- Email: [email protected]
Qualitative assessment of women's experiences with ECV
Women and Birth 26 (2013) e41–e44
Contents lists available at SciVerse ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Qualitative assessment of women’s experiences with ECV U.A. Menakaya a,*, A. Trivedi b a b
Liverpool Hospital, Sydney, NSW, Australia Frankston Hospital, Melbourne, VIC, Australia
A R T I C L E I N F O
Article history: Received 21 June 2012 Received in revised form 30 August 2012 Accepted 11 September 2012 Keywords: External cephalic version Caesarean section Breech Focus group discussion
A B S T R A C T
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. ß 2012 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Introduction External cephalic version (ECV) is an obstetric procedure for manipulating the breech presenting fetus to a cephalic presentation. It improves the chances of vaginal births by increasing the proportion of vertex presentations among babies formerly in breech position. The procedure has received renewed interest in the last 2 decades coincident with publication of results of the term breech trial as well as the global concerns about rising rates of caesarean section.1 ECV has been subjected to rigorous scientific appraisal and has demonstrated a reduction in caesarean births without any significant effect on perinatal mortality and morbidity.1 Hence the Royal College of Obstetricians and Gynaecology recommends that all women with an uncomplicated breech pregnancy at term should be offered ECV.2 The procedure has a success rate of 30–80%.2 This rate is influenced by race, parity, type of breech and the location of the placenta.3 In Sydney, a success rate of 39% has been reported.4 Thus, a significant proportion of ECVs are unsuccessful. For those women
* Corresponding author at: Liverpool Hospital, SSWAHS, Sydney, NSW 2170, Australia. Tel.: +61 0404 633 393. E-mail address: [email protected] (U.A. Menakaya).
with unsuccessful ECV, discussions about their mode of delivery should include the benefits and risks of a planned caesarean or vaginal breech birth.10 However, most obstetric units continue to offer only planned caesarean births5 when ECVs are unsuccessful despite the proven safety of vaginal breech births in selected patients.10 Such policies can be at variance with a woman’s desire and preference for vaginal birth.6,7 Thus, a conflict situation arises that could have varying medical, emotional and cultural implications. In the past, the debate on ECV has primarily focused on its cost effectiveness, safety, appropriate gestational age for the procedure as well as its impact on caesarean section rates.2,8 Recently, this debate has expanded to identify and include strategies for increasing patient’s understanding of the procedure to enable them make informed decisions.4,6 Unfortunately despite the sizable number of unsuccessful ECV among women who consent for the procedure, no studies to date have attempted an evaluation of women’s experiences with ECV. This paper therefore seeks to provide a perspective on ECV from women whose ECV were unsuccessful. It is our view that their contribution to the ECV debate can only improve the quality of ECV service. The paper was developed from an original research project that undertook a qualitative assessment of women’s experiences with ECV at a secondary level obstetric facility in the south eastern suburbs of Melbourne, Australia. Its maternity services records more than 2500 deliveries a year.
1871-5192/$ – see front matter ß 2012 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. http://dx.doi.org/10.1016/j.wombi.2012.09.001
e42
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
2. Materials and methods
3. Results and discussion
The antenatal and birth records of patients attending the antenatal clinics at the Women’s Children and Adolescent health department (WCAH) were reviewed over a 3 year period. The review was undertaken following the hospital ethics committee approval to undertake a qualitative assessment of women’s experiences with ECV at the hospital. Specific details about patients’ antenatal and birth records were elicited from the hospital database. All the women who had an ECV during the period under review were identified and invited to participate in a focus group discussion (FGD). One FGD was held for women with unsuccessful ECV and another for women who were successful with ECV. There were 5 participants in the FGD for women with unsuccessful ECV. A FGD facilitator and an assistant were recruited as part of the project. A FGD questionnaire was developed, piloted and then modified prior to use in the FGD. The FGD was voice recorded while an assistant took notes that highlighted the nonverbal cues that were associated with the expression of a participant’s point of view. Transcripts of the interview were analysed for content and specific themes identified from the participants’ description of their experiences with ECV.
A total of 21 ECVs were performed in the period under review. 13 (62%) were unsuccessful. Of these, 7 (58%) women accepted our invitation to participate in the focus group discussion but 5 (71.4%) attended. The reasons for declining to participate include ‘‘phobia for public speaking, ill health, economic engagement and the experience of ECV being too painful to talk about’’. The demographic characteristics of participants in the FGD were similar. Their mean age was 29 years. All the participants had a college education and resided in the catchment area served by the hospital. 43% of the ECV occurred with nulliparous women and 76% of the ECVs were performed after 37weeks gestation (see Table 1).
2.1. The ECV protocol We offer ECV to women with a breech presenting fetus at term that are eligible for the procedure. The exclusion criteria for an ECV in our unit include placenta praevia, reduced liquor volume, ruptured membranes, multiple pregnancy, maternal or fetal anatomical abnormality and previous uterine surgery. Others include severe gestational hypertension, fetal macrosomia and poorly controlled gestational diabetes mellitus. Eligible women are recruited through the antenatal clinic following standard counselling. Women who consent for the procedure are booked for an ECV. All ECVs are carried out on the labour ward. Prior to ECV, arrangements are made with the operating theatre for immediate access if required. The procedure may be performed by a registrar or a specialist. On admission to labour ward a written consent is obtained. A bedside ultrasound is used to confirm the breech presentation and an intravenous canula is inserted. A cardiotocograph is recorded prior to the commencement of the procedure. The ECV is attempted with the woman lying recumbent with a wedge under the right hip to give 30 degrees left lateral tilt to avoid vena caval compression. Tocolysis (salbutamol or tertbutaline) may be used to reduce uterine tone if earlier attempts are unsuccessful. Using ultrasonic gel as lubricant, an attempt is made to lift the breech out of the pelvis by manipulating the pregnant abdomen. This is followed by simultaneously encouraging forward movement of the head and backward movement of the buttocks to induce forward rotation. If this is ineffective, an attempt to move the fetus in the reverse direction may be undertaken provided the woman consents to continuing the procedure. A CTG is performed at intervals during the procedure to monitor the fetal heart rhythm. The procedure is abandoned if a number of attempts are unsuccessful or if the woman complained of excessive discomfort. The procedure may last up to 30 min. Following the ECV, the fetal presentation and heart rate are immediately assessed by ultrasound. A 1 h cardiotocogram is performed after the procedure and anti D immunoglobulin is administered to rhesus negative women. Women were discharged following a normal fetal heart rate tracing. Prior to discharge, women with unsuccessful ECV are consented and booked for a caesarean section at 39 weeks.
3.1. Emotions associated with caesarean section for breech presentation at term The experience of childbirth is an important life event for women. Indeed, memories of childbirth persist throughout life. A key component of a satisfactory childbirth experience is the actualization of a desired mode of delivery. Although, the majority of women prefer the option of vaginal birth6,7 the persistence of the breech at term is an indication for caesarean birth.5 Despite the criticisms of the term breech trial,11 many obstetric units continue to implement a policy of caesarean section for a persisting breech presentation at term. Such policies may be at variance with a woman’s desired mode of delivery and can result in various conflict situations. These situations were explored during the FGD. Our participants stated: ‘‘...It wasn’t the Caesar I was scared about, I was absolutely devastated because I wanted to puff and pant and I thought, it has taken that away. I wanted to have the birth... I can’t tell you why now... But I really wanted to... And I thought if I was to have a Caesar, I wanted to be awake. I don’t want someone to take my baby first... straight to midwife and they will get that first cuddle... that was my fear...’’ ‘‘...But he (Dr.) said to me if the baby does not turn, you will have to have a caesarean. And I think I was more worried about the caesarean than I was about the baby being breech...I knew how hard it was for my friends that had Caesar...my other daughter had just turned 18months... she is a handful... looking after Jamie (newborn) and her wasn’t easy with my tummy wound...’’ 3.2. Activities to turn breech to cephalic Participants in our FGD engaged in a number of activities to encourage spontaneous version and achieve vaginal birth despite Table 1 Demographic characteristics of patients undergoing ECV. Number (%)
Characteristics Age
30 years >30 years
15 (71.4%) 6 (28.6%)
BMI
30 >30
11 (52.4%) 10 (47.6%)
Parity
Nullipara Multipara
9 (42.9%) 12 (57.1%)
Race
Caucasian Asian Others
18 (85.7%) 2 (9.5%) 1 (4.8%)
Timing of ECV
36weeks 36–37weeks >37weeks
0 5 (23.8%) 16 (76.2%)
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
an unsuccessful ECV. Some of these activities include acupuncture, moxibustion, increased physical activities and Chinese massage.1 Although, there are no scientific data to confirm or disprove the efficacy and effectiveness of these activities, some of our participants chose to try them. One of them stated: ‘‘...and I did everything I could to try to make him turn. I used moxisticks and acupuncture and lots of other things which I found out from the clinics. Anything and everything you could do... I also researched on the internet...’’ Among the women in our discussion group, the aptitude for increased physical activity as a means to induce spontaneous version of the breech was variable. There were participants who increased their physical activities and others who were more reluctant to do so. For example, ‘‘...And I went swimming everyday for ages. I was on the ground like doing all these exercises...I was really pregnant!...With my feet up the wall and all sorts of things. It was very challenging. . .’’ ‘‘...The brochure showed me what to do...I think I did them (exercises) for a little while. I was pretty nervous, being pregnant and all. I couldn’t do it...’’ One participant chose a gentler approach in an attempt to induce spontaneous version to a cephalic presentation: ‘‘...A friend suggested... and I tried using music and playing it lower... so that the baby could hear it and turn towards the music and having my husband speaking down lower...’’ Unfortunately, none of these activities were successful in inducing a spontaneous version from breech to a cephalic presentation among our women. All but one of the women in our FGD had a caesarean section for breech. 3.3. Emotional consequences of an unsuccessful ECV When ECV is unsuccessful, the emotional consequences can be far reaching as demonstrated by the women in our FGD. The emotions elicited from our women in response to a question that explored their feelings towards ECV took us completely by surprise. It was clear that among our participants, the experience of an unsuccessful ECV was a painful one. Indeed, it seemed that the participants’ perceived their unsuccessful ECV as an indictment of the quality of their parenthood. For example, comments made by our participants include: ‘‘...We both felt and still do today that we did the wrong thing by my son... As a mother and mothers know things... I think my son came early because of that procedure and for days afterwards I was shaking and so upset over it and I could still cry now that’s how awful it was for me... I felt and so did my husband that we had to apologise to our baby that we had somehow hurt him. Yeah it was awful. I really felt it hurt him...’’ ‘‘... I just remember the pain and the feeling afterwards...the feeling that I had done something wrong because she did kick me and I remember the heart was beating very fast and remembering that she was not even in the world yet and she is already stressed...’’ ‘‘...I remember going home and rubbing my belly and saying sorry to my baby. I had had a completely normal pregnancy. . . And I thought imagine if I had stuffed that up by doing this. I
e43
might have hurt a perfectly normal baby and if I had done anything that might have harmed her, I wouldn’t forgive myself...but thank God she was completely healthy...’’ Counselling with provision of quality information on ECV is an essential aspect of the management of a breech presentation at term.6 Recently, the use of audio decision aids as an adjunct to standard counselling has stimulated women to be more active in decision making about their pregnancy care.4,9 These counselling processes are aimed at obtaining informed consent for the ECV procedure as well as caesarean section for women whose ECV were unsuccessful. In our unit, there is no formal post ECV follow up program that could help women deal with the disappointments of an unsuccessful ECV. Our approach is to immediately book a caesarean section at 39 weeks while continuing routine antenatal care. Unfortunately, the views expressed by our participants suggest that this ‘‘medicalized’’ approach to ECV fell short of their expectations of care. This was highlighted by the one of the participants in the FGD: ‘‘...no one called us a couple of days later to ask how we are feeling and if there was any questions...they did say to me that if I had any concerns to just ring up or come in but you just feel that you are overreacting by coming in... But if it was just a standard procedure it would be better...’’ Such a ‘‘standard procedure’’ would provide an opportunity for the women to discuss any emotions associated with an unsuccessful ECV and help them develop strategies to deal with any conflicts occasioned by the need for a caesarean birth. 4. Conclusion We were humbled by the willingness of the participants to relive their experiences during our FGD. Although some of the ECVs had occurred 18 months prior to the research project, these experiences remained as fresh as ever. Among our participants, there was clearly a need for emotional resolution. One participant stated: ‘‘... It is really nice to speak to all of you here. It’s good to know that all of you had pain as well and I was not the only one, because when you speak to people that had it 20 years ago and they said that it didn’t hurt at all, I think they just forgot about it...’’ There is no doubt that our study was limited by the number and size of our focus groups. It is therefore unlikely we reached saturation point for all the themes highlighted in our focus groups. As such our findings cannot be generalized. Nevertheless, the FGDs provided an opportunity for the participants to express their views, share their experiences and by so doing kick start a process of conflict resolution. All the participants in our FGD were offered referrals to the social work services linked to the WCAH department. We hope that by contributing this consumer perspective to the ECV research, we will stimulate further work in this area. Equally important is the value of their feed back on the ECV services provided by our unit. We have improved our counselling process by including an audio decision aid9 for women with a breech presenting baby at term and expanded our ECV services to include a role for the social worker. Acknowledgments The authors wish to thank all the women who gave their time to share their unique experiences with us. We are humbled by your contributions.
e44
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.wombi.2012.09.001. References 1. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Systematic Review 2000;(2):CD000083. 2. Royal College of Obstetricians and Gynaecologists. ECV and reducing the incidence of breech presentation. 2001. Clinical guidelines: No. 20a. 3. Regalia AL, Curiel P, Natale N, Galuzzi A, Spinelli G, Ghezzi GVL, et al. Routine use of external cephalic version in three hospitals. Birth 2000;27(1):19–24. 4. Natasha N, Christine l, Carolyn R, Brian P AC. Outcome of external cephalic version and breech presentation at term, an audit of deliveries at a sydney tertiary obstetric hospital, 1974–2004. Acta Obstetricia et Gynecologica Scandinavica 2006;85(10):1156–280.
5. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willlan AR. Planned caesarean section versus vaginal birth from Breech presentation at term: a randomised multicentre trial. Term Breech trial Collaborative group. Lancet 2000;356(9239):1375–83. 6. Raynes-Greenow CH, Roberts CL, Barratt A, Brodrick B, Peat B. Pregnant women’s preferences and knowledge of term breech management in an Australian setting. Midwifery 2003;20:181–7. 7. Chong ES, Mongelli MO. Attitudes of Singapore women toward caesarean and vaginal deliveries. International Journal of Gynecology and Obstetrics 2003;80:189–94. 8. Zhang J, Bowes WA, Fortney JA. Efficacy of external cephalic version: a review. Obstetrics and Gynecology 1993;82:306–12. 9. Nassar N, Roberts C, Raynes-Greenow C, Barratt A, Peat B. Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial. BJOG An International Journal of Obstetrics and Gynaecology 2007;114(3):325–33. 10. Royal College of Obstetricians and Gynaecologists. The management of breech presentation. 2006. Clinical guidelines: No. 20b. 11. Bewley S, Shennan A. Peer review and the term breech trial. The Lancet 2007;369(9565):906.
Contents lists available at SciVerse ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Qualitative assessment of women’s experiences with ECV U.A. Menakaya a,*, A. Trivedi b a b
Liverpool Hospital, Sydney, NSW, Australia Frankston Hospital, Melbourne, VIC, Australia
A R T I C L E I N F O
Article history: Received 21 June 2012 Received in revised form 30 August 2012 Accepted 11 September 2012 Keywords: External cephalic version Caesarean section Breech Focus group discussion
A B S T R A C T
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. ß 2012 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.
1. Introduction External cephalic version (ECV) is an obstetric procedure for manipulating the breech presenting fetus to a cephalic presentation. It improves the chances of vaginal births by increasing the proportion of vertex presentations among babies formerly in breech position. The procedure has received renewed interest in the last 2 decades coincident with publication of results of the term breech trial as well as the global concerns about rising rates of caesarean section.1 ECV has been subjected to rigorous scientific appraisal and has demonstrated a reduction in caesarean births without any significant effect on perinatal mortality and morbidity.1 Hence the Royal College of Obstetricians and Gynaecology recommends that all women with an uncomplicated breech pregnancy at term should be offered ECV.2 The procedure has a success rate of 30–80%.2 This rate is influenced by race, parity, type of breech and the location of the placenta.3 In Sydney, a success rate of 39% has been reported.4 Thus, a significant proportion of ECVs are unsuccessful. For those women
* Corresponding author at: Liverpool Hospital, SSWAHS, Sydney, NSW 2170, Australia. Tel.: +61 0404 633 393. E-mail address: [email protected] (U.A. Menakaya).
with unsuccessful ECV, discussions about their mode of delivery should include the benefits and risks of a planned caesarean or vaginal breech birth.10 However, most obstetric units continue to offer only planned caesarean births5 when ECVs are unsuccessful despite the proven safety of vaginal breech births in selected patients.10 Such policies can be at variance with a woman’s desire and preference for vaginal birth.6,7 Thus, a conflict situation arises that could have varying medical, emotional and cultural implications. In the past, the debate on ECV has primarily focused on its cost effectiveness, safety, appropriate gestational age for the procedure as well as its impact on caesarean section rates.2,8 Recently, this debate has expanded to identify and include strategies for increasing patient’s understanding of the procedure to enable them make informed decisions.4,6 Unfortunately despite the sizable number of unsuccessful ECV among women who consent for the procedure, no studies to date have attempted an evaluation of women’s experiences with ECV. This paper therefore seeks to provide a perspective on ECV from women whose ECV were unsuccessful. It is our view that their contribution to the ECV debate can only improve the quality of ECV service. The paper was developed from an original research project that undertook a qualitative assessment of women’s experiences with ECV at a secondary level obstetric facility in the south eastern suburbs of Melbourne, Australia. Its maternity services records more than 2500 deliveries a year.
1871-5192/$ – see front matter ß 2012 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. http://dx.doi.org/10.1016/j.wombi.2012.09.001
e42
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
2. Materials and methods
3. Results and discussion
The antenatal and birth records of patients attending the antenatal clinics at the Women’s Children and Adolescent health department (WCAH) were reviewed over a 3 year period. The review was undertaken following the hospital ethics committee approval to undertake a qualitative assessment of women’s experiences with ECV at the hospital. Specific details about patients’ antenatal and birth records were elicited from the hospital database. All the women who had an ECV during the period under review were identified and invited to participate in a focus group discussion (FGD). One FGD was held for women with unsuccessful ECV and another for women who were successful with ECV. There were 5 participants in the FGD for women with unsuccessful ECV. A FGD facilitator and an assistant were recruited as part of the project. A FGD questionnaire was developed, piloted and then modified prior to use in the FGD. The FGD was voice recorded while an assistant took notes that highlighted the nonverbal cues that were associated with the expression of a participant’s point of view. Transcripts of the interview were analysed for content and specific themes identified from the participants’ description of their experiences with ECV.
A total of 21 ECVs were performed in the period under review. 13 (62%) were unsuccessful. Of these, 7 (58%) women accepted our invitation to participate in the focus group discussion but 5 (71.4%) attended. The reasons for declining to participate include ‘‘phobia for public speaking, ill health, economic engagement and the experience of ECV being too painful to talk about’’. The demographic characteristics of participants in the FGD were similar. Their mean age was 29 years. All the participants had a college education and resided in the catchment area served by the hospital. 43% of the ECV occurred with nulliparous women and 76% of the ECVs were performed after 37weeks gestation (see Table 1).
2.1. The ECV protocol We offer ECV to women with a breech presenting fetus at term that are eligible for the procedure. The exclusion criteria for an ECV in our unit include placenta praevia, reduced liquor volume, ruptured membranes, multiple pregnancy, maternal or fetal anatomical abnormality and previous uterine surgery. Others include severe gestational hypertension, fetal macrosomia and poorly controlled gestational diabetes mellitus. Eligible women are recruited through the antenatal clinic following standard counselling. Women who consent for the procedure are booked for an ECV. All ECVs are carried out on the labour ward. Prior to ECV, arrangements are made with the operating theatre for immediate access if required. The procedure may be performed by a registrar or a specialist. On admission to labour ward a written consent is obtained. A bedside ultrasound is used to confirm the breech presentation and an intravenous canula is inserted. A cardiotocograph is recorded prior to the commencement of the procedure. The ECV is attempted with the woman lying recumbent with a wedge under the right hip to give 30 degrees left lateral tilt to avoid vena caval compression. Tocolysis (salbutamol or tertbutaline) may be used to reduce uterine tone if earlier attempts are unsuccessful. Using ultrasonic gel as lubricant, an attempt is made to lift the breech out of the pelvis by manipulating the pregnant abdomen. This is followed by simultaneously encouraging forward movement of the head and backward movement of the buttocks to induce forward rotation. If this is ineffective, an attempt to move the fetus in the reverse direction may be undertaken provided the woman consents to continuing the procedure. A CTG is performed at intervals during the procedure to monitor the fetal heart rhythm. The procedure is abandoned if a number of attempts are unsuccessful or if the woman complained of excessive discomfort. The procedure may last up to 30 min. Following the ECV, the fetal presentation and heart rate are immediately assessed by ultrasound. A 1 h cardiotocogram is performed after the procedure and anti D immunoglobulin is administered to rhesus negative women. Women were discharged following a normal fetal heart rate tracing. Prior to discharge, women with unsuccessful ECV are consented and booked for a caesarean section at 39 weeks.
3.1. Emotions associated with caesarean section for breech presentation at term The experience of childbirth is an important life event for women. Indeed, memories of childbirth persist throughout life. A key component of a satisfactory childbirth experience is the actualization of a desired mode of delivery. Although, the majority of women prefer the option of vaginal birth6,7 the persistence of the breech at term is an indication for caesarean birth.5 Despite the criticisms of the term breech trial,11 many obstetric units continue to implement a policy of caesarean section for a persisting breech presentation at term. Such policies may be at variance with a woman’s desired mode of delivery and can result in various conflict situations. These situations were explored during the FGD. Our participants stated: ‘‘...It wasn’t the Caesar I was scared about, I was absolutely devastated because I wanted to puff and pant and I thought, it has taken that away. I wanted to have the birth... I can’t tell you why now... But I really wanted to... And I thought if I was to have a Caesar, I wanted to be awake. I don’t want someone to take my baby first... straight to midwife and they will get that first cuddle... that was my fear...’’ ‘‘...But he (Dr.) said to me if the baby does not turn, you will have to have a caesarean. And I think I was more worried about the caesarean than I was about the baby being breech...I knew how hard it was for my friends that had Caesar...my other daughter had just turned 18months... she is a handful... looking after Jamie (newborn) and her wasn’t easy with my tummy wound...’’ 3.2. Activities to turn breech to cephalic Participants in our FGD engaged in a number of activities to encourage spontaneous version and achieve vaginal birth despite Table 1 Demographic characteristics of patients undergoing ECV. Number (%)
Characteristics Age
30 years >30 years
15 (71.4%) 6 (28.6%)
BMI
30 >30
11 (52.4%) 10 (47.6%)
Parity
Nullipara Multipara
9 (42.9%) 12 (57.1%)
Race
Caucasian Asian Others
18 (85.7%) 2 (9.5%) 1 (4.8%)
Timing of ECV
36weeks 36–37weeks >37weeks
0 5 (23.8%) 16 (76.2%)
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
an unsuccessful ECV. Some of these activities include acupuncture, moxibustion, increased physical activities and Chinese massage.1 Although, there are no scientific data to confirm or disprove the efficacy and effectiveness of these activities, some of our participants chose to try them. One of them stated: ‘‘...and I did everything I could to try to make him turn. I used moxisticks and acupuncture and lots of other things which I found out from the clinics. Anything and everything you could do... I also researched on the internet...’’ Among the women in our discussion group, the aptitude for increased physical activity as a means to induce spontaneous version of the breech was variable. There were participants who increased their physical activities and others who were more reluctant to do so. For example, ‘‘...And I went swimming everyday for ages. I was on the ground like doing all these exercises...I was really pregnant!...With my feet up the wall and all sorts of things. It was very challenging. . .’’ ‘‘...The brochure showed me what to do...I think I did them (exercises) for a little while. I was pretty nervous, being pregnant and all. I couldn’t do it...’’ One participant chose a gentler approach in an attempt to induce spontaneous version to a cephalic presentation: ‘‘...A friend suggested... and I tried using music and playing it lower... so that the baby could hear it and turn towards the music and having my husband speaking down lower...’’ Unfortunately, none of these activities were successful in inducing a spontaneous version from breech to a cephalic presentation among our women. All but one of the women in our FGD had a caesarean section for breech. 3.3. Emotional consequences of an unsuccessful ECV When ECV is unsuccessful, the emotional consequences can be far reaching as demonstrated by the women in our FGD. The emotions elicited from our women in response to a question that explored their feelings towards ECV took us completely by surprise. It was clear that among our participants, the experience of an unsuccessful ECV was a painful one. Indeed, it seemed that the participants’ perceived their unsuccessful ECV as an indictment of the quality of their parenthood. For example, comments made by our participants include: ‘‘...We both felt and still do today that we did the wrong thing by my son... As a mother and mothers know things... I think my son came early because of that procedure and for days afterwards I was shaking and so upset over it and I could still cry now that’s how awful it was for me... I felt and so did my husband that we had to apologise to our baby that we had somehow hurt him. Yeah it was awful. I really felt it hurt him...’’ ‘‘... I just remember the pain and the feeling afterwards...the feeling that I had done something wrong because she did kick me and I remember the heart was beating very fast and remembering that she was not even in the world yet and she is already stressed...’’ ‘‘...I remember going home and rubbing my belly and saying sorry to my baby. I had had a completely normal pregnancy. . . And I thought imagine if I had stuffed that up by doing this. I
e43
might have hurt a perfectly normal baby and if I had done anything that might have harmed her, I wouldn’t forgive myself...but thank God she was completely healthy...’’ Counselling with provision of quality information on ECV is an essential aspect of the management of a breech presentation at term.6 Recently, the use of audio decision aids as an adjunct to standard counselling has stimulated women to be more active in decision making about their pregnancy care.4,9 These counselling processes are aimed at obtaining informed consent for the ECV procedure as well as caesarean section for women whose ECV were unsuccessful. In our unit, there is no formal post ECV follow up program that could help women deal with the disappointments of an unsuccessful ECV. Our approach is to immediately book a caesarean section at 39 weeks while continuing routine antenatal care. Unfortunately, the views expressed by our participants suggest that this ‘‘medicalized’’ approach to ECV fell short of their expectations of care. This was highlighted by the one of the participants in the FGD: ‘‘...no one called us a couple of days later to ask how we are feeling and if there was any questions...they did say to me that if I had any concerns to just ring up or come in but you just feel that you are overreacting by coming in... But if it was just a standard procedure it would be better...’’ Such a ‘‘standard procedure’’ would provide an opportunity for the women to discuss any emotions associated with an unsuccessful ECV and help them develop strategies to deal with any conflicts occasioned by the need for a caesarean birth. 4. Conclusion We were humbled by the willingness of the participants to relive their experiences during our FGD. Although some of the ECVs had occurred 18 months prior to the research project, these experiences remained as fresh as ever. Among our participants, there was clearly a need for emotional resolution. One participant stated: ‘‘... It is really nice to speak to all of you here. It’s good to know that all of you had pain as well and I was not the only one, because when you speak to people that had it 20 years ago and they said that it didn’t hurt at all, I think they just forgot about it...’’ There is no doubt that our study was limited by the number and size of our focus groups. It is therefore unlikely we reached saturation point for all the themes highlighted in our focus groups. As such our findings cannot be generalized. Nevertheless, the FGDs provided an opportunity for the participants to express their views, share their experiences and by so doing kick start a process of conflict resolution. All the participants in our FGD were offered referrals to the social work services linked to the WCAH department. We hope that by contributing this consumer perspective to the ECV research, we will stimulate further work in this area. Equally important is the value of their feed back on the ECV services provided by our unit. We have improved our counselling process by including an audio decision aid9 for women with a breech presenting baby at term and expanded our ECV services to include a role for the social worker. Acknowledgments The authors wish to thank all the women who gave their time to share their unique experiences with us. We are humbled by your contributions.
e44
U.A. Menakaya, A. Trivedi / Women and Birth 26 (2013) e41–e44
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.wombi.2012.09.001. References 1. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Systematic Review 2000;(2):CD000083. 2. Royal College of Obstetricians and Gynaecologists. ECV and reducing the incidence of breech presentation. 2001. Clinical guidelines: No. 20a. 3. Regalia AL, Curiel P, Natale N, Galuzzi A, Spinelli G, Ghezzi GVL, et al. Routine use of external cephalic version in three hospitals. Birth 2000;27(1):19–24. 4. Natasha N, Christine l, Carolyn R, Brian P AC. Outcome of external cephalic version and breech presentation at term, an audit of deliveries at a sydney tertiary obstetric hospital, 1974–2004. Acta Obstetricia et Gynecologica Scandinavica 2006;85(10):1156–280.
5. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willlan AR. Planned caesarean section versus vaginal birth from Breech presentation at term: a randomised multicentre trial. Term Breech trial Collaborative group. Lancet 2000;356(9239):1375–83. 6. Raynes-Greenow CH, Roberts CL, Barratt A, Brodrick B, Peat B. Pregnant women’s preferences and knowledge of term breech management in an Australian setting. Midwifery 2003;20:181–7. 7. Chong ES, Mongelli MO. Attitudes of Singapore women toward caesarean and vaginal deliveries. International Journal of Gynecology and Obstetrics 2003;80:189–94. 8. Zhang J, Bowes WA, Fortney JA. Efficacy of external cephalic version: a review. Obstetrics and Gynecology 1993;82:306–12. 9. Nassar N, Roberts C, Raynes-Greenow C, Barratt A, Peat B. Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial. BJOG An International Journal of Obstetrics and Gynaecology 2007;114(3):325–33. 10. Royal College of Obstetricians and Gynaecologists. The management of breech presentation. 2006. Clinical guidelines: No. 20b. 11. Bewley S, Shennan A. Peer review and the term breech trial. The Lancet 2007;369(9565):906.