Detection of breech presentation: Abdominal palpation and hand-held scanning by midwives
The NHS Litigation Authority's ‘sign up to safety’ campaign aims to prevent undiagnosed breech birth and possible poor birth outcomes. An audit was completed following the introduction of hand-held scanning ultrasound examination.
The hand-held ultrasound was used by midwives for all women in labour and before induction of labour to confirm presentation.
A criterion-based retrospective audit, conducted over 6 months in 2016, with a sample of 2737 women.
The audit demonstrated that 22 breech presentations were detected when using the hand-held ultrasound before induction of labour or in labour. The audit standard of 100% of women receiving an ultrasound scan was not met, and potential reasons are explored.
The results support the use of hand-held ultrasound, as it did detect breech presentation before induction of labour or spontaneous labour and birth. Further work includes the audit of the reasons that hand-held ultrasound scanning was not used, to ensure that a targeted action plan can be created. Future research into midwifery values, cultural attitudes and the effectiveness of abdominal palpation is also needed, to develop the knowledge base on which scanning can be framed.
The ‘sign up to safety’ initiative (NHS Litigation Authority, 2016) was introduced in 2016 to support improvements in care, and to reduce the number of stillbirths, as part of the Royal College of Obstetricians and Gynaecologists (RCOG) ‘Each Baby Counts’ programme (RCOG, 2016).
The RCOG green top guideline (Impey et al, 2017) cites the risk of perinatal mortality as 0.5/1000 for an elective breech caesarean section at 39 weeks gestation, 2/1000 for a planned vaginal breech birth, and 1/1000 for a planned cephalic birth. A planned vaginal breech birth therefore has twice the risk of a planned cephalic birth and one-and-a-half times the risk of the caesarean section. However, the guideline also states that planned vaginal breech birth is nearly as safe as the cephalic birth with skilled birth attendants. It also states that there is an increased risk of maternal complications with emergency caesarean section as well as the long-term reproductive complications. The risks associated with breech diagnosed late in pregnancy or during labour include the highest rates of emergency caesarean section (64%), cord prolapse (1.4%) and the poorest infant outcomes (Gallagher et al, 2009). Planning the breech birth appears to be key, and the use of hand-held ultrasound scanning in midwifery could also support unbiased counselling.
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