Floortje Vlemmix

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.

An observational study of the success and complications of 2546 external cephalic versions in low-risk pregnant women performed by trained midwives

To evaluate the success of an external cephalic version (ECV) training programme, and to determine the rates of successful ECV, complications, and caesarean birth in a low‐risk population.Objective To evaluate the success of an external cephalic version (ECV) training programme, and to determine the rates of successful ECV, complications, and caesarean birth in a low-risk population. Design Prospective observational study. Setting Primary health care and hospital settings throughout the Netherlands (January 2008–September 2011). Population Low-risk women with a singleton fetus in breech presentation, without contraindications to ECV, were offered ECV at approximately 36 weeks of gestation. Methods Data were collected for all ECVs performed by midwives, and were entered into a national online database. Main measures Successful ECV was defined as the fetus having a cephalic presentation immediately following the procedure and at birth. Complications were observed at ≤30 minutes and between 30 minutes and 48 hours after the ECV procedure. All serious pregnancy outcomes that occurred after the ECV procedure until birth were reported. Results A total of 47% had a successful ECv and a cephalic at the time of birth: 34% of nulliparous and 66% of multiparous women. After ECV, 57% of women gave birth vaginally: 45% of nulliparous women and 76% of multiparous women. Within 30 minutes after ECV, and between 30 minutes and 48 hours after ECV, the proportion of women experiencing a complication or serious pregnancy outcome was 0.9% and 1.8%, respectively. Serious pregnancy outcome at any time following ECV until birth was experienced by 58 (2.5%) of the women. Conclusions The success rate of ECVs performed by trained midwives in primary health care or hospital settings is comparable with that of other providers, and the procedure is safe for low-risk women.

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

Patient's willingness to opt for external cephalic version.

Abstract Objective: External cephalic version (ECV) is a relatively simple and safe maneuver that reduces the cesarean section (CS) rate for breech presentation. There is professional consensus that ECV should be offered to all women, but only up to 70% of patients opt for this treatment. To improve counseling, we investigated the value patients place on various aspects of ECV. Methods: We studied patient preferences by means of a vignette study. Varying levels of treatment characteristics were investigated in 16 scenarios, all including the “opt out” alternative of an elective CS. The probability that women preferred ECV was estimated using a logistic regression approach. Results: Forty seven women participated in the study. Pain was the most important factor negatively influencing the willingness to opt for ECV (OR 0.11 (95% confidence interval (CI) 0.05–0.23) for a pain score of 8–10 compared to 1–2 on a visual analog scale of 0–10). Higher success rates of vaginal delivery after successful ECV increased women’s willingness (OR 3.42 (95% CI 2.04–5.74), if chance of vaginal delivery after successful ECV increased from 24% to 52%). The risk of an emergency CS during ECV did not influence the willingness to opt for ECV (OR 0.83 (95% CI 0.59–1.18) of chance increased from 0% to 1%). Conclusions: We conclude that expected pain during treatment and the success rate are the most important factors influencing the willingness to undergo ECV. Taking this information into account when counseling for ECV and reassuring women that unbearable pain is always a reason to stop ECV, and that the vast majority of women reported that the experienced pain is bearable, might improve the uptake of ECV and decrease the number of CS due to breech presentation.

Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version.

Please cite this paper as: Lambeek A, De Hundt M, Vlemmix F, Akerboom B, Bais J, Papatsonis D, Mol B, Kok M. Risk of developmental dysplasia of the hip in breech presentation: the effect of successful external cephalic version. BJOG 2012; DOI: 10.1111/1471‐0528.12013.

External validation of a prediction model for successful external cephalic version

We sought external validation of a prediction model for the probability of a successful external cephalic version (ECV). We evaluated the performance of the prediction model with calibration and discrimination. For clinical practice, we developed a score chart to calculate the probability of a successful ECV. We studied 320 women undergoing ECV, of which 117 (37%) were successful. The model underestimated the success rate by 4 to 14%. The area under the receiver operating characteristic curve was moderate (0.66; 95% confidence interval: 0.60 to 0.72), but the model was able to make good distinction between women with a higher predicted probability of a successful ECV (more than 50%) compared with women with a lower predicted probability of a successful ECV (less than 20%). Our model to predict the outcome of ECV holds in external validation. It can be used to support patient counseling and decision making for ECV in singleton term breech presentations.

Risk factors for cesarean section and instrumental vaginal delivery after successful external cephalic version.

Abstract Aim of this article is to examine if we could identify factors that predict cesarean section and instrumental vaginal delivery in women who had a successful external cephalic version. We used data from a previous randomized trial among 25 hospitals and their referring midwife practices in the Netherlands. With the data of this trial, we performed a cohort study among women attempting vaginal delivery after successful ECV. We evaluated whether maternal age, gestational age, parity, time interval between ECV and delivery, birth weight, neonatal gender, and induction of labor were predictive for a vaginal delivery on one hand or a CS or instrumental vaginal delivery on the other hand. Unadjusted and adjusted odds ratios were calculated with univariate and multivariate logistic regression analysis. Among 301 women who attempted vaginal delivery after a successful external cephalic version attempt, the cesarean section rate was 13% and the instrumental vaginal delivery rate 6%, resulting in a combined instrumental delivery rate of 19%. Nulliparity increased the risk of cesarean section (OR 2.7 (95% CI 1.2–6.1)) and instrumental delivery (OR 4.2 (95% CI 2.1–8.6)). Maternal age, gestational age at delivery, time interval between external cephalic version and delivery, birth weight and neonatal gender did not contribute to the prediction of failed spontaneous vaginal delivery. In our cohort of 301 women with a successful external cephalic version, nulliparity was the only one of seven factors that predicted the risk for cesarean section and instrumental vaginal delivery.