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Mappa I, Masturzo B, Carbone IF, Kiener A, Maruotti GM, Pintucci A, Suprani A, Visentin S, Ghi T, Rizzo G. A national survey on current practice of ultrasound in labor ward. J Perinat Med 2024; 52:509-514. [PMID: 38651816 DOI: 10.1515/jpm-2024-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVES Use of ultrasonography has been suggested as an accurate adjunct to clinical evaluation of fetal position and station during labor. There are no available reports concerning its actual use in delivery wards. The aim of this survey was to evaluate the current practice regarding the use of ultrasonography during labor. METHODS A questionnaire was sent to members of the Italian Society of Ultrasound in Obstetrics and Gynecology employed in delivery wards. The qFeuestionnaire was made up of 22 questions evaluating participant characteristics and the current use of ultrasound in labor in their hospital of employment. The answers were grouped according to participant characteristics. RESULTS A total of 200 participants replied. Ultrasound was considered useful before an operative vaginal delivery by 59.6 % of respondents, while 51.8 and 52.5 % considered it useful in the management of prolonged first and second stages of labor, respectively. The major indication for ultrasound use during labor was the assessment of fetal occiput position. The major difficulties in its application were the perceived lack of training and the complexity of the ultrasound equipment use. Participants that reported fewer difficulties were those employed in hospitals with a higher number of deliveries or having delivery units with more years of experience using ultrasound in labor, or those who had attended specific training courses. CONCLUSIONS The results indicate that, despite the reported evidence of a higher accuracy of ultrasound compared to clinical evaluation in assessing fetal position and station, its use is still limited, even amongst maternal-fetal medicine practitioners specialized in ultrasonography.
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Affiliation(s)
- Ilenia Mappa
- Department of Obstetrics and Gynecology, 9318 Fondazione Policlinico di Tor Vergata, University of Rome Tor Vergata , Rome, Italy
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology, Ospedale di Biella, Biella, Italy
| | - Ilma Floriana Carbone
- Unit of Obstetrics, Department of Woman, Child and Neonate, 9339 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico , Milan, Italy
| | - Ariane Kiener
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, 9370 University of Parma , Parma, Italy
| | | | - Armando Pintucci
- Department of Obstetrics and Gynaecology, ASST di Monza, Desio, Italy
| | - Alice Suprani
- Department of Women's and Children's Health, Forlì-Cesena, Cesena, Italy
| | - Silvia Visentin
- Department of Women's and Children's Health, 9308 University of Padua , Padova, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, 9370 University of Parma , Parma, Italy
| | - Giuseppe Rizzo
- Department of Obstetrics and Gynecology, 9318 Fondazione Policlinico di Tor Vergata, University of Rome Tor Vergata , Rome, Italy
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Skinner SM, Neil P, Hodges RJ, Murray NM, Mol BW, Rolnik DL. The use of intrapartum ultrasound in operative vaginal birth: a retrospective cohort study. Am J Obstet Gynecol MFM 2024; 6:101345. [PMID: 38479490 DOI: 10.1016/j.ajogmf.2024.101345] [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: 02/23/2024] [Accepted: 03/06/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Poor outcomes from operative vaginal birth have been associated with failure to recognize malposition, breakdown in interdisciplinary communication, and deviation from accepted guidelines. We recently implemented a safety bundle including routine intrapartum ultrasound and a structured time-out and procedural checklist aiming to reduce maternal and perinatal morbidity from operative vaginal birth. OBJECTIVE This study aimed to compare births where intrapartum ultrasound was used and those where it was not used during a safety bundle implementation period at Monash Health. STUDY DESIGN We performed a retrospective cohort study at Monash Health during the transitional phase of implementing an operative vaginal birth safety bundle. We studied all women with operative vaginal birth and fully dilated cesarean delivery with a singleton cephalic term fetus. We compared births for which intrapartum ultrasound was used and those for which it was not. The primary outcome was neonates delivered in an unexpected position. Neonatal and maternal morbidity were also assessed, including a neonatal composite of Apgar score <7 at 5 minutes, cord lactate >8 mmol/L, need for resuscitation, significant birth trauma, or neonatal intensive care unit admission. To control for confounding by indication, we estimated propensity scores for the probability of using intrapartum ultrasound for each case based on maternal and labor characteristics, and adjusted the effect estimates for the propensity scores using multivariable logistic regression models. RESULTS From August 2022 to July 2023, there were 1205 operative vaginal births or fully dilated cesarean deliveries at Monash Health, including 743 (61.7%) forceps, 346 (28.7%) vacuum, and 116 (9.6%) fully dilated cesarean deliveries. Over this time, we observed increased uptake of intrapartum ultrasound from 26% in August 2022 to 60% (P<.001) in July 2023, of the time-out from 21% to 58% (P<.001), and the checklist from 33% to 80% (P<.001) of operative second-stage births. Among the births where intrapartum ultrasound was used (n=509), compared with those where it was not (n=696), there were significantly more forceps births (67% vs 58%; adjusted odds ratio, 1.35; 95% confidence interval, 1.05-1.74; P=.021) and a reduction in vacuum births (24% vs 32%; adjusted odds ratio, 0.77; 95% confidence interval, 0.58-1.01; P=.059). There were no significant differences in fully dilated cesarean delivery or maternal morbidity. Intrapartum ultrasound use was associated with significantly fewer infants being delivered in an unexpected position (0.2% vs 2.2%; adjusted odds ratio, 0.08; 95% confidence interval, 0.00-0.44; P=.019) and a significant reduction in composite neonatal morbidity (22% vs 25%; adjusted odds ratio, 0.73; 95% confidence interval, 0.54-0.97; P=.031). CONCLUSION During the implementation of a safety bundle, the use of ultrasound before operative vaginal birth was associated with fewer infants delivered in an unexpected position and reduced neonatal morbidity.
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Affiliation(s)
- Sasha M Skinner
- Department of Obstetrics and Gynaecology, Women's and Newborns, Monash Health, Melbourne, Australia (Drs Skinner, Neil, and Hodges, Ms Murray, and Dr Rolnik); Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia (Drs Skinner, Mol, and Rolnik).
| | - Peter Neil
- Department of Obstetrics and Gynaecology, Women's and Newborns, Monash Health, Melbourne, Australia (Drs Skinner, Neil, and Hodges, Ms Murray, and Dr Rolnik)
| | - Ryan J Hodges
- Department of Obstetrics and Gynaecology, Women's and Newborns, Monash Health, Melbourne, Australia (Drs Skinner, Neil, and Hodges, Ms Murray, and Dr Rolnik)
| | - Nadine M Murray
- Department of Obstetrics and Gynaecology, Women's and Newborns, Monash Health, Melbourne, Australia (Drs Skinner, Neil, and Hodges, Ms Murray, and Dr Rolnik)
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia (Drs Skinner, Mol, and Rolnik)
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Women's and Newborns, Monash Health, Melbourne, Australia (Drs Skinner, Neil, and Hodges, Ms Murray, and Dr Rolnik); Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia (Drs Skinner, Mol, and Rolnik)
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Kong CW, To WWK. Precision of vacuum cup placement and its association with subgaleal hemorrhage and associated morbidity in term neonates. Arch Gynecol Obstet 2024; 309:1411-1419. [PMID: 37017783 DOI: 10.1007/s00404-023-07018-4] [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: 12/20/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
PURPOSE To evaluate whether the precision of vacuum cup placement is associated with failed vacuum extraction(VE), neonatal subgaleal hemorrhage(SGH) and other VE-related birth trauma. METHODS All women with singleton term cephalic fetuses with attempted VE were recruited over a period of 30 months. Neonates were examined immediately after birth and the position of the chignon documented to decide whether the cup position was flexing median or suboptimal. Vigilant neonatal surveillance was performed to look for VE-related trauma, including subgaleal/subdural hemorrhages, skull fractures, scalp lacerations. CT scans of the brain were ordered liberally as clinically indicated. RESULTS The VE rate was 5.89% in the study period. There were 17(4.9%) failures among 345 attempted VEs. Thirty babies suffered from subgaleal/subdural hemorrhages, skull fractures, scalp lacerations or a combination of these, giving an incidence of VE-related birth trauma of 8.7%. Suboptimal cup positions occurred in 31.6%. Logistic regression analysis showed that failed VE was associated with a non-occipital anterior fetal head position (OR 3.5, 95% CI 1.22-10.2), suboptimal vacuum cup placement (OR 4.13, 95% CI 1.38-12.2) and a longer duration of traction (OR 8.79, 95% CI 2.13-36.2); while, VE-related birth trauma was associated with failed VE (OR 3.93, 95% CI 1.08-14.3) and more pulls (OR 4.07, 95% CI 1.98-8.36). CONCLUSION Suboptimal vacuum cup positions were related to failed VE but not to SGH and other vacuum-related birth trauma. While optimal flexed median cup positions should be most desirable mechanically to effect delivery, such a position does not guarantee prevention of SGH.
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Affiliation(s)
- Choi Wah Kong
- Department of Obstetrics and Gynaecology, United Christian Hospital, 130 Hip Wo Street, Kwun Tong, Hong Kong, China.
| | - William Wing Kee To
- Department of Obstetrics and Gynaecology, United Christian Hospital, 130 Hip Wo Street, Kwun Tong, Hong Kong, China
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Ghi T, Dall'Asta A. Sonographic evaluation of the fetal head position and attitude during labor. Am J Obstet Gynecol 2024; 230:S890-S900. [PMID: 37278991 DOI: 10.1016/j.ajog.2022.06.003] [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: 07/05/2021] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 06/07/2023]
Abstract
Fetal malpresentation, malposition, and asynclitism are among the most common determinants of a protracted active phase of labor, arrest of dilatation during the first stage, and arrest of descent in the second stage. The diagnosis of these conditions is traditionally based on vaginal examination, which is subjective and poorly reproducible. Intrapartum sonography has been demonstrated to yield higher accuracy than vaginal examination in characterizing fetal malposition, and some guidelines endorse its use for the verification of the occiput position before performing an instrumental delivery. It is also useful for the objective diagnosis of the malpresentation or asynclitism of the fetal head. According to our experience, the sonographic assessment of the head position in labor is simple to perform also for clinicians with basic ultrasound skills, whereas the assessment of malpresentation and asynclitism warrants a higher level of expertise. When clinically appropriate, the fetal occiput position can be easily ascertained using transabdominal sonography combining the axial and the sagittal planes. With the transducer positioned on the maternal suprapubic region, the fetal head can be visualized, and landmarks including the fetal orbits, the midline, and the occiput itself with the cerebellum and the cervical spine (depending on the type of fetal position) can be demonstrated below the probe. Sinciput, brow, and face represent the 3 "classical" variants of cephalic malpresentation and are characterized by a progressively increasing degree of deflexion from vertex presentation. Transabdominal sonography has been recently suggested for the objective assessment of the fetal head attitude when a cephalic malpresentation is clinically suspected. Fetal attitude can be evaluated on the sagittal plane with either a subjective or an objective approach. Two different sonographic parameters such as the occiput-spine angle and the chin-chest angle have been recently described to quantify the degree of flexion in fetuses in non-occiput-posterior or occiput-posterior position, respectively. Finally, although clinical examination still represents the mainstay of diagnosis of asynclitism, the use of intrapartum sonography has been shown to confirm the digital findings. The sonographic diagnosis of asynclitism can be achieved in expert hands using a combination of transabdominal and transperineal sonography. At suprapubic sonography on the axial plane only, 1 orbit can be visualized (squint sign) while the sagittal suture appears anteriorly (posterior asynclitism) or posteriorly (anterior asynclitism) displaced. Eventually the transperineal approach does not allow the visualization of the cerebral midline on the axial plane if the probe is perpendicular to the fourchette. In this expert review we summarize the indications, technique, and clinical role of intrapartum sonographic evaluation of fetal head position and attitude.
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Affiliation(s)
- Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy.
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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Wilson RD. Fostering Excellence in Obstetrical Surgery. J Healthc Leadersh 2023; 15:355-373. [PMID: 38046534 PMCID: PMC10691271 DOI: 10.2147/jhl.s404498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction This obstetric surgery review is directed toward the common obstetrical surgeries (caesarean delivery, VBAC/TOLAC, operative vaginal delivery, placenta accreta spectrum) with evidence for quality and safety to allow for obstetrical outcome excellence. Materials and Methods This focused scoping review has used a structured process for article identification and inclusion for each of the focused surgeries. Results The review results provide an obstetrical surgery (OS) overview for caesarean delivery, vaginal birth after caesarean delivery and/or trial of labor after caesarean delivery, operative vaginal delivery, placenta accreta spectrum; considerations for quality and safety variance due to non-clinical human factors; quality improvement (QI) tools; OS QI implementation cohorts; implementation considering certain barriers and solutions. Conclusion Administrative health care systems and obstetrical surgery care providers cannot afford, not to consider and implement, certain evidenced-based "bottom-up/top-down" processes for quality and safety, as the patients will demand the quality and the safety, but the lawyers should not have to enforce it.
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Affiliation(s)
- R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
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Alves ÁLL, Silva LBD, Filho BJA, Nunes RD. Operative vaginal delivery. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:422-434. [PMID: 37595600 PMCID: PMC10438968 DOI: 10.1055/s-0043-1772581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Affiliation(s)
| | | | - Breno José Acauan Filho
- Escola de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Santana EFM, Castello RG, Passos MET, Ribeiro GCF, Araujo Júnior E. How to Reach the Best Ultrasound Performance in the Delivery Room. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:1070-1077. [PMID: 36580951 PMCID: PMC9800070 DOI: 10.1055/s-0042-1759773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Ultrasonography is an instrument that is present in the maternal-fetal assessment throughout pregnancy and with widely documented benefits, but its use in intrapartum is becoming increasingly relevant. From the assessment of labor progression to the assessment of placental disorders, ultrasound can be used to correlate with physiological findings and physical examination, as its benefit in the delivery room cannot yet be proven. There are still few professionals with adequate training for its use in the delivery room and for the correct interpretation of data. Thus, this article aims to present a review of the entire applicability of ultrasound in the delivery room, considering the main stages of labor. There is still limited research in evidence-based medicine of its various possible uses in intrapartum, but it is expected that further studies can bring improvements in the quality of maternal and neonatal health during labor.
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Affiliation(s)
- Eduardo Félix Martins Santana
- Medical Course, Albert Einstein Medical School, São Paulo, SP, Brazil.,Fetal Medicine Unit, Albert Einstein Hospital, São Paulo, SP, Brazil.
| | | | | | | | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil.,Medical Course, Municipal University of Sao Caetano do Sul, São Paulo, SP, Brazil.,Address for correspondence Edward Araujo Junior, PhD Rua Borges Lagoa, 1341, 04038-034, Vila Clementino, São Paulo, SPBrazil
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Rizzo G, Ghi T, Henrich W, Tutschek B, Kamel R, Lees CC, Mappa I, Kovalenko M, Lau W, Eggebo T, Achiron R, Sen C. Ultrasound in labor: clinical practice guideline and recommendation by the WAPM-World Association of Perinatal Medicine and the PMF-Perinatal Medicine Foundation. J Perinat Med 2022; 50:1007-1029. [PMID: 35618672 DOI: 10.1515/jpm-2022-0160] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 12/27/2022]
Abstract
This recommendation document follows the mission of the World Association of Perinatal Medicine in collaboration with the Perinatal Medicine Foundation. We aim to bring together groups and individuals throughout the world for standardization to implement the ultrasound evaluation in labor ward and improve the clinical management of labor. Ultrasound in labor can be performed using a transabdominal or a transperineal approach depending upon which parameters are being assessed. During transabdominal imaging, fetal anatomy, presentation, liquor volume, and placental localization can be determined. The transperineal images depict images of the fetal head in which calculations to determine a proposed fetal head station can be made.
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Affiliation(s)
- Giuseppe Rizzo
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- UOC Ostetricia e Ginecologia Azienda Ospedaliera Universitaria di Parma, Parma, Italy
- Della Scuola di Specializzazione in Ostetricia e Ginecologia Presidente del CdS Ostetricia, Parma, Italy
| | - Wolfgang Henrich
- Department of Obstetrics, University Medical Center Berlin, Charité, Berlin, Germany
| | - Boris Tutschek
- Specialist in Gynecology and Obstetrics FMH, Focus Obstetrics and Feto-Maternal Medicine, Zurich, Switzerland
| | - Rasha Kamel
- Department of Obstetrics and Gynecology Maternal-Fetal medicine unit, Cairo University, Cairo, Egypt
| | - Christoph C Lees
- Imperial College London and Head of Fetal Medicine, Imperial College Healthcare NHS Trust, London, UK
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Ilenia Mappa
- Università di Roma Tor Vergata, Unità Operativa di Medicina Materno Fetale Ospedale Cristo Re Roma, Rome, Italy
| | | | - Wailam Lau
- Department of O&G, Kwong Wah Hospital, Hong Kong SAR, China
| | - Torbjorn Eggebo
- National center for fetal medicine, St.Olavs Hospital, Trondheim, Norway
| | - Reuven Achiron
- Department of Obstetrics and Gynecology, Ultrasound unit, Tel-Hashomer, Sackler School of Medicine, Tel-Aviv University, Ramat-Gan, Israel
| | - Cihat Sen
- Perinatal Medicine Foundation, Istanbul, Turkey
- Department of Perinatal Medicine, Memorial BAH Hospital, Istanbul, Turkey
- Department of Perinatal Medicine, Obstetrics and Gynecology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Mappa I, D'Antonio F, Ghi T, Rizzo G. Ultrasound before instrumental vaginal delivery: A useful tool to avoid misdiagnosis of fetal head position. Acta Obstet Gynecol Scand 2022; 101:1342-1343. [PMID: 36129096 PMCID: PMC9812206 DOI: 10.1111/aogs.14463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Ilenia Mappa
- Department of Obstetics and Gynecology, Fondazione Policlinico Tor VergataUniversità di Roma Tor VergataRomeItaly
| | | | - Tullio Ghi
- Department of Obstetrics and GynecologyUniversità di ParmaParmaItaly
| | - Giuseppe Rizzo
- Department of Obstetics and Gynecology, Fondazione Policlinico Tor VergataUniversità di Roma Tor VergataRomeItaly
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Liu Z, Fu Z, Yang L. The role of ultrasound before instrumental vaginal delivery may be underestimated. Acta Obstet Gynecol Scand 2022; 101:1340-1341. [PMID: 36125389 PMCID: PMC9812093 DOI: 10.1111/aogs.14458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 01/07/2023]
Affiliation(s)
- Zhengli Liu
- Department of High‐risk ObstetricsGansu Provincial Maternity and Child‐care HospitalLanzhou CityGansuChina
| | - Zhongxia Fu
- Department of PediatricsGansu Provincial Maternity and Child‐care HospitalLanzhou CityGansuChina
| | - Lin Yang
- Perinatal Medical CenterGansu Provincial Maternity and Child‐care HospitalLanzhou CityGansuChina
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Bovbjerg ML, Tucker CM, Pillai S. Current Resources for Evidence-Based Practice, March 2022. J Obstet Gynecol Neonatal Nurs 2022; 51:225-237. [PMID: 35150643 DOI: 10.1016/j.jogn.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of systemic racism and its effect on maternal health in the United States and commentaries on reviews focused on barriers and facilitators to HPV vaccination and delayed cord clamping in preterm infants.
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