Women's attitudes towards management of breech presentation at term

Patient Experiences With Obstetric Counseling on Fetal Malpresentation

Introduction Fetal malpresentation is a complication of pregnancy in which the fetus does not present cephalically as required for vaginal birth. After a diagnosis is made, management options include cesarean section (CS) or external cephalic version (ECV). ECV is a procedure in which providers attempt to manually maneuver the fetus to cephalic position, allowing patients to attempt vaginal birth. Selecting between CS or ECV can be a complex and stressful decision, yet literature exploring patient perspectives on counseling of these options is limited. This study aims to describe patient perspectives on decision-making when diagnosed with fetal malpresentation. Methods We included English-speaking pregnant patients greater than 18 years of age diagnosed with malpresentation at 35-37 weeks' gestation. Patients who previously underwent CS or had maternal or fetal contraindications besides malpresentation to vaginal birth requiring CS were excluded. Semi-structured interviews were conducted with participants from four obstetric clinics in Baltimore, Maryland, at time of diagnosis. Themes were derived using data analysis in NVivo 11 (released 2015, Lumivero, USA). Results We recruited 10 participants (median age = 32 years, 90% Caucasian, 70% nulliparous, 50% chose ECV). We categorized our findings into the following themes: (1) facilitators and (2) barriers to deciding on malpresentation management, (3) participant priorities and values, and (4) other methods of malpresentation management. The participants identified incorporation of statistics and medical history into counseling as facilitators and the lack of information about ECV as a significant barrier. The participants prioritized fetal safety and, among those who chose ECV, a desire to avoid CS. Chiropractors, acupuncture, and moxibustion were identified as valuable additional methods of malpresentation management. Conclusion Overall, patients desire more information about ECV when diagnosed with fetal malpresentation. Uncertainty about ECV safety is a barrier to deciding between management options. Based on our findings, obstetric providers should provide comprehensive counseling on ECV and CS. Counseling should aim to demystify ECV and quantify risk in a patient-specific context. This will allow patients to make an informed decision on the management of fetal malpresentation that aligns with their goals for pregnancy.

External Cephalic Version: ACOG Practice Bulletin, Number 221

In the United States, there is a widespread belief that the overall cesarean birth rate is higher than necessary. Efforts are being directed toward decreasing the number of these procedures, in part by encouraging physicians to make changes in their management practices. Because breech presentations are associated with a high rate of cesarean birth, there is renewed interest in techniques such as external cephalic version (ECV) and vaginal breech delivery. The purpose of this document is to provide information about ECV by summarizing the relevant evidence presented in published studies and to make recommendations regarding its use in obstetric practice.

Factors Associated with Attempted External Cephalic Version for Fetal Malpresentation at Term

Objective  To assess differences in patient characteristics between women who did and did not undergo attempted external cephalic version (ECV) for fetal malpresentation at term. Study Design  This was a retrospective cohort study of women with a singleton gestation and noncephalic presentation at > 37.0 weeks between October 2014 and October 2015. We compared demographic and clinical characteristics of women who did and did not undergo attempted ECV and assessed the reasons that women did not attempt ECV. Results  Among 215 women, only 51 (24%) attempted ECV. There were no differences in age, race, insurance type, or body mass index between women who underwent attempted ECV and those who did not. Women who underwent ECV were significantly more likely to have had a prior vaginal delivery (69 vs. 36%, p  < 0.001). Seventy-six women (46%) declined ECV. Women who declined ECV were more likely to be nulliparous than those who accepted the procedure (66 vs. 29%, p  < 0.001). Among women who had ECV, the success rate was 55%. There were no adverse events after attempted ECV in this cohort. Conclusion  Among women with fetal malpresentation at term, those without a prior vaginal delivery were significantly less likely to undergo attempted ECV.

Association Between Attempted External Cephalic Version and Perinatal Morbidity and Mortality

OBJECTIVE

To examine whether, with fetal malpresentation at term, perinatal morbidity and mortality differ between women who undergo an external cephalic version (ECV) attempt and those who do not and are expectantly managed.

METHODS

We conducted a retrospective cohort study of women with nonanomalous singleton gestations in nonvertex presentation delivering at a tertiary care institution from 2006 to 2016. Women undergoing an ECV attempt at 37 weeks of gestation or greater were compared with those with nonvertex fetuses who did not undergo an ECV attempt and delivered at 37 weeks of gestation or greater. The primary outcome was a composite of perinatal morbidity and mortality including stillbirth, neonatal death within 72 hours, Apgar score less than 5 at 5 minutes, umbilical artery pH less than 7.0, base deficit 12 mmol/L or greater, or neonatal therapeutic hypothermia. Secondary outcomes were neonatal intensive care unit admission and neonatal anemia (hemoglobin value less than 13.5 g/dL). Bivariable and multivariable analyses were performed.

RESULTS

Of the 4,117 women meeting eligibility criteria, 1,263 (30.7%) attempted ECV; 509 (40.3%) of these attempts resulted in successful versions. In bivariable analyses, women who underwent attempted ECV were more likely to be non-Hispanic white and multiparous and had lower mean body mass indexes. The composite perinatal morbidity and mortality outcome did not differ significantly between women who did and did not undergo attempted ECV (2.9% vs 2.5%, P=.46). The frequencies of neonatal intensive care unit admission (3.6% vs 3.3%, P=.53) and neonatal anemia (1.6% vs 1.2%, P=.36) were also similar. There continued to be no association between ECV attempt and composite perinatal morbidity and mortality outcome after adjustment for potential confounders (adjusted odds ratio 1.02, 95% CI 0.66-1.60).

CONCLUSION

Compared with expectant management, an ECV attempt at term is not associated with increased perinatal morbidity or mortality.

Maternal and Neonatal Outcomes after Attempted External Cephalic Version among Women with One Previous Cesarean Delivery

Objective  This study was aimed to evaluate success rates of (1) external cephalic version (ECV) among women with one prior cesarean delivery (CD) and (2) maternal and neonatal outcomes after ECV among women with prior CD. Study Design  Two linked studies using U.S. Natality Database were performed. First we performed a retrospective cohort comparing ECV success rates of women with prior CD and women without prior CD. Then we compared the outcomes of TOLACs (trial of labor after cesarean delivery) that occurred after ECV with those that occurred without ECV. Multivariable logistic regression analysis was used to estimate adverse outcomes. Results  A total of 715 women had ECV after 36 weeks with prior CD and 9,976 had ECV without prior scar. ECV success rate with scar was 80.6% and without scar was 86.4% ( p  < 0.001). Seven hundred and sixteen women underwent TOLAC after ECV attempt and 234,617 underwent TOLAC without a preceding attempt. Women with preceding version had increased risks of maternal transfusion (1 vs. 0.4%, adjusted OR [odds ratio]: 2.48 [95% CI (confidence interval): 1.17-5.23]), unplanned hysterectomy (0.4 vs. 0.06%, adjusted OR: 6.90 [95% CI: 2.19-21.78]), and low 5-minute Apgar's score (2.5 vs. 1.5%, adjusted OR: 1.76 [95% CI: 1.10-2.82]). Conclusion  Women with prior CD may have a decrease in the rate of successful ECV. While the absolute risks are low, ECV appears to increase risks of adverse maternal and neonatal outcomes among women undergoing a trial of labor.

Implementation of external cephalic version in the Netherlands: a retrospective cohort study

BACKGROUND

External cephalic version (ECV) reduces the rate of elective cesarean sections as a result of breech presentation. Several studies have shown that not all eligible women undergo an ECV attempt. The aim of this study was to evaluate the implementation of ECV in the Netherlands and to explain variation in implementation rates with hospital characteristics and individual factors.

METHODS

We invited 40 hospitals to participate in this retrospective cohort study. We reviewed hospital charts for all singleton breech deliveries from 36 weeks' gestation and onwards between January 2008 and December 2009. We documented whether an ECV attempt was performed, reasons for not performing an attempt, mode of delivery, and hospital characteristics.

RESULTS

We included 4,770 women from 36 hospitals. ECV was performed in 2,443 women (62.2% of eligible women, range 8.2-83.6% in different hospitals). Implementation rates were higher in teaching hospitals, hospitals with special office hours for ECV, larger obstetric units, and hospitals located in larger cities. Suboptimal implementation was mainly caused by health care providers who did not offer ECV.

CONCLUSION

ECV implementation rates vary widely among hospitals. Suboptimal implementation is mostly caused by the care provider not offering the treatment and secondly due to women not opting for the offered attempt. A prerequisite for designing a proper implementation strategy is a detailed understanding of the exact reasons for not offering and not opting for ECV.

Anesthetic management of external cephalic version

Breech presentation is common at term and its reduction through external cephalic version represents a noninvasive opportunity to avoid cesarean delivery and the associated maternal morbidity. In addition to uterine relaxants, neuraxial anesthesia is associated with increased success of version procedures when surgical anesthetic dosing is used. The intervention is likely cost effective given the effect size and the avoided high costs of cesarean delivery.

[External cephalic version in case of persisting breech presentation at term: motivations and women's experience of the intervention]

OBJECTIVES

To evaluate the efficacy and acceptability of external cephalic version (ECV).

MATERIALS AND METHOD

From 2004 to 2008, 212 pregnant women between 34-37 weeks of gestation with fetus in breech presentation were included in a randomized clinical trial and 125 externals cephalic versions were studied.

RESULTS

A success rate of 37.6%t was recorded. At 34 weeks of gestation, 80.6% of women were considering an ECV in the event of persistent breech position at 37 weeks. These women expressed the desire to give birth vaginally (52% versus 24.4%, P<0.001). In contrast, others women preferred an elective cesarean section to avoid the risk of a breech vaginal delivery. Women felt pain during the ECV and scored 60 on average using the analogical visual scale. Women rated on a verbal rating scale the ECV as severely painful to unbearable (68%), and as stressful (70%). Despite this, the majority of women would recommend ECV to their friends or would be willing to repeat it for themselves.

DISCUSSION AND CONCLUSION

ECV remains a scary and painful medical procedure. More research is needed to reduce the impact. The use of analgesic medication for this indication is controversial. Hypnosis could be an alternative to evaluate.

A qualitative interview study exploring pregnant women's and health professionals' attitudes to external cephalic version

Background

Women who have a breech presentation at term have to decide whether to attempt external cephalic version (ECV) and how they want to give birth if the baby remains breech, either by planned caesarean section (CS) or vaginal breech birth. The aim of this study was to explore the attitudes of women with a breech presentation and health professionals who manage breech presentation to ECV.

Methods

We carried out semi-structured interviews with pregnant women with a breech presentation (n=11) and health professionals who manage breech presentation (n=11) recruited from two hospitals in North East England. We used purposive sampling to include women who chose ECV and women who chose planned CS. We analysed data using thematic analysis, comparing between individuals and seeking out disconfirming cases.

Results

Four main themes emerged from the data collected during interviews with pregnant women with a breech presentation: ECV as a means of enabling natural birth; concerns about ECV; lay and professional accounts of ECV; and breech presentation as a means of choosing planned CS. Some women’s attitudes to ECV were affected by their preferences for how to give birth. Other women chose CS because ECV was not acceptable to them. Two main themes emerged from the interview data about health professionals’ attitudes towards ECV: directive counselling and attitudes towards lay beliefs about ECV and breech presentation.

Conclusions

Women had a range of attitudes to ECV informed by their preferences for how to give birth; the acceptability of ECV to them; and lay accounts of ECV, which were frequently negative. Most professionals described having a preference for ECV and reported directively counselling women to choose it. Some professionals were dismissive of lay beliefs about ECV. Some key challenges for shared decision making about breech presentation were identified: health professionals counselling women directively about ECV and the differences between evidence-based information about ECV and lay beliefs. To address these challenges a number of approaches will be required.

The Early External Cephalic Version (ECV) 2 Trial: an international multicentre randomised controlled trial of timing of ECV for breech pregnancies

Objective

To investigate whether initiating external cephalic version (ECV) earlier in pregnancy might increase the rate of successful ECV procedures, and be more effective in decreasing the rate of non-cephalic presentation at birth and of caesarean section.

Design

An unblinded multicentred randomised controlled trial.

Setting

A total of 1543 women were randomised from 68 centres in 21 countries.

Population

Women with a singleton breech fetus at a gestational age of 33^0/7 weeks (231 days) to 35^6/7 weeks (251 days) of gestation were included.

Methods

Participants were randomly assigned to having a first ECV procedure between the gestational ages of 34^0/7 (238 days) and 35^6/7 weeks of gestation (early ECV group) or at or after 37^0/7 (259 days) weeks of gestation (delayed ECV group).

Main outcome measures

The primary outcome was the rate of caesarean section; the secondary outcome was the rate of preterm birth.

Results

Fewer fetuses were in a non-cephalic presentation at birth in the early ECV group (314/765 [41.1%] versus 377/768 [49.1%] in the delayed ECV group; relative risk [RR] 0.84, 95% CI 0.75, 0.94, P = 0.002). There were no differences in rates of caesarean section (398/765 [52.0%] versus 430/768 [56.0%]; RR 0.93, 95% CI 0.85, 1.02, P = 0.12) or in risk of preterm birth (50/765 [6.5%] versus 34/768 [4.4%]; RR 1.48, 95% CI 0.97, 2.26, P = 0.07) between groups.

Conclusion

External cephalic version at 34–35 weeks versus 37 or more weeks of gestation increases the likelihood of cephalic presentation at birth but does not reduce the rate of caesarean section and may increase the rate of preterm birth.

Helping pregnant women make better decisions: a systematic review of the benefits of patient decision aids in obstetrics

Objectives Patient decision aids can be used to support pregnant women engaging in shared decisions, but little is known about their effects in obstetrics. The authors aimed to evaluate the effects of patient decision aids designed for pregnant women on clinical and psychosocial outcomes. Design Systematic review. Data on all outcomes were extracted and summarised. All studies were critically appraised for potential sources of bias and, when possible to obtain, the reported decision aids were evaluated. Meta-analysis was not possible due to the heterogeneity of outcomes in primary studies and the small number of studies. Data sources Electronic searches were performed using Medline, Embase, the Cochrane Library and Medion databases from inception until December 2010. Reference lists of all included articles were also examined and key experts contacted. Eligibility criteria for selecting studies Eligibility criteria included randomised controlled trials, which reported on patient decision aids for women facing any treatment decision in pregnancy published in English. Studies evaluating health education material that did not address women's values and preferences were excluded. Results Patient decision aids have been developed for decisions about prenatal testing, vaginal birth after Caesarean section, external cephalic version and labour analgesia. Use of decision aids is associated with a number of positive effects including reduced anxiety, lower decisional conflict, improved knowledge, improved satisfaction and increased perception of having made an informed choice. Conclusions Patient decision aids have the potential to improve obstetric care. However, currently the evidence base is limited by the small number of studies, the quality of the studies and because they involved heterogeneous decision aids, patient groups and outcomes.

Prevalence, outcome, and women's experiences of external cephalic version in a low-risk population

BACKGROUND

Until recently, external cephalic version to prevent breech presentation at birth was not widely accepted. The objective of our study was to assess the prevalence, outcomes, and women's experiences of external cephalic version to improve the implementation of the procedure in the Netherlands.

METHODS

A prospective cohort study was conducted of 167 women under the care of a midwife with confirmed breech presentation at a gestational age of 33 completed weeks or more.

RESULTS

Between June 2007 and January 2008, 167 women with a confirmed breech presentation were offered an external cephalic version. Of this group, 123 women (73.7%, 95% CI: 65.5-80.5) subsequently received the version. These women had about a ninefold increased probability of a cephalic presentation at birth compared with women who did not undergo a version (relative risk [RR]: 8.8, 95% CI: 2.2-34.8). The chance of a vaginal birth after an external cephalic version was almost threefold (RR: 2.7, 95% CI: 1.5-5.0). The success rate was 39 percent, although considerable differences existed associated with region and parity. Ninety-four percent of women with a successful version rated it as a good experience compared with 71 percent of women who had a failed version (p = 0.015). Significant pain during the version was experienced by 34 percent of women, of whom 18 percent also experienced fear during the version, compared with no women who reported little or no pain (p = 0.006). Women who reported significant pain or fear during the version experienced the version more negatively (OR: 6.0, 95% CI: 3.3-12.2 and OR: 2.7, 95% CI: 1.1-6.0, respectively).

CONCLUSIONS

One in every four women with a breech presentation in independent midwifery care did not receive an external cephalic version. Of the women who received a version one third experienced significant pain during the procedure. Considerable regional variation in success rate existed.

Implementation of the external cephalic version in breech delivery. Dutch national implementation study of external cephalic version

Background

Breech presentation occurs in 3 to 4% of all term pregnancies. External cephalic version (ECV) is proven effective to prevent vaginal breech deliveries and therefore it is recommended by clinical guidelines of the Royal Dutch Organisation for Midwives (KNOV) and the Dutch Society for Obstetrics and Gynaecology (NVOG). Implementation of ECV does not exceed 50 to 60% and probably less.

We aim to improve the implementation of ECV to decrease maternal and neonatal morbidity and mortality due to breech presentations. This will be done by defining barriers and facilitators of implementation of ECV in the Netherlands. An innovative implementation strategy will be developed based on improved patient counselling and thorough instructions of health care providers for counselling.

Method/design

The ultimate purpose of this implementation study is to improve counselling of pregnant women and information of clinicians to realize a better implementation of ECV.

The first phase of the project is to detect the barriers and facilitators of ECV. The next step is to develop an implementation strategy to inform and counsel pregnant women with a breech presentation, and to inform and educate care providers. In the third phase, the effectiveness of the developed implementation strategy will be evaluated in a randomised trial. The study population is a random selection of midwives and gynaecologists from 60 to 100 hospitals and practices. Primary endpoints are number of counselled women. Secondary endpoints are process indicators, the amount of fetes in cephalic presentation at birth, complications due to ECV, the number of caesarean sections and perinatal condition of mother and child. Cost effectiveness of the implementation strategy will be measured.

Discussion

This study will provide evidence for the cost effectiveness of a structural implementation of external cephalic versions to reduce the number of breech presentations at term.

Trial Registration

Dutch Trial Register (NTR): 1878

Ultrasound factors to predict the outcome of external cephalic version: a meta-analysis

OBJECTIVE

To systematically review the medical literature reporting on ultrasound factors that can be predictive for the outcome of an attempt at external cephalic version (ECV).

METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials were searched. Studies reporting on potential ultrasound prognosticators and ECV success rates that allowed construction of a 2x2 table were selected.

RESULTS

We selected 37 primary articles reporting on 7709 women. Posterior placental location (odds ratio (OR), 1.9; 95% CI, 1.5-2.4), complete breech position (OR, 2.3; 95% CI, 1.9-2.8) and an amniotic fluid index>10 (OR, 1.8; 95% CI, 1.5-2.1) were predictors of successful ECV.

CONCLUSION

Success of an ECV attempt is associated with ultrasound parameters such as fetal position, amniotic fluid and placental location. This knowledge can be used to develop a prognostic model to predict successful ECV.

Clinical factors to predict the outcome of external cephalic version: a metaanalysis

OBJECTIVE

The objective of the study was to systematically review the medical literature reporting on potential clinical prognosticators for the outcome of external cephalic version (ECV).

STUDY DESIGN

Medline, EMBASE, and Cochrane Central Register of Controlled Trials were searched. Studies reporting on potential clinical prognosticators and ECV success rates that allowed construction of a 2 x 2 table were selected.

RESULTS

We detected 53 primary articles reporting on 10,149 women. Multiparity (P >/= 1.00; odds ratio [OR], 2.5; 95% confidence interval [CI], 2.3-2.8), nonengagement of the breech (OR, 9.4; 95% CI, 6.3-14), a relaxed uterus (OR, 18; 95% CI, 12-29), a palpable fetal head (OR, 6.3; 95% CI, 4.3-9.2), and maternal weight less than 65 kg (OR, 1.8; 95% CI, 1.2-2.6) were predictors for successful external cephalic version.

CONCLUSION

Success of an ECV attempt is associated with clinical factors. This should be taken into account in the counseling of women prior to an ECV attempt.

Development and pilot-testing of a decision aid for women with a breech-presenting baby

OBJECTIVE

To develop a decision aid for pregnant women with a breech presentation at term, and to assess its acceptability.

METHODS

The external cephalic version (ECV) decision aid was developed using the Ottawa Decision Support Framework and a systematic review of the evidence to provide probabilistic information about the benefits and risks of options. It incorporates a workbook supplemented by a CD and worksheet, and these were evaluated in a pilot study using self-administered questionnaires.

PARTICIPANTS

19 women with a breech presentation attending antenatal clinics at a local obstetric hospital and 11 recently pregnant women.

FINDINGS

Of 30 women surveyed, nearly all found the decision aid clear and easy to understand, and thought that enough information was provided for them to make a decision. Women experienced increased knowledge, reduced decisional conflict, increased satisfaction and participation in decision making without increased anxiety. Participants also found the tool helpful and would recommend it to others.

KEY CONCLUSIONS

The ECV decision aid was well accepted and helpful for pregnant women with a breech presenting baby. We are currently evaluating the decision aid in a randomised trial to assess cognitive, affective and health outcomes.

Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]

OBJECTIVES

To evaluate the effectiveness of a decision aid for women with a breech presentation compared with usual care.

DESIGN

Randomised controlled trial.

SETTING

Tertiary obstetric hospitals offering external cephalic version (ECV).

POPULATION

Women with a singleton pregnancy were diagnosed antenatally with a breech presentation at term, and were clinically eligible for ECV.

METHODS

Women were randomised to either receive a decision aid about the management options for breech presentation in addition to usual care or to receive usual care only with standard counselling from their usual pregnancy care provider. The decision aid comprised a 24-page booklet supplemented by a 30-minute audio-CD and worksheet that was designed for women to take home and review with a partner.

MAIN OUTCOME MEASURES

Decisional conflict (uncertainty), knowledge, anxiety and satisfaction with decision making, and were assessed using self-administered questionnaires.

RESULTS

Compared with usual care, women reviewing the decision aid experienced significantly lower decisional conflict (mean difference -8.92; 95% CI -13.18, -4.66) and increased knowledge (mean difference 8.40; 95% CI 3.10, 13.71), were more likely to feel that they had enough information to make a decision (RR 1.30; 95% CI 1.14, 1.47), had no increase in anxiety and reported greater satisfaction with decision making and overall experience of pregnancy and childbirth. In contrast, 19% of women in the usual care group reported they would have made a different decision about their care.

CONCLUSIONS

A decision aid is an effective and acceptable tool for pregnant women that provides an important adjunct to standard counselling for the management of breech presentation.

Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term

The aim of this study was to determine the frequency of adverse maternal and fetal outcomes of both external cephalic version (ECV) and persisting breech presentation at term. We conducted a systematic review of the literature using Medline, Embase and All Evidence Based Medicine (EBM) Reviews databases. Data were extracted from studies that compared women who had an ECV from 36 weeks' gestation with a similar control group of women enrolled at the same gestational age, eligible for, but who did not have an ECV. Eleven studies with a total of 2503 women were included. Adverse outcomes related to ECV were rarely reported and in most studies there was no evidence that relevant outcomes were ascertained among similar women who did not have an ECV. There was no increased risk of antepartum fetal death associated with ECV, but numbers were small. There were no reported cases of uterine rupture, placental abruption, prelabour rupture of membranes or cord prolapse, but these outcomes were not examined among controls. Onset of labour within 24 h and nuchal cord was non-significantly higher among women who had an ECV compared with those with a persisting breech. Despite limited reporting and small numbers, the results of our review suggest that adverse maternal and fetal outcomes of both ECV and persisting breech presentation are rare. Only with improved reporting and collection of safety data on ECV and persisting breech presentation can we provide high-quality information to assist informed decision making by pregnant women with a breech presentation at term.

Tocolysis in term breech external cephalic version

OBJECTIVES

To study the effect of ritodrine tocolysis on the success of external cephalic version (ECV) and to assess the role of ECV in breech presentation at our centre.

MATERIAL AND METHODS

A prospective randomized double-blind-controlled trial comparing ritodrine and placebo in ECV of singleton term breech pregnancy at a tertiary hospital.

RESULTS

Among the 60 patients who were recruited, there was a success rate of 36.7%. Ritodrine tocolysis significantly improved the success rate of ECV (50% vs. 23%; P=0.032). There was a marked effect of ritodrine tocolysis on the ECV success in nulliparae (36.4% vs. 13.0%) and multiparae (87.5% vs. 57.1%). External cephalic version has shown to reduce the rate of cesarean section for breech presentation by 33.5% in our unit.

CONCLUSION

External cephalic version significantly reduced the rate of cesarean section in breech presentation, and ritodrine tocolysis improved the success of ECV and should be offered to both nulliparous and parous women in the case of term breech presentation.