My mind starts to wander to the days spent training and the basic midwifery skills taught to the midwives in the health centres. The two health centres I taught at were in remote ‘kebeles’ (villages) in the Dilla Zuria region of Ethiopia.
During one meeting at a health centre, the health officer and midwives had asked for an ultrasound machine so they could better identify the gestation of pregnancies as most of the mothers do not know their last menstrual period date. To me, this seemed a strange request given that the region, as with much of Ethiopia, does not have the infrastructure to run such machines, neither do they have the training available in these remote areas to learn the skills for ultrasonography.
Instead, we taught them about the importance of basic midwifery skills, such as abdominal palpation and measuring symphysis fundal height as a guide to estimating gestational age and measuring the growth of the unborn infant. We stressed how ultrasound alone, particularly when used on very malnourished mothers, would not necessarily be an accurate way to estimate gestation.
Using our core midwifery skills, such as palpation, is an accepted and adequate way to assess growth, particularly in low-resourced regions. Even in these remote settings, where technology has not been efficiently established, core midwifery skills are being lost and the mindset is changing to ‘machines are best’.
This led me to think about current changes in guidelines in many units across the UK. It is becoming more common for mothers to be routinely offered an ultrasound scan at 36-weeks' gestation to screen for and identify those babies with intrauterine growth restriction. The Royal College of Obstetricians and Gynaecologists supports the use of symphysis fundal height (SFH) measurement in the detection of small-for-gestation-age babies, suggesting it improves the prediction of these small infants (Robson et al, 2014). And yet, I have learnt of many NHS Trusts who are now recommending an ultrasound scan for growth in the third trimester of pregnancy with no SFH measurement during the antenatal period.
Furthermore, if an SFH measurement is taken and it shows reduced growth, no scan will be performed until the third-trimester scan. This goes against everything I have been taught as a midwife. Myself, along with many other midwives I have spoken with, do not feel comfortable with not exercising core midwifery skills which may help detect a small infant. While I understand that ultrasound may be more accurate, this should not take over from using basic skills. Surely, it should be used in conjunction with these skills?
The rationale for this change in practice is for better identification of the pathologically small fetus to reduce the incidence of stillbirth. However, many stillbirths happen pre-30-weeks' gestation and, therefore, should SFH measurements not still be used and acted upon to detect small for gestational age at the earliest opportunity? Sadly, there is a cost associated with this and the acuity of performing this number of scans cannot be absorbed in most units across the UK with the ever-increasing birth rate. However, there needs to be further strategies to support this to combine both our basic core midwifery skills with the technology which would surely have better outcomes for the reduction in stillbirth.
SFH has long been debated in research as to the accuracy of the measurement (Peter et al, 2015; Papageorghiou, 2016) and it is well-known that it is most accurate when performed by the same practitioner at each antenatal visit, supporting continuity of carer. However, ultrasound scans can also be subject to user error and some margin of unreliability with detection of estimated fetal weight (Tell et al, 2019). Added to which, ultrasound is costly in an already under-financed NHS and therefore its use should be reserved for those mothers at greater risk of pathologically small infants rather than using it as a routine screening tool for all mothers, including those with a low chance of complications.
Technology is becoming more and more the ‘norm’ in midwifery practice and, as a result, I fear we, as a profession, are becoming more deskilled as midwifery practitioners, relying more on technology because that is what current guidelines and protocols are recommending us to do.
Even with all of this new technology, the stillbirth rate is not reducing significantly. Therefore, it is time to take a step back and revaluate what the evidence is telling us about improving outcomes. We need to use our core skills (including abdominal palpation and SFH) to care for mothers throughout their antenatal, intrapartum and postnatal journey.