Extra pregnancy scan significantly reduces the number of breech births, new research shows

Adding a third routine scan at the end of pregnancy can reduce the number of unexpected breech births by 70%, according to new research from our maternity team at NNUH and St George’s, University of London.

Researchers hope that findings published in PLOS Medicine will lead to a change in national guidelines, so all pregnant women are offered a scan in their third trimester to improve maternity care.

Currently, pregnant women have routine scans at 12 and 20 weeks only, with extra scans only offered for recognised complicated pregnancies. However, around 4% of babies are unexpectedly in a breech position at the end of pregnancy, where the baby is positioned feet or bottom first, which puts them at increased risk of being admitted to a neonatal unit, brain injury due to a lack of oxygen, or even death.

Our maternity team were the first in the country in 2016 to introduce a policy of midwives carrying out a third trimester scan, with handheld scanners funded by a £100,000 donation from the N&N Hospitals Charity.

The research compared 5,119 women who received standard ultrasound scans at NNUH and 4,575 who were given a ‘point-of-care’ ultrasound scan at 36 weeks using a handheld, portable device.

At St George’s University Hospital NHS Foundation Trust (SGUH), doctors analysed 16,777 cases against 7,351 who had an extra ultrasound scan by a sonographer at 36 weeks.

Both types of third trimester ultrasound scan dramatically reduced the rate of unexpected breech births – 71% lower with the standard type of ultrasound at SGUH and 69% lower with the hand-held portable device at NNUH. The babies of women who had the third ultrasound were 16% less likely to be admitted to the neonatal unit for closer monitoring and mothers were also less likely to need an emergency caesarean.

Fran Harlow, Consultant Obstetrician for the Norfolk and Norwich University Hospital and Maternal Medicine Lead for the Norwich Regional Maternal Medicine Centre, said: “We are delighted to have played our part in this significant research, which was driven by our community midwifery team at the Norfolk and Norwich University Hospital. This paper demonstrates the huge impact and improvement in patient care by carrying out an additional scan in the third trimester. At NNUH all our midwives have been trained to routinely perform handheld, bedside ultrasound scans using a machine smaller than a tablet, to look at the position of the baby. A competency-based, cascading, training program has enabled safe introduction of this initiative.”

“We are delighted that this study has shown that the benefits to the mother and baby are equivalent to a formal scan performed by an ultra-sonographer. This keeps care in the community and woman centred. We hope that the data from NNUH and St George’s provides the stimulus for a national policy of third trimester scanning. In addition, this study has demonstrated that use of a hand-held ultrasound device by a midwife is an innovative, progressive, and now proven, way of achieving this.”

Pam Sizer, Midwifery Matron, and Sam Knights, Community Midwife Team Leader, added: “In line with Better Births and our commitment to Sign up to Safety, it was our plan to provide a safer, more amenable service to women as part of their routine care. The pathway is now fully embedded in routine care and offered to all women from 36/40 weeks gestation. The results are fantastic, resulting in a drastic reduction in the amount of undiagnosed breech presentation births.  Not only has this been well received by the women, but the midwives are also pleased to be able to enhance their care at point of contact and offer an even more holistic approach.”

Professor Asma Khalil, Professor of Obstetrics and Maternal Fetal Medicine at St George’s, University of London, who led the study, said: “It’s vital we know how the baby is lying towards the end of pregnancy as we want to avoid a breech birth if at all possible. The two routine scans are far too early to tell us how the baby will be positioned at the time of labour and that’s why a third scan at 36-37 weeks could be a game-changer to pregnancy and birth care.”

“For the first time we’ve shown that just one extra scan could save mothers-to-be from trauma, an emergency C-section, and their babies from having severe health complications which could otherwise have been prevented.”

“Our research comes at a time when there’s a spotlight on the safety of maternity services and provides the NHS with a clear solution to help enable maternity units better prepare for safer healthier births.”

Impact of Point of Care Ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: an observational multi-centre cohort study, PLOS Medicine. https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1004192.

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