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Changing attitudes toward mode of delivery and external cephalic version in breech presentations
International Journal of Gynecology and Obstetrics 79 (2002) 221–224
Article
Changing attitudes toward mode of delivery and external cephalic version in breech presentations Y. Yogeva, E. Horowitza, A. Ben-Harousha, R. Chena, B. Kaplana,b,* a
Department of Obstetrics and Gynecology, Women’s Comprehensive Health Center, Rabin Medical Center, Petah Tikva, Israel b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Received 21 May 2002; received in revised form 22 August 2002; accepted 28 August 2002
Abstract Objectives: To compare the attitude of gravid women in breech presentation towards external cephalic version (ECV) and mode of delivery between 1995 and 2001. Methods: A questionnaire on ECV and mode of delivery was distributed to women in the third trimester of pregnancy with breech presentation, attending our departmental clinic for a routine check-up once in 1995 and again in 2001 in order to analyze changing attitudes. Results: One hundred fifty-four women completed the questionnaire in 1995 and 127 in 2001. There were no statistically significant differences between the groups in age, gestational age, gravidity, parity, or level of education. In 1995, more than half the women (52.7%) had heard of ECV and 53.8% were willing to consider it, whereas in 2001, 73.2% had heard of it but only 23.9% were willing to consider it. In both groups, the women who were familiar with ECV were more likely to work outside of the home, have a higher level of educated than the women who were not. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. The percentage of women who would choose planned cesarean section if the presentation remained breech was significantly higher in 2001 (97%) than in 1995 (64.7%). Conclusions: Attitudes toward breech delivery have changed since 1995. More women are aware of the option of ECV but are less inclined to consider it. Planned cesarean section for breech presentation is the overwhelming choice of women in general, with a significant increase in 2001 compared with 1995. 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. Keywords: Breech; External cephalic version; Attitude; Israel
1. Introduction In 3–4% of pregnancies, the fetus is in breech presentation at term. Until recently the mode of *Corresponding author. Tel.: q972-3-937-7534; fax: q9723-937-7504. E-mail address: [email protected] (B. Kaplan).
delivery was controversial. However, in 2000, Hannah et al. w1x, in a randomized multicenter study, reported that planned cesarean section is better for the neonate than planned vaginal birth, with no difference in maternal complications. On the basis of their findings, our department stopped the use of planned vaginal delivery for breech
0020-7292/02/$ - see front matter 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 2 . 0 0 2 7 4 - 6
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Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
presentation except for patients who refused other means. In these cases, the patients received a full explanation of the neonatal risks and signed an informed consent form. Today, women in breech presentation may choose external cephalic version (ECV) to attempt to convert the breech to vertex presentation. If the breech persists they may choose between vaginal breech delivery, and elective cesarean section. Data on women’s attitudes towards ECV and their choice of method of delivery for a breech baby remain sparse and many women, however, remain confused, due to inadequate knowledge provided by obstetricians or midwives. The few studies conducted so far show that most women tend to opt for cesarean section w2,3x, but if ECV is offered, the majority is willing to try it w3,4x. The objective of this study was to assess women’s awareness of ECV and choice of delivery method for breech presentation and to compare changes in attitude between 1995 and 2001, shortly after our departmental delivery policy was revised. 2. Materials and methods A one-page questionnaire was distributed to pregnant women with breech presentation in the third trimester ()36 weeks) who were attending our departmental clinic at Rabin Medical Center for a routine check-up. In our department, which is a tertiary, referral center there are approximately 8000 deliveries per year. Our department policy is to offer ECV to all women with singleton term breech pregnancies in the absence of contraindication for vaginal delivery. All women who met the criteria were asked to participate. Two groups of patients were analyzed—one in 1995 and one in 2001. Each patient underwent detailed counseling by a trained senior physician explaining the merits and demerits of all modes of delivery options. The study was held during the whole of 1995 and the whole of 2001. Women with a previous cesarean section, a multifetal pregnancy, or with a clear indication for cesarean section (e.g. placenta previa) were excluded. The questionnaire covered demographic data, knowledge about ECV, interest in undergoing ECV and preference for
vaginal breech delivery or cesarean section if the fetus remained in breech position. 2.1. Statistical analysis Continuous parameters are given as mean"standard deviation. Pearson correlation coefficient (r) and the significance (P) were calculated for the correlations in the sub-group analysis. The x2-test was used to compare categorical variables, and Student’s t-test was used to determine the statistical significance of differences in mean continuous parameters. A P-value F0.05 was considered statistically significant. 3. Results A total of 281 women completed the questionnaire, 154 women in 1995 and 127 in 2001. The overall response rate was 92%. The patients’ demographic characteristics are shown in Table 1. There was no statistically significant difference between the groups in age, gestational age, gravidity, parity, and level of education. Eighteen percent of the women in 1995 considered their pregnancy high risk because of the breech presentation compared with 38% in 2001 (P-0.002). Regarding the ECV option, 52.7% of the 1995 group had heard of the procedure and 53.8% of them were interested in trying it. In 2001, 73.2% of the group had knowledge about ECV but only 23.9% were willing to try it. The difference in the rate of women who would undergo ECV between the two periods was statistically significant (P-0.03). In the two groups, the women who were familiar with ECV were more likely to be educated and to work outside of the home, than the women who had no knowledge of ECV. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. In the event of failure of ECV, 64.7% of the women in the 1995 group preferred cesarean section as the method of delivery and 35.3% preferred vaginal delivery. By contrast, in the 2001 group, 97% were in favor of cesarean section and
Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
223
Table 1 Characteristics of gravid women with breech presentation
Age (years) (mean"S.D.) Gestational age (weeks) (mean"S.D.) Gravidity (mean"S.D.) Parity (mean"S.D.)
1995 group (ns154)
2001 group (ns127)
29.65"5.04 37.5"2.2
29.02"2.07 37.6"3.1
2.92"0.6 2.43"0.4
2.52"0.7 2.12"0.3
only 3% would consider a planned vaginal delivery. The increase in the number of women who preferred cesarean section in 2001 was statistically significant (Ps0.001). The women who chose cesarean section were older (P-0.02) and more likely to work outside of the home (P-0.04) than the women who opted for vaginal delivery. 4. Discussion The past 6 years have witnessed a significant change in women’s attitude towards breech delivery. Our study shows that more women are aware of the option of ECV but are less inclined to consider it and prefer a planned cesarean section. In addition, significantly more women today consider breech presentation a high risk factor in pregnancy. Specifically, we found that whereas half the women in 1995 would be interested in trying ECV, only 25% in 2001 would do so. Although the women who knew about ECV were more educated, more likely to work outside the home, those who were willing to try ECV were more likely not to work outside of the home. The overwhelming majority of women would choose cesarean section over vaginal breech delivery, though there was a significant increase from 64% in 1995 to 97% in 2001 in favor of this method. We speculate that this change is a result of the changing management of breech presentation and the cessation of planned vaginal delivery for breech presentation. Only a few authors have investigated women’s attitudes to breech presentation and ECV. Krause et al. w2,5x, in Germany, questioned both experienced obstetricians and pregnant women and found that of the 80 obstetricians, 71% advised elective ces-
arean section in primiparas and 80% advised vaginal delivery in multiparas w2x. The main reason in both cases (90% and 72.5%, respectively) was decreased fetal risk. ECV was not even mentioned as an option. Of the 100 pregnant women questioned, the majority chose elective cesarean section because of the perceived lesser risk to the child w5x. Importantly, both studies were conducted before the Term Breech Trial w1x would have been available to either practitioners, or women. In another study from Germany, Krupp et al. w3x analyzed the fears of women with breech presentation in late pregnancy regarding ECV, vaginal delivery and cesarean section. Those who considered ECV (41 of 61) were anxious about both the child and themselves and were apprehensive of a possible cesarean should ECV fail. However, compared with the women who chose elective cesarean section, they were more concerned about the risk of infection and of complications from anesthesia, and less concerned about permanent risk to the child due to the method of delivery. The authors noted that the women’s decision was mainly influenced by the obstetrician’s choice. Leung et al. w4x, in Hong Kong, interviewed women in early pregnancy (not necessarily in breech presentation) as to their future attitudes towards mode of delivery in either breech or cephalic presentation. The great majority (82%) chose ECV as their first choice if the fetus was in breech presentation. Two percent of the women considered ECV ineffective, 13.3% believed it to be dangerous for the woman, and 18.7% believed it to be dangerous for the fetus. In our patients with breech presentation, there was a discrepancy between the high percentage who had heard of ECV and the relative minority
224
Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
who were willing to try it. It might that some of these women are not getting the right or adequate information from their obstetricians and midwives. In conclusion, attitudes toward ECV and delivery of breech presentation have changed in the last 6 years. Managing breech presentations has become less of a dilemma as more and more women choose to have primary elective cesarean with or without a trial of ECV. References w1x Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicenter trial. Term Breech Trial Collaborative Group. Lancet 2000;21(356(9239):1375 –1383.
w2x Fischer T, Krause M, Feige A. Breech presentationinformation, anxiety and pattern of expectations of established obstetricians and pregnant patients. 2: Results of a survey of women with breech presentation. Z Gerburtshilfe Neonatal 1996;200(2):61 –65. w3x Kropp S, Schmidt S, Saling E. Influences on decisions of pregnant patients with breech presentation for external fetal version or cesarean section-information status and anxiety pattern. Z Geburtshilfe Perinatol 1989;193(2):84 –91. w4x Leung TY, Lau TK, Lo KW, Rogers MS. A survey of pregnant women’s attitude towards breech delivery and external cephalic version. Aust N Z J Obstet Gynaecol 2000;40(3):253 –259. w5x Krause M, Fischer T, Feige A. Breech presentationinformation, anxiety and expectations of established obstetricians and pregnant patients. 1: Results of a survey of established obstetricians. Z Geburtshilfe Perinatol 1994;198(4):113 –116.
Article
Changing attitudes toward mode of delivery and external cephalic version in breech presentations Y. Yogeva, E. Horowitza, A. Ben-Harousha, R. Chena, B. Kaplana,b,* a
Department of Obstetrics and Gynecology, Women’s Comprehensive Health Center, Rabin Medical Center, Petah Tikva, Israel b Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Received 21 May 2002; received in revised form 22 August 2002; accepted 28 August 2002
Abstract Objectives: To compare the attitude of gravid women in breech presentation towards external cephalic version (ECV) and mode of delivery between 1995 and 2001. Methods: A questionnaire on ECV and mode of delivery was distributed to women in the third trimester of pregnancy with breech presentation, attending our departmental clinic for a routine check-up once in 1995 and again in 2001 in order to analyze changing attitudes. Results: One hundred fifty-four women completed the questionnaire in 1995 and 127 in 2001. There were no statistically significant differences between the groups in age, gestational age, gravidity, parity, or level of education. In 1995, more than half the women (52.7%) had heard of ECV and 53.8% were willing to consider it, whereas in 2001, 73.2% had heard of it but only 23.9% were willing to consider it. In both groups, the women who were familiar with ECV were more likely to work outside of the home, have a higher level of educated than the women who were not. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. The percentage of women who would choose planned cesarean section if the presentation remained breech was significantly higher in 2001 (97%) than in 1995 (64.7%). Conclusions: Attitudes toward breech delivery have changed since 1995. More women are aware of the option of ECV but are less inclined to consider it. Planned cesarean section for breech presentation is the overwhelming choice of women in general, with a significant increase in 2001 compared with 1995. 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. Keywords: Breech; External cephalic version; Attitude; Israel
1. Introduction In 3–4% of pregnancies, the fetus is in breech presentation at term. Until recently the mode of *Corresponding author. Tel.: q972-3-937-7534; fax: q9723-937-7504. E-mail address: [email protected] (B. Kaplan).
delivery was controversial. However, in 2000, Hannah et al. w1x, in a randomized multicenter study, reported that planned cesarean section is better for the neonate than planned vaginal birth, with no difference in maternal complications. On the basis of their findings, our department stopped the use of planned vaginal delivery for breech
0020-7292/02/$ - see front matter 䊚 2002 International Federation of Gynecology and Obstetrics. Published by Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 0 2 0 - 7 2 9 2 Ž 0 2 . 0 0 2 7 4 - 6
222
Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
presentation except for patients who refused other means. In these cases, the patients received a full explanation of the neonatal risks and signed an informed consent form. Today, women in breech presentation may choose external cephalic version (ECV) to attempt to convert the breech to vertex presentation. If the breech persists they may choose between vaginal breech delivery, and elective cesarean section. Data on women’s attitudes towards ECV and their choice of method of delivery for a breech baby remain sparse and many women, however, remain confused, due to inadequate knowledge provided by obstetricians or midwives. The few studies conducted so far show that most women tend to opt for cesarean section w2,3x, but if ECV is offered, the majority is willing to try it w3,4x. The objective of this study was to assess women’s awareness of ECV and choice of delivery method for breech presentation and to compare changes in attitude between 1995 and 2001, shortly after our departmental delivery policy was revised. 2. Materials and methods A one-page questionnaire was distributed to pregnant women with breech presentation in the third trimester ()36 weeks) who were attending our departmental clinic at Rabin Medical Center for a routine check-up. In our department, which is a tertiary, referral center there are approximately 8000 deliveries per year. Our department policy is to offer ECV to all women with singleton term breech pregnancies in the absence of contraindication for vaginal delivery. All women who met the criteria were asked to participate. Two groups of patients were analyzed—one in 1995 and one in 2001. Each patient underwent detailed counseling by a trained senior physician explaining the merits and demerits of all modes of delivery options. The study was held during the whole of 1995 and the whole of 2001. Women with a previous cesarean section, a multifetal pregnancy, or with a clear indication for cesarean section (e.g. placenta previa) were excluded. The questionnaire covered demographic data, knowledge about ECV, interest in undergoing ECV and preference for
vaginal breech delivery or cesarean section if the fetus remained in breech position. 2.1. Statistical analysis Continuous parameters are given as mean"standard deviation. Pearson correlation coefficient (r) and the significance (P) were calculated for the correlations in the sub-group analysis. The x2-test was used to compare categorical variables, and Student’s t-test was used to determine the statistical significance of differences in mean continuous parameters. A P-value F0.05 was considered statistically significant. 3. Results A total of 281 women completed the questionnaire, 154 women in 1995 and 127 in 2001. The overall response rate was 92%. The patients’ demographic characteristics are shown in Table 1. There was no statistically significant difference between the groups in age, gestational age, gravidity, parity, and level of education. Eighteen percent of the women in 1995 considered their pregnancy high risk because of the breech presentation compared with 38% in 2001 (P-0.002). Regarding the ECV option, 52.7% of the 1995 group had heard of the procedure and 53.8% of them were interested in trying it. In 2001, 73.2% of the group had knowledge about ECV but only 23.9% were willing to try it. The difference in the rate of women who would undergo ECV between the two periods was statistically significant (P-0.03). In the two groups, the women who were familiar with ECV were more likely to be educated and to work outside of the home, than the women who had no knowledge of ECV. The women who were willing to try ECV were more likely not to work outside of the home, to consider their pregnancy low risk, and to opt for vaginal delivery (vs. cesarean section) if ECV did not succeed. In the event of failure of ECV, 64.7% of the women in the 1995 group preferred cesarean section as the method of delivery and 35.3% preferred vaginal delivery. By contrast, in the 2001 group, 97% were in favor of cesarean section and
Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
223
Table 1 Characteristics of gravid women with breech presentation
Age (years) (mean"S.D.) Gestational age (weeks) (mean"S.D.) Gravidity (mean"S.D.) Parity (mean"S.D.)
1995 group (ns154)
2001 group (ns127)
29.65"5.04 37.5"2.2
29.02"2.07 37.6"3.1
2.92"0.6 2.43"0.4
2.52"0.7 2.12"0.3
only 3% would consider a planned vaginal delivery. The increase in the number of women who preferred cesarean section in 2001 was statistically significant (Ps0.001). The women who chose cesarean section were older (P-0.02) and more likely to work outside of the home (P-0.04) than the women who opted for vaginal delivery. 4. Discussion The past 6 years have witnessed a significant change in women’s attitude towards breech delivery. Our study shows that more women are aware of the option of ECV but are less inclined to consider it and prefer a planned cesarean section. In addition, significantly more women today consider breech presentation a high risk factor in pregnancy. Specifically, we found that whereas half the women in 1995 would be interested in trying ECV, only 25% in 2001 would do so. Although the women who knew about ECV were more educated, more likely to work outside the home, those who were willing to try ECV were more likely not to work outside of the home. The overwhelming majority of women would choose cesarean section over vaginal breech delivery, though there was a significant increase from 64% in 1995 to 97% in 2001 in favor of this method. We speculate that this change is a result of the changing management of breech presentation and the cessation of planned vaginal delivery for breech presentation. Only a few authors have investigated women’s attitudes to breech presentation and ECV. Krause et al. w2,5x, in Germany, questioned both experienced obstetricians and pregnant women and found that of the 80 obstetricians, 71% advised elective ces-
arean section in primiparas and 80% advised vaginal delivery in multiparas w2x. The main reason in both cases (90% and 72.5%, respectively) was decreased fetal risk. ECV was not even mentioned as an option. Of the 100 pregnant women questioned, the majority chose elective cesarean section because of the perceived lesser risk to the child w5x. Importantly, both studies were conducted before the Term Breech Trial w1x would have been available to either practitioners, or women. In another study from Germany, Krupp et al. w3x analyzed the fears of women with breech presentation in late pregnancy regarding ECV, vaginal delivery and cesarean section. Those who considered ECV (41 of 61) were anxious about both the child and themselves and were apprehensive of a possible cesarean should ECV fail. However, compared with the women who chose elective cesarean section, they were more concerned about the risk of infection and of complications from anesthesia, and less concerned about permanent risk to the child due to the method of delivery. The authors noted that the women’s decision was mainly influenced by the obstetrician’s choice. Leung et al. w4x, in Hong Kong, interviewed women in early pregnancy (not necessarily in breech presentation) as to their future attitudes towards mode of delivery in either breech or cephalic presentation. The great majority (82%) chose ECV as their first choice if the fetus was in breech presentation. Two percent of the women considered ECV ineffective, 13.3% believed it to be dangerous for the woman, and 18.7% believed it to be dangerous for the fetus. In our patients with breech presentation, there was a discrepancy between the high percentage who had heard of ECV and the relative minority
224
Y. Yogev et al. / International Journal of Gynecology and Obstetrics 79 (2002) 221–224
who were willing to try it. It might that some of these women are not getting the right or adequate information from their obstetricians and midwives. In conclusion, attitudes toward ECV and delivery of breech presentation have changed in the last 6 years. Managing breech presentations has become less of a dilemma as more and more women choose to have primary elective cesarean with or without a trial of ECV. References w1x Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomized multicenter trial. Term Breech Trial Collaborative Group. Lancet 2000;21(356(9239):1375 –1383.
w2x Fischer T, Krause M, Feige A. Breech presentationinformation, anxiety and pattern of expectations of established obstetricians and pregnant patients. 2: Results of a survey of women with breech presentation. Z Gerburtshilfe Neonatal 1996;200(2):61 –65. w3x Kropp S, Schmidt S, Saling E. Influences on decisions of pregnant patients with breech presentation for external fetal version or cesarean section-information status and anxiety pattern. Z Geburtshilfe Perinatol 1989;193(2):84 –91. w4x Leung TY, Lau TK, Lo KW, Rogers MS. A survey of pregnant women’s attitude towards breech delivery and external cephalic version. Aust N Z J Obstet Gynaecol 2000;40(3):253 –259. w5x Krause M, Fischer T, Feige A. Breech presentationinformation, anxiety and expectations of established obstetricians and pregnant patients. 1: Results of a survey of established obstetricians. Z Geburtshilfe Perinatol 1994;198(4):113 –116.