Ageeth N. Rosman

Decision aids to improve informed decision-making in pregnancy care: a systematic review

Rapid development in health care has resulted in an increasing number of screening and treatment options. Consequently, there is an urgency to provide people with relevant information about benefits and risks of healthcare options in an unbiased way. Decision aids help people to make decisions by providing unbiased non‐directive research evidence about all treatment options.

Term breech deliveries in the Netherlands: did the increased cesarean rate affect neonatal outcome? A population‐based cohort study

The aim of this study was to evaluate the effect of the increased cesarean rate for term breech presentation on neonatal outcome. We also investigated whether the clinical case selection for vaginal delivery applied by Dutch obstetricians led to an optimization of neonatal outcome, or whether there is still room for improvement in terms of perinatal outcome.

Contraindications for external cephalic version in breech position at term: a systematic review

Objective. External cephalic version (ECV) is a safe and effective intervention that can prevent breech delivery, thus reducing the need for cesarean delivery. It is recommended in national guidelines. These guidelines also mention contraindications for ECV, and thereby restrict the application of ECV. We assessed whether the formulation of these contraindications in guidelines are based on empiric data. Design. Systematic review. Population. Pregnant women with a singleton breech presentation from 34 weeks. Methods. We searched the National Guideline Clearinghouse, the Cochrane Central Register of Controlled Trials, MEDLINE (1953–2009), EMBASE (1980–2009), TRIP database (until 2011), NHS (National Health Services, until 2011), Diseases database (until 2011) and NICE guidelines (until 2011) for existing guidelines on ECV and studied the reproducibility of the contraindications stated in the guidelines. Furthermore, we systematically reviewed the literature for contraindications and evidence on these contraindications. Main outcome measures. Contraindications of ECV. Results. We found five guidelines mentioning 18 contraindications, varying from five to 13 per guideline. The contraindications were not reproducible between the guidelines with oligohydramnios as the only contraindication mentioned in all guidelines. The literature search yielded 60 studies reporting on 39 different contraindications, of which we could only assess evidence of six of them. Conclusion. The present study shows that there is no general consensus on the eligibility of patients for ECV. Therefore we propose to limit contraindications for ECV to clear empirical evidence or to those with a clear pathophysiological relevance.

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term, a qualitative analysis in the Netherlands

OBJECTIVE external cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term. DESIGN qualitative study with semi-structured interviews. SETTING Dutch hospitals. PARTICIPANTS pregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation. MEASUREMENTS on the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists). FINDINGS among pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region. CONCLUSION we identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands. This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.

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

BackgroundBreech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling.Method/designThe ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured.DiscussionThis study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term.Trial RegistrationDutch Trial Register (NTR): 1878

Implementation of client versus care-provider strategies to improve external cephalic version rates: a cluster randomized controlled trial.

To determine the effectiveness of a client or care‐provider strategy to improve the implementation of external cephalic version.

Mode of childbirth and neonatal outcome after external cephalic version: A prospective cohort study

OBJECTIVE to assess the mode of childbirth and adverse neonatal outcomes in women with a breech presentation with or without an external cephalic version attempt, and to compare the mode of childbirth among women with successful ECV to women with a spontaneous cephalic presentation. DESIGN prospective matched cohort study. SETTING 25 clusters (hospitals and its referring midwifery practices) in the Netherlands. Data of the Netherlands perinatal registry for the matched cohort. PARTICIPANTS singleton pregnancies from January 2011 to August 2012 with a fetus in breech presentation and a childbirth from 36 weeks gestation onwards. Spontaneous cephalic presentations (selected from national registry 2009 and 2010) were matched in a 2:1 ratio to cephalic presentations after a successful version attempt. Matching criteria were maternal age, parity, gestational age at childbirth and fetal gender. Main outcomes were mode of childbirth and neonatal outcomes. MEASUREMENTS AND FINDINGS of 1613 women eligible for external cephalic version, 1169 (72.5%) received an ECV attempt. The overall caesarean childbirth rate was significantly lower compared to women who did not receive a version attempt (57% versus 87%; RR 0.66 (0.62-0.70)). Women with a cephalic presentation after ECV compared to women with a spontaneous cephalic presentation had a decreased risk for instrumental vaginal childbirth (RR 0.52 (95% CI 0.29-0.94)) and an increased risk of overall caesarean childbirth (RR 1.7 (95%CI 1.2-2.5)). KEY CONCLUSIONS women who had a successful ECV are at increased risk for a caesarean childbirth but overall, ECV is an important tool to reduce the caesarean rate. IMPLICATION FOR PRACTICE ECV is an important tool to reduce the caesarean section rates.

The influence of counseling on the mode of breech birth: A single-center observational prospective study in The Netherlands

OBJECTIVE women in the Netherlands, with a fetus in breech presentation, are thoroughly counseled to make an informed choice for the mode of delivery. The aim of this study was to assess the influence of counseling techniques on womens choices for the mode of delivery and subsequently to compare fetal and maternal outcomes of vaginal breech birth versus planned caesarean section. STUDY DESIGN we performed an observational prospective study. Data on breech deliveries were prospectively collected. We used ANOVA to identify variables influencing womens choice for the mode of delivery. SETTING the obstetric department of the Red Cross Hospital in Beverwijk, the Netherlands. PARTICIPANTS women with a singleton gestation (>37 + 0 weeks) and a fetus in breech presentation were included. MEASUREMENTS AND FINDINGS between January 2007 and December 2015 364 women were included. Counseling technique (p =<0.001) and maternal education (p = 0.046) were significantly associated with the choice of mode of delivery. Of all included women 33% (N = 119) opted for a vaginal breech delivery and 52% (N = 190) opted for a planned cesarean section. 15% (N = 55) were unexpected breeches. Of the planned vaginal delivery group 66% (N = 79) delivered vaginal, whereas 99.5% (N = 189) of the women in the planned cesarean section group underwent a planned cesarean section. There were no significant differences in maternal and neonatal outcomes. KEY CONCLUSIONS womens choice on the mode of delivery and the eventual modus partus of fetuses in breech presentation is strongly influenced by the counseling technique. Vaginal breech birth in low-risk women is a safe option without long term morbidity in neonates. IMPLICATIONS FOR PRACTICE counselors should be aware of their influence on womens choice for mode of delivery in breech presentation. Counseling should be done using evidence based information.

Implementation of external cephalic version: A multicentre cluster randomised controlled trial

This paper exploreswomen’s experience of psychosocial assessment and depression screening before and after birth. Background: In NSW health policy recommends psychosocial assessment and depression screening for all women at the antenatal booking visit and after birth. Few studies exist that explore women’s experience of assessmentand their subsequentdisclosureof sensitive information. Thiswas a qualitative ethnographic study. Datawere collected through observations of 34 women antenatally in the clinic with 18 midwives. Twenty of these women were then observed in interactions with 13 child and family health nurses (CFHNs) after birth in the home or the clinic environment. An observational tool (4D&4R) together with field notes was used to record observations and were analysed descriptively using content analysis and reporting frequencies of actions. Women also participated in faceto-face interviews. Field note and interview data was analysed thematically. Women reported it was important to be asked the psychosocial questions; however, they were surprised by the sensitive nature of the questions.Womenwho had a history of trauma or loss were distressed by retelling their experiences. Five key themes emerged. Three themes; ‘Unexpected – a bit out of the blue’, ‘Intrusive – very personal questions’ and ‘Uncomfortable – digging over that old ground’, describe the impact that assessment had on women. Women’s experience of assessment and screening was influenced by the approach the midwife or nurse took when addressing a woman’s disclosure. This is reflected in the themes titled: Approach: ‘sensitivity and care’ and ‘being watched’. The findingsemphasise thatwomenwouldbenefit frombeingprepared for this assessment prior to and after birth. Ongoing training and support is needed for midwives (and nurses) to deliver care that is empathetic and sensitive to women who are disclosing personal information.