Sono-breech

Diagnostic accuracy of handheld ultrasound at 36-weeks of gestation to determine fetal presentation.

We want to find out if midwives can accurately identify a baby’s position before it is born using a small handheld ultrasound device. At a late pregnancy check, midwives feel a woman’s abdomen using their hands (abdominal palpation) for baby’s position but miss up to 40% of breech (bottom down) babies. Being specific about the baby’s position is particularly important so that plans for safe delivery can be made. Breech babies are at higher risk of injury during normal birth than cephalic (head down) babies. Emergency births in undiagnosed breech can be associated with poor outcome for baby and mother, so determining which way the baby is positioned is important to provide women with the information they need to make an informed choice about their care.

An alternative to abdominal palpation to determine the baby’s position is by using ultrasound scanning which can more accurately detect whether a baby is breech or cephalic. Conventional ultrasound scans are usually undertaken in a hospital by specialist sonographers, require a large room and air conditioning. Point of Care ultrasound (PoCUS) with handheld devices have become popular in some areas of diagnostic imaging. This new technology is small, portable, and quick to use in any setting. If baby is confirmed to be breech, women have the option of having a breech baby turned to head-down and this reduces emergency Caesareans. Some women may also choose a planned Caesarean delivery or vaginal breech birth.

To determine if PoCUS should be introduced as everyday practice in the NHS, we need to be sure that it is accurate, cost effective, and acceptable to women and midwives. To do this we will compare PoCUS to the ‘gold standard’ conventional ultrasound. There is always a risk of unintended consequences of introducing a new technology, for example over intervention or unnecessary checks and we will be looking out for all of these. Furthermore, midwives report a desire to learn to scan for a baby’s position in order to improve their practice and professional development. For this study, midwives will be provided with the PoCUS devices and will undergo special training on how to use them, in addition to palpating a woman’s abdomen at the routine 36-week antenatal appointment. These women will be offered a further conventional ultrasound scan with a sonographer so that we can compare the findings with those from the handheld ultrasound scan. The acceptability of handheld ultrasound will be explored through recorded interviews with selected women and midwives.

We will invite around 10,000 women of different backgrounds from our collaborating maternity units which are geographically diverse and include the North of England, the Midlands, South Coast, London and the East of England to take part in this study. The team running the study include experts in trial design and statistics (Centre for Trials Research, Cardiff University), obstetricians, midwives, sonographers, neonatologists and health economists from a number of institutions with direct patient involvement.