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

Contemporary Trends in Cesarean Delivery Rates and Indications

OBJECTIVE

This study aimed to describe cesarean delivery rates and indications at a single center in order to assess the impact of the guidelines published by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine on trends in labor management.

STUDY DESIGN

This is a retrospective cohort study of patients ≥23 weeks' gestation delivering at a single tertiary care referral center from 2013 to 2018. Demographic characteristics, mode of delivery, and main indication for cesarean delivery were ascertained by individual chart review. Cesarean delivery indications (mutually exclusive) were the following: repeat cesarean delivery, nonreassuring fetal status, malpresentation, maternal indications (e.g., placenta previa or genital herpes simplex virus), failed labor (any stage labor arrest), or other (i.e., fetal anomaly and elective). Polynomial (cubic) regression models were used to model rates of cesarean delivery and indications over time. Subgroup analyses further examined trends in nulliparous women.

RESULTS

Of the 24,637 patients delivered during the study period, 24,050 were included in the analysis; 7,835 (32.6%) had a cesarean delivery. The rates of overall cesarean delivery were significantly different over time (p < 0.001), declining to a minimum of 30.9% in 2014 and peaking at 34.6% in 2018. With regard to the overall cesarean delivery indications, there were no significant differences over time. When limited to nulliparous patients, the rates of cesarean delivery were also noted to be significantly different over time (p = 0.02) nadiring at 30% in 2015 from 35.4% in 2013 and then rising up to 33.9% in 2018. As for nulliparous patients, there was no significant difference in primary cesarean delivery indications over time except for nonreassuring fetal status (p = 0.049).

CONCLUSION

Despite changes in labor management definitions and guidelines encouraging vaginal birth, the rates of overall cesarean delivery did not decrease over time. The indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have not significantly changed over time.

KEY POINTS

· The rates of overall cesarean deliveries did not decrease despite the 2014 published recommendations for the reduction in cesarean deliveries.. · There were no significant differences in the indications of cesarean deliveries among nulliparous or multiparous women.. · Despite the adoption of strategies to reduce the overall and primary cesarean delivery rates, these trends remain unchanged.. · Indications for delivery, particularly failed labor, repeat cesarean delivery, and malpresentation have also not significantly changed over time.. · Additional strategies to encourage and increase vaginal delivery rates must be adopted..

Patient Experiences With Obstetric Counseling on Fetal Malpresentation

Introduction Fetal malpresentation is a complication of pregnancy in which the fetus does not present cephalically as required for vaginal birth. After a diagnosis is made, management options include cesarean section (CS) or external cephalic version (ECV). ECV is a procedure in which providers attempt to manually maneuver the fetus to cephalic position, allowing patients to attempt vaginal birth. Selecting between CS or ECV can be a complex and stressful decision, yet literature exploring patient perspectives on counseling of these options is limited. This study aims to describe patient perspectives on decision-making when diagnosed with fetal malpresentation. Methods We included English-speaking pregnant patients greater than 18 years of age diagnosed with malpresentation at 35-37 weeks' gestation. Patients who previously underwent CS or had maternal or fetal contraindications besides malpresentation to vaginal birth requiring CS were excluded. Semi-structured interviews were conducted with participants from four obstetric clinics in Baltimore, Maryland, at time of diagnosis. Themes were derived using data analysis in NVivo 11 (released 2015, Lumivero, USA). Results We recruited 10 participants (median age = 32 years, 90% Caucasian, 70% nulliparous, 50% chose ECV). We categorized our findings into the following themes: (1) facilitators and (2) barriers to deciding on malpresentation management, (3) participant priorities and values, and (4) other methods of malpresentation management. The participants identified incorporation of statistics and medical history into counseling as facilitators and the lack of information about ECV as a significant barrier. The participants prioritized fetal safety and, among those who chose ECV, a desire to avoid CS. Chiropractors, acupuncture, and moxibustion were identified as valuable additional methods of malpresentation management. Conclusion Overall, patients desire more information about ECV when diagnosed with fetal malpresentation. Uncertainty about ECV safety is a barrier to deciding between management options. Based on our findings, obstetric providers should provide comprehensive counseling on ECV and CS. Counseling should aim to demystify ECV and quantify risk in a patient-specific context. This will allow patients to make an informed decision on the management of fetal malpresentation that aligns with their goals for pregnancy.

The feasibility of team care for women seeking to plan a vaginal breech birth (OptiBreech 1): an observational implementation feasibility study in preparation for a pilot trial

BACKGROUND

OptiBreech Care is a care pathway for breech presentation at term, including where chosen, physiological breech birth attended by professionals with advanced training and/or proficiency. We aimed to assess the feasibility of implementing OptiBreech team care prior to proceeding with a planned pilot randomised controlled trial.

METHODS

Our design was an observational implementation feasibility assessment across England and Wales, January 2021-June 2022. Our objectives were to determine whether Trusts could provide attendants with advanced training (implementation feasibility), who deliver protocol-consistent care (fidelity), within existing resources (costs), while maintaining low neonatal admission rates (safety) and adequate recruitment rates (trial feasibility). Participants included women > 37 weeks pregnant with a breech-presenting foetus, requesting support for a vaginal breech birth following standard counselling, and staff involved in the study. No randomisation occurred in this first stage of feasibility work.

RESULTS

Thirteen National Health Service sites were recruited. A total of 82 women planned births in the study. Sites with a breech specialist midwife recruited at double the rate of sites without (0.90/month, 95% CI 0.64-1.16 vs 0.40, 95% CI 0.12-0.68). Referrals into the study came from midwives (46%), obstetricians (34%) and women themselves (20%). Vaginal births were attended by staff with OptiBreech training at 87.5% (35/40, 95% CI 0.732-0.958) and by staff who met additional proficiency criteria at 67.5% (27/40, 95% CI 0.509-0.814). Fidelity criteria were more consistently met by staff who also met proficiency criteria. There were four neonatal admissions (4.9%, 4/82), including one serious adverse outcome (1.2%, 1/82).

CONCLUSIONS

A prospective observational cohort of OptiBreech collaborative care, which could potentially support nested or cluster randomisation, appears feasible in sites willing to establish a dedicated clinic and strategically develop further proficient members of staff, with back-up plans for supporting rapidly progressing births. Randomisation procedures remain to be feasibility tested. It is funded by the NIHR (NIHR300582).

Factors Associated with Attempted External Cephalic Version for Fetal Malpresentation at Term

Objective  To assess differences in patient characteristics between women who did and did not undergo attempted external cephalic version (ECV) for fetal malpresentation at term. Study Design  This was a retrospective cohort study of women with a singleton gestation and noncephalic presentation at > 37.0 weeks between October 2014 and October 2015. We compared demographic and clinical characteristics of women who did and did not undergo attempted ECV and assessed the reasons that women did not attempt ECV. Results  Among 215 women, only 51 (24%) attempted ECV. There were no differences in age, race, insurance type, or body mass index between women who underwent attempted ECV and those who did not. Women who underwent ECV were significantly more likely to have had a prior vaginal delivery (69 vs. 36%, p  < 0.001). Seventy-six women (46%) declined ECV. Women who declined ECV were more likely to be nulliparous than those who accepted the procedure (66 vs. 29%, p  < 0.001). Among women who had ECV, the success rate was 55%. There were no adverse events after attempted ECV in this cohort. Conclusion  Among women with fetal malpresentation at term, those without a prior vaginal delivery were significantly less likely to undergo attempted ECV.

Association Between Attempted External Cephalic Version and Perinatal Morbidity and Mortality

OBJECTIVE

To examine whether, with fetal malpresentation at term, perinatal morbidity and mortality differ between women who undergo an external cephalic version (ECV) attempt and those who do not and are expectantly managed.

METHODS

We conducted a retrospective cohort study of women with nonanomalous singleton gestations in nonvertex presentation delivering at a tertiary care institution from 2006 to 2016. Women undergoing an ECV attempt at 37 weeks of gestation or greater were compared with those with nonvertex fetuses who did not undergo an ECV attempt and delivered at 37 weeks of gestation or greater. The primary outcome was a composite of perinatal morbidity and mortality including stillbirth, neonatal death within 72 hours, Apgar score less than 5 at 5 minutes, umbilical artery pH less than 7.0, base deficit 12 mmol/L or greater, or neonatal therapeutic hypothermia. Secondary outcomes were neonatal intensive care unit admission and neonatal anemia (hemoglobin value less than 13.5 g/dL). Bivariable and multivariable analyses were performed.

RESULTS

Of the 4,117 women meeting eligibility criteria, 1,263 (30.7%) attempted ECV; 509 (40.3%) of these attempts resulted in successful versions. In bivariable analyses, women who underwent attempted ECV were more likely to be non-Hispanic white and multiparous and had lower mean body mass indexes. The composite perinatal morbidity and mortality outcome did not differ significantly between women who did and did not undergo attempted ECV (2.9% vs 2.5%, P=.46). The frequencies of neonatal intensive care unit admission (3.6% vs 3.3%, P=.53) and neonatal anemia (1.6% vs 1.2%, P=.36) were also similar. There continued to be no association between ECV attempt and composite perinatal morbidity and mortality outcome after adjustment for potential confounders (adjusted odds ratio 1.02, 95% CI 0.66-1.60).

CONCLUSION

Compared with expectant management, an ECV attempt at term is not associated with increased perinatal morbidity or mortality.

This baby is not for turning: Women's experiences of attempted external cephalic version

BACKGROUND

Existing studies regarding women's experiences surrounding an External Cephalic Version (ECV) report on women who have a persistent breech post ECV and give birth by caesarean section, or on women who had successful ECVs and plan for a vaginal birth. There is a paucity of understanding about the experience of women who attempt an ECV then plan a vaginal breech birth when their baby remains breech. The aim of this study was to examine women's experience of an ECV which resulted in a persistent breech presentation.

METHODS

A qualitative descriptive exploratory design was undertaken. In-depth semi-structured interviews were conducted and analysed thematically.

RESULTS

Twenty two (n = 22) women who attempted an ECV and subsequently planned a vaginal breech birth participated. Twelve women had a vaginal breech birth (55 %) and 10 (45 %) gave birth by caesarean section. In relation to the ECV, there were five main themes identified: 'seeking an alternative', 'needing information', 'recounting the ECV experience', 'reacting to the unsuccessful ECV' and, 'reflecting on the value of an ECV'.

CONCLUSIONS

ECV should form part of a range of options provided to women, rather than a default procedure for management of the term breech. For motivated women who fit the safe criteria for vaginal breech birth, not being subjected to a painful experience (ECV) may be optimal. Women should be supported to access services that support vaginal breech birth if this is their choice, and continuity of care should be standard practice.

Survey of external cephalic version for breech presentation and neuraxial blockade use

STUDY OBJECTIVE

Neuraxial blockade may increase external cephalic version (ECV) success rates. This survey aimed to assess the frequency and characteristics of neuraxial blockade used to facilitate ECV.

SETTING AND DESIGN

We surveyed Society for Obstetric Anesthesia and Perinatology members regarding ECV practice using a 15-item survey developed by 3 obstetric anesthesiologists and tested for face validity. The survey was e-mailed in January 2015 and again in February 2015 to the 1056 Society of Obstetric Anesthesiology and Perinatology members. We present descriptive statistics of responses.

PARTICIPANTS

Our survey response rate was 322 of 1056 (30.5%).

MAIN RESULT

Neuraxial blockade was used for ECV always by 18 (5.6%), often by 52 (16.1%), sometimes by 98 (30.4%), rarely by 78 (24.2%), and never by 46 (14.3%) of respondents. An anesthetic sensory block target was selected by 141 (43.8%) respondents, and analgesic by 102 (31.7%) respondents. Epidural drug doses ranged widely, including sufentanil 5-25 μg; lidocaine 1% or 2% 10-20 mL, bupivacaine 0.0625% to 0.5% 6-15 mL, and ropivacaine 0.2% 20 mL. Intrathecal bupivacaine was used by 182 (56.5%) respondents; the most frequent doses were 2.5 mg used by 24 (7.5%), 7.5 mg used by 35 (10.9%), and 12 mg used by 30 (9.3%).

CONCLUSIONS

Neuraxial blockade is not universally offered to facilitate ECV, and there is wide variability in neuraxial blockade techniques, in drugs and doses administered, and in the sensory blockade (anesthetic or analgesic) targeted. Future studies need to evaluate and remove barriers to allow for more widespread use of neuraxial blockade for pain relief and to optimize ECV success rates.