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Eggebø TM, Hjartardottir H. Descent of the presenting part assessed with ultrasound. Am J Obstet Gynecol 2024; 230:S901-S912. [PMID: 34461079 DOI: 10.1016/j.ajog.2021.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/15/2021] [Accepted: 08/19/2021] [Indexed: 11/29/2022]
Abstract
Fetal head descent can be expressed as fetal station and engagement. Station is traditionally based on clinical vaginal examination of the distal part of the fetal skull and related to the level of the ischial spines. Engagement is based on a transabdominal examination of the proximal part of the fetal head above the pelvic inlet. Clinical examinations are subjective, and objective measurements of descent are warranted. Ultrasound is a feasible diagnostic tool in labor, and fetal lie, station, position, presentation, and attitude can be examined. This review presents an overview of fetal descent examined with ultrasound. Ultrasound was first introduced for examining fetal descent in 1977. The distance from the sacral tip to the fetal skull was measured with A-mode ultrasound, but more convenient transperineal methods have since been published. Of those, progression distance, angle of progression, and head-symphysis distance are examined in the sagittal plane, using the inferior part of the symphysis pubis as reference point. Head-perineum distance is measured in the frontal plane (transverse transperineal scan) as the shortest distance from perineum to the fetal skull, representing the remaining part of the birth canal for the fetus to pass. At high stations, the fetal head is directed downward, followed with a horizontal and then an upward direction when the fetus descends in the birth canal and deflexes the head. Head descent may be assessed transabdominally with ultrasound and measured as the suprapubic descent angle. Many observational studies have shown that fetal descent assessed with ultrasound can predict labor outcome before induction of labor, as an admission test, and during the first and second stage of labor. Labor progress can also be examined longitudinally. The International Society of Ultrasound in Obstetrics and Gynecology recommends using ultrasound in women with prolonged or arrested first or second stage of labor, when malpositions or malpresentations are suspected, and before an operative vaginal delivery. One single ultrasound parameter cannot tell for sure whether an instrumental delivery is going to be successful. Information about station and position is a prerequisite, but head direction, presentation, and attitude also should be considered.
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Affiliation(s)
- Torbjørn M Eggebø
- National Center for Fetal Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Obstetrics and Gynecology, Helse Stavanger, Stavanger University Hospital, Stavanger, Norway.
| | - Hulda Hjartardottir
- Department of Obstetrics and Gynecology, Landspitali University Hospital, Reykjavík, Iceland; Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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2
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Fidalgo AM, Miguel R, Fernández-Buhigas I, Aguado A, Cuerva MJ, Corrales E, Rolle V, Santacruz B, Gil MM, Poon LC. Level of agreement between midwives and obstetricians performing ultrasound examination during labor. Int J Gynaecol Obstet 2024; 164:131-139. [PMID: 37401541 DOI: 10.1002/ijgo.14956] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/18/2023] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To evaluate the level of agreement between ultrasound measurements to evaluate fetal head position and progress of labor by attending midwives and obstetricians after appropriate training. METHODS In this prospective study, women in the first stage of labor giving birth to a single baby in cephalic presentation at our Obstetric Unit between March 2018 and December 2019 were invited to participate; 109 women agreed. Transperineal and transabdominal ultrasound was independently performed by a trained midwife and an obstetrician. Two paired measurements were available for comparisons in 107 cases for the angle of progression (AoP), in 106 cases for the head-to-perineum distance (HPD), in 97 cases for the cervical dilatation (CD), and in 79 cases for the fetal head position. RESULTS We found a good correlation between the AoP measured by obstetricians and midwives (intra-class correlation coefficient [ICC] = 0.85; 95% confidence interval [CI] 0.80-0.89). There was a moderate correlation between the HPD (ICC = 0.75; 95% CI 0.68-0.82). There was a very good correlation between the CD measured (ICC = 0.94; 95% CI 0.91-0.96). There was a very good level of agreement in the classification of the fetal head position (Cohen's κ = 0.89; 95% CI 0.80-0.98). CONCLUSIONS Ultrasound assessment of fetal head position and progress of labor can effectively be performed by attending midwives without previous experience in ultrasound.
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Affiliation(s)
- Ana M Fidalgo
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Raquel Miguel
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | | | - Asunción Aguado
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Marcos J Cuerva
- Department of Obstetrics and Gynecology, Hospital Universitario La Paz, Madrid, Spain
| | - Elisa Corrales
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Valeria Rolle
- Bioestatistics and Epidemiology Platform at Fundación para la Investigación e Innovación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Belén Santacruz
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
- School of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - María M Gil
- Department of Obstetrics and Gynecology, Hospital Universitario de Torrejón, Madrid, Spain
- School of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Liona C Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong
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Jung JE, Lee YJ. Intrapartum transperineal ultrasound: angle of progression to evaluate and predict the mode of delivery and labor progression. Obstet Gynecol Sci 2024; 67:1-16. [PMID: 38029738 DOI: 10.5468/ogs.23141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
Intrapartum ultrasonography serves as a valuable tool for the objective evaluation of labor progression and effectively identifies underlying factors, such as asynclitism, in cases of abnormal labor progression. Among the various ultrasound measurement techniques, the angle of progression (AOP) demonstrates favorable reproducibility and accuracy in assessing fetal head descent. In the context of abnormal labor, interventions differ across different stages of labor, emphasizing the importance of investigating the utility of AOP according to labor stages in this review article. Pre-labor assessment of AOP can be beneficial in terms of counseling for the timing of induction of labor, while a wider AOP value during the prolonged first stage of labor has demonstrated a positive correlation with successful vaginal delivery and shorter time to delivery. In the second stage of labor, the AOP has exhibited efficacy in predicting the mode of delivery and complicated operative deliveries. Furthermore, it has assisted in predicting the duration of labor, thereby highlighting its potential as a decision-making model for labor progression. However, further research is needed to investigate aspects, such as the determination of cutoff values, of AOP, considering the multifaceted characteristics of labor progression, which are influenced by complex interactions among maternal, fetal, and other contributing factors.
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Affiliation(s)
- Ji Eun Jung
- Department of Obstetrics and Gynecology, Kyung Hee University Medical Center, Seoul, Korea
| | - Young Joo Lee
- Department of Obstetrics and Gynecology, Kyung Hee University College of Medicine, Seoul, Korea
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Enomoto N, Maki S, Nii M, Yamaguchi M, Tamaishi Y, Takakura S, Magawa S, Tanaka K, Tanaka H, Kondo E, Katsuragi S, Ikeda T. Accurate evaluation of the progress of delivery with transperineal ultrasound may improve vaginal delivery: a single-center retrospective study. Sci Rep 2023; 13:20945. [PMID: 38016993 PMCID: PMC10684555 DOI: 10.1038/s41598-023-47457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 11/14/2023] [Indexed: 11/30/2023] Open
Abstract
Although digital examination of the cervix is the standard method used worldwide for evaluating the progress of delivery, it is subjective. Transperineal ultrasound (TPU) is combined with digital evaluation for accurate assessment of fetal descent and rotation of the advanced part of the fetus. This retrospective study aimed to clarify the impact of introducing TPU on perinatal outcomes at Mie University Hospital. We analyzed singleton pregnant women who underwent delivery management at our hospital between April 2020 and March 2021. Perinatal outcomes were compared between patients who used TPU (TPU+ group) and those who did not (TPU- group). The angle of progression and head direction were measured. The rate of vaginal delivery was significantly increased (90.9% vs. 71.6%; P = 0.0017), and the second stage of labor was significantly prolonged in the TPU+ group (148.1 vs. 75.8 min; P < 0.0001). A significant difference was observed in termination in the latent phase between the TPU+ group [3/8 (37.5%) cases] and TPU- group [20/25 (80.0%) cases] (P = 0.036). The rate of vaginal delivery can be increased through accurate evaluation of the progress of delivery with TPU.
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Affiliation(s)
- Naosuke Enomoto
- Department of Obstetrics and Gynecology, Matsusaka Chuo General Hospital, 102 Kawaimachi, Matsusaka, Mie, Japan.
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan.
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Mizuki Yamaguchi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Yuya Tamaishi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shoichi Magawa
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Kayo Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Hiroaki Tanaka
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shinji Katsuragi
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
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Garcia-Jimenez R, Valero I, Borrero C, Garcia-Mejido JA, Fernandez-Palacin A, Serrano R, Sainz-Bueno JA. Can Intrapartum Ultrasonography Improve the Placement of the Vacuum Cup in Operative Vaginal Deliveries? Tomography 2023; 9:247-254. [PMID: 36828371 PMCID: PMC9961862 DOI: 10.3390/tomography9010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
Although the fetal head position has traditionally been evaluated by digital examination (DE), it has a failure rate ranging between 20 and 70%; hence, intrapartum transabdominal ultrasonography (TUS) has become relevant. We aimed to evaluate the utility of the TUS to identify the fetal head positions in vacuum-assisted deliveries. We performed a prospective observational study including 101 pregnant patients in active labor who required a vacuum-assisted delivery. The fetal head position was assessed by a DE and a TUS prior to vacuum cup placement. After delivery, the optimal vacuum cup placement was evaluated as the distance between the chignon and the flexion point ≤2 cm. The general concordance rate between the DE and TUS was 72.2%, with the poorest concordance rate for occiput posterior positions at 46.1%. In five cases (4.9%), it was not possible to determine the fetal head position through the DE. The correlation was higher in low and medium planes, with 77% and 68.1% concordance rates, respectively, while it was lower in high planes (60%). In 90.1% of cases, the vacuum cup placement was optimal. Our findings show that intrapartum transabdominal ultrasonography is a useful technique to identify the fetal head position allowing optimal placement of the vacuum cup necessary for correct vacuum-assisted delivery.
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Affiliation(s)
- Rocio Garcia-Jimenez
- Obstetrics and Gynecology Department, Juan Ramon Jiménez Hospital, 21005 Huelva, Spain
| | - Irene Valero
- Obstetrics and Gynecology Department, Juan Ramon Jiménez Hospital, 21005 Huelva, Spain
| | - Carlota Borrero
- Obstetrics and Gynecology Department, Valme University Hospital, 41014 Seville, Spain
- Obstetrics and Gynecology Department, Faculty of Medicine, University of Seville, 41009 Seville, Spain
| | - Jose Antonio Garcia-Mejido
- Obstetrics and Gynecology Department, Valme University Hospital, 41014 Seville, Spain
- Obstetrics and Gynecology Department, Faculty of Medicine, University of Seville, 41009 Seville, Spain
| | - Ana Fernandez-Palacin
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, 41009 Seville, Spain
| | - Rosa Serrano
- Obstetrics and Gynecology Department, Jerez University Hospital, 11407 Jerez de la Frontera, Spain
| | - Jose Antonio Sainz-Bueno
- Obstetrics and Gynecology Department, Valme University Hospital, 41014 Seville, Spain
- Obstetrics and Gynecology Department, Faculty of Medicine, University of Seville, 41009 Seville, Spain
- Correspondence:
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Nassr AA, Hessami K, Berghella V, Bibbo C, Shamshirsaz AA, Shirdel Abdolmaleki A, Marsoosi V, Clark SL, Belfort MA, Shamshirsaz AA. Angle of progression measured using transperineal ultrasound for prediction of uncomplicated operative vaginal delivery: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:338-345. [PMID: 35238424 DOI: 10.1002/uog.24886] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/17/2022] [Accepted: 02/21/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To determine whether intrapartum transperineal ultrasound measurement of the angle of progression (AoP) during the second stage of labor can predict uncomplicated operative vaginal delivery (OVD) using vacuum or forceps extraction. METHODS A systematic search in PubMed, EMBASE, Scopus, Web of Science and Google Scholar was performed from inception to February 2021. Studies assessing the predictive accuracy of AoP, measured using intrapartum transperineal ultrasound, for uncomplicated OVD, defined as successful vaginal delivery within three pulls using forceps or no more than two detachments of the vacuum extractor cup, were included. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Summary receiver-operating-characteristics (ROC) curves, pooled sensitivity and specificity, area under the ROC curve (AUC) and summary likelihood ratios (LRs) were calculated. RESULTS Seven studies reporting on a total of 782 patients undergoing OVD were included in this systematic review and meta-analysis. Second-stage AoP measured during maternal rest had a pooled sensitivity of 80% (95% CI, 59-92%) and specificity of 89% (95% CI, 76-95%), with a LR+ of 7.3 (95% CI, 3.1-15.8) for uncomplicated OVD. AoP measured during active pushing had a sensitivity of 91% (95% CI, 85-94%) and specificity of 83% (95% CI, 69-92%), with a LR+ of 5.4 (95% CI, 2.7-10.6) for uncomplicated OVD. The performance of AoP measured at rest was particularly high in nulliparous women, with a sensitivity of 87% (95% CI, 75-94%) and specificity of 90% (95% CI, 82-94%) for uncomplicated OVD. CONCLUSION AoP may be a reliable predictor for uncomplicated OVD when measured during the second stage of labor, especially in nulliparous women. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - K Hessami
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - V Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - C Bibbo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's, Boston, MA, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - A Shirdel Abdolmaleki
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - V Marsoosi
- Department of Obstetrics and Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - S L Clark
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - M A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - A A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
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Haumonte JB, Blanc J, Castel P, Mace P, Auquier P, d’Ercole C, Bretelle F. Uncertain fetal head engagement: a prospective randomized controlled trial comparing digital exam with angle of progression. Am J Obstet Gynecol 2022; 227:625.e1-625.e8. [PMID: 35452654 DOI: 10.1016/j.ajog.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/26/2022] [Accepted: 04/13/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Uncertain fetal head engagement represents 4% of obstetrical situations associated with an increased risk of postpartum hemorrhage, notably in cases of cesarean delivery and increased neonatal impairment owing to failed vaginal instrumental delivery. In this obstetrical condition, cesarean delivery is recommended, but vaginal delivery is possible in two-thirds of the cases. During the second stage of labor, the descent of the fetal head can be assessed by sonography, particularly by measuring the angle of progression. OBJECTIVE To evaluate, after a prolonged second stage of labor, the impact of measuring the angle of progression in addition to a digital examination on cesarean delivery rates when fetal head engagement remains uncertain. STUDY DESIGN This open multicenter randomized pragmatic trial included women at term with a singleton cephalic fetus in a clinical occiput anterior position after a prolonged 2-hour second stage of labor with uncertain fetal head engagement. After inclusion in the study, an independent investigator performed ultrasound systematically to confirm the occiput anterior position and measured the angle of progression at the climax of Valsalva pushing. This operator did not participate in labor management. In the study group but not in the control group, the angle of progression was communicated to the obstetrician in charge of labor management. Obstetricians were encouraged to attempt vaginal birth if the angle of progression was >120°. The primary outcome was the cesarean delivery rate. Secondary outcomes were operative delivery rate (cesarean delivery and operative vaginal delivery), maternal complications (third and fourth-degree perineal tears, failed vaginal instrumental delivery, postpartum hemorrhage, hysterectomy), and neonatal outcomes (Apgar score <5 at 10 minutes, umbilical arterial pH <7.10, neonatal wounds, neonatal intensive care unit admission). RESULTS A total of 45 women were included in the study. Occiput anterior position was confirmed in 33 women: 16 in the study group and 17 in the control group. Women's characteristics at baseline were similar between the groups. The median (range) angles of progression were similar: 138.4° (15) and 140.3° (16.9) in the study and control group, respectively. Cesarean delivery rates were 12.5% in the study group and 41.1% in the control group (P=.06). Secondary outcomes were similar between the 2 groups. No failed vaginal instrumental delivery was reported. CONCLUSION Measurement of the angle of progression in addition to digital examination when fetal head engagement remained uncertain showed promising results in decreasing cesarean delivery rates. A larger multicenter randomized controlled trial is needed to confirm these results.
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Bellussi F, Di Mascio D, Salsi G, Ghi T, Dall’Asta A, Zullo F, Pilu G, Barros JG, Ayres-de-Campos D, Berghella V. Sonographic knowledge of occiput position to decrease failed operative vaginal delivery: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol 2022; 226:499-509. [PMID: 34492220 DOI: 10.1016/j.ajog.2021.08.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to assess the efficacy of sonographic assessment of fetal occiput position before operative vaginal delivery to decrease the number of failed operative vaginal deliveries. DATA SOURCES The search was conducted in MEDLINE, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid, and Cochrane Library as electronic databases from the inception of each database to April 2021. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA Selection criteria included randomized controlled trails of pregnant women randomized to either sonographic or clinical digital diagnosis of fetal occiput position during the second stage of labor before operative vaginal delivery. METHODS The primary outcome was failed operative vaginal delivery, defined as a failed fetal operative vaginal delivery (vacuum or forceps) extraction requiring a cesarean delivery or forceps after failed vacuum. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals using the random effects model of DerSimonian and Laird. An I2 (Higgins I2) >0% was used to identify heterogeneity. RESULTS A total of 4 randomized controlled trials including 1007 women with singleton, term, cephalic fetuses randomized to either the sonographic (n=484) or clinical digital (n=523) diagnosis of occiput position during the second stage of labor before operative vaginal delivery were included. Before operative vaginal delivery, fetal occiput position was diagnosed as anterior in 63.5% of the sonographic diagnosis group vs 69.5% in the clinical digital diagnosis group (P=.04). There was no significant difference in the rate of failed operative vaginal deliveries between the sonographic and clinical diagnosis of occiput position groups (9.9% vs 8.2%; relative risk, 1.14; 95% confidence interval, 0.77-1.68). Women randomized to sonographic diagnosis of occiput position had a significantly lower rate of occiput position discordance between the evaluation before operative vaginal delivery and the at birth evaluation when compared with those randomized to the clinical diagnosis group (2.3% vs 17.7%; relative risk, 0.16; 95% confidence interval, 0.04-0.74; P=.02). There were no significant differences in any of the other secondary obstetrical and perinatal outcomes assessed. CONCLUSION Sonographic knowledge of occiput position before operative vaginal delivery does not seem to have an effect on the incidence of failed operative vaginal deliveries despite better sonographic accuracy in the occiput position diagnosis when compared with clinical assessment. Future studies should evaluate how a more accurate sonographic diagnosis of occiput position or other parameters can lead to a safer and more effective operative vaginal delivery technique.
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Kamel R, Negm S, Badr I, Kahrs BH, Eggebø TM, Iversen JK. Fetal head descent assessed by transabdominal ultrasound: a prospective observational study. Am J Obstet Gynecol 2022; 226:112.e1-112.e10. [PMID: 34389293 DOI: 10.1016/j.ajog.2021.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Determining fetal head descent, expressed as fetal head station and engagement is an essential part of monitoring progression in labor. Assessing fetal head station is based on the distal part of the fetal skull, whereas assessing engagement is based on the proximal part. Prerequisites for assisted vaginal birth are that the fetal head should be engaged and its lowermost part at or below the level of the ischial spines. The part of the fetal head above the pelvic inlet reflects the true descent of the largest diameter of the skull. In molded (reshaped) fetal heads, the leading bony part of the skull may be below the ischial spines while the largest diameter of the fetal skull still remains above the pelvic inlet. An attempt at assisted vaginal birth in such a situation would be associated with risks. Therefore, the vaginal or transperineal assessments of station should be supplemented with a transabdominal examination. We suggest a method for the assessment of fetal head descent with transabdominal ultrasound. OBJECTIVE To investigate the correlation between transabdominal and transperineal assessment of fetal head descent, and to study fetal head shape at different labor stages and head positions. STUDY DESIGN Women with term singleton cephalic pregnancies admitted to the labor ward for induction of labor or in spontaneous labor, at the Cairo University Hospital and Oslo University Hospital from December 2019 to December 2020 were included. Fetal head descent was assessed with transabdominal ultrasound as the suprapubic descent angle between a longitudinal line through the symphysis pubis and a line from the upper part of the symphysis pubis extending tangentially to the fetal skull. We compared measurements with transperineally assessed angle of progression and investigated interobserver agreement. We also measured the part of fetal head above and below the symphysis pubis at different labor stages. RESULTS The study population comprised 123 women, of whom 19 (15%) were examined before induction of labor, 8 (7%) in the latent phase, 52 (42%) in the active first stage and 44 (36%) in the second stage. The suprapubic descent angle and the angle of progression could be measured in all cases. The correlation between the transabdominal and transperineal measurements was -0.90 (95% confidence interval, -0.86 to -0.93). Interobserver agreement was examined in 30 women and the intraclass correlation coefficient was 0.98 (95% confidence interval, 0.95-0.99). The limits of agreement were from -9.5 to 7.8 degrees. The fetal head was more elongated in occiput posterior position than in non-occiput posterior positions in the second stage of labor. CONCLUSION We present a novel method of examining fetal head descent by assessing the proximal part of the fetal skull with transabdominal ultrasound. The correlation with transperineal ultrasound measurements was strong, especially early in labor. The fetal head was elongated in the occiput posterior position during the second stage of labor.
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Ghi T. Intrapartum ultrasound and evidence-based medicine: a necessary but challenging marriage. Am J Obstet Gynecol MFM 2021; 3:100428. [PMID: 34303655 DOI: 10.1016/j.ajogmf.2021.100428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Tullio Ghi
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy.
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11
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Youssef A, Brunelli E, Azzarone C, Di Donna G, Casadio P, Pilu G. Fetal head progression and regression on maternal pushing at term and labor outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:105-110. [PMID: 32730691 DOI: 10.1002/uog.22159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing. METHODS This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed. RESULTS Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission. CONCLUSIONS In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Youssef
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - E Brunelli
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - C Azzarone
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Di Donna
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - P Casadio
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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12
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Intrapartum ultrasound and the choice between assisted vaginal and cesarean delivery. Am J Obstet Gynecol MFM 2021; 3:100439. [PMID: 34216834 DOI: 10.1016/j.ajogmf.2021.100439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/25/2021] [Accepted: 06/25/2021] [Indexed: 11/24/2022]
Abstract
Inaccurate assessment of the fetal head position and station might increase the risk for difficult or failed assisted vaginal delivery. Compared with digital vaginal examination, an ultrasound examination is objective and more accurate. The International Society of Ultrasound in Obstetrics and Gynecology has issued practical guidelines on intrapartum ultrasound in 2018 and recommended that an ultrasound assessment should be conducted when there is suspected delay or arrest of the first or second stage of labor or before considering assisted vaginal delivery. Fetal head position is assessed transabdominally by identifying the fetal occiput, orbit, or midline cerebral echo. Studies have shown that ultrasound assessment improved the correct diagnosis of fetal head position and accuracy of instrument placement, however, it did not reduce morbidity. Studies on ultrasound assessment of asynclitism are limited but show promising results. Fetal head station is assessed transperineally in the midsagittal or axial plane. Of the various ultrasound parameters, angle of progression and head-perineum distance are the most widely studied and found to be highly correlated with the clinical fetal head station. An angle of progression of 120° correlates with a clinical head station of 0 and is an important landmark for engagement of successful vaginal delivery, whereas an angle of progression of 145° correlates with a clinical head station of ≥+2 and has been associated with successful assisted vaginal delivery. In contrast, a head perineum distance of ≥40 mm has been associated with an increased risk for difficult assisted vaginal delivery. A "head-up" direction of descent assessed transperineally in sagittal plane is also a favorable factor for successful vaginal delivery. Current evidence seems to suggest that a prediction model with >1 sonographic parameter performed better than a model that only used 1 parameter. We suggest that an algorithm model incorporating both clinical and sonographic parameters would be useful in guiding clinicians on their decision for assisted vaginal delivery.
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13
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Tang H, Wang W, Pan Y, Liu M, Shao F, Xu B, Su Y, Hu Y, Dai Y, Zheng M. Process of fetal head descent as recorded by ultrasonography: How does this compare with the conventional first stage of labor? Int J Gynaecol Obstet 2021; 156:28-33. [PMID: 33459352 DOI: 10.1002/ijgo.13605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/12/2020] [Accepted: 01/14/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To construct an ultrasound partogram using serial transperineal sonographic measurements of the angle of fetal head progression during the first stage of labor, and to compare it with a conventional partogram based on digital vaginal examinations. METHODS Between 2017 and 2018, a prospective cohort study at Drum Tower Hospital, Nanjing, China, recruited 375 nulliparous women with singleton pregnancy and spontaneous onset of labor at 37 or more gestational weeks. Transperineal ultrasound scans were performed to measure the angle of progression (AoP) every 0.5-1 h until the second stage. Vaginal examinations were also used to measure cervical dilatation. Repeated-measures analysis was used to generate labor curves. RESULTS The labor curve generated by AoP had a pattern similar to that based on cervical dilatation. There was an initial slow period lasting approximately 5.5 h until the cervical dilatation or AoP reached the inflection point (4 cm and 119°, respectively), followed by a second, more rapid period, lasting approximately 2.5 h. CONCLUSION Based on ultrasound data, it was feasible to construct an "angle of progression partogram" of the first stage of labor, which was similar in pattern to the partogram based on cervical dilatation measured in the same cohort.
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Affiliation(s)
- Huirong Tang
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Wenwen Wang
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yunyun Pan
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Mo Liu
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Fang Shao
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Biyun Xu
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yu Su
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yali Hu
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Yimin Dai
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Mingming Zheng
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
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Barros JG, Afonso M, Martins AT, Carita AI, Clode N, Ayres-de-Campos D, Graça LM. Transabdominal and transperineal ultrasound vs routine care before instrumental vaginal delivery - A randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:1075-1081. [PMID: 33319355 DOI: 10.1111/aogs.14065] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The role of intrapartum ultrasound as an ancillary method to instrumental vaginal delivery is yet to be determined. This study aimed to compare the use of transabdominal and transperineal ultrasound with routine clinical care before performing an instrumental vaginal delivery, regarding the incidence of adverse maternal and neonatal outcomes. MATERIAL AND METHODS A randomized controlled trial was conducted between October 2016 and March 2019 in two tertiary care maternity hospitals in Lisbon, Portugal. Women at term, with full cervical dilatation, singleton fetuses in cephalic presentation, and with an established indication for instrumental vaginal delivery, were approached for enrollment. After informed consent was obtained, randomization into one of two groups was carried out. In the experimental arm, women underwent transabdominal ultrasound for determination of the fetal head position and transperineal ultrasound for evaluation of the angle of progression, before instrumental vaginal delivery. In the control arm, no ultrasound was carried out before instrumental vaginal delivery. Primary outcomes were composite measures of maternal and neonatal morbidity. Composite maternal morbidity consisted of severe postpartum hemorrhage, perineal trauma, and prolonged hospital stay. Composite neonatal morbidity consisted of low 5-minute Apgar score, umbilical artery metabolic acidosis, birth trauma, and neonatal intensive care unit admission. RESULTS A total of 222 women were enrolled (113 in the experimental arm and 109 in the control arm). No significant differences between the two arms were found in composite measures of maternal (23.9% in the experimental group vs 22.9% in the control group, odds ratio 1.055, 95% CI 0.567-1.964) or neonatal morbidity (9.7% in the experimental group vs 6.4% in the control group, odds ratio 1.571, 95% CI 0.586-4.215), nor in any of the individual outcomes. CONCLUSIONS In this small randomized controlled trial that was stopped for futility before reaching the required sample size, transabdominal and transperineal ultrasound performed just before instrumental vaginal delivery did not reduce the incidence of adverse maternal and neonatal outcomes, when compared with routine clinical care.
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Affiliation(s)
- Joana G Barros
- Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, Portugal
| | - Maria Afonso
- Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, Portugal
| | - Ana T Martins
- Department of Obstetrics, Dr Alfredo da Costa Maternity Hospital, Lisbon, Portugal
| | - Ana I Carita
- Faculty of Human Motricity, University of Lisbon, Interdisciplinary Center of Human Perfomance, Biolad, Lisbon, Portugal
| | - Nuno Clode
- Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, Portugal
| | - Diogo Ayres-de-Campos
- Department of Obstetrics and Gynecology, Santa Maria University Hospital, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Luís M Graça
- Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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15
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Abstract
Safe management of the second stage of labor is important. Wait for spontaneous delivery, operative vaginal deliveries and second stage cesarean sections are all options when prolonged second stage occurs. The important question is which option to choose. Fetal head station and fetal head position are used to decide mode of delivery; this has traditionally been decided by performing a digital vaginal examination. Studies have shown that theses clinical examinations of both fetal head station and position are unreliable and that ultrasound might be better option. The International Society of Ultrasound in Obstetrics and Gynecology (ISUOG) published in 2018 guidelines on intrapartum ultrasound and recommends that ultrasound is performed for ascertainment of fetal head position and station before considering or performing an instrumental vaginal delivery for slow progress or arrested labor in the second stage. The determination of the fetal head position, fetal head station and the movement of the fetal head can easily be determined with the help of ultrasound and can help the clinicians in making the right decision on how to proceed when prolonged second stage of labor is diagnosed.
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Affiliation(s)
- Birgitte H Kahrs
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway - .,Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway -
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16
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Fetal molding examined with transperineal ultrasound and associations with position and delivery mode. Am J Obstet Gynecol 2020; 223:909.e1-909.e8. [PMID: 32585224 DOI: 10.1016/j.ajog.2020.06.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/12/2020] [Accepted: 06/18/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND To accommodate passage through the birth canal, the fetal skull is compressed and reshaped, a phenomenon known as molding. The fetal skull bones are separated by membranous sutures that facilitate compression and overlap, resulting in a reduced diameter. This increases the probability of a successful vaginal delivery. Fetal position, presentation, station, and attitude can be examined with ultrasound, but fetal head molding has not been previously studied with ultrasound. OBJECTIVE This study aimed to describe ultrasound-assessed fetal head molding in a population of nulliparous women with slow progress in the second stage of labor and to study associations with fetal position and delivery mode. STUDY DESIGN This was a secondary analysis of a population comprising 150 nulliparous women with a single fetus in cephalic presentation, with slow progress in the active second stage with pushing. Women were eligible for the study when an operative intervention was considered by the clinician. Molding was examined in stored transperineal two-dimensional and three-dimensional acquisitions and differentiated into occipitoparietal molding along the lambdoidal sutures, frontoparietal molding along the coronal sutures, and parietoparietal molding at the sagittal suture (molding in the midline). Molding could not be classified if positions were unknown, and these cases were excluded. We measured the distance from the molding to the head midline, molding step, and overlap of skull bones and looked for associations with fetal position and delivery mode. The responsible clinicians were blinded to the ultrasound findings. RESULTS Six cases with unknown position were excluded, leaving 144 women in the study population. Fetal position was anterior in 117 cases, transverse in 12 cases, and posterior in 15 cases. Molding was observed in 79 of 144 (55%) fetuses. Molding was seen significantly more often in occiput anterior positions than in non-occiput anterior positions (69 of 117 [59%] vs 10 of 27 [37%]; P=.04). In occiput anterior positions, the molding was seen as occipitoparietal molding in 68 of 69 cases and as parietoparietal molding in 1 case with deflexed attitude. Molding was seen in 19 of 38 (50%) of occiput anterior positions ending with spontaneous delivery, 42 of 71(59%) ending with vacuum extraction, and in 7 of 8 (88%) with failed vacuum extraction (P=.13). In 4 fetuses with occiput posterior positions, parietoparietal molding was diagnosed, and successful vacuum extraction occurred in 3 cases and failed extraction in 1. Frontoparietal molding was seen in 2 transverse positions and 4 posterior positions. One delivered spontaneously; vacuum extraction failed in 3 cases and was successful in 2. Only 1 of 11 fetuses with either parietoparietal or frontoparietal molding was delivered spontaneously. CONCLUSION The different types of molding can be classified with ultrasound. Occipitoparietal molding was commonly seen in occiput anterior positions and not significantly associated with delivery mode. Frontoparietal and parietoparietal moldings were less frequent than reported in old studies and should be studied in larger populations with mixed ethnicities.
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17
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Angeli L, Conversano F, Dall'Asta A, Volpe N, Simone M, Di Pasquo E, Pignatelli D, Schera GBL, Di Paola M, Ricciardi P, Ferretti A, Frusca T, Casciaro S, Ghi T. New technique for automatic sonographic measurement of change in head-perineum distance and angle of progression during active phase of second stage of labor. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:597-602. [PMID: 31909525 DOI: 10.1002/uog.21963] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/27/2019] [Accepted: 12/29/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the performance of a new ultrasound technique for the automatic assessment of the change in head-perineum distance (delta-HPD) and angle of progression (delta-AoP) during the active phase of the second stage of labor. METHODS This was a prospective observational cohort study including singleton term pregnancies with fetuses in cephalic presentation during the active phase of the second stage of labor. In each patient, two videoclips of 10 s each were acquired transperineally, one in the axial and one in the sagittal plane, between rest and the acme of an expulsive effort, in order to measure HPD and AoP, respectively. The videoclips were processed offline and the difference between the acme of the pushing effort and rest in HPD (delta-HPD) and AoP (delta-AoP) was calculated, first manually by an experienced sonographer and then using a new automatic technique. The reliability of the automatic algorithm was evaluated by comparing the automatic measurements with those obtained manually, which was considered as the reference gold standard. RESULTS Overall, 27 women were included. A significant correlation was observed between the measurements obtained by the automatic and the manual methods for both delta-HPD (intraclass correlation coefficient (ICC) = 0.97) and delta-AoP (ICC = 0.99). The high accuracy provided by the automatic algorithm was confirmed by the high values of the coefficient of determination (r2 = 0.98 for both delta-HPD and delta-AoP) and the low residual errors (root mean square error = 1.2 mm for delta-HPD and 1.5° for delta-AoP). A Bland-Altman analysis showed a mean difference of 0.52 mm (limits of agreement, -1.58 to 2.62 mm) for delta-HPD (P = 0.034) and 0.35° (limits of agreement, -2.54 to 3.09°) for delta-AoP (P = 0.39) between the manual and automatic measurements. CONCLUSIONS The automatic assessment of delta-AoP and delta-HPD during maternal pushing efforts is feasible. The automatic measurement of delta-AoP appears to be reliable when compared with the gold standard manual measurement by an experienced operator. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- L Angeli
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - F Conversano
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - A Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - N Volpe
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | | | - E Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - D Pignatelli
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - G B L Schera
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - M Di Paola
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - P Ricciardi
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - A Ferretti
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - T Frusca
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
| | - S Casciaro
- National Research Council, Institute of Clinical Physiology, Lecce, Italy
| | - T Ghi
- Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy
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18
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Angeli L, Conversano F, Dall'Asta A, Eggebø T, Volpe N, Marta S, Pisani P, Casciaro S, Di Paola M, Frusca T, Ghi T. Automatic measurement of head-perineum distance during intrapartum ultrasound: description of the technique and preliminary results. J Matern Fetal Neonatal Med 2020; 35:2759-2764. [PMID: 32727248 DOI: 10.1080/14767058.2020.1799974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the accuracy and reliability of a new ultrasound technique for the automatic assessment of the head-perineum distance (HPD) during childbirth. METHODS HPD was measured on a total of 40 acquisition sessions in 30 laboring women both automatically by an innovative algorithm and manually by trained sonographers, assumed as gold standard. RESULTS A significant correlation was found between manual and automatic measurements (Intra-CC = 0.994). High values of the coefficient of determination (r2=0.98) and low residual errors: RMSE = 2.01 mm (4.9%) were found. CONCLUSION The automatic algorithm for the assessment of the HPD represents a reliable technique.
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Affiliation(s)
- Laura Angeli
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | | | - Andrea Dall'Asta
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Torbjørn Eggebø
- National Center for Fetal Medicine, Trondheim University Hospital (St. Olavs Hospital), Trondheim, Norway.,Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nicola Volpe
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | | | - Paola Pisani
- Institute of Clinical Physiology, National Council Research, Lecce, Italy
| | - Sergio Casciaro
- Institute of Clinical Physiology, National Council Research, Lecce, Italy
| | - Marco Di Paola
- Institute of Clinical Physiology, National Council Research, Lecce, Italy
| | - Tiziana Frusca
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
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19
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Kamel R, Negm S, Montaguti E, Dodaro MG, Brunelli E, Di Donna G, Soliman E, Sharaf MF, ElHarty AS, Youssef A. Reliability of transperineal ultrasound for the assessment of the angle of progression in labor using parasagittal approach versus midsagittal approach. J Matern Fetal Neonatal Med 2019; 34:3175-3180. [PMID: 31640437 DOI: 10.1080/14767058.2019.1678143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the inter-method agreement between midsagittal (msAoP) and parasagittal (psAoP) measurements of the angle of progression (AoP) during labor. In addition, we aimed to evaluate the correlation between AoP measurements by both midsagittal and parasagittal approaches with the mode of delivery. METHODS We recruited a nonconsecutive series of women in active labor with a singleton uncomplicated term pregnancy with fetuses in vertex presentation. Women underwent transperineal ultrasound in the absence of uterine contractions or maternal pushing to measure both msAoP and psAoP. The inter-method agreement between the two acquisitions was then assessed. Lastly, both measurements were compared between women who had a vaginal delivery versus those who underwent cesarean section (CS). RESULTS Overall, 151 women were included in the study. We found an excellent agreement between msAoP and psAoP (ICC 0.935; 95% CI 0.912-0.953, p < .001). On the other hand, psAoP overestimated the measurements in comparison with msAoP (101.2 ± 15.6 versus 98.2 ± 16.0, p < .001). There was a significant correlation between both methods of AoP assessment and duration of the active second stage of labor and AoP measured by either method was significantly wider in patients who delivered vaginally compared to those who had a CS. CONCLUSIONS Our data showed a significant difference in the measured angle between the psAoP and the originally described msAoP. The automated measurements of AoP that have been introduced are designed using the parasagittal visualization of the more echogenic pubic arch, rather than the hypoechogenic pubic symphysis. We think that in the light of our data, care should be taken before applying data from midsagittal measurement in centers using the parasagittal automated approach.
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Affiliation(s)
- Rasha Kamel
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - Sherif Negm
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - Elisa Montaguti
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Maria Gaia Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Elena Brunelli
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gaetana Di Donna
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Ehab Soliman
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - Marwa Fouad Sharaf
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - Ahmed Salah ElHarty
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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20
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Youssef A, Dodaro MG, Montaguti E, Consolini S, Ciarlariello S, Farina A, Bellussi F, Rizzo N, Pilu G. Dynamic changes of fetal head descent at term before the onset of labor correlate with labor outcome and can be improved by ultrasound visual feedback. J Matern Fetal Neonatal Med 2019; 34:1847-1854. [PMID: 31394944 DOI: 10.1080/14767058.2019.1651266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the dynamic changes of angle of progression (AoP) before the onset of labor and their correlation with labor outcome and to investigate the effect of visual feedback using transperineal ultrasound on maternal pushing. METHODS We recruited a group of low-risk nulliparous women with singleton pregnancy at term. We measured AoP at rest, during pelvic floor contraction and Valsalva maneuver (before and after visual feedback). We compared AoP between women who delivered vaginally (VD) and those who underwent a cesarean section (CS). We also assessed the correlation between AoP and labor durations. RESULTS Overall, 222 women were included in the study; 129 (58.1%) had spontaneous VD, 35 (15.8%) had instrumental delivery, and 58 (26.1%) underwent CS. In comparison with rest, AoP decreased at PFMC (p < .001) and increased at first Valsalva (p < .001). AoP increased further significantly at Valsalva after visual feedback (p < .001). Women with VD had wider AoP at rest (p = .020), during Valsalva maneuver before (p = .024), and after visual feedback (p = .037). At cox regression analysis, wider AoP was associated with shorter first, second, and active second stages. CONCLUSION Wider AoP at rest and under Valsalva is associated with vaginal delivery, the shorter interval to delivery, and shorter labor duration in nulliparous women at term. The accuracy of AoP in the prediction of cesarean delivery is modest and is unlikely to be clinically applicable in isolation for the prediction of the mode of delivery.
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Affiliation(s)
- Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Maria Gaia Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Elisa Montaguti
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Consolini
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Ciarlariello
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Antonio Farina
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Federica Bellussi
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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Kamel R, Youssef A. How reliable is fetal occiput and spine position assessment prior to induction of labor? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:535-540. [PMID: 29947161 DOI: 10.1002/uog.19169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/16/2018] [Accepted: 06/18/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To assess the reliability of fetal occiput and spine position determination in nulliparous women prior to induction of labor (IOL), and to evaluate identification of fetal occiput and spine positions prior to IOL in the prediction of labor outcome. METHODS A series of 136 nulliparous women were recruited prospectively, immediately after the decision to perform IOL was made. Transabdominal ultrasound was performed to determine fetal head and spine positions. After at least 1 h, and prior to IOL, fetal occiput and spine positions were reassessed. Fetal occiput and spine positions were then compared between women who underwent vaginal delivery and those who delivered by Cesarean section. RESULTS On the first and second assessments, respectively, fetal occiput position was anterior in 55 (40.4%) and 62 (45.6%) women, transverse in 52 (38.2%) and 49 (36.0%) women, and posterior in 29 (21.3%) and 25 (18.4%) women, while fetal spine position was anterior in 58 (42.6%) and 52 (38.2%) women, transverse in 42 (30.9%) and 50 (36.8%) women, and posterior in 36 (26.5%) and 34 (25.0%) women. Discordance between the first and second assessments of fetal occiput position was identified in 34 (25.0%) women, whereas discordance of fetal spine position was observed in 40 (29.4%) women. The incidence of fetal occiput posterior position in women undergoing Cesarean section was comparable to that in the vaginal-delivery group (19 (18.8%) vs 6 (17.1%); P = 0.826), which was similarly the case for fetal posterior spine position (27 (26.7%) vs 7 (20%); P = 0.428). Women with fetal occiput posterior position had a longer induction-to-delivery interval in comparison to those with non-occiput posterior fetal position (1786 ± 805 vs 1347 ± 784 min; P = 0.013). CONCLUSIONS Fetal occiput and spine positions are dynamic in a considerable proportion of women undergoing IOL, and their assessment does not seem to correlate with mode of delivery. Occiput and spine position assessment in women prior to IOL is unlikely to be clinically useful. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Kamel
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
| | - A Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Malvasi A, Raimondo P, Beck R, Tinelli A, Kuczkowski KM. Intrapartum ultrasound monitoring of malposition and malrotation during labor neuraxial analgesia: maternal outcomes. J Matern Fetal Neonatal Med 2019; 33:3584-3590. [PMID: 30782016 DOI: 10.1080/14767058.2019.1579193] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objective: This study analyzes the important role of ultrasonography (IUS) related to the maternal outcomes in women with fetal persistent occiput posterior position (POPP) and asynclitism (A) in labor neuraxial analgesia (LNA).Study design: Prospective assessment of 148 primiparous women diagnosed with the prolonged second stage of labor. Transabdominal and transperineal IUS were used to detect fetal head position and to evaluate the angle of progression (AOP) and pubic arch angle (PAA). Statistical data about maternal aspects, modalities of delivery and maternal outcomes were observed.Results: In all parturients included in the study, the operative delivery rate was 73%. In patients delivered via cesarean section, the PAA was ≤ of 96.5°. There was statistical correlation between doses of LNA and Apgar score at first minute (r0.8).Conclusions: There is a greater frequency of Fetal POPP and asynclitism related with maternal complications. The results of our study confirmed the importance of determination of angle of progression (AoP) and PAA in the prolonged second stage of labor. Unfavorable AoP and PAA, in presence of POPP and A, are related with high percentage of operative delivery. If the prolonged labor and delivery in these patients exceed time limit proposed by American College of Obstetricians and Gynecologists guidelines, it may be viewed as a possible malpractice. In cases of POPP with asynclitism, in the second stage of labor detected by IUS it is advisable to discontinue the anesthetic drugs administration in LNA; because the labor pain is related to the dystocia, an operative delivery is necessary to avoid maternal and fetal complications.
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Affiliation(s)
- Antonio Malvasi
- Department Obstetrics and Gynecology, Santa Maria Hospital, GVM. Care & Research, Bari, Italy
| | - Pasquale Raimondo
- Pediatric Department of Anesthesia and Intensive Care Unit (General and Post Cardiac Surgery), Giovanni XXIII - Policlinico di Bari, Bari, Italy
| | - Renata Beck
- Department of Anesthesia, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Andrea Tinelli
- Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy
| | - Krzysztof Marek Kuczkowski
- Anesthesiology and Obstetrics and Gynecology, Texas Tech University Health Sciences Center at El Paso, El Paso, TX, USA
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Sainz JA, García-Mejido JA, Aquise A, Borrero C, Bonomi MJ, Fernández-Palacín A. A simple model to predict the complicated operative vaginal deliveries using vacuum or forceps. Am J Obstet Gynecol 2019; 220:193.e1-193.e12. [PMID: 30391443 DOI: 10.1016/j.ajog.2018.10.035] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Complicated operative vaginal deliveries are associated with high neonatal morbidity and maternal trauma, especially if the procedure is unsuccessful and a cesarean delivery is needed. The decision to perform an operative vaginal delivery has traditionally been based on a subjective assessment by digital vaginal examination combined with the clinical expertise of the obstetrician. Currently there is no method for objectively quantifying the likelihood of successful delivery. Intrapartum ultrasound has been introduced in clinical practice to help predict the progression and final method of delivery. OBJECTIVE The aim of this study was to compare predictive models for identifying complicated operative vaginal deliveries (vacuum or forceps) based on intrapartum transperineal ultrasound in nulliparous women. STUDY DESIGN We performed a prospective cohort study in nulliparous women at term with singleton pregnancies and full dilatation who underwent intrapartum transperineal ultrasound evaluation prior to operative vaginal delivery. Managing obstetricians were blinded to the ultrasound data. Intrapartum transperineal ultrasound (angle of progression, progression distance, and midline angle) was performed immediately before instrument application, both at rest and concurrently with pushing. Intrapartum evaluation of fetal biometric parameters (estimated fetal weight, head circumference, and biparietal diameter) was also carried out. An operative vaginal delivery was classified as complicated when 1 or more of the following complications occurred: ≥3 tractions needed; third- to fourth-degree perineal tear; severe bleeding during episiotomy repair (decrease of ≥2.5 g/dL in the hemoglobin level); or significant traumatic neonatal lesion (subdural-intracerebral hemorrhage, epicranial subaponeurotic hemorrhage, skeletal injuries, injuries to spine and spinal cord, or peripheral and cranial nerve injuries). Six predictive models were evaluated (information available in Table 2). RESULTS We recruited 84 nulliparous patients, of whom 5 were excluded because of the difficulty of adequately evaluating the biparietal diameter and head circumference. A total of 79 nulliparous patients were studied (47 vacuum deliveries, 32 forceps deliveries) with 13 cases in the occiput-posterior position. We identified 31 cases of complicated operative vaginal deliveries (19 vacuum deliveries and 12 forceps deliveries). No differences were identified in obstetric, neonatal, or intrapartum characteristics between the 2 study groups (operative uncomplicated vaginal delivery vs operative complicated vaginal delivery), with the following exceptions: estimated fetal weight (3243 ± 425 g vs 3565 ± 330 g; P = .001), biparietal diameter (93.2 ± 2.1 vs 95.2 ± 2.3 mm; P = .001), head circumference (336 ± 12 vs 348 ± 6.4 mm; P = .001), sex (female 62.5% vs 29.0%; P = .010), newborn weight (3258 ± 472 g vs 3499 ± 383 g; P = .027), and number of tractions (median, interquartile range) (1 [1-2] vs 4 [3-5]; P < .0005). To predict complicated operative deliveries, all 6 of the studied models presented an area under the receiver-operating characteristics curve between 0.863 and 0.876 (95% confidence intervals, 0.775-0.950 and 0.790-0.963; P < .0005). The results of the study met the criteria of interpretability and parsimony (simplicity), allowing us to identify a binary logistic regression model based on the angle of progression and head circumference; this model has an area under the receiver-operating characteristics curve of 0.876 (95% confidence interval, 0.790-0.963; P < .0005) and a calibration slope B of 0.984 (95% confidence interval, 0.0.726-1.243; P < .0005). CONCLUSION The combination of the angle of progression and the head circumference can predict 87% of complicated operative vaginal deliveries and can be performed in the delivery room.
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Youssef A, Kamel R. Ultrasound in labor: impact of a theoretical and practical course on caregiver's perspective and accuracy. J Matern Fetal Neonatal Med 2019; 33:3163-3169. [PMID: 30700229 DOI: 10.1080/14767058.2019.1570113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The aim of the present study was two-fold; first is to assess the impact of a theoretical and practical course on the caregiver's perspective on the use of ultrasound in labor. Second is to evaluate the impact of the course on the measurement of the angle of progression.Materials and methods: Obstetricians participating in the course responded twice to a questionnaire addressing the caregiver's perspective on the use of ultrasound in labor, before and at the end of the course. In addition, all participants measured the angle of progression on a digital simulation software once following the theoretical part and a second time after the conclusion of both the theoretical and practical sessions. All answers to the questionnaire were compared before versus after the course. The angle of progression assessments after the theoretical part and those after the course were compared with those performed by an expert operator.Results: Overall, data from 51 participants were analyzed. In comparison with the pre-course questionnaire, more participants after the course believed ultrasound can be a useful instrument for fetal occiput presentation diagnosis (45; 88.2% versus 26; 51%, p < .001) and for fetal head progression evaluation (37; 72.5% versus 19; 37.3%; p < .001). Although before the course, most participants (32; 62.7%) thought that the transperineal parameters were too complex to be applied, only 19 (37.3%) still considered the complexity of the ultrasound indices, an obstacle against their application in clinical practice after the course (p = .002). Regarding the angle of progression, precourse measurements showed a systematic overestimation in comparison with the gold standard. Furthermore, the coefficient of variation, more than halved following the practical simulation reflecting at least a doubling of the angle of progression (AoP) measurement precision (14.2 versus 5.5%).Conclusions: A theoretical and practical course conducted by expert operators may positively change obstetricians' perspective on the use of ultrasound in labor. Moreover, a practical session seems to improve the participants' accuracy and precision in the assessment of fetal head descent by transperineal ultrasound.
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Affiliation(s)
- Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Rasha Kamel
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
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Chan VYT, Lau WL, So MKP, Leung WC. Measuring angle of progression by transperineal ultrasonography to predict successful instrumental and cesarean deliveries during prolonged second stage of labor. Int J Gynaecol Obstet 2018; 144:192-198. [PMID: 30430566 DOI: 10.1002/ijgo.12712] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 08/23/2018] [Accepted: 11/13/2018] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To compare the angle of progression (AoP) measured by transperineal ultrasonography before indicating an instrumental delivery or cesarean delivery. METHODS A prospective observational study was conducted among women with singleton term pregnancies with prolonged second stage of labor at Kwong Wah Hospital, Hong Kong, China, between May 16, 2011, and May 25, 2016. Transabdominal and transperineal ultrasonography were performed to determine fetal head position and AoP, respectively, both at rest and during uterine contraction with pushing. Mode of delivery was decided after vaginal examination without relying on ultrasonography. RESULTS Of 143 women, 116 underwent successful instrumental delivery and 27 underwent cesarean delivery. Median AoP was 153.0° in the instrumental group versus 139.0° in the cesarean group at rest (P<0.001), and 182.5° in the instrumental group versus 156.5° in the cesarean group during contraction (P<0.001). The best predictive cutoff AoP for successful instrumental delivery was 138.7° at rest (sensitivity 86.2%, specificity 51.9%) and 160.9° during contraction (sensitivity 87.1%, specificity 74.1%). No between-group differences in AoP were found for ease of vacuum extraction at rest (P=0.457) or during contraction with pushing (P=0.095). CONCLUSION The AoP predicted approximately 80% of successful instrumental deliveries performed for prolonged second stage of labor.
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Affiliation(s)
- Viola Y T Chan
- Department of Obstetrics and Gynecology, Kwong Wah Hospital, Hong Kong, China
| | - Wai-Lam Lau
- Department of Obstetrics and Gynecology, Kwong Wah Hospital, Hong Kong, China
| | - Mike K P So
- Department of information Systems, Business Statistics and Operations Management, School of Business and Management, The Hong Kong University of Science and Technology, Hong Kong, China
| | - Wing-Cheong Leung
- Department of Obstetrics and Gynecology, Kwong Wah Hospital, Hong Kong, China
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Ghi T, Eggebø T, Lees C, Kalache K, Rozenberg P, Youssef A, Salomon LJ, Tutschek B. ISUOG Practice Guidelines: intrapartum ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:128-139. [PMID: 29974596 DOI: 10.1002/uog.19072] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/08/2018] [Accepted: 03/16/2018] [Indexed: 06/08/2023]
Abstract
The purpose of these Guidelines is to review the published techniques of ultrasound in labor and their practical applications, to summarize the level of evidence regarding the use of ultrasound in labor and to provide guidance to practitioners on when ultrasound in labor is clinically indicated and how the sonographic findings may affect labor management. We do not imply or suggest that ultrasound in labor is a necessary standard of care.
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Affiliation(s)
- T Ghi
- Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Eggebø
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - C Lees
- Centre for Fetal Care, Queen Charlottes and Chelsea Hospital, London, UK
| | - K Kalache
- Sidra Medical and Research Center, Doha, Qatar
| | - P Rozenberg
- Centre Hospitalier Poissy Saint Germain, Obstetrics & Gynaecology, Paris, France
| | - A Youssef
- Obstetrics and Gynecology, S. Orsola Malpighi Hospital, Bologna, Italy
| | - L J Salomon
- Hôpital Universitaire Necker-Enfants Malades, AP-HP, Université Paris Descartes, Maternité, Paris, France
- Société Française pour l'Amélioration des Pratiques Echographiques, SFAPE
| | - B Tutschek
- Prenatal Zurich, Heinrich-Heine-University, Medical Faculty, Zürich, Switzerland
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García-Mejido JA, de la Fuente-Vaquero P, Aquise-Pino A, Castro-Portillo L, Fernández-Palacín A, Sainz-Bueno JA. Can we predict levator ani muscle avulsion in instrumental deliveries through intrapartum transperineal ultrasound? J Matern Fetal Neonatal Med 2018; 32:3137-3144. [PMID: 29577793 DOI: 10.1080/14767058.2018.1457642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Introduction: To determine whether intrapartum translabial ultrasound (ITU) is useful for the prediction of levator ani muscle (LAM) avulsions in instrumental deliveries (vacuum and forceps). Materials and methods: Prospective, observational study, including (1/2016 - 5/2016) 77 nulliparous women, with singleton pregnancies of ≥37 weeks of gestation and with cephalic presentation, who required vacuum or forceps instrumentation to complete the delivery. The ITU parameters evaluated were Angle of Progression (AoP), Progression Distance (PD), Head Direction (HD), and Midline Angle (MLA), both at rest and with maternal push. Evaluation of LAM avulsion was performed at 6 months postpartum with 3-4D transperineal ultrasound. Complete avulsion was defined as an abnormal insertion of LAM in the lower pubic branch identified in all three central slices. Results: Data from 48 nulliparous women were finally included in the study (34 vacuum and 14 forceps). We observed no difference in obstetric parameters between the two study groups (group with avulsion of LAM -14 cases, 29.2% - and group without avulsion of LAM -34 cases, 70.8%). The "LAM avulsion group" had an AoP and a PD of 136.7 ± 22.4 and 43.5 ± 15.6, respectively, versus 141.6 ± 21.3 and 47.2 ± 16.8 recorded in the group without avulsion (NS), respectively. We obtained a ROC curve for AoP and PD with a push of 0.66 (95% CI, 0.28-1.00) and 0.57 (95% CI, 0.39-0.75), respectively. Conclusions: ITU is not a useful technique to predict the occurrence of LAM avulsion in instrumental deliveries with vacuum or forceps.
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Affiliation(s)
| | | | - Adriana Aquise-Pino
- c Harris Birthright Research Centre for Fetal Medicine , King's College Hospital , London , UK
| | - Laura Castro-Portillo
- a Department of Obstetrics and Gynecology , Valme University Hospital , Seville , Spain
| | - Ana Fernández-Palacín
- d Biostatistics Unit, Department of Preventive Medicine and Public Health , University of Seville , Seville , Spain
| | - José Antonio Sainz-Bueno
- a Department of Obstetrics and Gynecology , Valme University Hospital , Seville , Spain.,e Department of Obstetrics and Gynecology , University of Seville , Seville , Spain
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Sainz JA, García-Mejido JA, Aquise A, Bonomi MJ, Borrero C, De La Fuente P, Fernández-Palacín A. Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women. Acta Obstet Gynecol Scand 2017; 96:1490-1497. [DOI: 10.1111/aogs.13230] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 09/01/2017] [Indexed: 12/28/2022]
Affiliation(s)
- José A. Sainz
- Department of Obstetrics and Gynecology; Valme University Hospital; Seville Spain
- Department of Obstetrics and Gynecology; University of Seville; Seville Spain
| | | | - Adriana Aquise
- Department of Obstetrics and Gynecology; Valme University Hospital; Seville Spain
| | - María J. Bonomi
- Department of Obstetrics and Gynecology; Valme University Hospital; Seville Spain
| | - Carlota Borrero
- Department of Obstetrics and Gynecology; Valme University Hospital; Seville Spain
| | - Paloma De La Fuente
- Department of Obstetrics and Gynecology; Valme University Hospital; Seville Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit; Department of Preventive Medicine and Public Health; University of Seville; Seville Spain
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Sainz JA, Fernández-Palacín A, Borrero C, Aquise A, Ramos Z, García-Mejido JA. Intra and interobserver variability of intrapartum transperineal ultrasound measurements with contraction and pushing. J OBSTET GYNAECOL 2017; 38:333-338. [DOI: 10.1080/01443615.2017.1354179] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- José A. Sainz
- Department of Obstetrics and Gynaecology, Valme University Hospital, Seville, Spain
- Department of Obstetrics and Gynaecology, University of Seville, Seville, Spain
| | - Ana Fernández-Palacín
- Biostatistics Unit, Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain
| | - Carlota Borrero
- Department of Obstetrics and Gynaecology, Valme University Hospital, Seville, Spain
| | - Adriana Aquise
- Department of Obstetrics and Gynaecology, Valme University Hospital, Seville, Spain
- Harris Birthright Research Centre for Fetal Medicine, King’s College Hospital, London, UK
| | - Zenaida Ramos
- Department of Obstetrics and Gynaecology, Valme University Hospital, Seville, Spain
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Perlman S, Kivilevitch Z, Moran O, Katorza E, Kees S, Achiron R, Gilboa Y. Correlation between clinical fetal head station and sonographic angle of progression during the second stage of labor. J Matern Fetal Neonatal Med 2017; 31:2905-2910. [DOI: 10.1080/14767058.2017.1359533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Sharon Perlman
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Kivilevitch
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Orit Moran
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Salim Kees
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reuven Achiron
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yinon Gilboa
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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García Mejido JA, De la Fuente Vaquero P, Fernández Palacín A, Aquise Pino A, Bonomi Barby MJ, Sainz Bueno JA. Influence of difficulty of instrumentation with vacuum on the rate of levator ani muscle avulsion identified by 3–4 d transperineal ultrasound. J Matern Fetal Neonatal Med 2017; 31:591-596. [DOI: 10.1080/14767058.2017.1293022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | | | | | - José Antonio Sainz Bueno
- Hospital Universitario de Valme, Obstetrica y Ginecología, Sevilla, España
- Universidad de Sevilla, Sevilla, Andalucía, España
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Antonio Sainz J, Borrero C, Aquise A, García-Mejido JA, Gutierrez L, Fernández-Palacín A. Intrapartum translabial ultrasound with pushing used to predict the difficulty in vacuum-assisted delivery of fetuses in non-occiput posterior position. J Matern Fetal Neonatal Med 2016; 29:3400-5. [DOI: 10.3109/14767058.2015.1130816] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Eggebø TM, Hassan WA, Salvesen KÅ, Torkildsen EA, Østborg TB, Lees CC. Prediction of delivery mode by ultrasound-assessed fetal position in nulliparous women with prolonged first stage of labor. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:606-610. [PMID: 25536955 DOI: 10.1002/uog.14773] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 09/22/2014] [Accepted: 12/16/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To ascertain if fetal head position on transabdominal ultrasound is associated with delivery by Cesarean section in nulliparous women with a prolonged first stage of labor. METHODS This was a prospective observational study performed at Stavanger University Hospital, Norway, and Addenbrooke's Hospital, Cambridge, UK, between January 2012 and April 2013. Nulliparous pregnant women with a singleton cephalic presentation at term and prolonged labor had fetal head position assessed by ultrasound. The main outcome was Cesarean section vs vaginal delivery, and secondary outcomes were association of fetal head position with operative vaginal delivery and duration of remaining time in labor. RESULTS Fetal head position was assessed successfully by ultrasound examination in 142/150 (95%) women. In total, 19/50 (38%) women with a fetus in the occiput posterior (OP) position were delivered by Cesarean section compared with 16/92 (17%) women with a fetus in a non-OP position (P = 0.01). On multivariable logistic regression analysis, the OP position predicted delivery by Cesarean section with an odds ratio (OR) of 2.9 (95% CI, 1.3-6.7; P = 0.01) and induction of labor with an OR of 2.4 (95% CI, 1.0-5.6; P = 0.05). Fetal head position was not associated with operative vaginal delivery or with remaining time in labor. The agreement between a digital and an ultrasound assessment of OP position was poor (Cohen's kappa = 0.19; P = 0.18). CONCLUSION OP fetal head position assessed by transabdominal ultrasound was significantly associated with delivery by Cesarean section.
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Affiliation(s)
- T M Eggebø
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
- National Center for Fetal Medicine, Trondheim University Hospital (St Olavs Hospital), Trondheim, Norway
| | - W A Hassan
- Fetal Medicine Department, Rosie Maternity Hospital, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - K Å Salvesen
- Department of Obstetrics and Gynaecology, Clinical Sciences, Lund University, Lund, Sweden
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Trondheim, Norway
| | - E A Torkildsen
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - T B Østborg
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger, Norway
| | - C C Lees
- Fetal Medicine Department, Rosie Maternity Hospital, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, UK
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Dębska M, Kretowicz P, Dębski R. Intrapartum sonography - eccentricity or necessity? J Ultrason 2015; 15:125-36. [PMID: 26675398 PMCID: PMC4579748 DOI: 10.15557/jou.2015.0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 04/01/2015] [Accepted: 04/07/2015] [Indexed: 11/22/2022] Open
Abstract
Ultrasonography has been extensively used in obstetrics and gynecology since 1980's. It found application in pediatric gynecology, procreation period, post-menopause, pregnancy monitoring and after delivery. Although the first reports on the use of ultrasonography in assessing delivery mechanism were published in 1990's, yet to date labor progress is evaluated by means of physical examination in most delivery units. Intrapartum sonography is not routinely performed despite the fact that numerous studies documented high error rates of conventional obstetrical examination. Even an experienced physician makes a mistake in every third case of the fetal head descent and fontanelle position assessment. Nowadays, obstetrician's role is not to strain for vaginal delivery at all costs, but to provide the patient in labor and her newborn with maximal safety. To achieve this objective, an obstetrician should distinguish between women who will deliver spontaneously and whose who require Cesarean section. Proper decision should be made on the basis of objective and valid evaluation of obstetric setting, which cannot be achieved solely with physical examination. Intrapartum sonography was shown to be far more accurate than digital examination. Moreover, it is not technically demanding, provides high reproducibility and neither increases the rate of ascending infection or causes discomfort to the patient. Current research suggests that if used routinely, intrapartum sonography can increase the safety of labor and reduce cesarean section rate.
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Affiliation(s)
- Marzena Dębska
- II Department of Obstetrics and Gynaecology, The Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Piotr Kretowicz
- II Department of Obstetrics and Gynaecology, The Medical Centre of Postgraduate Education, Warsaw, Poland
| | - Romuald Dębski
- II Department of Obstetrics and Gynaecology, The Medical Centre of Postgraduate Education, Warsaw, Poland
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Sainz JA, Borrero C, Aquise A, Serrano R, Gutiérrez L, Fernández-Palacín A. Utility of intrapartum transperineal ultrasound to predict cases of failure in vacuum extraction attempt and need of cesarean section to complete delivery. J Matern Fetal Neonatal Med 2015; 29:1348-52. [DOI: 10.3109/14767058.2015.1048680] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Patwardhan M, Hernandez-Andrade E, Ahn H, Korzeniewski SJ, Schwartz A, Hassan SS, Romero R. Dynamic Changes in the Myometrium during the Third Stage of Labor, Evaluated Using Two-Dimensional Ultrasound, in Women with Normal and Abnormal Third Stage of Labor and in Women with Obstetric Complications. Gynecol Obstet Invest 2015; 80:26-37. [PMID: 25634647 PMCID: PMC4536955 DOI: 10.1159/000370001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/18/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate dynamic changes in myometrial thickness during the third stage of labor. METHODS Myometrial thickness was measured using ultrasound at one-minute time intervals during the third stage of labor in the mid-region of the upper and lower uterine segments in 151 patients including: women with a long third stage of labor (n = 30), postpartum hemorrhage (n = 4), preterm delivery (n = 7) and clinical chorioamnionitis (n = 4). Differences between myometrial thickness of the uterine segments and as a function of time were evaluated. RESULTS There was a significant linear increase in the mean myometrial thickness of the upper uterine segments, as well as a significant linear decrease in the mean myometrial thickness of the lower uterine segments until the expulsion of the placenta (p < 0.001). The ratio of the measurements of the upper to the lower uterine segments increased significantly as a function of time (p < 0.0001). In women with postpartum hemorrhage, preterm delivery, and clinical chorioamnionitis, an uncoordinated pattern among the uterine segments was observed. CONCLUSION A well-coordinated activity between the upper and lower uterine segments is demonstrated in normal placental delivery. In some clinical conditions this pattern is not observed, increasing the time for placental delivery and the risk of postpartum hemorrhage.
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Affiliation(s)
- Manasi Patwardhan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University, Detroit, Michigan; USA
| | - Edgar Hernandez-Andrade
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University, Detroit, Michigan; USA
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Hyunyoung Ahn
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University, Detroit, Michigan; USA
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Steven J Korzeniewski
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University, Detroit, Michigan; USA
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Alyse Schwartz
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Sonia S Hassan
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Wayne State University, Detroit, Michigan; USA
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA
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Yeo L. Re: The sonopartogram: a novel method for recording the progress of labor by ultrasound. W. A. Hassan, T. Eggebø, M. Ferguson, A. Gillett, J. Studd, D. Pasupathy and C. C. Lees. Ultrasound Obstet Gynecol 2014; 43: 189-194. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:137-138. [PMID: 24497420 DOI: 10.1002/uog.13300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- L Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA.
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