Doctors do not dichotomise
Editor- With interest we read the recent study by Nassar et. al.
reporting on diagnostic accuracy of clinical examination for the detection
of non-cephalic presentation. The authors report that sensitivity and
specificity of the clinical examination are limited. We would like to
comment on the design of the study.
Clinicians participating in this study were forced to decide between
two diagnostic categories, i.e. cephalic presentation or non-cephalic
presentation. This same design has been used in earlier studies on the
subject(1-3). In clinical practice nevertheless, this dichotomisation is
not used, since there is always the option that the clinician remains
uncertain about the fetal presentation. In this manner the clinician
always has the possibility to order an ultrasound in case of doubt after
the clinical examination, whereas in case of certainty about cephalic
presentation the ultrasound can be withholded.
If in the present study the option doubt about fetal presentation
would have been available for the clinicians, the test accuracy of
clinical examination would probably have been higher than reported. The
subsequent strategy would then have been that ultrasound is only indicated
in case there is doubt about cephalic presentation of the fetus.
(1) Lydon-Rochelle M, Albers L, Gorwoda J, Craig E, Qualls C.
Accuracy of Leopold maneuvers in screening for malpresentation: a
prospective study. Birth 1993; 20(3):132-135.
(2) Thorp JM, Jr., Jenkins T, Watson W. Utility of Leopold maneuvers
in screening for malpresentation. Obstet Gynecol 1991; 78(3 Pt 1):394-396.
(3) Watson WJ, Welter S, Day D. Antepartum identification of breech
presentation. J Reprod Med 2004; 49(4):294-296.
Competing interests: No competing interests