Use of External Cephalic Version for Breech Pregnancy and Mode of Delivery for Breech and Twin Pregnancy: A Survey of Canadian Practitioners
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OBJECTIVES: (1) To understand how external cephalic version (ECV) is used in the management of breech pregnancies; (2) to determine if Canadian practitioners have changed their recommendations regarding the mode of breech delivery since becoming aware of the findings of the Term Breech Trial; and (3) to establish a baseline of how twins are being delivered in Canada. METHODS: In March 2001, a survey was mailed to 920 obstetrician/gynaecologists, 409 family physicians, and 62 midwives from the membership list of the Society of Obstetricians and Gynaecologists of Canada. RESULTS: The response rate was 52% (476/920) for obstetrician/ gynaecologists, 22% (90/409) for family physicians, and 53% (32/62) for midwives. Eighty-nine percent of practitioners routinely offered women ECV. The median self-estimated ECV success rate for nulliparous women was 30%, and for multiparous women, it was 58%. Forty-seven percent of practitioners used tocolytics, 9% used analgesics, and 14% recommended repeat ECV when initial attempts failed. Eighty-four percent of practitioners recommended vaginal breech birth before learning the results of the Term Breech Trial, and 14% afterwards. When both twins present as vertex, most respondents planned vaginal delivery (100% for term, 95% for preterm > 32 weeks, and 73% for preterm < or = 32 weeks). Vaginal birth was recommended for Twin A vertex, Twin B breech at term by 92% of practitioners for frank, 92% for complete, and 88% for footling breech; at preterm > 32 weeks by 84% of practitioners for frank, 81% for complete, and 78% for footling breech; and at preterm < or = 32 weeks by 43% of practitioners for frank, 42% for complete, and 39% for footling breech pregnancies. When Twin A was non-footling breech and Twin B vertex, 7%, 5%, and 2% of practitioners recommended vaginal birth for term, preterm > 32 weeks, and preterm < or = 32 weeks pregnancies, respectively. Sixty-four percent of respondents on twin births were interested in a randomized controlled trial to compare planned Caesarean section with planned vaginal birth for twin pregnancies. CONCLUSION: Although the use of ECV is high in Canada, the success rate is low. Increasing the use of tocolytics, considering epidural analgesic, and repeating the procedure when the initial attempt fails may increase success and decrease Caesarean section rates. The survey results reflect a dramatic shift toward recommending Caesarean section for management of term breech pregnancies. Vaginal birth is the method of delivery of choice for most twin pregnancies of 32 weeks' gestation, especially for vertex/vertex presentations.
