Study design and setting

This quasi-experimental study with a pre-post research design was conducted in the Department of Obstetrics and Gynecology, University Hospital of Leuven (Belgium). All midwives (n=45) working within the labor ward were invited to participate by an email sent out by the labor ward lead (JR) in April 2023. Enrolment was possible for 4 weeks, and those willing to participate were asked to give written informed consent.

Participants

All midwives working in the labor ward were eligible for inclusion, without any restrictions regarding their age or years of clinical experience. The sample size was determined by convenience (i.e. willingness to participate).

Knowledge, attitude, and practice (KAP) survey

A knowledge, attitude, and practice survey on intrapartum ultrasound was designed by the main study investigators (BP and AS) in collaboration with the senior investigator (JR). The survey consisted of 5 ‘knowledge’ questions on the sonographic assessment of fetal head position and station during labor, based on the 2018 International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) guideline on these topics². For fetal head station, a specific focus was on the angle of progression (AoP)². Next, the survey asked about midwives’ attitudes regarding ultrasound use during labor (5 questions, i.e. whether they believed it was acceptable for patients or beneficial for their decision-making), and their current practice (i.e. whether they already used ultrasound themselves in certain clinical scenarios). For the knowledge section, respondents were able to judge each statement as ‘correct’ or ‘incorrect’, or indicate they had ‘no idea’. For the attitude and practice sections, statements could be judged either positively or negatively. For the final part of the KAP survey, participants were asked to indicate on a 10-point Likert scale how confident they felt performing intrapartum ultrasound themselves. It is worth noting that when the surveys were conducted, these tasks were typically performed by medical doctors working in the department. Hence, midwives were familiar with these techniques to a certain extent, though novices themselves.

Before implementation, the KAP survey was reviewed by four senior obstetricians with experience in intrapartum ultrasound, who were asked to provide feedback on the relevance of each question. It was also pilot-tested on a group of five first-year residents working in the department, who were like the midwives, novices in performing intrapartum ultrasounds themselves. They were asked to share their subjective assessment of the survey’s clarity. Overall, the questionnaire was deemed relevant and clear. Thus, no modifications were required before implementation. The KAP survey is shown in Table 1.

Intervention

A baseline KAP survey was completed upon enrolment. After completion, participants were asked to read the 2018 ISUOG practice guideline² and watch the corresponding video⁸ as part of an online education module, sent out through a personal link using the Research Electronic Data Capture tool (REDCap^® 13.1.9, Vanderbilt University, Nashville, TN, USA). Within four weeks of completion, they were asked to complete the KAP survey for a second time. Survey scores were subsequently calculated. For the knowledge section, one point was attributed to a correct answer, a score of zero to ‘no idea’ and a score of -0.5 to an incorrect answer. For the attitude and practice section, a score of one was attributed to a positive answer (i.e. in favor of intrapartum ultrasound) and a score of zero to a negative answer.

Statistical analysis

The distribution of continuous variables was assessed based on visual inspection of histograms and as per the Kolmogorov-Smirnov test. Because of their skewed distribution, continuous variables are reported as medians and interquartile ranges (IQRs). Categorical variables are reported as absolute numbers and relative frequencies (%). To measure the effect of the online education module on their knowledge of and attitude towards intrapartum ultrasound, survey scores were compared between both timepoints using a two-sided Wilcoxon signed rank test⁹. A p< 0.05 was considered significant. Statistical analyses were conducted using SPSS (version 29.0.2.0) and Microsoft Excel (version 16.69.1).

Main findings

Participating midwives working in our tertiary obstetric unit perceive intrapartum ultrasound for assessing fetal head position and station as a patient-friendly, time-efficient, and safe imaging modality. The majority had little experience and thus low confidence levels for performing intrapartum ultrasounds themselves. Baseline knowledge of these topics was limited but significantly improved after completing a short online education module. Scores related to the sonographic evaluation of the fetal head station through the AoP were overall the least positive.

Comparison to the existing literature and implications for future research

Youssef et al.¹⁰ conducted a short survey on physicians’ perception of ultrasound use during labor among participants of a prenatal medicine and obstetric ultrasound course in Bologna, Italy, in 2013. Most participants (66.3%) believed the sonographic variables of fetal head descent were too complex to be applied in clinical practice¹⁰. Although we did not formally ask this, the low confidence levels reported in our survey may indicate a similar problem. As devices are available in most labor wards, lack of knowledge, skills, and experience are possible barriers to the uptake of intrapartum ultrasound. In another study from Youssef et al.¹¹, a significant improvement in obstetricians’ perception of intrapartum ultrasound was demonstrated after attending a theoretical in-person course on the topic. A practical teaching session also improved their accuracy and precision for the offline assessment of the fetal head station through the AoP¹¹. Evidence from a real-world clinical setting, however, is scarce, especially among midwives. In a small interventional study by Di Pasquo et al.¹², five midwives with no relevant experience were trained on the sonographic assessment of fetal head station through either a theoretical lecture (control group, n=3) or a lecture combined with a practical training session on a purposely designed simulator (training group, n=2). The latter resulted in significantly higher image quality scores in the evaluation phase of the study, indicating simulation training could be beneficial for midwives’ learning curve¹².

Artificial intelligence can automate several aspects of medical imaging with limited operator intervention, including acquisition guidance and automated image analyses¹³. Ghi et al.¹⁴ developed an AI algorithm for the automated classification of fetal occiput position (anterior vs posterior) based on transperineal ultrasound images acquired during the 2nd stage of labor. Similar efforts have been conducted for the automated assessment of fetal head station through the AoP¹⁵.These automated technologies can reduce the skills and knowledge required to carry out intrapartum ultrasound, therefore facilitating the uptake by less experienced caregivers. Nonetheless, further implementation research is needed to investigate how these techniques can be implemented in real-world settings, and equally important, if they can beneficially affect patient care.

Strengths and limitations

Strengths of our study include its novelty in terms of the target population and the scope of the questionnaire. We also acknowledge several limitations. First, the study had a single-center setup. Therefore, our results have limited generalizability. Second, since training was not mandatory, roughly only half of the midwives working in our department agreed to participate. From these, just over half completed the online education module and second KAP survey. Hence, our results are likely to be positively biased by the inclusion of midwives with a specific interest in the topic. Another limitation is the fact the second KAP survey was completed closely after the online education module. Therefore, it is uncertain whether the knowledge improvement is maintained in the long-term. We also did not collect information on possible confounders, making it difficult to ascertain if the knowledge improvement after the online education module was not influenced by other effect modifiers.