HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by van Iddekinge, B. Search for Related Content PubMed Articles by van Iddekinge, B.

Planned vaginal breech delivery: should this be the mode of choice?

^1. Formerly at: Department of Obstetrics and Gynaecology Johannesburg Hospital and the University of the Witwatersrand, Johannesburg South Africa Email: vaniddekinge.b{at}bigpond.com (corresponding author)

	Abstract

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
Key content:

• The risks of serious early perinatal morbidity and mortality are three times higher for planned vaginal breech delivery than for elective caesarean section.
  
• Because morbidity and mortality are relatively low, a large number of caesarean sections needs to be performed to avoid a single adverse event.
  
• External cephalic version appears to be a safe procedure that can halve the number of breech presentations but the procedure is not risk-free.
  
• Four guidelines or directives are outlined but need to be adapted to the setting in which they are applied.
  
• Planned vaginal breech delivery is an acceptable choice to offer, provided strict protocols are followed.
  

Learning objectives:

• To gain an awareness of the risk factors and benefits of external cephalic version.
  
• To gain an awareness of the short and long-term risk factors and benefits to the mother and child of planned vaginal breech delivery compared with elective caesarean section.
  
• To be able to manage breech presentation at term in different clinical and in differently resourced settings.
  

Ethical issues:

• Can planned vaginal breech delivery be justified?
  
• How can expertise in vaginal breech delivery be learned or taught if a policy of elective caesarean section is implemented?
  
• How can we obtain genuine informed consent when there are so many areas of uncertainty for degree of risk and benefit?
  

Please cite this article as: van Iddekinge B. Planned vaginal breech delivery: should this be the mode of choice? The Obstetrician & Gynaecologist 2007;9:171–176.

Keywords caesarean section / consent / external cephalic version / mode of delivery / risk / vaginal breech delivery

	Introduction

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
Following publication in 2000 of the Term Breech Trial there has been a major shift toward elective caesarean section for breech delivery at term.¹ This is mainly because of the finding that neonatal mortality and serious morbidity were 5% in the planned vaginal birth group compared with 1.6% in the planned elective caesarean section group.

Although the trial clearly outlines and quantifies the risk, Glezerman² is adamant that concerns regarding the design and methods of the trial are sufficiently serious to justify them withdrawing their recommendations. However, there is no prospect of repeating such a large randomised controlled trial to address any of these deficiencies and obstetricians are going to have to decide which method of delivery to offer women. The available information that we can reasonably give to women will have to be sufficient to enable an informed decision to be made on the method of delivery.

There have recently been three large population-based comparative studies from the Netherlands,³ Sweden⁴ and Denmark:⁵ all confirm improved perinatal morbidity and mortality with elective caesarean section. However, in a more recent observational prospective study in France and Belgium, the neonatal mortality and morbidity for vaginal breech delivery was 1.6% – this is much lower than in the Term Breech Trial and not significantly different from the caesarean section group.¹,⁶

The risk versus benefit aspect needs to be brought into perspective for all obstetric practitioners. Experience, resources and working conditions need to be taken into account. Rietberg et al.³ calculated that 175 caesarean sections are needed to avoid one fetal death, while Hofmeyr and Hannah⁷ suggested that 29 caesarean sections would avoid one case of serious neonatal morbidity or death. There will also, no doubt, be an increase in potential problems, such as uterine scar dehiscence and placenta praevia accreta, in future pregnancies: these are life threatening to mother and baby. In the Rietberg et al.³ study it was estimated that, for every infant saved by a caesarean section, one woman would experience a uterine rupture during a subsequent pregnancy.

In a large epidemiological study, Smith et al.⁸ showed an absolute risk of unexplained stillbirth at or after 39 weeks of gestation of 1.1 per 1 000 women who had a previous caesarean section, compared with 0.5 per 1 000 women who had not. However unlikely such complications are deemed, they must be brought to the attention of the parents when discussing method of delivery and informed consent. In the United Kingdom, 11% of all caesarean sections are now performed for breech presentation, despite guidelines that recommend external cephalic version (ECV).⁹

In poorly-resourced health services the benefit of elective caesarean section becomes even more dubious. In low-resource settings, caesarean section is often performed by relatively inexperienced operators and anaesthetists. This increases the risk to the mother, which may be even greater in the future because of lack of access to facilities for caesarean section in following pregnancies. While clinicians, and the societies who represent them, have drawn up guidelines that are reasonable and sustainable for the conditions in which they practise, they may not be appropriate in other countries.

In short, one should always ask what one would choose for oneself or one's family in this situation.

	Established guidelines and directives

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
Royal College of Obstetricians and Gynaecologists
Green-top Guideline No. 20
In their Green-top Guideline No. 20 (April 2001), the Royal College of Obstetricians and Gynaecologists (RCOG) recommended offering all women with an uncomplicated breech presentation an external cephalic version (ECV) at term (37–42 weeks), provided there were no contraindications.¹⁰ If this is not performed, or is unsuccessful, an elective caesarean section at term should be offered. Two important points are highlighted in the guideline:

It remains important that clinicians and hospitals are prepared for vaginal breech delivery.

Any woman who gives birth to a breech vaginally should be cared for by an attendant with suitable experience.

Green-top Guidelines Nos. 20a and 20b
In December 2006, Guideline No. 20 was updated and divided into two parts,¹¹,¹² addressing ECV and breech presentation separately (parts 20a and 20b, respectively) and increasing the total number of pages from 9 to 21. This reflects the complex nature of the guideline and that it outlines a less rigid approach to mandatory elective caesarean section, which followed the Term Breech Trial.¹ There is more detailed information on the benefits and risks of planned caesarean section versus planned vaginal breech delivery and on counselling women with a breech presentation. Benefits, risks and the role of ECV are discussed in more detail.

Other important issues addressed are:

• Information that should be given about risk to mother and baby in the short and long term for each method of delivery.
  
• Details of intrapartum management of breech presentation and delivery.
  
• Training, skill and experience of the intrapartum attendant.
  
• The need for clear documentation, including details of counselling and the identity of all those involved in the procedures.
  

American College of Obstetricians and Gynecologists
Through their Committee on Obstetric Practice, the American College of Obstetricians and Gynecologists (ACOG) issued a Committee opinion paper on ‘Mode of term singleton breech delivery’ in 2006.¹³ This is not as emphatic about elective caesarean section as the earlier RCOG guideline and indicates that planned vaginal breech delivery may be reasonable under hospital-specific protocol guidelines. Documented, informed consent, clearly outlining the increased short-term serious risk to the infant, is a prerequisite. To assist with this, the ACOG has produced an excellent patient information sheet, which can be downloaded from their website.¹⁴ This can be amended to suit one's own practice and will assist with informed consent issues related to ECV and vaginal breech delivery.

Royal Australian and New Zealand College of Obstetricians and Gynaecologists
In March 2005 the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) issued a formal statement concerning breech delivery at term.¹⁵ This can be viewed on their website. In essence, it indicates that the level of risk is higher in planned vaginal breech delivery than in elective caesarean section but does not exclude it as an option. The statement outlines factors that reduce the risk of vaginal delivery and also points out the risk in subsequent pregnancies after caesarean section, including uterine scar rupture and placenta praevia accreta. The final point made is that maternal preference should also be considered.

National Institute for Health and Clinical Excellence
In their 2003 Clinical Guideline,¹⁶ the National Institute for Health and Clinical Excellence (NICE) recommend ECV for breech presentation at 36 weeks of gestation and elective caesarean section if the procedure is declined or fails.

The difficulty in setting rigid guidelines is clearly apparent. Clinicians, in consultation with their patients, must make the final decisions regarding ECV as well as method of delivery.

	Pros and cons of external cephalic version, planned vaginal breech delivery and elective caesarean section

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
External cephalic version
In a Cochrane review,¹⁷ ECV appeared to be a safe and effective way of reducing the number of elective caesarean sections for breech presentation but there was not enough evidence to quantify serious complications. Large observational studies suggest that these are uncommon.¹⁸ In this review of 44 studies, which included 7 377 participants, transient abnormal heart rate patterns occurred in 5.7% of cases, with persistent abnormality in 0.37%. Other complications included vaginal bleeding (0.47%), placental abruption (0.12%) and emergency caesarean section (0.43%). Perinatal mortality was 0.16% but this needs to be kept in perspective with an expected fetal loss rate of 0.6% between 36 and 42 weeks of gestation in a low-risk population.

It is also clear that ECV should not be offered if ready access to emergency caesarean section is not available. Busy units may not be able to offer this assurance and this may be a reason why the implementation of ECV is inconsistent.¹⁹ If needed, emergency caesarean section may be performed more quickly under general than epidural anaesthesia but this would require rapid sequence induction. It seems unreasonable to fast all women undergoing ECV.

The relative and absolute contraindications to ECV are outlined in a review by Green and Walkinshaw.²⁰ Success rates in the review varied between 50–80%. The validity of the contraindications has not yet been tested in randomised controlled studies. Fetal heart monitoring is recommended as bradycardia occurs frequently and, if persistent, urgent delivery may be required.²¹ Use of tocolytic agents improves the success rate of ECV and, at the doses required, they have few risks or side effects.²²

In a case controlled study²³ the caesarean section rate was almost three times higher in a group of 279 women who had undergone successful ECV compared with controls who had spontaneous cephalic presentations (23.3% compared with 9.4%, respectively). The indications for caesarean section were mainly: failed induction of labour, fetal distress and failure to progress in labour. Informed consent for ECV is extremely difficult, as the risks to both mother and fetus are small but it would be unreasonable not to ensure awareness of the risk of emergency caesarean section and the small possibility of perinatal death.

If ECV fails or the procedure is declined, the choice of planned vaginal breech delivery or elective caesarean section must be discussed. The two issues of ECV and caesarean section are closely linked. Counselling and consent issues, therefore, need to be initiated by the 36-week visit to give the woman sufficient time to make an informed decision.

Training in ECV is much simpler than for vaginal breech delivery and it should be included in the formal training programme. Methods and protocols for performing the procedure should be in place. A very good training video can be found at the World Health Organization (WHO) Reproductive Health Library.²⁴

Planned vaginal breech delivery
Information regarding risk to the fetus with vaginal breech delivery has been partly quantified by the Term Breech Trial. However, future risk of childbirth after caesarean section, pelvic floor damage and urinary or other incontinence issues after vaginal delivery have not been considered.

In the 2-year follow-up study²⁵ of the children of the women enrolled in the Term Breech Trial, the primary outcomes of death and neurodevelopmental delay at 2 years of age were similar between the two groups. The smaller number of perinatal deaths with planned caesarean section was balanced by a greater number of babies with neurodevelopmental delay. This was unexpected as there had been fewer babies with severe perinatal morbidity in the planned caesarean section group. While inherent neurological abnormality may be the reason for persistent breech presentation, randomisation should have excluded this possible bias.

Planned vaginal delivery thus seems a reasonable alternative to elective caesarean section provided that strict hospital-based protocols are followed, patient selection is carefully supervised and sufficient personnel trained in vaginal breech delivery are available for the delivery. However, training in assessment and delivery of breech presentations must be continued, even if much of it is by simulation with models and video demonstrations. A very good video demonstration of vaginal breech delivery can be found in the WHO Reproductive Health Library on their website.²⁴

Training with models and videos must be backed up by observation of experienced obstetricians and closely supervised application in practice. These skills need to be assessed as part of the training programme for registrars. Workshops should be offered for those who are not confident in assessing and performing vaginal breech delivery. Consultants should be available to advise and assist junior staff with vaginal breech assessment, method and timing of delivery.

Although both sets of RCOG Green-top guidelines recommend that a ‘suitably experienced person’ be available for a vaginal breech delivery, there is no clear definition of the skills and requirements of such a person.

In each unit where vaginal breech delivery is offered, clear protocols and contact personnel need to be documented and continuously audited to help avoid poor outcomes or medicolegal issues.

Women and their partners need to be counselled as to the availability of a suitably experienced person if they request a vaginal breech delivery. If they are not informed of this it may create the basis for litigation, should the outcome be poor. Alternatively, they may feel that elective caesarean section is a safer option in circumstances where appropriate staff members are not always available.

Breech deliveries that do occur may, of course, be under unfavourable circumstances, including preterm or advanced labour, where it may not be possible to offer caesarean section. Clearly, complications are more likely to occur, especially if the breech delivery is attended by inexperienced personnel.

Elective caesarean section
Since the Term Breech Trial,¹ elective caesarean section at term has been adopted in many parts of the world as the proven delivery method of choice for breech presentation at term. Although criticisms have been raised about the trial, sub-analysis of groups within the trial has resolved many of them, particularly with regard to the short-term fetal outcome. The 2-year neurodevelopmental follow-up is of some concern, as is the risk to the mother in future pregnancies, while the latter has not yet been addressed.

In a secondary analysis of the Term Breech Trial,²⁶ adverse perinatal outcomes were lowest when prelabour caesarean section was performed and increased with women in labour. Independent risk factors were: labour augmentation, birthweight below 2.8 kg and a long interval between pushing and delivery. The presence of an experienced clinician during vaginal delivery decreased the risk.

A study from Ireland²⁷ of primigravid women showed that, although the chance of having a breech presentation in the next pregnancy was increased, the overall caesarean section rate was not greater than in women who had had a caesarean section for other indications with cephalic presentation in their first pregnancy.

Subsequent occurrence of scar dehiscence and placenta praevia accreta are life-threatening complications and informed consent should include them, even though they may occur in fewer than 1% of cases.

It is wise to document all the risks inherent to either method of delivery and to give women an information sheet outlining these risks, as they may not remember them all. This will help to inform partners or family who may be involved in the decision-making process.

If the ACOG patient information document is chosen, modification of the information to include risks in future pregnancies after caesarean section and risk of pelvic floor damage after vaginal delivery is advisable.¹⁴

	Consent and medicolegal issues

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
As with all forms of consent, a woman needs to understand the nature of the procedure (competence) and have sufficient information to reach a decision to agree or refuse the procedure (knowledge). Lastly, she must be willing to undergo the procedure with the information she has been given (voluntariness). This informed consent must be clearly and carefully documented.

Following the view of Eddy²⁸ (which applies to English law), if the Bolam test²⁹ is applied, we might assume that ECV can be offered in accordance with accepted medical practice. However, if we fail to warn of all possible risks of the procedure and a complication occurs, we could be found to have been negligent.

In general terms, women should know about any serious risk that can occur in more than 1% of cases. Since the Bolitho case,³⁰ however, this may not be sufficient for risk of serious injury or death where it may be left for the courts to decide the matter. In-depth discussion of benefits and risks should help avoid litigation but accepted medical practice on its own is not sufficient.

The decreased risk to the fetus may sway a woman to choose planned caesarean section on this basis alone. However, should a vaginal breech delivery become necessary through unforeseen circumstances, might she not have grounds for litigation? Clearly, this would depend on the specific circumstances and the accuracy of the information that had been provided about risks of preterm labour, timing of the elective caesarean section and facilities available to accommodate the procedure. Should she choose to have a vaginal delivery after the information has been given, optimal conditions for a vaginal breech delivery, in line with the guidelines, and the presence of a person with sufficient experience to perform the delivery will need to be in place. In many clinical settings this would be difficult to achieve and unless this is made clear to the woman before delivery it may lead to litigation if the outcome is not satisfactory.

	What should we do?

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
There is no simple solution. External cephalic version is an attractive option. However, the small risk associated with ECV partly offsets the benefit from elective caesarean section at term compared with planned vaginal breech delivery. Success rates vary and there may be a higher incidence of caesarean section, despite ECV being successful.²³ Successful ECV does reduce the risk of caesarean section and its subsequent sequelae and the additional risks of cord prolapse and unexpected breech delivery.

Elective caesarean section is probably the safest option in terms of short-term risk for the fetus and, from a medicolegal perspective, for the obstetrician. In the long term, neurodevelopmental delay may change this view. Caesarean section has the benefit in primigravid women of sparing the pelvic floor unless they subsequently deliver vaginally. However, the small but real risk of scar dehiscence and placenta praevia accreta in future pregnancies may negate the advantages of short-term risk to the fetus.

There is no doubt that there is a place for planned vaginal breech delivery. However, the criteria that have to be met with regard to selection, monitoring and experience with breech delivery can be difficult to achieve in many clinical settings. If the facilities are adequate and the woman is fully informed of the risks and benefits, this option should be offered. If the requirements cannot be met, it would be reasonable to refer women to a unit that can meet them. Patient information sheets can help with obtaining informed consent and may help to avoid litigation if the outcome is not favourable.

	Conclusion

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

 
From the information we have it seems that we should offer elective caesarean section as the method of choice for delivery of the term breech presentation. This will come at the cost of a higher number of caesarean sections and lost expertise in vaginal breech delivery. It is inevitable that vaginal breech deliveries will still occur. Many of these may be in emergency situations that will be more difficult to manage than planned term deliveries. Training in ECV and vaginal breech delivery should be continued, even in departments and settings where elective caesarean section is the method of choice for breech delivery at term. Breech deliveries will happen!

View larger version (113K): [in this window] [in a new window]   Box 1 A summary of guideline and directive recommendations on breech delivery

	References

TOP Abstract Introduction Established guidelines and... Pros and cons of... Consent and medicolegal issues What should we do? Conclusion References

1. Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR and the Term Breech Trial Collaborative Group. Planned caesarean section versus planned vaginal birth for breech presentation at term; a randomised multicentre trial. Lancet 2000;356:1375–83. doi:10.1016/S0140-6736(00)02840-3[Medline]
2. Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol 2006;194:20–5. doi:10.1016/j.ajog.2005.08.039[Medline]
3. Rietberg CC, Elferink-Stinkens PM, Visser GHA. The effect of the Term Breech Trial on medical intervention behaviour and neonatal outcome in The Netherlands: an analysis of 35 453 term breech infants. BJOG 2005;112:205–9. doi:10.1111/j.1471-0528.2004.00317.x[Medline]
4. Swedish Collaborative Breech Study Group, Perinatal-ARG (Perinatal Working Group Swedish Society of Obstetrics and Gynecology). Term breech delivery in Sweden: mortality relative to fetal presentation and planned mode of delivery. Acta Obstet Gynecol Scand 2005;84:593–601. doi:10.1111/j.0001-6349.2005.00852.x[Medline]
5. Krebs L, Langhoff-Roos J. Elective cesarean delivery for term breech. Obstet Gynecol 2003;101:690–6. doi:10.1016/S0029-7844(02)03073-9[Medline]
6. Goffinet F, Carayol M, Foidart FM, Alexander S, Uzan S, Subtil D, et al. PREMODA Study Group. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194:1002–11. doi:10.1016/j.ajog.2005.10.817[Medline]
7. Hofmeyr GJ, Hannah ME. Planned caesarean section for term breech delivery. Cochrane Database Syst Rev 2000;2:CD000166.[Medline]
8. Smith GC, Pell JP. Dobbie R. Caesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet 2003;362:1179–84. doi:10.1016/S0140-6736(03)14896-9
9. National Collaborating Centre for Women's and Children's Health. Caesarean Section. Clinical Guideline. London: RCOG Press; 2004
10. Royal College of Obstetricians and Gynaecologists. The Management of Breech Presentation. Green-top Guideline No. 20. London: RCOG; 2001
11. Royal College of Obstetricians and Gynaecologists. External Cephalic Version and Reducing the Incidence of Breech Presenation. Green-top Guideline No.20a. London: RCOG; December 2006. [www.rcog.org.uk/resources/Public/pdf/green_top20a_externalcephalica.pdf].
12. Royal College of Obstetricians and Gynaecologists. The Management of Breech Presentation. Green-top Guideline No. 20b. London: RCOG; 2006. [www.rcog.org.uk/resources/Public/pdf/green_top20b_breech.pdf].
13. ACOG Committee Opinion No. 340. Mode of term singleton breech delivery. Obstet Gynecol 2006;108:235–7.[Medline]
14. The American College of Obstetricians and Gynecologists. If Your Baby is Breech. [Pamphlet.] Washington: The American College of Obstetricians and Gynecologists; 2002. [www.acog.org/from_home/websiteBenefits/patient.htm].
15. Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Breech Deliveries at Term. College Statement No. C-Obs 11. Victoria, Australia: RANZCOG; 2005. [www.ranzcog.edu.au/publications/statements/C-obs11.pdf].
16. National Institute for Health and Clinical Excellence. Antenatal Care: Routine Care for the Healthy Pregnant Woman. Clinical Guideline 6. London: NICE; 2003. [www.nice.org.uk/pdf/CG6_ANC_NICEguideline.pdf].
17. Hofmeyr GJ, Kulier R. External cephalic version for breech presentation at term. Cochrane Database Syst Rev 2000;2:CD000083.[Medline]
18. Collaris RJ, Oei SG. External cephalic version: a safe procedure? A systematic review of version-related risks. Acta Obstet Gynecol Scand 2004;83:511–8. doi:10.1111/j.0001-6349.2004.00347.x[Medline]
19. Coltart T, Edmonds DK, al-Mufti R. External cephalic version at term: a survey of consultant obstetric practice in the United Kingdom and Republic of Ireland. BJOG 1997;104:544–7. doi:10.1111/j.1471-0528.1997.tb11529.x
20. Green PM, Walkinshaw S. Management of breech deliveries. The Obstetrician & Gynaecologist 2002;4:87–91.
21. Hofmeyr GJ, Sonnendecker EW. Cardiotocographic changes after external cephalic version. BJOG 1983;90:914–8. doi:10.1111/j.1471-0528.1983.tb06763.x
22. Hofmeyr GJ, Gyte G. Interventions to help external cephalic version for breech presentation at term. Cochrane Database Syst Rev 2004;1:CD000184. doi:10.1002/14651858.CD000184.pub2[Medline]
23. Chan LY, Leung TY, Fok WY, Chan LW, Lau TK. High incidence of obstetric interventions after successful external cephalic version. BJOG 2002;109:627–31. doi:10.1111/j.1471-0528.2002.01514.x[Medline]
24. The World Health Organization Reproductive Health Library. [www.rhlibrary.com].
25. Whyte H, Hannah M, Saigal S, Term Breech Trial Collaborative Group. Outcome of children at 2 years of age in the term breech trial. Am J Obstet Gynecol 2003;189:S57. doi:10.1016/j.ajog.2003.10.007
26. Su M, McLeod L, Ross R, Willan A, Hannah WJ, Hutton E, et al. Term Breech Trial Collaborative Group. Factors associated with adverse perinatal outcome in the Term Breech Trial. Am J Obstet Gynecol 2003;189:740–5. doi:10.1067/S0002-9378(03)00822-6[Medline]
27. Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery in primigravidae who have an elective caesarean section for breech presentation? BJOG 2002;109:624–6. doi:10.1111/j.1471-0528.2002.01365.x[Medline]
28. Eddy A. Consent in obstetrics – a legal view. The Obstetrician & Gynaecologist 2002;4:97–100.

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by van Iddekinge, B. Search for Related Content PubMed Articles by van Iddekinge, B.