Abstract
BackgroundBreech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling.Method/designThe ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured.DiscussionThis study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term.Trial RegistrationDutch Trial Register (NTR): 1878
Highlights
Breech presentation occurs in 3 to 4% of all term pregnancies
This study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term
In pregnancies complicated by breech presentation, perinatal mortality, neonatal mortality or serious neonatal morbidity are increased as compared to pregnancies where the fetes is in cephalic position [2]
Summary
Breech presentation occurs in 3 to 4% of all term pregnancies [1]. In pregnancies complicated by breech presentation, perinatal mortality, neonatal mortality or serious neonatal morbidity are increased as compared to pregnancies where the fetes is in cephalic position [2]. Since publication of the results of the term breech trial, the caesarean delivery rate in women with a fetes in breech presentation in the Netherlands has increased from 45% to around 80% [3]. External cephalic version (ECV) reduces the rate of noncephalic presentations at term with 40-50%, and the number of caesarean deliveries performed for at term breech presentation, without any increased risk to the baby [6]. There are often major discrepancies between best evidence and practice, resulting in a large variation between professionals [1417] Based on this national and international literature, two main barriers for ECV implementation are identified 1) lack of patients' knowledge about risk for and consequences of ECV and breech delivery 2) the attitude and knowledge of midwives and gynaecologists towards ECV. Our proposal is a collaborative effort of midwives and gynaecologists, and is supported by both the KNOV and NVOG
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