Clinical exam inaccurate for breech presentation

Journal of Family Practice, Dec, 2006 by N. Nassar, C.L. Roberts, C.A. Cameron, E.C. Olive

* Clinical Question

How well does the clinical examination identify breech presentation in late-stage pregnancy?

* Bottom Line

Clinical examination of a pregnant woman for cephalic presentation will miss a noncephalic presentation 30% of the time. A clinical diagnosis of noncephalic presentation will only be correct 55% of the time, given a typical rate of occurrence (8%). More than half the examiners in this study were in training, and it is possible that clinicians with more experience will have better identification rates. (LOE: 2b)

Study Design

Diagnostic test evaluation

Funding

Government

Setting

Inpatient (ward only)

Synopsis

These researchers evaluated 1633 pregnant women between 35 and 37 weeks' gestation. The women were an average 31 years old, 31% were obese, and 61% were white. The clinical examination was performed by 60 different clinicians; 28% by midwives, 17% by obstetricians, and the rest by residents or registrars. The examination consisted of palpation of the abdomen; vaginal examination was not performed. Subsequently, ultrasound (the gold standard) was performed on all women by an examiner unaware of the results of the clinical examination.

Noncephalic presentation was identified by ultrasound in 8% of the women; most of the presentations were breech (6.3%). Noncephalic presentation was correctly identified by clinical examination in 70% of women and cephalic presentation was correctly diagnosed in 95% (sensitivity = 70%; specificity = 95%). Given a rate of 8% noncephalic presentation, the positive predictive value of the clinical examination was only 55%.

FAST TRACK

Given a rate of 8% noncephalic presentation, the positive predictive value of clinical exam was only 55%

Nassar N, Roberts CL, Cameron CA, Olive EC. Diagnostic accuracy of clinical examination for detection of non-cephalic presentation in late pregnancy: cross sectional analytic study. BMJ 2006; 333:578-580.