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.

Objective To determine the prevalence of the inflammatory bowel diseases (IBD), ulcerative colitis (UC) and Crohn's disease (CD), in pregnant women and determine pregnancy and fetal/neonatal outcomes.Design Population-based cohort study.Setting New South Wales, Australia, 2001-11.Population A total of 630 742 women who delivered at ≥20 weeks of gestation.Methods Descriptive and multivariate regression analyses of perinatal data linked to hospital admission data. We compared birth outcomes of women with and without a documented diagnosis of IBD.Main outcome measures Caesarean section, severe maternal morbidity, preterm birth <37 weeks of gestation, planned preterm birth, small-for-gestational-age (birthweight <10th centile), perinatal mortality (stillbirth/neonatal death ≤28 days).Results In all, 1960 women (0.31%) with IBD, who had 2781 births (1183 UC, 1287 CD and 311 IBD-indeterminate). Women with IBD were more likely than women without IBD to have a caesarean section [41.5 versus 28.2%, adjusted risk ratio (aRR) 1.38, 95% CI 1.31-1.45], severe maternal morbidity (2.6 versus 1.6%, aRR 1.54, 95% CI 1.17-2.03), preterm birth (9.7 versus 6.6%, aRR 1.47, 95% CI 1.30-1.66), planned preterm birth (5.3 versus 2.9%, aRR 1.74, 95% CI 1.47-2.07), and their infants to be small-for-gestational-age (9.7 versus 9.5%, aRR 1.19, 95% CI 1.04-1.36). There was no evidence of a difference in perinatal mortality.Conclusion Pregnancy-associated IBD is more common than previously reported. Pregnancies complicated by IBD at or near the time of birth have significantly higher rates of adverse pregnancy outcomes than pregnancies of women without IBD.Keywords Crohn's disease, inflammatory bowel disease, population-based, pregnancy, ulcerative colitis.Tweetable abstract Increased rates preterm birth and caesarean section in women with inflammatory bowel disease.Please cite this paper as: Shand AW, Chen JS, Selby W, Solomon M, Roberts CL. Inflammatory bowel disease in pregnancy: a population-based study of prevalence and pregnancy outcomes.

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Objective To explore the variation in hospital caesarean section (CS) rates for nulliparous women, to determine whether different case-mix, labour and delivery, and hospital factors can explain this variation and to examine the association between hospital CS rates and outcomes.Design Population-based cohort study.Setting New South Wales, 2009Wales, -2010 Population Nulliparous women with singleton cephalic live births at term.Methods Random effect multilevel logistic regression models using linked hospital discharge and birth data.Main outcome measures Prelabour and intrapartum CS rates following spontaneous labour or labour induction; maternal and neonatal severe morbidity rates.Results Of 67 239 nulliparous women, 4902 (7.3%) had a prelabour CS, 39 049 (58.1%) laboured spontaneously, and 23 288 (34.6%) had labour induced. Overall, there were 18 875 (28.1%) CSs, with labour inductions twice as likely to result in an intrapartum CS compared with women with a spontaneous onset of labour (34.0% versus 15.5%). After adjusting for differences in case-mix, labour and delivery, and hospital factors, the overall variation in CS rates decreased by 78% for prelabour CSs, 52% for intrapartum CSs following spontaneous labour and 9% following labour induction. Adjusting for labour and delivery practices increased the unexplained variation in intrapartum CSs. The adjusted rates of severe maternal and neonatal morbidity were not significantly different across CS rate quintile groups, except for women in spontaneous labour, where the hospitals in the lowest CS quintile had the lowest neonatal morbidity rate.Conclusions Differences in clinical practice were substantial contributors to variation in intrapartum CS rates. Our findings suggest that CS rates in some hospitals could be lowered without adversely affect pregnancy outcomes.Keywords Caesarean section, induction, labour, maternal outcome, neonatal outcome, spontaneous labour, term nullipara.Please cite this paper as: Nippita TA, Lee YY, Patterson JA, Ford JB, Morris JM, Nicholl MC, Roberts CL. Variation in hospital caesarean section rates and obstetric outcomes among nulliparae at term: a population-based cohort study . BJOG 2015;122:702-711.

The pharmacological agents used for induction of labour have changed over the past decade. An important area for future research is to investigate how the dosage of oxytocin and prostaglandin affects pregnancy outcomes.