Understanding patient perspectives on fetal malpresentation management

Patients diagnosed with fetal malpresentation desire more information about external cephalic version (ECV), according to a recent study published in Cureus.

Three percent to 4% of deliveries worldwide are impacted by fetal malpresentation, with cesarean section (CS) as the method of delivery in 85% of pregnancies with fetal malpresentation. ECV or scheduled CS is the standard management method, but CS is associated with increased maternal risk compared to vaginal birth.

During ECV, clinicians attempt manual maneuvering of the fetus to cephalic position, allowing for vaginal birth to be attempted in patients with fetal malpresentation. Potential complications include rupture of membranes, placental abruption, maternal-fetal hemorrhage, umbilical cord prolapse, and stillbirth, but these complications occur in less than 1% of cases.

ECV is reported in under 50% of individuals with fetal malpresentation despite associated reductions in adverse obstetric outcomes and health care utilization rates. Currently it is unknown whether patients’ preferences or a lack of provider communication is responsible for the lack of ECV utilization.

Investigators conducted a study to determine facilitators and barriers to fetal malpresentation management among pregnant individuals in the United States. Participants included patients aged 18 years and older with fetal malpresentation at 35- to 37-weeks’ gestation confirmed by ultrasound between March 2022 and September 2022.

Exclusion criteria included previous CS, not speaking English, and presenting with maternal or fetal diagnoses besides malpresentation requiring CS. OB/GYN physicians and mid-level providers gave routine prenatal care to patients, but those counseling on malpresentation management were not always the same as those performing ECV or CS.

A team member conducted and recorded interviews over Zoom, during which participants had their video turned off. Following the interview, the team member transcribed and de-identified the recording.

Interviews took place following malpresentation diagnosis and before ECV or CS and lasted for 30 minutes. Interview questions were open-ended and discussed counseling received from providers, patients’ understanding of management options, facilitators and barriers for choosing ECV or CS, and ECV or CS expectations.

Three research team members performed content analysis. The members developed an initial framework from the transcripts, then reviewed and refined the structure to determine subthemes.

There were 10 participants who completed the interview, aged a median 32 years. Of participants, 5 decided to undergo ECV and 5 decided to undergo CS.

Study authors listed the primary themes as, “facilitators' decision on malpresentation management, barriers to decision on malpresentation management, priorities and values for participants, and methods of malpresentation management beyond ECV or CS.”

Appreciation for quantitative data during counseling was cited as the most common subtheme. According to participants, discussion about success and complication rates impacted decision-making. The 50% success odds of ECV quoted by providers was commonly noted to be a factor in participants’ decisions.

Another subtheme for malpresentation management was including medical and pregnancy history into decision-making. Factors that influenced decision-making include fetus Turner syndrome diagnosed in utero, in vitro fertilization, and complex surgical history.

Many patients mentioned having unanswered questions and desiring more information about ECV following prenatal visits. Concerns about ECV arose because of the lack of certainty surrounding the procedure.

There were also participants who believed ECV may be riskier for fetal safety than CS. Some participants believed there was a source behind the malposition and fetal health would be at risk from attempts to manipulate the fetus. However, others expressed confidence in ECV safety and believed they were properly counseled about the low risk of complications.

Another common theme was the desire to avoid CS. Many participants were concerned about recovering from the surgery while caring for the newborn and preferred vaginal birth which they considered the “natural” option. Patients with prior vaginal birth also viewed it as the more familiar option compared to CS.

Finally, participants were interested in other methods to convert their fetus to vertex presentation. These included acupuncture, moxibustion, birthing ball, chiropractor, and strategies highlighted on the Spinning Babies website.

These results indicated patients do not believe they are adequately counseled about fetal malpresentation decision-making. Investigators concluded counseling should be patient-centric and consider patients’ medical histories and birth preferences.

Reference

Ramaiyer MS, Lulseged B, Glynn S, Esguerra C. Patient experiences with obstetric counseling on fetal malpresentation. Cureus. 2024;16(1):e52683. doi:10.7759/cureus.52683