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Malvasi A, Malgieri LE, Cicinelli E, Vimercati A, D’Amato A, Dellino M, Trojano G, Difonzo T, Beck R, Tinelli A. Artificial Intelligence, Intrapartum Ultrasound and Dystocic Delivery: AIDA (Artificial Intelligence Dystocia Algorithm), a Promising Helping Decision Support System. J Imaging 2024; 10:107. [PMID: 38786561 PMCID: PMC11122467 DOI: 10.3390/jimaging10050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/25/2024] Open
Abstract
The position of the fetal head during engagement and progression in the birth canal is the primary cause of dystocic labor and arrest of progression, often due to malposition and malrotation. The authors performed an investigation on pregnant women in labor, who all underwent vaginal digital examination by obstetricians and midwives as well as intrapartum ultrasonography to collect four "geometric parameters", measured in all the women. All parameters were measured using artificial intelligence and machine learning algorithms, called AIDA (artificial intelligence dystocia algorithm), which incorporates a human-in-the-loop approach, that is, to use AI (artificial intelligence) algorithms that prioritize the physician's decision and explainable artificial intelligence (XAI). The AIDA was structured into five classes. After a number of "geometric parameters" were collected, the data obtained from the AIDA analysis were entered into a red, yellow, or green zone, linked to the analysis of the progress of labor. Using the AIDA analysis, we were able to identify five reference classes for patients in labor, each of which had a certain sort of birth outcome. A 100% cesarean birth prediction was made in two of these five classes. The use of artificial intelligence, through the evaluation of certain obstetric parameters in specific decision-making algorithms, allows physicians to systematically understand how the results of the algorithms can be explained. This approach can be useful in evaluating the progress of labor and predicting the labor outcome, including spontaneous, whether operative VD (vaginal delivery) should be attempted, or if ICD (intrapartum cesarean delivery) is preferable or necessary.
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Affiliation(s)
- Antonio Malvasi
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.M.); (E.C.); (A.D.); (M.D.); (T.D.)
| | - Lorenzo E. Malgieri
- FIAT-ENI, Environmental Companies, and Chief Innovation Officer in CLE, 70124 Bari, Italy;
| | - Ettore Cicinelli
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.M.); (E.C.); (A.D.); (M.D.); (T.D.)
| | - Antonella Vimercati
- Department of Precision and Regenerative Medicine and Jonic Area, University of Bari “Aldo Moro”, 70121 Bari, Italy;
| | - Antonio D’Amato
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.M.); (E.C.); (A.D.); (M.D.); (T.D.)
| | - Miriam Dellino
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.M.); (E.C.); (A.D.); (M.D.); (T.D.)
| | - Giuseppe Trojano
- Department of Maternal, Child Gynecologic Oncology Unit, “Madonna delle Grazie” Hospital ASM, 75100 Matera, Italy;
| | - Tommaso Difonzo
- Department of Interdisciplinary Medicine (DIM), Unit of Obstetrics and Gynecology, University of Bari “Aldo Moro”, Policlinico of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (A.M.); (E.C.); (A.D.); (M.D.); (T.D.)
| | - Renata Beck
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Unit, Policlinico Riuniti Foggia, University of Foggia, 71122 Foggia, Italy;
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), Veris delli Ponti Hospital Scorrano, 73020 Lecce, Italy
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Jennewein L, Heemann R, Hoock SC, Hentrich AE, Eichbaum C, Feidicker S, Louwen F. Sonographic examination at the beginning of the second stage of labor predicts birth outcome in vaginally intended breech deliveries: a blinded prospective study. Arch Gynecol Obstet 2024; 309:1333-1340. [PMID: 36961567 PMCID: PMC10894138 DOI: 10.1007/s00404-023-07011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 03/13/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE In order to spread competence in vaginal breech deliveries, it is necessary to develop new and easily applicable tools for birth progression and safety evaluation. Ultrasound is a useful and ubiquitously available tool with already documented value for birth progression observation. In deliveries out of breech presentation, an established ultrasound examination is missing. We determined the descent of the fetal buttocks in relation to the maternal pelvic inlet using intrapartum ultrasound. We evaluated these results in comparison to the clinical vaginal examination with the aim to establish an easily applicable method for birth outcome prediction. Therefore, we analyzed the predictive value of our examinations on birth outcome parameters, such as cesarean section rate, as well as fetal and maternal outcome parameters. METHODS We performed a prospective blinded study on 106 mothers with vaginally intended breech delivery. At beginning of stage two in labor, the descent of the fetal buttocks into the mother's pelvic inlet was detected with transabdominal ultrasound and vaginal examination by different observers. PRIMARY OUTCOME VARIABLE Cesarean section rate. Secondary outcome variables: rate of manual assistance in vaginal deliveries, birth duration, 5' APGAR score, umbilical arterial pH, maternal blood loss, and perineal injury. For non-parametric values, Wilcoxon's χ2 test was performed. In order to analyze the predictive value of our examination, lack-of-fit analysis was conducted. Reliability evaluation of the sonographic examination was done with a matched-pair analysis. RESULTS Women with positive intrapartum ultrasound breech engagement sign (+ IPUBES) had a significantly lower rate of cesarean section in comparison with those with negative IPUBES (5/67; 7.5% vs. 18/39; 46.2%; p < 0.0001). The area under the ROC curve for the prediction of CS for negative IPUBES was 0.765 with a sensitivity of 78.3% and a specificity of 74.7%. Sonographic examination showed an excellent reliability in a matched-pair analysis comparing vaginal and sonographic examinations with a mean difference of 0.012 (SD ± 0.027, 95% CI - 0.014 to 0.065). Mean birth duration was significantly longer in deliveries with negative IPUBES (533 min vs. 440 min; p = 0.0011). Fetal and maternal outcome parameters were not significantly different between deliveries with positive and negative IPUBES. CONCLUSIONS Sonographic evaluation of the fetal descent in relation to the mother's pelvic inlet screens reliably for emergency cesarean section. This newly presented method for birth progression observation might be a powerful tool for distribution of expertise in vaginal breech delivery and is able to give reference for clinical vaginal examination by obstetricians in training. TRAIL REGISTRY Clinical trial. Date of registration: 13.03.2019; Date of initial participant enrollment: 20.03.2019; DRKS00016885; https://www.drks.de ; German clinical trials register.
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Affiliation(s)
- Lukas Jennewein
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
| | - Ricarda Heemann
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Samira Catharina Hoock
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Anna Elisabeth Hentrich
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Christine Eichbaum
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Susanne Feidicker
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Frank Louwen
- Department of Gynecology and Obstetrics, School of Medicine, Goethe-University, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
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Eggebø TM, Hjartardottir H. Descent of the presenting part assessed with ultrasound. Am J Obstet Gynecol 2024; 230:S901-S912. [PMID: 34461079 DOI: 10.1016/j.ajog.2021.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 08/15/2021] [Accepted: 08/19/2021] [Indexed: 11/29/2022]
Abstract
Fetal head descent can be expressed as fetal station and engagement. Station is traditionally based on clinical vaginal examination of the distal part of the fetal skull and related to the level of the ischial spines. Engagement is based on a transabdominal examination of the proximal part of the fetal head above the pelvic inlet. Clinical examinations are subjective, and objective measurements of descent are warranted. Ultrasound is a feasible diagnostic tool in labor, and fetal lie, station, position, presentation, and attitude can be examined. This review presents an overview of fetal descent examined with ultrasound. Ultrasound was first introduced for examining fetal descent in 1977. The distance from the sacral tip to the fetal skull was measured with A-mode ultrasound, but more convenient transperineal methods have since been published. Of those, progression distance, angle of progression, and head-symphysis distance are examined in the sagittal plane, using the inferior part of the symphysis pubis as reference point. Head-perineum distance is measured in the frontal plane (transverse transperineal scan) as the shortest distance from perineum to the fetal skull, representing the remaining part of the birth canal for the fetus to pass. At high stations, the fetal head is directed downward, followed with a horizontal and then an upward direction when the fetus descends in the birth canal and deflexes the head. Head descent may be assessed transabdominally with ultrasound and measured as the suprapubic descent angle. Many observational studies have shown that fetal descent assessed with ultrasound can predict labor outcome before induction of labor, as an admission test, and during the first and second stage of labor. Labor progress can also be examined longitudinally. The International Society of Ultrasound in Obstetrics and Gynecology recommends using ultrasound in women with prolonged or arrested first or second stage of labor, when malpositions or malpresentations are suspected, and before an operative vaginal delivery. One single ultrasound parameter cannot tell for sure whether an instrumental delivery is going to be successful. Information about station and position is a prerequisite, but head direction, presentation, and attitude also should be considered.
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Affiliation(s)
- Torbjørn M Eggebø
- National Center for Fetal Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Obstetrics and Gynecology, Helse Stavanger, Stavanger University Hospital, Stavanger, Norway.
| | - Hulda Hjartardottir
- Department of Obstetrics and Gynecology, Landspitali University Hospital, Reykjavík, Iceland; Faculty of Medicine, University of Iceland, Reykjavík, Iceland
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Youssef A, Brunelli E, Fiorentini M, Pilu G, Spelzini F. Soft-tissue dystocia due to paradoxical contraction of the levator ani as a cause of prolonged second stage: concept, diagnosis, and potential treatment. Am J Obstet Gynecol 2024; 230:S856-S864. [PMID: 38462259 DOI: 10.1016/j.ajog.2022.12.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 03/12/2024]
Abstract
Smaller pelvic floor dimensions seem to have been an evolutionary need to provide adequate support for the pelvic organs and the fetal head. Pelvic floor dimension and shape contributed to the complexity of human birth. Maternal pushing associated with pelvic floor muscle relaxation is key to vaginal birth. Using transperineal ultrasound, pelvic floor dimensions can be objectively measured in both static and dynamic conditions, such as pelvic floor muscle contraction and pushing. Several studies have evaluated the role of the pelvic floor in labor outcomes. Smaller levator hiatal dimensions seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Furthermore, smaller levator hiatal dimensions are associated with a higher fetal head station at term of pregnancy, as assessed by transperineal ultrasound. With maternal pushing, most women can relax their pelvic floor, thus increasing their pelvic floor dimensions. Some women contract rather than relax their pelvic floor muscles under pushing, which is associated with a reduction in the anteroposterior diameter of the levator hiatus. This phenomenon is called levator ani muscle coactivation. Coactivation in nulliparous women at term of pregnancy before the onset of labor is associated with a higher fetal head station at term of pregnancy and a longer duration of the second stage of labor. In addition, levator ani muscle coactivation in nulliparous women undergoing induction of labor is associated with a longer duration of the active second stage of labor. Whether we can improve maternal pelvic floor relaxation with consequent improvement in labor outcomes remains a matter of debate. Maternal education, physiotherapy, and visual feedback are promising interventions. In particular, ultrasound visual feedback before the onset of labor can help women increase their levator hiatal dimensions and correct levator ani muscle coactivation in some cases. Ultrasound visual feedback in the second stage of labor was found to help women push more efficiently, thus obtaining a lower fetal head station at ultrasound and a shorter duration of the second stage of labor. The available evidence on the role of any intervention aimed to aid women to better relax their pelvic floor remains limited, and more studies are needed before considering its routine clinical application.
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Affiliation(s)
- Aly Youssef
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy.
| | - Elena Brunelli
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Marta Fiorentini
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Gianluigi Pilu
- Obstetric and Prenatal Medicine Unit, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Federico Spelzini
- Azienda Unità Sanitaria Locale della Romagna, Infermi Hospital, Rimini, Italy
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Usman S, Hanidu A, Kovalenko M, Hassan WA, Lees C. The sonopartogram. Am J Obstet Gynecol 2023; 228:S997-S1016. [PMID: 37164504 DOI: 10.1016/j.ajog.2022.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 03/17/2023]
Abstract
The assessment of labor progress from digital vaginal examination has remained largely unchanged for at least a century, despite the current major advances in maternal and perinatal care. Although inconsistently reproducible, the findings from digital vaginal examination are customarily plotted manually on a partogram, which is composed of a graphical representation of labor, together with maternal and fetal observations. The partogram has been developed to aid recognition of failure to labor progress and guide management-specific obstetrical intervention. In the last decade, the use of ultrasound in the delivery room has increased with the advent of more powerful, portable ultrasound machines that have become more readily available for use. Although ultrasound in intrapartum practice is predominantly used for acute management, an ultrasound-based partogram, a sonopartogram, might represent an objective tool for the graphical representation of labor. Demonstrating greater accuracy for fetal head position and more objectivity in the assessment of fetal head station, it could be considered complementary to traditional clinical assessment. The development of the sonopartogram concept would require further undertaking of serial measurements. Advocates of ultrasound will concede that its use has yet to demonstrate a difference in obstetrical and neonatal morbidity in the context of the management of labor and delivery. Taking a step beyond the descriptive graphical representation of labor progress is the question of whether a specific combination of clinical and demographic parameters might be used to inform knowledge of labor outcomes. Intrapartum cesarean deliveries and deliveries assisted by forceps and vacuum are all associated with a heightened risk of maternal and perinatal adverse outcomes. Although these outcomes cannot be precisely predicted, many known risk factors exist. Malposition and high station of the fetal head, short maternal stature, and other factors, such as caput succedaneum, are all implicated in operative delivery; however, the contribution of individual parameters based on clinical and ultrasound assessments has not been quantified. Individualized risk prediction models, including maternal characteristics and ultrasound findings, are increasingly used in women's health-for example, in preeclampsia or trisomy screening. Similarly, intrapartum cesarean delivery models have been developed with good prognostic ability in specifically selected populations. For intrapartum ultrasound to be of prognostic value, robust, externally validated prediction models for labor outcome would inform delivery management and allow shared decision-making with parents.
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Youssef A, Brunelli E, Fiorentini M, Lenzi J, Pilu G, El-Balat A. Breech progression angle: new feasible and reliable transperineal ultrasound parameter for assessment of fetal breech descent in birth canal. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:609-615. [PMID: 33847431 DOI: 10.1002/uog.23649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/20/2021] [Accepted: 03/26/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To assess the feasibility and reliability of transperineal ultrasound in the assessment of fetal breech descent in the birth canal, by measuring the breech progression angle (BPA). METHODS Women with a singleton pregnancy with the fetus in breech presentation between 34 and 41 weeks' gestation were recruited. Transperineal ultrasound images were acquired in the midsagittal view for each woman, twice by one operator and once by another. Each operator measured the BPA after anonymization of the transperineal ultrasound images. BPA was defined as the angle between a line running along the long axis of the pubic symphysis and another line extending from the most inferior portion of the pubic symphysis tangentially to the lowest recognizable fetal part in the maternal pelvis. Each operator was blinded to all other measurements performed for each woman. Intra- and interobserver reproducibility of BPA measurement was evaluated using the intraclass correlation coefficient (ICC). To investigate the presence of any bias, intra- and interobserver agreement was also analyzed using Bland-Altman analysis. Student's t-test and Levene's W0 test were used to investigate whether a number of different clinical factors had an effect on systematic differences and homogeneity, respectively, between BPA measurements. RESULTS Overall, 44 women were included in the analysis. BPA was measured successfully by both operators on all images. Both intra- and interobserver agreement analyses showed excellent reproducibility in BPA measurement, with ICCs of 0.88 (95% CI, 0.80-0.93) and 0.83 (95% CI, 0.71-0.90), respectively. The mean difference between measurements was 0.4° (95% CI, -1.4 to 2.2°) for intraobserver repeatability and -0.4° (95% CI, -2.6 to 1.8°) for interobserver repeatability. The upper limits of agreement were 12.0° (95% CI, 8.9-15.1°) and 13.6° (95% CI, 9.9-17.3°) for intra- and interobserver repeatability, respectively. The lower limits of agreement were -11.2° (95% CI, -14.3 to -8.1°) and -14.4° (95% CI, -18.2 to -10.7°) for intra- and interobserver repeatability, respectively. No systematic difference between BPA measurements was found on either intra- or interobserver agreement analysis. None of the clinical factors examined (maternal body mass index, maternal age, gestational age at the ultrasound scan and parity) showed a statistically significant effect on intra- or interobserver reliability. CONCLUSIONS BPA represents a new feasible and highly reproducible measurement for the evaluation of fetal breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful external cephalic version and breech vaginal delivery are needed. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Youssef
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - E Brunelli
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - M Fiorentini
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - J Lenzi
- Section of Hygiene, Public Health and Medical Statistics, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - G Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, IRCCS Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - A El-Balat
- Department of Obstetrics and Gynecology, Goethe University Frankfurt, Frankfurt, Germany
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Youssef A, Brunelli E, Pilu G, Dietz HP. The maternal pelvic floor and labor outcome. Am J Obstet Gynecol MFM 2021; 3:100452. [PMID: 34365028 DOI: 10.1016/j.ajogmf.2021.100452] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/13/2021] [Accepted: 07/20/2021] [Indexed: 12/29/2022]
Abstract
Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.
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Affiliation(s)
- Aly Youssef
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Drs Youssef, Brunelli, and Pilu); Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy (Drs Youssef, Brunelli, and Pilu).
| | - Elena Brunelli
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Drs Youssef, Brunelli, and Pilu); Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy (Drs Youssef, Brunelli, and Pilu)
| | - Gianluigi Pilu
- Obstetric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy (Drs Youssef, Brunelli, and Pilu); Istituto di Ricovero e Cura a Carattere Scientifico Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy (Drs Youssef, Brunelli, and Pilu)
| | - Hans Peter Dietz
- Sydney Medical School Nepean, Department of O&G, University of Sydney, Penrith, New South Wales, Australia (Dr Dietz)
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Haberman S, Atallah F, Nizard J, Buhule O, Albert P, Gonen R, Ville Y, Paltieli Y. A Novel Partogram for Stages 1 and 2 of Labor Based on Fetal Head Station Measured by Ultrasound: A Prospective Multicenter Cohort Study. Am J Perinatol 2021; 38:e14-e20. [PMID: 32120420 DOI: 10.1055/s-0040-1702989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE This study was aimed to describe continuous labor curves, including second stage, based on fetal head station. STUDY DESIGN We performed a prospective multicenter cohort study. The inclusion criteria were women with singleton uncomplicated cephalic term pregnancies in labor, who delivered vaginally. We used a device that combines ultrasound imaging with position-tracking technology to monitor the head station noninvasively throughout labor. We collected data on demographics, labor parameters, and delivery and neonatal outcomes. RESULTS A total of 613 women delivered vaginally, 327 (53.3%) were nulliparous, while 286 (46.7%) were multiparous. Time to delivery (TTD) diminished progressively with descent of the fetal head. When the head is engaged, the labor curve of multiparous women demonstrated a more prominent downward shift in curve as compared with nulliparous women. When comparing multipara and nullipara at engagement level, the median TTD was 1 and 1.62 hours, respectively. In 95% of women with unengaged head during the second stage, TTD of nulliparous and multiparous women were less than 3.8 and 3 hours, respectively. CONCLUSION While current labor curves end at full dilatation, the described curves were developed throughout stages 1 and 2 of labor. The TTD, according to the station curves, shows an acceleration of labor, once passed the engagement level, especially in multiparous women.
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Affiliation(s)
- Shoshana Haberman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Fouad Atallah
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Maimonides Medical Center, Brooklyn, New York
| | - Jacky Nizard
- Service de gynécologie obstétrique, Groupe hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Sorbonne Universités, Paris, France
| | - Olive Buhule
- National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Paul Albert
- National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Ron Gonen
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Bnai Zion Medical Center, Technion, Israel Institute of Technology, Israel
| | - Yves Ville
- Department of Obstetrics and Fetal Medicine, Hôpital Necker-Enfants-Malade, Paris, France
| | - Yoav Paltieli
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Bnai Zion Medical Center, Technion, Israel Institute of Technology, Israel
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9
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Youssef A, Brunelli E, Azzarone C, Di Donna G, Casadio P, Pilu G. Fetal head progression and regression on maternal pushing at term and labor outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:105-110. [PMID: 32730691 DOI: 10.1002/uog.22159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/13/2020] [Accepted: 07/22/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of our study was two-fold. First, to evaluate the association between the change in the angle of progression (AoP) on maternal pushing and labor outcome. Second, to assess the incidence and clinical significance of the reduction of AoP on maternal pushing. METHODS This was a prospective cohort study of nulliparous women with singleton pregnancy at term. AoP was measured at rest and on maximum Valsalva maneuver before the onset of labor, and the difference between AoP on maximum Valsalva and that at rest (ΔAoP) was calculated for each woman. Following delivery and data collection, we assessed the association between ΔAoP and various labor outcomes, including Cesarean section (CS), duration of the first, second and active second stages of labor, Apgar score and admission to the neonatal intensive care unit (NICU). The prevalence of women with reduction of AoP on maximum Valsalva maneuver (AoP-regression group) was calculated and its association with the mode of delivery and duration of different stages of labor was assessed. RESULTS Overall, 469 women were included in the analysis. Among these, 273 (58.2%) had spontaneous vaginal birth, 65 (13.9%) had instrumental delivery and 131 (27.9%) underwent CS. Women in the CS group were older, had narrower AoP at rest and on maximum Valsalva, higher rate of epidural administration and lower 1-min and 5-min Apgar scores in comparison with the vaginal-delivery group. ΔAoP was comparable between the two groups. On Pearson's correlation analysis, AoP at rest and on maximum Valsalva maneuver had a significant negative correlation with the duration of the first stage of labor. ΔAoP showed a significant negative correlation with the duration of the active second stage of labor (Pearson's r, -0.125; P = 0.02). Cox regression model analysis showed that ΔAoP was associated independently with the duration of the active second stage (hazard ratio, 1.014 (95% CI, 1.003-1.025); P = 0.012) after adjusting for maternal age and body mass index. AoP reduction on maximum Valsalva was found in 73 (15.6%) women. In comparison with women who showed no change or an increase in AoP on maximum Valsalva, the AoP-regression group did not demonstrate significant difference in maternal characteristics, mode of delivery, rate of epidural analgesia, duration of the different stages of labor or rate of NICU admission. CONCLUSIONS In nulliparous women at term before the onset of labor, narrower AoP at rest and on maximum Valsalva, reflecting fetal head engagement, is associated with a higher risk of Cesarean delivery. The increase in AoP from rest to Valsalva, reflecting more efficient maternal pushing, is associated with a shorter active second stage of labor. Fetal head regression on maternal pushing is present in about 16% of women and does not appear to have clinical significance. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A Youssef
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - E Brunelli
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - C Azzarone
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Di Donna
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - P Casadio
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, IRCCS, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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The role of the angle of progression in the prediction of the outcome of occiput posterior position in the second stage of labor. Am J Obstet Gynecol 2021; 225:81.e1-81.e9. [PMID: 33508312 DOI: 10.1016/j.ajog.2021.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 01/20/2021] [Accepted: 01/20/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Occiput posterior position is the most frequent cephalic malposition, and its persistence at delivery is associated with a higher risk of maternal and perinatal morbidity. Diagnosis and management of occiput posterior position remain a clinical challenge. This is partly caused by our inability to predict fetuses who will spontaneously rotate into occiput anterior from those who will have persistent occiput posterior position. The angle of progression, measured with transperineal ultrasound, represents a reliable tool for the evaluation of fetal head station during labor. The relationship between the persistence of occiput posterior position and fetal head station in the second stage of labor has not been previously assessed. OBJECTIVE This study aimed to evaluate the role of fetal head station, as measured by the angle of progression, in the prediction of persistent occiput posterior position and the mode of delivery in the second stage of labor. STUDY DESIGN We recruited a nonconsecutive series of women with posterior occiput position diagnosed by transabdominal ultrasound in the second stage of labor. For each woman, a transperineal ultrasound was performed to measure the angle of progression at rest. We compared the angle of progression between women who delivered fetuses in occiput anterior position and those with persistent occiput posterior position at delivery. Receiver operating characteristics curves were performed to evaluate the accuracy of the angle of progression in the prediction of persistent occiput posterior position. Finally, we performed a multivariate logistic regression to determine independent predictors of persistent occiput posterior position. RESULTS Overall, 63 women were included in the analysis. Among these, 39 women (62%) delivered in occiput anterior position, whereas 24 (38%) delivered in occiput posterior position (persistent occiput posterior position). The angle of progression was significantly narrower in the persistent occiput posterior position group than in women who delivered fetuses in occiput anterior position (118.3°±12.2° vs 127.5°±10.5°; P=.003). The area under the receiver operating characteristics curve was 0.731 (95% confidence interval, 0.594-0.869) with an estimated best cutoff range of 121.5° (sensitivity of 72% and specificity of 67%). On logistic regression analysis, the angle of progression was found to be independently associated with persistence of occiput posterior position (odds ratio, 0.942; 95% confidence interval, 0.889-0.998; P=.04). Finally, women who underwent cesarean delivery had significantly narrower angle of progression than women who had a vaginal delivery (113.5°±8.1 vs 128.0°±10.7; P<.001). The area under the receiver operating characteristics curve for the prediction of cesarean delivery was 0.866 (95% confidence interval, 0.761-0.972). At multivariable logistic regression analysis including the angle of progression, parity, and gestational age at delivery, the angle of progression was found to be the only independent predictor associated with cesarean delivery (odds ratio, 0.849; 95% confidence interval, 0.775-0.0930; P<.001). CONCLUSION In fetuses with occiput posterior at the beginning of the second stage of labor, narrower values of the angle of progression are associated with higher rates of persistent occiput posterior position at delivery and a higher risk of cesarean delivery.
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Youssef A, Brunelli E, Montaguti E, Di Donna G, Dodaro MG, Bianchini L, Pilu G. Transperineal ultrasound assessment of maternal pelvic floor at term and fetal head engagement. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:921-927. [PMID: 31975450 DOI: 10.1002/uog.21982] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 12/17/2019] [Accepted: 01/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To evaluate the association between pelvic floor dimensions in nulliparous women at term and fetal head engagement, as assessed by transperineal ultrasound. METHODS This was a prospective observational study of nulliparous women at term. Before the onset of labor, transperineal ultrasound was used to measure the anteroposterior diameter (APD) of the levator hiatus and the angle of progression (AoP) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver (before and after visual feedback). We assessed the correlation between pelvic floor static and dynamic dimensions (levator hiatal APD and levator ani muscle coactivation) and AoP, which is an objective index of fetal head engagement. RESULTS In total, 282 women were included in the analysis. Among these, 211 (74.8%) women had a vaginal delivery while 71 (25.2%) had a Cesarean delivery. AoP was narrower in the Cesarean-delivery group at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva, whereas no differences in levator hiatal APD were found between the two groups. We found a negative correlation between levator hiatal APD at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva and the duration of the second stage of labor. There was a positive correlation between AoP and levator hiatal APD on maximum Valsalva maneuver after visual feedback (r = 0.15, P = 0.01). Women with levator ani muscle contraction on Valsalva maneuver (i.e. coactivation), both pre and post visual feedback, had a narrower AoP at rest and on maximum Valsalva. After visual feedback, women with levator ani muscle coactivation had a longer second stage of labor than did those without (80.8 ± 61.4 min vs 62.9 ± 43.4 min (P = 0.04)). CONCLUSIONS Smaller pelvic floor dimensions and levator ani muscle coactivation are associated with higher fetal head station and with a longer second stage of labor in nulliparous women at term. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - E Brunelli
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - E Montaguti
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Di Donna
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - M G Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - L Bianchini
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - G Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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Dall’Asta A, Angeli L, Masturzo B, Volpe N, Schera GBL, Di Pasquo E, Girlando F, Attini R, Menato G, Frusca T, Ghi T. Prediction of spontaneous vaginal delivery in nulliparous women with a prolonged second stage of labor: the value of intrapartum ultrasound. Am J Obstet Gynecol 2019; 221:642.e1-642.e13. [PMID: 31589867 DOI: 10.1016/j.ajog.2019.09.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/22/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND A limited number of studies have addressed the role of intrapartum ultrasound in the prediction of the mode of delivery in women with prolonged second stage of labor. OBJECTIVE The objective of the study was to evaluate the role of transabdominal and transperineal sonographic findings in the prediction of spontaneous vaginal delivery among nulliparous women with prolonged second stage of labor. STUDY DESIGN This was a 2-center prospective study conducted at 2 tertiary maternity units. Nulliparous women with a prolonged active second stage of labor, as defined by active pushing lasting more than 120 minutes, were eligible for inclusion. Transabdominal ultrasound to evaluate the fetal head position and transperineal ultrasound for the measurement of the midline angle, the head-perineum distance, and the head-symphysis distance were performed in between uterine contractions and maternal pushes. At transperineal ultrasound the angle of progression was measured at rest and at the peak of maternal pushing effort. The delta angle of progression was defined as the difference between the angle of progression measured during active pushing at the peak of maternal effort and the angle of progression at rest. The sonographic findings of women who had spontaneous vaginal delivery vs those who required obstetric intervention, either vacuum extraction or cesarean delivery, were evaluated and compared. RESULTS Overall, 109 were women included. Spontaneous vaginal delivery and obstetric intervention were recorded in 40 (36.7%) and 69 (63.3%) patients, respectively. Spontaneous vaginal delivery was associated with a higher rate of occiput anterior position (90% vs 53.2%, P < .0001), lower head-perineum distance and head-symphysis distance (33.2 ± 7.8 mm vs 40.1 ± 9.5 mm, P = .001, and 13.1 ± 4.6 mm vs 19.5 ± 8.4 mm, P < .001, respectively), narrower midline angle (29.6° ± 15.3° vs 54.2° ± 23.6°, P < .001) and wider angle of progression at the acme of the pushing effort (153.3° ± 19.8° vs 141.8° ± 25.7°, P = .02) and delta-angle of progression (17.3° ± 12.9° vs 12.5° ± 11.0°, P = .04). At logistic regression analysis, only the midline angle and the head-symphysis distance proved to be independent predictors of spontaneous vaginal delivery. More specifically, the area under the curve for the prediction of spontaneous vaginal delivery was 0.80, 95% confidence interval (0.69-0.92), P < .001, and 0.74, 95% confidence interval (0.65-0.83), P = .002, for the midline angle and for the head-symphysis distance, respectively. CONCLUSION Transabdominal and transperineal intrapartum ultrasound parameters can predict the likelihood of spontaneous vaginal delivery in nulliparous women with prolonged second stage of labor.
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Youssef A, Dodaro MG, Montaguti E, Consolini S, Ciarlariello S, Farina A, Bellussi F, Rizzo N, Pilu G. Dynamic changes of fetal head descent at term before the onset of labor correlate with labor outcome and can be improved by ultrasound visual feedback. J Matern Fetal Neonatal Med 2019; 34:1847-1854. [PMID: 31394944 DOI: 10.1080/14767058.2019.1651266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the dynamic changes of angle of progression (AoP) before the onset of labor and their correlation with labor outcome and to investigate the effect of visual feedback using transperineal ultrasound on maternal pushing. METHODS We recruited a group of low-risk nulliparous women with singleton pregnancy at term. We measured AoP at rest, during pelvic floor contraction and Valsalva maneuver (before and after visual feedback). We compared AoP between women who delivered vaginally (VD) and those who underwent a cesarean section (CS). We also assessed the correlation between AoP and labor durations. RESULTS Overall, 222 women were included in the study; 129 (58.1%) had spontaneous VD, 35 (15.8%) had instrumental delivery, and 58 (26.1%) underwent CS. In comparison with rest, AoP decreased at PFMC (p < .001) and increased at first Valsalva (p < .001). AoP increased further significantly at Valsalva after visual feedback (p < .001). Women with VD had wider AoP at rest (p = .020), during Valsalva maneuver before (p = .024), and after visual feedback (p = .037). At cox regression analysis, wider AoP was associated with shorter first, second, and active second stages. CONCLUSION Wider AoP at rest and under Valsalva is associated with vaginal delivery, the shorter interval to delivery, and shorter labor duration in nulliparous women at term. The accuracy of AoP in the prediction of cesarean delivery is modest and is unlikely to be clinically applicable in isolation for the prediction of the mode of delivery.
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Affiliation(s)
- Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Maria Gaia Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Elisa Montaguti
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Consolini
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Silvia Ciarlariello
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Antonio Farina
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Federica Bellussi
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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Youssef A, Kamel R. Ultrasound in labor: impact of a theoretical and practical course on caregiver's perspective and accuracy. J Matern Fetal Neonatal Med 2019; 33:3163-3169. [PMID: 30700229 DOI: 10.1080/14767058.2019.1570113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The aim of the present study was two-fold; first is to assess the impact of a theoretical and practical course on the caregiver's perspective on the use of ultrasound in labor. Second is to evaluate the impact of the course on the measurement of the angle of progression.Materials and methods: Obstetricians participating in the course responded twice to a questionnaire addressing the caregiver's perspective on the use of ultrasound in labor, before and at the end of the course. In addition, all participants measured the angle of progression on a digital simulation software once following the theoretical part and a second time after the conclusion of both the theoretical and practical sessions. All answers to the questionnaire were compared before versus after the course. The angle of progression assessments after the theoretical part and those after the course were compared with those performed by an expert operator.Results: Overall, data from 51 participants were analyzed. In comparison with the pre-course questionnaire, more participants after the course believed ultrasound can be a useful instrument for fetal occiput presentation diagnosis (45; 88.2% versus 26; 51%, p < .001) and for fetal head progression evaluation (37; 72.5% versus 19; 37.3%; p < .001). Although before the course, most participants (32; 62.7%) thought that the transperineal parameters were too complex to be applied, only 19 (37.3%) still considered the complexity of the ultrasound indices, an obstacle against their application in clinical practice after the course (p = .002). Regarding the angle of progression, precourse measurements showed a systematic overestimation in comparison with the gold standard. Furthermore, the coefficient of variation, more than halved following the practical simulation reflecting at least a doubling of the angle of progression (AoP) measurement precision (14.2 versus 5.5%).Conclusions: A theoretical and practical course conducted by expert operators may positively change obstetricians' perspective on the use of ultrasound in labor. Moreover, a practical session seems to improve the participants' accuracy and precision in the assessment of fetal head descent by transperineal ultrasound.
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Affiliation(s)
- Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Rasha Kamel
- Department of Obstetrics and Gynecology, Kasr Al-Ainy University Hospital, Cairo University, Cairo, Egypt
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Salsi G, Cataneo I, Dodaro G, Rizzo N, Pilu G, Sanz Gascón M, Youssef A. Three-dimensional/four-dimensional transperineal ultrasound: clinical utility and future prospects. Int J Womens Health 2017; 9:643-656. [PMID: 28979167 PMCID: PMC5602462 DOI: 10.2147/ijwh.s103789] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
During the last decade, there has been a huge advancement in the use of transperineal ultrasound (TPU) in the field of obstetrics and gynecology. Its main applications in obstetrics include the monitoring of fetal progression in labor and recently the assessment of maternal pelvic dimensions, whereas in gynecology, TPU is at present widely used for the evaluation of the female pelvic floor, opening new boundaries for the assessment of pelvic floor disorders. The association of volumetric three-dimensional techniques has largely contributed to the remarkable progress that has occurred in the use of TPU. The aim of this paper is to offer an overview of the advantages, challenges and future perspectives of the use of TPU for women’s imaging.
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Affiliation(s)
- Ginevra Salsi
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Ilaria Cataneo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gaia Dodaro
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Mar Sanz Gascón
- Department of Obstetrics and Gynecology, La Fé University Hospital, University of Valencia.,Prenatal Diagnosis Unit, Casa del Salud University Hospital, Valencia, Spain
| | - Aly Youssef
- Department of Obstetrics and Gynecology, Sant'Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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Yonetani N, Yamamoto R, Murata M, Nakajima E, Taguchi T, Ishii K, Mitsuda N. Prediction of time to delivery by transperineal ultrasound in second stage of labor. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:246-251. [PMID: 27089836 DOI: 10.1002/uog.15944] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 03/26/2016] [Accepted: 04/14/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To investigate whether the transperineal sonographic (TPS) parameters angle of progression (AoP) and midline angle (MLA) can predict the time remaining in the second stage of labor. METHODS We evaluated prospectively women with a singleton pregnancy in cephalic presentation at term between October 2013 and September 2014. TPS volumes were obtained immediately after confirmation by digital vaginal examination of a fully dilated cervix. AoP and MLA were measured offline by analyzing the ultrasound volumes. Progression of labor was evaluated every hour during the second stage. The associations of AoP and MLA with the interval between TPS assessment and delivery were evaluated using multivariable Cox proportional hazards analyses in nulliparous and parous women separately. RESULTS A total of 557 women were evaluated. An AoP ≥ 160° (adjusted hazard ratio (aHR), 2.52 (95% CI, 1.98-3.19)) and MLA ≤ 10° (aHR, 1.79 (95% CI, 1.35-2.34)) in nulliparous women and an AoP ≥ 150° (aHR, 1.86 (95% CI, 1.34-2.57)) and MLA ≤ 20° (aHR, 1.69 (95% CI, 1.21-2.34)) in parous women were significantly associated with the remaining time in labor. The positive/negative likelihood ratios of AoP, MLA, clinical station (fetal head descent as observed by digital examination) and clinical rotation (fetal head rotation as observed by digital examination) at these cut-off points were 3.6/0.6, 2.0/0.6, 1.6/0.6 and 1.6/0.8, respectively, in nulliparous women, and 2.4/0.6, 1.3/0.7, 7.6/0.5 and 5.2/0.7, respectively, in parous women. CONCLUSION TPS assessment of AoP and MLA in the second stage of labor was useful for predicting the time remaining in labor and had higher predictive value than did digital vaginal examination in nulliparous women. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- N Yonetani
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - R Yamamoto
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - M Murata
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - E Nakajima
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - T Taguchi
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - K Ishii
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
| | - N Mitsuda
- Department of Maternal Fetal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Osaka, Japan
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Montaguti E, Rizzo N, Pilu G, Youssef A. Automated 3D ultrasound measurement of the angle of progression in labor. J Matern Fetal Neonatal Med 2017; 31:141-149. [DOI: 10.1080/14767058.2016.1277701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elisa Montaguti
- Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Nicola Rizzo
- Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Gianluigi Pilu
- Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Aly Youssef
- Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy
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Nishimura K, Yoshimura K, Kubo T, Hachisuga T. Objective diagnosis of arrested labor on transperineal ultrasound. J Obstet Gynaecol Res 2016; 42:803-9. [DOI: 10.1111/jog.12967] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 01/05/2016] [Accepted: 01/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Kazuaki Nishimura
- Department of Obstetrics and Gynecology; Wakamatsu Hospital, University of Occupational and Environmental Health; Kitakyushu Japan
| | - Kazuaki Yoshimura
- Department of Obstetrics and Gynecology; Wakamatsu Hospital, University of Occupational and Environmental Health; Kitakyushu Japan
| | - Tatsuhiko Kubo
- Department of Public Health; University of Occupational and Environmental Health; Kitakyushu Japan
| | - Toru Hachisuga
- Obstetrics and Gynecology; University of Occupational and Environmental Health; Kitakyushu Japan
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Youssef A, Ghi T, Martelli F, Montaguti E, Salsi G, Bellussi F, Pilu G, Rizzo N. Subpubic Arch Angle and Mode of Delivery in Low-Risk Nulliparous Women. Fetal Diagn Ther 2015; 40:150-5. [DOI: 10.1159/000441517] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 10/05/2015] [Indexed: 11/19/2022]
Abstract
Objective: To assess whether subpubic arch angle (SPA) measurement before labor onset can predict labor outcome among low-risk pregnant women. Methods: 3D ultrasound volume was transperineally acquired from a series of nulliparous women with uncomplicated pregnancy at term before the onset of labor. SPA was measured offline using Oblique View Extended Imaging (OVIX) on each volume performed by an investigator not involved in the clinical management. Labor outcome was prospectively investigated in the whole study group. Results: Overall, 145 women were enrolled in the study. Of these, 83 underwent spontaneous vaginal delivery, whereas obstetric intervention was performed in 62 cases (Cesarean section in 40 and vacuum extraction in 22). The SPA appeared to be significantly narrower in the women submitted to obstetric intervention compared with those undergoing spontaneous vaginal delivery (116.8 ± 10.3° vs. 123.7 ± 9.6°, p < 0.01). At multivariate analysis SPA and maternal age were identified as independent predictors of the mode of delivery. On the other hand, the duration of labor did not show a significant relationship with SPA. Conclusions: In low-risk nulliparous women at term gestation, SPA measurement obtained by 3D ultrasound before the onset of labor seems to predict the likelihood of an obstetric intervention but not the duration of labor.
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Affiliation(s)
- Sana Usman
- Imperial CollegeInstitute of Reproductive Developmental BiologyHammersmith CampusW12 0DN; Queen Charlottes and Chelsea HospitalImperial College Healthcare NHS TrustDu Cane RoadLondonW12 0HS
| | - Christoph Lees
- Imperial CollegeInstitute of Reproductive Developmental BiologyHammersmith CampusW12 0DN; Queen Charlottes and Chelsea HospitalImperial College Healthcare NHS TrustDu Cane RoadLondonW12 0HS
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