Background
Methods
Delphi technique
Selection of the Delphi panel
Preparation of the Delphi questionnaires
The rounds
Results
Characteristic | Midwife-led Care Panellist | Obstetrician-led Care Panellist | Total group | ||
---|---|---|---|---|---|
N = 27 (48%) |
N = 29 (52%) |
N = 56 (100%) | |||
Secondary care | Tertiary care | Combined | |||
Years of experience in current position, mean (range) | 16.30 (3–39) | 12.32 (1–40) | 14.97 (1–40) | ||
Midwife | 11 (19.6%) | 11 (19.6%) | |||
+ sonographer | 12 (21.4%) | 0 | 1 (1.8%) | 1 (1.8%) | 14 (25.0%) |
+ policy and guideline development | 4 (7.1%) | 4 (7.1%) | |||
Obstetrician | 11 (19.6%) | 5 (8.9%) | 1 (1.8%) | 17 (30.4%) | |
+ perinatologist | 2 (3.6%) | 2 (3.6%) | 1 (1.8%) | 5 (8.9%) | |
+ policy & guideline development and perinatologist | 1 (1.8%) | 3 (5.4%) | 0 | 4 (7.1%) | |
Expert sonographer | 0 | 1 (1.8%) | 0 | 1 (1.8%) | |
Work address | |||||
Drenthe | 0 | 0 | 0 | ||
Flevoland | 0 | 0 | 0 | ||
Friesland | 2 (3.6%) | 0 | 2 (3.6%) | ||
Gelderland | 4 (7.1%) | 2 (3.6%) | 6 (10.7%) | ||
Groningen | 0 | 1 (1.8%) | 1 (1.8%) | ||
Limburg | 2 (3.6%) | 2 (3.6%) | 4 (7.1%) | ||
North Brabant | 4 (7.1%) | 3 (5.4%) | 7 (12.5%) | ||
North Holland | 3 (5.4%) | 11 (19.6%) | 14 (25.0%) | ||
Overijssel | 1 (1.8%) | 1 (1.8%) | 2 (3.6%) | ||
South Holland | 4 (7.1%) | 5 (8.9%) | 9 (16.1%) | ||
Utrecht | 6 (10.7%) | 4 (7.1%) | 10 (17.9%) | ||
Zeeland | 1 (1.8%) | 0 | 1 (1.8%) |
Screening
Statement | Answer | Midwife-led Care | Obstetrician-led Care | Consensus total group |
---|---|---|---|---|
n (%) | n (%) | |||
1.1. Slow growth should be defined as a decrease of a specified number of centiles of SFH measurements on the CGC. Eye-balling is of secondary importance. | A | 20 (87%) | 26 (93%) |
Consensus: agree
|
D | 3 (13%) | 2 (7%) | ||
N | 0 | 0 | ||
M | 4 | 1 | ||
1.2. Slow growth is a decrease of at least 20 centiles (e.g. from P70 to P50, with a minimum interval of 2 weeks) of SFH measurements on the CGC. This is an indication for an ultrasound biometry. | A | 20 (91%) | 20 (91%) |
Consensus: agree
|
D | 2 (9%) | 2 (9%) | ||
N | 3 | 4 | ||
M | 2 | 3 | ||
1.3. With ultrasound biometry, slow growth should be stated as a decrease of a specified number of centiles of EFW on the CGC. Eye-balling is of secondary importance in this evaluation. | A | 22 (96%) | 25 (89%) |
Consensus: agree
|
D | 1 (4%) | 3 (11%) | ||
N | 0 | 0 | ||
M | 4 | 1 | ||
1.4. With ultrasound biometry, slow growth is a decrease of at least 20 centiles (e.g. from P70 to P50, with a minimum interval of 2 weeks) of EFW on the CGC. This is an indication for referral to obstetrician-led care. | A | 20 (91%) | 20 (83%) |
Consensus: agree
|
D | 2 (9%) | 4 (17%) | ||
N | 2 | 2 | ||
M | 3 | 3 | ||
1.5. In the IRIS study it will be advised, not obligatory, that two consecutive biometry ultrasounds are performed by the same sonographer | A | 22 (96%) | 20 (71%) |
Consensus: agree
|
D | 1 (4%) | 8 (29%) | ||
N | 0 | 0 | ||
M | 4 | 1 | ||
1.6. To guarantee quality in the IRIS study, sonographers who are trained for the 18–23 weeks FAS are preferable, however other sonographers are acceptable if at least trained in biometry until 3rd trimester. | A | 18 (82%) | 23 (82%) |
Consensus: agree
|
D | 4 (18%) | 5 (18%) | ||
N | 1 | 0 | ||
M | 4 | 1 | ||
1.7. To guarantee quality, sonographers should obtain a minimum number of credits from their professional organization, by following a training once a year. | A | 20 (83%) | 17 (71%) |
Consensus: agree
|
D | 4 (17%) | 7 (29%) | ||
N | 0 | 2 | ||
M | 3 | 3 | ||
1.8. To guarantee quality, sonographers should perform at least 100 biometry ultrasounds a year | A | 18 (90%) | 22 (96%) |
Consensus: agree
|
D | 2 (10%) | 1 (4%) | ||
N | 4 | 3 | ||
M | 3 | 3 | ||
1.9. Ultrasound quality should be checked yearly, evaluation of a log should be an essential part of this | A | 20 (87%) | 19 (86%) |
Consensus: agree
|
D | 3 (13%) | 3 (14%) | ||
N | 1 | 4 | ||
M | 3 | 3 | ||
1.10. The ultrasound machine should meet the requirements for 18–23 weeks FAS as stated by the NVOG quality norm ‘Fetal ultrasound’16
| A | 12 (80%) | 15 (79%) |
Consensus: agree
|
D | 3 (20%) | 4 (21%) | ||
N | 9 | 7 | ||
M | 3 | 3 | ||
1.11. Which cut-off value for the single deepest vertical pocket measurement for assessing amniotic fluid volume is an indication for referral to obstetrician-led care? | < P 2.3 | 0 | 2 (7%) | No consensus |
< P5 | 6 (40%) | 11 (39%) | ||
<2 cm (regardless of gestational age) | 9 (60%) | 15 (54%) | ||
N | 8 | 0 | ||
M | 4 | 1 |
Diagnosis
Statement | Answer | Midwife-led Care | Obstetrician-led Care | Consensus total group |
---|---|---|---|---|
n (%) | n (%) | |||
2.1. An ultrasound biometry and assessment of amniotic fluid volume is to be repeated immediately after referral to obstetrician-led care, even if this is within 2 weeks of the previous scan (in midwife-led care). | A | 12 (60%) | 20 (80%) | No consensus |
D | 8 (40%) | 5 (20%) | ||
N | 3 | 1 | ||
M | 4 | 3 | ||
2.2. As fetal growth can only be evaluated through serial measurements, we will advise to plot EFW on the CGC in obstetrician-led care as well (as in midwife-led care). We will also advise to be alert for asymmetrical growth based on the ratios of AC, FL, BPD and HC. | A | 23 (100%) | 20 (80%) |
Consensus: agree
|
D | 0 | 5 (20%) | ||
N | 0 | 2 | ||
M | 4 | 2 | ||
2.3. In obstetrician-led care, decreased amniotic fluid volume should be defined using the same cut-off values as in midwife-led care. | A | 23 (100%) | 24 (96%) |
Consensus: agree
|
D | 0 | 1 (4%) | ||
N | 0 | 1 | ||
M | 4 | 3 | ||
2.4. Suspicion of IUGR is an indication for measuring the umbilical artery Doppler in obstetrician-led care. Which measurement is the first abnormal sign for fetal deterioration?
(multiple options)
| Pulsatility Index (PI) | 10 (91%) | 23 (92%) |
Consensus: Pulsatility Index (PI)
No consensus on the other answers |
Resistance Index (RI) | 4 (36%) | 0 | ||
Absent diastolic flow | 2 (18%) | 20 (80%) | ||
Reversed diastolic flow | 3 (27%) | 18 (72%) | ||
Other | 0 | 0 | ||
N | 16 | 0 | ||
M | 0 | 4 | ||
2.5. A PI of the umbilical artery Doppler ≥ P95 is abnormal (and management of pregnancy should be adjusted). | A | 11 (92%) | 24 (96%) |
Consensus: agree
|
D | 1 (8%) | 1 (4%) | ||
N | 11 | 1 | ||
M | 4 | 3 | ||
2.6. In the IRIS study it will be advised to assess the PI of the middle cerebral artery Doppler when IUGR is suspected. | A | 10 (100%) | 21 (88%) |
Consensus: agree
|
D | 0 | 3 (12%) | ||
N | 13 | 3 | ||
M | 4 | 2 | ||
2.7. The ductus venosus Doppler should be measured when IUGR is suspected. | A | 5 (83%) | 6 (46%) | No consensus |
D | 1 (17%) | 7 (54%) | ||
N | 17 | 13 | ||
M | 4 | 3 | ||
2.8. In the IRIS study we will recommend a FAS in case of IUGR, if not previously performed. | A | 22 (100%) | 24 (89%) |
Consensus: agree
|
D | 0 | 3 (11%) | ||
N | 1 | 0 | ||
M | 4 | 2 | ||
2.9. At which degree of IUGR, defined by centiles of EFW on the CGC, should a FAS be offered to the pregnant woman? | ≤ P5 | 12 (60%) | 12 (50%) | No consensus |
≤ P2.3 | 7 (35%) | 10 (42%) | ||
Degree of IUGR is not relevant for the assessment of fetal anatomical anomalies | 1 (5%) | 2 (8%) | ||
N | 3 | 3 | ||
M | 4 | 2 | ||
2.10. A FAS because of suspected IUGR, should be performed by: | A sonographer in secondary care, who is trained for FAS. Depending on the results, referral for advanced sonography in tertiary care will take place | 11 (55%) | 6 (22%) | No consensus |
An obstetric ultrasound specialist, trained for advanced sonography (under the responsibility of tertiary care) | 9 (45%) | 21 (78%) | ||
N | 3 | 0 | ||
M | 4 | 2 | ||
2.11. In the IRIS study, in case of suspicion of IUGR, it will be advised not to commence CTG monitoring as long as there is no decrease in fetal movements nor a hypertensive disorder and no abnormal Doppler profiles. | A | 18 (90%) | 23 (85%) |
Consensus: agree
|
D | 2 (10%) | 4 (15%) | ||
N | 3 | 0 | ||
M | 4 | 2 | ||
2.12. At which degree of IUGR, defined by centiles of EFW on the CGC, should assessment for specific fetal infections be advised? | < P10 | 2 (12%) | 1 (4%) | No consensus |
< P5 | 5 (29%) | 7 (27%) | ||
< P2.3 | 10 (59%) | 16 (61%) | ||
At another P-value | 0 | 2 (8%) | ||
N | 6 | 1 | ||
M | 4 | 2 | ||
2.13. Gestational age, in addition to degree of IUGR, determines whether one should check for specific fetal infections | A | 2 (12%) | 4 (16%) |
Consensus: disagree
|
D | 15 (88%) | 21 (84%) | ||
N | 8 | 1 | ||
M | 2 | 3 | ||
2.14. If fetal infections are to be checked for because of suspicion of IUGR than test for: Coxsackie Virus | A | 3 (14%) | 0 |
Consensus: disagree
|
D | 18 (86%) | 23 (100%) | ||
N | 6 | 2 | ||
M | 0 | 4 | ||
Cytomegalovirus | A | 19 (90%) | 20 (87%) |
Consensus: agree
|
D | 2 (10%) | 3 (13%) | ||
N | 6 | 2 | ||
M | 0 | 4 | ||
Malaria | A | 1 (5%) | 0 |
Consensus: disagree
|
D | 20 (95%) | 23 (100%) | ||
N | 6 | 2 | ||
M | 0 | 4 | ||
Toxoplasmosis | A | 17 (100%) | 19 (76%) |
Consensus: agree
|
D | 0 | 6 (24%) | ||
N | 6 | 1 | ||
M | 4 | 3 | ||
Rubella | A | 14 (88%) | 11 (55%) | No consensus |
D | 2 (12%) | 9 (45%) | ||
N | 7 | 6 | ||
M | 4 | 3 | ||
Herpes | A | 13 (100%) | 12 (55%) | No consensus |
D | 0 | 10 (45%) | ||
N | 10 | 4 | ||
M | 4 | 3 | ||
Parvo B19 | A | 18 (100%) | 14 (70%) |
Consensus: agree
|
D | 0 | 6 (30%) | ||
N | 5 | 6 | ||
M | 4 | 3 | ||
Syphilis | A | 11 (79%) | 8 (40%) | No consensus |
D | 3 (21%) | 12 (60%) | ||
N | 9 | 6 | ||
M | 4 | 3 | ||
2.15. In the IRIS study, offering invasive prenatal testing will not be advised routinely in case of IUGR; but rather individual risk factors and gestational age should be considered. | A | 22 (100%) | 25 (93%) |
Consensus: agree
|
D | 0 | 2 (7%) | ||
N | 1 | 0 | ||
M | 4 | 2 | ||
2.16. In the IRIS study, invasive prenatal testing will be offered to the couple if the EFW ≤ P2.3. | A | 18 (95%) | 23 (85%) |
Consensus: agree
|
D | 1 (5%) | 4 (15%) | ||
N | 4 | 0 | ||
M | 4 | 2 |
Management
Statement | Answer | Midwife-led Care | Obstetrician-led Care | Consensus total group |
---|---|---|---|---|
n (%) | n (%) | |||
3.1. If additional tests (Doppler, amniotic fluid volume, FAS and on indication: invasive prenatal testing and assessment of infections) show no anomalies, in which level of care should the pregnancy with EFW (and/or AC) P2.3 - P5 be continued? | Continue in midwife-led care | 0 | 0 |
Consensus: Continue in obstetrician-led care
|
Continue in midwife-led care and offer serial ultrasound biometry | 6 (26%) | 3 (12%) | ||
Continue in obstetrician-led care | 17 (74%) | 23 (88%) | ||
N | 0 | 0 | ||
M | 4 | 3 | ||
3.2. If the EFW on the CGC is P5-P10, the pregnancy should be continued: | In midwife-led care with serial ultrasound biometry | 18 (78%) | 12 (44%) | No consensus |
In obstetrician-led care | 5 (22%) | 15 (56%) | ||
N | 0 | 0 | ||
M | 4 | 2 | ||
3.3. If a pregnancy needs to be monitored in obstetrician-led care because of suspicion of IUGR, ultrasound biometry should be repeated: | Every day | 0 | 0 |
Consensus: Every 2 weeks
|
Every other day | 0 | 0 | ||
Twice a week | 0 | 2 (8%) | ||
Once a week | 3 (16%) | 2 (8%) | ||
Every 10 days | 1 (5%) | 2 (8%) | ||
Every 2 weeks | 14 (74%) | 18 (72%) | ||
With another frequency | 1 (5%) | 1 (4%) | ||
Ultrasound biometry should not be part of the routine monitoring | 0 | 0 | ||
N | 4 | 1 | ||
M | 4 | 3 | ||
3.4. If a pregnancy needs to be monitored in obstetrician-led care because of suspicion of IUGR, assessment of the amniotic fluid volume should be repeated: | Every day | 0 | 0 | No consensus |
Every other day | 0 | 0 | ||
Twice a week | 1 (5%) | 1 (4%) | ||
Once a week | 4 (21%) | 18 (72%) | ||
Every 10 days | 1 (5%) | 1 (4%) | ||
Every 2 weeks | 9 (48%) | 2 (8%) | ||
With another frequency | 3 (16%) | 3 (12%) | ||
Amniotic fluid volume should not be routinely monitored | 1 (5%) | 0 | ||
N | 4 | 1 | ||
M | 4 | 3 | ||
3.5. If a pregnancy needs to be monitored in obstetrician-led care because of suspicion of IUGR, assessment of the umbilical artery Doppler should be repeated: | Every day | 0 | 0 | No consensus |
Every other day | 0 | 0 | ||
Twice a week | 2 (11%) | 2 (8%) | ||
Once a week | 7 (39%) | 15 (60%) | ||
Every 10 days | 1 (5%) | 1 (4%) | ||
Every 2 weeks | 2 (11%) | 0 | ||
With another frequency | 5 (28%) | 7 (28%) | ||
Umbilical artery Doppler should not be routinely monitored | 1 (5%) | 0 | ||
N | 5 | 1 | ||
M | 4 | 3 | ||
3.6. In the IRIS study a tertiary care centre should be consulted about the administration of MgSO4 for fetal neuroprotection if there is suspicion of severe IUGR at a gestational age < 32 weeks 0 days. | A | 6 (100%) | 20 (87%) |
Consensus: agree
|
D | 0 | 3 (13%) | ||
N | 17 | 4 | ||
M | 4 | 2 |