Correspondence
Jos van Roosmalen and Tarek Meguid have discussed the decrease of vaginal breech delivery in contemporary obstetric practice in their Comment.1 The publication of the Term Breech Trial 2 in 2000 has undoubtedly been associated with an almost complete elimination of breech presentations from delivery suites in the developed world. Our group has previously reported, however, that the practice of vaginal breech delivery was already decreasing prior to publication of the Term Breech Trial and that the trial’s findings simply accelerated that trend. 3 The figure shows the rate of vaginal breech delivery at the three major Dublin maternity hospitals over a 16-year period, which included the delivery of 11 913 breech presentations (8 years pre-publication and 8 years post-publication of the Term Breech Trial). The shift in practice toward caesarean delivery of breech presenting infants has resulted in an inevitable deskilling of obstetricians, with opportunities for vaginal breech delivery becoming more and more rare. We suggest that an increased use by the obstetric community of practices such as external cephalic version (ECV), particularly in multiparous mothers, could be a more appropriate measure to control
the increasing numbers of caesarean deliveries due to breech presentation. This is an evidence-based standard of care with proven benefits for both mother and baby and thus should be offered to most women with a breech presentation after 36 weeks gestation.4 We believe that the trend of caesarean delivery of breech presentations is unlikely to be reversed, but instead, decreasing the incidence of persistent breech presentation is more likely to affect the overall rate of caesarean section. We declare no competing interests.
*Mark P Hehir, Fergal D Malone [email protected] RCSI Unit, Rotunda Hospital, Dublin 1, Ireland 1
2
3
4
van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet 2014; 383: 1863–64. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for the Term Breech Trial Collaborative. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 1375–83. Hehir MP, O’Connor HD, Kent EM, Fitzpatrick C, Boylan PC, Coulter-Smith S, Geary MP, Malone FD. Changes in vaginal breech delivery rates in a single large metropolitan area. Am J Obstet Gynecol 2012; 206: 498 e1–4. Royal College of Obstetrics and Gynaecology. Green top guideline no. 20a. External cephalic version and reducing the incidence of breech presentation. 2010. http://thegynaecologyclinic. com/wp-content/media/ECV-GTG-20a.pdf (accessed July 30, 2014).
Authors’ reply We thank the correspondents for their remarks on our Comment.1 We agree that external cephalic version (ECV) should be done for all suitable women with breech presentation. Unfortunately, ECV is seldom done in sub-Saharan Africa and in many other parts of the world. ECV should, however, be part of obstetric training, but even when ECV is practised, vaginal breech delivery will still result from the many failed ECVs. We do not agree that a failed ECV is an indication for an elective caesarean section. By contrast, we believe that the way forward must be the return of vaginal breech delivery and we do not agree that not enough knowledge or clinical expertise blocks this direction. Knowledge and clinical expertise can and should be enhanced by simulation-based training. We declare no competing interests.
*Jos van Roosmalen, Tarek Meguid [email protected] VU University Medical Centre, Amsterdam, Netherlands (JvR); Leiden University Medical Centre, 2300 RC Leiden, Netherlands (JvR); Mnazi Mmoja Hospital, Zanzibar, Tanzania (TM); School of Health and Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania (TM); and Helse Bergen, Haukeland University Hospital, Bergen, Norway (TM) 1
van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet 2014; 383: 1863–64.
35
Vaginal breech delivery (%)
30
Publication of Term Breech Trial
25 20 15 10 5 0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Figure: Vaginal breech delivery The graph shows the rate of vaginal delivery in breech presenting infants from 1993 to 2008. The dashed line indicates the point at which the Term Breech Trial was published.3
1184
Whipple’s disease: surprised by the surprise We read with a great surprise that Sarah Walters and colleagues presented their Case Report (June 28, p 2268) as an atypical case of Whipple’s disease.1 50% of the patients with Whipple’s disease have lymphadenopathies at the time of diagnosis, mainly mediastinal and mesenteric, and they are a typical presentation of the disease.2,3 Knowledge of Whipple’s disease and Tropheryma whipplei infections has increased greatly in the past few years. www.thelancet.com Vol 384 September 27, 2014
Jos van Roosmalen and Tarek Meguid have discussed the decrease of vaginal breech delivery in contemporary obstetric practice in their Comment.1 The publication of the Term Breech Trial 2 in 2000 has undoubtedly been associated with an almost complete elimination of breech presentations from delivery suites in the developed world. Our group has previously reported, however, that the practice of vaginal breech delivery was already decreasing prior to publication of the Term Breech Trial and that the trial’s findings simply accelerated that trend. 3 The figure shows the rate of vaginal breech delivery at the three major Dublin maternity hospitals over a 16-year period, which included the delivery of 11 913 breech presentations (8 years pre-publication and 8 years post-publication of the Term Breech Trial). The shift in practice toward caesarean delivery of breech presenting infants has resulted in an inevitable deskilling of obstetricians, with opportunities for vaginal breech delivery becoming more and more rare. We suggest that an increased use by the obstetric community of practices such as external cephalic version (ECV), particularly in multiparous mothers, could be a more appropriate measure to control
the increasing numbers of caesarean deliveries due to breech presentation. This is an evidence-based standard of care with proven benefits for both mother and baby and thus should be offered to most women with a breech presentation after 36 weeks gestation.4 We believe that the trend of caesarean delivery of breech presentations is unlikely to be reversed, but instead, decreasing the incidence of persistent breech presentation is more likely to affect the overall rate of caesarean section. We declare no competing interests.
*Mark P Hehir, Fergal D Malone [email protected] RCSI Unit, Rotunda Hospital, Dublin 1, Ireland 1
2
3
4
van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet 2014; 383: 1863–64. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for the Term Breech Trial Collaborative. Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Lancet 2000; 356: 1375–83. Hehir MP, O’Connor HD, Kent EM, Fitzpatrick C, Boylan PC, Coulter-Smith S, Geary MP, Malone FD. Changes in vaginal breech delivery rates in a single large metropolitan area. Am J Obstet Gynecol 2012; 206: 498 e1–4. Royal College of Obstetrics and Gynaecology. Green top guideline no. 20a. External cephalic version and reducing the incidence of breech presentation. 2010. http://thegynaecologyclinic. com/wp-content/media/ECV-GTG-20a.pdf (accessed July 30, 2014).
Authors’ reply We thank the correspondents for their remarks on our Comment.1 We agree that external cephalic version (ECV) should be done for all suitable women with breech presentation. Unfortunately, ECV is seldom done in sub-Saharan Africa and in many other parts of the world. ECV should, however, be part of obstetric training, but even when ECV is practised, vaginal breech delivery will still result from the many failed ECVs. We do not agree that a failed ECV is an indication for an elective caesarean section. By contrast, we believe that the way forward must be the return of vaginal breech delivery and we do not agree that not enough knowledge or clinical expertise blocks this direction. Knowledge and clinical expertise can and should be enhanced by simulation-based training. We declare no competing interests.
*Jos van Roosmalen, Tarek Meguid [email protected] VU University Medical Centre, Amsterdam, Netherlands (JvR); Leiden University Medical Centre, 2300 RC Leiden, Netherlands (JvR); Mnazi Mmoja Hospital, Zanzibar, Tanzania (TM); School of Health and Medical Sciences, State University of Zanzibar, Zanzibar, Tanzania (TM); and Helse Bergen, Haukeland University Hospital, Bergen, Norway (TM) 1
van Roosmalen J, Meguid T. The dilemma of vaginal breech delivery worldwide. Lancet 2014; 383: 1863–64.
35
Vaginal breech delivery (%)
30
Publication of Term Breech Trial
25 20 15 10 5 0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
Figure: Vaginal breech delivery The graph shows the rate of vaginal delivery in breech presenting infants from 1993 to 2008. The dashed line indicates the point at which the Term Breech Trial was published.3
1184
Whipple’s disease: surprised by the surprise We read with a great surprise that Sarah Walters and colleagues presented their Case Report (June 28, p 2268) as an atypical case of Whipple’s disease.1 50% of the patients with Whipple’s disease have lymphadenopathies at the time of diagnosis, mainly mediastinal and mesenteric, and they are a typical presentation of the disease.2,3 Knowledge of Whipple’s disease and Tropheryma whipplei infections has increased greatly in the past few years. www.thelancet.com Vol 384 September 27, 2014
