Detection and clinical management of intrauterine growth restriction in a low-risk population: experience and attitudes of midwives and obstetricians Dr Dale Spence Ms Joanne Gluck Prof Fiona Alderdice Prof Jim Dornan Queens 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 midwives 5 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 midwives 208 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 midwives 66 obstetricians Working in maternity units in each of the 5 Health and Social Care Trusts in NI

Results Midwives n (%); * mean (SD) Gender female198 (100) Age*44.8 (7.7) Experience in midwifery (years) *19.3 (8.9) Current pay scale band 6119 (60.1) Currently working in antenatal setting157 (82.2) Clinical experience antenatal (years)*11.6 (8.5) Clinical experience of ultrasound (years)*6.8 (7.1) Qualification in ultrasound62 (31.3)

Results Obstetricians n (%); * mean (SD) Gender female35 (53%) Age*39.4 (11.0) Experience in obstetrics (years) *13.5 (11.9) Consultant obstetrician29 (43.9) Currently working in antenatal setting63 (95.5) Clinical experience antenatal (years)*12.7 (11.9) Clinical experience of ultrasound (years)*10.9 (10.8) Qualification in ultrasound20 (30.3)

Look after low-risk pregnancies

Look after high-risk pregnancies

Setting in which technique taught to assess fetal growth & wellbeing

Very important factors in assessment of fetal growth & wellbeing Midwives 1.Continuity of care 2.Fetal movement 3.Lifestyle (smoking) 4.Liquor 5.Maternal history 6.Multiple pregnancy 7.Fundal height palpation 8.Placenta Obstetricians 1.Continuity of care 2.Fetal movement 3.Lifestyle (smoking) 4.Liquor 5.Maternal history 6.Multiple pregnancy 7.Estimated fetal weight 8.Doppler

Always use to assess fetal growth & wellbeing

Strongly agree sensitive in determining fetal growth & wellbeing

Very confident in use of tools to detect IUGR

Consider experience very important for successful implementation

Consider training very important for successful implementation

Consider guidelines very important for successful implementation

Confidence in clinical skills to detect IUGR

Confidence in clinical skills to manage IUGR antenatally

Further training in the detection of IUGR very useful

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?

Guidelines rigorously adhered to

Search for IUGR babies

Challenge to identify those babies at risk