Biomedical subjects

Eileen K Hutton

Publications and source records attributed to Eileen K Hutton.

5 recordsLinked to original sources

PubMed2006

The costs of planned cesarean versus planned vaginal birth in the Term Breech Trial.

BACKGROUND: The Term Breech Trial compared the safety of planned cesarean and planned vaginal birth for breech presentations at term. The combined outcome of perinatal or neonatal death and serious neonatal morbidity was found to be significantly lower among babies delivered by planned cesarean section. In this study we conducted a cost analysis of the 2 approaches to breech presentations at delivery. METHODS: We used a third-party-payer (i.e., Ministry of Health) perspective. We included all costs for physician services and all hospital-related costs incurred by both the mother and the infant. We collected health care utilization and outcomes for all study participants during the trial. We used only the utilization data from countries with low national rates of perinatal death (< or = 20/1000). Seven hospitals across Canada (4 teaching and 3 community centres) were selected for unit cost calculations. RESULTS: The estimated mean cost of a planned cesarean was significantly lower than that of a planned vaginal birth (7165 dollars v. 8042 dollars per mother and infant; mean difference -877 dollars, 95% credible interval -1286 dollars to -473 dollars). The estimated mean cost of a planned cesarean was lower than that of a planned vaginal birth for both women having a first birth (7255 dollars v. 8440 dollars) and women having had at least one prior birth (7071 dollars v. 7559 dollars). Although the treatment effect was largest in the subgroup of women having their first child, there was no statistically significant interaction between treatment and parity since the 95% credible intervals for difference in treatment effects between parity equalling zero and parity of one or greater all include zero. INTERPRETATION: Planned cesarean section was found to be less costly than planned vaginal birth for the singleton fetus in a breech presentation at term in the Term Breech Trial.

Adult↗

PubMed2003

The management of breech pregnancies in Australia and New Zealand.

AIM: To assess current obstetric practice in the management of singleton breech pregnancies in Australia and New Zealand. METHODOLOGY: Survey mailed to all members and fellows of the Royal Australian and New Zealand College of Obstetrics and Gynaecology. RESULTS: Of 1284 surveyed, 956 (74%) responded of whom 696 (73%) were practicing obstetrics. Prior to the Term Breech Trial (TBT), 72% of obstetricians reported that they routinely offered vaginal breech birth for uncomplicated singleton breech pregnancies. After the TBT publication this rate declined to 20%. External cephalic version (ECV) was usually recommended by 67% of obstetricians and only 53% use tocolytics. Common practices for which safety has yet to be demonstrated included 28% of obstetricians carrying out ECV outside hospitals and 42% carrying out ECV before 37 weeks' gestation. CONCLUSIONS: While the majority of obstetricians recommend ECV and/or planned Caesarean section for breech presentation, barriers to the promotion of ECV and the use of tocolysis for ECV need to be identified if the rates of this effective manoeuvre are to be increased.

Australia↗

PubMed2003

External cephalic version beginning at 34 weeks' gestation versus 37 weeks' gestation: a randomized multicenter trial.

OBJECTIVE: In about 3% to 4% of all pregnancies at term, the fetal presentation will be noncephalic. External cephalic version (ECV) at term has been shown to decrease the rate of noncephalic presentation at birth and to decrease the rate of cesarean section associated with breech presentation. However, success rates for ECV are low. We did a randomized trial to compare a policy of beginning ECV early, at between 34 and 36 weeks' gestation, and beginning ECV at 37 to 38 weeks' gestation. STUDY DESIGN: At 25 centers in seven countries, 233 women with a singleton breech fetus were randomly assigned to having an ECV procedure done early (at between 34 weeks 0 days and 36 weeks 0 days), or delayed (at between 37 weeks 0 days and 38 weeks 0 days). An experienced practitioner undertook the ECV procedure, and repeat ECV procedures were allowed. Tocolytics and use of epidural analgesia were included as part of the protocol. The primary outcome was the rate of noncephalic presentation at birth. An intention-to-treat analysis was used. RESULTS: Data were received for 232 women, with 116 women in each of the early and delayed ECV groups. Of these, 86.2% in the early ECV group and 67.2% in the delayed ECV group had at least one ECV performed. The rate of noncephalic presentation at birth in the early ECV group was 66 of 116 (56.9%) and 77 of 116 (66.4%) in the delayed ECV group (relative risk [RR] [95% CI] 0.86 [0.70-1.05], P =.09). The rate of serious fetal complications and the rate of preterm birth at <37 weeks were not significantly increased in the early ECV group compared with the delayed ECV group (6.9% vs 7.8%, RR [95% CI] 0.89 [0.36-2.22], P =.69 and 8.6% vs 6.1%, RR [95% CI] 1.42 [0.56-3.59], P =.31, respectively). The rate of cesarean section in the early ECV group was 75 of 116 (64.7%) and 83 of 116 (71.6%) in the delayed ECV group (RR [95% CI] 0.90 [0.76-1.08], P =.32). Neonatal outcomes were comparable in the two groups. The rate of reversion to noncephalic was low in both groups. The majority of women in both groups indicated that they would consider having an ECV in another pregnancy. CONCLUSION: Early ECV performed at 34 to 36 weeks compared with 37 to 38 weeks may reduce the risk of noncephalic presentation at delivery. A large pragmatic trial of early ECV is now required to assess this approach further in terms of cesarean section rates and neonatal outcomes before changes in clinical practice.

Breech Presentation↗

PubMed2003

Cesarean delivery for twins: a systematic review and meta-analysis.

OBJECTIVE: We undertook a systematic review and meta-analysis to determine whether a policy of planned cesarean section or vaginal delivery is better for twins. STUDY DESIGN: We searched MEDLINE and EMBASE from 1980 through May 2001 using combinations of the following terms: twin, delivery, cesarean section, vaginal birth, birth weight, and gestational age. Studies that compared planned cesarean section to planned vaginal birth for babies weighing at least 1500 g or reaching at least 32 weeks' gestation were included. We computed pooled odds ratios for perinatal or neonatal mortality, low 5-minute Apgar score, neonatal morbidity, and maternal morbidity. The infant was the unit of statistical analysis. Results were considered statistically significant if the 95% CI did not encompass 1.0. RESULTS: We retrieved 67 articles, 63 of which were excluded. Four studies with a total of 1932 infants were included in the analysis. A low 5-minute Apgar score occurred less frequently in twins delivered by planned cesarean section (odds ratio, 0.47; 95% CI, 0.26-0.88) principally because of a reduction among twins if twin A was in breech position (odds ratio, 0.33; 95% CI, 0.17-0.65). Twins delivered by planned cesarean section spent significantly longer in the hospital (mean difference, 4.01 days; 95% CI, 0.73-7.28 days). There were no significant differences in perinatal or neonatal mortality, neonatal morbidity, or maternal morbidity. CONCLUSION: Planned cesarean section may decrease the risk of a low 5-minute Apgar score, particularly if twin A is breech. Otherwise, there is no evidence to support planned cesarean section for twins.

Apgar Score↗

PubMed2002

Use of external cephalic version for breech pregnancy and mode of delivery for breech and twin pregnancy: a survey of Canadian practitioners.

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.

Adult↗