Intrapartum sonography - eccentricity or necessity?

Intrapartum ultrasound and mother acceptance: A study with informed consent and questionnaire

Introduction

Intrapartum ultrasound (IU) is used in the delivery ward; even if IU monitors the labouring women, it could be perceived as a discomfort and even as an" obstetric violence", because it is a young technique, not often well "accepted". A group of clinicians aimed at obtain an informed consent from patients, prior to perform a translabial ultrasound (TU). The aim of this study was to evaluate the acceptance of both translabial and transabdominal IU.

Methods

In this study, performed at the University Hospital of Bari (Unit of Obstetrics and Gynecology), were enrolled 103 patients in the first or second stage of labor in singleton cephalic presentation. A statistical frequency and an association analysis were performed. As a significant result, we consider the peace of mind/satisfaction and the" obstetric violence". IU was performed both transabdominal and translabial to determine the presentation, head positions, angle of progression and head perineum distance. During the first and second stage of labor, the ASIUG questionnaires (Apulia study intrapartum ultrasonography group) were administered.

Results

74 (71, 84%) patients underwent IU and 29 had a vaginal examination (28, 15%). Significant less "violence" has been experienced with a IU (73 out 74/98, 65%) and only one person (1 /1, 35%) recorded that. On the contrary, 10 patients (10/29) perceived that "violence" (34, 48%) while 19 (65, 52%) did not respond on a similar way, after a vaginal examination (VE). More patients felt satisfaction (71 out 74/95, 95%) with the use of IU and only 3 (3/4, 05%) felt unease. A different picture was evident in the vaginal examination group. Only 17 patients (17 out 29/58, 62%) felt comfort while 12 (41, 38%) felt unease.

Conclusions

In our study, IU use is well accepted by most of patients, because it could reassure women about their fetal condition. Moreover, they can see the fetus on the screen, while the obstetrician is performing the US and this is important for a visual feedback, in comparison with the classical VE.

Can We Use the Bishop Score as a Prediction Tool for the Mode of Delivery in Primiparous Women at Term Before the Onset of Labor?

The Bishop score serves as an evaluation system performed by digital vaginal examination (DVE) to determine cervical ripening. The scoring system includes cervical dilatation, position, effacement and consistency of the cervix and fetal head station1. Nowadays, the Bishop score is frequently used as an important parameter for the prediction of successful induction of labor.

OBJECTIVE

Our objective was to demonstrate the role of the Bishop scoring system in prediction of the mode of delivery in primiparous women at term before the onset of labor.

METHOD

We included in this study unselected primiparous women at term, after 37 weeks of gestation, who presented to the Prenatal Diagnostic Unit (PDU) of the University Emergency County Hospital of Craiova. We excluded from the study multiparous patients, pregnancies with a planned Caesarean section delivery (CD), non-cephalic presentations and multiple pregnancies, twin pregnancies and those with detected fetal anomalies. The protocol included weekly DVEs until delivery for all patients, to determine the evolution of the Bishop score at term and in the week before delivery, and potential correlations with delivery outcome. To reduce clinical bias, the DVEs were performed by three experienced obstetricians involved in the research.

RESULTS

Statistical analysis yielded a 4 to 6 Bishop score in all weekly examinations. At 37 weeks of gestation, the majority of primiparous women had a Bishop score of 4, with no significant differences between the primiparous who delivered vaginally and the ones where Caesarean section was necessary. During the following weekly evaluations, we noted a slight turn to a Bishop score of 6 for most of them, without any significant differences between the two groups. However, at 41 weeks of gestation, there was a significant higher Bishop score in the group of primiparous women who delivered vaginally.

CONCLUSION

In our study, the use of the Bishop score failed as a prediction tool for the mode of delivery in primiparous women at term before the onset of labor, at a gestational age less than 40 weeks. Therefore, Bishop score should not be used to counsel regarding the probability of an uncomplicated vaginal delivery (VD) before the onset of labor.

Intrapartum ultrasound: viewpoint of midwives and parturient women and reproducibility

Introduction

Vaginal examination (VE) is known to be subjective in interpretation and is considered uncomfortable by many women. Intrapartum ultrasound aims to be more objective and less invasive. The purpose of this study was to evaluate the acceptability of introducing intrapartum ultrasound to both midwives and parturients. Furthermore, we wanted to evaluate the reproducibility of different measurements when introduced de novo among operators without prior ultrasound experience.

Subjects and methods

This study determined intra- and interobserver variability of intrapartum ultrasound in nulliparous women in labor. Ultrasound examinations were performed independently by a midwife and a gynecologist. The symphysis–head distance (SHD) and the angle of progression (AOP) were measured by translabial ultrasound. Structured questionnaires were given to midwives and parturients. Intraclass correlation coefficient (ICC) and limits of agreement (LA) were calculated to evaluate variability.

Results

A total of 33 patients were included; of whom, 28 filled in the questionnaire. A total of 19 midwives working on a delivery ward were asked to respond to the questionnaire, and 13 returned the forms. Midwives clearly continued to prefer VE over ultrasound, the majority evaluated translabial ultrasound as easy to use, but some declared to be unable to use it. The majority of patients, 71%, preferred ultrasound over VE. Reproducibility of intrapartum trans-labial ultrasound was good; ICC for interobserver variability was 0.603 (p=0.001) for SHD, and ICC for intraobserver variability was 0.844 (p<0.001) and 0.914 (p<0.001) for SHD and AOP, respectively.

Conclusion

Patients prefer ultrasound over VE; midwives tend to stick to trusted VE. Reproducibility of intrapartum ultrasound in non-experienced operators is good.