Search

Background: Intrapartum ultrasound scanning has been proposed as an ancillary tool in the decision-making process of instrumental vaginal delivery., Objective: The purpose of this study was to evaluate the correlation between the sonographic visualization with a transperineal scan of the fetal occiput or forehead distal to the pubic symphysis with anterior or posterior presentation, respectively (fetal occiput or forehead sign), and the outcome of a vacuum delivery., Study Design: We conducted a retrospective cohort study of patients who underwent a vacuum application in our hospital from 2011-2017, excluding outlet applications. In each case, a preliminary transperineal scan was performed to confirm fetal presentation and position and to demonstrate the presence or absence of the fetal occiput or forehead sign. The head direction, angle of progression, and the head perineum distance were also noted. The primary outcome measure was the success of the vacuum. The secondary outcome measures included fetal complications and perineal lacerations., Results: A total of 196 consecutive patients were enrolled in the study. The occiput or forehead sign was present in 150 and was associated with a successful vaginal extraction in all cases. Of the 46 cases without the sign, 5 babies (10.8%) were delivered by cesarean section after a failed vacuum (P=.0006). The occiput or forehead sign was also associated with fewer grade 3-4 perineal lacerations (10.7% vs 35.7%; P=.0005) and cephalohematomas, although the difference was not statistically significant (1.4% vs 4.3%). There was a good correlation between the occiput or forehead sign and the other sonographic methods that previously had been proposed to predict a successful vacuum extraction, such as head direction, angle of progression, and head perineum distance., Conclusion: In our hands, the fetal occiput or forehead sign was associated strongly with successful vacuum application and with a very low rate of maternal and fetal complications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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 compare the accuracy of transperineal (TP) ultrasound with transabdominal (TA) approach in the sonographic assessment of fetal occiput position during the second stage of labour., Methods: A series of low-risk women at term attending the labour ward of three university hospitals were prospectively recruited for the purpose of this study. During the second stage of labor patients were evaluated first by TP and than by TA ultrasound to determine the fetal position. The occiput position was labelled as DOA (direct occiput anterior), ROA (right occiput anterior), LOA (left occiput anterior), DOP (direct occiput posterior), ROP (right occiput posterior), LOP (left occiput posterior), ROT (right occuput transverse) and LOT (left occiput transverse). The agreement between the two techniques was assessed., Results: Overall 80 patients were recruited in the study group. Ultrasound examination was performed at 21(± 8) minutes from the beginning of the active pushing. The ultrasound findings of the fetal occiput position were recorded. In all cases TA ultrasound confirmed the fetal occiput position as determined at TP approach except in one case of ROA that had been recorded as ROT using TP ultrasound., Conclusions: Ultrasound TP examination is accurate in the diagnosis of fetal occiput position during the second stage of labor.

Objective To compare longitudinal changes in angle of progression (AoP) and midline angle (MLA) during the active second stage of labor according to the mode of delivery. Methods A three-dimensional transperineal ultrasound volume was acquired in a series of nulliparous women at the beginning of the active second stage (T1) and every 20 min thereafter (T2, T3, T4, T5 and T6). Following delivery, all ultrasound volumes were analyzed and AoP and MLA were measured. Results Among 71 women included in the study, 58 underwent spontaneous vaginal delivery (Group A) and 13 underwent operative delivery (Group B) (eight by .vacuum extraction and five by Cesarean section). When compared with Group B, Group A had a wider AoP only at T1 (140.0±20.2° vs 122.94-16.7°; P=O.010) and T2 (149.7±20.7° vs 126.9 ± 17.5°; P = 0.006). MLA was narrower in Group A only at T3 (21.2±11.7° vs 40.8±27.9°; P=0.043), T4 (18.2±15.0° vs 47.4±29.6°; P=0.020) and T5 (18.3±6.0° vs 34.7±4.2°; P=0.034). On stepwise forward multiple logistic regression analysis, both AoP and MLA were independently associated with operative delivery (OR = 0.955 and OR = 1.018, respectively). Conclusion Ultrasonographic assessment of fetal head descent in the second stage of labor may play a role in the prediction of the mode of delivery. [ABSTRACT FROM AUTHOR]

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]