Additional routine ultrasounds benefit mothers and babies, and could be cost saving, study finds

Offering universal late pregnancy ultrasounds at 36 weeks' gestation eliminates undiagnosed breech presentation of babies, lowers the rate of emergency caesarean sections, and improves the health of mothers and babies. These are some of the conclusions of the Pregnancy Outcome Prediction (POP) study published this week in PLOS Medicine by David Wastlund of the University of Cambridge, UK, and colleagues.

Undiagnosed breech presentation--when a baby's buttocks or feet emerge first at birth--increases the risk of perinatal morbidity and mortality. In current practice, fetal presentation is assessed by palpation of the maternal abdomen, but the sensitivity of this approach varies by practitioner. By routinely using ultrasound screening, undiagnosed breech presentation in labour could be avoided, lowering the risk of morbidity and mortality for both mother and baby.

In the new study, researchers performed research screening ultrasounds at 36 weeks' gestation in 3879 women having first pregnancies in England. A total of 179 women (4.6%) were diagnosed with breech presentation by the research scan. However, in over half of these cases (55%) there was no prior suspicion that the baby was presenting in the breech position. Making the diagnosis at 36 weeks allowed women to opt for an attempt at turning the baby, called external cephalic version. For the women who declined this procedure, or where it was unsuccessful, a planned caesarean section was arranged. None of the women opted to attempt a vaginal breech birth, which is known to be associated with an increased risk of complications, particularly in first pregnancies.

Across the UK, the analysis estimated that routine scanning could prevent ~15,000 undiagnosed breech presentations, more than 4,000 emergency caesarean sections and 7 to 8 baby deaths per year. If a scan could be done for less than £12.90 then it could be cost-saving to the NHS. This could be possible once midwives are instructed how to perform the simple technique, using inexpensive portable equipment.

"Whether the health improvements are enough to justify the increased cost of ultrasound screening is still uncertain, mainly because the cost of ultrasound screening for presentation alone is unknown," the authors say. "If ultrasound screening could be provided at low cost, for example by making it a part of a standard midwife appointment, routinely offering ultrasound screening could well represent a good use of NHS resources."

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This study was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme, grant number 15/105/01. EW is part funded by the NIHR Cambridge Biomedical Research Centre. US is funded by the NIHR Cambridge Comprehensive Biomedical Research Centre. The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

I have read the journal's policy and the authors of this manuscript have the following competing interests: GS reports grants from the National Institute for Health Research (NIHR), Stillbirth and Neonatal Death Society, and MRC and reports other from GE and NIHR Cambridge Clinical Research Facility, during the study; reports personal fees and other from GlaxoSmithKline and Roche, and reports other from Chiesi, outside of the study. GS is an Academic Editor on PLOS Medicine's editorial board. DW, AM, AD, US, and EW declare no competing interests.

Wastlund D, Moraitis AA, Dacey A, Sovio U, Wilson ECF, Smith GCS (2019) Screening for breech presentation using universal late-pregnancy ultrasonography: A prospective cohort study and cost effectiveness analysis. PLoS Med 16(4): e1002778. https://doi.org/10.1371/journal.pmed.1002778

Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, Cambridge, United Kingdom

The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom

Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge, United Kingdom

Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, United Kingdom

In your coverage please use this URL to provide access to the freely available paper: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002778