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Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38919.681563.4F (Published 14 September 2006) Cite this as: BMJ 2006;333:578

Clinical examination for non-cephalic presentation: training and experience can make a difference

Author’s reply

Editor- We appreciate the interest and responses to our paper.1-7 One issue that was raised consistently by correspondents was the training and experience of the antenatal care providers. Antenatal care in Australia is provided by a variety of carers with various years of experience. We collected information on care-providers for our study but this was not presented in the published paper8 because the Editor was concerned the differences in sensitivity and specificity (presented in the table below) were confounded by case mix. While we cannot rule out the possibility of bias as some practitioners may be more likely to see high-risk patients or those women more difficult to assess, our results highlight wide variation amongst care providers and associated years of experience. Sensitivities of over 90% by some clinician groups, suggests there is scope for improvement in the clinical diagnosis of breech presentation through training and quality assurance.

Furthermore, as Falcao pointed out,3 localisation of the fetal heart may be an additional means of diagnosing breech presentation. We do not know whether care providers in our study were using localisation of fetal heart (by Pinnards stethoscope or hand-held Doppler) in their assessment of fetal presentation. To our knowledge, this has not previously been evaluated and may be important to assess in future studies.

Finally, we would like to reiterate that we do not advocate the routine use of ultrasound for the detection of fetal presentation in late pregnancy and do not suggest this in our article.

Characteristic		Non-cephalic, correctly diagnosed		Cephalic, correctly diagnosed
			No of cases	Sensitivity (95% CI)		No of cases	Specificity (95% CI)
Overall			91/130		70 (62 to 78)			1429/1503	95 (94 to 96)

Care-provider and years of experience:			
Midwife (<_5years _11="_11" _12="_12" _92="_92" _62="_62" to="to" _100="_100" _73="_73" _80="_80" _91="_91" _83="_83" _96="_96" midwife="midwife" _5-9years="_5-9years" _9="_9" _13="_13" _69="_69" _39="_39" _145="_145" _149="_149" _97="_97" _93="_93" _99="_99" _10years="_10years" _14="_14" _16="_16" _88="_88" _98="_98" _175="_175" _184="_184" _95="_95" resident="resident" _5years="_5years" _7="_7" _58="_58" _28="_28" _85="_85" _219="_219" _231="_231" registrar="registrar" _23="_23" _59="_59" _42="_42" _74="_74" _471="_471" _496="_496" _15="_15" _68="_68" _101="_101" _109="_109" _86="_86" obstetrician="obstetrician" _57="_57" _34="_34" _77="_77" _237="_237" _247="_247" _="_" pre="pre"/>

N Nassar, research fellow

Telethon Institute for Child Health Research, Centre for Child Health Research, The University of Western Australia, PO Box 855, West Perth, WA, 6872, Australia.
natashan@ichr.uwa.edu.au

CL Roberts, research director

CA Cameron, research associate

EC Olive, obstetric fellow

Centre for Perinatal Health Services Research, School of Public Health, University of Sydney NSW 2006, Australia
Competing interests: None declared.

References

1. Price PA. Inconclusive. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (6 August 2006)

2. Collins E. What does this study add? http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (7 August 2006)

3. Falcao VG. Handlehd Dopplers Can Rule Out Breech. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (9 August 2006)

4. Macdonald S. RCM response on clinical examination technique. BMJ 2006;333:705 (30 September 2006)

5. Moran NF. Diagnosing Breech at Term. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (15 September 2006)

6. Kuku SY, Bewley S. Use of ECV should be a maternity service quality indicator. BMJ 2006;333:705-706 (30 September 2006)

7. Aung S. Kappa Calculation. http://bmj.bmjjournals.com/cgi/eletters/333/7568/578 (30 September 2006)

8. Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ 2006;333:578-580 (16 September 2006)

Competing interests:
None declared

Competing interests: Characteristic Non-cephalic, correctly diagnosed Cephalic, correctly diagnosed No of cases Sensitivity (95% CI) No of cases Specificity (95% CI)Overall 91/130 70 (62 to 78) 1429/1503 95 (94 to 96)Care-provider and years of experience: Midwife (

25 October 2006
Natasha Nassar
Postdoctoral research fellow
Christine L. Roberts, Carolyn A. Cameron, Emily C. Olive
Telethon Institute for Child Health Research, Centre for Child Health Research, The University of We