Fetal lie and presentation in the late third trimester have traditionally been determined by abdominal palpation using Leopold's manoeuvres or a similar technique. Although accuracy may be increased when this is undertaken by an experienced clinician (Lydon-Rochelle et al, 1993), correct diagnosis of non-cephalic presentation may prove difficult, especially in the context of increased maternal BMI or polyhydramnios. Several studies have found palpation alone to have low sensitivity (Thorp et al, 1991; Nassar et al, 2006). Unfortunately, in approximately 30% of women whose babies remain breech after 36 weeks' gestation, the diagnosis is made for the first time in labour (Walker, 2013; Hemelaar et al, 2015). As ‘high-risk’ women in the UK often receive a late third-trimester ultrasound as part of standard antenatal care, it is a reasonable assumption that many of these women diagnosed in labour with breech presentation would have been ‘low-risk’, and otherwise receiving midwife-led care.
The discovery of an undiagnosed breech in labour is an undesirable outcome, with large population studies reporting it as an independent risk factor for fetal morbidity and mortality (Confidential Enquiry into Stillbirths and Deaths in Infancy and Maternal and Child Health Research Consortium, 2000). Although causation in these cases has not been delineated and many confounding factors exist, advance diagnosis allows for a thorough assessment to identify those women for whom vaginal breech birth may increase the risk of poor neonatal outcome (Royal College of Obstetricians and Gynaecologists (RCOG), 2017a). Equally, when detailed antenatal ultrasound assessment demonstrates an absence of such risk factors, it reassures both the woman and the clinicians involved, and informs unbiased, patient-centred decision-making.
Qualitative studies have shown that women find the discovery of breech presentation at term to be extremely stressful, and that it is associated with feelings of loss of choice and control, anger and even grief. Women have described how evidence-based, personalised counselling helped them to make an informed decision and regain a sense of empowerment (Homer et al, 2015). When breech presentation is found unexpectedly in labour, it may add significant pressure to an already fraught situation and balanced counselling to promote an informed choice may be impossible. Many clinicians are not experienced in vaginal breech birth; their feelings of stress and fear may be unconsciously transferred to women, and this situation may result in avoidable emergency operative intervention. The Term Breech Trial secondary analyses reported a three-fold increase in maternal morbidity where caesarean section was undertaken during established labour, compared with vaginal birth (Su et al, 2007).
Ultrasound is now widely used in maternity settings, with all women in the UK offered dating and anomaly scans and many receiving additional scans to monitor fetal growth and wellbeing. Ultrasound is a non-invasive and well-accepted diagnostic tool that, when used appropriately, complements clinical practice and has the potential to prevent fetal and maternal morbidity and mortality. Following established guidelines (British Medical Ultrasound Society, 2010), its safety record when used for diagnostic purposes with standard obstetric settings is well established. In recent years, steadily increasing demand for ultrasound scans has put pressure on departments (Edwards, 2009).
The qualifications and duration of training required to practice obstetric ultrasonography vary greatly worldwide. In some countries all obstetric scanning is undertaken by physicians, and in others the majority of ultrasound scans are undertaken by midwives (World Health Organization, 1998). Routine maternity ultrasound scans in the UK are usually carried out by radiographers, alongside an increasing number of midwife ultrasonographers who have undertaken focused university courses accredited by the Consortium for the Accreditation of Sonographic Education (CASE). These courses (which may be paid for independently or, where demand exists, by hospital Trusts) last between 6 months and 2 years and require a minimum of 120 hours' supervised scanning (CASE, 2018). By contrast, the majority of bedside presentation scans are undertaken by junior doctors training in obstetrics and gynaecology. Teaching for these trainees is usually carried out apprentice-style at the bedside, and there is no specific competence that must be signed off before obstetric doctors may scan independently for presentation, although all trainees must attend a basic ultrasound course (usually 1 or 2 days' duration) within their first 2 years (RCOG, 2017b). Scanning for fetal presentation is usually an obstetrician's first experience of ultrasound and, when undertaken prudently with an understanding of machine settings and probe orientation, it is a fast and highly accurate procedure.
The reducing cost of ultrasound technology has led to increased availability of portable scan machines. Worldwide there have been a number of safety initiatives using this new technology. Short ultrasound training courses for midwives and nurses have high sensitivity and specificity for detection of conditions that increase high obstetric risk, including non-cephalic presentation (Swanson et al, 2014).
Over the past few years, a number of UK units have offered in-house training enabling midwives to undertake scans for presentation in labour ward (Norfolk and Norwich University Hospitals NHS Foundation Trust, 2016) and community settings (Smith Walker et al, 2010), with some reporting a significant reduction in rate of undiagnosed breech presentation in labour (Ajibade et al, 2015). There is, however, considerable variation in this practice between hospitals and no guidelines or recommendations for suitable training, which may result in substandard teaching or potentially leave practitioners vulnerable. Although no register of practitioners exists, it is thought that only a small number of UK midwives carry out ultrasound scans, and a survey carried out by the Royal College of Midwives (RCM) in 2008 identified only 197 practitioners from the 58 hospitals who responded. These midwives provided ultrasound for a wide variety of indications: 64% were qualified midwife sonographers and 36% had learned using in-house or other short non-accredited courses (Edwards, 2009).
In 2017, the authors began running a 1-day, hands-on introductory ultrasound course for small groups of midwives. This proved popular, although many of the delegates were not supported by their units to continue scanning afterwards. The possibility of gaining a certificate of accreditation solely for diagnosis of fetal presentation has been explored, but a university who would be willing to support this has not yet been found. This survey of midwives and student midwives was therefore undertaken to learn more about UK-wide variation in practice, midwives' opinions on scanning for presentation and the potential demand for a short course.
Methods
A nine-question anonymous online survey was first disseminated by email locally, and then via social media. It was open to all UK non-sonographer midwives (ie midwives who had not completed an accredited postgraduate qualification in sonography) and midwifery students. A total of 870 responses were received over a 3-month period (January to April 2018).
Results
Of the 870 midwives who responded, 38.4% identified themselves as mostly working on the labour ward, with 22.8% in community, 11.6% on wards and 5.5% in a day assessment unit/triage setting. Students made up 7.8% of respondents. All regions of the UK were represented (Figure 1), with south-east England providing the greatest proportion of responses (21.8%) due to a high rate of participation among staff in the local unit.
In response to the question ‘do you currently scan pregnant women for fetal presentation?’, 89.7% of midwives reported that they did not, although several commented that they had in previous roles. A small proportion (7.2%) reported that they scanned women to assess fetal presentation but had never attended a formal course, and 3.0% reported that they had attended a formal course (this includes those who commented that they had undertaken in-house training courses).
When asked in which locations midwives would scan for fetal presentation if able, labour ward (69.3%) and triage/day assessment unit (63.2%) were the most common responses, although many also selected in clinic, on the wards or in the community (Figure 2). Other suggestions included on the midwife-led birthing unit, or before procedures such as induction of labour or caesarean section. Four midwives commented that lack of availability of ultrasound machines would limit this skill in settings such as the community. Four midwives replied that they were completely confident in their abdominal palpation, and would therefore not need to refer patients for scans to confirm. When asked to estimate how often they would scan for fetal presentation if able, 91.8% responded once per month or more frequently, with 40.8% choosing ‘several times per week’ (Figure 3).
Of the 779 midwives and student midwives who did not scan for fetal presentation, 85.2% felt that being able to do so would improve their practice and 93.4% reported that they ‘would like to learn’. When asked ‘would you be interested in attending a structured short course which would result in an accredited certificate of competence in assessing fetal presentation?’, 93.6% responded that they would, which equated to 94.4% of those who did not scan at the time of asking.
Free-text responses
The final question invited further comments and suggestions. Approximately one-quarter of participants responded, with a range of different viewpoints. Some of these comments further highlighted the significant variation in practice across the UK, with several Trusts running in-house training programmes, either for all midwives, or for specific groups (such as midwives working in antenatal clinic, labour ward or day units). The described standards for sign-off also varied, but most often included undertaking observed scans:
‘I had a [5 minute] talk … and [was] observed for 10 scans by a peer.’
‘I have been taught … by our chief antenatal sonographer, it was brief and then I had to be supervised for a few before I could be signed off.’
‘We had to perform 20 under supervision and then were signed off by our fetal medicine consultant.’
Overall, the majority of responses were in support of midwives being taught to scan for fetal presentation. Many of these made reference to the potential improvement in patient safety and experience (and reduction in caesarean section rate) that could be brought about by early diagnosis of breech presentation:
‘Admission [ultrasound] gives the woman a chance to make a choice about possible vaginal birth in a calm way.’
‘Over my many years of practice undiagnosed breeches have resulted in birth trauma, [maybe] … this practice … will help to prevent such things!’
‘With increasing obesity it's even harder to be confident about fetal presentation. It's too late to consider options … when the women present as undiagnosed breech.’
‘It is unacceptable to have an undiagnosed breech in labour when it is so easy to scan for presentation.’
The responses also highlighted how ubiquitous the use of ultrasound was already becoming, with some Trusts requiring presentation scans for all women admitted to the labour ward. One community midwife responded that her Trust used hand-held ultrasound machines to check presentation for all women giving birth outside of a hospital setting. The majority of positive responses made reference to improvement in workflow and patient and staff satisfaction:
‘Obtaining a presentation scan … is the bane of my life. If I could carry out these scans myself it would make things so much easier for the women.’
‘This is an excellent suggestion and a way forward to improve the women's experience in clinic; enhancing senior midwife skills and freeing up medics.’
‘Would save a lot of delayed inductions … which would impact positively on the workload for subsequent shifts.’
‘Would save money in the long term by not wasting so many [scan] slots just for presentation.’
Many community midwives felt similarly:
‘[It] would save the women so much worry about waiting to be squeezed in for a scan in maternity outpatients (which is usually full).’
‘In community it feels like we are always referring women for scans to assess presentation … a lot of these [women] have no mode of transport and it is far.’
Other responses made reference to the use of this skill in maintaining normality:
‘If we can scan and keep a woman normal by confirming a cephalic presentation … this is philosophically enough justification for midwives to utilise [ultrasound].’
‘Women who booked for a [midwife led unit] to have their baby are advised to go to [labour ward] until they have had confirmation—which ultimately can make a difference in their birth choices.’
Similarly, some felt that performing ultrasounds would enhance their professional autonomy:
‘There wouldn't be the need to call doctors … thus reducing stress and anxiety for women and their families.’
‘[This] means the midwife becomes more and more autonomous.’
Several respondents had already investigated the possibility of taking an accredited sonography course, but had given up, either due to either a shortage of available places locally (‘I have been trying to get a place for four years!’ or ‘Have been asking my [hospital] for ages’), or a lack of support and mentorship (‘We [were] granted funding… but the sonographers did not have the capacity or time’). In the RCM survey (Edwards, 2009), midwife sonographers described meeting resistance from other clinicians who felt that scanning was ‘not a midwife's job’. Some of the respondents in this study commented that, given the wide availability of ultrasound machines, it would make sense for presentation scanning to be incorporated into the primary midwifery degree, or as a postgraduate competence, similar to suturing. Interestingly, several responses described having ‘a quick go with the scanner whilst impatiently waiting for the doctor to arrive!’
Unsurprisingly, some respondents were more apprehensive about the idea of midwives scanning for presentation. A general feeling that seemed to underlie some of the less positive comments was that this could contribute to a ‘slippery slope’ and a greater use of technology for technology's sake (‘midwives may use [ultrasound] where they wouldn't have before when they were not trained to’). The most common concern (n=30; 3.4%), was that use of ultrasound to check presentation could undermine clinical skills:
‘Reliance on technology takes away from a midwife's palpation skills … which tells us so much more than just position.’
‘My concern would be … deskilling midwives and losing another part of the art of midwifery.’
‘Staff will lose the skill of abdominal palpation … this is similar to the management of vaginal breech delivery where we no longer have staff with the skills to support women who wish to achieve this.’
However, one respondent felt that the use of ultrasound could improve clinical skills:
‘Linking presentation [findings] noted on scan with corresponding manual palpation [could] ensure that [skills are] retained and developed.’
Another frequently mentioned concern was that the use of ultrasound could contribute to increased medicalisation of the birthing experience:
‘This could potentially … over medicalise our role and women's' birthing experiences which are medicalised enough.’
‘I believe … we are medicalising normality by intending to do this in every woman.’
These views contradicted those of the midwives who felt that the use of ultrasound in low-risk settings could avoid unnecessary obstetric referrals; however, they are consistent with those expressed by midwives in a qualitative study about ultrasound undertaken in Australia (Edvarsson et al, 2015). One study undertaken in the US found that having more than four ultrasound scans was an independent risk factor for caesarean section in low-risk women (Chiossi et al, 2016). However, this argument is less valid when referring solely to scanning for presentation after the finding of uncertain presentation on palpation, as an ultrasound scan would be required regardless of practitioner.
Many midwives commented that ultrasound should be used only where clinical examination findings were unclear (‘should not be completed on all women as an ‘easy’ option’) and only after 36 weeks' gestation; indeed, there is generally no merit in assessing presentation before this except in cases of preterm labour or rupture of membranes. Four respondents were concerned about the effect of ultrasound on the fetus (‘I am yet to see evidence that proves that ultrasound does not cause fetal harm’). Finally, three respondents felt concerned that this would increase workload and responsibility for midwives, especially with no commensurate increase in salary:
‘We don't need any other strings to our bow … we may as well be paid as doctors … at present we are not … our role is continually expanding and we are supposed to just suck it up. It's not that this wouldn't be useful … but when we get it wrong and we have been trained in the use of [ultrasound] the midwife will be blamed yet again.’
‘Midwives have a lot of responsibility as it is … what if you scanned the woman and potentially missed something that was wrong?’
Several comments were made about the proposal of a short (1- or 2-day) course to learn how to scan for fetal presentation, with the majority of midwives viewing it as a positive step (‘there is definitely a gap in the market … a short course would be much more appealing’). In keeping with the findings above, where 85.2% felt that learning to scan would improve [their] practice and 93.4% ‘would like to learn’, some of the respondents indicated that they would find attending such a course interesting, with one midwife describing how she ‘really enjoy[s] doing… scans’. Suggestions included setting a national qualification or standard recognised by all Trusts, to ensure that teaching was consistent and adequate. Two midwives raised concerns about the potential financial cost of such a course.
Conclusions
This large survey of UK midwives and students demonstrated significant variation in practice across the country, with 10.3% of respondents carrying out presentation scans in their practice. Maternity care in the UK is evolving, and the use of ultrasound is becoming more widespread. Many hospitals now require routine presentation scans before all inductions, increasing the workload for busy obstetric staff and potentially leading to delays. Ultrasound assessment of fetal presentation is a low-complexity skill that can be safely taught in a short period of time and, with the increasing availability and reducing cost of portable ultrasound, this can be done in a variety of settings. Where used as an adjunct to traditional midwifery skills and techniques, it may improve patient safety and satisfaction as well as workflow. As Andrews (2002) states:
‘This is not a zero-sum gain, where midwives need to make a choice between traditional midwifery skills and modern techniques. It is about successfully using the best opportunities available for midwifery care—old and new.’
The role of the midwife has expanded and evolved significantly over recent years to meet the changing demands of the population. Practical skills such as suturing and cannulation have become standard practice, and various specialist midwife roles have been introduced. In line with this, fetal presentation scanning could be incorporated into the scope of practice of a select group of midwives. The majority of respondents were interested, and so the main factor prohibiting development of this skill could be a lack of a consistent and clear guideline or competency assessment. Although there are midwife sonography courses available, these are expensive, time-consuming and require significant local support and supervision. Training for those who only wish to carry out presentation scans is (where available) usually done in-house, where the standard and content of teaching will vary, and any agreed competence may not be transferable between Trusts. Introduction of clear national guidelines for midwives wishing to learn to scan for presentation, or the development of a short course that would result in a nationally accredited certificate of competence would appear to be a sensible next step.