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Rapid Responses: Rapid Responses published:
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inconclusive
- penny a price (6 August 2006)
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What does this study add?
- Elizabeth Collins (7 August 2006)
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Handheld Dopplers Can Rule Out Breech
- Veronica G. (Ronnie) Falcao (9 August 2006)
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RCM response on clinical examination technique
- Sue Macdonald (10 August 2006)
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Diagnosing Breech at Term
- Neil F. Moran (15 September 2006)
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Use of ECV should be a maternity service quality indicator
- Stephanie Y Kuku, Susan Bewley (18 September 2006)
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Kappa calculation
- Soe-nyunt Aung, DR SSIVARAJAN (30 September 2006)
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Clinical examination for non-cephalic presentation: training and experience can make a difference
- Natasha Nassar, Christine L. Roberts, Carolyn A. Cameron, Emily C. Olive (25 October 2006)
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Doctors do not dichotomise
- Marjolein Kok, Joris A.M. van der Post, Ben Willem Mol (2 November 2006)
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Confidence Intervals in the Table are Wrong
- Thomas B. Newman (24 August 2007)
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penny a price, nurse practitioner and antenatal teacher primary care
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Ladies, I feel that insufficient data is given to justify the conclusion. A busy antenatal clinic with different grades of staff is probably not the best place to assess sensitivity and specificity of clinical examination with regard to foetal presentation. May I suggest a community clinic with experienced midwives who know their patients may have given a different result. This research seems to imply that all women need u/s. This data should not be applied routinely in the uk as only women with some abnormalities routinely attend hospital antenatal clinics. It does however raise training issues in clinical examination for australian obstetric staff. yours sincerely penny price Competing interests: None declared |
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Elizabeth Collins, Student Midwife North Hampshire Hospital
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This study adds nothing to evidence on which to base antenatal care, other than the Austrailian practitioners involved need to improve their palpation skills. It is not relevant in the UK where the majority of abdominal palpations are carried out by highly trained and experienced community midwives. In addition, I would question the merit of adding yet another costly, 'routine' scan to those already offered, which have significant limitations in themselves, further medicalising otherwise normal pregnancies. Competing interests: None declared |
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Veronica G. (Ronnie) Falcao, Midwife Mountain View, CA, USA 94041
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Of course, a handheld Doppler is a form of ultrasound. It uses the Doppler shift effect to detect motion and then translates that motion into sound. Different kinds of movement in the uterus typically are represented by different sounds produced by the Doppler: baby movement, placental souffle, maternal pulsations in the uterine arteries, fetal pulsations in the umbilical cord or large vessels, or the rhythmic contractions of the fetal heart. Just a little bit of experimentation can quickly build skill in detecting the difference between the sounds of the fetal heart and the other sounds so that an attentive practitioner can locate the fetal heart fairly quickly. The difference in heart location for a breech is very different from that of a vertex baby. I consider it responsible practice to use this skill at every prenatal appointment after 32 weeks to confirm a vertex presentation, especially if palpation isn't convincing. It is also helpful to be attentive to the issue of fetal rotational orientation (anterior / transverse / posterior) so that a woman carrying a baby in a posterior position can also be attentive to this issue. This test can be done with just a few extra seconds of time for a skilled practitioner. For those who do not have access to a Doppler, listening to the fetal heart directly with the ear is also very sensitive to the location of the fetal heart. Competing interests: None declared |
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Sue Macdonald, RCM Education and Resarch Manager Royal College of Midwives, London W1G 9NH
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The BMJ Online (4/8/08) reports on a study of clinical examination technique (abdominal palpation) which concluded that a third of breech pregnancies are missed using that method (Nassar et al 2006). It is tempting to use this research to advocate more reliance on technological solutions rather than clinical examination. However the Royal College of Midwives would recommend caution before embarking on that course. This study was carried out in Australia, where antenatal care practices are different to the UK. In the UK, midwives provide the majority of maternity care – and midwives are highly trained in abdominal palpation – defining the position of the fetus. The research raises important issues around good clinical skills in assessing the fetal position during pregnancy. It is possible that some babies in breech position are ‘missed’ – which reinforces the need to use this research to inform current education and training of midwives and obstetricians. Relying further on increasing technology such as ultrasound scans may increase the risk (that the researchers themselves identify) of reducing practitioners’ clinical skills. Indeed. the researcher suggested that some clinicians in the study may have not been as vigilant as they could have been because they knew that their findings were going to be checked with an ultrasound scan. Finally, the RCM would agree that though ultrasound scans would identify the fetal position effectively – the issues of cost, resources; and the long term effect on mother and baby have not been fully evaluated. Scans are already used to provide a ‘second opinion’ when there is difficulty in palpation – perhaps for overweight women. However, it is crucial that women are provided with unbiased information and with the choice about whether they have an additional scan or not. The RCM would recommend that colleagues read this research, and instead of following the technology path, follow the recommendation for developing practitioners’ accuracy and diligence of carrying out clinical examination, using audit and feedback. Sue Macdonald
Competing interests: None declared |
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Neil F. Moran, Head, Department of Obstetrics and Gynaecology Mahatma Gandhi Memorial Hospital, Mount Edgecombe, KwaZulu-Natal, 4300, South Africa
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Many thanks to Nassar and colleagues for confirming what I experience in a busy state hospital in South Africa: that a significant proportion of breech presentations or transverse lies are missed on routine palpation at antenatal clinic at term. These malpresentations or abnormal lies are missed both by doctors and midwives. It is understandable,(though still not acceptable), given the heavy patient load that the care providers at the clinic have to get through. The other important time for diagnosis of breech is when the woman goes into labour and presents to the labour ward. Not infrequently, breeches that have been missed at the last antenatal visit are again missed on initial palpation in labour, making a poor outcome for the baby more likely. The main reason for these mistakes is obvious to me. It is not due to a lack of skill on the part of the care providers. It is due to a lack of focus on the need to exclude a breech or abnormal lie at the crucial times: the 36 week antenatal visit and the first palpation in labour. If asked specifically to exclude a breech presentation, the care provider can do this confidently and correctly in all but a few cases. The problem is forgetting to think about it. Doing routine scans at 36 weeks is therefore not apropriate. What is required is regular inservice education emphasising the need to look out for breech presentations at 36 weeks and on admission in labour, and the reasons why it is important to do so.In cases where the care provider suspects a breech or is unsure, then an ultrasound scan is indicated to confirm the presentation. Competing interests: None declared |
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Stephanie Y Kuku, Senior SHO St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH, Susan Bewley
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EDITOR – The recent study by Nasser et al (1) reported in the BMJ highlights the long known clinical failure to diagnose all breech presentations at term, especially in the obese. However, there is little point in improving clinical detection unless it makes a difference to mothers or babies. The point of detecting a breech is to offer external cephalic version (ECV) and to discuss mode of delivery if persistent. If ECV is successful, this avoids the hazards both of vaginal breech delivery (2) and caesarean section (CS) (3). Disturbingly, the National Sentinel Caesarean Section Audit (4) showed that only 33% of women in the UK having caesarean section for breech had been offered an ECV, and less than half of these had undergone the procedure. A recent systematic review (5) confirmed the high success rates (>60% in some studies) and the extremely low risks of ECV. Set against the well-documented risks of caesarean section, those obstetricians and gynaecologists who do not offer ECV, offer it timidly, or find many so- called ‘exclusion criteria’ are failing their patients. Along with the principles of ‘non-maleficence’ and ‘informed consent’, the NHS should be providing excellent evidence-based care with minimum risks to patients. Those maternity units that are not offering and carrying out ECVs, as well as training juniors to be proficient, must be considered sub-standard. Women (and their GPs) need to know that urgent referrals at term for ECV can be made and that elective caesarean section should not be the first resort. External quality indicators of maternity services must include not only % of term breechs diagnosed, but also the % offered ECV and % turning success rates. Stephanie Kuku, Senior SHO Susan Bewley, Consultant Obstetrician Womens’ Health Directorate, St Thomas’ Hospital, Lambeth Palace Road, London SE1 7EH Contact: Stephanie.Kuku@gstt.nhs.uk (1) Nasser N, Roberts CL, Cameron CA, Olive. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ 2006 333: 578 - 580 (2) Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR, for 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: 1375-1383 (3) Hofmeyr GJ. External cephalic version facilitation for breech presentation at term. Cochrane Database Syst Rev 2000;2:CD000184. (4) Thomas J, Paranjothy S. National Sentinal Caesarean Section Audit Report. RCOG Clinical Effectiveness Support Unit. RCOG press, London 2001:43 (5) Nasser et al. Systematic review of adverse outcomes of external cephalic version and persisting breech presentation at term. Paed. Perinat Epidem 2006 March (2); 163-71 Competing interests: None declared |
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Soe-nyunt Aung, SHO in Obst &GYN Basildon university Hospital SS 165NL, DR SSIVARAJAN
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In this study whether using the priciple of Kappa calculation could have a made a difference in view of the variabillity of accuracy rate based upon the level of experience of the clinician. One can calculate chance-corrected agreement when more than two raters are involved. We would appreciate authors view on this issue. Competing interests: None declared |
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Natasha Nassar, Postdoctoral research fellow Telethon Institute for Child Health Research, Centre for Child Health Research, The University of We, Christine L. Roberts, Carolyn A. Cameron, Emily C. Olive
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Author’s reply
Editor- We appreciate the interest and responses to our paper.1-7 One issue that was raised consistently by correspondents was the training and experience of the antenatal care providers. Antenatal care in Australia is provided by a variety of carers with various years of experience. We collected information on care-providers for our study but this was not presented in the published paper8 because the Editor was concerned the differences in sensitivity and specificity (presented in the table below) were confounded by case mix. While we cannot rule out the possibility of bias as some practitioners may be more likely to see high-risk patients or those women more difficult to assess, our results highlight wide variation amongst care providers and associated years of experience. Sensitivities of over 90% by some clinician groups, suggests there is scope for improvement in the clinical diagnosis of breech presentation through training and quality assurance. Furthermore, as Falcao pointed out,3 localisation of the fetal heart may be an additional means of diagnosing breech presentation. We do not know whether care providers in our study were using localisation of fetal heart (by Pinnards stethoscope or hand-held Doppler) in their assessment of fetal presentation. To our knowledge, this has not previously been evaluated and may be important to assess in future studies. Finally, we would like to reiterate that we do not advocate the routine use of ultrasound for the detection of fetal presentation in late pregnancy and do not suggest this in our article. Characteristic Non-cephalic, correctly diagnosed Cephalic, correctly diagnosed No of cases Sensitivity (95% CI) No of cases Specificity (95% CI) Overall 91/130 70 (62 to 78) 1429/1503 95 (94 to 96) Care-provider and years of experience: Midwife (<5years) 11/12 92 (62 to 100) 73/80 91 (83 to 96) Midwife (5-9years) 9/13 69 (39 to 91) 145/149 97 (93 to 99) Midwife (10+years) 14/16 88 (62 to 98) 175/184 95 (91 to 98) Resident (<5years) 7/12 58 (28 to 85) 219/231 95 (91 to 97) Registrar (<5years) 23/39 59 (42 to 74) 471/496 95 (93 to 97) Registrar (5+years) 14/15 93 (68 to 100) 101/109 93 (86 to 97) Obstetrician 13/23 57 (34 to 77) 237/247 96 (93 to 98) N Nassar, research fellow
CL Roberts, research director CA Cameron, research associate EC Olive, obstetric fellow Centre for Perinatal Health Services Research, School of Public Health, University of Sydney NSW 2006, Australia Competing interests: None declared. References 1. Price PA. Inconclusive. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (6 August 2006) 2. Collins E. What does this study add? http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (7 August 2006) 3. Falcao VG. Handlehd Dopplers Can Rule Out Breech. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (9 August 2006) 4. Macdonald S. RCM response on clinical examination technique. BMJ 2006;333:705 (30 September 2006) 5. Moran NF. Diagnosing Breech at Term. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (15 September 2006) 6. Kuku SY, Bewley S. Use of ECV should be a maternity service quality indicator. BMJ 2006;333:705-706 (30 September 2006) 7. Aung S. Kappa Calculation. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (30 September 2006) 8. Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ 2006;333:578-580 (16 September 2006) Competing interests: None declared |
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Marjolein Kok, M.D. Academic Medical Centre, Amsterdam 1105 AZ, Joris A.M. van der Post, Ben Willem Mol
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Editor- With interest we read the recent study by Nassar et. al. reporting on diagnostic accuracy of clinical examination for the detection of non-cephalic presentation. The authors report that sensitivity and specificity of the clinical examination are limited. We would like to comment on the design of the study. Clinicians participating in this study were forced to decide between two diagnostic categories, i.e. cephalic presentation or non-cephalic presentation. This same design has been used in earlier studies on the subject(1-3). In clinical practice nevertheless, this dichotomisation is not used, since there is always the option that the clinician remains uncertain about the fetal presentation. In this manner the clinician always has the possibility to order an ultrasound in case of doubt after the clinical examination, whereas in case of certainty about cephalic presentation the ultrasound can be withholded. If in the present study the option doubt about fetal presentation would have been available for the clinicians, the test accuracy of clinical examination would probably have been higher than reported. The subsequent strategy would then have been that ultrasound is only indicated in case there is doubt about cephalic presentation of the fetus. (1) Lydon-Rochelle M, Albers L, Gorwoda J, Craig E, Qualls C. Accuracy of Leopold maneuvers in screening for malpresentation: a prospective study. Birth 1993; 20(3):132-135. (2) Thorp JM, Jr., Jenkins T, Watson W. Utility of Leopold maneuvers in screening for malpresentation. Obstet Gynecol 1991; 78(3 Pt 1):394-396. (3) Watson WJ, Welter S, Day D. Antepartum identification of breech presentation. J Reprod Med 2004; 49(4):294-296. Competing interests: None declared |
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Thomas B. Newman, Professor of Epidemiology and Biostatistics and Pediatrics University of California, San Francisco, California 94143-0560
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There are some errors in the Table of the article by Nassar et al, on diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy. A clue that most of the confidence intervals for sensitivity are wrong is that they are narrower for almost all of the subgroups than for the whole group of 130 noncephalic presentations, even though the sample sizes of the subgroups are smaller. In addition, the confidence interval for the sensitivity in Asian patients (67% to 72%) does not include the point estimate (46%). Similarly, the confidence intervals for specificity all have width of 2%, even though the number of subjects per group varies more than 10-fold (from 115 to 1158). The authors of this otherwise fine study may wish to publish a correction to set the record straight. Competing interests: None declared |
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