detection and clinical management of intrauterine growth restriction in a low-risk population:...
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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
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Intrauterine growth restriction (IUGR)?
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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
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Recent reports
• Under-diagnosed complication of pregnancy
• Inadequate monitoring of growth
• Failure to recognise IUGR
• Failure to act on IUGR
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Study aims
• Describe current practice
• Explore experience and preferred clinical practice
• Identify potential barriers, training or practice needs
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Methodology
• Mixed methods approach
• Ethical approval and Health & Social Care Trust indemnification
• Study population
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Setting
Phase 1: • Semi-structured interviews• a regional maternity unit in Northern Ireland
Phase 2:• Survey• All maternity units in Northern Ireland
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Sample selection
• Midwives:providing antenatal care
• Obstetricians:working in obstetrics &
gynaecology
Contact made through Heads of Midwifery and Clinical Directors
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Phase 1
• Semi-structured face-to-face interviews
• Transcribed verbatim
• Content analysis
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Results: response data
Phase 1:11 midwives5 obstetricians
Working in large regional maternity unit in NI
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Results (part 1)
Themes emerging for detection of IUGR include:
• confidence and accuracy in detection of IUGR
• consistency and continuity
• skills/training
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Results (part 1)
Themes emerging for management of IUGR include
• referral
• further assessment and decision-making
• suggested strategies for detection and
management of IUGR
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Sample selection
Phase 2:767 midwives208 obstetricians
Providing antenatal care in all maternity units (n= 10) throughout Northern Ireland (NI)
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Survey
Main components:• Demographics• Current practice• Experience• Preferred clinical practice• Identify potential barriers, training or practice
needs
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Results: response data
Phase 2:198 midwives66 obstetricians
Working in maternity units in each of the 5 Health and Social Care Trusts in NI
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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)
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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)
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Look after low-risk pregnancies
0
20
40
60
80
Always Very freq Sometimes Rarely
MW
Obst
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Look after high-risk pregnancies
05
101520253035
MW
Obst
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Setting in which technique taught to assess fetal growth & wellbeing
0102030405060
MWObst
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‘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
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‘Always’ use to assess fetal growth & wellbeing
020406080
100
Abd Palp Tape USS CGC
MWObst
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‘Strongly agree’ sensitive in determining fetal growth & wellbeing
01020304050
Abd Palp USS CGC
MWObst
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‘Very confident’ in use of tools to detect IUGR
0
10
20
30
40
50
Abd Palp Tape USS CGC
MWObst
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Consider experience ‘very important’ for successful implementation
020406080
100
Abd Palp Tape USS CGC
MWObst
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Consider training ‘very important’ for successful implementation
020406080
100
Abd Palp Tape USS CGC
MWObst
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Consider guidelines ‘very important’ for successful implementation
0
20
40
60
80
Abd Palp Tape USS CGC
MW
Obst
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Confidence in clinical skills to detect IUGR
0102030405060
Very Confident Moderately Some what Not at all
MW
Obst
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Confidence in clinical skills to manage IUGR antenatally
01020304050
MWObst
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Further training in the detection of IUGR ‘very useful’
0
20
40
60
Abd Palp Tape USS CGC
MWObst
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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
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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
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Challenge to identify those babies at risk
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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
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Aware of guidelines on management of IUGR in unit?
0
20
40
60
80
Yes No
MW
Obst
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Guidelines rigorously adhered to
0
20
40
60
80
Always Very Freq Sometimes
MWObst
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Search for IUGR babies