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Soma-Pillay, Priya

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Obstetrics & Gynaecology Forum • May 2011 21IntroductionThe “systematic observation of patients” began about 430 yearsbefore the birth of Christ when Hippocrates and other Greekdoctors began to look at the issues of poor health and disease byusing a process of reasoning and observation. This processsubsequently led to the evolution of the clinical quartet ofobservation, palpation, percussion and auscultation and for manycenturies important diagnoses were made using the approach ofhistory taking and clinical evaluation. The use of technology inmodern medicine has complemented this process of systematicclinical evaluation and for some disease conditions technology-assisted diagnosis is superior to clinical evaluation alone. Medicaltechnology and specifically the advances of modern ultrasound arebecoming ever more important in obstetrics. Ultrasound is an easy,quick and cost-effective imaging technique without any knownadverse effects on the mother or developing fetus.1 The use oftechnology also helps to diagnose certain disease conditions, beforeovert clinical symptoms and signs manifest, and thus help to reducepotential complications.Early pregnancyEctopic pregnancyEctopic pregnancy is a considerable cause of morbidity andmortality and is responsible for 1.4% of maternal deaths in SouthAfrica.2 Less than 50% of patients present with the classic picture of ahistory of amenorrhea, abdominal pain, irregular vaginal bleedingand cervical excitation tenderness on vaginal examination.Abdominal pain and vaginal bleeding are highly sensitive (97% and69% respectively) but are not specific (15% and 26%) for ectopicpregnancy. Cervical excitation tenderness is most specific at 91% buthas a poor sensitivity rate of 33%.3 Transvaginal ultrasound forwomen attending an early pregnancy unit has shown to be anaccurate diagnostic test for ectopic pregnancy with a sensitivity of87-99% and a specificity of 94-99%.4 Early diagnosis decreasesmaternal morbidity and mortality, helps preserve future reproductivefunction and gives patients an option of ambulatory medical therapy. Mid-gestationSmall for gestational age (SGA) fetusesThe most common methods used to diagnose SGA fetuses areabdominal palpation, measurement of symphyseal fundal height,ultrasound biometry, ultrasound estimated fetal weight and dopplerflow velocimetry. In several countries a clear distinction is madebetween high and low risk pregnancies by obstetric care-givers andin certain obstetric units, abdominal palpation is the only screeningtest for intra-uterine growth restriction (IUGR) in low risk groups.5Therefore the detection of IUGR depends on the effectiveness ofabdominal palpation. Examination of the abdomen by inspectionand palpation only detects about 30% of SGA fetuses, so if SGA issuspected, it is necessary to supplement abdominal palpation withultrasound biometric tests.6,7 A study involving 2941 women foundthe sensitivity and specificity of symphyseal fundal heightmeasurement to be 27% and 88% respectively.8 Serialmeasurements may improve sensitivity and specificity, but theimpact on perinatal outcome is uncertain. The use of customisedfundal height charts improves the accuracy to predict a SGA fetus,resulting in an improvement in the sensitivity to 48% and a reductionin hospital admissions.9Ultrasound biometry of the fetal abdominal circumference andestimated fetal weight are the most accurate diagnosticmeasurements to predict SGA with reported sensitivities of 72-94%and specificities of 50-84% for abdominal circumference and 33-89% and 53-90% for effective fetal weight respectively.10 The use ofumbilical artery doppler as a primary surveillance tool in high riskpregnancies is associated with a significant reduction in the numberof antenatal admissions, reduction of perinatal morbidity andmortality and inductions of labour.11Mutiple pregnancyTwin pregnancies may be diagnosed clinically by the followingfindings:• Fundal height more than anticipated• Excessive fetal parts• Small fetal head in proportion to the size of the uterus• Palpation of at least 3 fetal poles• Auscultation of 2 fetal heartsUltrasound, however is the gold standard for diagnosing multiplepregnancies as it is superior to symphyseal fundal heightmeasurement and palpation in determining the presence of multiplepregnancy.12 Ultrasound also provides important information aboutchorionicity. Many obstetric units perform routine earlyultrasonography as this practice enables better gestational ageassessment, earlier detection of multiple pregnancies and earlierdetection of clinically unsuspected fetal malformation.13 If multiplepregnancies are diagnosed using routine ultrasonography there willbe no need for further abdominal palpation and this skill will be lost. REVIEW O&G Forum 2011;21:21-23The inevitable demise of clinicalskills in examination of patientsPriya Soma-PillayDepartment of Obstetrics & Gynaecology, University of Pretoria, Pretoria, South AfricaCorrespondencePriya Soma-Pillayemail: Priya.somapillay@up.ac.zaObstetrics & Gynaecology Forum • May 2011 22Fetal weight estimationMonitoring fetal growth is a standard component of antenatal care.Abnormalities of fetal growth are associated with an increased riskof adverse perinatal outcome so information provided by fetalweight estimation often determines how the pregnancy anddelivery is managed. Fetal weight estimation may be performed byabdominal palpation or by ultrasound measurement of various fetalparameters. Several studies have shown that clinical estimates offetal weight by an experienced clinician in the late third trimesterand intra-partum correlate well with ultrasound.14 However,ultrasound performs better at the most clinically relevant function ofestimating fetal weight, i.e. predicting the low- or high-birth-weightfetus. In centres where ultrasound is readily available, estimation offetal weight by palpation of the abdomen is rarely done in clinicalpractice because we have come to rely so heavily on ultrasound. Labour and deliveryBreech deliveryAbout 3-4% of foetuses are in a breech presentation at term. Sincethe publication of the Term Breech trial the rates for caesareansection for breech presentation has increased worldwide and in theUnited States, caesarean delivery for breech presentation rose from12% in 1970 to 87% in 2001.15 The term breech trial showed that apolicy of elective caesarean delivery was associated withsignificant decrease in perinatal morbidity and mortality, with only amodest increase in short-term maternal mortality, compared withplanned vaginal delivery.16 Further evidence supporting thefindings of the Term Breech trial was provided by a systematicreview involving 2496 participants.17 Planned caesarean section wasassociated with a reduction in perinatal or neonatal death (RR 0.29,95% CI 0.10-0.86) and a reduction in serious neonatal morbidity(RR 0.33, 95% CI 0.19-0.56). In a further subgroup analysis,prelabour caesarean delivery was associated with a lower risk ofadverse perinatal outcome than caesarean performed duringlabour, especially if the labour was associated with labouraugmentation and pushing for more than 60 minutes.18 Plannedcaesarean delivery is also not more costly than planned vaginalbirth. In the Term Breech Trial, when all costs related to maternaland neonatal physician services and hospitalisation fromrandomisation to 6 weeks postpartum were taken into account, theoverall cost of planned caesarean section was $7255 versus $8042(Canadian dollar) for planned vaginal birth. However, a 2-yearfollow-up of the Term Breech Trial showed no difference in theprimary outcome, death or neurodevelopmental delay at age 2years (RR 1.09, 95% CI 0.52-2.30).Although the evidence supporting planned caesarean section isconvincing, all obstetricians should be able to perform a vaginalbreech delivery. A policy of planned caesarean may not be feasiblein resource-poor settings. There may be other clinical situationswhere the risks of caesarean delivery to the mother, or the mother’sdesire to avoid caesarean delivery may outweigh the risks ofvaginal birth to the baby. Operative vaginal deliveryOperative vaginal delivery refers to the use of a vacuum or forcepsto assist in delivering the baby. The alternative approach iscaesarean section in the second stage of labour. Instrumentaldeliveries were first performed to assist mothers who were at highrisk of maternal mortality due to prolonged or obstructed labour.19Saving the mother’s life was more important than the risk ofpossible harm to the fetus. Advances in the safety of modernanaesthesia and surgical technique has resulted in a shift in thefocus of these procedures. Therefore the possible maternal andfetal complications of these procedures are now weighed againstthe alternative option of caesarean section. It is for these reasonsthat the overall rate of operative vaginal delivery is now decreasing. Short-term maternal complications associated with instrumentaldelivery include, perineal pain, lower genital tract lacerations andhematomas, urinary retention and incontinence, anemia and analincontinence. A review of  50 210 vaginal deliveries concluded thatmaternal complications are more likely to be associated withinstrumental delivery than with spontaneous vaginal delivery.20 Inthis study the rates of third and fourth degree tears were 2% forspontaneous, 10% for vacuum extraction and 20% for forcepsdelivery. Long-term maternal sequelae are associated withproblems related to urinary and anal function. In a prospectivecohort study in women in the second stage of labour whounderwent either instrumental or caesarean delivery, the incidenceof urinary incontinence after one and three years was 2% in thecaesarean section group compared with 10% in the instrumentaldelivery group.21The short-term complications for the fetus include intracranialhaemorrhage, bruises, lacerations, facial nerve palsy,cephalohematoma and skull fractures. In 1998 the United StatesFood and Drug Administration issued a warning about the possiblerisks associated with vacuum delivery.22 This followed reports ofinfant deaths secondary to intracranial haemorrhage. Long-termneurodevelopmental outcomes for children born by assisteddelivery have also been noted as a concern. Although indications for operative delivery have changed overtime, this skill should be learnt by all practitioners involved inobstetric care. The American College of Obstetricians andGynaecologists recognise certain indications for operative deliverybut suggest further that no indication is absolute, each case shouldbe considered individually and caesarean delivery is also an optionin these clinical settings.23 The indications for operative vaginaldelivery include, prolonged second stage of labour, non-reassuringfetal status and maternal cardiac or neurological disease.Sonographic evaluation to assess fetal head descent inlabourPrior to the development of the partogram, the evaluation of labourwas subjective and monitored according to its duration. Thepartogram has provided a more objective assessment of theprogress of labour by plotting cervical dilatation and fetal station asa function of time. Unfortunately estimation of station by digitalvaginal examination is imprecise and poorly reproducible.24Ultrasound has been found to be superior to digital vaginalexamination in determining fetal station prior to operative vaginaldelivery and will most likely, in the future, contribute substantially tothe clinical management of the second stage of labour. The angle(figure 1) between the pubic symphysis and the leading part of thefetal spine, (“angle of progression”) may be measured usingtransperineal or translabial ultrasound and is now used in somecentres to predict which patients will deliver vaginally and whichare at risk of abdominal delivery. Barbera et al have found that anangle of progression of > 120˚ in the second stage of labour wasassociated with subsequent spontaneous vaginal delivery in allstudy patients.25 The “angle of progression” was also associatedwith the duration of the examination-to-delivery interval and therewas a good correlation with the clinical assessment of progress.These findings were confirmed by Kalache et al and among 26REVIEW O&G Forum 2011;21:21-23Obstetrics & Gynaecology Forum • May 2011 23cases with an occiput anterior position an angle of progression of>120˚ was associated with a successful vaginal delivery of 90%.26Ultrasound is most definitely going to be used with increasingfrequency in the management of labour because it has the potentialto predict “true” failure to progress in labour. It may also aid withregards to operative vaginal delivery. Conclusion Medicine is a dynamic field and diagnoses and treatment will alwayschange as we alter our practice in line with evidence basedguidelines. As medicine evolves, the nature of our clinical skills maychange. Physicians will rely more and more on advances intechnology to assist in making diagnoses and treating patients.However, in an imperfect world with limited resources and lack ofuniversal access to technology, clinical skills are still extremelyimportant. In certain clinical scenarios, a more traditional method oftreatment may be indicated. Where we are unable to perfect theseskills in everyday clinical practice we should ensure that we arecompetent by regularly using models or computer assisted teachingaides. Therefore technology and clinical practice should becomplementary and technology should never replace good clinicalskills. References 1. Deurloo KL, Kist WJ, van Vugt JMG. Three dimensional ultrasound: anoverview of its clinical use. Fetal and Maternal Review 2007; 18: 145-179.2. Saving Mothers 2005-2007. Fourth Confidential Enquiries into MaternalDeaths in South Africa. Pretoria: Department of Health, 2007.http://www.doh.gov.za/docs/index.html (accessed 30 March 2011).3. Ramakrishnan K, Scheid DC. Ectopic pregnancy: Forget the “classicpresentation” if you want to catch it sooner. The Journal of Family Practice2006; 55: 388-395.4. Kirk E, Papageorghiou AT, Condous G, Tan L, Bora S, Bourne T. Thediagnostic effectiveness of an initial transvaginal scan in detecting ectopicpregnancy. Human Reproduction 2007; 22: 2824-2828.5. Bais JMJ, Eskes M, Pel M, Bonsel GJ, Bleker OP. Effectiveness of detection ofintrauterine growth retardation by abdominal palpation as screening test ina low risk population: an observational study. European Journal of Obstetricsand Gynaecology and Reproductive Biology 2004; 116: 164-169.6. Hall MH, Chang PK, MacGillivray I. Is routine antenatal care worth while?Lancet 1980; 2: 78-80.7. Rosenberg K, Grant JM, Hepburn M. Antenatal detection of growthretardation: actual practice in a large maternity hospital. Br J ObstetGynaecol 1982; 89: 12-15.8. Persson B, Stangenberg M, Lunell NO, Brodin U, Holmberg NG, VaclavinkovaV. Prediction of size of infants at birth measurement of symphysis fundusheight. Br J Obstet Gynaecol 1986; 93: 206-211.9. Pearce JM, Campbell S. A comparison of symphysis-fundal height andultrasound as screening tests for light-for-gestational age infants. Br J ObstetGynaecol 1987; 94: 100-104. 10. Chang TC, Robson SC, Boys RJ, Spencer JA. Prediction of the small forgestational age infant: which ultrasonic measurement is best? Obset Gynecol1992; 80: 1030-8.11. Alfirevic Z, Neilson JP. Doppler ultrasonography in high risk pregnancies:systematic review with meta-analysis. Am J Obstet Gynecol 1995; 172: 1379-87.12. Seffah JD, Adanu RMK. Obstetric ultrasonography in low-income countries.Clinical Obstetrics and Gynecology 2009; 52: 250-255.13. Neilson JP. Ultrasound for fetal assessment in early pregnancy. The CochraneCollaboration 2007; 1-22.14. Peregrine E, O’Brien P, Jauniaux E. Clinical and ultrasound estimation of birthweight prior to induction of labor at term. Ultrasound Obstet Gynecol 2007;29: 304-309.15. Centres for Disease Control. Births: Final data for 2001. National vitalstatistics reports 2002; 51: 77.16. Hannah ME, Hannah WJ, Hewson SA et al. Planned caesarean section versusplanned vaginal birth presentation at term: a randomised multicentre trial.Term Breech Trial Collaborative Group. Lancet 2000; 356: 1375.17. Hofmeyr GJ, Hannah ME. Planned caesarean section for term breechdelivery. Cochrane Database Syst Rev 2003; CD000166.18. Su M, Mcleod L, Ross S et al. Factors associated with adverse perinataloutcome in the Term Breech Trial. Am J Obstet Gynecol 2003; 189:740.19. Wegner EK, Bernstein IM. Operative vaginal delivery. UpToDate 2011.www.uptodate.com. (accessed 31 March 2011)20. Angioli R, Gomez-Marin O, Cantuaria G, O’sullivan MJ. Severe perineallacerations during vaginal delivery: the University of Miami experience. Am JObstet Gynecol 2000; 182:1083.21. Bahl R, Strachan B, Murphy DJ. Pelvic floor morbidity at 3 years afterinstrumental delivery caesarean delivery in the second stage of labour andthe impact of a subsequent delivery. Am J Obstet Gynecol 2005; 192:789.22. US Food and Drug Adminstration. Food and Drug Adminstration PublicHealth Advisory: Need for CAUTION when using vacuum assisted deliverydevices. 1998. http://www.fda .gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/UCM062295 (accessed 31March 2011)23. American College of Obstetricians and Gynecologists. Operative vaginaldelivery. ACOG Practice Bulletin number 17, American College ofObstetricians and Gynecologists, Washington, DC 2000.24. Buchmann E, Libhaber E. Interobserver agreement in intrapartumestimation of fetal head station. International Journal of Gynecology andObstetrics 2008; 101: 285-289.25. Barbera AF, Pombar X, Perugino G, Lezottte DC, Hobbins JC. A new methodto assess fetal head descent in labor with transperineal ultrasound.Ultrasound Obstet Gynecol 2009; 33: 313-319.26. Kalache KD, Duckelmann AM, Michaelis SAM, Lange J, Cichon G,Dudenhausen JW. Transperineal ultrasound imaging in prolonged secondstage of labor with occipitoanterior presenting foetuses: how well does the“angle of progression” predict mode of delivery? Ultrasound ObstetGynecol 2009; 33: 326-330. REVIEW O&G Forum 2011;21:21-23Figure 1: Angle of progression. In this figure the angle ofprogression is >120˚

Inevitable demise of clinical skills in examination of patients

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Inevitable demise of clinical skills in examination of patients

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