BMJ  2006;333:705-706 (30 September), doi:10.1136/bmj.333.7570.705-c

Letter

Clinical examination for non-cephalic presentation

External cephalic version should be a maternity service quality indicator

EDITOR—The recent study by Nassar et al highlights the long known clinical failure to diagnose all breech presentations at term, especially in obese women.¹ However, there is little point in improving clinical detection unless it makes a difference to mothers or babies. The point of detecting a breech is to offer external cephalic version and to discuss mode of delivery if persistent. If external cephalic version is successful it avoids the hazards of vaginal breech delivery and caesarean section.²³

The National Sentinel Caesarean Section Audit showed that only 33% of women in the United Kingdom who were having caesarean sections for breech presentations had been offered an external cephalic version, and less than half of these had had the procedure.⁴ A recent systematic review confirmed the high success rates (> 60% in some studies) and the extremely low risks of external cephalic version.⁵ Set against the well documented risks of caesarean section, those obstetricians and gynaecologists who do not offer external cephalic version (or offer it timidly) are failing their patients.

Along with the principles of non-maleficence and informed consent, the NHS should be providing excellent evidence based care with minimum risks to patients. Maternity units that are not offering and carrying out external cephalic version, as well as training juniors to be proficient, must be considered substandard. Women (and their general practitioners) need to know that urgent referrals at term for external cephalic version can be made and that elective caesarean section should not be the first resort. External quality indicators of maternity services must include not only the proportion of breech presentations diagnosed at term but also the proportions offered external cephalic version and turning success rates.

Womens' Health Directorate, St Thomas' Hospital, London SE1 7EH Stephanie.Kuku{at}gstt.nhs.uk

Womens' Health Directorate, St Thomas' Hospital, London SE1 7EH

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Competing interests: None declared.

References

1. Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ 2006 333: 578-80. (16 September.)[Abstract/Free Full Text]
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.[CrossRef][ISI][Medline]
3. Hofmeyr GJ. External cephalic version facilitation for breech presentation at term. Cochrane Database Syst Rev 2000;2: CD000184.
4. Thomas J, Paranjothy S. National sentinal caesarean section audit report. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. London: RCOG Press, 2001: 43.
5. Nassar N, Roberts CL, Barratt A, Bell JC, Olive EC, Peat B. Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term. Paed Perinat Epidemiol 2006;2: 163-71.

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Relevant Article

Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study

Natasha Nassar, Christine L Roberts, Carolyn A Cameron, and Emily C Olive
BMJ 2006 333: 578-580. [Abstract] [Full Text] [PDF]