Intrapartum translabial ultrasound demonstrating brow presentation during the second stage of labor.

A 25-year-old woman (gravida 6, para 0) was admitted at 41 weeks and 3 days of pregnancy. The patient had a history of 5 previous surgical terminations. The fetus was in cephalic presentation, three-fifths above the pelvic brim, with an estimated fetal weight of 3200 g. At 2 cm cervical dilatation, artificial rupture of the membranes was performed and oxytocin augmentation commenced. Epidural analgesia was given for pain relief. There was good progress of labor and the cervix became fully dilated after 4 hours. Vaginal examination revealed a left occipitoposterior position at the S+1 level with mild caput and molding. The fetal head was deflexed and the anterior fontanelle could be felt at the right upper quadrant. Vacuum extraction was initially planned 75 minutes after full cervical dilatation. However, orbito-right anterior brow presentation was noted on repeat vaginal examination. The brow presentation was further demonstrated by intrapartum translabial ultrasound (MyLab25; Biosound Esaote, Indianapolis, IN, USA) (Fig.1). The orbitwas just below the pubic symphysis, which differs from a typical occipito-posterior presentation. No descent occurredwithmaternal pushing. Low segment cesarean delivery of a healthy female neonate weighing 3330 g was performed without complication. Brow presentation can be missed on vaginal examination [1]. Most fetuses in brow presentation will be delivered by cesarean because in this position the largemento-vertical diameter of the fetal head,which can be larger than the pelvic brim, approaches the pelvic cavity. Although in the present case themodeof deliverywas based on clinical assessment of the patient, intrapartum translabial ultrasound may help demonstrate this uncommon malpresentation and assist with subsequent management. Recent literature has suggested that intrapartum translabial ultrasound can play an important role in the objective documentation of landmarks and parameters valuable for management of the second stage of labor [2–4]. In addition, intrapartum translabial ultrasound may be useful for patient counseling and education of trainees.