Dr Dale Spence Ms Joanne Gluck Prof Fiona Alderdice Prof Jim Dornan Queen’s University Belfast

1. 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 Queen’s University Belfast

2. Intrauterine growth restriction (IUGR)?

3. 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

4. Recent reports • Under-diagnosed complication of pregnancy • Inadequate monitoring of growth • Failure to recognise IUGR • Failure to act on IUGR

5. Study aims • Describe current practice • Explore experience and preferred clinical practice • Identify potential barriers, training or practice needs

6. Methodology • Mixed methods approach • Ethical approval and Health & Social Care Trust indemnification • Study population

7. Setting Phase 1: • Semi-structured interviews • a regional maternity unit in Northern Ireland Phase 2: • Survey • All maternity units in Northern Ireland

8. Sample selection • Midwives: providing antenatal care • Obstetricians: working in obstetrics & gynaecology Contact made through Heads of Midwifery and Clinical Directors

9. Phase 1 • Semi-structured face-to-face interviews • Transcribed verbatim • Content analysis

10. Results: response data Phase 1: 11 midwives 5 obstetricians Working in large regional maternity unit in NI

11. Results (part 1) Themes emerging for detection of IUGR include: • confidence and accuracy in detection of IUGR • consistency and continuity • skills/training

12. Results (part 1) Themes emerging for management of IUGR include • referral • further assessment and decision-making • suggested strategies for detection and management of IUGR

13. Sample selection Phase 2: 767 midwives 208 obstetricians Providing antenatal care in all maternity units (n= 10) throughout Northern Ireland (NI)

14. Survey Main components: • Demographics • Current practice • Experience • Preferred clinical practice • Identify potential barriers, training or practice needs

15. 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

16. Results

17. Results

18. Look after low-risk pregnancies

19. Look after high-risk pregnancies

20. Setting in which technique taught to assess fetal growth & wellbeing

21. ‘Very important’ factors in assessment of fetal growth & wellbeing Midwives Obstetricians Continuity of care Fetal movement Lifestyle (smoking) Liquor Maternal history Multiple pregnancy Estimated fetal weight Doppler • Continuity of care • Fetal movement • Lifestyle (smoking) • Liquor • Maternal history • Multiple pregnancy • Fundal height palpation • Placenta

22. ‘Always’ use to assess fetal growth & wellbeing

23. ‘Strongly agree’ sensitive in determining fetal growth & wellbeing

24. ‘Very confident’ in use of tools to detect IUGR

25. Consider experience ‘very important’ for successful implementation

26. Consider training ‘very important’ for successful implementation

27. Consider guidelines ‘very important’ for successful implementation

28. Confidence in clinical skills to detect IUGR

29. Confidence in clinical skills to manage IUGR antenatally

30. Further training in the detection of IUGR ‘very useful’

31. 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

32. 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

33. Challenge to identify those babies at risk

34. 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

35. d.spence@qub.ac.uk

36. Aware of guidelines on management of IUGR in unit?

37. Guidelines rigorously adhered to

38. Search for IUGR babies

39. Challenge to identify those babies at risk d.spence@qub.ac.uk