998-1999 and 2008-2009.

RESULTS

Only 33.8 percent of women had undergone a (failed) ECV attempt. This low proportion was mainly because breech presentation was not diagnosed antenatally (27.9%). Other contributing factors were: ECV not offered by clinicians (12.2%), ECV declined by women (14%), and contraindications to ECV (10.7%). Over the 10-year period, the proportion of breech presentations that were not diagnosed antenatally increased from 23.2 to 32.5 percent (p = 0.04), which constituted 52.8 percent of women who had not undergone an ECV attempt in 2008-2009. Failure of clinicians to offer ECV reduced from 21.6 to 3.0 percent (p = 0.0001) and the proportion of women declining ECV decreased from 19.1 to 9.0 percent (p = 0.005). Overall, ECV attempts increased from 28.9 to 38.5 percent (p = 0.05).

CONCLUSIONS

Although ECV counseling, referral, and attempt rates have increased, failure to detect breech presentation antenatally is the principal barrier to successful ECV. Improved breech detection would have a greater impact than methods to increase ECV success rates.

A systematic approach to implementing and evaluating clinical guidelines: The results of fifteen years of Preventive Child Health Care guidelines in the Netherlands

Preventive Child Health Care (PCHC) services are delivered to all children in the Netherlands by approximately 5500 doctors, nurses and doctor's assistants. In 1996, The Dutch Ministry of Health, Welfare and Sports asked for the development of evidence-based PCHC guidelines. Since 1998, twenty-five guidelines have been published. Levels of implementation affect outcomes and so implementation and evaluation of the actual use of guidelines are essential. At the outset, there was a national implementation plan with six main activities: a) determinant analysis before the implementation of a guideline, b) innovation strategies tailored to the determinants, c) dissemination to all professionals, d) ongoing evaluation of the awareness and use of the guidelines, e) trained implementation coordinator(s) in each PCHC organization and f) a national help desk. The awareness and use of the guidelines in random samples of doctors, nurses and doctor's assistants were surveyed using questionnaires. The respondents stated (on a 7-point scale) the proportion of all children they had exposed to given core elements in a guideline. The aim is for at least 90% of the professionals to be aware of the guideline and for 80% to perform the core elements for all (or nearly all) children. The six main activities, with the exception of ongoing evaluation, were gradually put into place, albeit only gradually, between 1998 and 2015 for all guidelines. In 2012, the use of individual core elements in all guidelines, dating from before 2012, varied from 28% to 100%. One guideline met both criteria of 90% awareness and 80% use, and three guidelines nearly met these criteria. Looking back on fifteen years of PCHC guidelines, we may conclude that the guidelines produced recently are implemented in accordance with the national implementation plan. Unfortunately, the evaluation of guideline use continues to be a difficulty.

Implementation of a cost-effective strategy to prevent neonatal early-onset group B haemolytic streptococcus disease in the Netherlands

Background

Early-onset Group B haemolytic streptococcus infection (EOGBS) is an important cause of neonatal morbidity and mortality in the first week of life. Primary prevention of EOGBS is possible with intra-partum antibiotic prophylaxis (IAP.) Different prevention strategies are used internationally based on identifying pregnant women at risk, either by screening for GBS colonisation and/or by identifying risk factors for EOGBS in pregnancy or labour. A theoretical cost-effectiveness study has shown that a strategy with IAP based on five risk factors (risk-based strategy) or based on a positive screening test in combination with one or more risk factors (combination strategy) was the most cost-effective approach in the Netherlands. IAP for all pregnant women with a positive culture in pregnancy (screening strategy) and treatment in line with the current Dutch guideline (IAP after establishing a positive culture in case of pre-labour rupture of membranes or preterm birth and immediate IAP in case of intra-partum fever, previous sibling with EOGBS or GBS bacteriuria), were not cost-effective. Cost-effectiveness was based on the assumption of 100% adherence to each strategy. However, adherence in daily practice will be lower and therefore have an effect on cost-effectiveness.

Method/Design

The aims are to: a.) implement the current Dutch guideline, the risk-based strategy and the combination strategy in three pilot regions and b.) study the effects of these strategies in daily practice. Regions where all the care providers in maternity care implement the allocated strategy will be randomised. Before the introduction of the strategy, there will be a pre-test (use of the current guideline) involving 105 pregnant women per region. This will be followed by a post-test (use of the allocated strategy) involving 315 women per region. The outcome measures are: 1.) adherence to the specific prevention strategy and the determinants of adherence among care providers and pregnant women, 2.) outcomes in pregnant women and their babies and 3.) the costs of each strategy in relation to the effects.

Discussion

This study will provide recommendations for the implementation of the most cost-effective prevention strategy for EOGBS in the Netherlands on the basis of feasibility in daily practice.

Trial registration

Dutch Trial Register, NTR3965

The implementation of the functional task exercise programme for elderly people living at home

Background

The Functional Task Exercise programme is an evidence-based exercise programme for elderly people living at home. It enhances physical capacity with sustainable effects. FTE is provided by physiotherapists and remedial therapists. Although the intervention was found to be effective in a Randomised Controlled Trial, we may not assume that therapists will automatically supply the programme or that elderly people will automatically join the programme. This study protocol focuses on identifying determinants of implementation, developing implementation strategies and studying the effects of the implementation in daily practice.

Methods/Design

Phase 1: The systematic identification of determinants of the implementation of FTE among therapists and the elderly. A questionnaire study was conducted in a random sample of 100 therapists, and interviews took place with 23 therapists and 8 elderly people (aged 66 to 80 years). The determinants were broken down into four categories: the characteristics of the environment, the organisation, the therapists, and the training programme.

Phase 2: Developing and applying strategies adapted to the determinants identified. Fifteen physiotherapists will be trained to provide FTE and to recruit elderly people living at home. The therapists will then deliver the 12-week programme to two groups of elderly, each consisting of six to twelve people aged 70 years or older.

Phase 3: Study of implementation and the impact. To study the actual use of FTE: 1) therapists record information about the selection of participants and how they apply the key features of FTE, 2) the participating elderly will keep an exercise logbook, 3) telephone interviews will take place with the therapists and the elderly and there will be on-site visits. The effects on the elderly people will be studied using: 1) the Patient-Specific Questionnaire, the Timed Up and Go test and a two performance tests. All tests will be performed at the start of the FTE programme, half way through, and at the end of the programme.

Discussion

The number of older people will increase in many countries in the years to come and so the project outcomes will be of interest to policy-makers, insurance companies, health-care professionals and implementation researchers.

Successful implementation of new technologies in nursing care: a questionnaire survey of nurse-users

Background

A growing number of new technologies are becoming available within nursing care that can improve the quality of care, reduce costs, or enhance working conditions. However, such effects can only be achieved if technologies are used as intended. The aim of this study is to gain a better understanding of determinants influencing the success of the introduction of new technologies as perceived by nursing staff.

Methods

The study population is a nationally representative research sample of nursing staff (further referred to as the Nursing Staff Panel), of whom 685 (67%) completed a survey questionnaire about their experiences with recently introduced technologies. Participants were working in Dutch hospitals, psychiatric organizations, care organizations for mentally disabled people, home care organizations, nursing homes or homes for the elderly.

Results

Half of the respondents were confronted with the introduction of a new technology in the last three years. Only half of these rated the introduction of the technology as positive.

The factors most frequently mentioned as impeding actual use were related to the (kind of) technology itself, such as malfunctioning, ease of use, relevance for patients, and risks to patients. Furthermore nursing staff stress the importance of an adequate innovation strategy.

Conclusions

A prerequisite for the successful introduction of new technologies is to analyse determinants that may impede or enhance the introduction among potential users. For technological innovations special attention has to be paid to the (perceived) characteristics of the technology itself.

Maternal thyroid function and the outcome of external cephalic version: a prospective cohort study

Background

To investigate the relation between maternal thyroid function and the outcome of external cephalic version (ECV) in breech presentation.

Methods

Prospective cohort study in 141 women (≥ 35 weeks gestation) with a singleton fetus in breech. Blood samples for assessing thyroid function were taken prior to ECV. Main outcome measure was the relation between maternal thyroid function and ECV outcome indicated by post ECV ultrasound.

Results

ECV success rate was 77/141 (55%), 41/48 (85%) in multipara and 36/93 (39%) in primipara. Women with a failed ECV attempt had significantly higher TSH concentrations than women with a successful ECV (p < 0.001). Multiple logistic regression showed that TSH (OR: 0.52, 95% CI: 0.30-0.90), nulliparity (OR: 0.11, 95% CI: 0.03-0.36), frank breech (OR: 0.30, 95% CI: 0.10-0.93) and placenta anterior (OR: 0.31, 95% CI: 0.11-0.85) were independently related to ECV success.

Conclusions

Higher TSH levels increase the risk of ECV failure.

Trial registration number

ClinicalTrials.gov: NCT00516555