Strategies to enhance assessment of the fetal head position before instrumental delivery: a survey of obstetric practice in the United Kingdom and Ireland

Abstract

Objective: To establish the current practice of obstetricians with regard to assessment of women in labour before instrumental delivery.

Study design: A national postal survey of obstetricians in consultant-led obstetric units in the United Kingdom and Ireland. Clinical assessment before instrumental delivery, factors associated with difficulty in determining the fetal head position, approaches used to enhance determination of the fetal head position, perceived accuracy rates in assessment of the fetal head position and willingness to participate in a clinical trial of ultrasound assessment of the fetal head position before instrumental delivery were explored.

Results: The response rate was 75%. The majority of obstetricians assess women clinically before instrumental delivery as recommended by guidelines. Both consultants and trainees reported the following factors as being associated with difficulty in diagnosing the fetal head position: inadequate maternal pain relief, fetal caput and clinical inexperience. Strategies used when experiencing difficulty in determining the fetal head position varied, with trainees more likely than consultants to seek a second opinion (40% vs. 5%, p<0.0001), reassess in an operating theatre (80% vs. 68%, p=0.048) or abandon the procedure in favour of caesarean section (14% vs. 6%, p=0.035). One in five obstetricians reported using abdominal ultrasound to aid diagnosis, with some consultants reporting the use of ultrasound as 'a great idea' and others being 'appalled'. One in eight consultants perceived that they made an incorrect diagnosis of the fetal head position at instrumental delivery in more than 10% of deliveries compared to one in four trainees.

Conclusion: The contrasting views on the role of ultrasound to enhance the assessment of the fetal head position before instrumental delivery suggest that it should be evaluated in a randomised clinical trial.