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Objective: To assess whether sonographic diagnosis of fetal head position before instrumental vaginal delivery can reduce the risk of failed vacuum extraction and improve delivery outcome., Methods: Randomised Italian Sonography for occiput POSition Trial Ante vacuum (R.I.S.POS.T.A.) is a randomized controlled trial of term (37 + 0 to 41 + 6 weeks' gestation) singleton pregnancies with cephalic presentation requiring instrumental delivery by vacuum extraction, which was conducted between April 2014 and June 2017 and involved 13 Italian maternity hospitals. Patients were randomized to assessment of fetal head position before attempted instrumental delivery by either vaginal examination (VE) alone or VE plus transabdominal sonography (TAS). Primary outcome was incidence of emergency Cesarean section due to failed vacuum extraction. A sample size of 653 women per group was planned to compare the primary outcome between the two groups. The sample size estimation was based on the hypothesis that the risk of failed vacuum delivery in the VE group would be 5% and that ultrasound assessment of fetal position prior to vacuum extraction would decrease this risk to 2%., Results: On interim analysis, the trial was stopped for futility. During this period, 222 women were randomized and 221 were included in the final data analysis, of whom 132 (59.7%) were randomized to evaluation of fetal head position by VE only and 89 (40.3%) to assessment by VE plus TAS prior to vacuum extraction. No significant differences were observed between the two groups with respect to incidence of emergency Cesarean section due to failed instrumental delivery and other maternal and fetal outcomes. Women randomized to assessment by VE plus TAS showed higher incidence of non-occiput anterior position of the fetal head at randomization and lower incidence of incorrect diagnosis of occiput position compared with women undergoing assessment by VE alone. A higher rate of episiotomy was noted in the women undergoing both VE and TAS compared with those in the VE-only group., Conclusions: Our prematurely discontinued randomized controlled trial did not demonstrate any benefit in terms of reduced risk of failed instrumental delivery or maternal and fetal morbidity in women undergoing sonographic assessment of fetal head position prior to vacuum extraction. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To evaluate whether the fetal head-symphysis distance measured by three-dimensional transperineal ultrasound during the active second stage predicts operative delivery., Design: Prospective observational study., Setting: University hospital, Bologna, Italy., Population: Seventy-one nulliparous women at term in active second stage of labor., Methods: We acquired a series of sonographic volumes at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5, T6) until delivery. All volumes were retrospectively analyzed and head-symphysis distance was measured for each acquisition. We compared head-symphysis distance between women with spontaneous vaginal delivery and those with operative delivery. Receiver operator characteristic curves were constructed to estimate the accuracy of head-symphysis distance in the prediction of operative delivery. Logistic regression was used to identify independent variables associated with operative delivery., Main Outcome Measures: Operative delivery (vacuum or cesarean)., Results: Of the women included, 81.7% had a spontaneous vaginal delivery and 18.3% underwent operative delivery. Women with spontaneous vaginal delivery had shorter head-symphysis distance than women in the operative delivery group at T1 (p < 0.001), T2 (p < 0.001) and T3 (p = 0.025), whereas no significant differences were recorded thereafter. Receiver operator characteristic curves revealed accuracy values of 81.0%, 87.9% and 77.6% in the prediction of operative delivery at T1, T2 and T3, respectively. At multivariate logistic regression head-symphysis distance and epidural analgesia were the only independent predictors of operative delivery among ultrasonographic, maternal and intrapartum variables., Conclusions: Ultrasonographic measurement of head-symphysis distance in the second stage of labor can be used to predict operative delivery., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Multivariable logistic regression analysis showed that, in our hands, the sonographic diagnosis of fetal head deflexion was an independent risk factors for Caesarean section regardless the occiput position (OR 5.83, 95% CI 2.47-13.73). According to our data, the sonographic diagnosis of fetal head deflexion performed at the beginning of the second stage is the most consistent predictor of Caesarean section. [Extracted from the article]

An abstract of the article "Neonatal respiratory morbidity in twins versus singletons after elective late-preterm cesarean section," by M. Nanni and colleagues is presented.