Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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ECV is effective but is it safe?
- Robert Fox (3 August 2001)
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Term Breech Trial - a double edged sword?
- S Krishnamurthy (6 August 2001)
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WHY IS EXTERNAL CEPHALIC VERSION NOT PART OF ROUTINE CLINICAL PRACTICE IN THE UK?
- Rajesh Varma, David Horwell (7 August 2001)
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Moxibustion: a Chinese medicine treatment for breech position
- Marina Cuttini (7 August 2001)
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The Term Breech Trial does not provide unequivocal evidence...
- David Somerset (8 August 2001)
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Re: Moxibustion: a Chinese medicine treatment for breech position
- Roger Sutton (8 August 2001)
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Patient values are crucial for good medical decision making.
- Amaju Ikomi, Dattakumar Kunde (28 August 2001)
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Robert Fox, Consultant obstetrician Taunton & Somerset Hospital, Taunton TA1 5DA
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EDITOR – Andrew Shennan and Susan Bewley have laid out the case for planned caesarean section for singleton term fetus presenting by the breech.1 They describe how we now have precise information from well- designed studies on both fetal and maternal outcome. Because of increased maternal morbidity associated with planned caesarean section, they go on to advise the use of external cephalic version (ECV) to reduce the need for caesarean delivery. This guidance is also based on prospective studies but these have only looked at maternal outcome. The available evidence to date does not allow us to draw conclusions about safety of the procedure for the fetus,2 particularly now that elective caesarean section is the preferred advice for all woman and the breech fetus will no longer face the risks of vaginal birth. ECV is known to carry certain risks including cord prolapse and entanglement, placental abruption, and feto-maternal haemorrhage, all of which may cause mortality and serious morbidity. These events are rare but in one series, 8.4% of 429 fetuses subjected to ECV developed a transient bradycardia.3 The effect of these in terms of perinatal morbidity is not precisely known. I believe that the safety of ECV and no ECV requires further study. This is an important issue primarily because we need to know what best for the fetus. It is also important because babies presenting by the breech are more likely to have neurological deficits, possibly including cerebral palsy, which are not related to medical intervention; some babies with prenatal neurological problems cannot adopt a correct position in utero.4,5 Such problems can become the focus of costly medico-legal action. Robert Fox, consultant obstetrician
1. Shennan A, Bewley S. How to manage term breech deliveries. BMJ 2001; 323:244-45. 2. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2000; 2: CD000083. 3. Lau TK, Lo KW, Leung TY, Fok WY, Rogers MS. BJOG 2000; 107:401-5. 4. Sorensen HT, Steffensen FH, Olsen J, et al. Long-tern follow-up of cognitive outcome after breech presentation at birth. Epidemiology 1999; 10:554-6. 5. Krebs L, Topp M, Langhoff-Roos J. The relation of breech presentation at term to cerebral palsy. Br J Obstet Gynaecol 1999; 106: 943-7. |
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S Krishnamurthy, Associate Professor McGill University Health Centre, Montreal
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Dear sir, I read with interest the editorial by Shennan and Bewley. I personally the term breech trial has done a great disservice to those countries where caesarean sections still put mothers at risk both in the index pregnancy and subsequent pregnancies. By this I mean that where there are poor facilities for regional anaesthesia, blood transfusion and aseptic precautions etc, increase the risk to women as well as put them at greater risk in their future pregnancies due to the presence of the scar in the uterus (whichever way the incision was made in the uterus). My greatest disappointment with the trial was that it included countries and obstetricians who rarely perform breech deliveries despite their vast years of experience and I am in no doubt that this will have contributed to the poor outcome that is reported even at the earlier parts of the study. Lack of resources to perform such studies in the developing countries usually means that they follow the data and recommendations provided by the western studies are adhered to. On this occasions and in many similar ones such information is counter-productive to their own population and even worse can be positively harmful. I am glad that Shennan and Bewley have given all of us who practise obstetrics an 'escape clause'. This hopefully will avoid the harm that has been done to some extent and may make us all think that there are other ways of managing our mothers with breech presentations |
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Rajesh Varma, Specialist Registrar Obstetrics and Gynaecology, Consultant Gynaecologist Luton and Dunstable NHS Trust, Luton, LU4 ODZ,UK, David Horwell
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The editorial by Shennan and Bewley 1 concisely summarizes the long- standing dilemma in managing term breech presentation. However, despite the RCOG’s recommendation 2 of ‘external cephalic version (ECV) for all uncomplicated term breech pregnancies’, ECV does not appear to be part of routine clinical practice in the UK. The reasons for this deficit involve local, national and training issues. Various hospital-based studies have identified low overall uptake of ECV services. Factors such as patient refusal, contra-indications to ECV, and failure to diagnose breech presentation have all been cited as responsible 3. Better antenatal detection of breech presentation, and broadening the inclusion criteria to include higher risk pregnancies (e.g. previous caesarean, intrapartum ECV) may enhance the impact of ECV. Counselling by health professionals (GPs, midwives, and obstetricians) strongly influences the decision-making process, and this should be consistent and supplemented by local ECV success rates. Questionnaire-based studies suggest that few UK centres offer ECV 4, although these should be interpreted with caution, as there is likely to be significant reporting bias. The true national picture of ECV provision remains unclear and a systematic enquiry into ECV practice in the UK is necessary. There is a need for further training of practitioners in ECV, especially as it is not listed as an assessed objective in the RCOG specialist registrar training syllabus. In contrast, the syllabus for RCOG sub-specialist training in maternal and fetal medicine states that ‘the trainee should be expert in ECV’. ECV is renowned for its long learning curve and starting this process relatively late in career development does not seem appropriate. Furthermore, there are no recognized training courses in ECV, so acquisition of the skill is principally achieved through apprenticeship. Obstetricians’ inexperience in managing vaginal breech delivery has contributed to adverse outcome 5, and is unfortunately now likely to increase as result of the current change in practice 1. Nevertheless, it is impossible to deliver all term breech pregnancies by Caesarean section. The mother may insist on vaginal delivery, breech labour may be precipitate, and there are special situations such as the second fetus in twins. It is therefore imperative that trainee obstetricians continue to receive comprehensive training in vaginal breech delivery, either at the time of Caesarean delivery, or by using simulation models. ECV is the only effective method for reducing operative intervention for term breech presentation and is recommended as Good Medical Practice, being both safe and cost-effective 2. A retrospective comparative study of ECV (n=108) vs. non-ECV (n=254) for term breech presentation between 1998 -2000 in our District General Hospital showed that 4.0 (95% CI 2.8-6.8) attempted ECVs were required to prevent one Caesarean section 3. Since the Term Breech Trial, and as implied by Shennan and Bewley1, obstetric units in the UK no longer recommend trial of vaginal breech delivery. Thus, applying this study’s findings to current practice, the effectiveness of ECV increases, such that 2.2 (95% CI 1.8-2.8) attempted ECVs may prevent one Caesarean section. ECV is therefore one of the most effective procedures in modern obstetrics. References 1. Shennan A, Bewley S. How to manage term breech deliveries. BMJ 2001; 323: 244-245 2. The Management of Breech Presentation. Clinical Guideline No.20. July 1999. Royal College of Obstetricians and Gynaecologists 3. Varma R, Horwell DH, Burrell SJ. The impact of external cephalic version at term in a district general hospital. Abstract No. 265. 29th British Congress of Obstetrics and Gynaecology, Birmingham, UK, July 2001. 4. Burr RW. Johanson RB, Jones P et al. A survey of obstetricians attitudes to the management of term breech. Journal of Clinical Excellence 1999; 1: 35-40 5. Confidential Enquiry into Stillbirths and Deaths in Infancy. 7th Annual Report. CESDI Secretariat. Chiltern Court, 188 Baker St, London, 2000. |
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Marina Cuttini, Maternal and Child Health epidemiologist Tuscany Agency for Health (Florence) and Burlo Garofolo Hospital (Trieste), Italy
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In their editorial Shennan and Bewley [1] recommend external cephalic version for term breech as an alternative to planned cesarean birth. However, the procedure has contraindications and adverse effects have been reported, although rarely [2,3]:it should be performed only in a facility equipped for emergency cesarean section [4]. Moxibustion, a traditional Chinese treatment which utilizes the heat generated by burning the plant Artemisia vulgaris (moxa) to stimulate the acupuncture point BL67 (Zhiyin) at the outer corner of the toenail of the fifth toe, has proved effective in correcting breech presentation in a randomised controlled trial carried out in China [5]. It is not known whether the same result may be achieved in a Western country setting. We present the experience of 189 consecutive women who underwent a modified moxibustion treatment for breech presentation at the Chinese Medicine centre “Fior di Prugna” of Florence (Italy) during 1997-2001. Treatment consisted in a first cicle of bilateral stimulations (1 to 3 according to effect) through heated acupuncture needles; in case of no effect, a second cicle was performed using a lighted moxa stick. Treatment was ended at the achievement of cephalic position, as demonstrated by ultrasound examination, or after six unsuccessful applications. A description of the sample is presented in Table 1. Cephalic version was obtained in 106 women (56.1%), a result comparable to that of external cephalic version. Success rate was higher in primi-pluriparae (75%) than in nulliparae (46.4%). In all cases but 3 the correct position was maintained up to delivery. External cephalic version was performed in 22 women (21 who did not respond to moxibustion, and 1 where the effect was transitory) and was effective in 14 (63.6%). Table 2 shows the results of a multiple logistic regression analysis exploring factors associated with success in our sample of moxibustion- treated women. Parity 1 or over, maternal age less then 35 years, and starting treatment within 34 gestational age weeks significantly increased the likelihood of achieving cephalic version. Once the first cicle of applications failed, a second cicle had a significantly lower probability of success. Moxibustion is a simple, inexpensive and effective procedure which does not preclude the use of external cephalic version later in pregnancy, nor the planning of cesarean birth. No adverse effects have been reported, apart from some women’ discomfort for the smell of the burning moxa. It represents a worthwhile treatment also in countries where facilities for cesarean delivery are not freely available. M. Cuttini, MD PhD (* §) S. Baccetti, MD (**) A. Traversi (**) L. Meli (**) G. Martorana, MD (***) E. Buiatti, MD (*) (*) Regional Agency for Health of Tuscany, Florence (Italy) (**) Chinese Medicine Centre “Fior di Prugna”, Florence (Italy) (***) Careggi Hospital, Florence (Italy) (§) Maternal and Child Health Institute “Burlo Garofolo”, Trieste (Italy) 1. Shennan A, Bewley S. How to manage term breech deliveries. BMJ 2001, 323: 244-5 2. Ghidini A, Korker V. Fetal complication after external cephalic version at term: case report and literature review. J Matern Fetal Med 1999; 8:190-2. 3. Lau TK, Lo KW, Chan LY, Leung TY, Lo YM. Cell-free fetal deoxyribonucleic acid in maternal circulation as a marker of fetal- maternal hemorrhage in patients undergoing external cephalic version near term. Am J Obstet Gynecol 2000; 183: 712-6. 4. Coco AS, Silverman SD. External cephalic version. Am Fam Physician 1999 ; 59 : 1122. 5. Cardini F, Weixin H. Moxibustion for correction of breech presentation: a randomized controlled trial. JAMA 1998; 280: 1580-84.
TABLE 1. Characteristics of the women and success of treatment
according to parity
Parity 0 (no.= 125) Parity 1-3 (no.= 64)
No. (%) No. (%)
Nationality
italian 110 (88.0) 48 (75.0)
chinese 5 (4.0) 9 (14.1)
other 10 (8.0) 7 (10.9)
Maternal age (y.)* 31 (4.6) 33 (4.0)
Birthweight (gr.)* 3208 (408) 3407 (363)
Gestational age 39 (1.4) 39 (1.4)
at delivery (w.)*
Fetal sex
female 63 (50.8) 35 (56.5)
male 61 (49.2) 27 (43.6)
Gestational age at first
moxibustion treatment
32-34 w. 70 (56.0) 38 (59.4)
35-37 w. 55 (44.0) 26 (40.6)
No. of treatments
1-3 55 (44.0) 33 (51.6)
4-6 70 (56.0) 31 (48.4)
Success of moxibustion
after treatment 58 (46.4) 48 (75.0)
at birth 57 (45.6) 46 (71.9)
External cephalic version
performed 14 (11.3) 8 (12.9)
successful (°) 7 (50.0) 7 (87.5)
Cesarean section 68 (54.8) 15 (24.2)
(all indications)
(*) mean (SD)
(°) among the performed procedures
TABLE 2. Results of multivariate logistic model predicting the
probability of cephalic version after modified moxibustion treatment.
adjusted (95% CI) p value°
OR§
Parity <0.001
0 1.0‡
1-3 5.2 (2.2 - 12.5)
Maternal age (y.) 0.02
< 30 1.0‡
30- 34 0.5 (0.2 - 1.3)
> 34 0.2 (0.05 – 0.6)
Fetal sex 0.04
female 1.0‡
male 0.4 (0.2 - 1.0)
Gestational age at first moxibustion treatment (w.)
<0.001
32-34 1.0‡
35-37 0.6 (0.4 - 0.8)
Number of treatments
<0.001
1-3 1.0‡
4-6 0.1 (0.04 - 0.2)
§ Odds Ratio (OR) are adjusted for all the variables listed in the
table, plus birthweight and year of treatment (NS).
‡ Reference category
°p values refer to the overall statistically significance of the
association between the explanatory variable and the outcome
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David Somerset, Lecturer in Obstetrics & Gynaecology Birmingham Women's Hospital
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Dear Editor, In their editorial on managing breech deliveries at term(1), Shennan and Bewley state that "The term breech trial(2) provides unequivocal evidence that women with a breech presentation at term who plan a caesarean section will have a baby less likely to die or have a serious outcome…… than those who plan a vaginal delivery." This statement must surely be clarified by the caveat "..if managed under the protocol for vaginal breech delivery specified for this trial." This protocol, as outlined in the editorial, would not have been acceptable at either of the UK teaching hospitals at which I have trained. A normal contemporary ultrasound scan (excluding IUGR, excessive growth, abnormal liquor volume, abnormal presentation and fetal anomaly), spontaneous labour, rapid progress and a short second stage are considered essential pre-requisites to vaginal breech delivery. Thus an 18 hour first stage, 3˝ hour second stage and liberal use of induction and augmentation would not be allowed. Analysis of the more detailed information concerning the perinatal deaths published in the on-line version of the paper suggests that induction, augmentation and low birth weight are indeed risk factors for adverse outcome. Of the 14 deaths in the intended vaginal delivery arm, nine (64%) were either induced or augmented. Five deaths (5/14; 36%) were of small for gestational age infants ( Overall, in the intended vaginal delivery arm there were only 3 deaths involving labours that were not induced or augmented, or where accurate pre-labour ultrasound assessment might have been reasonably expected to have precluded a trial of labour on the basis of possible IUGR. This compares with three neonatal deaths in the intended Caesarian section group, one following a difficult vaginal delivery, one of whom was small for gestational age (2300g) and one following a ruptured myelomeningocoele. If the analysis is restricted to the sub-group of "low perinatal mortality countries" there were no perinatal deaths in the planned caesarian section group versus three in the planned vaginal delivery group. These three labours were all either induced or augmented and one was the (presumably) undiagnosed dead 1150g twin. On the basis of these results, I do not feel that it is possible to say unequivocally that planned Caesarian section is safer for the baby, so long as accurate antenatal ultrasound assessment is performed and labour is neither induced nor augmented. However, following the results of the term breech trial it will be necessary for any unit continuing with a policy of planned vaginal breech delivery to audit their results to ensure that such a policy remains safe. David Somerset
1. Sennan A, Bewley S. How to manage term breech deliveries. BMJ 2001;323:245-6. 2. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for the Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375-83. |
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Roger Sutton, General Practitioner Havant Health Centre, Hampshire
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Cuttini's description of the use of Moxibustion for breech presentation makes interesting reading. The success rate seems impressive, but it's not clear how effective the treatment is with the 44% of women who were at 35-37 weeks gestation. It's not surprising that there was a better response for gestations of 32-34 weeks as a certain proportion of these would have reverted to a cephalic presentation naturally in that time. More information on the later gestation treatments would be very welcome. |
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Amaju Ikomi, Consultant Dept. of Obstetrics and Gynaecology, Basildon Hospital, Dattakumar Kunde
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Editor – The editorial by Shennan and Bewley1 on how to manage term breech deliveries understates the importance of patient values in the decision making process. If external cephalic version is unsuccessful, the options are to deliver vaginally or by caesarean section. The actual conclusion of the multicentre study2 was that caesarean section is the safer option for the baby but many practising clinicians have extrapolated this to mean that the best decision for most women in developed countries is to “avoid vaginal breech delivery” and deliver by caesarean section. The flaw in this type of reasoning is that it assumes both modes of delivery represent equivalent “disasters” to all women. The fact is that individual women place different values on birth processes and outcomes. Also these values are very different from those of obstetricians3. These differences must be recognised and respected in obstetric decision making. Anything less will validate accusations of paternalism. A “good” decision is choosing the option that is most likely to result in the most satisfactory outcome for the patient. It requires a combination of the research evidence, the patient’s values and the clinician’s professional judgement. Most clinicians and patients combine these components intuitively to arrive at a decision but intuition is subject to many biases (anchoring, availability, representativeness, framing effect) and hence errors of judgement when faced with complex decisions. A more objective approach is decision analysis4. In a small pilot study, we interviewed nine midwives who had a history of successful vaginal deliveries. We asked them to imagine they were pregnant, with a breech presentation at term and for each woman we obtained value scores for the eight possible outcomes following delivery. They were then shown the results of the multicentre study and after perusal, they were asked to choose their preferred mode of delivery. Subsequently, their individual value scores for each outcome were inserted into a computerised decision tree, which had been constructed using the probabilities from the multicentre study. This generated a “logical” decision for each woman, which was then compared with her “actual” decision. In all the women, the “logical” decision was to attempt a vaginal delivery but only two of the nine women had actually chosen this option. The majority had chosen the option of planned caesarean section yet this was less likely to give them the outcome they most desired (vaginal delivery, healthy mother and healthy baby). There is a tendency to make illogical decisions, despite access to good research evidence. Therefore, clinicians must remember the importance of patient values and should be prepared to embrace decision aids, especially when faced with complex decisions. This is the way to convert good evidence into good practice. Amaju Ikomi Dattakumar Kunde Department of Obstetrics and gynaecology, Basildon Hospital, Basildon, Essex SS16 5NL. 1. Shennan A, Bewley S. How to manage term breech deliveries. BMJ 2001;323: 244-45. 2. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for the Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000;356:1375-83. 3. Vandenbussche FP, De Jong-Potjer LC, Stiggelbout AM, Le Cessle S, Keirse MJ. Differences in the valuation of birth outcomes among pregnant women, mothers, and obstetricians. Birth 1999; 26(3): 178-83. 4. Thornton JG. Decision analysis in obstetrics and gynaecology. Ballieres Clin Obstet Gynaecol. 1990; 4(4): 857-66. |
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