Patient opinion of analgesia during external cephalic version at term in singleton pregnancy.

To assess the opinion and the level of satisfaction of patients concerning analgesia during external cephalic version (ECV), we present the results of a survey of 120 women undergoing ECV at term during a randomised controlled trial (July 2012 to February 2013) comparing remifentanil and nitrous oxide. Overall, 110 (91.7%) women said they would repeat the procedure and 111 (92.5%) that they would recommend it to another pregnant woman, with no significant differences by type of analgesia. The administration and sense of comfort were rated better in the remifentanil group (p < .01). In conclusion, the use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women.Impact statementWhat is already known on this subject? ECV is commonly a painful manoeuvre for the woman. This pain triggers maternal reactive abdominal muscle contraction and involuntary abdominal tensing, reducing the likelihood of successful version and causing some women to reject the technique.What do the results of this study add? The use of analgesia during ECV is associated with a high rate of willingness among women to repeat the procedure and recommend it to other pregnant women. The sense of comfort during ECV was also significantly better in the remifentanil group, probably because of its greater analgesic power and greater comfort during its administration.What are the implications of these findings for clinical practice and/or further research? ECV should be carried out under analgesia, when available, not only to decrease pain but also to encourage wider adoption of the technique and enable more women to benefit from it.

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.

Women's experiences of planning a vaginal breech birth in Australia.

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.

Fear for external cephalic version and depression: predictors of successful external cephalic version for breech presentation at term?

BACKGROUND: Objective was to determine whether fear for external cephalic version (ECV) and depression are associated with the success rate of ECV in women with a breech presentation at term. METHODS: Prospective study conducted in the Catharina Hospital Eindhoven between October 2007 and May 2012. Participants fulfilled The Edinburgh Depression Scale (EDS) questionnaire and expressed their degree of fear on a visual analogue scale from one to ten before ECV. Obstetric factors were evaluated as well. Primary outcome was the relation between psychological factors (fear for ECV and depression EDS scores) and ECV success rate. Secondary outcome was a possible relation between fear for ECV and increased abdominal muscle tension. RESULTS: The overall success rate was 55% and was significantly lower (p < 0.001) in nulliparous women (44.3%) compared with parous women (78.0%). Fear for ECV and depression EDS-scores were not related with ECV success rate. Parity, placental location, BMI and engagement of the fetal breech were obstetric factors associated with ECV outcome. There was no relation between fear for ECV and abdominal muscle tone. CONCLUSION: Fear for ECV and depression were not related with ECV success rate in this study. Engagement of the fetal breech was the most important factor associated with a successful ECV. TRIAL REGISTRATION EBIS: The Eindhoven Breech Intervention Study, NCT00516555.

Determinants of pain perception after external cephalic version in pregnant women.

OBJECTIVE: A considerable proportion of pregnant women with a fetus in breech position refuses external cephalic version (ECV), with fear of pain as important barrier. As a consequence, they are at high risk for caesarean section at term. The current study investigated determinants of pain perception during ECV, with special attention to maternal mental state such as depression and fear of ECV. DESIGN: Prospective study of 249 third-trimester pregnant women with breech position with a request for an ECV attempt. SETTING: Department of Obstetrics and Gynaecology in a large teaching hospital in the Netherlands. METHODS: Prior to the ECV attempts, obstetric factors were registered, participants fulfilled the Edinburgh Depression Scale (EDS) and reported fear of ECV on a 10-point visual analog scale. Perception of pain intensity was measured with a 10-point visual analog scale, immediately after ECV. FINDINGS: Multivariate linear regression analyses showed success of ECV to be the strongest predictor of pain perception. Furthermore, scores on the depression questionnaire and degree of fear of ECV independently explained pain perception, which was not the case for obstetrical or ECV related factors. CONCLUSION: Apart from ECV outcome, psychological factors like depression and fear of ECV were independently related to pain perception of an ECV attempt. IMPLICATION FOR PRACTICE: Maternal mood state should be taken into account when offering an ECV attempt to women with a fetus in breech position. Due to the painful experience and the importance of successful outcome, ECV should only be attempted in institutions with experienced practitioners and with careful attention to maternal mood and the way a woman is coping with the ECV attempt.

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

BACKGROUND: Women who have a breech presentation at term have to decide whether to attempt external cephalic version (ECV) and how they want to give birth if the baby remains breech, either by planned caesarean section (CS) or vaginal breech birth. The aim of this study was to explore the attitudes of women with a breech presentation and health professionals who manage breech presentation to ECV. METHODS: We carried out semi-structured interviews with pregnant women with a breech presentation (n=11) and health professionals who manage breech presentation (n=11) recruited from two hospitals in North East England. We used purposive sampling to include women who chose ECV and women who chose planned CS. We analysed data using thematic analysis, comparing between individuals and seeking out disconfirming cases. RESULTS: Four main themes emerged from the data collected during interviews with pregnant women with a breech presentation: ECV as a means of enabling natural birth; concerns about ECV; lay and professional accounts of ECV; and breech presentation as a means of choosing planned CS. Some women's attitudes to ECV were affected by their preferences for how to give birth. Other women chose CS because ECV was not acceptable to them. Two main themes emerged from the interview data about health professionals' attitudes towards ECV: directive counselling and attitudes towards lay beliefs about ECV and breech presentation. CONCLUSIONS: Women had a range of attitudes to ECV informed by their preferences for how to give birth; the acceptability of ECV to them; and lay accounts of ECV, which were frequently negative. Most professionals described having a preference for ECV and reported directively counselling women to choose it. Some professionals were dismissive of lay beliefs about ECV. Some key challenges for shared decision making about breech presentation were identified: health professionals counselling women directively about ECV and the differences between evidence-based information about ECV and lay beliefs. To address these challenges a number of approaches will be required.

Qualitative assessment of women's experiences with ECV.

UNLABELLED: For women with unsuccessful ECV, discussions about their mode of delivery should include the benefits and risks of a planned caesarean or vaginal breech birth. However, most obstetric units continue to offer only planned caesarean births when ECVs are unsuccessful despite the proven safety of vaginal breech births in selected patients. Such unit policies can be at variance with a woman's desire and preference for vaginal birth. Thus, a conflict situation arises that could have varying medical, emotional and cultural implications. AIM: To provide a consumer perspective on ECV from women who had an unsuccessful procedure. METHODOLOGY: A qualitative study involving focus group discussions with women who had unsuccessful ECV at secondary obstetric facility in Melbourne, Australia. RESULTS: Emergent themes from the focus group discussions were related to emotions associated with the inevitability of a caesarean section for breech, consequences of an unsuccessful ECV and the various activities undertaken by women to induce spontaneous version. CONCLUSION: A medicalized approach to ECV fell short of women's expectations of care. There is a need to develop strategies that will help women deal with any conflicts occasioned by an unsuccessful ECV.

[External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention]. / Version céphalique externe en cas de siège persistant à terme : motivations et vécu de l'intervention par les femmes.

OBJECTIVES: To evaluate the efficacy and acceptability of external cephalic version (ECV). MATERIALS AND METHOD: From 2004 to 2008, 212 pregnant women between 34-37 weeks of gestation with fetus in breech presentation were included in a randomized clinical trial and 125 externals cephalic versions were studied. RESULTS: A success rate of 37.6%t was recorded. At 34 weeks of gestation, 80.6% of women were considering an ECV in the event of persistent breech position at 37 weeks. These women expressed the desire to give birth vaginally (52% versus 24.4%, P<0.001). In contrast, others women preferred an elective cesarean section to avoid the risk of a breech vaginal delivery. Women felt pain during the ECV and scored 60 on average using the analogical visual scale. Women rated on a verbal rating scale the ECV as severely painful to unbearable (68%), and as stressful (70%). Despite this, the majority of women would recommend ECV to their friends or would be willing to repeat it for themselves. DISCUSSION AND CONCLUSION: ECV remains a scary and painful medical procedure. More research is needed to reduce the impact. The use of analgesic medication for this indication is controversial. Hypnosis could be an alternative to evaluate.

Women's experiences of participating in the early external cephalic version 2 trial.

BACKGROUND: The international, multicenter External Cephalic Version 2 (ECV2) Trial compared early external cephalic version at 34(0/7) to 35(6/7) weeks with that at greater than 37 weeks. A total of 1,543 women were randomized from 68 centers in 21 countries. The goal of this component of the trial was to understand women's views about participation in a research trial and timing of external cephalic version. METHODS: A postpartum questionnaire was completed containing a 5-point Likert scale examining contact and availability of staff, choice of timing of external cephalic version, preference of randomization, convenience of participating, and overall satisfaction. Participants also completed two open-ended questions related to timing of external cephalic version and satisfaction with the trial. Descriptive statistics and content analysis were used to analyze data. RESULTS: A total of 1,458 women completed the questionnaire, of whom 86 percent said "yes"-they would participate in the trial again. Themes influencing decisions about participating were perceptions of the external cephalic version experience, preferred mode of delivery, preferred timing of external cephalic version, and perceptions of the effectiveness of external cephalic version and of the trial environment. Many participants preferred the early timing of the procedure offered through the trial because of perceived advantages of a smaller baby being easier to turn and the opportunity for repeat procedures. CONCLUSIONS: Women were positive about their participation in the trial. Early external cephalic version was preferred over the traditional timing as it was perceived to afford both physiologic and practical advantages.

[Is fear of external cephalic version well-founded?]. / Jsou obavy z obratu zevními hmaty oprávnené?

BACKGROUND AND OBJECTIVE: External cephalic version (ECV) is often denied due to fear of complications and pain during this procedure. The aim of this study was to assess maternal pain perception during ECV and to report the incidence of complications associated with this procedure. DESIGN: Prospective study. SETTING: Hospital of Merciful Brothers, Brno. METHODS: Study included 110 women undergoing ECV. Pain was measured by visual analog scale (VAS) and descriptive part of Czech version of McGill Pain Questionnaire (MPQ). The overall pain rating index (PRI) and PRI of sensoric (S), affective (A), evaluating (E) and miscellaneuos (M) descriptors of pain was assesed. The assesment was performed in all patient and group of successful and failed ECV was compared by t-test. All complications during ECV were recorded. Incidence of operative deliveries after successful ECV was compared with control group included parturients with cephalic presentantion by odds ratio (OR) with 95% confidence interval (95% CI). RESULTS: Forty two ECV (38%) was successful. Mean value of VAS was 4.9, PRI 14.4 (SD = 1.9). PRI of particular qualities of pain: S = 8.0, A = 1.9, E = 2.6, M = 2.1. The significant diference between successful and failed ECV group was in VAS (4.2 vs 5.4, p = 0.001), PRI -A (1.3 vs 2.2, p = 0.018) and PRI-M (1.5 vs 2.5, p = 0.015). We recorded 2 (1.8%) cases of transient fetal bradycardia, 8 ECV (7%) was discontinued for pain and in 52% women after ECV transient decrease in fetal heart rate variability occured. No serious complication was recorded. The incidence of caesarean section after successful ECV was 21% and in control group 16% (OR 1.4 95%.CI 0.62; 3.01). Incidence of instrumental delivery after ECV was 12%, in control group 5% (OR 2.7 95% CI 0.93; 7.27). CONCLUSION: The pain during ECV was mild and well tolareted. The incidence of complications was small and the most of them were not serious. In this study no reasons for denying ECV were found.

Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598].

OBJECTIVES: To evaluate the effectiveness of a decision aid for women with a breech presentation compared with usual care. DESIGN: Randomised controlled trial. SETTING: Tertiary obstetric hospitals offering external cephalic version (ECV). POPULATION: Women with a singleton pregnancy were diagnosed antenatally with a breech presentation at term, and were clinically eligible for ECV. METHODS: Women were randomised to either receive a decision aid about the management options for breech presentation in addition to usual care or to receive usual care only with standard counselling from their usual pregnancy care provider. The decision aid comprised a 24-page booklet supplemented by a 30-minute audio-CD and worksheet that was designed for women to take home and review with a partner. MAIN OUTCOME MEASURES: Decisional conflict (uncertainty), knowledge, anxiety and satisfaction with decision making, and were assessed using self-administered questionnaires. RESULTS: Compared with usual care, women reviewing the decision aid experienced significantly lower decisional conflict (mean difference -8.92; 95% CI -13.18, -4.66) and increased knowledge (mean difference 8.40; 95% CI 3.10, 13.71), were more likely to feel that they had enough information to make a decision (RR 1.30; 95% CI 1.14, 1.47), had no increase in anxiety and reported greater satisfaction with decision making and overall experience of pregnancy and childbirth. In contrast, 19% of women in the usual care group reported they would have made a different decision about their care. CONCLUSIONS: A decision aid is an effective and acceptable tool for pregnant women that provides an important adjunct to standard counselling for the management of breech presentation.

Development and pilot-testing of a decision aid for women with a breech-presenting baby.

OBJECTIVE: To develop a decision aid for pregnant women with a breech presentation at term, and to assess its acceptability. METHODS: The external cephalic version (ECV) decision aid was developed using the Ottawa Decision Support Framework and a systematic review of the evidence to provide probabilistic information about the benefits and risks of options. It incorporates a workbook supplemented by a CD and worksheet, and these were evaluated in a pilot study using self-administered questionnaires. PARTICIPANTS: 19 women with a breech presentation attending antenatal clinics at a local obstetric hospital and 11 recently pregnant women. FINDINGS: Of 30 women surveyed, nearly all found the decision aid clear and easy to understand, and thought that enough information was provided for them to make a decision. Women experienced increased knowledge, reduced decisional conflict, increased satisfaction and participation in decision making without increased anxiety. Participants also found the tool helpful and would recommend it to others. KEY CONCLUSIONS: The ECV decision aid was well accepted and helpful for pregnant women with a breech presenting baby. We are currently evaluating the decision aid in a randomised trial to assess cognitive, affective and health outcomes.

Pregnant women's preferences and knowledge of term breech management, in an Australian setting.

OBJECTIVE: To assess women's familiarity with breech presentation and external cephalic version (ECV), and to identify women's preferences and attitudes regarding breech management. DESIGN: Cross-sectional survey. SETTING: King George V (KGV) Memorial Hospital for Mothers and Babies, Sydney, Australia, a major metropolitan teaching hospital. POPULATION: 174 pregnant women (20-38 weeks gestation) attending KGV for antenatal care in 2001. METHODS: Data were obtained from a self-administered questionnaire that was distributed through the antenatal clinics. MAIN OUTCOME MEASURES: Women's familiarity of breech presentation and ECV, women's attitude towards ECV, decision to attempt ECV, and with whom participants would like to make a decision regarding ECV. FINDINGS: Of the 174 respondents, 85% could correctly identify breech presentation, and 66% had heard of ECV. For 87% this information was from books, and family/friends, and not their midwife/doctor. Equal numbers of women responded that they would or would not choose ECV (39%), and the remaining 22% were uncertain. Factors influencing their decision included concerns about the safety for the baby, ECV not guaranteeing vaginal birth despite successful version, and ECV not being effective enough. Seventy-two per cent wanted to make the decision to attempt ECV together with their doctor. CONCLUSION: Although the majority of the women had a preference for vaginal birth, their knowledge of ECV appeared insufficient to enable them to make informed decisions about attempting ECV. These findings suggest that care-providers should offer women information on ECV, in a shared-decision-making environment.

Women's attitudes towards management of breech presentation at term.

Current advice on the management of breech presentation at term is that all uncomplicated cases should be offered external cephalic version (ECV) or an elective caesarean section. Clinical experience suggests that ECV is currently not offered as widely as advised and that the majority are delivered electively by caesarean section. We present the results of a patient attitude survey of term breech deliveries in a university teaching hospital over 12 months. The results show that half of respondents were not offered ECV and that two-thirds of these women were not eligible for ECV, either having had a previous caesarean or breech presentation diagnosed in labour. One-third of women, potentially suitable for ECV, were not made aware of their options. The majority are offered elective caesarean section with a small minority (10%) opting for planned vaginal breech delivery.

[Influences on decisions of pregnant patients with breech presentation for external fetal version or cesarean section--information status and anxiety pattern]. / Einflüsse auf Entscheidungen von Schwangeren mit BEL zur äusseren Wendung oder zur Schnittentbindung--Aufklärungsstatus and Angstmuster.

Within the framework of a retrospective and prospective analysis of 61 women with breech presentation in late pregnancy and with the help of a half-standardised questionnaire, we investigated the subjective reaction of these patients after they had been informed of their situation, as to what fears resulted and how well informed they were regarding the various obstetrical procedures in cases with breech presentation. The patients in the version group were clearly more anxious (n = 41). They were frightened of putting the child's well-being at risk, damaging personal health and having a cesarean section. The fear patterns were very varied in both groups. In the cesarean group (n = 20) the patients were not so afraid of the anesthesia and the risk of infection, whereas those in the version group were considerably more afraid; it was quite the reverse as regards the risk of permanent damage to the child due to the version--in the cesarean group this was rated as a high risk, whereas in the version group it was rated as a slight risk. The decision on the obstetrical procedure was mainly influenced by the doctor. In conclusion it can be said, that too little is known about the obstetrical procedure of cephalic version near to term and that it is tainted with unnecessary fears. We recommend that more intensive, specialised information should be given before undertaking obstetrical management of breech presentation.