Thesis (MMed)-- Stellenbosch University, 2013. / ENGLISH ABSTRACT: AIM: Review outcome of pregnancies following successful external cephalic version (ECV) for breech presentation at term, particularly the caesarian section (CS) rate. ECV is a safe procedure with a minimal cost implication that can reduce non-cephalic presentation at onset of labour at term. The outcome of pregnancies following successful ECV is certainly of interest. A meta analysis of studies done between 1997 and 2004, found that pregnancies after successful ECV at term were not the same as those with spontaneous cephalic presentations and was associated with a CS rate twice that in pregnancies with spontaneous cephalic presentations. The conclusion was that pregnancies after successful ECV should not be considered the same as normal pregnancies. In a matched retrospective analysis of CS risk after successful ECV, done in the USA, it was concluded that CS delivery and operative vaginal delivery rates following successful ECV, were not increased. To date there are no such studies in South Africa. METHODOLGY: A retrospective descriptive study was done to audit all successful ECV’s done at the Fetal Evaluation Clinic (FEC) of Tygerberg Academic Hospital. The electronic data from the FEC was searched for successful ECV patients. The facilities where these patients delivered were identified. The outcome of the pregnancies was determined from patient files and/or the labor registers. The relevant information of each patient was captured. All file reviews and data capturing was done by the principal investigator. RESULTS: A total of 78 patients were included in the study. The median age was 28.7 years with a range from 17 to 40 years, the median parity 1 and the range 0 to 6 and the median body mass index 27.2 and the range 18.2 to 45.0. The method of determining gestational age is known in 71 (91%) patients of whom 37 (52%) had an early ultrasound examination. The median gestational age at ECV was 37 weeks with the inter quartile range 36 to 38 weeks. The median ECV to delivery time was 2 weeks with the inter quartile range 1 to 4 weeks. Higher levels of care were required at time of delivery by 47 (60.3%) patients. Vaginal deliveries occurred in 49 patients and 29 (37.2%) had CS. The most common indications for CS were cephalo pelvic disproportion 8, fetal distress 6, reversion back to breech presentations 4 and other abnormal presentations 4 (2 face presentations and 2 transverse lies). The mean birth weight of the babies was 3360g and the range 2100 to 4655g. On comparing the groups that had vaginal deliveries and CS, only nulliparous patients had a significantly (p=0.02) higher risk for CS. CONCLUSIONS: Following successful ECV all patients need to be carefully followed up for possible reversion to breech presentation or transverse lie. Nulliparous and gravid 2 para 1 patients with a previous CS need to be delivered in hospitals with CS facilities. Further studies are required to assess whether successful ECV results in more face presentations. / AFRIKAANSE OPSOMMING: DOELWIT: Om die uitkoms van swangerskappe na suksesvolle eksterne kefaliese kerings (EKK) vir stuit presentasies op voltyd, spesifiek die keisersnit (KS) insidensie te bepaal. EKK is ‘n veilige prosedure wat teen minimale koste die nie-kefaliese presentasies op voltyd kan verminder. Die uitkoms van swangerskappe na suksesvolle EKK is van belang. ‘n Meta-analise van studies gedoen tussen 1997 en 2004 vind dat swangerskappe na suksesvolle EKK op voltyd nie dieselfde is vergeleke met spontane kefaliese presentasies nie en gepaard gaan met ‘n KS koers tweekeer hoër as dié met spontane kefaliese presentasies op voltyd. Die gevolgtrekking was dat swangerskappe na suksesvolle EKK nie as normale swangerskappe beskou moet word nie. In ‘n gepaarde retrospektiewe ontleding van die KS risiko wat in die VSA gedoen is, word gevind dat die KS en operatiewe vaginale verlossing koerse na suksesvolle EKK, nie verhoog is nie. Tot op hede is daar geen studies hieroor in Suid-Afrika gedoen nie. METODE: ’n Retrospektiewe beskrywende studie is gedoen om all suksesvolle EKK wat by die Fetale Evaluasie Kliniek (FEK) gedoen is te oudit. ‘n Elektroniese data soektog van suksesvolle EKK by die FEK is gedoen. Die instellings waar die pasiënte verlos is, is vasgestel. Die uitkoms van die swangerskappe is bepaal deur pasiënt lêers en/of die kraamregisters na te gaan. Die relevant inligting oor elke pasiënt is versamel. RESULTATE: ‘n Totaal van 78 pasiënte is by die studie ingesluit. Die mediane ouderdom was 28.7 jaar met ‘n reikwydte van 17 tot 40 jaar, die mediane pariteit was 1 met ‘n reikwydte van 0 tot 6 en die mediane liggaamsmassa indeks 27.2 met ‘n reikwydte van 18.2 tot 45.0. Die metode waavolgens swangerskapsduurte bepaal is, was bekend in 71 (91%) van pasiënte, waarvan 37 (52%) vroeë ultraklank ondersoeke gehad het. Die mediane swangerskapsduurte tydens die EKK was 37 weke met die interkwartiele interval 36 tot 38 weke. Die mediane EKK tot verlossing tydsverloop was 2 weke met die interkwartiele interval 1 tot 4 weke. Hoër vlakke van sorg was nodig ten tye van die verlossing by 47 (60.3%) van pasiënte. Van die pasiënte het 49 vaginale verlossings en 29 (37.2%) KS gehad. Die mees algemene indikasies vir KS was skedel-bekken disproporsie 8, fetale nood 6, terugkeer na stuitpresentasie 4 en abnormale presentasies 4 (2 aangesigsliggings en 2 transversliggings). Die gemiddelde geboorte gewig van die babas was 3360g en die reikwydte 2100 tot 4655g. Wanneer die groep wat vaginale verlossing en KS gehad het vergelyk word, het slegs nullipareuse pasiënte ‘n betekenisvolle (p=0.02) hoër risiko vir KS gehad. GEVOLTREKKING: Na suksesvolle EKK moet alle pasiënte noukeurig opgevolg word vir terugkeer na ‘n stuit presentasie of transversligging. Nullipareuse en gravida 2 para 1 pasiënte met ‘n vorige KS moet in hospitale met KS fasiliteite verlos word. Verdere studies is nodig om te bepaal of suksesvolle EKK meer aangesig presentasies tot gevolg het.

<p><strong>Background </strong>External cephalic version (ECV) is an effective intervention to reduce breech presentation and the corresponding Caesarean section (CS) rate. The Early ECV (EECV) trials were international multicentre randomized controlled trials that compared the timing of ECV (early or delayed) on obstetric and neonatal outcomes. In consideration of current recommendations that multicentre trials should account for centre effects in their analysis, a secondary analysis of the EECV trials was undertaken.</p> <p><strong>Purpose</strong> To analyse the EECV Trial data using statistical methods that account for centre effect and compare the results to standard analysis.<strong></strong></p> <p><strong>Methods </strong>Fisher’s exact test was used to provide overall results unadjusted for centre effects. The outcomes of interest were CS, preterm birth, and non-cephalic presentation at birth.</p> <p>Seven statistical models that accounted for centre effects were applied to the data: i) Mantel-Haenzsel test, ii) fixed effects regression, iii) fixed effects regression with a treatment-by-centre interaction term (weighted and iv) un-weighted by centre size), v) random intercept model, vi) random intercept and random slope model, and vii) generalized estimating equations.</p> <p><strong>Results </strong>Accounting for centre effects showed strengthened statistical associations with point estimates moving away from the null value.</p> <p><strong>Conclusion </strong>Effect estimates and confidence intervals changed for the three selected outcomes after accounting for centre effects, but the overall conclusions of the trial did not change. For this application, the Mantel-Haenzsel test and the random effects regressions performed the best. This study provides empirical evidence to support recommendations that multicentre trials account for centre in both design and analysis.</p> / Master of Health Sciences (MSc)

Contexte : Le management de la présentation foetale en siège est complexe car la littérature scientifique est contrastée. Objectif : Mettre en évidence les effets des attitudes et des interventions professionnelles sur le vécu des femmes. Méthodes : Cinq recherches quantitatives et qualitatives, incluant 311 participantes, ont été menées à la maternité des Hôpitaux Universitaires de Genève. Résultats : Les femmes doivent souvent faire un deuil par anticipation de l'accouchement idéalisé. Elles sont très motivées à tenter de corriger la malposition foetale. 69% des participantes ont recours aux médecines alternatives et complémentaires pour se soigner. 68% des participantes ont qualifié la tentative de version céphalique externe (VCE) de « forte à insupportable. Un accompagnement par hypnose ne réduit pas l'intensité de la douleur, comparé à un accompagnement par une sage-femme (échelle visuelle analogique : 6,0 vs 6,3 /10 respectivement, p=0.25). Pour le choix du mode d'accouchement les femmes ont rapporté des conflits décisionnels majeurs. L'information médicale est souvent perçue en faveur de la césarienne élective. Le sentiment de contrôle, les émotions et les premiers instants avec le nouveau-né sont perçus différemment selon le mode d'accouchement, en défaveur de la césarienne en urgence. Conclusion : Un processus émotionnel et décisionnel inattendu et souvent difficile est associé au diagnostic de siège. Développer des outils d'aide à la décision pour la femme, et des techniques de relation d'aide pour les professionnels faciliteraient ces processus. La prise en charge de la douleur durant la tentative de VCE est indispensable / Context: Management of breech remains complex due to divergence of practices and recommendations reported in the literature. Objective: To highlight the effects of health professionals' interventions on women's experiences. Methods: Five research studies qualitative were conducted at the University Hospitals of Geneva, including a total of 311 participants. Two studies used a method with interviews and thematic analysis, two used a quantitative method with a statistical analysis, and one used a mixed methods' design. Results: Breech diagnosis often requires anticipating a disappointment of an idealized childbirth. Women demonstrate a strong motivation to try to turn their fetus. 69% of women use complementary and alternative medicine (CAM) for their treatment. 68% of participants qualified external cephalic version (ECV) as "strong to unbearable". An accompaniment by a hypnotist compared to a midwife did not decrease pain intensity (visual analogic scale: 6.0 vs 6.3/10, respectively; p=.25). For the choice of breech delivery mode, women reported strong decisional conflicts. Medical information is often perceived in favour of a planned caesarean. Feelings of control, emotions and the first moments with the newborn are perceived differently and, notably, negatively in the case of emergency ceasarean section. Conclusion: A difficult emotional and decision-making process is associated with term breech. Use of CAM should be considered by professionals. Developing tools to assist women, and relationship techniques for professionals could facilitate these processes. Reduction of pain during ECV is necessary