Transperineal ultrasound of fetal head progression in prolonged labor: women’s acceptance and ability to predict the mode of delivery
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Abstract Background Digital transvaginal examination of fetal head progression is subjective evaluation with many limitations. Using ultrasound (US) in the assessment of labor progression in prolonged labor is the current trend to predict the mode of delivery. The study intends to evaluate the women’s acceptance to the transperineal ultrasound (TPUS) compared with digital transvaginal examination, and its ability to predict the mode of delivery in prolonged labor. We included 28 pregnant ladies in a prolonged active phase of first or second stages of labor and followed them till delivery. TPUS was used to measure the fetal head–perineum distance (FHPD) and the angle of fetal head descent. Results Of the 28 participants, 53.5% of them delivered vaginally and 46.5% by Cesarean section (CS). All pregnant ladies described the TPUS as more convenient and less painful than digital vaginal examination. Cervical dilatation was negatively correlated with FHPD, and positively correlated with angle of fetal head descent. Both FHPD and angle of fetal head descent had a strong significant negative correlation. Using a cutoff value of 115° for the angle of fetal head descent, the positive predictive value (PPV) of vaginal delivery was 87%; using a cutoff value of 4.2 cm for FHPD, the PPV for vaginal delivery was 85%. Conclusion TPUS is more convenient, more accepted, and less painful than digital vaginal examination. Angle of head descent and FHPD are reliable predictors of the mode of delivery in prolonged labor.Keywords:
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Cut-off
Abstract Molecular simulations of nanoscale systems invariably involve assumptions and approximations to describe the electrostatic interactions, which are long‐ranged in nature. One approach is the use of cutoff schemes with a reaction‐field contribution to account for the medium outside the cutoff scheme. Recent reports show that macroscopic properties may depend on the exact choice of cutoff schemes in modern day simulations. In this work, a systematic analysis of the effects of different cutoff schemes was performed using a set of 52 proteins. We find no statistically significant differences between using a twin‐range or a single‐range cutoff scheme. Applying the cutoff based on charge groups or based on atomic positions, does lead to significant differences, which is traced to the cutoff noise for energies and forces. While group‐based cutoff schemes show increased cutoff noise in the potential energy, applying an atomistic cutoff leads to artificial structure in the solvent at the cutoff distance. Carefully setting the temperature control, or using an atomistic cutoff for the solute and a group‐based cutoff for the solvent significantly reduces the effects of the cutoff noise, without introducing structure in the solvent. This study aims to deepen the understanding of the implications different cutoffs have on molecular dynamics simulations.
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Fetal head
Contraindication
Cesarean delivery
Univariate analysis
Caesarean delivery
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To determine if a history of vaginal delivery and station of the fetus at the time of vaginal exam impact the accuracy of determining fetal position in labour when assessed by third and fourth year obstetrics residents. Residents performed digital examinations for location and axis of fetal sutures and fontanelles when patients were 8 cm dilated or more, had ruptured membranes, and the gestation was 35 weeks or greater. Transabdominal and transperineal scanning using a 3.5mHz probe were performed immediately following digital exams. Exams were considered correct if within 15 degrees of ultrasound findings. For analysis, assessments were grouped based upon a history of vaginal delivery and then by fetal station of -1 or higher (high), 0 to +1.5 (mid), and +2 or lower (low). Chi-squared analysis was performed using SPSS. Twelve residents assessed 143 labouring women for fetal position. The overall accuracy rate was 47.9%. Women who had a prior vaginal delivery were more likely to have fetal position inaccurately assessed by exam. Correct assessment occurred in 55.4% (N=46) of women without a history of vaginal delivery versus 38.3% (N=23) of women with a vaginal delivery (p=0.044). When the axis of the fetal head was assessed without taking into account the location of the brow or occiput, the rate of accuracy was 66.4% overall, with 75.9% (N= 63) in women without a history of a vaginal delivery versus 53.3% with a history of vaginal delivery (p=0.005). As the fetal head descended into the pelvis, accuracy of assessments increased with the highest rate of accuracy at low station (table 1). Low station at time of fetal assessment improves accuracy of determining fetal position by vaginal examination, while a prior vaginal delivery decreases the likelihood of accurate assessment. P13.02: Table 1.
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This chapter presents an easy-to-follow algorithm for obstetric management of operative vaginal delivery. Operative vaginal delivery refers to any operative procedure designed to expedite vaginal delivery, including forceps delivery and vacuum extraction. Indications for operative vaginal delivery include: maternal indications such as maternal exhaustion and inadequate maternal expulsive efforts; fetal indications such as non-reassuring fetal testing. Potential complications of operative vaginal delivery include maternal perineal injury and fetal complications such as facial bruising, laceration, and cephalhematoma. The choice of which instrument to use depends largely on clinician preference and experience. Exact knowledge of fetal position, station, and degree of asynclitism is essential to proper forceps application. After performing a 'phantom application', the posterior blade is placed first in order to prevent loss of station of the fetal head. To promote flexion of the fetal head with descent, the suction cup of the vacuum should be placed over the 'median flexing point'.
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To evaluate the best translabial ultrasound parameters for the prediction of successful vaginal delivery at prolonged second stage of labor. This was a prospective observational study of women with singleton cephalic presentation above 37 weeksof gestation diagnosedduring prolonged second stage of labor. Translabial sonography was performed by an ultrasound specialist who was blinded to the head station. The sonographic data except head position was not revealed to the obstetricians managing the delivery. In each patient the angle of progression, head direction and head descent during pushing were assessed. The primary outcome was assessed with the 4 modes of delivery, spontaneous vaginal delivery, vacuum extraction (VE), failed VE and Cesarean section (CS). 64 women patients in prolonged second stage were enrolled in the study 36 delivered by VE, 16 spontaneous deliveries 8 CS for failure to progress, 4 CS after failed VE. Although the angle of progression did not differ significantly between delivery modes a significantly difference was observed between successful VE and failed attempt VE groups (P < 0.03). Head direction during pushing significantly differed between modes of delivery. No spontaneous delivery observed if head was down oriented. Fetal head descent during pushing predicted success of vaginal delivery (Fisher exact test P < 0.04, LR = 2). We have shown that the head direction and head descent during pushing could predict the success of vaginal delivery at prolonged 2nd stage.
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Simulations involving the Lennard-Jones potential usually employ a cutoff at r = 2.5σ. This communication investigates the possibility of reducing the cutoff. Two different cutoff implementations are compared, the standard shifted potential cutoff and the less commonly used shifted forces cutoff. The first has correct forces below the cutoff, whereas the shifted forces cutoff modifies Newton's equations at all distances. The latter is nevertheless superior; we find that for most purposes realistic simulations may be obtained using a shifted forces cutoff at r = 1.5σ, even though the pair force is here 30 times larger than at r = 2.5σ.
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Using a dedicated novel software (SonoVCAD labor), we analyzed 3D-volumes of fetal head just prior attempted instrumental delivery in theatre to see if we can define a ‘cut-off value’ based on various sonographic parameters that would predict a successful vaginal birth. We performed an offline analysis of 11 fetal head volumes stored immediately prior attempted instrumental delivery using GEs novel 3D software ‘SonoVCAD labor’. We related head direction angle, midline angle, progression distance and angle of progression with the success or failure to achieve vaginal birth. Four out 11 women had Caesarean section (two without trial and two following failed trial). Seven women had successful instrumental delivery. Head direction angle of > 95 degrees was associated with successful vaginal birth. All cases that ended with Caesarean section had head direction angle of less than 95 degrees. For angle of progression, a cut off of 160 degrees or more predicted successful outcome for all cases. All cases with CS had angle of progression < 160 degrees. As regards progression distance, all cases with vaginal birth had distance > 60 mm prior to delivery. However, one woman who ended with CS had distance of 44 mm. Midline angle ranged from 28–148 degrees and did not predict the outcome in women with CS. Head direction angle > 95 degrees and angle of progression > 160 were predictors of successful instrumental delivery. The midline angle and progression distance did not correlate well with the outcome of the trial. We will continue analyzing these parameters in future cases to assess their diagnostic accuracy. Given this is a relatively new technique, more data are needed to elucidate the clinical contribution of this new tool and the best way to use it. OP32.02: Table 1. Delivery outcome in 11 cases
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Clinical lack of fetal head engagement (FHE) in term primiparous has a controversial incidence and has been associated with labour arrest disorders. Our objective was to analyse longitudinally the evolution of fetal head situation at term and the correlations with the delivery mode in primiparous at term. Starting at 37GW we determined weekly in unselected primiparous the occiput position and TPU measurements: progression angle (PA), progression distance (PD), direction angle (DA) and head to perineum distance (HPD). The evolution of these measurements was studied and compared against the station 0 cut-offs from the literature. Maternal and labour characteristics were noted. In 262 studied term primiparous the rates of FHE at any examination at term were between 3.3–5.7% (depending on the TPU measurement). We did not identify a specific trendline for the US measurements at term. Moreover, the differences between vaginal and Caesarean cases were generally not significant. Analysing only the data from the week before delivery WBD, the relation between the US parameters and the delivery mode failed or was only poor (AUC = 0.550 for DA, 0.588 for PA and 0.623 for PD). When considering the occiput position, the analysis performs slightly better, but the correlations remain poor (AUC = 0.584, 0.663, 0.671). Engagement rate at term was lower than any report published so far, but this is the only study that used objective US evaluation. We could not find strong associations between US determinations at term and the delivery mode. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
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Objective:To apply a new assisted vaginal delivery technique-palm for assisted vaginal delivery and evaluate its value in assisted vaginal delivery.Methods:50 cases applying palm for assisted vaginal delivery and 50 cases applying forceps delivery and vacuum extraction of fetal head were analyzed and compared from January 2008 to June 2009,the damage of palm for assisted vaginal delivery,spontaneous delivery and the other assisted vaginal delivery methods to mothers and infants were compared.Results:The volume of postpartum hemorrhage and the number of soft birth canal laceration in palm for assisted vaginal delivery group were significantly lower than those in forceps delivery group (P 0.05),but the single success rate of palm for assisted vaginal delivery group (90%) was significantly lower than that of forceps delivery group (100%),there was no significant difference between palm for assisted vaginal delivery group and vacuum extraction of fetal head group (P 0.05) ;the incidence of neonatal injury in palm for assisted vaginal delivery group was significantly lower than those in forceps delivery group and vacuum extraction of fetal head group (P 0.05).Conclusion:Obstetric palm for assisted vaginal delivery is a safe,effective,simple,easy to grasp,quick and minimally invasive and new technique in assisted vaginal delivery,which can replace forceps delivery under certain conditions,but the single success rate is significantly lower than that of forceps delivery,and it can replace vacuum extraction of fetal head,which is worth clinical popularizing.
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( Obstet Gynecol. 2015;126:521–529) It has been suggested that midpelvic operative vaginal delivery methods (eg, vacuum extraction, Thierry’s spatulas, or forceps) might significantly increase maternal and neonatal morbidity. However, the data are not up-to-date. Subsequently, the authors of the present study assessed severe maternal and neonatal morbidity after attempted operative vaginal delivery and also compared morbidity after midpelvic and low pelvic delivery attempts.
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Maternal morbidity
Vacuum extraction
Forceps delivery
Obstetrical Forceps
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