Intended for healthcare professionals


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

BMJ 2006; 333 doi: (Published 14 September 2006) Cite this as: BMJ 2006;333:578

RCM response on clinical examination technique

The BMJ Online (4/8/08) reports on a study of clinical examination
technique (abdominal palpation) which concluded that a third of breech
pregnancies are missed using that method (Nassar et al 2006). It is
tempting to use this research to advocate more reliance on technological
solutions rather than clinical examination. However the Royal College of
Midwives would recommend caution before embarking on that course.

This study was carried out in Australia, where antenatal care
practices are different to the UK. In the UK, midwives provide the
majority of maternity care – and midwives are highly trained in abdominal
palpation – defining the position of the fetus.

The research raises important issues around good clinical skills in
assessing the fetal position during pregnancy. It is possible that some
babies in breech position are ‘missed’ – which reinforces the need to use
this research to inform current education and training of midwives and
obstetricians. Relying further on increasing technology such as ultrasound
scans may increase the risk (that the researchers themselves identify) of
reducing practitioners’ clinical skills. Indeed. the researcher suggested
that some clinicians in the study may have not been as vigilant as they
could have been because they knew that their findings were going to be
checked with an ultrasound scan.

Finally, the RCM would agree that though ultrasound scans would
identify the fetal position effectively – the issues of cost, resources;
and the long term effect on mother and baby have not been fully evaluated.
Scans are already used to provide a ‘second opinion’ when there is
difficulty in palpation – perhaps for overweight women. However, it is
crucial that women are provided with unbiased information and with the
choice about whether they have an additional scan or not.

The RCM would recommend that colleagues read this research, and
instead of following the technology path, follow the recommendation for
developing practitioners’ accuracy and diligence of carrying out clinical
examination, using audit and feedback.

Sue Macdonald

Education and Research Manager

Royal College of Midwives,
15 Mansfield Street,

Competing interests:
None declared

Competing interests: No competing interests

10 August 2006
Sue Macdonald
RCM Education and Resarch Manager
Royal College of Midwives, London W1G 9NH