Detection and clinical management of intrauterine growth restriction in a low-risk population:...

Detection and clinical management of intrauterine growth restriction in

a low-risk population: experience and attitudes of midwives and

obstetriciansDr Dale Spence

Ms Joanne GluckProf Fiona Alderdice

Prof Jim DornanQueen’s University Belfast

Intrauterine growth restriction (IUGR)?

Background

• Significant complication of pregnancy globally• Significant implications for maternal, infant,

child and later health• Most cases occur in pregnancies with no risk

factors• Single most important component of stillbirth

statistics• Routine growth screening strategies failing

Recent reports

• Under-diagnosed complication of pregnancy

• Inadequate monitoring of growth

• Failure to recognise IUGR

• Failure to act on IUGR

Study aims

• Describe current practice

• Explore experience and preferred clinical practice

• Identify potential barriers, training or practice needs

Methodology

• Mixed methods approach

• Ethical approval and Health & Social Care Trust indemnification

• Study population

Setting

Phase 1: • Semi-structured interviews• a regional maternity unit in Northern Ireland

Phase 2:• Survey• All maternity units in Northern Ireland

Sample selection

• Midwives:providing antenatal care

• Obstetricians:working in obstetrics &

gynaecology

Contact made through Heads of Midwifery and Clinical Directors

Phase 1

• Semi-structured face-to-face interviews

• Transcribed verbatim

• Content analysis

Results: response data

Phase 1:11 midwives5 obstetricians

Working in large regional maternity unit in NI

Results (part 1)

Themes emerging for detection of IUGR include:

• confidence and accuracy in detection of IUGR

• consistency and continuity

• skills/training

Results (part 1)

Themes emerging for management of IUGR include

• referral

• further assessment and decision-making

• suggested strategies for detection and

management of IUGR

Sample selection

Phase 2:767 midwives208 obstetricians

Providing antenatal care in all maternity units (n= 10) throughout Northern Ireland (NI)

Survey

Main components:• Demographics• Current practice• Experience• Preferred clinical practice• Identify potential barriers, training or practice

needs

Results: response data

Phase 2:198 midwives66 obstetricians

Working in maternity units in each of the 5 Health and Social Care Trusts in NI

Results

Midwives n (%); * mean (SD)

Gender female 198 (100)Age* 44.8 (7.7)Experience in midwifery (years) * 19.3 (8.9)Current pay scale band 6 119 (60.1)Currently working in antenatal setting 157 (82.2)Clinical experience antenatal (years)* 11.6 (8.5)Clinical experience of ultrasound (years)* 6.8 (7.1)Qualification in ultrasound 62 (31.3)

Results

Obstetriciansn (%); * mean (SD)

Gender female 35 (53%)Age* 39.4 (11.0)Experience in obstetrics (years) * 13.5 (11.9)Consultant obstetrician 29 (43.9)Currently working in antenatal setting 63 (95.5)Clinical experience antenatal (years)* 12.7 (11.9)Clinical experience of ultrasound (years)* 10.9 (10.8)Qualification in ultrasound 20 (30.3)

Look after low-risk pregnancies

0

20

40

60

80

Always Very freq Sometimes Rarely

MW

Obst

Look after high-risk pregnancies

05

101520253035

MW

Obst

Setting in which technique taught to assess fetal growth & wellbeing

0102030405060

MWObst

‘Very important’ factors in assessment of fetal growth & wellbeing

Midwives1. Continuity of care2. Fetal movement3. Lifestyle (smoking)4. Liquor5. Maternal history6. Multiple pregnancy7. Fundal height palpation8. Placenta

Obstetricians1. Continuity of care2. Fetal movement3. Lifestyle (smoking)4. Liquor5. Maternal history6. Multiple pregnancy7. Estimated fetal weight8. Doppler

‘Always’ use to assess fetal growth & wellbeing

020406080

100

Abd Palp Tape USS CGC

MWObst

‘Strongly agree’ sensitive in determining fetal growth & wellbeing

01020304050

Abd Palp USS CGC

MWObst

‘Very confident’ in use of tools to detect IUGR

0

10

20

30

40

50

Abd Palp Tape USS CGC

MWObst

Consider experience ‘very important’ for successful implementation

020406080

100

Abd Palp Tape USS CGC

MWObst

Consider training ‘very important’ for successful implementation

020406080

100

Abd Palp Tape USS CGC

MWObst

Consider guidelines ‘very important’ for successful implementation

0

20

40

60

80

Abd Palp Tape USS CGC

MW

Obst

Confidence in clinical skills to detect IUGR

0102030405060

Very Confident Moderately Some what Not at all

MW

Obst

Confidence in clinical skills to manage IUGR antenatally

01020304050

MWObst

Further training in the detection of IUGR ‘very useful’

0

20

40

60

Abd Palp Tape USS CGC

MWObst

Conclusions

• Variance in tools used to assess fetal growth and wellbeing

• Variance in agreement how sensitive these tools are in detecting IUGR

• Variance in level of confidence in using these tools

• Training considered very important in terms of successful implementation of these tools

Conclusions (2)

• Less than 60% confident in their clinical skills to detect and manage IUGR

• Room for improvement with regards identification and management of babies at risk

• Evidence suggests many consequences of IUGR could be prevented by improved detection, appropriate surveillance and timely intervention

Challenge to identify those babies at risk

Implications for practice

• findings challenge current practice amongst midwives and obstetricians in the detection and management of IUGR

• highlights the importance of the multidisciplinary team in ensuring optimal care for these women and their babies

d.spence@qub.ac.uk

Aware of guidelines on management of IUGR in unit?

0

20

40

60

80

Yes No

MW

Obst

Guidelines rigorously adhered to

0

20

40

60

80

Always Very Freq Sometimes

MWObst

Search for IUGR babies

Challenge to identify those babies at risk

d.spence@qub.ac.uk