Study protocol. IDUS - Instrumental delivery & ultrasound: a multi-centre randomised controlled trial of ultrasound assessment of the fetal head position versus standard care as an approach to prevent morbidity at instrumental delivery

Sonographic Evaluation of the Mechanism of Active Labor (SonoLabor Study): observational study protocol regarding the implementation of the sonopartogram

INTRODUCTION

Over the last decades, a large body of literature has shown that intrapartum clinical digital pelvic estimations of fetal head position, station and progression in the pelvic canal are less accurate, compared with ultrasound (US) scan. Given the increasing evidence regarding the advantages of using US to evaluate the mechanism of labour, our study protocol aims to develop sonopartograms for fetal cephalic presentations. They will allow for a more objective evaluation of labour progression than the traditional labour monitoring, which could enable more rapid decisions regarding the mode of delivery.

METHODS/ANALYSIS

This is a prospective observational study performed in three university hospitals, with an unselected population of women admitted in labour at term. Both clinical and US evaluations will be performed assessing fetal head position, descent and rotation. Specific US parameters regarding fetal head position, progression and rotation will be recorded to develop nomograms in a similar way that partograms were developed. The primary outcome is to develop nomograms for the longitudinal US assessment of labour in unselected nulliparous and multiparous women with fetal cephalic presentation. The secondary aims are to assess the sonopartogram differences in occiput anterior and posterior deliveries, to compare the labour trend from our research with the classic and other recent partogram models and to investigate the capability of the US labour monitoring to predict the outcome of spontaneous vaginal delivery.

ETHICS AND DISSEMINATION

All protocols and the informed consent form comply with the Ministry of Health and the professional society ethics guidelines. University ethics committees approved the study protocol. The trial results will be published in peer-reviewed journals and at the conference presentations. The study will be implemented and reported in line with the Strengthening the Reporting of Observational Studies in Epidemiology statement.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02326077).

Ultrasound feedback training increases trainee accuracy in vaginal assessment of fetal head position in labor

OBJECTIVE

To evaluate the impact of an immediate ultrasound feedback intervention on trainee accuracy in vaginal-examination-based assessment of fetal head position.

METHODS

This was a prospective cohort study conducted at a single tertiary care center. Six third-year and six fourth-year residents in an obstetrics and gynecology residency training program were the study subjects. The third-year residents underwent a training intervention in which they assessed fetal head position by transvaginal digital examination and then received immediate feedback through ultrasound demonstration of the actual position. All examinations were performed in women with a singleton gestation ≥ 35 weeks and cervical dilation ≥ 8 cm, following rupture of membranes. The comparison groups were third-year residents before, during and after training and fourth-year residents who were not exposed to the training intervention. The primary outcome was the difference in accuracy of fetal-head-position assessment on vaginal examination by third-year residents before and after ultrasound feedback training. Univariate and multivariate analyses were performed to identify factors associated with digital examination accuracy.

RESULTS

Overall, 390 examinations were performed. The accuracy of fetal-head-position assessments of third-year residents was 55% (53/96) before training, 65% (74/114) during training and 70% (63/90) after training, while that of fourth-year residents who did not undergo training was 52% (47/90) (P = 0.04). Fourth-year residents who did not undergo ultrasound training demonstrated similar baseline accuracy to that of third-year residents pretraining (52% (47/90) vs 55% (53/96), P = 0.68), but had significantly lower accuracy than had the third-year residents post-training (52% (47/90) vs 70% (63/90); P = 0.01). Multivariable analysis revealed a positive association between ultrasound feedback training and the ability to assess accurately fetal head position. After adjusting for the variables included in the final model, examinations performed by third-year residents pretraining and those performed by fourth-year residents who did not undergo training were less likely to be accurate than those performed by third-year residents post-training (adjusted odds ratio, 0.48 (95% CI, 0.26-0.91) and 0.42 (95% CI, 0.22-0.80), respectively).

CONCLUSION

Immediate ultrasound feedback training increased trainee accuracy in vaginal assessment of fetal head position in labor. Its integration into obstetric training programs should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

[What is new about obstetrical interventions during labor and normal delivery?]

This systematic review of the literature reports studies published over the last five years (2008-2013) about interventions during labor and normal delivery. The points made concerning active management of labor, interventions aimed at improving maternal comfort, management of occiput posterior fetal presentations, management of second stage of labor and prevention techniques for perineal lesions. Although obstetrics remains an "art" to which training is mainly based on experience and clinical expertise, this "art" at present cannot live without the evidence-based medicine. Numerous randomized trials published and in process, demonstrate awareness of this reality in our specialty.