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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
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