Patient Experiences With Obstetric Counseling on Fetal Malpresentation

Abstract

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.