Intrapartum Ultrasonography For Labor Management

Intrapartum Ultrasonography
for Labor Management

Antonio Malvasi
Editor
Intrapartum
Ultrasonography
for Labor Management
Editor
Antonio Malvasi, M.D.
Department of Obstetric
and Gynecology
Santa Maria Hospital
Bari
Italy
ISBN 978-3-642-29938-4 ISBN 978-3-642-29939-1 (eBook)

DOI 10.1007/978-3-642-29939-1
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2012952508
© Springer-Verlag Berlin Heidelberg 2012

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To my wife, Elena, and my children, Mariaelena and Vito
Maurizio, who, of all that walk the earth, are most precious
to me: They are the reason I am here. They have always been
there for me and have never doubted my dreams, no matter how
crazy they might be.
Preface
Ultrasound has revolutionized the traditional midwife, and semiotics in par-

ticular gave a dignity to the unborn child, who is now framed as a patient.
However, the main interest has been on ultrasound fetal malformations and
fetal growth, whether normal or pathological, while little interest has been
directed to the delivery event.
Indeed, although the birth is a common phenomenon, few technologies have
been developed for the monitoring of labor. This phenomenon contrasts with
everyday reality. In fact, for example, although fetal distress represents 1–2% of
deliveries, it can be monitored with different instrumental techniques
(cardiotocography, pulse oximetry using Stan®, pH-metry), dystocia affects
about 40% of the deliveries but it is still diagnosed manually, as it was in 1700.
Intrapartum sonography is a relatively new technique; it adds to what is
felt by the fingers as the eye can see objectively the commitment, the descent,
and the rotation of the fetal head in the birth canal. This makes it possible to
follow the labor in a more objective view by midwives and enables early
detection of labor dystocia, allowing timely intervention and reducing mater-
nal and fetal complications. On the other hand, an objective evaluation of
labor reduces operative deliveries based on a presumptive diagnosis of dysto-
cia, provides a documentation of labor developments, and enables operators
to lower exposure to possible litigation in case of complications that bring
charges of malpractice. A new ultrasonography area, intrapartum obstetric
ultrasound, has been documented by a growing number of scientific articles
that increase the literature. In fact, it is forming a scientific level, a real “pel-
vimetric ultrasound,” that does not replace but strongly supports pelvimetry
by providing clinical support of objectivity and by showing the mechanisms
of parturition in occipito anterior, posterior, and transverse presentations. In
the near future, the literature will be subject to an inevitable revision of the
results obtained from the classical clinical symptomatology alone. This text,
in the authors’ opinion, is easy to consult and offers practical support to those
who operate and work in the delivery room and attempt to better diagnose
physiological from pathological labor and to reduce the inevitable risks
involved in the complex phenomenon that is childbirth. Furthermore, our
work fills a gap in publishing today on a topic of considerable practical inter-
est that we hope will inspire the attention it deserves.
Bari, Italy Antonio Malvasi, M.D.

Perugia, Italy Gian Carlo Di Renzo, M.D., Ph.D.
vii
Contents
1 Clinical Evaluation of Labor and Intrapartum

Sonography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Thomas Popowski and Patrick Rozenberg
2 General Intrapartum Sonography Setup
and Use in Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Miguel Angel Barber, Francisca S. Molina,
Margarita Medina, Azahar Romero,
and Jose A. Garcia-Hernandez
3 The Use of Two-Dimensional (2D)
and Three-Dimensional (3D)
Ultrasound in the First Stage of Labor . . . . . . . . . . . . . . . . . . . 29
Ariel L. Zimerman
4 Intrapartum Sonography and Labor Progression . . . . . . . . . . 41
Torbjørn Moe Eggebø and Kjell Åsmund Salvesen
5 Occiput Posterior Position
and Intrapartum Sonography . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Antonino F. Barbera, Andrea Tinelli, Elena Pacella,
and Antonio Malvasi
6 Asynclitism: Clinical and Intrapartum
Diagnosis in Labor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Antonino F. Barbera, Andrea Tinelli, and Antonio Malvasi
7 The Angle of Progression: An Objective Assessment
of Fetal Head Descent in the Birth Canal . . . . . . . . . . . . . . . . . 87
Antonino F. Barbera
8 Head Rotation in Labor and Intrapartum
Sonography Diagnosis with 2D and 3D . . . . . . . . . . . . . . . . . . . 101
Tullio Ghi, Aly Youssef, Elisa Maroni,
Gianluigi Pilu, and Nicola Rizzo
9 Intrapartum Translabial Ultrasound (ITU)
to Assess Birth Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Boris Tutschek, Thorsten Braun, Frederic Chantraine,
and Wolfgang Henrich
ix
x Contents
10 Use of Cervical Length in Labor and Delivery. . . . . . . . . . . . . 119

Sushma Potti, Gian Carlo Di Renzo,
and Vincenzo Berghella
11 Intrapartum Sonography and Clinical
Risk Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Andrea Tinelli, Sarah Gustapane, Francesco Giacci,
Domenico Dell’Edera, and Antonio Malvasi
12 New Technologies for Monitoring Labor Progress . . . . . . . . . 149
Dan Farine, Drorith Hochner-Celnikier,
Yoav Paltieli, and Mario Bochicchio
13 Fetal Progression in Birth Canal: State of the Art . . . . . . . . . 159
Anna Maria Dückelmann and Karim D. Kalache
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Contributors
Miguel Angel Barber, M.D., Ph.D. Prenatal Diagnosis and Fetal Therapy
Unit, Department of Obstetrics and Gynecology, Insular and Maternal
Universitary Hospitalary Complex (CHUIMIC), Las Palmas of Grand
Canary, Spain
Department of Obstetrics and Gynecology, Canaries University Hospital
Maternity Ward, Las Palmas de Gran Canaria, Spain
Antonio F. Barbera, M.D. Swan Mountain, Women’s Center,
Breckenridge, CO, USA
Department of Obstetrics and Gynecology, School of Medicine,
University of Colorado Denver, Aurora, CO, USA
Rocky Vista University College of Osteopathic Medicine, Parker, CO, USA
Department of Obstetric and Gynecology, Denver Health Medical Center,
Denver, CO, USA
Vincenzo Berghella, M.D., Ph.D. Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology, Jefferson Medical College
of Thomas Jefferson University, Philadelphia, PA, USA
Mario Bochicchio, Ph.D. Department of Innovation Engineering,
University of Salento, Lecce, Italy
Thorsten Braun, M.D. Department of Obstetrics, Charité Medical
University Berlin, Berlin, Germany
Frederic Chantraine, M.D. Department of Gynecology and Obstetrics, Centre
Hospitalier Régional de la Citadelle, University of Liège, Liège, Belgium
Domenico Dell’Edera, Ph.D. Unit of Cytogenetic and Molecular Genetics,
“Madonna delle Grazie” Hospital, Matera, Italy
Gian Carlo Di Renzo, M.D., Ph.D. Department of Obstetrics and
Gynecology, Centre for Perinatal and Reproductive Medicine, University of
Perugia, Perugia, Italy
Anna Maria Dückelmann, M.D. Department of Obstetrics,
Charité – University Hospital, Campus Charité Mitte, Berlin, Germany
xi
xii Contributors
Torbjørn Moe Eggebø, Ph.D. Department of Obstetrics and Gynecology,

Stavanger University Hospital, Stavanger, Norway
National Center for Fetal Medicine, Trondheim University Hospital
(St. Olav’s Hospital), Trondheim, Norway
Dan Farine, M.D., FRCS Department of Obstetrics and Gynaecology,
Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
Jose A. Garcia-Hernandez, M.D., Ph.D. Prenatal Diagnosis and Fetal
Therapy Unit, Department of Obstetrics and Gynecology, Insular and
Maternal Universitary Hospitalary Complex (CHUIMIC), Las Palmas of
Grand Canary, Spain
Tullio Ghi, M.D., Ph.D. Department of Obstetrics and Gynecology,
Sant’Orsola Malpighi University Hospital, University of Bologna,
Bologna, Italy
I Clinica Ostetrica-Ginecologica, Policlinico S. Orsola-Malpighi,
Bologna, Italy
Francesco Giacci, M.D. Department of Obstetric and Gynecology,
SS. Annunziata Hospital, Chieti, Italy
Sarah Gustapane, M.D. Department of Obstetric and Gynecology,
SS. Annunziata Hospital, Chieti, Italy
Wolfgang Henrich, M.D. Department of Obstetrics, Charit´e Virchow
Clinic, Berlin, Berlin, Germany
Drorith Hochner-Celnikier, M.D. Department of Obstetrics
and Gynecology, Hadassah University Hospital, Jerusalem, Israel
Karim D. Kalache, M.D., Ph.D. Department of Obstetrics,
Charité – University Hospital, Campus Charité Mitte, Berlin, Germany
Antonio Malvasi, M.D. Department of Obstetric and Gynecology,
Santa Maria Hospital, Bari, Italy
Elisa Maroni, M.D. Department of Obstetrics and Gynecology,
Bologna, Italy
Margarita Medina, M.D. Prenatal Diagnosis and Fetal Therapy Unit,
Department of Obstetrics and Gynecology, Insular and Maternal
Canary, Spain
Francisca S. Molina, M.D., Ph.D. Maternal-Fetal Medicine Unit,
Department of Obstetrics and Gynecology, San Cecilio University Hospital
(HUSC), Granada, Spain
Elena Pacella, M.D., Ph.D. Department of Sense Organs-Ophthalmology,
Sapienza University of Rome, Italy
Contributors xiii
Yoav Paltieli, M.D., Ph.D., LLB Division of Infertility,

Bnei Zion Hospital Haifa, Haifa, Israel
Trig Medical, Ridgefield Park, NJ, USA
Trig Medical Ltd., YoqneamIlit, Israel
Gianluigi Pilu, M.D., Ph.D. Department of Obstetrics and Gynecology,
Bologna, Italy
Thomas Popowski, M.D. Department of Obstetrics and Gynecology,
Reproductive Biology and Cytogenetics, Poissy-Saint Germain Hospital,
University Versailles-St Quentin, Poissy, France
Sushma Potti, M.D. Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, Jefferson Medical College of Thomas Jefferson,
University, Philadelphia, PA, USA
Nicola Rizzo, M.D., Ph.D. Department of Obstetrics and Gynecology,
Bologna, Italy
Azahar Romero, M.D. Prenatal Diagnosis and Fetal Therapy Unit,
Department of Obstetrics and Gynecology, Insular and Maternal
Canary, Spain
Patrick Rozenberg, M.D. Department of Obstetrics and Gynecology,
Reproductive Biology and Cytogenetics, Poissy-Saint Germain Hospital,
Centre Hospitalier Poissy-Saint-Germain, Poissy, France
Kjell Åsmund Salvesen, M.D., Ph.D., dr.med National Center for Fetal
Medicine, Trondheim University Hospital (St. Olav’s Hospital), Trondheim,
Norway
Department of Laboratory Medicine, Children’s and Women’s Health,
Norwegian University of Science and Technology, Trondheim, Norway
Andrea Tinelli, M.D. Division of Experimental Endoscopic Surgery,
Imaging, Minimally Invasive Therapy and Technology, Department of
Obstetric and Gynecology, Vito Fazzi Hospital, Lecce, Italy
Boris Tutschek, M.D. Department of Obstetrics and Gynecology,
Bern University Hospital, Bern, Switzerland
Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
Aly Youssef, M.D. Department of Obstetrics and Gynecology,
Bologna, Italy
Ariel L. Zimerman, M.D., Ph.D. Department of Obstetrics
and Gynecology, Assaf Harofeh Medical Center (affiliated with the
Sackler School of Medicine, Tel-Aviv University), Zerifin, Israel
Clinical Evaluation of Labor
and Intrapartum Sonography 1
Thomas Popowski and Patrick Rozenberg
1.1 Introduction cardboard boxes to simulate cervical examina-

tions (Fig. 1.1) [1].
Clinical evaluation remains the criterion stan- In all, 1,574 simulated measurements of cervi-
dard, or more agonistically the gold standard, for cal diameter were obtained from 102 different
managing labor. In the intrapartum period, digital examiners. Overall accuracy for determining the
vaginal examination allows the assessment of exact diameter was 56.3%, but improved to 89.5%
cervical dilatation as well as both the station and when an error of ±1 cm was allowed. The intrao-
position of the fetal head. Few studies, however, bserver variability for a given measurement was
have assessed the accuracy of clinical evaluation 52.1% and decreased to 10.5% when an error of
of labor. In this chapter, we review the publica- ±1 cm was allowed. The authors thus concluded
tions that have examined this topic. that intraobserver variability is an important con-
sideration in evaluating dysfunctional labor.
An electronic search in PubMed (1966 –
1.2 Evaluation of Cervical December 2011), using the keywords “cervical
Dilatation dilatation,” “digital examination,” and “accuracy,”
The accuracy and intraobserver variability of

clinical cervical diameter measurements were
studied by Phelps et al., who used polyvinyl
chloride pipes 1–10 cm in diameter mounted in
T. Popowski, M.D.
Department of Obstetrics and Gynecology,
Reproductive Biology and Cytogenetics,
Poissy-Saint Germain Hospital,
P. Rozenberg, M.D. ()
Reproductive Biology and Cytogenetics,
Poissy-Saint Germain Hospital,
Centre Hospitalier Poissy-Saint-Germain,
10 Rue du Champ Gaillard, Cedex, 78303
Poissy, France Fig. 1.1 Cervical simulator model according to
e-mail: [email protected] Phelps et al. [1]
A. Malvasi (ed.), Intrapartum Ultrasonography for Labor Management, 1

DOI 10.1007/978-3-642-29939-1_1, © Springer-Verlag Berlin Heidelberg 2012
2 T. Popowski and P. Rozenberg
found only one article comparing the accuracy of Table 1.1 Intervals of angle of head descent, derived
ultrasound and vaginal examination for determin- from the geometric model and computed tomography
data, associated with each specific fetal head station
ing cervical dilatation during labor. In 2009,
Zimerman et al. assessed the accuracy and repro- Lower Mean Upper
Station angle (°) angle (°) angle (°)
ducibility of intrapartum translabial three-dimen-
−5 62 65 68
sional (3D) ultrasonographic measurements of
−4 69 71 74
cervical dilatation during labor in a prospective −3 75 78 81
observational study [2]. −2 82 85 88
They collected 3D ultrasonographic vol- −1 89 92 95
ume data sets from 52 patients during labor and 0 96 99 102
stored them. The correlation between the digital 1 103 106 109
assessments by delivery room personnel and the 2 110 113 116
digital vaginal examinations was studied, and 3 117 120 123
interobserver and intraobserver agreement were 4 124 127 131
determined. Translabial 3D ultrasonographic 5 132 135 139
measurements of the mean and maximum cervi- According to Barbera et al. [3]
cal diameters and inner cervical area correlated
positively with the digital findings (p < 0.001) with and a line drawn downward from the inferior
interobserver and intraobserver intraclass corre- margin of the symphysis – that best corresponds
lation coefficients of 0.82 and 0.85, respectively. to the midpoint of a line drawn between the two
The authors concluded that the assessment of ischial spines (representing clinical station 0).
cervical dilatation with 3D ultrasonography dur- They showed that the mean angle (standard devi-
ing labor is feasible and reproducible. However, ation) between these vectors was 99° (6°).
this study did not demonstrate any benefit to the They next built an algorithm to associate each
use of ultrasound. Therefore, despite the imper- clinical station defined by the American College
fect accuracy of digital examination for evaluat- of Obstetricians and Gynecologists with a specific
ing cervical dilatation, no tool is currently more set of theoretical angles by creating consecutive
accurate. nonoverlapping intervals around the theoretical
mean (Table 1.1).
For example, at station 0, the theoretical mean
1.3 Evaluation of Fetal Head is 99°. Its lower angle was calculated as the mid-
Station point between 92° (−1 station) and 99° (0 sta-
tion), namely, 95°; its upper angle was calculated
Digital examination is also the criterion standard as the midpoint between 99° (0 station) and 106°
for the evaluation of fetal head station. Barbera (+1 station), namely, 102°. Finally, Barbera et al.
et al. specifically addressed its accuracy for this assessed how closely clinical estimates of station,
purpose [3]. by digital examination, compared with ultrasound
They developed a method for the objective station by TPU in 88 laboring patients.
assessment of fetal station and progression Figure 1.2 shows the relations between digi-
through the birth canal, based on simultaneous tally assessed fetal head station and the TPU-
imaging by transperineal ultrasound (TPU) of recorded angles for each clinical station between
both the maternal symphysis pubis and the fetal −2 and +2 as well as their relation to the geomet-
head. ric model created with the CT data.
Since the true level of the ischial spines is Table 1.2 shows the extent of agreement
critical to the assessment of clinical station, they between station determined by digital examina-
developed a computed tomography (CT) geomet- tion and that assigned by the geometric model.
ric model to determine the angle between two The highest percentage of complete agreement
vectors – the long axis of the pubic symphysis was only 46%, at −2 station. The percentage of
1 Clinical Evaluation of Labor and Intrapartum Sonography 3
Computed stations
−3 −2 −1 0 +1 +2 +3
2
Clinical stations
−1
−2
−3
60 74 81 88 95 102 110 115 122 160

78 85 92 99 106 113 120
Computed angles (°)
Fig. 1.2 Relationship between digitally assessed fetal of head descent (shaded boxes) determined, using a geo-
head station and angle of head descent measured on trans- metric model, to be associated with each specific fetal
perineal ultrasound (•). Also shown are intervals of angle head station (Barbera et al. [3])
Table 1.2 Agreement between the assessment of fetal This result is certainly not surprising since
head station by digital examination and by measurement the assessing fingers are able to feel both the
of the angle of head descent, assessed by transperineal
ultrasound spines and the fetal skull when the head is above
the level of the spines. In contrast, once the fetal
Agreement (%)
head is below 0 station, the ability to appreciate
Computed
station Complete ±1 cm ±2 cm the relation between the ischial spines, located
−3 27 60 87 laterally in the pelvis, and the most prominent
−2 46 92 100 part of the centrally located fetal skull, presents
−1 14 64 89 a major challenge, demonstrated by progres-
0 18 53 92 sively worsening agreement below 0 station. An
1 16 32 56 agreement between 89% and 100% was observed
2 2.6 26 39 only with a ±2-cm variation, that is, every time
3 0 12 40 a clinician diagnoses the fetal head to be at 0
According to Barbera et al. [3] station, the real station may vary between −2
and +2. This inaccuracy is especially vexing at
complete agreement declined progressively from station +2.
their downward. At computed station 0, for exam- As ACOG states that forceps application (low)
ple, the digital examination completely agreed in is safe only at or after this station [4], it is rather
only 18% of cases and for computed station +2, critical.
only 2.6%. On the other hand, station +2 as deter- Thus, each angle measured by TPU corre-
mined by digital examination was within ±2 cm sponded to a wide range of clinically assessed
of the computed station in 39% of cases. stations, and clinical digital assessment of station
correlated poorly with computed station, especially The second study included 112 patients dur-
at stations below zero, where the clinical impact ing the second stage of labor [8] and used the
could be substantial. same methodology. Disagreement between the
We must therefore search for more accurate ultrasound and digital examinations (absolute
tools to evaluate fetal head descent and to predict error) was found for 65% of patients. Stratification,
fetal head engagement. Digital examination when the transvaginal digital examination was
should not be the criterion standard for evaluat- recorded as correct if occurring within ±45° of
ing these new tools. the ultrasound assessment, reduced the error of
these examinations to 39% (Figs. 1.3 and 1.4).
Akmal et al. confirmed these results in a larger
1.4 Evaluation of Fetal Head study including 496 singleton pregnancies during
Position labor at term [9].
The position of the fetal head was determined
The data about intrapartum assessment of fetal by ultrasound examination in all 496 cases exam-
head position are based on the time-honored ined, but digital examination failed to define the
X-ray study by Caldwell and Moloy [5] and a fetal head position in 166 (33.5%) cases. In the
subsequent report by Calkins [6], both dating 330 cases where position could be determined,
back to the1930s. Recent use of intrapartum the digital and sonographic examinations agreed
ultrasound gives us the opportunity to address the in only 163 (49.4%) cases.
accuracy of digital transvaginal examination in Correct identification of fetal position by
assessing fetal head position. Sherer et al. con- digital examination increased with cervical dila-
ducted two prospective studies to compare trans- tation, from 20.5% at 3–4 cm to 44.2% at
vaginal digital examination and transabdominal 8–10 cm, and was higher in the absence (com-
ultrasound assessment [7, 8]. pared with the presence) of caput succedaneum
The first study was performed during the (33% vs. 25%).
active stage of labor in 102 consecutive patients Dupuis et al. studied 110 patients in the sec-
at term with normal singleton fetuses in cephalic ond stage of labor and reported that both clinical
presentation [7]. and transabdominal ultrasound examinations
All participants had ruptured membranes; cer- indicated the same position of the fetal head in
vical dilation ³4 cm and fetal head at ischial spine 70% of cases. Agreement between the two meth-
station −2 or lower. Transvaginal digital exami- ods reached 80% when allowing a difference of
nations were performed by either senior residents up to 45° in the head rotation. However, even in
or attending physicians and followed immedi- that case, the accuracy of transvaginal examina-
ately by transverse suprapubic transabdominal tion was only 50% in the occiput posterior and
ultrasound assessments, considered to be the cri- occiput transverse positions.
terion standard. Examiners were blinded to each Again, caput succedaneum tended to diminish
other’s findings. Transvaginal digital examina- (p = 0.09) the accuracy of clinical examination [10].
tions were consistent with ultrasound assess- As the occiput posterior and transverse posi-
ments for only 24% of the patients (p = 0.002). tions (Figs. 1.5 and 1.6) are often associated with
Logistic regression revealed that cervical efface- obstructed labor requiring medical intervention,
ment (p = 0.03) and ischial spine station (p = 0.01) the risk of clinical error is potentially high when
significantly affected the accuracy of transvagi- instrumental delivery is needed [11, 12].
nal digital examination. Surprisingly, however, Akmal et al. compared clinical and ultrasono-
examiner experience did not. The accuracy of the graphic finding in 64 singleton pregnancies
transvaginal digital findings rose to 47% when undergoing operative vaginal delivery. The fetal
fetal head position at transvaginal digital exami- head position was determined by transvaginal
nation was recorded as correct if reported within digital examination by the attending obstetri-
±45° of the ultrasound assessment. cian. Immediately after or before this clinical
Fig. 1.3 Intrapartum transabdominal

sonography detecting a fetal head presentation
in left anterior occiput position

in right anterior occiput position

in right transverse occiput position

in left transverse occiput position
examination, the fetal head position was deter- combined abdominal and perineal ultrasound
mined by ultrasound by a trained sonographer examination. The vaginal and sonographic exam-
who was not aware of the clinical findings [12]. inations were compared to the true position of the
Digital examination failed to define the cor- vertex, determined by direct visualization follow-
rect fetal head position in 17 (26.6%) cases. In 12 ing delivery and spontaneous restitution of the
of these 17 (70.6%) errors, the difference was fetal head.
³90°, and in 5 (29.4%), it ranged from 45°to 90°. The error rate in detecting fetal occiput posi-
The accuracy of vaginal digital examination was tion was significantly lower with the ultrasound
83% for the occiput-anterior and 54% for the technique (6.8%) than the vaginal examination
occiput-lateral and occiput-posterior positions. (29.6%, p = 0.011). The clinical error was <90°
The main weakness of these studies, however, in 5 of 44 cases (11.4%), 90° in 4 of 44 cases
is that they considered ultrasound assessment to (9.1%), and >90° in 4 of 44 cases (9.1%). All the
be the criterion standard, without any prior evi- ultrasound errors occurred in patients examined
dence that its accuracy in determining fetal head in the +1 cm to +2 cm station. There were three
position was superior to that of clinical examina- errors <90° in 1 of 44 cases (2.3%), and equal to
tion. However, Kreiser et al. conducted a pro- 90° in 2 of 44 cases. The ultrasound technique
spective cohort study of 44 parturients to compare produced no errors of >90°. The error rate was
the accuracy of ultrasonography and vaginal not affected by parity, maternal body mass index,
examination for determination of fetal occiput or fetal weight.
position [13]. Chou et al. also compared the accuracy of
During the second stage of labor, an attending ultrasonography and vaginal examination in the
obstetrician performed a vaginal examination to determination of fetal occiput position (Figs. 1.7
detect fetal occiput position, and a sonographer, a and 1.8) during the second stage of labor [14].

in right posterior occiput position

in left posterior occiput position
In all, 88 women in the second stage of labor Because they showed that ultrasound exami-
were evaluated by vaginal examination and by nation is more accurate than vaginal examination
combined transabdominal and transperineal for this diagnosis, the former should be consid-
ultrasound examination to determine occiput ered the criterion standard.
position. These predictions of position were com- Finally, transabdominal ultrasonography is
pared with the actual delivery position at vaginal not only more accurate than digital examination
delivery after spontaneous restitution or at cesar- in determining fetal head position in labor, it is
ean delivery. Different examiners performed each also easier to learn [15].
type of examination, always blinded to the deter- A prospective study with a student midwife
mination of the other examiner. Vaginal examina- who had never performed either type of examina-
tion determined fetal occiput position correctly tion found an error rate of around 50% for vagi-
71.6% of the time, and ultrasound examination, nal examination nearly constantly through the
92.0% of the time (p = 0.018). first 50 examinations; it decreased subsequently
These two studies, using appropriate method- and stabilized at a low level from the 82nd patient.
ology, thus confirm the results of other publica- Errors of ±180° were the most frequent. The
tions that used ultrasound examination as the learning curve for ultrasound imaging stabilized
criterion standard for assessing the accuracy of much earlier, from the 23rd patient. This impres-
vaginal examination in the determination of fetal sion was confirmed at the 32nd patient with the
occiput position. LC-CUSUM test. The most frequent errors with
the ultrasound examination were an inability to were within these limits with digital vaginal
reach a conclusive diagnosis, particularly at the examination (Table 1.3) [15].
beginning of training, followed by errors of ±45°. The use of ultrasound and, particularly, the
With ultrasound examination, all the errors but transabdominal method improves the diagnosis
one (6/7) were within 45° whereas only 8/25 versus vaginal examination, especially in asyn-
clitisms (Figs. 1.9, 1.10, 1.11, 1.12, 1.13, and
Table 1.3 Learning curve of ultrasound versus digital 1.14): in the first stage, it is difficult to diagnose
examination: amplitude of errors [15] due to poor cervical dilation, and in the second
Digital vaginal Sonographic stage, the vaginal examination of the fetal head
Parameter examination examination fountain sutures is hampered by the formation of
Number of 100 99 “caput succedaneum.”
examinations
In the posterior and transverse fetal head posi-
No conclusion by 12 (12) 9 (9)
trainee (n (%)) tion, the asynclitism can be diagnosed by display-
Agreement/error (n (%)) ing only one fetal orbit, called by Malvasi et al.
0o 63 (72) 83 (92) “squint sign.” This sign is well seen in the marked
±45o 8 (9) 6 (7) cases of asynclitism, but it does not allow the
±90o 2 (2) 0 (0) diagnosis of the degree of asynclitism [16–18].
±135o 3 (3) 1 (1) In conclusion, this review should encourage
±180o 12 (14) 0 (0) physicians to introduce ultrasound examination
Rozenberg et al. [15]

in left transverse occiput position with
posterior asynclitism. In the image, the orbit
seen is represented by a circle in the figure

in right transverse occiput position with
anterior asynclitism
Fig. 1.11 Intrapartum transabdominal sonography

detecting a fetal head presentation in left posterior
occiput position, with anterior left asynclitism

in median posterior occiput position, with left
asynclitism

in right anterior occiput position, with
posterior right asynclitism

in right posterior occiput position, with
posterior asynclitism

in posterior occiput position
into their clinical practice. Ultrasound examina- head position. J Matern Fetal Neonatal Med
tion is easy to learn and more accurate than digi- 12(3):172–177
10. Dupuis O, Ruimark S, Corinne D, Simone T, Andre D,
tal vaginal examination for fetal head station and Rene-Charles R (2005) Fetal head position during the
position assessment (Fig. 1.15). second stage of labor: comparison of digital vaginal
examination and transabdominal ultrasonographic
examination. Eur J Obstet Gynecol Reprod Biol
123(2):193–197
References 11. Souka AP, Haritos T, Basayiannis K, Noikokyri N,
Antsaklis A (2003) Intrapartum ultrasound for the
1. Phelps JY, Higby K, Smyth MH, Ward JA, Arredondo examination of the fetal head position in normal and
F, Mayer AR (1995) Accuracy and intraobserver vari- obstructed labor. J Matern Fetal Neonatal Med
ability of simulated cervical dilatation measurements. 13(1):59–63
Am J Obstet Gynecol 173(3 Pt 1):942–945 12. Akmal S, Kametas N, Tsoi E, Hargreaves C,
2. Zimerman AL, Smolin A, Maymon R, Weinraub Z, Nicolaides KH (2003) Comparison of transvaginal
Herman A, Tobvin Y (2009) Intrapartum measurement digital examination with intrapartum sonography to
of cervical dilatation using translabial 3-dimensional determine fetal head position before instrumental
ultrasonography: correlation with digital examination delivery. Ultrasound Obstet Gynecol 21(5):437–440
and interobserver and intraobserver agreement assess- 13. Kreiser D, Schiff E, Lipitz S, Kayam Z, Avraham A,
ment. J Ultrasound Med 28(10):1289–1296 Achiron R (2001) Determination of fetal occiput posi-
3. Barbera AF, Imani F, Becker T, Lezotte DC, Hobbins JC tion by ultrasound during the second stage of labor. J
(2009) Anatomic relationship between the pubic sym- Matern Fetal Med 10(4):283–286
14. Chou MR, Kreiser D, Taslimi MM, Druzin ML,
physis and ischial spines and its clinical significance in
El-Sayed YY (2004) Vaginal versus ultrasound exam-
the assessment of fetal head engagement and station dur- ination of fetal occiput position during the second
ing labor. Ultrasound Obstet Gynecol 33(3):320–325 stage of labor. Am J Obstet Gynecol 191(2):521–524
4. ACOG ACoOaG (2000) Committee on Practice 15. Rozenberg P, Porcher R, Salomon LJ, Boirot F, Morin
Bulletin: operative vaginal delivery. ACOG Practice C, Ville Y (2008) Comparison of the learning curves
bulletin 2000:171–178 of digital examination and transabdominal sonogra-
5. Caldwell W, Moloy H, D’Esopo D (1934) A röent- phy for the determination of fetal head position during
genologic study of the mechanism of engagement of labor. Ultrasound Obstet Gynecol 31(3):332–337
the fetal head. Am J Obstet Gynecol 28:824–841 16. Malvasi A, Tinelli A, Stark M (2011) Intrapartum
6. Calkins L (1939) The etiology of occiput presenta- sonography sign for occiput posterior asynclitism diag-
tions. Am J Obstet Gynecol 37:618–623 nosis. J Matern Fetal Neonatal Med 24(3):553–554
7. Sherer DM, Miodovnik M, Bradley KS, Langer O 17. Malvasi A, Tinelli A, Brizzi A, Guido M, Laterza F,
(2002) Intrapartum fetal head position I: comparison De Nunzio G, Bochicchio M, Ghi T, Stark M,
between transvaginal digital examination and transab- Benhamou D, Di Renzo GC (2011) Intrapartum
dominal ultrasound assessment during the active stage sonography head transverse and asynclitic diagnosis
of labor. Ultrasound Obstet Gynecol 19(3):258–263 with and without epidural analgesia initiated early
8. Sherer DM, Miodovnik M, Bradley KS, Langer O during the first stage of labor. Eur Rev Med Pharmacol
(2002) Intrapartum fetal head position II: comparison Sci 15(5):518–523
between transvaginal digital examination and transab- 18. Malvasi A, Stark M, Ghi T, Farine D, Guido M, Tinelli
dominal ultrasound assessment during the second A (2012) Intrapartum sonography for fetal head asyn-
stage of labor. Ultrasound Obstet Gynecol clitism and transverse position: sonographic signs and
19(3):264–268 comparison of diagnostic performance between trans-
9. Akmal S, Tsoi E, Kametas N, Howard R, Nicolaides vaginal and digital examination. J Matern Fetal
KH (2002) Intrapartum sonography to determine fetal Neonatal Med 25(5):508–512, Epub 2012 Feb 14
General Intrapartum Sonography
Setup and Use in Labor 2
Miguel Angel Barber, Francisca S. Molina,
Margarita Medina, Azahar Romero,
and Jose A. Garcia-Hernandez
2.1 Introduction 2.2 General Intrapartum

Ultrasound Setup
We are currently witnessing a change in obstet-
rics. For more than 10 years, obstetric sonogra- 2.2.1 Portable Ultrasound
phy has been the main diagnostic tool available to
specialists. Currently, the prediction of condi- Recent changes in the profile of the ultrasound
tions such as preeclampsia, preterm labor, or pla- machine have been fundamental for its more
cental insufficiency within the context of general use in the delivery room and have made
intrauterine growth restriction is based on ultrasonography much more effective in a small and
sound use. It is logical to hypothesize that sonog- dynamic space, compared to the large ultra-
raphy could play a significant, expanded role in sound machines used during a consultation.
labor management and assistance, particularly in While the use of ultrasound is the prerogative
situations that require quick obstetric decisions of each individual examiner and depends on the
based on clinical explorations that are subjective machine at hand, we have used this type of
and have a considerable learning curve. machine in our center to conduct studies related
to sonographic applications in the delivery
room [1].
M.A. Barber, M.D., Ph.D. ()
Prenatal Diagnosis and Fetal Therapy Unit, Department
of Obstetrics and Gynecology, Insular and Maternal
Universitary Hospitalary Complex (CHUIMIC), 2.2.2 Ultrasound Probes
Las Palmas of Grand Canary, Spain
Department of Obstetrics and Gynecology, Ultrasound explorations can be performed either
Canaries University Hospital Maternity Ward, transabdominally and/or transperineally. We rec-
Avenida maritima del sur sn., Las Palmas de Gran
ommend the use of a convex abdominal probe and
Canaria, Spain 35005
e-mail: [email protected] abdominal 3D-4D ultrasound. Our group gener-
ally uses the RIC5-9H probe by General Electric®.
F.S. Molina, M.D., Ph.D.
Maternal-Fetal Medicine Unit, Department of Obstetrics During intrapartum sonography, we generally do
and Gynecology, San Cecilio University Hospital not use probes for vaginal exploration.
(HUSC), Granada, Spain
M. Medina, M.D. • A. Romero, M.D.
J.A. Garcia-Hernandez, M.D., Ph.D. 2.2.3 Examiner
Prenatal Diagnosis and Fetal Therapy Unit,
Insular and Maternal Universitary Hospitalary Complex The use of sonography in the delivery room
(CHUIMIC), Las Palmas of Grand Canary, Spain is not yet routine for all obstetric services.

16 M.A. Barber et al.
Historically, there has been a gap between for the decubitus supine position [3]. Prior
obstetricians with delivery room training and bladder-emptying facilitates visualization and
obstetricians with greater sonography skills. standardizes the measurements. For abdominal
Consequently, a number of ultrasound applica- exploration, the abdominal probe (convex or
tions are not used in the delivery room because 3D) must be placed transversally in the supra-
of the delivering obstetrician’s lack of experi- pubic region of the maternal abdomen; for
ence with their use. Intrapartum ultrasound translabial or transperineal exploration, the
explorations must be conducted by experts in abdominal probe must be placed inside a rubber
sonography or by obstetricians who are experts glove covered with ultrasound gel and then
in labor assistance and who have received the placed longitudinally in the medial sagittal
necessary sonography training because deci- position between both labia majora, below the
sions about the delivery route are often based symphysis pubis (Fig. 2.1a–d). If measurements
on sonography results. are needed during studies conducted with a 3D
probe, it is very important to keep the patient
still during the procedure; to identify the medial
2.2.4 Exploration Techniques sagittal plane, where the long axis of the sym-
physis pubis and the fetal head can be identified
Based on our experience, the most appropriate prior to starting; and to lightly tilt the probe to
maternal position for determining the fetal prevent a shadow from being produced by the
head descent in the maternal pelvis is the dorsal symphysis pubis over the fetal head [4]. The
lithotomy position [2]; to determine the fetal image obtained is shown in Fig. 2.2a, b, in
head position with respect to the pelvis in which recognizable maternal and fetal struc-
the anterior or posterior position, one can opt tures are indicated.
a b
Fig. 2.1 The ultrasound scan of fetal head During the head sovprabubic. (c) The figures show the subpubic sag-
labor, in longitudinal and transverse section and in sopra- ittal (or translabial) scan of fetal head. (d) The figures
pubic (or transabdominal) subpubis (or translabial) scan. show the transversal sonogram of fetal head (or transla-
(a) The figures shows the soprapubic sagittal scan of the bial) under the simphisis
fetal head. (b) The figures shows a transverse scan of fetal
2 General Intrapartum Sonography Setup and Use in Labor 17
c d
Fig. 2.1 (continued)
a b
Fig. 2.2 (a) Sagittal section of female pelvis at term of obtained after intrapartum sagittal medial translabial
pregnancy in the first stage of labor and transvaginal exploration; “a” indicates the maternal pubis, “b” indi-
sonography: the lines passing through the scan represent cates the fetal head, and “c” indicates the fetal caput
the main longitudinal and transverse scans. (b) Image succedaneum
Table 2.1 Recommended ultrasound settings [4] 2.2.5 Determining the Type
1 – Lowest possible angle of insonation of Exploration
2 – Lower output frequency
3 – Highest insonation depth Ultrasound exploration in the delivery room can
4 – Wide volumetric area with low sound volume be useful for two purposes: first, to document
the fetal head position in relation to the maternal
pelvis (e.g., before an instrumental delivery),
Ghi et al. [4] suggest a series of settings for the and second, to determine labor progression.
acquisition of adequate intrapartum fetal head These two purposes are undoubtedly the param-
and maternal pelvis volumes (Table 2.1). eters of most interest in the intrapartum study.
Fetal head descent in the maternal pelvis, summarized as serving two purposes: deter-
rotation, and fetal head direction can be evalu- mining fetal head position in relation to the
ated to determine whether labor is progressing maternal pelvis and objectively documenting
adequately. inadequate progression of labor.
2.3 Ultrasound Use in Labor 2.3.1 Ultrasound Use to Determine

Fetal Head Position
The use of intrapartum ultrasound has been
widely discussed in the last five years. Different The digital determination of the fetal head posi-
studies discuss the uses of ultrasound in the tion using an obstetric exploration that requires
delivery room [1, 5]. Some of these uses are training is greatly influenced by the laboring
considered basic and do not require a significant woman’s degree of cervical dilation and has
level of specialization in obstetric sonography added difficulties with the presence of caput
[1], such as with excluding or confirming fetal succedaneum or asynclitism. Some studies have
death, determining fetal status, determining shown that the digital determination of fetal
fetal biometry to estimate approximate weight, head position with respect to the maternal pel-
and determining the degree of flexion of the vis during labor is not exact [6, 7]. Likewise,
fetal head. When describing the uses of ultra- Akmal et al. [8] conducted a study of 496
sound in the delivery room, these indications abdominal ultrasounds after digital exploration
cannot be forgotten; however, they will not be and found that fetal head position could not be
the most important indications when a patient determined via vaginal touch in 33% of the
is in labor [1]. Other uses of intrapartum sonog- cases, especially in cases with occipitoposterior
raphy, such as amniotic fluid evaluation and positions [9]. Souka et al. [10] could not deter-
placenta localization, should be conducted mine fetal head position in 61% of subjects dur-
within fetal pathophysiology and not within ing the first stage of labor and in 31% during
the delivery room [1]. In Table 2.2, we provide the second stage. In a study of 44 pregnant
a classification system that we created to clas- women in the intrapartum setting, Kreise et al.
sify the uses of intrapartum sonography [1]. [11] found erroneous interpretations of fetal
Practically speaking and to the best of our head position in 30% of cases after digital
knowledge, ultrasound use during labor can be exploration. Dupuis et al. [12] found a 70%
concordance of both methods in determining
Table 2.2 Classification of ultrasound uses in the intra- fetal head position, with more difficulties
partum setting [1] observed in cases with caput succedaneum and
1. Basic uses posterior positions.
Identification of fetal heartbeat Chou et al. [13] found greater precision for
Determination of fetal presentation determining occipitoposterior positions with
Attainment of somatometry; determination of transabdominal ultrasound than with vaginal
estimated fetal weight (to detect fetal macrosomia)
touch (92% vs. 72%, respectively). Zahalka
Placental location
et al. [14] compared the use of vaginal touch,
Determination of the degree of cephalic flexion
(podalic birth) transabdominal ultrasound, and transvaginal
Assistance in the birth of the second twin ultrasound to determine fetal head position and
Postpartum metrorrhagia found that transvaginal ultrasound was the most
2. Advanced uses exact method. In our center, which had an aver-
Determination of fetal head position age of 7,900 births in the last 10 years and an
Diagnosis of stalled labor average C-section rate lower than 12%, we
Assessment of intrapartum fetal well-being believe that there is no substitute for adequate
(intrapartum Doppler) clinical management; however, the majority of
a b
Fig. 2.3 (a) 2D transabdominal ultrasound in cross sec- labor with the fetus in the occipitoposterior position. Note
tion during labor with fetal head in median occiput poste- that both orbits are directed toward the ultrasound
rior position. (b) Intrapartum transabdominal ultrasound transducer
(suprapubic transverse) of a patient in the second stage of
delivering obstetricians find that transabdominal ultrasound, we did not find significant differences
or translabial ultrasound is useful for determin- between these methods’ ability to determine the
ing fetal head position, primarily at the point at fetal head position. Clinically, it was possible to
which an instrumental delivery is indicated [15]. determine fetal head position in 93% of the
In other centers with perhaps less clinical expe- patients in the first stage of labor and in 96% of
rience, ultrasound could be useful for decreas- the patients in the second stage of labor, and there
ing the number of C-sections performed was a concordance with the ultrasound results in
defensively by obstetricians who wish to avoid 98% of the cases. A body mass index in the top
the possibility of a complicated delivery [16]. 15% of women was the only significant factor
In a recently published article, we evaluated that made transabdominal ultrasound exploration
the usefulness of transabdominal ultrasound to difficult, while the presence of caput succeda-
determine fetal head position during the first and neum was important for determining fetal head
second stages of labor in 86 consecutive patients position [1]. Instrumental delivery with forceps
[1]. With the patient in the decubitus supine posi- or a vacuum requires awareness of the fetal head
tion or the dorsal lithotomy position after bladder- position because the incorrect application of
emptying, we placed the abdominal probe these instruments can lead to adverse results.
transversally in the suprapubic area. The fetal Wong et al. [18] randomized 50 patients with a
head position was defined by the identification of prolonged second stage of labor prior to vacuum
the orbits (occipitoposterior), midline echo extraction to digital pelvic exploration only or
(occipitotransverse), and cerebellum or column transabdominal ultrasound exploration in con-
(occipitoanterior) [17] (Fig. 2.3a, b). Using trans- junction with digital exploration. The authors
vaginal exploration followed by transabdominal showed that including ultrasound allowed a more
precise application of the vacuum extractor. In number of C-sections is increasing in an unjustified

our studies, we determined the exact clinical and manner, often due to the practice of defensive
ultrasound fetal head position prior to the medicine. We commented previously on the
application of forceps in 13 cases. In our center, impreciseness of digital touch for the evaluation
which has a C-section rate of approximately 12% of the fetal head position relative to the maternal
and a forceps delivery rate of 14%, it is impera- pelvis [22]; the combination of ultrasound explo-
tive to determine the fetal head position for better ration with clinical exploration could be useful
labor management. In contrast, Akmal et al. [19] for decreasing the number of C-sections.
studied 64 labors prior to instrumental delivery The inaccuracy of clinical examination during
and found that digital exploration failed to deter- labor has also been demonstrated regarding the
mine the fetal head position in 26% of the cases. descent of the head across the different planes of
The existence of a higher C-section rate or the the maternal pelvis. Dupuis et al. [23] investi-
use of vacuum extraction as the instrumental gated the reliability of transvaginal assessment of
technique of choice may be responsible for the fetal head station using a newly designed birth
inaccuracy of fetal head position determination simulator. A fetal head mannequin was placed in
via transvaginal exploration. The differences in one of the 11 American College of Obstetricians
the published data demonstrate the need for a and Gynecologists (ACOG) stations in a birth
prospective study to more precisely specify the simulator equipped with a real-time miniaturized
usefulness of ultrasound to determine the fetal sensor. The operators (32 residents and 25 obste-
head position prior to an instrumental delivery. tricians) then determined the head position clini-
To a lesser extent, studies have also described cally. The ACOG position was incorrectly
the determination of fetal head position using 3D determined in 50–88% of cases for residents and
transperineal ultrasound [20]. In our center, we in 36–80% of cases for obstetricians, depending
obtained 20 captures of sutures and fontanels on the position. When the stations were exam-
using translabial ultrasound with a transabdomi- ined in groups (high, midpelvis, low, and outlet),
nal probe. Such volumetric captures allow us to the mean group error was 30% (95% CI: 25–35%)
identify the sutures and fontanels of the fetal for residents and 34% (95% CI: 27–41%) for
head, which is useful prior to an instrumental obstetricians. Alarmingly, the group errors show
delivery or when deciding whether to allow a that the misdiagnosis of a station as midpelvic
vaginal delivery attempt or perform C-section rather than high-pelvic accounted for 88% and
(Fig. 2.4a, b). 67% of the errors made by residents and obstetri-
The objective information about the fetal head cians, respectively. This misdiagnosis can have
position that 2D or 3D ultrasound provides prior serious implications for the management of
to an instrumental delivery appears to be among patients in labor.
the most useful data for decreasing the number of To determine the progression of labor using
C-sections or adverse results after the inadequate either 2D or 3D sonography, the exploration must
performance of instrumental deliveries. be performed translabially. The patient must be
placed in a semicurved position with flexed legs,
and amniotomy is recommended [24]. The ultra-
2.3.2 Ultrasound Use for Diagnosing sound transducer is placed in the medial sagittal
a Stalled Labor plane, between the labia majora and precisely
below the symphysis pubis. Several studies have
If the fetal head position is anterior, posterior, or used ultrasound to provide an objective measure
transverse, ultrasound is clearly warranted to of head progression in labor:
determine the exact fetal position before delivery; • The most important measurement is the angle
however, using ultrasound during delivery can of progression of the fetal head, described as
also provide objective data for diagnosing inade- the angle between a line through the midline of
quate progression of labor [8, 21]. Currently, the the pubic symphysis and a line from the infe-
Fig. 2.4 “Drawing of sutures and fontanels and ours (or sagittal suture). O occiput, S sinciput. (b) Identification
digital palpations: (A) coronal sutures; (B) frontal sutures; of sutures and fontanels using 3D ultrasound in a patient
(C) anterior fontanel (bregma or major fontanel); (D) during the second stage of labor. Note that the lambdoid
occipital sutures; (E) “circumference” posterior fontanel fontanels are to the right in a fetus with an occipitoante-
or lambdoid suture or small fontanel; (F) parietal suture rior position”
a b
Fig. 2.5 (a) Ultrasound image and drawing demonstrat- inferior apex of the symphysis to the leading part of the
ing the angle of fetal head progression, described as the fetal skull (interrupted red line). (b) The image shows the
angle between a line through the midline of the pubic equivalent diagram of the angle of the progression of the
symphysis (continuous yellow line) and a line from the fetal head
rior apex of the symphysis to the leading part (Fig. 2.6a, b). Using this technique, three types
of the fetal skull (Fig. 2.5a, b). An angle of of head directions were determined: head
progression of 120° or greater is an excellent down, horizontal, and head up. “Head up” is
predictor of a successful vaginal delivery. when the line perpendicular to the widest
Kalache et al. [25] evaluated this measurement diameter of the fetal head points ventrally at
prospectively in women at term with failure to an angle of ³ 30°; “head down” is when this
progress in the second stage of labor. Logistic angle is <0°; all other angles are considered
regression analysis showed a strong relation- horizontal. The head direction, together with
ship between the angle of progression and the the descent in the maternal pelvis, is a good
need for cesarean delivery. When the angle of indicator of successful vaginal delivery. An
progression was 120°, the fitted probability of upward direction of the fetal head is a good
either an easy and successful vacuum extrac- prognostic sign for vaginal delivery, in con-
tion or a spontaneous vaginal delivery was trast with a downward or horizontal head
90%. The same angle was measured by Barbera direction [22].
et al. [2, 26] in 88 term laboring patients. The • Progression distance: Defined by Dietz et al.
authors described a good intra- and interob- [28] as the minimum distance between a line
server variability for measurements that were through the inferoposterior margin of the sym-
less than 3°. Their data showed that an angle of physis pubis and the border of the fetal skull-
at least 120° was always associated with sub- cap (Fig. 2.7a, b). This indicator is a useful
sequent spontaneous vaginal delivery. marker for the determination of fetal head sta-
• Head direction: Defined by Hernich [27] as tion. Information about the degree of fetal head
the angle between the infrapubic line of the descent is necessary prior to the use of forceps
pelvis (a line perpendicular to the longer diam- or a vacuum. It may be helpful to determine
eter of the pubis starting from the inferior these measurements when determining fetal
border) and another line drawn perpendicular head station [29, 30]. The results of one of our
to the widest diameter of the fetal head studies comparing all the measurements of 50
a b
Fig. 2.6 (a) Ultrasound image and drawing demonstrat- diameter of the fetal head (red arrow). (b) The ultrasound
ing the fetal head direction, described as the angle between image shows the corresponding angle of the direction of
a vertical line from the inferior apex of the symphysis the fetal head in the birth canal
(yellow line) and a line drawn perpendicular to the widest
a b
Fig. 2.7 (a) Ultrasound image and drawing demonstrat- apex of the symphysis (yellow line) to the leading edge of
ing the progression distance of the head, described as the the fetal skull. (b) The ultrasound image shows the dis-
distance (red line) between a vertical line from the inferior tance of progression of the fetal head in the birth canal
women in the second stage of labor indicated With the systematic use of these parameters in
that angle progression has the best intra- and women for whom no or inadequate progression
interobserver reproducibility when studying of labor is diagnostically suspected, we could
fetal head progression during labor [31]. objectively demonstrate the presence of such
Evidently, when such rotations resulted in ante-

rior positions, the situation was more favorable,
producing vaginal births in 87% of the cases [1]
(Fig. 2.8a, b).
Ghi et al. [30] recommend not allowing vagi-
nal birth and evaluating the possibility of a
C-section in cases without rotations or with rota-
tions greater than 45º from the anteroposterior
diameter of the midline.
The creation of the SonoVCADTM Labor soft-
ware has allowed us to obtain three simultaneous
measurements: head direction, angle of progres-
sion, and progression distance. This evaluation
is conducted in the intrapartum setting and can
be used to objectively demonstrate cases with an
inadequate progression of labor. No retrospec-
tive studies have yet evaluated this tool or indi-
cated which parameter is the best predictor of a
vaginal birth. In a study by Molina et al. [22],
the “angle of progression” was described as the
Fig. 2.8 The drawing schematizes the rotation angle of most easily reproducible measurement. This
45°, from 1 (inlet pelvis) to 2 (midpelvis), of the fetal head measurement seems to be the best option to be
during labor in childbirth by ultrasound transabdominal
combined with clinical exploration to more pre-
cisely determine which C-sections result from
diagnoses. These parameters would result in the inadequate progression of labor. One incon-
more accurate diagnoses and more exact indica- venience such measurements present is the tech-
tioplens for C-sections. nical need for a portable ultrasound machine
The determination of fetal head position may and specific software, which represent addi-
be of interest in cases of stalled labor [32–35]. tional costs. Another aspect to resolve is the
We know that posterior positions present a higher need for a posteriori or offline evaluations along
risk of inadequate labor progression (with epi- with the need for sonographic skills, particularly
siotomy, instrumental delivery, C-section deliv- the use of 3D ultrasound, which not all obstetri-
ery, and oxytocin and ergotamine derivative cians have. It is very probable that once these
infusion), perineal tear, and puerperal bleeding technical difficulties are eliminated, the objec-
[36]. Furthermore, the degree of cephalic rotation tive diagnosis of inadequate labor progression
can be combined with fetal head station. In our could become the main use of intrapartum
center, we evaluated 80 cases during the expul- sonography.
sive period to determine cephalic rotations in
comparison with the active phase of labor. We
considered the existence of “rotation” when 2.3.3 Other Uses
transabdominal ultrasound revealed progressions
from the brain midline greater than 45º compared There are various basic ultrasound uses that do
with the anteroposterior diameter of the maternal not require a significant level of specialization in
pelvis. Vaginal deliveries were achieved in 95% obstetric sonography [1] (Table 2.2). These uses
of the cases in which we were able to demon- include ruling out or confirming fetal death when
strate a rotation greater than 45º. In contrast, only the woman in labor does not report fetal move-
60% of the cases in which it was impossible to ments or when the fetal heart rate cannot be
demonstrate such rotation delivered vaginally. detected; determining fetal position, which is
particularly important in multiple births; intrapartum changes [44–47]. The exploration of

confirming the fetal station or presentation; deter- fetal vessels can be very difficult in the intrapar-
mining fetal biometry to estimate weight in cases tum setting because in many cases, our patients
of clinical suspicion of macrosomy; and deter- are experiencing intense pain or are under the
mining the degree of fetal head flexion, primarily effects of epidural analgesia. The fetal head may
in cases with breech presentations [37, 38]. Shipp be very engaged or in an unfavorable position for
et al. [39] define fetal head hyperextension as the the study of the cerebral medial artery. We used
persistence of the cervical column in maximal Doppler to measure the cerebral medial artery
extension (greater than 150º). In our center, we during the first and second stages of labor in 78
evaluated cephalic flexion prior to a podalic birth cases, and it was impossible for us to determine
using abdominal radiology. In 26 ultrasound differences between both mean measurements.
evaluations, we were able to identify the exis- We could not demonstrate a change in brain per-
tence or absence of cervical flexion in breech pre- fusion when we compared both stages of labor. In
sentation deliveries, demonstrating that abdominal contrast, the explorations were highly complex,
radiology was a useful option [1]. In such cases, and we experienced great difficulty with obtain-
we considered the existence of cephalic flexion ing waves of sufficient quality to obtain appropri-
when we found an angle of 90º or less between ate pulsatility indices. Currently, there is no
the fetal column and the base of the skull. Other evidence of the usefulness of intrapartum Doppler
uses of intrapartum sonography should be ultrasound to manage fetal well-being [1].
included in the fetal pathophysiology and not Different publications have examined the possi-
conducted in the delivery room, although such ble usefulness of color Doppler to detect a nuchal
uses may have indications in specific situations in cord [48]; however, we find this information
the delivery room, such as amniotic fluid evalua- somewhat limited because no possibilities for
tion or determining placental location [40]. In intervention exist, and detection could create
cases of intrapartum or postpartum metrorrhagia, unnecessary alarm. Likewise, studies continue to
ultrasound studies can help determine placental present new possibilities for ultrasound use in the
location or the retention of placental remains and delivery room [49], thus positioning this subject
can help diagnose placental acretism [41, 42]. as a major topic for future obstetrics research.
Among the previously discussed advanced
uses of intrapartum sonography, the determina- Conclusions
tion of fetal head position and the diagnosis of Ultrasound is an essential tool in contempo-
inadequate progression of labor are undoubtedly rary obstetrics. Its use has been generalized to
the most important; as such, they are the focus of the point that we have transitioned from
the majority of the studies [43]. However, we “obstetrics ultrasound” to “ultrasonographic
must also consider those studies conducted with obstetrics” [50]. The screening of diseases
Doppler ultrasound. We support the assurance of such as preeclampsia or prematurity is cur-
the fetus’ intrapartum well-being with electronic rently substantiated by ultrasound. This gener-
fetal monitoring and acid–base equilibrium mea- alization of ultrasound use coincides with a
surement. Accordingly, we have evaluated the focus on the use of ultrasound at the time of
use of fetal vascular Doppler studies for such pur- delivery. In the last five years, different
poses and have studied the following structures: publications have attempted to clarify the pos-
the uterine arteries, umbilical artery, medial cere- sible uses of ultrasound in the delivery room
bral artery, and the ductus venosus. We know that [51, 52] and find objective data that can pro-
the uterine arteries and the medial cerebral artery vide guidance during labor progression [53].
undergo modifications in relation to uterine con- Obstetrician interest has favored the develop-
tractions; in contrast, the umbilical artery does ment of intrapartum sonography, and the
not change in relation to the uterine dynamic. It is development of easily portable machines, 3D
unknown whether the ductus venosus undergoes technologies, and exploration software has
a b
Fig. 2.9 Sonographic diagnosis of fetal presentation in labor, with the first fetus in breach presentation and second
labor (a) a sonographic diagnosis of breach presentation. fetus in cephalic presentation
(b) an ultrasonographic diagnosis of twin pregnancy in
facilitated more in-depth intrapartum studies useful way to evaluate the fetal head’s descent
and more frequent publications regarding into the birth canal. Three-dimensional sonog-
intrapartum sonography. Despite these raphy is increasingly used in obstetrics, and
advances, the majority of hospitals do not pro- intrapartum sonography is no exception. The
vide ultrasound machines to delivery room identification of sutures and fontanels through
doctors, and in many cases, delivering physi- the rendering mode can be used to classify the
cians do not have the training necessary to fetal head position. SonoVCADTM Labor soft-
conduct an ultrasound exploration under such ware for volume calculation uses volumes
conditions. The appropriateness of many of acquired through a translabial ultrasound.
the indications attributed to intrapartum sonog- These volumes allow for the adequate evalua-
raphy has not yet been validated with prospec- tion of labor progression and enable the clini-
tive studies. Nevertheless, the possibilities of cian to take pertinent clinical action.
intrapartum sonography have been gaining
acceptance with the appearance of standard-
ized applications and the incorporation of
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The Use of Two-Dimensional (2D)
and Three-Dimensional (3D) 3
Ultrasound in the First Stage
of Labor
Ariel L. Zimerman
3.1 Background have been incorporated into routine clinical man-

agement of labor. Today sonography is the most
Friedman’s labor partogram is the central pillar for accepted and widely used imaging modality in
clinical management of labor today. First pub- obstetrics and gynecology with a proven capabil-
lished more than a half-century ago in 1955 [1], ity to provide safe, fast, and accurate measure-
the partogram charts labor progression by the dila- ments of fetal and maternal anatomy. The aim of
tation of the uterine cervix and descent of fetal this chapter is to review the use two-dimensional
presenting part over time. Friedman’s partogram (2D) and three-dimensional (3D) ultrasound in the
divides labor into two stages: The first stage first stage of labor.
includes a preparatory division (latent phase) that
begins with regular contractions and minimal cer-
vical changes and a dilatation division (active 3.2 2D Ultrasound
phase) at which cervical dilatation advances at a
greater rate, accompanied by descent of the fetal 3.2.1 Transabdominal Ultrasound
presenting part. The second stage (the pelvic divi-
sion) starts with cervical full dilatation and the The first stage of labor presents a series of techni-
final descend of fetal presenting part (Fig. 3.1) [2]. cal challenges for transabdominal 2D sono-
Physicians realized early that digital examination graphic imaging (Fig. 3.2). At this stage, the
alone was a poor tool for assessing changes in the ossified fetal skull lies deep in the bony pelvis
first stage of labor with low accuracy and poor and shadows the posteriorly located uterine cer-
reproducibility [3, 4]. In response several cervim- vix; In addition, during labor the cervix effaces
etry devices for the objective measurements of and dilates further impairing its sonographic
cervical dilatation were proposed by Friedman imaging. Due to these limitations, the use of
and others to overcome physical examination transabdominal ultrasound in the first stage of
inherent lack of accuracy [5, 6]. Yet, heretofore labor has been restricted to the imaging of the
none of these attempts, all of which require vagi- fetal presenting part, its intracranial structures,
nal instrumentation and expensive apparatuses, and their relation to maternal to assess fetal head
pelvic engagement (Fig. 3.3a–c) and fetal head
position.
A.L. Zimerman, M.D., Ph.D. Sherer et al. [7] compared transabdominal
Department of Obstetrics and Gynecology, ultrasound and digital examination to assess
Assaf Harofeh Medical Center (affiliated with the
fetal head engagement in 222 patients in labor.
Sackler School of Medicine, Tel-Aviv University),
70300 Zerifin, Israel The pelvic inlet was established as an oblique
e-mail: [email protected] line from the symphysis pubis to L5-S1 vertebra.

30 A.L. Zimerman
Latent phase Active phase

10
−3
8
−2
Deceleration phase
Cervical dilatation (cm)
Second stage
−1
6
Station (cm)
0
4 +1
Phase of maximum slope

+2
Acceleration
2 +3
phase
+4
0 +5
0 2 4 6 8 10 12 14
Time in labor (h)
Fig. 3.1 Friedman sigmoid partogram, first published in 1955, divides first stage of labor in latent and active phase
(Adapted from Friedman, 1978 [2])
Fetal head engagement was determined if the as occiput anterior (OA) (Fig. 3.4), posterior
biparietal diameter (BPD) was at or below the (OP) (Fig. 3.5), left or right occiput transverse
line. The ultrasonographic assessment shows (Fig. 3.6) (LOT) (ROT), and left or right occiput
agreement with digital examination in most anterior or posterior (LOA) (ROA) (LOP) (ROP).
cases (85.6%. 95% CI, 80.8–90.3). When nul- Ultrasonographic and digital examination cor-
liparous and parous patients were compared, relation was poor and agreed in only 24% of
the correlation between digital and sonographic patients (95% CI, 16–33) [8]. Similar results
assessment remains high (nulliparous 81.5%. were presented by Akmal et al. [9] in a prospec-
95% CI, 73.4–88.0, and parous 90.3%. 95% tive study including 496 singleton pregnancies
CI, 84.1–95.9). In another study [8], the same in labor at term that compared digital examina-
group compared ultrasonographic determinations to transabdominal ultrasound. In this study,
tion of fetal head position, defined as the rela- digital examination was considered correct if the
tion of fetal occiput to maternal longitudinal fetal head position was within 45° of the ultra-
axis, to digital examination in 102 patients in the sound imaging. They found that digital exami-
first stage of labor. Transabdominal ultrasound nation failed to define the fetal head position in
was used to image midline intracranial struc- 166 (33.5%) cases and in the 330 (66.5%) cases
tures (cavum septum pellucidum, falx cerebri, where the position was determined correctly. The
thalami, and cerebellar hemispheres) and cra- findings of the digital and sonographic examina-
nial structure (eyes, nasal bridge, and cervical tions were in full agreement in only 163 (49.4%)
spine) to determine fetal head position. Results cases. The rate of correct identification of the
were compared to digital examinations classified fetal position by digital examination increased
3 The Use of Two-Dimensional (2D) and Three-Dimensional (3D) Ultrasound in the First Stage of Labor 31
Fig. 3.2 Axial (a) and longitudinal (b) transabdominal intrapartum ultrasound
a1 a2
e
an
pl
n g a
ni .2
an e 3
sc gur
US Fi
l
ta
a rie ter Symphysis
p e
Bi iam e pubis
d th t
o ve inle
Ab lvic
pe
Sacral Occiput above

promontory ischial spines
Fig. 3.3 (a) Diagram depicting the ultrasonographic it is observed that the biparietal diameter (dashed line) is
assessment of head engagement. The dotted line depicts parallel to the conjugated diagonal (red line). With its nar-
the scanning plane at the level of the inlet used to deter- row upper diameters: the thick line represents the trans-
mine the engagement of fetal head. A fetal biparietal verse diameter left (t.s.), on which engages more
diameter at or below pelvic inlet sign fetal head engage- frequently the fetal head (dotted line). (c) The image dem-
ment (Sherer et al. 2003 [5]). (b) Sign of Farabeuf: nor- onstrates the commitment of the fetal head during the first
mal engagement of the fetal head in synclitism, in which stage of labor in synclitism by transabdominal ultrasound
32 A.L. Zimerman
c
b
Fig. 3.4 The image demonstrates the anterior occiput position of the fetal head: (a) median anterior occiput position,
(b) right anterior occiput position, and (c) left anterior occiput position
with cervical dilatation, from 20.5% at 3–4 cm 3.2.2 Translabial and Transperineal
to 44.2% at 8–10 cm. The authors concluded that Ultrasound
digital examinations fail to identify the correct
position of fetal head in the majority of cases Before the advent of transvaginal probes, trans-
when compared to transabdominal ultrasound labial and transperineal ultrasound was used to
(Fig. 3.7). image the uterine cervix using abdominal
Fig. 3.5 The image demonstrates the posterior occiput position of the fetal head: (a) left posterior occiput position,
(b) right posterior occiput position, and (c) median posterior occiput position
Fig. 3.6 The image demonstrates the transverse occiput position of the fetal head: (a) left transverse occiput position
and (b) right transverse occiput position
34 A.L. Zimerman
first stage of labor and observed a progressive

cervical shortening (effacement) and synchro-
nous opening starting at the cervix internal os.
The external cervical os started its dilatation
process only after the cervical effacement was
completed.
3.2.3 Transvaginal Ultrasound
Transvaginal ultrasound is widely used for the

prenatal measurement of cervical lenght. The
high-frequency and low-penetration transduc-
ers are less adequate for the imaging of the
entire pelvis and the cervix in the first stage of
labor (Fig. 3.9a, b). Saito et al. [11] used trans-
vaginal ultrasound to determine the degree of
cervical change during a uterine contraction
in 73-term patients, and found that the cervix
was shortened in length by about 50% on aver-
age during a uterine contraction. The degree
Fig. 3.7 Fetal occipital position in the pelvis during labor
of cervical shortening was significantly greater
and corresponding presentation indices. The indices of
presentation are distant 45° degrees from each other. The in the normal latent and active phases than it
dotted lines between LOA, LOT, and LOP indicate that was in the prolonged latent phase, protracted
between an index and the other one can determine other active phase, and false labor. Nulliparous
different degrees of position index. In case some are more
and parous women exhibited almost the same
prone to the right rear position, while others transverse to
the right degree of shortening in the normal latent and
active phases.
transducers. To obtain a transperineal picture the 3.2.4 Uterine Cervix Sonoelastography

patient is placed in a dorsal lithotomy position
with the hips flexed and slightly abducted. A A recent application of transvaginal ultrasound
standard abdominal curved-array transducer is in sonoelastography of the uterine cervix
covered with a plastic wrap or a glove is posi- (Fig. 3.10). Real-time sonoelastography esti-
tioned in the midsagittal plane against the sym- mates tissue stiffness by measuring tissue dis-
physis pubis. The transperineal and translabial placement in response to compression and
approach bypasses the pelvic bone structures superimposes it as a color map in real-time
providing unobstructed access to pelvic soft tis- B-mode image [12]. Applying this technology
sues imaging, the resulting image includes (ante- in a preliminary study of 29 patients,
rior – posterior) the symphysis pubis, the bladder Swiatkowska-Freund et al. [13] estimated cervi-
and urethra, vagina, cervix and rectum, and cra- cal consistency prior to induction of labor as
nially the fetal presenting part and pelvic walls Elastography index (EI) and found that the mean
(Fig. 3.8). EI of the internal os in the group of patients with
Zilianti et al. [10] used 2D transperineal successful induction of labor compared with
ultrasound to monitor the first stage of labor patients with failed induction of labor was higher
uterine cervix effacement using longitudinal but not statistically significant (EI 1.23 vs. 0.39,
and transverse planes in 86-term patients at the P = 0.024).
Fig. 3.8 Intrapartum translabial 2D ultrasound imaging maternal pelvis and fetal head and anatomical landmarks
a b
Fig. 3.9 (a) Intrapartum transvaginal 2D ultrasound of cervix. (b) The drawing shows the transvaginal ultrasound
showing the cervix and fetal head in the first stage of labor
3.3 3D Ultrasound sonographic volume and the production of a rendered

image reconstruction. The dataset of the sono-
Three-dimensional ultrasound uses special probes graphic volume can be stored for post-acquisition
and dedicated software for the acquisition of ultra- off-line processing [14]. Three-dimensional
36 A.L. Zimerman
Fig. 3.10 Sonoelastography of pregnant uterine cervix (From Swiatkowska-Freund et al. 2011 [13])
ultrasound has been used in the translabial and at different cervical dilatation diameters and the
transperineal approach to image the pelvic floor measurement of mean and maximal cervical
musculature [15]. A similar approach can be used diameters and inner cervical area by two observ-
to image deeper maternal pelvic structures and to ers (Fig. 3.12). A good interobserver and intraob-
image the uterine cervix and fetal presenting part server agreement was demonstrated between the
in the first stage of labor. After voiding, patients two examiners and also a good correlation with
are positioned in dorsal supine lithotomy position concomitant vaginal digital examinations. The
with hips flexed and slightly abducted. A mid- interobserver mean difference between paired
sagittal view is obtained by placing a wrapped measurements for mean and inner cervical dilata-
ultrasound transducer parting the labia or over tion and cervical maximal area was 0.1 cm (±0.49),
the perineum oriented cranially through the 0.12 cm (±0.48), and −0.2 cm2 (±5.69), and the
symphysis pubis to include the fetal presenting intraclass correlation coefficient (ICC) were 0.82,
part. This approach allows the rendering of the 0.85, and 0.87, respectively. The intraobserver
pelvic floor musculature, the uterine cervix and mean difference between paired measurements
its entire contour, and the image of fetal present- of the mean and maximal cervical dilatation and
ing part and the surrounding pelvis (Fig. 3.11). inner cervical area were 0.002 cm (±1.15), 0.02
Another feature associated with this approach is (±1.4), and −0.41 cm (±1.15), and the ICC were
that it is done externally sparing vaginal penetra- 0.85, 0.79, and 0.75, respectively. And the cor-
tion, reducing the risk of ascending infections (in relation with digital vaginal examination was
cases of premature rupture of membranes), and (r2 = 0.609, 0.587, and 0.469, respectively, all
it reduces the need of repeated painful vaginal correlations P < 0.001 [16]. The same technique
examinations increasing patient’s comfort. Using could be also used to sequentially document cer-
this technique, our group reported the successful vical changes over time in the first stage of labor
image of the dilating uterine cervix in 54 patients and to detect cervical effacement and dilatation
Fig. 3.11 Intrapartum translabial 3D ultrasound acquisition
without vaginal penetration. We successfully 68 patients using hourly translabial 3D ultrasound

demonstrated the detection of latent to active (unpublished data), and currently, we are testing
phase transition, defined as the progression from a protocol for the ultrasonographic-assisted man-
3 to 5 cm dilatation without vaginal penetration in agement of first stage of labor (Fig. 3.13).
38 A.L. Zimerman
Fig. 3.12 Intrapartum translabial 3D ultrasound of uterine cervix anatomical landmarks
3.4 Conclusion – Toward a is another promising new technology that might

Sonographic-Assisted provide an insight to cervical ripening processes
Management of the and labor induction. Labor and delivery room
First Stage of Labor? work is traditionally conservative and complex
and needs to address both obstetricians and mid-
This chapter reviewed the use of 2D and 3D ultra- wives’ practices as well as patient’s wishes, sensi-
sound during the first stage of labor. Current litera- tivities, and cultural backgrounds. The integration
ture provides the guides for a sonographic imaging of ultrasonographic practices to the delivery-
of the main parameters involved in clinical man- room routines depends not only on technological
agement of the first stage of labor. Starting with capacities and evidence-based clinical protocols
the assessment of head position, head descent, but also on its cultural acceptance by patients as
and head engagement, and the imaging of cervical well as by the local medical culture. In our experi-
effacement, ripening, and dilatation. Among the ence working in a bustling delivery room in Israel
different ultrasound approaches, the translabial that provides assistance to nonreligious and reli-
3D ultrasound stands out as the most promising gious Jewish, Muslim, and Christian populations,
for the practical use of ultrasonographic technol- the new technologies were well-accepted by our
ogies. In addition to the information obtained in patients as well as by the delivery-room person-
2D mode on head position and descent, the 3D nel. In summary, for the last 30 years ultrasound
ultrasound also provides accurate cervical cer- has proven to be a safe and useful technology in
vimetry, the most critical parameter in the man- prenatal diagnosis. Sonographic imaging of main
agement of first stage of labor. Sonoelastography parameters involved in the clinical management
Fig. 3.13 Hourly translabial 3DUS images of uterine cervical area measurements; and lower row, 2D axial
cervix in first stage of labor latent to active phase transi- orthogonal plane. Cervical maximal diameter by column:
tion. Upper row, 2D midsagittal plane; middle row, ren- (a) 1.39 cm, (b) 2.57 cm, (c) 3.35 cm, and (d) 6.1 cm
dered axial orthogonal plane with cervical diameters and
of first stage of labor have been described using 5. Lucidi RS, Blumenfeld LA, Chez RA (2000)
2D and 3D ultrasound. As practitioners become Cervimetry: a review of methods for measuring cervi-
cal dilatation during labor. Obstet Gynecol Surv 55(5):
more familiar with the advantages and capabili- 312–320
ties of sonographic imaging in the delivery room 6. Nizard J, Haberman S, Paltieli Y, Gonen R, Ohel G,
further research to evaluate their clinical use, fea- Nicholson D (2009) How reliable is the determination
sibility and specific protocols for their application of cervical dilation? Comparison of vaginal examina-
tion with spatial position-tracking ruler. Am J Obstet
are warranted. Gynecol 200(4):402.e1–402.e4
7. Sherer D, Abulafia O (2003) Intrapartum assessment
of fetal head engagement: comparison between trans-
vaginal digital and transabdominal ultrasound deter-
References minations. Ultrasound Obstet Gynecol 21(5):430–436
8. Sherer D, Miodovnik M, Bradley K, Langer O (2002)
1. Friedman EA (1955) Primigravid labor; a graphi- Intrapartum fetal head position II: comparison between
costatistical analysis. Obstet Gynecol 6(6):567–589 transvaginal digital examination and transabdominal
2. Friedman EA (1978) Labor: clinical evaluation and man- ultrasound assessment during the second stage of
agement, 2nd edn. Appleton-Century-Crofts, New York labor. Ultrasound Obstet Gynecol 19(3):264–268
3. Phelps JY, Higby K, Smyth MH, Ward JA, Arredondo 9. Akmal S, Tsoi E, Kametas N, Howard R, Nicolaides K
F, Mayer AR (1995) Accuracy and intraobserver vari- (2002) Intrapartum sonography to determine fetal head
ability of simulated cervical dilatation measurements. position. J Mat Fetal Neonat Med 12(3):172–177
Am J Obstet Gynecol 173(3 Pt 1):942–945 10. Zilianti M, Azuaga A, Calderon F, Pagés G, Mendoza G
4. Tuffnell DJ, Bryce F, Johnson N, Lilford RJ (1989) (1995) Monitoring the effacement of the uterine cer-
Simulation of cervical changes in labour: reproducibility vix by transperineal sonography: a new perspective.
of expert assessment. Lancet 2(8671):1089–1090 J Ultrasound Med 14(10):719–724
40 A.L. Zimerman
11. Saito M, Kozuma S, Kikuchi A, Sakai M, Fujii T, 14. Timor-Tritsch IE, Platt LD (2002) Three-dimensional
Unno N et al (2003) Sonographic assessment of the ultrasound experience in obstetrics. Curr Opin Obstet
cervix before, during and after a uterine contraction is Gynecol 14(6):569
effective in predicting the course of labor. Ultrasound 15. Unger CA, Weinstein MM, Pretorius DH (2011)
Obstet Gynecol 22(6):604–608 Pelvic floor imaging. Obstet Gynecol Clin North Am
12. Thomas A, Kummel S, Gemeinhardt O, Fischer T 38(1):23–43
(2007) Real-time sonoelastography of the cervix: tis- 16. Zimerman AL, Smolin A, Maymon R, Weinraub Z,
sue elasticity of the normal and abnormal cervix. Herman A, Tobvin Y (2009) Intrapartum measurement
Acad Radiol 14(2):193–200 of cervical dilatation using translabial 3-dimensional
13. Swiatkowska-Freund M, Preis K (2011) Elastography ultrasonography: correlation with digital examination
of the uterine cervix: implications for success of induc- and interobserver and intraobserver agreement assess-
tion of labor. Ultrasound Obstet Gynecol 38(1):52–56 ment. J Ultrasound Med 28(10):1289–1296
Intrapartum Sonography and Labor
Progression 4
Torbjørn Moe Eggebø and Kjell Åsmund Salvesen
4.1 Introduction an active phase (stage 1 and 2), and a third stage
defined as the time period between the delivery of
All pregnant women, and in particular the women the baby and the delivery of the placenta.
expecting their first child, want to know if they will According to the classic definition, onset of labor
deliver vaginally or experience an operative deliv- is when regular contractions have been estab-
ery. Will the pain and effort put into laboring be lished. Friedman published graphic analysis of
worth it? Are there ways of telling them that they the labor and found the onset of regular contrac-
will have a successful vaginal delivery before labor tions to occur 1.7–15 h (mean 7.3 h) before the
starts, in the early stages of labor, or if they experi- onset of appreciable cervical dilatation in prim-
ence a protracted labor? Should a cesarean section iparous women [1]. This period is commonly
be preferred? Information about labor progress labeled the latent phase of labor. A prolonged
might help the women feel safe. This chapter will latent phase is often defined as exceeding 20 h in
explore the possibility of new ultrasound methods primiparous women or 14 h in multiparous
to assess labor progress, but also how the same women [2]. During the latent phase, the cervix
ultrasound methods predict labor outcome. undergoes several changes, such as shortening,
softening, and effacement.
The latent phase is followed by the acceleration
4.2 Stages of Labor period or the active phase of labor [1]. The starting
point of the active phase is discussed, but a com-
An old saying is: “Everybody know when the monly used definition is when the contractions
labor is over, but nobody knows when it starts.” are regular and the cervix is effaced and dilated
The labor is divided into a latent phase (stage 0), 3–4 cm. This definition is in accordance with the
definition used by World Health Organization
T.M. Eggebø, Ph.D. () (WHO) [3]. A Cochrane review has pointed out
Department of Obstetrics and Gynecology, that strict criteria for diagnosis of active labor are
Stavanger University Hospital, essential [4]. During the first active stage of labor,
Postboks 8100, 4068 Stavanger, Norway cervix dilates from 4 to 9 cm, and Friedman subdi-
e-mail: [email protected]
vided this phase into the acceleration, maximum
K.Å. Salvesen, M.D., Ph.D., dr.med slope, and deceleration phases [1].
National Center for Fetal Medicine, Trondheim
University Hospital (St. Olav’s Hospital), The second stage of labor starts when the cer-
Trondheim, Norway vix is fully dilated. This stage is divided into a
non-expulsive phase and an expulsive (pushing)
Department of Laboratory Medicine, Children’s and
Women’s Health, Norwegian University of Science phase when the presenting part has reached the
and Technology, Trondheim, Norway pelvic floor [3].

42 T.M. Eggebø and K.Å. Salvesen
Fig. 4.1 Keer-Muller maneuver performed with the patient the top indicates the possible thrust of aid, practiced on the
on the delivery table; the top operator in the left hand placed uterine fundus (upper picture). Below maneuver palpation
on the abdomen pushes the fetal head down and evaluates to highlight the sign of the step, in fetal–pelvic dispropor-
the fetal–pelvic proportion while with his right hand placed tion (lower picture)
in the vagina currency progression. The large arrow at
4.3 Labor Progression always remember the three P’s; the power, the
pelvis, and the passenger [2]. A delayed (“slow”)
Labor progression depends on uterine contrac- progress of labor is called labor dystocia. Dystocia
tions, the birth canal, and the size and position of originates from the Greek word “dustokia” mean-
the presenting part. A birth attendant should ing difficult childbirth. However, no generally
4 Intrapartum Sonography and Labor Progression 43
a b
Fig. 4.2 Palpation of the ischial spines. (a) The ischial spines can be felt before the commitment of the presenting part.
(b) Maneuver to assess the midpelvis
accepted definition of labor dystocia exists. tion [6] and an association between high station
Protracted labor refers to slower than normal rate at arrest of labor and adverse outcome [7].
of cervical dilation and delayed descent of the Philpott suggested in 1972 to use “alert lines”
presenting part, whereas arrested labor is defined and “action lines” (4 h from the “alert line”) in
as full stop in cervical dilatation and fetal descent. partographs to evaluate labor progress [8], and
Protracted labor is usually due to insufficient WHO has adopted this method [3]. Prolonged
contractions, whereas arrested labor is often due labor is defined when cervical dilatation crosses
to mechanical disproportion (Fig. 4.1). the “action line.” Some hospitals use partographs
Labor dystocia is one of the most common from the Dublin school of “active management of
indications for cesarean section [5]. labor” [9] and expect one-cm dilatation/hour (the
The fetal lie can be longitudinal or transverse, slope of the alert line), whereas other hospitals
presentation describes the lowest fetal part in the define prolonged labor when cervical dilatation is
birth canal, position means how the fetus is <1.2 cm/h in nulliparous women and <1.5 cm/h
rotated, and station refers to the level of the pre- in parous women [2].
senting part in the birth canal. Müller first Traditionally, labor progression has been
described the concept of station in 1868. The assessed by digital examination of cervical dila-
fetal descent in the birth canal is assessed by vag- tation and fetal descent. In one study from the
inal digital examinations and related to the ischial 1980s, repeatability of digital examinations was
spine (Fig. 4.2a, b). Minus five corresponds to the found to be acceptable [10]. Recent studies, how-
pelvic inlet, zero to the level of the ischial spine, ever, dispute these findings and found clinical
and plus four corresponds to the pelvic floor examination of fetal descent and position to be
(Fig. 4.3a, b) [3]. In 1954, Friedman introduced subjective with high interobserver variation [11,
the partograph [1]. He has documented a strong 12]. Dupuis et al. made an important contribution
correlation between cervical dilatation and sta- to this debate when he rigorously assessed the
Fig. 4.3 (a) Levels of a

obstetric pelvis level 0
passes through the ischial
spines. (expressed in cm)
(b) Palpation of the fetal
head placed at −3, at the LEVEL –3
narrow top (the other two
hands indicate palpation at
LEVEL 0
level 0 that is the narrow,
medium, and at +3, i.e.,
close to the bottom)
(expressed in inches)
LEVEL + 3
b –3
–2
–1
0
+1
+2
+3
Fig. 4.4 Sagittal section of midwives’ pelvis: on the left, descent of Pigeaud, F = triangle the disengagement of
it shows the curvature of the birth canal, while on the Fochier). (1) Inlet pelvis, (2) midpelvis, (3) outlet pelvis,
right, it shows the pelvic floor Hodge (P = cylinder of (4) pelvic floor
accuracy of station diagnosis with digital exami- 4.4 Cardinal Movements

nations [13]. He used a birth simulator with
objectively defined stations and studied the reli- The birth canal is curved, and the fetal head at
ability of clinical assessment of engagement and term is quite large compared to the pelvis
fetal station in 57 physicians (32 residents and 25 (Fig. 4.4). Therefore, the fetal head has to rotate
attending physicians). A fetal head mannequin in order to pass through the birth canal. For a
was placed in 11 different stations in a random fetus in occiput anterior position, the four cardi-
order. The error in the diagnosis of station was nal movements of labor are flexion, internal rota-
assessed by calculating the difference between tion, extension, and external rotation. The fetal
the true station (established by sensors in the head usually enters the birth canal transversely
birth simulator) and that determined by the clini- and engages in the pelvic inlet. Descent will
cian’s fingers. Numerical errors occurred in occur due to pressure from uterine contractions.
50–88% of cases for residents (average experi- As soon as the descending head meets resistance,
ence 2 years) and in 36–80% of cases for attend- the fetal head flexes and rotates. During the active
ing physicians (average experience 9 years). The first stage of labor, the fetal head descent first
mean error rate in the diagnosis of engagement depends on internal rotation and later on deflexion
was 12%, and this misdiagnosis was distributed of the neck (extension) (Fig. 4.5a–f).
equally between false-positives and false-nega- Figure 4.5a–f show the movements of the car-
tives. Undiagnosed “high” stations accounted for dinal delivery in both the first in the second stage,
22% of the errors made by residents, and 16% of for didactic.
those made by attending physicians [13]. This For a fetus in an occiput posterior position,
study provides evidence that digital assessment the cardinal movements are slightly different.
of fetal head station is unreliable. The first, second, and fourth movements are the
Consequently, an objective method for assess- same (flexion, internal and external rotation), but
ing labor progression is highly desirable. Sherer the third is maximal flexion followed by exten-
has compared the search for new methods to sion. Not surprisingly these complex movements
assess descent of the fetal head with the search are difficult to assess objectively using digital
for “the holy grail” and called it the ultimate chal- examinations. Ultrasound might add important
lenge of clinical applicability of intrapartum information when trying to assess the cardinal
ultrasound imaging [14]. movements.
4.5 Ultrasound Methods Assessing ischial spine is difficult to define using ultrasound.
Fetal Station Consequently, other landmarks are necessary, and
several different ultrasound methods for assess-
The bony maternal pelvis limits the quality of ing fetal descent have been proposed.
ultrasound acquisitions. The traditional clinical Already in 1977 Lewin et al. suggested using
examination relates the presenting part of the ultrasound to evaluate station. They measured the
fetus to the ischial spine. Unfortunately, the distance from the fetal head to the sacral tip of
Fig. 4.5 (a) Illustration of a transabdominal ultrasound anteroposterior diameter of the pelvis. (d) Translabial
showing the mechanism of commitment, the bending of ultrasound image showing the complete rotation (internal
the head down the narrow upper left oblique diameter rotation) and the full extent of the fetal head. (e) Movement
according to the transverse (right). (b) Transabdominal of return (or external rotation of the fetal head) in which
ultrasound image showing the progression of the head the frontal–occipital diameter is oriented along the oblique
toward the close medium and rotation (right). (c) An diameter left (right), as similar to the one position that the
ultrasound image of translabial that displays the rotation head assumes the entrance pelvic. (f) Fetal head expres-
of the head that has reached the ischial spines, and the sion from birth canal. (g) Birth of the anterior shoulder
diameter of the occipito-front is aligned with the (arrow). (h) Birth of the posterior shoulder (arrow)


the mother [15]. The transducer was placed has an oval shape and the lowest part of the pre-
over the sacral tip, and A-mode ultrasound was senting part is not necessarily identical with the
used. The first echo was from the sacral tip; the point where the tangent touches the fetal head. The
second from the fetal scull and the distance could angle of progression method was designed for use
be measured. This method was never imple- during the second stage of labor, and the method
mented in clinical practice. has been found to predict the probability of an easy
In 2003, Sherer and Abulafia suggested a operative vaginal delivery [19]. The repeatability
transabdominal approach. The fetal head was of this method is very good [20]; however, the
considered engaged on transverse suprapubic scientific documentation is restricted to fetuses in
ultrasound if the fetal biparietal diameter was occiput anterior position only.
below the maternal pelvic inlet [16].
However, due to shadowing from the bony
structures of the maternal pelvis, transabdominal 4.5.3 Head Direction
ultrasound is not reliable when the presenting
part has descended to low levels in the birth canal. Henrich et al. focused on the fetal head deflection
Therefore, transperineal or translabial approaches and assessed the direction of the fetal head. They
have been suggested, and a number of different also used the “infrapubic line” perpendicular to the
methods have emerged. long axis of the symphysis as a reference and
At present, the best landmark is the symphysis assessed the widest fetal head diameter and its
pubis which is better viewed with ultrasound than movement with regard to the infrapubic line. At
digital examination, as ultrasound immediately high stations, the fetal head points downward, and
meets the symphysis (Fig. 4.6a, b). at low stations, the head points upward [21]. This
method has also been used in assessment of station.
The parallel plane through the ischial spines is
4.5.1 Progression Distance defined 3 cm below the infrapubic line. Ultrasound-
assessed head station can be measured along the
A sagittal transperineal ultrasound method for longest visible axis of the fetal head, between the
assessing fetal head descent was published by intersections with the infrapubic line and the deep-
Dietz and Lanzarone in 2005. They used a line est bony part of the fetal head, subtracting 3 cm for
vertical to the central axis of the symphysis pubis the level of the ischial spines (Fig. 4.9) [22]. The
as reference (the “infrapubic line”) and measured clinical value of the method is probably best in the
the distance between this line and the presenting active phase of the second stage, and a change in
part [17]. This method is called the progression fetal head direction during pushing can easily be
distance (Fig. 4.7). Although this method was observed.
originally suggested evaluating head engage-
ment, the method can also be used to evaluate
labor progression. 4.5.4 Midline
The rotation (position) of the fetal head can be

4.5.2 Angle of Progression defined in a transverse perineal scan as pub-
lished by Ghi et al. and illustrated in Fig. 4.10.
A similar but more convenient method is suggested This result can be combined with fetal head
by Barbera et al. They also refer to a line through direction [23]. However, the midline echo of the
the symphysis pubis and draw a line tangentially fetal head is difficult to obtain in fetuses at high
to the fetal head to measure the angle between the stations, and a high degree of interobserver vari-
lines (Fig. 4.8) [18]. The angle increases with fetal ation has been documented [20]. The midline is
head descent. The two methods (progression dis- easier to observe directly in a transverse 2-D
tance and angle of progression) are correlated, but acquisition than obtaining the B-plane from a
not mathematically identical because the fetal head 3-D acquisition.
Fig. 4.6 The figures illustrate the ways to palpate the symphysis pubis during the digital obstetric examination (a) and
to show symphysis by translabial ultrasounds (b)
4.5.5 Head–Perineum Distance [24, 25]. The transducer is placed between the
labia majora obtaining a transverse view. The soft
Fetal head descent can be measured as the short- tissue is easy to compress, and the transducer
est distance between the outer bony limit of the meets resistance against the pubic arch. The
fetal skull and the perineum (head–perineum dis- transducer should be wide enough not to enter
tance) as suggested by Eggebø et al. (Fig. 4.11) the vagina, and the “goal line” of the labor will be
Fig. 4.7 The progression distance is related to the “infra-

pubic line”
Fig. 4.10 The midline of the fetal head is related to a

sagittal plane through the maternal pelvis
Fig. 4.8 The angle of progression is measured as the

angle between a line through the pubic symphysis and a
line tangentially to the fetal head
Fig. 4.11 Head–perineum distance
distance will be shorter with fetal descent even

though the fetus passes through a curved birth
canal (Fig. 4.12a, b). The soft tissue between the
labia majora is easy to compress even in obese
women, and it is not painful for the women [25].
4.5.6 Continuous Ultrasound Monitoring
Computerized continuous labor-monitor systems

have been developed [26, 27]. These systems allow
Fig. 4.9 The head direction is related to the “infrapubic a continuous registration of the labor progress.
line.” In this figure, the fetal head is directed upward and at
Sensors are attached to the maternal pelvis, and
the level of the spine (3 cm below the “infrapubic line”)
with an additional sensor attached to the physi-
cian’s finger, the position of the ischial spines can
the reference line. To obtain the shortest distance, be defined. Using this information in combination
the transducer should be moved and angled before with a sensor attached to the fetal head and on to a
the distance is defined. This method can be used transperineal ultrasound transducer, the fetal head
at all stations and for fetuses in all positions. The descent can be continuously monitored.
Fig. 4.12 (a) Schematic Fetal head

drawing of fetal head descent a
in a curved birth. (b) Sagittal
section of pelvis and
obstetrical birth canal shows
that the mechanism of Remaining
engagement, descent, and distance
rotation of the fetal head in
vertex presentation of left
occiput anterior (LOA). The
three arrows indicate the
position of the head close to Perineum
the upper, middle, and
bottom and the direction of
the summit (as described by
Cadwell, Moloy, and
D’Esopo)
4.6 Clinical Studies when the largest diameter of the fetal head
(biparietal diameter) has traversed the pelvic
4.6.1 Ultrasound Assessment inlet [28]. In primiparous women, engagement
of Engagement of the fetal head is traditionally expected to
occur during the last weeks of pregnancy.
Engagement of the fetal head (fixation of the However, this is not always true, and in some
fetal head in the maternal pelvis) has occurred primiparous women, engagement does not occur
before the start of labor. Both the flexion and distance and angle of progression, respectively,
descent of the fetal head contribute to successful and 66% (95% CI, 54–79%) for digital assess-
engagement, and ultrasound imaging may be ment of fetal station.
utilized for assessing flexion of the fetal head. Using ³110 degrees as cutoff for angle of pro-
This can be done by tracking the fetal spine in a gression, 87% of the women delivered vaginally
sagittal plane toward the fetal head [14, 29]. (sensitivity 56%, specificity 75%, positive pre-
Among primiparous women, an unengaged ver- dictive value 87%, negative predictive value 37%,
tex in the early phases of labor has been found positive likelihood ratio (LR) 2.2, and negative
to be a significant risk factor for cesarean deliv- LR 0.6). 38% of the women delivered vaginally if
ery for arrest disorders [30]. the angle of progression was <100 degrees [25].
A high rate of agreement (86%) between Using head–perineum distance, £40 mm as cut-
transabdominal ultrasound and transvaginal dig- off, 93% of the women delivered vaginally (sen-
ital assessment of fetal head engagement has sitivity 62%, specificity 85%, positive predictive
been documented [16]. The “progression dis- value 93%, negative predictive value 43%, posi-
tance” measured by transperineal ultrasound tive LR 4.2, and negative LR 0.4). Using >50 mm
correlates well with abdominal palpation of head as cutoff, only 18% delivered vaginally [25].
engagement [17]. A combination of clinical vari- Figure 4.14 illustrates the association between
ables and ultrasound measured progression dis- head–perineum distance and angle of progres-
tance assessed before start of labor yielded a sion. In another study, the association between
model that could predict delivery mode in up to fetal head station and head–perineum distance is
87% of cases [31]. found to be: high cavity, 50 mm; midcavity,
The association between ultrasound-measured 38 mm; and low cavity, 20 mm [32].
head–perineum distance and transvaginal palpa- The labor progression has been investigated
tion of engagement has been investigated by longitudinally with repeated measurements in
Maticot-Baptista et al. Whenever the head– 100 primiparous Chinese women. The mean
perineum distance was >60 mm, the fetal head change in angle of progression and in progres-
was not engaged in the pelvic cavity, (specificity sion distance was 19.3 ± 15.4 degrees and
89% and a negative predictive value of 94%), and 14.6 ± 12.2 mm/h in women with a vaginal deliv-
if the distance was <60 mm, the fetal head was ery versus 2.4 ± 4.8 degrees and 2.7 ± 4.7 mm/h in
engaged with a sensitivity of 98% and a positive women, whom the delivery ended in cesarean
predictive value of 96% [32]. section for protracted active phases of labor [33].
New longitudinal studies are necessary before an
ultrasound partograph can be made.
4.6.2 Ultrasound in the First Stage Studies have evaluated continuous monitor-
of Labor ing of labor using the “labor pro” system in a
clinical setting. Patients delivered by cesarean
In the active first stage of labor, angle of progres- section due to obstructed labor had significantly
sion and head–perineum distance have been stud- different interspinous diameter compared to
ied in primiparous women with prolonged first women with normal vaginal delivery [34], and
stage of labor. The aim was to predict vaginal the station was found to predict a successful vac-
delivery versus cesarean section, and both meth- uum delivery [35]. The “labor pro” system can
ods demonstrated clinically valuable results. The identify labor dystocia at an early stage in high-
predictive value is illustrated using receiver– risk women. A significant disadvantage of this
operating characteristic (ROC) curve analyses method, however, is that the laboring women
(Fig. 4.13). Area and the curves for the prediction must be continuously connected to a high-tech-
of vaginal delivery were 81% (95% CI, 71–91%) nology system and they cannot move freely
and 76% (95% CI, 66–87%) for head–perineum around during labor.
Fig. 4.13 Receiver–

operating characteristic 100
curves for head–perineum
distance (—) and angle of
progression (…….) and for
digital assessment of fetal
station (-⋅-⋅-⋅-), in predicting 80
vaginal delivery (Torkildsen
et al. [25]: 704)
Sensitivity (%)
60
40
20
0
0 20 40 60 80 100
False-positive rate (%)
Fig. 4.14 Association

between head–perineum 140
distance and angle of
progression (Torkildsen
et al. [39]) 130
Mean 2D angle of progression
120
110
100
90
80
10 20 30 40 50 60 70
Mean 2D fetal head-perinum distance
4.6.3 Ultrasound in the Second Stage Thus, an ultrasound method differentiating

of Labor between high or low probability for a success-
ful operative delivery would be of value.
A difficult or failed operative vaginal delivery Vacuum deliveries are found to be easy when
is associated with risk of severe complications. the fetal head is directed upward [21]. The
duration of the second stage is also found to importance that the ultrasound method of choice
correlate with ultrasound parameters [22]. must be easy to learn and easy to perform.
Several publications have investigated the clini- Ultrasound experts are not available 24 h, 7 days
cal value of angle of progression in the second a week, and the obstetricians and the midwives
stage of labor [18, 19, 22], and a cutoff value of on call should be taught to perform the examina-
120 degrees has been suggested. A cohort of tions. Consequently, given that two methods have
women with failure to progress in the second similar predictive values, a simple method is
stage of labor was studied, and when the angle preferable to more complicated ones.
of progression was ³120 degrees, the labor
ended in an easy vacuum extraction or sponta-
neous vaginal delivery in 90% of cases [19]. 4.7.2 Can Ultrasound Methods
However, the fetal head was in occiput anterior Replace Digital Examinations?
position in all these cases, and the pattern of
descent might be different in women with fetal The answer is no! Although ultrasound assess-
head in other positions [22]. ment of cervical dilatation has been successfully
The fetal head position is an important param- done with 3-D acquisitions [37], the agreement
eter in the second stage of labor. Transperineal between 2-D ultrasound assessment of cervical
sonography allows an accurate diagnosis of fetal dilatation and digital examinations is low [38].
head position at low stations, and the ultrasound Digital assessment implies that one or two fingers
assessment gives important information before are placed into the cervical canal (Fig. 4.15). If
an operative vaginal delivery [23]. the cervical consistency is soft, the cervical canal
will dilate during this procedure. Thus, a combi-
nation of digital assessment and ultrasound mea-
4.7 Discussion surements (Fig. 4.16) should be recommended
for monitoring labor progress.
Munro Kerr has stated: “The most important
single issue in labor is diagnosis” [36]. The
difficulty of achieving an exact diagnosis of 4.7.3 One Single Scan or Serial Scans
fetal presentation, position, and station may to Assess Labor Progression?
have contributed to the increasing trend in cesar-
ean section rates all over the world. Ultrasound One single scan can predict the probability of a
may help clinicians to make more precise diag- successful vaginal delivery before labor, in
noses and prevent unnecessary interventions. women with prolonged labor and before an oper-
ative vaginal delivery [19, 21, 25]. However,
serial measurements are necessary to evaluate the
4.7.1 Which Ultrasound Method progress in labor. All ultrasound methods
Should Be the Method of described in this chapter can be used for longitu-
Choice? dinal surveillance (serial scans). Changes during
contractions or pushing can be observed directly
The ideal ultrasound method should be easy to and add important information. Caput succeda-
perform, easy to learn, clinically valuable, useful neum and molding of the head bones (Fig. 4.17)
at all stations, useful in all positions, applicable are also easily observed, and changes can be
to all women, acceptable for the women, have measured objectively using ultrasound.
high repeatability, and not be operator depen-
dent. A method satisfying all these criteria could
be very difficult to find. Different methods may 4.7.4 2D or 3D Ultrasound?
be preferred at different stages of labor, and a
combination of various methods may prove use- The progression distance, the angle of progression,
ful for clinical purposes. However, it is of vital the head direction, and the head midline are
Fig. 4.15 Vaginal examination of ripening and dilatation of the cervix in labor
Fig. 4.17 The molding phenomenon of the cranial bones

in the second stage of labor, shown by translabial US
(overlapping posterior parietal bone on the front) and cor-
responding ultrasound
Fig. 4.16 Ultrasound examination of ripening and dilata-
tion of the cervix in labor company. Also, assessing 3D acquisitions off-line
complicates the ultrasound procedures. Obtaining
implemented in a three dimensional (3D) software 2D acquisitions online will make ultrasound exami-
of an ultrasound device. In this way, the information nations much more applicable. Agreement between
from different methods can easily be combined and 2D and 3D acquisitions using angle of progression
assessed over time, and longitudinal measurements and head–perineum distance is good [39].
are essential in assessing labor progression. However, Consequently, 2D ultrasound acquisitions can prob-
this software is restricted to one ultrasound ably be recommended for clinical daily practice.
4.7.5 Ultrasound Imaging of the Pelvic

Floor: Can We Agree on a Name?
Perineal ultrasound is a general and frequently

used term in medical literature. Transperineal
ultrasound is less frequently used, but it fits well
with other universally accepted names, e.g., trans-
abdominal, transvaginal, and transrectal ultra-
sound. Trans-, in this context is “looking through,”
and for intrapartum sonography, we are “looking
through” the perineum on to the fetal head.
Labial, translabial, interlabial, and introital
ultrasound (Fig. 4.18) are other specific descrip-
tions of imaging the female perineum. The gender
specificity can be viewed as both pros and cons for
Fig. 4.18 Positioning the probe in translabial area
the use of these names. Translabial ultrasound has
been promoted as the name of choice for this
modality. However, translabial is not always a cor- Although the ideal test in obstetric surveillance
rect description since parting of the labia may be is difficult to find, ultrasound examinations during
necessary to improve image quality. Also, there are labor have no risk for the mother or fetus and are
other labia of the human body, and the lips of the less uncomfortable for the women than vaginal dig-
mouth are definitely better known to most people. ital examinations. We should look for new methods
We would argue to use “transperineal ultra- to make labor surveillance more objective, but it is
sound” as a general description of this ultrasound important to document clinical value before new
approach, since perineum is defined as the region methods are implemented into clinical practice.
between the pubic symphysis and the coccyx [40],
and transperineal ultrasound is a more general Conclusion
term and includes the term translabial ultrasound. We believe that ultrasound in labor will
become important in future obstetrics.
However, there is a need for more studies, and
4.7.6 Can Ultrasound Be we urge researchers all over the world to take
Recommended for Routine Use? part in this new and exciting area of ultrasound
use. We agree with the editorial in Ultrasound
As illustrated in this chapter, several ultrasound in Obstetrics and Gynecology saying: “We are
methods monitoring labor progress have been pro- moving from obstetric ultrasound to ultra-
posed, but all methods have limitations. At pres- sonographic obstetrics” [42].
ent, it is not clear if there is enough evidence to
support routine intrapartum sonography or if this
practice should be strictly limited to the context of Acknowledgment Erik Andreas Torkildsen performed some
of the ultrasound acquisitions illustrated in this chapter.
research studies [41]. In one study, the positive
likelihood ratio of ultrasound in predicting labor
outcome in women with prolonged first stage was
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Occiput Posterior Position
and Intrapartum Sonography 5
Antonino F. Barbera, Andrea Tinelli,
Elena Pacella, and Antonio Malvasi
5.1 Introduction of this position throughout the entire labor, called

persistent occiput posterior position, or it may arise
The occiput posterior (OP) is considered to be the from a malrotation happening during the second
most common fetal malposition of a fetus in a stage of labor from an initial non-OP position.
cephalic presentation. Delivery of a fetus in an OP Diagnosis of OP position via digital examina-
position could be either the result of the persistency tion is made by identifying the fetal sagittal suture
and fontanels and their location in relationship to
maternal pelvis landmarks [1]. OP position diag-
nosis is made when the posterior fontanel is felt
A.F. Barbera, M.D. () toward the sacrum and the anterior fontanel
Swan Mountain, Women’s Center, 16175 Hwy 9, toward the symphysis.
Breckenridge, CO 80443, USA
Occiput posterior position occurs in about
Department of Obstetrics and Gynecology, 10–25% of pregnancy during the early stage of
School of Medicine, University of Colorado Denver,
labor and in 10–15% during the active phase
12631 East 17th Avenue, PO Box 6511, Aurora,
CO 80045, USA [1, 2]. Ponkey et al. [3] reported a prevalence of
persistent occiput posterior at time of delivery
Rocky Vists University, College of Osteopathic
Medicine, 8401 S. Chamber Rd, being overall 5.5%, 7.2% in nulliparous, and
Parker 80134, USA 4.0% in multiparous (P < 0.001).
Department of Obstetric and Gynecology, The OP position poses challenges in every
Denver Health Medical Center, Denver, aspect of intrapartum care: prevention, diagnosis,
CO 80204, USA correction, supportive care, labor management,
and delivery. Unfortunately vaginal digital exam-
A. Tinelli, M.D. ination in the diagnosis of occiput position though
Division of Experimental Endoscopic Surgery,
is very subjective and very dependent on the
Imaging, Minimally Invasive Therapy and Technology,
Department of Obstetric and Gynecology, operator’s experience (Fig. 5.1) [4].
Vito Fazzi Hospital, Lecce, Italy Ultrasound has become a very useful tool in
e-mail: [email protected] the diagnosis of fetal head position during labor,
E. Pacella, M.D., Ph.D. in both active phase and second stage (Fig. 5.2).
Department of Sense Organs-Ophthalmology, Different approaches, transabdominal (TA),
Sapienza University of Rome, Italy
transperineal (TP), and transvaginal (TV), have
been investigated by various authors [5–14].
A. Malvasi, M.D.
The transabdominal approach is performed
Department of Obstetric and Gynecology,
Santa Maria Hospital, Bari, Italy obtaining a transverse view with reference to
e-mail: [email protected] maternal anatomy. Specific fetal anatomical

62 A.F. Barbera et al.
Fig. 5.1 Vaginal examination in labor with fetal head in

occiput posterior position
Fig. 5.3 Identification of occiput posterior position by trans-

abdominal ultrasound. The probe is placed on mom’s abdo-
men on a transverse view (panel a). Specific fetal anatomic
structures are visualized. In this case, fetal orbits and nasal
bridge are clearly visualized at 12:00 o’clock, just underneath
the exploring probe, with the occiput consequently in a poste-
rior position (panel b). In this position one can see the lens of
Fig. 5.2 Graphic representation of occiput posterior the eye and, through them, one can see the Rotal Eyes
position by transabdominal ultrasound examination in a Movements (REM). These movements are visible outside the
longitudinal section contraction and end during the contraction
midline structures (cavum septi pellucidi, falx This approach is easy and very reliable during the
midline, thalami, and cerebellar hemispheres) first stage of labor (see Figs. 5.3, 5.4, and 5.5).
and anterior or posterior cranial structures (orbits, During the second stage of labor, when the
nasal bridge, and cervical spine) may be visualized fetal head is engaged and progressing into the
[5, 8, 11, 12]. The position of the fetal spine pelvic canal, transabdominal approach may be
should also be identified at the level of the fetal very limiting in obtaining the desired informa-
heart in relationship to the mother’s abdomen. tion. The ultrasound probe can then be covered
5 Occiput Posterior Position and Intrapartum Sonography 63
a a
b b
Fig. 5.4 Identification of occiput posterior position by Fig. 5.5 Identification of occiput posterior position by
transabdominal ultrasound. The probe is placed on mom’s transabdominal ultrasound. The probe is placed on mom’s
abdomen on a transverse view (panel a). Fetal orbits are abdomen on a transverse view (panel a). Fetal orbits are
visualized at 02:00 o’clock, toward the upper portion of visualized at 10:00 o’clock, toward the upper portion of
the left pubic rami. Consequently, the occiput is localized the right pubic rami. Consequently, the occiput is local-
at 07:00 o’clock, making an objective diagnosis of right ized at 04:00 o’clock, making an objective diagnosis of
occiput posterior (panel b) left occiput posterior (panel b)
with a glove and positioned transversally at the Zahalka et al. [14] introduced the transvagi-
perineum to achieve a coronal view with refer- nal approach as the most successful and accu-
ence to maternal anatomy. An image of the fetal rate method for the determination of fetal head
head is obtained and specific landmarks identified position in the second stage of labor (see
[5, 11] (see Fig. 5.6). Fig. 5.7).
Fig. 5.6 Identification of maternal and fetal landmark by but specific fetal landmark can be easily recognized (panel
transperineal ultrasound. The probe is positioned on b). S symphysis, P parietal bone, O occiput, M midline
mom’s perineum on a transverse view (panel a). The brain echo, IPR ischiopubic rami
ultrasound image is reporting an occiput anterior position,
spontaneous rotation (Figs. 5.8 and 5.9). The

remaining 13% of OP delivering in such a posi-
tion are thought to be a consequence of a malro-
tation from an initial occiput anterior or transverse
position. The exact reason for failure of sponta-
neous rotation is unknown but a strong contribut-
ing factor is certainly a transverse narrowing of
the midpelvis.
Akmal et al. [16] reported that they did not
find any supportive evidence of this concept
of malrotation. In their study, the vast majority
of OP deliveries were the consequence of failure
to rotate from this position during labor, rather
Fig. 5.7 Transvaginal axial view of fetal head. The mid- than malrotation from an initial occiput
line echo is easily recognized as well as the occiput at
anterior.
02:00 o’clock. Fetal head in left occiput anterior position
They found that 70%, 91%, and 100% of OP
deliveries were in this position at 3–5, 6–9, and
10 cm of cervical dilatation, respectively.
Conflicting results were also reported by other
5.2 Etiology of OP Position authors.
Gardberg and associates [17] used transabdom-
Cunningham et al. [15] report that 87% of the inal sonography to record the position of the fetal
OP position at the onset of labor end with an head in 408-term pregnancies at either before the
occiput anterior (OA) position at time of deliv- onset of labor or in the early stage of active labor.
ery, and this is most likely secondary to a They reported that 68% of OP position deliveries
Fig. 5.8 Top, representation of the occipito-anterior rota- and the midline are aligned with the anteroposterior axis
tion of 45° with the head close to the average over the pelvic, which corresponds precisely to a rotation of 45°,
ischial spines. The arrow indicates the rotation in the from left to right. At the center, normal rotation in occip-
occipito left front, the narrow top, where the midline sag- ito anterior 45 degrees and below, anomalous rotation in
ittal suture or ultrasound are in axis with the conjugated occipito-posterior position of 135°
diagonal, and the narrow medium where the sagittal suture
resulted from malrotation during labor from an In contrast, Souka et al. [11] reported that 75% of
initially occipito-anterior position, whereas only OP deliveries were due to a persistent occiput posi-
32% of persistent cases were occipito-posterior tion during the entire labor. Souka’s ultrasounds were
(dorsoposterior) at the onset of labor (Fig. 5.10). performed during the first and second stage of labor.
Fig. 5.9 Mechanism of

confinement in position
occipito back and consequent
rotation in occipito anterior,
in which the occiput rotates
toward the pubic symphysis
of 135°
5.3 Maternal and Neonatal (3.8% for OP, 1.9% for OA; adjusted odds ratio
Outcomes [OR] 1.50 with 95% CI 1.17–1.91), umbilical
artery pH less than 7 (1.8% for OP, 0.5% for OA;
Independently of its etiology, being persistent OR 2.92 with 95% CI 1.84–4.62), and base excess
during the entire labor or the result of malrota- <−12 (2.2% for OP, 0.9% for OA; OR 1.96 with
tion, the OP position is associated with increased 95% CI 1.42–2.69); more incidence of meco-
maternal and neonatal morbidity. nium-stained amniotic fluid (32.3% for OP,
In comparison with deliveries occurring in 22.7% for OA; OR 1.29 with 95% CI 1.17–1.42),
occiput anterior position, OP position deliveries meconium aspiration syndrome (1.2% for OP,
were complicated by increased maternal and neo- 0.7% for OA; OR 1.21 with 95% CI 0.80–1.81),
natal morbidity [3]. Length of labor >12 h (OA birth trauma (1.4% for OP, 0.8% for OA; OR 1.77
26.2%, OP 49.7%; P < 0.001), oxytocin augmen- with 95% CI 1.22–2.57), and admission to the
tation (OA 36.8%, OP 48.9%; P < 0.001), chorio- intensive care nursery (5.6% for OP, 3.1% for
amnionitis (OA 1.1%, OP 4.7%; P < 0.001), OA; OR 1.57 with 95% CI 1.28–1.92); and higher
assisted vaginal delivery (OA 9.4%, OP 24.6%; mean duration of stay in hospital (3.68 days for
P < 0.001), cesarean section (OA 6.6%, OP OP, 2.60 days for OA; P < 0.001). Furthermore,
37.7%; P < 0.001), 3rd/4th degree tear (OA 6.7%, when a composite variable, “neonatal morbidity,”
OP 18.2%; P < 0.001), excessive blood loss (OA was created to examine the association between
9.9%, OP 13.6%; P = 0.03), postpartum infection fetal position and neonatal outcome, higher rates
(OA 0.8%, OP 2,2%; P < 0.01), and Apgar at of neonatal morbidity in occiput posterior deliv-
1 min 0–6 (OA 7.1%, OP 12.4%; P < 0.001) were ery were noted (10.7% for OP, 6.0% for OA; OR
all significantly different in nulliparous and mul- 1.45 with 95% CI 1.24–1.65).
tiparous combined in OA position deliveries ver-
sus OP position deliveries, confirming that OP
position delivery is associated with a variety of 5.4 Relationship Between Vaginal
adverse maternal outcomes. Digital Examination and
Cheng et al. [18] reported a difference in short- Intrapartum Sonography
term neonatal outcomes of infants delivered in
the occiput posterior position when compared In the light of all these data about maternal and
with those in the occiput anterior position. neonatal outcomes associated with delivery of a
Neonates born in occiput posterior position had fetus in OP position, the correct diagnosis of fetal
higher rates of 5-min Apgar scores less than 7 position in labor is extremely important.
a [9] and 65% error rate in 112 women during the

second stage of labor [10].
In 2003, Akmal et al. [7] examined 496 patients
and showed that when compared to abdominal
ultrasound, the vaginal digital examinations failed
to define the fetal head position in 34% of the
cases, and in those in whom the position was
defined it was incorrect in 52% if the cases. In 64
patients undergoing to operative vaginal delivery,
either vacuum or forceps, Akmal et al. [8] inves-
tigated the accuracy of vaginal digital examina-
tion in defining the position of fetal head prior to
instrumental delivery. He reported that vaginal
digital examination failed to identify the correct
b fetal head position in 26.6% of the cases. The
accuracy of vaginal digital examination was lower
for OP plus occiput lateral than it was for OA
position (54% vs. 83%). They concluded that
since vaginal examination is accurate in only
about 75% of the cases, ultrasound scanning for
accurate determination of the fetal head position
should be performed routinely before instrumen-
tal delivery. Furthermore, they also demonstrated
that for sonographers with experience in obstet-
rics scanning, determination of the fetal position,
based on such landmarks as the fetal orbits, cere-
bellum, midline echo of the brain, and occiput, is
easy and reproducible in >90% of the cases [19].
Using transabdominal and transperineal scan-
c ning as a complementary and integrated approach
in all patients, Chou et al. were able to determine
a correct occiput position in 92% of the cases
compared to a 71.6% of cases obtained by vagi-
nal examination [11]. More specifically in the
case of OP position, the combined ultrasound
approach correctly indentified all cases of OP
position, whereas vaginal examination correctly
identified an occiput position only in 30.8% of
the cases.
Zahalka et al. [14] compared the accuracy of
digital examination combined with transabdomi-
nal ultrasound versus the use of transvaginal
Fig. 5.10 Measurement of progression angle by translabial ultrasound in the assessment of occiput position
ustrasonography in occiput posterior position: (a) Down in the second stage of labor. He found that in
position, (b) Horizontal position, and (c) Up position
addition to the obvious superiority of all sono-
graphic methods to the vaginal digital examina-
Sherer’s data demonstrated that when com- tion, the transvaginal technique might carry
pared with transabdominal ultrasound evaluation, significant advantages over other sonographic
digital assessment of fetal head position showed techniques. In the second stage of 66 laboring
a 76% error rate in 102 women in the active labor patients with a deeply engaged head, fetal head
Fig. 5.11 Identification of maternal and fetal landmark connecting its lower pole tangential to the fetal contour is
by transperineal ultrasound. The probe is positioned on created [21]. Panels (a–c) show different angle of pro-
mom’s perineum on a sagittal view showing the long axis gression at different station in the birth canal. Molding
of the symphysis pubic and the fetal head contour. The and asynclitism in this occiput posterior position can eas-
angle between the long axis of the symphysis and the line ily be recognized
position could be determined in all cases by [5, 10]. In this case, the only difference compared
transvaginal scan, but not in 7 cases and 9 cases with OA position is an internal rotation of 135°
by digital vaginal examination and transabdomi- (from right occiput posterior or left occiput pos-
nal scan, respectively (P < 0.03; P < 0.008). The terior) instead of 45°. In the case of multiparity
vaginal approach was found to be more accurate with an already proven pelvic outlet and proven
because the probe is placed directly on the fetal vaginal outlet and perineum, rapid spontaneous
head, and fetal brain anatomy could be discerned vaginal delivery may take place in the OP posi-
extremely clear in the near field of the transducer. tion. The expulsive effort associated at each uter-
Furthermore, the time spent in performing a ine contraction will push the fetal head against
transvaginal ultrasound was on average 10 s, the perineum to a much greater degree than when
which was 62–73% less time in comparison to anterior (see Fig. 5.12).
other techniques (digital vaginal examination Figure 5.13 shows Barbera et al.’s [6] experi-
22.7 s, P < 0.0001; transabdominal sonography ence in 37 patients followed during their entire
31.7 s, P < 0.0001). labor. This was the first time ultrasound was
Barbera et al. [6, 20, 21] introduced a new used to follow occiput position during the entire
way to assess fetal head descent by transperineal duration of labor. During the first stage of labor,
ultrasound, measuring the angle of progression occiput position was established by transab-
of the fetal head in its descent in the birth canal in dominal ultrasound, while during the second
OA position fetuses (see Chap. 7). The angle of stage of labor a transperineal approach was
progression may be followed as well in fetuses in used. In all cases, the position of the fetal spine
OP position. These fetuses may require more was concordant with the position of the occiput
time to progress in the birth canal and the pres- throughout the entire labor. Position at delivery
ence of molding as well as asynclitism is more was established after external rotation of the
frequent (see Fig. 5.11). occiput. Forty-six percent of fetuses started
labor in OP position. Of these, 29% were in left
OP (LOP) and 71% in right OP (ROP). All
5.5 Delivery of Fetuses in Occiput fetuses engaged in an OA position. In their rota-
Posterior Position tion toward the symphysis, all the LOP posi-
tions maintained their side becoming LOA,
5.5.1 Normal Spontaneous while 25% of ROP positions became LOA at
Vaginal Delivery time of delivery. This change in side, even
though the fetal spine was always in the right
Most often the OP posterior position undergoes side during labor, could have been explained by
spontaneous anterior rotation even at 10-cm external maneuvers at time of delivery that may
dilatation, followed by uncomplicated delivery have forced the shoulder rotation and their
Fig. 5.12 Graphic representation of progression of the occiput posterior position in the birth canal during the second
stage (panel a) and the peculiar expulsion of fetal head at the perineum (panel b)
L R L R
15 5 5 12
First stage
1
6
2
12 Second stage
4
14 7
14 7 3 4 9 Delivery time
Fig. 5.13 Fetal head position during the entire labor. stage, and by clinical assessment at time of delivery. L
Diagnosis made by transabdominal ultrasound during the left, R right (Barbera et al. [6], with permission)
first stage, by transperineal ultrasound during the second
engagement into the inlet of the pelvis. All 17 5.6 Induction of Labor
fetuses that started their labor in OP position
rotated anteriorly prior to their engagement, The occiput position has been also associated with
avoiding in this way an internal rotation in the the prediction of outcome of induction of labor.
birth canal. Rane et al. [22] studied 604 singleton pregnancies
Blasi et al. [13] assessed the fetal spine and at term undergoing induction of labor for different
head position during the first and second stage of indications. Immediately prior to induction trans-
labor for the diagnosis of persistent OP position. vaginal ultrasound was performed to measure cer-
They showed that when the fetal head was in OA vical length and the angle between the cervix and
position at the second stage of labor it was likely fetal head contour, whereas transabdominal ultra-
that the head will have an anterior position at sound was carried out to determine the position of
delivery, whereas if the head was in OP position the fetal occiput. In the prediction of vaginal
at the second stage of labor, the probability that it delivery within 24 h, the sensitivity of these ultra-
will be in the same position at delivery was sound parameters was 89%, whereas for the
around 26%. Furthermore, the fetal spine posi- Bishop score, it was 65%. The respective sensi-
tion appeared to be a highly diagnostic sign in tivities for cesarean section were 78% and 53%.
predicting the OP position at delivery. Out of the Occiput position was noted to be related to cervi-
23 fetuses that started the second stage in OP cal length which was shorter in occiput anterior
position, only 7 had their spine in a posterior and occiput transverse than in OP positions. The
position, and of these 6 were in OP position at occiput position was found to enhance the effect
birth. The other 16 had an anterior spine and of cervical length in the prediction of the outcome,
delivered in OA position. Both the sensitivity and with the OP position on its own to be associated
specificity of the spine position were high, as with a significantly reduced likelihood of vaginal
were the positive predictive value (PPV) and neg- delivery within 24 h and a significantly increased
ative predictive value (NPV), in predicting OP likelihood of cesarean section.
position at delivery.
This is in agreement with the results of
manual rotation of fetuses that are in OP posi- 5.7 Operative Vaginal Delivery
tion at the beginning of the second stage (per-
sonal unpublished data). Manual rotation from In case of the need of an instrument-assisted vag-
an OP to an OA position has been always inal delivery, correct determination of fetal head
successful in 13 cases in which the spine was at position is of paramount importance for the suc-
03:00 and at 09:00 in a transverse position or cess of the procedure and for safety of both
even more anterior toward the symphysis. On patients, mom and fetus.
the contrary, the manual rotation failed in 6 Akmal et al. [8] found that vaginal digital
cases in which the occiput and the spine were examination prior to instrumented delivery when
both posterior. compared to transabdominal ultrasound failed to
Akmal et al. [16] report that at 3–5 cm 33% of identify the correct fetal position in about only
fetuses were in OP position assessed by transab- one quarter of cases. The degree of failure was
dominal ultrasound. They followed 918-term even bigger, 37% of cases, in cases of OP posi-
laboring patients in cephalic presentation tion. In 53% of errors, there was a difference
throughout labor. The occiput was posterior in between 135 and 180 degrees, which would have
33%, 33.9%, and 19% of fetuses at respective led to a deflexing placement of the vacuum cup,
cervical dilatation of 3–5, 6–9, and 10 cm and had the management clinician not been notified
persisted as such at delivery in 21.5%, 31.7%, of the correct head position diagnosed by ultra-
and 43.8% of cases. In 70%, 91%, and 100% of sound. These authors concluded that determina-
occiput posterior deliveries, there was persistence tion of fetal head position determined by
from this position at 3–5, 6–9, and 10 cm of cer- ultrasound should be performed routinely prior to
vical dilatation. vaginal operative delivery.
on 1,562 women in the expulsive period, showed

that only 20.7% of fetuses with occiput back to
8-cm dilatation was born in the same position.
Conclusion
Diagnosis of fetal occiput posterior position
poses challenges in every aspect of intrapartum
care: prevention, diagnosis, correction, support-
ive care, labor management, and safe delivery,
spontaneous or operative. It has been clearly
proven that vaginal digital examination in the
determination of fetal occiput position is very
subjective and inaccurate, resulting in failure to
identify and correct the problem. Such error
contributes to high surgical delivery rates and
traumatic births. The use of ultrasound during
labor has been shown to be an easy to accom-
plish objective and reproducible method to make
a correct diagnosis of occiput posterior position.
It is far superior to other methods and has the
potential to improve outcomes. Transabdominal,
Fig. 5.14 Intrapartum translabial ultrasound in the sec- transperineal, and transvaginal may be used,
ond stage of labor in occipito-posterior position in which and their use is very specific in relationship to
it shows the movement of flexion of the fetal head which the different stages of labor. The transabdominal
adapts to the sacral concavity (which allows for cleavage approach is preferable during the first stage of
of the head) and the movement of extension that allows
the fetal head to cross the symphysis pubis. The clock labor, whereas when the fetal head is engaging
symbolizes a prolonged second stage of labor in occipito- and progressing in the birth canal, the trans-
posterior position, which may last even 3 h before the perineal and or the transvaginal approach pro-
spontaneous expulsion of the fetal head vide good results. Once the diagnosis of OP
position has been correctly made, the clinician
is then able to provide precise information to the
mother, to allow more accurate management of
5.8 Occiput Posterior and Epidural the entire labor, in the attempt to continue to
Analgesia reduce maternal and neonatal morbidity poten-
tially associated with this malposition.
The incidence of occipito-posterior rotation in
patients in labor analgesia, however, depends on Acknowledgment The author wants to express his
gratitude to Helen Macfarlane for the extensive and superb
the technique used, the drugs, and the mode of
work in the production of the graphic representations.
administration. Indeed, some authors have
reported that the incidence of the occipito-poste-
rior in patients undergoing childbirth analgesia
with the combined technique CSE administering
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Asynclitism: Clinical and
Intrapartum Diagnosis in Labor 6
Antonino F. Barbera, Andrea Tinelli,
and Antonio Malvasi
6.1 Introduction the level of mid- and lower pelvis. However,

asynclitism is often present [2].
The position of the fetal head at engagement and Asynclitism describes the relationship between
during descent through the birth canal has proven anterior and posterior parietal bones and the sagittal
to be one of the hardest obstacles to overcome suture with the maternal pelvis (Figs. 6.1 and 6.2).
during labor [1] and quite frequently it is a cause When neither of the parietal bones precedes the
of failure of labor progress, with consequent sagittal suture, the head is synclitic (Fig. 6.3). If the
delivery of the fetus via cesarean section.
Ideally the sagittal suture should be parallel to
the key diameters of the pelvis that allow pro-
gression of the fetal head, the oblique at the inlet
of the pelvic inlet, and the anteroposterior (AP) at
A.F. Barbera, M.D. ()

Swan Mountain, Women’s Center,
16175 Hwy 9, Breckenridge, CO 80443, USA
Department of Obstetrics and Gynecology, School of
Medicine, University of Colorado Denver,
Fig. 6.1 Palpation of the fetal sagittal suture, with vaginal
12631 East 17th Avenue, P.O. Box 6511,
exploration, in eutocic labor with fetal head synclitic
Aurora, CO 80045, USA
Rocky Vista University, College of Osteopathic Medicine,
8401 S. Chamber Rd, Parker, CO 80134, USA
Denver Health Medical Center, Denver, CO 80204, USA
A. Tinelli, M.D.
Division of Experimental Endoscopic Surgery, Imaging,
Minimally Invasive Therapy and Technology,
Vito Fazzi Hospital, Lecce, Italy
A. Malvasi, M.D.
Department of Obstetric and Gynecology, Fig. 6.2 Palpation of the posterior and anterior fontanel
Santa Maria Hospital, Bari, Italy of the synclitic fetal head, through the vagina, during
e-mail: [email protected] eutocic labor

a b
Fig. 6.3 Sagittal section of the pelvis and abdomen in labor with the fetus in cephalic presentation (a) in posterior asyn-
clitism, (b) in anterior asynclitism
Fig. 6.5 Palpation of the anterior fontanel via the vaginal

digital examination, during labor, in left occiput trans-
verse position, with posterior asynclitism
anterior parietal bone precedes the sagittal suture,

there is an anterior asynclitism (Fig. 6.4). When the
Fig. 6.4 Palpation of the fetal head sagittal suture during
vaginal digital examination, during labor, in left occiput posterior parietal bone precedes the sagittal suture,
position, transverse, with anterior asynclitism there is a posterior asynclitism (Fig. 6.5) [3].
6 Asynclitism: Clinical and Intrapartum Diagnosis in Labor 75
Parietal
bone
Pa
riet
al f
or am
en
Ar ticulates
with Articulates
frontal with
bone occipital bone
Squamous portion of
temporal bone
Sphenoid
Fig. 6.6 Parietal bone different portion of the outer sur- diameter to allow the normal engagement of fetal head in
face [4], with permission (left). Fetal skulls and fetal head the medpelvis, and perform the head asynclitism in disto-
diameters, in the circumference are reported the cic labor (rigth)
sub-occiput-bregmatic diameter (9,5 centimetres). This
In 1858, Smith [2] reported that in a left level of the pelvic inlet to the AP diameter in
occiput anterior (LOA) position, the right side of the mid and lower pelvis in its progression in the
the cranium is considerably lower than that of the birth canal. In emerging form of the pelvis, the
left, so that the most depending part of the cranial obliquity of the head is almost as great as at its
surface is the protuberance of the right parietal entrance, the right parietal bone being still lower
bone. This lateral depression was called the than the left. The head does not emerge either
“obliquity of the head.” When assessing the fetal with the occipital or parietal protuberance fore-
head at the level of the pelvic inlet in LOA posi- most, the part which escapes first being a point
tion, the bulging of the right parietal bone is felt between the two, namely, the upper and posterior
through the walls of the anterior portion of the part of the right parietal bone, named parietal
cervix. This is the point with which the finger eminence or tuber parietale (Fig. 6.6) [4].
comes in contact with the most depending part of Any fetal head position may be associated with
the head. If the finger is passed in to the cervical asynclitism, and Table 6.1 shows the different
os, the sagittal suture is felt crossing the field of kind of asynclitism in all the occiput positions.
the os in an oblique direction. The sagittal suture To diagnose asynclitism, it is first necessary to
divides the os unequally, and a larger portion of determine the position of the fetal occiput with
the middle and upper part of the right parietal respect to the maternal pelvis. The side to which
bone is included within the ring of the os more the occiput is positioned will indicate the lateral-
than the left. It is this middle and upper portion of ity of the asynclitism. In an anterior asynclitism,
the right parietal bone which is felt in making a the presenting parietal bone will be opposite to
vaginal examination at this time. The earlier the which side it is rotated toward. Conversely, the
digital examination is made, the sagittal suture presenting parietal bone in a posterior asynclit-
will be found to be more markedly oblique or ism is the same side to which the occiput is
approaching the transverse direction. The fetal rotated. This holds true regardless of the occiput
occiput rotates 45° clockwise (from the fetal being positioned anteriorly, posteriorly, or trans-
point of view) from the oblique diameter at the versely (Fig. 6.7).
Moderate degrees of asynclitism though are nal and fetal care during the intrapartum period,
the rule in normal labor, and specifically the fetal the most common of which are arrest disorders of
head in occiput anterior engages with an anterior the fetal head during descent in the birth canal,
asynclitism. If it is pronounced enough, it can be even with an otherwise normal size pelvis. The
responsible of many complications in the mater- most common etiologies of an excessive
Table 6.1 The table represents the various forms of

asynclitism in the anterior occipital positions of the fetal
head
Fetal Type of Presenting

Position asynclitism parietal bone
Anterior Left
ROA, ROT,
ROP
Posterior Right
Anterior Right
LOA, LOT,
LOP
Posterior Left
Fig. 6.7 Vaginal digital examination in left occiput trans-

verse with posterior asynclitism. The exploring fingers
will palpate the sagittal suture closer to the symphysis
a b
Fig. 6.8 (a) Posterior

asynclitism in the flat basin
(or obliquity of Naegale
phenomenon), with
overlapping of the cranial
bones, which is a phenom-
enon of adaptation to the
commitment and progression
of the fetal head. (b)
Sellheim theory according to
which an egg-shaped body
can pass through a cylinder
of a size smaller than its
transverse diameter, if it
breaks down into two parts
which are arranged obliquely.
(c) The molding phenomenon
of fetal cranial bones is well
visualized by translabial US,
especially in the head up.
The overlapping of the
cranial bones is a positive
sign for the performance
prediction of spontaneous
delivery

c
nonphysiologic asynclitism may be the peculiar

maternal bony pelvic anatomy (Fig. 6.8a–c), the
tone of the pelvic musculature, and the force and
consistency of uterine contractions. During the
vaginal digital examination, if the sagittal suture
is felt to be curving anteriorly (Naegele’s obliq-
uity, Fig. 6.9a, b) or posteriorly (Litzmann’s
obliquity, Fig. 6.10a–d), such cranial asymmetry
increases the diameter of fetal cranium and can
lead to dystocia.
Most of the time anterior asynclitism is not
a
diagnosed unless attention is placed to the hollow
of the maternal sacrum [5]. The posterior pelvis
feels empty unless the fetal head is at a low sta-
tion. Failure of the sacral hollow to be occupied
by the fetal head is suggesting of a higher fetal
head station than what the initial palpation of the
presenting part may suggest. As understandable,
the presence of asynclitism becomes a very impor-
tant factor in the already subjective and unreliable
diagnosis of correct fetal head station [6, 7].
Fig. 6.9 (a) Ultrasound evaluation of posterior asynclit-

ism with translabial longitudinal section, (b) Ultrasound
evaluation of posterior asynclitism with transabdominal b
sagittal section
a b
c d
Fig. 6.10 (a) Fetal head vertex presentation, in the right (O). (d) Posterior asynclitism in right occipital transverse
occiput transverse position with posterior asynclitism. (b) position, displayed by ultrasound (the thicker line passing
Draw representing ultrasonographic evaluation of fetal through the sagittal suture relative to the small line that
posterior asynclitism. (c) Ultrasound image of fetal poste- indicates the degree of asynclitism)
rior asynclitism: midline (ML), thalamus (TH), and orbit
Generally, diagnosis of asynclitism is made Different sonographic approaches including

subjectively in an indirect way, i.e., when labor transabdominal, transperineal, and transvaginal,
slows down or fetal head progression in the birth both in 2D and 3D, have been utilized in the
canal stops. determination of fetal position based on such
Ultrasound has recently been used as a more landmark as the fetal orbits, cerebellum, mid-
objective tool in supporting and validating the line echo of the brain, and occiput (Fig. 6.11)
clinical diagnosis of asynclitism [8–12]. [10, 13–18].
Fig. 6.11 Perfect synclitism in left occiput anterior position by transabdominal ultrasound (panel a), transperineal
ultrasound (panel b), and transvaginal ultrasound (panel c)
Fig. 6.12 Direct occiput position well identified by the fetal orbits directly under the symphysis (panel a: graphic
representation; panel b: transabdominal ultrasound used up to the beginning of the second stage of labor)
6.2 Asynclitism in the Occiput physis in the case of direct OP position (Fig. 6.12)
Posterior (OP) Position or toward the upper portion of the right inferior
ramus of the pubis, in left occiput position (LOP) or
The occiput posterior position has been easily diag- toward the upper portion of the left inferior ramus
nosed by ultrasound by both approach, transab- of the pubis, and in right occiput position (ROP). If
dominal and transperineal examinations [14, 18]. the asynclitism is also present, only one orbit will
The orbits are an easily identified marker in the be visualized by ultrasound, the so-called squint
fetal head, and they will be directly under the sym- sign [10]. In case of LOP position, the only visual-
Fig. 6.13 Fetal cephalic presentation in left occiput poste- graphic representation; panel b: transabdominal ultrasound
rior, with anterior asynclitism and only the anterior orbit used up to the beginning of the second stage of labor)
visualized by ultrasound, “squint sign” [10] (panel a:
ization of the right anterior orbit will be called ante- Dupuis et al. [20] found that the presence of
rior asynclitism (Fig. 6.13), whereas the only the caput succedaneum was substantially affect-
visualization of the left posterior orbit will be called ing the accuracy of digital examination in the
posterior asynclitism. The same definitions will be diagnosis of fetal head position compared to
used in case of ROP, where the anterior orbit is the transabdominal ultrasound. A difference in 20 %
left (Fig. 6.14) and the posterior is the right. The OP of cases between the two methods reached 50 %
and OT shows different degrees of asynclitism, in cases of OT position, especially in the second
anterior or posterior (Fig. 6.15) and the “squint stage. Sherer et al. [21] studied 102 patients in the
sign”, using transabdominal sonography. first and second stages of labor by transabdomi-
nal ultrasound. They found a LOT position in
23.5 % and a ROT position in 11.8 % of the cases.
6.3 Asynclitism in the Occiput During the second stage of labor, they found a
Transverse (OT) Position persistence of OT position in 8.9 % on the left
side (LOT) and in 5.3 % on the right side (ROT).
The OT position happens when the fetal head is The asynclitism is often present in the OT posi-
unable to rotate anteriorly or posteriorly and is tions as the fetal head attempts to descend below
frequently associated with asynclitism. Most of the ischial spines. In the anterior asynclitism, the
the time diagnosis of OT position, being either sagittal suture is closer to the sacrum, the poste-
right (ROT) or left (LOT), is difficult to ascertain rior parietal bone is arrested at the level of the
because the presence of the caput succedaneum promontorium, and the uterine contractions act
makes the digital identification of the sagittal primarily to push the anterior parietal bone in the
suture challenging (Fig. 6.16a, b). attempt to pass the level of the symphysis pubic.
Fig. 6.14 Fetal cephalic presentation in right occiput pos- graphic representation; panel b: transabdominal ultrasound
terior, with anterior asynclitism and only the anterior orbit used up to the beginning of the second stage of labor)
visualized by ultrasound, “squint sign” [10] (panel a:
In the posterior asynclitism, on the contrary, the

sagittal suture is closer to the symphysis, the
Posterior asynclitism
anterior parietal bone is arrested behind the sym-
physis pubic, and the uterine contractions act pri-
marily to push the posterior parietal bone in the
attempt to progress below the promontorium.
The majority of OT position rotates in an OA
or less frequently in an OP position prior to reach-
ing the midpelvis at the level of the ischial spines.
In some cases, this rotation does not happen
US transducer
(Fig. 6.17).
This is known as “deep transverse head posi- Pubis
tion,” or called “sunset thalamus and cerebellum”
(Fig. 6.18), and operative vaginal delivery may
be attempted. However, this is not a simple
Sagittal suture
Fig. 6.15 Transabdominal ultrasound in transverse fetal
21 3
head position: the probe is in transverse suprapubic area,
and the fetal head shows an posterior asynclitism (the
large black line is the sagittal suture, the thinner black line
midline). The left anterior orbit (at 21 h) is called also Posterior
“squint sign,” and the occiput is on the right (at 3 h) (From: orbit
Malvasi et al. [19])
a b
Fig. 6.16 (a) Palpation of the cephal head tumor from birth in labor (Y = external uterine orifice, X = internal
uterine orifice). (b) Tumor from childbirth and cephalohematoma (in black as the lower image)
maneuver. Deflection needs to be corrected, since This swelling is known as the caput succeda-
the nonflexed head presents a bigger diameter to neum. In a LOA position at about 3 cm of cervi-
the pelvis than if flexion is present. Asynclitism, cal dilatation, the part felt within the circle of the
if present, needs to be corrected as well and can external cervical os is the upper and nearly the
be done with a Barton forceps or by direct middle portion of the right parietal bone [2]. As
application. This generally works if marked ante- labor advances, the part of the head in the center
rior asynclitism is present [5]. If there is a lack of of the cervical opening is the middle portion of
operator experience in forceps procedures, a the posterior and upper quarter of the same bone.
cesarean section will be the route of choice. When the cervix is almost completely dilated, the
Figure 6.19 shows a left occiput transverse posi- right tuber of the parietal bone and the right ear
tion with anterior asynclitism. may be palpated. As the head advances through
the vagina and presents at the outlet, it is the
upper and posterior angle of the right parietal
6.4 Caput Succedaneum bone that is most prominent. It is on these parts in
and Molding succession that the caput succedaneum is formed
by the pressure of the cervix and the other portion
In prolonged labors before complete cervical of the birth canal on the fetal head. The edema of
dilatation, the portion of the fetal scalp immedi- the scalp formed on the middle of the upper half
ately over the cervical os becomes edematous. of the right parietal bone may be called “primary
Fig. 6.17 (a–b) Mechanism of labor in left occiput trans- head that results in the subsequent presentation of the
verse position, seen longitudinally. The posterior parietal front wall. Then occurs the engagement of the head and
bone presentation arranged transversely with respect to the subsequent progression, rotation, and extension of the
the diagonal conjugate is followed by lateral flexion of the same
Fig. 6.18 Transverse position of the fetal head with the pressed (sinciput) (Amended by: Malvasi et al. [11]). (a)
occiput to the right displayed in labor with transabdomi- Transverse position, shown by ultrasound translabial cross
nal ultrasound in cross section, which is clearly visible on section of the same pregnant woman (b)
the occiput (occiput), thalami, cavum pellucidum, and
Fig. 6.19 Left occiput transverse position with anterior asynclitism. Panel a: Graphic representation. Panel b:
Transabdominal ultrasound used up to the beginning of the second stage of labor
caput succedaneum” [2]. In the case of prolonged

labor, a swelling of the scalp is formed over the
posterior and superior angle of the right parietal
bone. This may be called “secondary caput suc-
cedaneum” and may be sufficiently extensive to
prevent the differentiation of the various sutures
and fontanels. Because it develops over the most
dependent area of the head, one may deduce the
original fetal head position by noting the location
of the caput succedaneum. In LOT position, for
example, it is found over the upper and posterior
portion of the right parietal bone, while in ROT
position is over the corresponding area of the left Fig. 6.20 Newborn delivered by forceps in occiput pos-
parietal bone. It follows that after labor the origi- terior position. The caput succedaneum on the left parietal
bone clearly ascertains the left asynclitism that created
nal position, complicated or not by asynclitism, prolonged second stage of labor and arrest of descent
may often be ascertained by noting the location
of the caput [22].
Figure 6.20 shows the fetal head of a 3,635-g of three pushes) until the sagittal suture was felt
fetus delivered by forceps after diagnosis of OP more median. At this point, the right blade of the
position [23], and arrest of progression at +2 sta- forceps was placed and delivery occurred with a
tion [22], angle of progression of 160° [24], and second degree vaginal laceration.
diagnosis of left asynclitism were made [12]. The During delivery the fetal head shape is altered
location of the caput succedaneum on the left as it is forced through the birth canal in vertex
parietal bone clearly ascertains the left asynclit- presentations. The skull bones may actually over-
ism that created the prolonged second stage of lap in a process referred to as molding. Such
labor and arrest of descent. Asynclitism was cor- molding produces a shortened suboccipitobreg-
rected placing only the left blade of the forceps matic diameter and a lengthening of the men-
first and allowing the patient to push (for a total tovertical diameter [22]. This phenomenon is
Fig. 6.21 Sagittal view of transperineal ultrasound showing absent (a), minimal (b), and marked (c) molding
extremely important in contracted pelvis and in Acknowledgment The author wants to express his grati-
the case of asynclitism. In this case, the degree of tude to Helen Macfarlane for the extensive and superb
bone overlapping may make the difference in Further thank you to Elizabeth Figa for her contribution in
allowing a normal vaginal delivery versus a vagi- structuring Table 6.1.
nal operative vaginal delivery or a cesarean sec-
tion (Fig. 6.21). This elongated look usually
disappears a few hours after birth as the bones
assume their normal relationships. References
1. Nizard J, Haberman S, Paltieli Y, Gonen R, Ohel G,
Conclusions
Le Bourthe Y, Ville Y (2009) Determination of fetal
Any fetal head position may be associated with head station and position during labor: a new tech-
some degree of asynclitism. Within certain nique that combines ultrasound and a position-track-
limits this should be seen as an adjustment of ing system. Am J Obstet Gynecol 200:404–e1–5
2. Smith WT (1858) The mechanism of labor. In: A
the fetal head to the specific maternal pelvic manual of obstetrics: theoretical and practical, Chapter
diameters. It is thanks to this adjustment and XXII. Savill and Edwards, Printers, Chandon Street,
to the overlapping of skull bones (molding) London, pp 265–289
that the fetal head will successfully descend 3. ACOG Practice Bulletin, Number 17, June 2000.
Operative Vaginal Delivery. Compendium of selected
within the birth canal, especially in the situa- publications, ACOG: Washington, DC, 2007
tion of a borderline pelvis. In the case of 4. 5a.2. The parietal bone. Figure 132 – Left parietal
marked asynclitism though, particularly the bone. Outer surface. www.theodora.com/anatomy/
posterior type, a prolonged or obstructed labor the_parietal_bone.html
5. O’Grady JP (1988) Forceps operation. In: Modern
may occur. Diagnosis of asynclitism has been instrument delivery, Chapter 3. Williams and Wilkins,
traditionally based on clinical findings in Baltimore, pp 83–154
patients in which the diagnosis of arrest of fetal 6. Dupuis O, Silveira R, Zentner A, Dittmar A,
head descent has been made. But vaginal digi- Gaucherand P, Cucherat M, Redarce T et al (2005)
Birth simulator: reliability of transvaginal assessment
tal examination may be extremely inaccurate. of fetal head station as defined by the American
Nowadays, with the utilization of ultrasound in College of Obstetricians and Gynecologist
labor and delivery rooms, the subjective evalu- classification. Am J Obstet Gynecol 192:868–874
ation obtained by vaginal digital examination 7. Barbera AF, Imani F, Necker T, Lezotte DC, Hobbins
JC (2009) Anatomic relationship between the pubic
has been objectively improved. The informa- symphysis and ischial spines and its clinical
tion obtained, with both 2D and 3D ultrasound significance in the assessment of fetal engagement
will help the clinician to reduce the potential and station during labor. Ultrasound Obstet Gynecol
fetal and maternal morbidity related to both a 33:320–325
8. Fuchs I, Tutschek B, Henrich W (2008) Visualization
prolonged second stage destined to end with a of the fetal fontanels and skull by three-dimensional
difficult cesarean section, or to a difficult translabial ultrasound during the second stage of
attempt at an instrumented vaginal delivery. labor. Ultrasound Obstet Gynecol 31:484–486
9. Malvasi A, Tinelli A, Stark M (2011) Intrapartum examination of fetal head position occiput position
sonography sign for occiput posterior asynclitism diag- during the second stage of labor. Am J Obstet Gynecol
nosis. J Matern Fetal Neonatal Med 24(3):553–554 19:521–524
10. Blasi I, D’Amico R, Fenu V, Volpe A, Fuchs I, Henrich 18. Zahalka N, Sadan O, Malinger G, Liberati M, Boaz
W, Mazza V (2010) Sonographic assessment of fetal M, Glezerman M et al (2005) Comparison of trans-
spine and head position during the first and second vaginal sonography with digital examination and
stages of labor for the diagnosis of persistent occiput transabdominal sonography for the determination of
posterior position: a pilot study. Ultrasound Obstet fetal head position in the second stage of labor. Am J
Gynecol 35:210–215 Obstet Gynecol 193:381–386
11. Malvasi A, Tinelli A, Brizzi A, Guido M, Laterza F, 19. Malvasi A, Stark M, Ghi T, Farine D, Guido M,
De Nunzio G, Bochicchio M, Ghi T, Stark M, Tinelli A (2012) Intrapartum sonography for fetal
Benhamou D, Di Renzo G (2011) Intrapartum sonog- head asynclitism and transverse position: sonographic
raphy head transverse and asynclitic diagnosis with signs and comparison of diagnostic performance
and without epidural analgesia initiated early during between transvaginal and digital examination. J
the first stage of labor. Eur Rev Med Pharmacol Sci Matern Fetal Neonatal Med 25(5):508–12, Epub
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12. Ghi T, Youssef A, Pilu G, Malvasi A, Ragusa A (2012) 20. Dupuis O, Ruimark S, Corinne D, Simone T, Andre’
Intrapartum sonographic imaging of fetal head asyn- D, Rene’-Charles R (2005) Fetal head position during
clitism. Ultrasound Obstet Gynecol 39(2):238–240. the second stage of labor: comparison of digital vagi-
doi:10.1002/uog.9034 nal examination and transabdominal ultrasonographic
13. Akmal S, Tsoi E, Kametas N, Howard R, Nicolaides KH examination. Eur J Obstet Gynecol Reprod Biol
(2002) Intrapartum sonography to determine fetal head 123:193–197
position. J Matern Fetal Neonatal Med 12:172–177 21. Sherer DM (2007) Intrapartum ultrasound. Ultrasound
14. Akmal S, Kametas N, Tsoi E, Hargreaves C, Obstet Gynecol 30:123–139
Nicolaides KH (2003) Comparison of transvaginal 22. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC
digital examination with intrapartum sonography to III, Hauth JC, Wenstrom KD (2001) Mechanisms of
determine fetal head position before instrumental normal labor. In: Williams obstetrics, 21nd edn,
delivery. Ultrasound Obstet Gynecol 21:437–440 Section III, Chapter 12. McGraw-Hill, New York, pp
15. Sherer DM, Miodovnik M, Bradley KS, Langer O 291–307
(2002) Intrapartum fetal head position I: Comparison 23. Barbera A, Hobbins JC (1997) Applicazioni di semei-
between transvaginal digital examination and transab- otica ecografica in travaglio di parto. In: Gruppo di
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of labor. Ultrasound Obstet Gynecol 19:258–263 Ostetricia e Ginecologia. Trattato di Ecografia in
16. Souka AP, Haritos T, Basayiannis K, Noikokyri N, Ostericia e Ginecologia. Prima edizione. Poletto
Antsaklis A (2003) Intrapartum ultrasound for the exam- Editore, pp 389–394
ination of the fetal head position in normal and obstructed 24. Barbera AF, Pombar X, Perugino G, Lezotte DC,
labor. J Matern Fetal Neonatal Med 13:59–63 Hobbins JC (2009) A new method to assess fetal head
17. Chou MR, Kreizer D, Taslimi MM, Druzin ML, El descent in labor with transperineal ultrasound.
Sayed Y (2004) Vaginal versus ultrasound Ultrasound Obstet Gynecol 33:313–319
The Angle of Progression:
An Objective Assessment of Fetal 7
Head Descent in the Birth Canal
Antonino F. Barbera
7.1 Introduction succedaneum and skull molding can make the

scenario more complex.
Fetal head engagement and fetal head station dur- The most important factor not taken in consid-
ing the second stage of labor have traditionally eration with this assessment is the peculiar shape
been diagnosed based on the relationship between of the pelvic axis, the so-called Carus curve [2].
the leading edge of the head contour and an The pathway of the fetal head through the pelvis
imaginary line that passes through the ischial is not a straight line but a curvilinear one. More
spines [1]. By convention, this reference line is specifically the birth canal can be divided in two
called “0 station” (Fig. 7.1). The stations above sections. In the upper section (clinical station −5
the ischial spines are 1 cm apart and are expressed to 0), the fetal head travels along a straight line
with negative numbers, with a value of −5 at the until it reaches the reference point at station 0
inlet of the pelvis. In the opposite direction, the (Fig. 7.2, panel a). From here to delivery, the fetal
stations below the ischial spines are 1 cm apart
but are numbered from +1 to +5, the latter num-
ber corresponding to the perineum. However,
with this digital assessment, even among experi-
enced clinicians, there is marked variability of
interpretation of fetal station, reflecting how sub-
jective, difficult, and unreliable this evaluation
may be. On top of that, factors like caput
A.F. Barbera, M.D.

Swan Mountain Women’s Center,
16175 Hwy 9, Breckenridge, CO 80443, USA
School of Medicine, University of Colorado Denver,
12631 East 17th Avenue, PO Box 6511, Aurora,
CO 80045, USA
Rocky Vista University, College of Osteopathic
Medicine, 8401 S. Chamber Rd, Parker,
Fig. 7.1 Vaginal digital examination in the assessment of
CO 80134, USA
fetal head station. Fetal head is defined as engaged when
Department of Obstetric and Gynecology, its most leading point is at or below the imaginary line
Denver Health Medical Center, Denver, passing through the ischial spines. The different stations
CO 80204, USA are 1 cm above (negative sign) and below (positive sign)
e-mail: [email protected] this imaginary line

88 A.F. Barbera
Fig. 7.2 Pelvic axis that a b

fetal head needs to follow in
its progression in the birth
canal. Panel a: Two different
axis are present, one in the
upper portion and one in the
lower portion. Panel b: The
pelvic axis is better
represented by a curved line
(Carus curve) [2]. Panel c:
Delivery occurs by extension
of the previously flexed
engaged head. Panel d: The
lower margin of the c d
symphysis acts as a fulcrum
around which fetal head
extends
head traverses a path that is best represented by a were able to record the distance between the
curved line (clinical station +1 to +5) (Fig. 7.2, sacrum and the fetal head circumference. Their
panel b). In fact, delivery occurs by extension of observations though were confined to the upper
the previously flexed engaged head (Fig. 7.2, straight portion of the birth canal, above the Carus
panel c). The occiput descend until it contacts the curve.
end of the pubic symphysis, which acts as a ful- Richey et al. [4] evaluated head station utiliz-
crum around which the fetal head changes direc- ing the linear measurement drawn from the
tion, extending through the last curvilinear perineum to the fetal head. Their correlation
portion of the birth canal (Fig. 7.2, panel d). From between measurement of the station of the fetal
this fundamental knowledge of physiology comes presenting part by transperineal ultrasound and
the need of finding a more reliable and objective vaginal digital examination (VDE) were once
tool to correctly assess fetal head station and again limited to the stations above the ischial
descent in the birth canal. This is of course of spines.
extreme importance in deciding whether or not to Sherer and Abulafia [5] showed an 85.6%
attempt a vaginal delivery either spontaneous or agreement between transvaginal digital and trans-
operative, or to perform a cesarean section. abdominal ultrasound determination of fetal head
engagement. Their evaluation, however, was lim-
ited only to fetal head engagement.
7.2 Use of Transperineal Dietz and Lanzarone [6] used the pubic sym-
Ultrasound physis and the most distal point of fetal head con-
tour as a landmark in quantifying head engagement
Since 1977, ultrasound has been reported as an using translabial ultrasound imaging. Their
adjunctive method for evaluating the level of the method showed a reasonable correlation with
fetal head within the maternal pelvis. fetal station assessed digitally, but the study was
Lewin et al. [3] positioned an ultrasound probe conducted in patients whose fetal station was not
on the mother’s skin at the level of the sacral tip lower than +1. Although the technique seemed to
oriented toward her umbilicus. In this way, they be useful in high stations, at which the curved
7 The Angle of Progression: An Objective Assessment of Fetal Head Descent in the Birth Canal 89
nature of the lower portion of the birth canal is attention has been placed on monitoring the true
not relevant, it was not tested in those patients for unit that changes during the progression in the
whom it is most important to accurately estimate birth canal: the angle of flexion and extension of
station, those with fetal head station below +1. the fetal head. The fetal head will be able to
Heinrich et al. [7] reported their experience engage only if it will be completely flexed with
with a translabial ultrasound approach. He was the chin touching the fetal sternum. This will
able to identify the pubic symphysis joint, the allow the smallest anteroposterior diameter of the
widest diameter of the fetal skull, the “infrapubic head, namely, the suboccipitobregmatic diameter,
line” running perpendicular to the long axis of to face and progress through the inlet-, mid-, and
the symphysis and originating from its caudal lower pelvic diameter, respectively the oblique
end, and the “head direction” defined as the direc- and the two anteroposterior. At the lower seg-
tion of a line perpendicular to the widest diameter ment of the upper portion of the birth canal, the
of the fetal head in the infrapubic plane, with head will extend following the curve of the lower
respect to the infrapubic line. In this study though portion of the birth canal, being delivered due to
the widest diameter of the fetal head was defined the extension mechanism that will use the lower
arbitrarily as well as its relationship with the margin of the pubic symphysis as a fulcrum
interspinous plane. around which the fetal head will change direction
Eggebo et al. [8] reported that a fetal head- (Fig. 7.2, panel d).
perineum distance measured by transperineal Having this anatomical concept very clear, we
imaging can predict vaginal delivery after induc- started assessing the feasibility and reproducibil-
tion of labor. They showed an association, but not ity of measuring station and observing descent of
a direct relationship, between fetal head-perineum the fetal head using transperineal ultrasound
distance and fetal head station. Unfortunately, (TPU) examination during labor. Another objec-
these measurements may vary with the degree of tive of our investigation was to compare the clini-
compression of the soft tissue, affecting the real cal evaluation of fetal station through vaginal
station of the fetal head in the birth canal. digital examinations with concomitant TPU
Furthermore, the positioning of the outer bony assessments of station. Lastly, we examined
limit on the fetal skull was chosen arbitrarily. trends in TPU data in laboring patients that could
Ghi et al. [9] reported their experience on the help to identify those who would go on to deliver
use of translabial ultrasound following fetal head vaginally rather than needing cesarean section for
descent in the birth canal reporting three different failure to progress. This, in turn, will be useful in
categories of fetal head direction: (1) downward developing a decision-making strategy to deter-
direction, with the head in the upper third of the mine the need for operative delivery in patients
pelvis; (2) horizontal direction, with the head in progressing slowly through the second stage of
the midplevis; and (3) upward direction, with the labor.
head most likely in the lower third of the pelvis.
They concluded that translabial sonography
allows a diagnosis of fetal station with accuracy 7.4 Population
comparable to that of digital examination.
Our original work started in Italy in 1996 and was
completed in the USA in 2004. Eighty-eight
7.3 The “Angle of Progression” pregnant women in labor were included in the
study (47 women in Milan, Italy, and 41 women
In all these studies using the transperineal/trans- in Denver, CO, USA) [10–12]. All women had a
labial ultrasound approach, none of the tech- live singleton pregnancy with the fetus in cephalic
niques have concentrated on the arc-like pathway presentation and a gestational age of more than
that the head must follow to move through the 37 completed weeks dated by first- and/or midtri-
upper and lower portions of the birth canal. No mester ultrasound.
90 A.F. Barbera
Fig. 7.3 Transperineal ultrasound (TPU) in the assess- symphysis pubic and fetal head contour. Panel c:
ment of the angle of progression. Panel a: Practical tech- Ultrasound appearance of the measurement of the angle
nique for TPU, with glove covering the ultrasound probe of progression. The upper and lower pole of the symphy-
in a sagittal section. The probe is moved gently side by sis are clearly identified allowing the drawing of its long
side to see the gravel appearance of the symphysis in axis; a line is drawn from its inferior pole tangentially to
between the two rami. Panel b: Wax representation of the fetal head contour easily identified
fetal head in the birth canal and relationship between
7.5 Real-Time Ultrasound empty bladder. TPU scans were performed at dif-
Measurements ferent times during labor for the 88 subjects
included in the study.
Patients were examined in their labor rooms. A For assessments performed during the second
5.0-MHz ultrasound probe was enclosed in a stage of labor, the time was noted and later used
latex glove covered with ultrasound gel and was to calculate the interval from scanning to deliv-
then placed between the labia below the pubic ery. In all cases, measurements were performed
symphysis. The sagittal view, in which the long in concert with digital examinations. All patients
axis of the pubic symphysis could be visualized, tolerated the TPU procedure well, without any
was obtained by gently rocking the transducer reported discomfort. Ultrasound assessment of
upward. While in this same plane, the fetal head the head station never took more than 1 min.
could easily be discerned and its skull line
identified. On the sagittal image, a line was drawn
on the screen between calipers placed at the two 7.6 Intraobserver and
points identifying the long axis of the pubic sym- Interobserver Variability
physis. A second caliper line was then created on
the frozen image that extended from the most Seventy-five of the 86 patients studied had one
inferior portion of the pubic symphysis tangen- set of between 2 and 5 replicated scans obtained
tially to the fetal skull contour. The angle between at approximately the same time. These 75 women
the constructed lines was then measured (Fig. 7.3, provided a total of 172 sets of scans, which were
panel a–c). The symphysis pubis may have vary- used to assess intraobserver variability.
ing ultrasound appearance (Fig. 7.4), and because In order to assess interobserver variability, a
it is a rather short structure, care was taken to second independent and well-trained observer,
identify its exact ends so that the long axis could blinded to the other’s results, obtained 15 dupli-
be precisely determined. The transducer was cate sets of scans at distinct times of labor among
maintained perfectly median to avoid the acous- 12 randomly selected women as generated by the
tic shadow given by the adjacent superior pubic primary observer. The consecutive scans were
rami (Fig. 7.5). The use of the sagittal view also performed with no more than 3 min between the
allowed clear identification of caput succeda- assessments of the two observers. The goal was
neum (Fig. 7.6) and molding (Fig. 7.7) when to generate paired sets of replicated images under
present. All of the images were obtained with an nearly identical conditions.
Fig. 7.4 The symphysis pubis has most of the time a is important though to get a median scan to avoid acoustic
gravel appearance, sometimes hyperechoic and some shadow given by the adjacent superior pubic rami
other times hypoechoic, depending on its water content. It
The intraobserver variability was calculated to data. These examiners included a senior consul-
be 2.96°, whereas the interobserver variability tant and a mixture of residents and fellows with at
was of 1.24° [12]. least 3 years of experience.
Station was determined by assessing the rela-
tionship between the most distal cranial point and
7.7 Assessment of Clinical the level of the ischial spines. The timing of the
Head Station clinical station assessments coincided with TPU
assessments during the various stages of labor so
Assessments of fetal head station were performed that correlations and associations between these two
by vaginal digital examination (VDE) conducted distinct methods could be evaluated statistically.
by the managing clinician, who was not involved There was a significant linear correlation
in the study and was blinded to the ultrasound between the angle of progression measured on
92 A.F. Barbera
Fig. 7.5 Panel a: Suprapubic transverse section showing identifying the gravel appearance of the symphysis. Panel
the median raphae (symphysis pubic) and the acoustic b: Paramedian transperineal section affected by the acous-
shadow given by the 2 superior pubic rami. It is through tic shadow given by the superior pubic rami (to be
the median raphae that the ultrasound beams will pass avoided)
seriously overlap, thereby compromising any

precision in predicting TPU angles from clinical
station assessed by vaginal digital examination.
In turn, the clinical station as assessed by VDE
can vary widely at any given TPU angle of pro-
gression, which we believe represents a more
objective variable.
7.8 Association Between the

Angle of Progression on
TPU Examination and Time
of Delivery
To evaluate the possible association between the

calculated TPU angle of progression and the time
Fig. 7.6 Sagittal view of transperineal ultrasound show- to delivery, 23 women, all of whom delivered
ing how easy it is to distinguish the caput succedaneum vaginally, were followed and measured serially
from the fetal skull up to the time of delivery, producing a total of 71
TPU angles. Each woman underwent between
TPU and the clinical station assessed by digital two and eight assessments and, for each angle
examination (R2 = 0.2659, P < 0.001) (Fig. 7.8). measured, the interval to delivery expressed in
Because of the large standard deviations for minutes was later calculated.
each station (roughly nine times the standard In order to determine whether the time to
error), the prediction intervals of TPU angle delivery was associated with the magnitude of
Fig. 7.7 Sagittal view of transperineal ultrasound showing absent (a), minimal (b), and marked (c) molding
200
y = 5.5603x + 110.1
180
R2 = 0.2659
160
140
TPU angle
120
100
80
60
40
20
-5 -4 -3 -2 -1 0 1 2 3 4 5
Clinical station
Fig. 7.8 Relationship between angle of progression measured by transperineal ultrasound and fetal head station
assessed by vaginal digital examination (Barbera et al. [12], with permission)
the TPU angle of progression, TPU angles were In all women, once full dilatation was attained,
divided into four groups: £135°, 136°–167°, and a TPU angle progression greater than 120°
168°–200°, and >200°, with the intervals chosen was associated with engagement of the head
to minimize the proportion of repeat measure- assessed by clinical examination. More impor-
ments obtained from the same women in each tantly, in all the vaginal deliveries, there was a
group. consistent increase in TPU angle of progression
The group with the smallest angles (£135°) (Fig. 7.9) and spontaneous delivery occurred in
had a markedly greater time to delivery (median all cases in which the TPU angle exceeded 120°.
45.5 (range, 23–48) min) than the other groups Among the six patients who had cesarean sec-
(136–167°: median, 16.5 (range, 12–27) min; tions for failure to progress, the average TPU
168–200°: median, 8.0 (range, 5–17) min; >200°: angle at the time of the last examination was 108°
median, 5.0 (range, 1–9) min). The decrease in and none achieved a TPU angle of >120°. In all
time to delivery became relatively smaller as the cases, clinical digital assessment of fetal head
magnitude of the angle increased [12]. station was +2 or more [12].
94 A.F. Barbera
Fig. 7.9 Transperineal

ultrasound images showing
increases of the angle of
progression (from panel a
through panel c) during the
second stage of labor
associated with normal
spontaneous vaginal delivery
7.9 Validation of the “Angle need for cesarean section. They reported a fitted
of Progression” probability of successful vacuum extraction or
spontaneous delivery being 90% with an angle of
Kalache et al. [13], following the technique progression of 120°. This confirmed what was
described by Barbera [11], found a strong rela- previously reported by Barbera [12] on the prog-
tionship between the angle of progression and the nostic value of 120° angle of progression.
70
60
Distance from presenting part
50
to ischial spine level (mm)
40
30
20
10
0
50 60 70 80 90 100 110 120
Angle of progression (*)
Fig. 7.10 Correlation between the angle of progression and fetal head station assessed by open magnetic resonance
imaging (Bamberg et al. [15], with permission)
Duckelmann et al. [14] reported that the angle by open magnetic resonance imaging (MRI)
of progression measured by TPU is reliable expressed by the distance from the presenting
regardless of fetal head station or the clinician’s part to the ischial spine plane. A significant cor-
level of ultrasound experiences. They studied 44 relation was found between the two methods in
laboring patient with fetuses in occiput anterior 31 patients at full term with a fetus in occip-
position and with a prolonged second stage of itoanterior position (Fig. 7.10). Their results sug-
labor. The images collected by one observer with gested that 0 station would correspond to a 120°
>10 years’ ultrasound experience were stored. angle of progression. This is in disagreement
Three fellows with 1, 3 and 4 years’ experience; with Barbera’s data [16] that calculated an angle
three consultants in obstetrics and fetal medicine of progression of 99° at computed station 0 using
with 10, 12 and 18 years’ experience; and mid- a geometric model based on computed tomogra-
wives with no ultrasound experience were involved phy of pelvis in nonpregnant patients.
in the evaluation of the images stored. Prior to the Ghi et al. [17] used the Sono VCADTM labor
analysis, all the observers underwent a training software (Voluson I, GE Medical System, Zipf,
session of 15 min to learn how to identify the long Austria) to analyze ultrasound volumes collected
axis of the symphysis, its inferior apex, and the by using an infrapubic or translabial approach in
fetal head contour. Duckelmann emphasized the 30-term laboring patients. The assessment of fetal
potential role of the angle of progression as a sim- head progression in the second stage of labor was
ple and reliable marker of progressive fetal head obtained by calculating the “head direction”
descent independently of ultrasound experience in (angle between the infrapubic line and the major
interpreting the images collected. longitudinal axis of the fetal head [7]), the “angle
Bamberg et al. [15] validated the angle of pro- of progression” (angle between the long axis of
gression by studying the correlation between the the symphysis pubic and a line joining its lowest
angle of progression measured by TPU and the margin to the contour of the fetal head [12, 13]),
gold standard and fetal head station measured the “head progression” (defined as the distance in
96 A.F. Barbera
millimeters between the infrapubic line and the clinically to each fetal head station, as defined
lowest part of the fetal skull [6]), and the “midline by the American College of Obstetricians and
angle” (angle between the anteroposterior axis of Gynecologists (ACOG [20]).
the maternal pelvis and the head midline [9]). Last, he assessed how close clinical estimations
Among the four different parameters analyzed of station through digital examination compared
by 3D ultrasound in the assessment of fetal head with ultrasound station by TPU in 88 laboring
progression in the second stage of labor, the angle patients [12]. On the CT images, three-dimen-
of progression and the head progression were the sional (3D) coordinates of the upper (USP) and
most reproducible. lower (LSP) borders of the symphysis pubis and
the right (RIS) and left (LIS) ischial spines were
obtained. Given the actual 3D coordinates (x, y, z)
7.10 Anatomic Relationship for both RIS and LIS, we were able to compute the
Between the Pubic Symphysis coordinates of the theoretical line connecting both
and Ischial Spines ischial spines and identifying its middle point
(MIS). Next, the angle between two lines connect-
Many studies showed how inaccurate vaginal ing LSP to MIS and LSP to USP was calculated.
digital examination is in the assessment of fetal The coordinates of vectors from LSP to USP and
head station in the birth canal. LSP to MIS were obtained (Fig. 7.11).
A study using a birth simulator found that The vectors obtained represent the long axis
vaginal digital examination showed errors occur- of the symphysis pubis (V1), and the axis (V2)
ring in 50–80% of examinations, depending on connecting the lower margin of the symphysis to
the true level of the head [18]. the midpoint of the line that ideally connects the
Buchmann et al. [19], in a prospective study of two ischial spines (V3). The angle between V1
fetal head station in 508-term laboring women, and V2 was then calculated, providing the angle
found very poor interobserver agreement. between the long axis of the symphysis pubis and
Nevertheless, even with several limitations related the line from its lower border to the midpoint
to the subjectivity of the evaluation of vaginal between the ischial spines (Fig. 7.12).
digital examination, using the ischial spines as a Calculations to determine angles associated
reference point is still considered the “gold stan- with clinical stations were obtained. When
dard” for the assessment of fetal head engage- located on the midpoint of the line joining the
ment and station in the birth canal. ischial spines, the angle corresponded to what
Transperineal ultrasound clearly shows the has been defined clinically to be 0 station.
long axis of the symphysis pubic and fetal head Different angles for the different stations −5 to
contour. Its limitation is the impossibility of +5 were calculated based on natural progression
visualizing the ischial spines that indeed lay on of the head in the birth canal. From −5 to 0 sta-
a different plane, laterally and anteriorly, com- tion, the axis of the birth canal is a straight line,
pared to what is actually happening in the mid- parallel to the long axis of symphysis pubis.
line of the pelvis. In relationship to these two Distal to station 0, namely, from stations +1 to
factors, Barbera [16] developed a geometric +5, the axis of the birth canal is curvilinear, the
model from computed tomography images fetal head moving down an arc centered at the
obtained from the pelvis of 70 nonpregnant lower border of the symphysis pubis, with a
patients to find the angle existing between the radius equal to the distance between the lower
long axis of the symphysis pubis and the middle border of the symphysis pubis and the midpoint
point of the line drawn between the two ischial between the ischial spines. Along the entire path-
spines, representing clinical 0 station. The sec- way it was possible to calculate specific angles
ond objective was to develop, based on this that would correspond to stations 1 cm apart from
objective geometric model, a set of angles of each other from the inlet to the outlet of the birth
progression assessed by TPU that would correspond canal (Table 7.1).
U Symphysis pubis - (ULS’ angle)

L O’’
-
O
-
O’
-
O’’
-
O’
ß
-
O
S′
Path of vertex in birth canal
S M
Fig. 7.11 Geometric model for assigning a specific angle to each computed tomographic station in both the upper and
lower segment of the birth canal
Table 7.1 Intervals of angle of head progression, derived

from our geometric and computed tomography data,
associated with each specific fetal head station
Station Lower angle Mean angle Upper angle
−5 62 65 68
−4 69 71 74
−3 75 78 81
−2 82 85 88
−1 89 92 95
0 96 99 102
1 103 106 109
Fig. 7.12 The angle between the long axis of the sym- 2 110 113 116
physis pubic (V1) and the line (V2) from its lower border 3 117 120 123
to the midpoint between the ischial spines (V3). This is 4 124 127 131
the angle of progression that can be easily measured by 5 132 135 139
transperineal ultrasound and corresponds to the 0 station
assessed by vaginal digital examination Barbera et al. [16], with permission
7.11 Relationship Between Digitally

Table 7.1 shows the interval for which we have Assessed Fetal Head Station
correlated computed angles to specific clinical and Angle of Progression
stations. Consecutive nonoverlapping intervals Measured by TPU
around the theoretical mean were created, and
specific stations within the pelvis were assigned The identification of different angles associated
to different angles of progression. In specific the to specific stations within the pelvis resulting
angle between the long axis of the symphysis and from the geometric model was a very important
the midpoint of the imaginary line connecting the result. In fact, it allowed the comparison between
two ischial spines, conventionally defined as zero the assessment of fetal head station obtained by
station, was 99°. vaginal digital examination and the angle of
98 A.F. Barbera
Computed stations
-3 -2 -1 0 +1 +2 +3
1
Clinical stations
-1
-2
-3
60 74 81 88 95 102 110 115 122

78 85 92 99 106 113 120
Computed angles
Fig. 7.13 Relationship between digitally assessed fetal of head progress (shaded boxes) determined, using our
head station and angle of progression measure by trans- geometric model, to be associated with each specific head
perineal ultrasound (•). Also shown are interval of angle station (Barbera et al. [16], with permission)
progression recorded by TPU for each clinical Table 7.2 Agreement between the assessment of fetal
station in relationship to the geometric model head station by vaginal digital examination and by mea-
surement of the angle of head progression using trans-
created with the CT data. Figure 7.13 shows this
perineal ultrasound (with computed station determined
relationship. We found that the digital assess- using the intervals derived from our geometric model)
ment correlated very poorly with the TPU-
Agreement (%)
assigned station. From our model, we would Computed
have expected the mean TPU angle of any given station Complete ± 1 cm ± 2 cm
clinical station, indicated by simultaneous digi- −3 27 60 87
tal examination, to be reasonably close to the −2 46 92 100
theoretically calculated angle assigned to that −1 14 64 89
station (shaded areas in Fig. 7.13). Instead, for 0 18 53 92
each station clinically assessed, a wide range in 1 16 32 56
the angle measured by TPU was clearly noted 2 2.6 26 39
(• in Fig. 7.13). Few clinical estimations of sta- 3 0 12 40
tion corresponded to the station assigned by our Barbera et al. [16], with permission
geometric model. This inaccuracy is further
expressed in Table 7.2. This table reports the contrast, once the fetal head is below 0 station,
extent of agreement between station determined the ability to appreciate the relationship between
by digital examination and that assigned by the the ischial spines, which are laterally located in
geometric model. The highest percentage of the pelvis, and the most prominent part of the
complete agreement was only 46%, at −2 sta- centrally located fetal skull represents a major
tion. This result is certainly not surprising since challenge. This is exemplified by a progressively
when the fetal head is above the level of the worsening agreement below 0 station. For exam-
ischial spines the assessing fingers are able to ple, at computed 0 station, the digital examination
appreciate both the spines and the fetal skull. In completely agreed in only 18% of cases. An
agreement between 89% and 100% was only The angle of progression assessed by trans-
observed with ±2 cm variation, meaning that every perineal ultrasound is an objective, reproduc-
time a clinician diagnoses the fetal head to be ible, noninvasive, and easy to perform technique.
at 0 station, the real station may vary between −2 After 15 min of training, independently of fetal
and +2. This inaccuracy is especially vexing at head station and of experience in ultrasound,
station +2, where complete agreement was the only maternal and fetal landmark used are
obtained in only 2.6% of cases and reached only easily identified with high reproducibility. Only
39% with ±2 cm variation. It is of note that +2 the symphysis pubic and its long axis and the
station is a crucial station since the ACOG rec- contour of the fetal skull are the structures
ommends that forceps application (low forceps) involved in the assessment. 2D capability with
should be safe only at ³+2 cm station [21]. software able to measure an angle is the only
requirement. Neither caput succedaneum nor
Conclusion molding of the skull will affect the identification
The correct assessment of fetal head engage- of the fetal head contour really progressing in
ment and fetal station during its descent in the the birth canal. This makes the technique easy
birth canal is of paramount importance in the to be used by any provider taking care of labor-
management of any delivery, vaginal and/or ing patients, being he or she a maternal-fetal
operative. It is now clear that the vaginal digi- specialist, a generalist, a family practice physi-
tal examination, still considered the gold stan- cian, a midwife, a resident, or a medical stu-
dard, is extremely subjective, poorly dent. The proven reliability of the measurement
reproducible, and inaccurate. of the angle of progression makes it an emerg-
The introduction of ultrasound in the man- ing method that could be widely available and
agement of labor and delivery is continuously completely risk-free.
giving a growing information database able to The ever continuing dilemma on the man-
improve maternal and/or neonatal outcome. agement of the management of a prolonged
Many are the clinical scenarios when an stage of labor, either to continue to manage it
under estimation of fetal head station pushes expectantly or to change route performing a
the clinician to procrastinate and delay the cesarean section, may find its solution with
time of delivery with possible assisted vaginal this simple method that should therefore
birth versus cesarean section. The opposite become part of the armamentarium of any pro-
clinical scenario occurs when the overestima- vider involved in the care of any parturient.
tion of fetal head station makes the clinician
decide on an operative vaginal delivery with Acknowledgment The author wants to express his grati-
tude to Helen Macfarlane for the extensive and superb
consequent failure.
In view of these potentially devastating deci-
sions, it is clear that a more accurate diagnosis
of fetal head station is imperative. The tech- References
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Head Rotation in Labor and
Intrapartum Sonography Diagnosis 8
with 2D and 3D
Tullio Ghi, Aly Youssef, Elisa Maroni, Gianluigi Pilu,

and Nicola Rizzo
8.1 Introduction The passage of the head at the level of the

middle part of the birth canal is certainly one of
Fetal head descent in the second stage of labor is the most critical steps of the whole mechanics of
a dynamically complex process characterized by labor. At this level, the presence of the ischial
the coordinate and simultaneous occurrence of spines dramatically reduces the transverse diam-
descent, rotation, and deflexion within the birth eter of the birth canal with the anteroposterior
canal. diameter being the largest one at this point [2] as
The head is forced by maternal pushing shown in Fig. 8.1.
through a rigid and irregularly shaped osteomus- If the fetus is in vertex presentation and occiput
cular canal, and dynamic changes of the spatial anterior position, engagement in the birth canal
relationship between the head itself and birth usually occurs along the oblique diameter of pel-
canal are requested to occur in order to achieve vic inlet (13 cm), with the fetal occiput approach-
vaginal delivery [1]. ing the left iliopectineal eminence. After descent
Changes of fetal head orientation in respect of to midpelvis, the fetal head may not progress fur-
the birth canal are known as dynamic phenomena ther down on this orientation due to the transverse
of labor and are aimed to approach ergonomi- narrowing caused by the above-mentioned ischial
cally the different sections of the birth canal and spines which would block head progression.
to ensure the passage of the cephalic circumfer- Consequently, the head physiologically under-
ence despite the presence of anatomical strictures goes a movement of internal rotation approach-
that may counteract the progression to the outlet. ing the pubis with the occiput and aligning its
largest diameter (suboccipitobregmatic diameter
9.5 cm) with the widest diameter of the birth
canal at the level of the midpelvis, which is in
T. Ghi, M.D., Ph.D. ()
fact the anteroposterior (11.5 cm) (Fig. 8.2).
Department of Obstetrics and Gynecology, Sant’Orsola
Malpighi University Hospital, University of Bologna, After the internal rotation, the head may now
Bologna, Italy progress to the low pelvis and being finally deliv-
I Clinica Ostetrica-Ginecologica, Policlinico S. ered through a deflexion movement of the occiput
Orsola-Malpighi, Via Massarenti 13, below the pubic symphysis, which is the fulcrum
Bologna 40100, Italy of the movement itself [2].
e-mail: [email protected], [email protected]
The whole process of fetal head delivery has
A. Youssef, M.D. • E. Maroni, M.D. • G. Pilu, M.D., Ph.D. been the object of study of traditional obstetrics,
N. Rizzo, M.D., Ph.D.
and its detailed knowledge is based upon digital
Department of Obstetrics and Gynecology, Sant’Orsola
Malpighi University Hospital, University of Bologna, assessment of cephalic sutures and fontanels in
Bologna, Italy respect of the landmarks of the birth canal.

102 T. Ghi et al.
Sacrum
Ischial spines
Fig. 8.1 Female pelvic anatomy at the midpelvis plane
Fig. 8.2 Internal rotation movement of the fetal head at midpelvis plane
However, clinical evaluation of such findings First of all, the assessment of the occiput posi-
particularly during the second stage of labor is tion in the birth canal by digital exploration has
commonly reported to be inaccurate and poorly been consistently reported to be extremely inac-
reproducible [3]. curate. Furthermore, the process of fetal head
8 Head Rotation in Labor and Intrapartum Sonography Diagnosis with 2D and 3D 103
descent and rotation is suspected to follow differ- Accurate diagnosis of persistent occiput pos-
ent pathways depending on particular obstetric terior position in the second stage of labor has
conditions, including persistent posterior occiput therefore a critical role in the appropriate man-
position, deflexion, or asynclitism. On this basis, agement of labor. Furthermore, correct determi-
the use of ultrasound in labor has been recently nation of the head position is crucial before
suggested in order to assist physicians in the instrumental delivery. An error in such evaluation
assessment of fetal head rotation. The sonographic may result in inappropriate vacuum or forceps
study combined with clinical findings may there- blade placement, both increasing the risk of fetal
fore refine the proper management of labor, par- injury and or the failure rate of the instrumental
ticularly when an expedite delivery is indicated procedure [8–10]. Failed instrumental delivery
and the correct choice between a cesarean section followed by cesarean section is associated with
and an operative vaginal delivery is warranted. an increased decision-to-delivery interval and
with a much increased risk of fetal trauma
[11–13].
8.2 2D Ultrasound and Fetal Head Lastly, some preventive measures can be
Position: The Occiput Posterior undertaken in cases of cephalic malposition, as
mediolateral episiotomy in occiput posterior
Intrapartum assessment of the fetal head position position has been found to reduce significantly
and rotation is of paramount importance and is the risk of anal sphincter damage [14, 15].
traditionally based upon digital palpation of the However, digital examination is highly sub-
posterior fontanel and sagittal suture and their jective, and using a birth simulator, some authors
correlation with specific landmarks of the mater- have independently shown that clinical diagnosis
nal birth canal. In accordance with the aforemen- of occiput position was inaccurate in a relevant
tioned mechanism of physiologic vertex delivery, proportion of cases [3].
the degree of fetal head rotation in respect of the In this respect, an overt superiority of ultra-
maternal pelvis may indirectly witness the level sound vs. digital examination has been witnessed
of fetal head descent in the birth canal. in the recent past. The exact position of fetal
However, the dynamics of labor may at times occiput in respect of the birth canal may be easily
be altered by mechanic conditions which may documented by suprapubic 2D ultrasound, using
affect the course of labor, interfering with fetal fetal orbits as the anatomic landmark (Fig. 8.3).
head progression in the birth canal. Among these Furthermore, the orientation of the head mid-
conditions, a persistent posterior position of the line and the degree of fetal head rotation may be
fetal occiput in the birth canal is widely acknowl- also demonstrated at suprapubic or translabial
edged and is considered the commonest fetal ultrasound.
head malposition in labor. Using sonographic findings as the gold stan-
Occiput posterior position is encountered in dard, some authors have demonstrated that digi-
5–15% of all deliveries [4, 5], but a significantly tal examination is highly inaccurate with a rate of
higher prevalence is described in the first stage of error ranging from 30% to 70% [6, 16–22] and
labor. In several cases, spontaneous conversion to significant error (>45°) ranging from 20% to
an anterior occiput position has been demon- 40%. Clinical evaluation is reported to be less
strated to occur [6], but this chance becomes accurate in cases of occiput posterior and trans-
much smaller in fetuses with persistent occiput verse, when medical intervention is more likely
posterior position in the advanced second stage. to be needed [3, 17, 18, 20].
In this latter group, a high risk of cesarean section Reliability of digital assessment may be fur-
or operative vaginal deliveries is consistently ther decreased by the presence of caput succe-
reported and a globally increased incidence of daneum and molding, both of them more
maternal and perinatal complications is widely frequently associated with obstructed labor.
acknowledged [5, 7]. Many authors have failed to demonstrate a
104 T. Ghi et al.
Fig. 8.3 Suprapubic 2D ultrasound, fetal orbits as the anatomic landmark of occiput posterior position
significant difference in accuracy between expe- 8.3 Fetal Head Rotation

rienced and inexperienced obstetricians [3, 18,
19], although this finding has been questioned In the second stage of labor, the degree of fetal
by others [16]. head rotation in respect of anteroposterior axis
Some authors [16] have assessed by suprapu- of maternal pelvis is strongly related to the level
bic 2D ultrasound fetal head position just prior to of the presenting part in the birth canal. As men-
instrumental delivery and demonstrated that digi- tioned above, in the commonest type of labor
tal examination during delivery fails to identify with a vertex presenting fetus, the internal rota-
the correct fetal head position in about one quar- tion of the head at the level of ischial spines
ter of cases. allows the head to pass from the mid- to the low
At the light of these observations, in dubious pelvis just prior to delivery. The alignment of
cases or prior to the operative vaginal delivery, fetal head in comparison with obstetric conju-
the use of 2D ultrasound to reassess clinical gate is therefore a critical finding to assess the
findings and confirm the occiput position would descent of presenting part and is traditionally
be highly recommended. investigated by digital examination of the sagit-
More recently, Blasi et al. have observed that tal suture.
among fetuses with occiput posterior in active However, clinical evaluation of this parameter
labor, the persistence of posterior occiput posi- is once more affected by low reproducibility, and
tion may be accurately predicted looking at fetal in this respect, the use of 2D ultrasound to define
spine orientation. They have reported indeed a the exact rotation of fetal head in the birth canal
conversion to anterior occiput at delivery among has been recently suggested.
almost all cases with anterior fetal spine and per- Using the translabial approach, the transducer is
sistence of occiput posterior position among placed transversally on the major labia. Subsequently,
those with posterior fetal spine [23]. the echogenic line interposed between the two cere-
On the other hand, in contrast with previous bral hemispheres (midline) is identified, and the
beliefs, longitudinal assessment of fetuses angle formed by the midline and the anteroposterior
throughout labor has demonstrated that OP posi- diameter of the pubis is measured (so-called “mid-
tion at delivery is the result of a failure of rotation line” angle) as shown in Fig. 8.4.
from the OP position, rather than a malrotation This measurement of midline angle seems to cor-
from the anterior position [6, 23]. relate with clinically assessed station particularly
Fig. 8.4 Placing the transducer transversally on the the angle formed by the midline and the anteroposterior
major labia, the echogenic line interposed between diameter of the pubis is assessed (so-called “midline” angle)
the two cerebral hemispheres (midline) is identified, and
among fetuses with occiput anterior. In cases the

midline angle was <45°, the station is ³+2 cm in 8.4 Three-Dimensional Ultrasound
the vast majority of cases. On the contrary, in
fetuses with midline angle >45° or not clearly It was reported that 2D real-time translabial ultra-
measurable, at clinical assessment, the head sta- sound may be prone to a high degree of variation
tion is mostly reported as <+2 cm from ischial due to several factors, but mostly to the insonation
spines [24]. Two examples of ultrasound image angle relative to the pubic bone, which may
are depicted in Fig. 8.5. significantly affect the reproducibility of the
In the same study, the midline angle value has measurements [25].
been also proven to be of help in predicting the The use of 3D ultrasound in labor has been
success of operative vaginal delivery as no failure suggested to offer some advantages, including a
was described in fetuses with occiput anterior if multiplanar reconstruction of the birth canal
the midline angle was £45°. Figure 8.6 shows the (Fig. 8.7) in order to guarantee standardization of
high correlation between midline angle and digi- the planes of measurements and thus more repro-
tal examinations [24]. ducible data.
The correlation between the midline angle and By following a standardized procedure, sono-
the fetal head station in fetuses with persistent graphic assessment of fetal head rotation through
occiput posterior position in the second stage has measurement of the midline angle could be
not been demonstrated to be as reliable as in performed.
fetuses with occiput anterior. The reproducibility of this novel sonographic
At the light of this finding, some have specu- parameter has been recently investigated by
lated that the fetal head descent in fetuses with offline analysis of a series of 3D ultrasound vol-
persistent occiput posterior position may follow a ume acquired translabially in the second stage of
different course with the fetal head rotation pos- labor [25].
sibly occurring at the pelvic brim or the engage- Inter- and intraobserver agreement of midline
ment of the presenting part ensuing on the angle measurement has appeared acceptable but
anteroposterior axis rather than on the oblique lower than other sonographic parameters, mostly
diameter of the birth canal inlet. due to the difficulty in assessing head midline
106 T. Ghi et al.
Fig. 8.5 Midline angle view: (a) Midline angle >45° with fetal head at pelvic inlet. (b) Midline angle < 45° following
internal rotation of the fetal head at midpelvis
<45˚
a volume data set has been acquired at regular
intervals starting from the active phase of the
p <0.0001
³45˚ second stage until delivery. The midline angle

together with other sonographic parameters has
Not seen been measured by offline analysis of the vol-
ume, and its longitudinal changes throughout
the second stage have been thoroughly investi-
£+ 1 cm +2 cm ³+ 3 cm
gated. No significant difference in the degree of
Fig. 8.6 Correlation between fetal head rotation and fetal head rotation has been noted at the onset
digital examinations of the second stage between women who were
on epidural analgesia and those who were not,
but interestingly, a significantly slower reduc-
direction when the presenting part is above the tion of the midline angle accounting for a lon-
ischial spines. ger second stage has been registered in the
A major advantage of 3D US in labor over tra- epidural group.
ditional 2D US is the ability to acquire serial vol- This observation is original and may be due to
umes from the same patient and to compare the diminished tone of the maternal perineal
sonographic measurements obtained at different muscles, which after epidural fail to contribute
time intervals with the aim of assessing the longi- actively to internal rotation of fetal head.
tudinal change of the data and ultimately the pro- Furthermore, a significantly slower change of
gression of labor. the midline angle has been also found among
Among the sonographic measurements, the women delivered by cesarean section or vacuum
midline angle may be longitudinally assessed in due to obstructed labor.
order to evaluate the rotation of the head through- Finally, the longitudinal pattern of fetal head
out the second stage of labor. rotation has been compared between fetuses with
We have recently undertaken a prospective occiput anterior and a small group delivered in
study on a cohort of 70 G1 women in second persistent occiput posterior position. The midline
stage of labor (unpublished data). In all patients, angle measured in the early second stage among
Fig. 8.7 Multiplanar 3D reconstruction of the birth canal. In the B plane, a clear image of the midline is shown
fetuses with occiput posterior position did not References

differ significantly from those with occiput
anterior. 1. Cunningham F, MacDonald PC, Gant NF, Leveno KJ,
Gilstrap LC 3rd, Hankins GDV et al (1997) Anatomy
In conclusion, ultrasound may be added to
of the reproductive tract. In: Licht J (ed) Williams
digital examination in order to evaluate fetal head obstetrics. Appleton & Lange, Stamford
rotation in the second stage of labor. Due to the 2. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, hauth
high accuracy and reproducibility, in our opinion, JC, Wenstrom KD (1997) Mechanisms of normal labour.
In Cunningham FG, MacDonald PC, Gant NF, Leveno
the use of ultrasound is recommended when clin-
KJ, Gilstrap LC, Hankins. Willoams Obstetrics, 20th ed.,
ical findings are dubious and an option of an stamford, Connecticut: Appleton and Lange, USA
operative vaginal delivery is considered by the 3. Dupuis O, Ruimark S, Corrine D, Simone T, Andre D,
attending physician. Rene-Charles R (2005) Fetal head position during the
second stage of labor: comparison of digital and vagi-
There is no sufficient evidence to support the
nal examination and transabdominal ultrasonographic
use 3D ultrasound in labor. examination. Eur J Obstet Gynecol Reprod Biol
Nonetheless, we believe that 3D ultrasound in 123:193–197
labor may help in standardizing the sonographic 4. Ponkey SE, Cohen AP, Heffner LJ, Lieberman E
(2003) Persistent fetal occiput posterior position:
measurements. Large studies evaluating the lon-
obstetric outcomes. Obstet Gynecol 101:915–920
gitudinal changes of sonographic data during 5. Cheng YW, Shaffer BL, Caughey AB (2006) Associated
labor may permit in the future the construction of factors and outcomes of persistent occiput posterior
normative charts for fetal head rotation and position: A retrospective cohort study from 1976 to
2001. J Matern Fetal Neonatal Med 19:563–568
descent (sonographic partogram).
108 T. Ghi et al.
6. Akmal S, Tsoi E, Howard R, Osei E, Nicolaides KH determine fetal head position before instrumental
(2004) Investigation of occipito posterior delivery by delivery. Ultrasound Obstet Gynecol 21:437–440
intrapartum sonography. Ultrasound Obstet Gynecol 17. Akmal S, Tsoi E, Nicolaides KH (2004) Intrapartum
24:425–428 sonography to determine fetal occipital position:
7. Gei AF, Smith RA, Hankins GD (2003) Brachial interobserver agreement. Ultrasound Obstet Gynecol
plexus paresis associated with fetal neck compression 24:421–424
from forceps. Am J Perinatol 20:289–291 18. Sherer DM, Miodovnik M, Bradley S, Langer O
8. Mola GD, Amoa AB, Edilyong J (2002) Factors asso- (2002) Intrapartum fetal head position I: comparison
ciated with success or failure in trials of vacuum between transvaginal digital examination and transab-
extraction. Aust N Z J Obstet Gynaecol 42:35–39 dominal ultrasound assessment during the active stage
9. Vacca A, Keirse MJNC (1989) Instrumental vaginal of labor. Ultrasound Obstet Gynecol 19:258–263
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University Press, Oxford, pp 1216–1233 between transvaginal digital examination and transab-
10. Olagundoye V, MacKenzie IZ (2007) The impact of a dominal ultrasound assessment during the second stage
trial of instrumental delivery in theatre on neonatal of labor. Ultrasound Obstet Gynecol 19:264–268
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women on neonatal intracranial injury. N Engl J Med labor. J Matern Fetal Neonatal Med 13:59–63
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Thom E, Spong CY, Varner MW, Moawad AH, Caritis tion by ultrasound during the second stage of labor. J
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Intrapartum Translabial Ultrasound
(ITU) to Assess Birth Progress 9
Boris Tutschek, Thorsten Braun, Frederic Chantraine,
and Wolfgang Henrich
9.1 Introduction palpation, measured using a phantom, showed

that obstetric vaginal palpation is very operator
For many years, diagnostic ultrasound has had a dependent and, overall, not accurate; this applies
place in the labor ward [1]. Recently, it has also to palpated head stations expressed in centime-
been applied to assess birth progress. Initially, the ters above or below the mid-pelvis (Fig. 9.1) and
position of the fetal spine and occiput was simply as “high,” “mid,” and “low,” according to
assessed by transabdominal ultrasound and cor- the ACOG classification [11].
related with vaginal palpation to improve detec-
tion of OP presentation [2]. From 2005, translabial
ultrasound was used, initially before [3, 4] but 9.2 Translabial Ultrasound
then also during labor [5–10] to measure head
station objectively. Studies of accuracy of vaginal Different descriptive terms have been used for the
insonation of the birth canal from below the pubic
B. Tutschek, M.D. () symphysis, for which the transducer is placed
Department of Obstetrics and Gynecology, between the pubic bones and the anus: translabial,
Bern University Hospital, Bern, Switzerland
perineal, and transperineal. “Translabial ultra-
Medical Faculty, Heinrich Heine University, sound” describes best how the transducer is actu-
Düsseldorf, Germany
ally applied: A (curved array) transducer that is
e-mail: [email protected], [email protected]
typically used for a transabdominal mid- and
T. Braun, M.D.
third-trimester exam is placed on the labia,
Department of Obstetrics,
Charité Medical University Berlin, sagittally in a median plane. In the top of the
Campus Virchow-Klinikum, Augustenburger Platz 1, image and close to the entrance, a longitudinal
Berlin DE–13353, Germany section of the pubic symphysis is displayed and
the perineum (the anatomical region between the
F. Chantraine, M.D. posterior commissure and the anus) is on the right
Department of Gynecology and Obstetrics, Centre
(Fig. 9.2a, b).
Hospitalier Régional de la Citadelle, University of Liège,
1 Boulevard 12éme de Ligne, Liège B-4000, Belgium The term “perineal” or “transperineal”
e-mail: [email protected] insonation is ambiguous because in English text-
W. Henrich, M.D. books, different definitions for “perineum” exist
Department of Obstetrics, one of which also includes the vulva. Hence, for
Charité Virchow Clinic, Berlin, clarity the term, “intrapartum translabial ultra-
Augustenburger Platz 1, 13353 Berlin, Germany
sound” or “ITU” should be used.

110 B. Tutschek et al.
Proportion of correctly palpated 100%

head stations (i%)
Junior obstetricians Senior obstetricians
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
–5 –4 –3 –2 –1 0 1 2 3 4 5
Real head station (cm)
Fig. 9.1 Correct palpation of head station in an obstetrical phantom, expressed in centimeters above or below the level
of the ischial spines, as assessed by 32 residents and 25 consultant obstetricians (Data from [11])
9.3 Obtaining ITU Images station at rest and at the height of pushing dur-
ing a naturally occurring contraction. These
A curved array transducer such as typically used dynamics can be observed also using ITU and
for mid- and third-trimester transabdominal ultra- can even be quantified (Fig. 9.3). From a practi-
sound is used for ITU, but placed median on the cal point of view, the image can be optimized in
labia yields a “panoramic” view of the birth canal. the absence of a contraction and while the
In this easy to obtain plane, the bony structures woman is resting. When the contraction peaks,
that define the head station cannot be seen: the the next image should be taken. Then, the
ischial spinae define the narrowest plane of the woman can be told to push, and another image
bony birth canal and indicate head station ±0 cm. is taken. Finally, the parameters described
However, there is a fixed anatomical relationship should be analyzed for these three situations to
between the pubic symphysis and the ischial enable recognition of dynamic changes
plane: In a median section, line perpendicular to (Fig. 9.3).
the inferior border of the pubic symphysis is 3 cm
above the parallel plane through the ischial spines
on both sides [6, 13]. 9.4 Parameters of Intrapartum
Using this reference system, the head station Translabial Ultrasound
determined objectively by ultrasound can be
directly compared and related to the “classical” The quantitative parameters of ITU (Table 9.1)
coordinates of vaginal obstetrical palpation, are all based on an exact median section of the
expressing the station of the presenting part in pubic symphysis (Fig. 9.4). The leading land-
centimeters above or below mid-pelvis. mark is the lower end of the symphysis or, more
From a clinical perspective, the dynamic specifically, a perpendicular line extending dor-
aspect of ITU are important, same as during a sally; this line can easily be visualized in all
palpation when the clinician assesses the head patients; it is called the “infrapubic line.”
9 Intrapartum Translabial Ultrasound (ITU) to Assess Birth Progress 111
a1 a2
b1 b2
Fig. 9.2 Comparison of abdominal and translabial ultra- is cut in the midline and lies horizontally on the top of the
sound images. (a1) Median transabdominal longitudinal image. The fetal head is easily recognized, and the direc-
section cranial to the pubic symphysis, showing a dorsoan- tion of its longest axis with regard to the axis of the curved
terior, occipito-anterior cephalic lie. (a2) Transabdominal birth canal (the so-called head direction) is apparent. The
ultrasound evaluation technique shows the fetal head posi- dorsal part of the birth canal (soft tissue and sacral bones)
tion in longitudinal scan on the first stage of labor, of a cannot be delineated well (Images with permission from
fetus in cephalic presentation, and occipito-transverse [12]). (b2) “Head down”: ultrasound translabial schematic
position. (b1) Intrapartum translabial ultrasound ITU (the sagittal scan representing the direction of the fetal head
pubic symphysis is not visible). The transducer is placed down. We distinguish the pubic bone and the outline of the
median on the labia in such a way that the pubic symphysis fetal head with evident tumor from birth
The ischial spines are the anatomical struc- spines are 3 cm apart, and measurements relating
tures whose level along the birth canal defines to the infrapubic line – which is easily seen on
mid-pelvis (station ±0 cm); however, they cannot ITU – can be converted into the established
be seen on ITU. CT studies have shown that the obstetrical system of centimeters above or below
infrapubic lines runs 3 cm cranial to a parallel the ischial spines.
plane that traverses the ischial spines [6]. In addition, reference to the long axis of the
Because, practically, there is a fixed anatomi- symphysis enables angle measurements, for
cal relationship between the ischial spines and example, that of the head direction (direction
the pubic bone, the pubic symphysis can be used of the longest visible axis of the fetal head in
to calculate the level of the ischial spines: Parallel the birth canal as seen in this insonation) as
planes through the infrapubic line and the ischial well as placing a tangent on the deepest bony
a b
c d
Fig. 9.3 Descent of the fetal head as seen on infrapubic exis of the pubic symphysis. (a) resting, without contrac-
intrapartum ultrasound. The long sides of the yellow tion, (b) at the height of a contraction, (c) with pushing
boxes indicate the infrapubic line (on the left) and the during contraction, and (d) after a further contraction and
level of the ischial spines (on the right). The axis of the immediately prior to a successful vacuum extraction
upper short side of the box is coincident with the long (modified after 12)
Table 9.1 Parameters used to describe birth progress as seen on intrapartum translabial ultrasound (ITU)
ITU parameter Comments
Head station Corresponds to the well-established palpated head station, is also expressed
in centimeters above or below mid-pelvis as defined by the ischial spines
Head direction A new parameter that describes the physiological direction of the fetal head
as it descends through the birth canal
“Angle of descent” (also called “angle Easy to learn and assess, correlates with ITU head station in a linear
of progression”) fashion
Descent during a contraction Includes assessment of the dynamics of the birth “powers”
(±augmentation by pushing)
part of the fetal head; together with the long As the fetal head descends through the birth
axis of the pubic symphysis, this tangent canal, the angle between the symphysis axis and
defines the “angle of descent” or “angle of the longest axis of the fetal head visible on ITU
progression.” changes direction: While it may be “down” to
9.5 ITU and Palpation of Head

Station
When comparing the objectively determined ITU

parameters with vaginal palpation, there is a
significant positive correlation between the two.
However, the poor reproducibility of vaginal pal-
pation also becomes apparent, showing a wide
scatter of values around objectively and quantita-
tively determined ITU measurements (Fig. 9.5).
One of the greatest potentials of ITU may
indeed be the objectivity and the comparability
Fig. 9.4 Possible objective parameters of intrapartum
that it may provide in care for laboring women.
translabial ultrasound (ITU). All quantitative parameters
require an exact median section of the pubic symphysis.
The main landmark is the caudal end of the symphysis or 9.6 Clinical Usefulness
rather a perpendicular line extending dorsally, the so-
called infrapubic line. This infrapubic lines run 3 cm cra-
nial to a parallel plane that traverses the ischial spines, The clinical usefulness of the ITU parameters has
which in turn define mid-pelvis (station ±0 cm). In addi- been studied [7, 14].
tion, reference to the long axis of the symphysis enables Ideally, a new clinical parameter should be
angle measurements, for example, that of the head direc-
tion (direction of the longest visible axis of the fetal head
comparable to established references. The param-
in the birth canal as seen in this insonation) as well as eter that seems to have the best reproducibility is
placing a tangent on the deepest bony part of the fetal the “angle of descent” [7, 14].
head; together with the long axis of the pubic symphysis, The “angle of descent” (between the long axis
this tangent defines the “angle of descent” or “angle of
progression.” Note: During a normal birth, almost always
of the pubic symphysis and a tangent on the deep-
a scalp edema (caput succedaneum) becomes visible (in est part of the fetal skull) correlates linearly and
the image indicated by “*”) which must not be confused narrowly with the head direction as determined
with the skull by ITU. Because of this close correlation, both
values can be converted directly, i.e., each angle
“horizontal” in the upper part of the birth canal, of descent can easily be converted into the corre-
it eventually “homes” towards an upward direc- sponding head station (Table 9.2). Important
tion (>20°) once the head has passed the mid- thresholds are an angle of descent of 118°, cor-
pelvis. This relatively simple qualitative responding with a head station of ±0 cm (i.e.,
assessment for the “head-up sign” seems to be exact mid-pelvis), and 137°, corresponding to a
important when deciding operative vaginal deliv- head station of +2 cm.
ery (see below). The chance for a delivery ending vaginally
It is noteworthy that during a normal birth (Table 9.3) as well the time to delivery (Fig. 9.6)
almost always a scalp edema (caput succeda- also correlates with ITU. The lower the ITU head
neum) appears, and on ITU, it becomes visible. station and the greater the angle of descent (both
This scalp edema is shown in figure (ITU), its express progress, but on different scales), the
border are marked by “*.” This caput succeda- higher the chance of eventual vaginal delivery.
neum may make it clinically difficult or impos- Head direction may change from down to hori-
sible to determine head station correctly and to zontal at higher head stations, but at lower head
assess the sutures to correctly diagnose head stations, head direction must change to up from a
rotation (occipito-anterior or occipito-posterior). head station of about +2 cm.
On ITU, however, the caput succedaneum can The extent of internal rotation of the fetal
easily be recognized and confusion with the skull head, another marker for birth progress of the
avoided. largest part of the fetal head to or beyond the
3
Palpated head
station (cm)
2 x
x 1 x x xx x x xx x x
x x xx x xx
–4 –3 –2 –1 0 1 2 3 4 5 6
ITU head
station (cm)
x xx xx x x x x–1 x x x x
x x –2 x x x
x x –3 x x xx
x –4
Fig. 9.5 Comparing palpated head stations with ITU measurements in the same patients shows a weak correlation with
a wide scatter of palpated head stations around the true (ITU-determined) values (Data from [7])
Table 9.2 Conversion of head station as determined by Table 9.3 Percentages of vaginal births depending on
ITU with the “angle of descent” ITU parameter thresholds
ITU head station (in cm) Angle of descent (in degrees) Probability of vaginal
−2.5 94 ITU parameter Value delivery
−2.0 99 ITU head station ³+1.5 cm 92% (12/13)
−1.5 10 Head direction >20° 92% (12/13)
−1.0 108 Angle of descent >120° 93% (25/27)
−0.5 113 Modified from [7]
±0 (mid-pelvis) 118
+0.5 123
narrowest part of the bony pelvis, can be seen
+1.0 127
using ITU. For this, the transducer is placed
+1.5 132
below the symphysis, but in a transverse orienta-
+2.0 137
tion, or using a 3D probe, the corresponding
+2.5 142
+3.0 146
planes can be extracted using volume ultrasound
+3.5 151 (see Fig. 9.7) [5, 9].
+4.0 156 Deliveries with a posterior occiput (OP) show
+4.5 161 a different course of head descent as seen by ITU.
+5.0 166 Occipito-posterior births, deliveries with deflected
Data from [7] heads, and breech deliveries are currently await-
There is a linear correlation n between these two parameters ing formal ITU studies.
Time to delivery
6:00 (h)
5:00
4:00
3:00
2:00
1:00
0:00
–20 –10 0 10 20 30 40 50
Head direction (degrees)
Fig. 9.6 Time to delivery depending on head direction. The higher the head direction (the more upwards, following the
curved birth canal), the shorter the interval to delivery (Data from [7])
a b
Fig. 9.7 ITU to diagnose the internal rotation and to deflection is visible because the large fontanel can be
visualize the sagittal suture and the fontanels. In these seen. (b) 3D “surface” rendering shows a head after com-
examples, the head is just below mid-pelvis, but internal plete internal rotation. The sagittal suture is visible as is
rotation is complete. (a) Tomographic imaging, coronal the posterior fontanel. Note the pronounced configuration
sections. In the bottom left image of this panel, head of the skull bones (From [5])
a b
Fig. 9.8 Pathological ITU images, taken immediately line) far above infrapubic line (solid line)). (b) ITU imme-
before clinically indicated (attempted) operative vaginal diately before a failed vacuum. Note the insufficient head
delivery (From [6]). (a) ITU immediately before “difficult station, the pronounced caput succedaneum, and the
vacuum.” Note the high real head station obscured by the unphysiological head direction, pointing dorsally
large caput succedaneum (largest head diameter (dashed
9.7 ITU Before Instrumental invasive method to assess birth progress objec-
Vaginal Delivery tively and dynamically. The parameters head
station, head direction, and angle of descent as
At the end of stage 2, but in particular when oper- well as their dynamic changes during a con-
ative vaginal delivery is contemplated, ITU can traction and during pushing can be acquired
provide useful information [6]. easily and rapidly, both during normal and
In this situation, the same criteria and param- abnormal labor as well as before clinically
eters apply. Even though in these there may be indicated operative vaginal delivery. ITU
time pressures, confident assessment of head sta- parameters seem to have a predictive value for
tion and rotation as derived the sagittal suture are the further progress of deliveries with regard
prerequisites; however, after a vaginal course of a to success of the vaginal route as well as to the
birth so far, often, a scalp edema precludes time to delivery. ITU is easy to learn and easy
confident assessment. ITU, however, can easily to apply. It helps to recognize normal labor
differentiate between a caput succedaneum and and to correctly diagnose obstructed labor.
the skull (Fig. 9.8). ITU enables objective assessment of birth
In these situations, initial data suggest that progress and enables a scientific analysis of
head direction seems to be particularly important: birth mechanics.
If the head direction is horizontal or even down,
the chances for a failed vacuum delivery are
likely to be higher.
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head in the second stage of labor with intrapartum uog.7709
Use of Cervical Length in Labor
and Delivery 10
Sushma Potti, Gian Carlo Di Renzo,
and Vincenzo Berghella
10.1 Introduction Almost half of all preterm births are preceded by

preterm labor (PTL). Proper identification of
Over the last two decades, extensive research had those women presenting with symptoms of PTL
been done evaluating the role of ultrasonographic who are truly at risk of PTB is crucial in order to
assessment of the cervix in various clinical set- maximize the utilization of available resources as
tings. This chapter reviews the evidence behind well as for the cost savings by preventing unnec-
the use of cervical length in various clinical sce- essary hospitalizations and interventions.
narios encountered on labor and delivery unit. When a patient presents with symptoms of
abdominal cramping, tightening, back pain, pel-
vic pressure, vaginal bleeding, or leakage of
10.1.1 Preterm Labor fluids, risk of PTB should be evaluated. Physical
examination should include ruling out preterm
Preterm birth (PTB) is defined as birth between premature rupture of membranes (PPROM) and
200/7 and 366/7 weeks of gestation, and it is a major presence of infection. In patients presenting with
cause of perinatal morbidity and mortality. significant vaginal bleeding, evaluation for abrup-
tion or placenta previa should also be done. Once
PPROM and placenta previa are excluded, digital
S. Potti, M.D. examination of the cervix is usually done on
Division of Maternal-Fetal Medicine, women presenting with suspected PTL. Digital
examination of the cervix is very subjective and
Jefferson Medical College of Thomas Jefferson University,
834 Chestnut St., Suite 400, 19107, Philadelphia, not reproducible. With digital examination of the
PA, USA cervix, some authors have quoted interobserver
e-mail: [email protected] variability of 52% [1] and others reported it to be
G.C. Di Renzo, M.D., Ph.D. nonspecific [2].
Department of Obstetrics and Gynecology, Various studies have shown that transvaginal
Centre for Perinatal and Reproductive Medicine,
ultrasound cervical length (TVU CL) measure-
University of Perugia,
Perugia, Italy ment is superior to digital examination of the cer-
e-mail: [email protected] vix in prediction of PTB among women presenting
V. Berghella, M.D., Ph.D. () with symptoms of PTL [3–5].
Division of Maternal-Fetal Medicine, Compared to the transabdominal and trans-
Department of Obstetrics and Gynecology, perineal cervical length measurement methods,
Jefferson Medical College of Thomas Jefferson
TVU CL has emerged as the preferred and gold
University, 834 Chestnut St., Suite 400, 19107
Philadelphia, PA, USA standard for CL assessment. TVU CL as com-
e-mail: [email protected] pared to other methods of measurement has the

120 S. Potti et al.
Fig. 10.1 Normal cervical length Fig. 10.2 Shortening of cervix after transfundal pressure
advantage of the probe being closer to the cervix

and eliminating the problem of obscuring bowel
gas.
Current recommendations for the performance
of TVU of the cervix are as follows:
1. Have the patient empty her bladder.
2. Prepare the clean probe covered by a condom.
3. Insert the probe (probe can be inserted by
patient herself for more comfort).
4. Place the probe in the anterior fornix of the
vagina.
5. Obtain a sagittal view of the cervix, with the
long axis view of echogenic endocervical Fig. 10.3 Presence of funneling
mucosa along the length of the canal.
6. Withdraw the probe until the image is blurred surface of the posterior lip to the cervical canal
and reapply just enough pressure to restore should be equal to the distance from the surface
the image (to avoid excessive pressure on the of the anterior lip to the cervical canal.
cervix which can elongate it). There should not be any increased echogenic-
7. Enlarge the image so that the cervix occupies ity in the cervix (a sign of excessive pressure).
at least 2/3 of the image and external and Table 10.1 shows various studies that had
internal os are well seen. evaluated TVU CL as a predictor for PTB in
8. Measure the cervical length from the internal women presenting with symptoms of PTL. In a
to the external os along the endocervical recent meta-analysis evaluating TVU CL in pre-
canal (Fig. 10.1). diction of PTB among symptomatic women, 28
9. Obtain at least three measurements and studies were analyzed [25].
record the shortest best measurement in There is considerable heterogeneity across
millimeters. the studies included. Studies varied in terms of
10. Apply transfundal pressure for 15 s and their sample size, inclusion criteria, cervical
record any changes in cervical length or fun- length cutoffs, and primary outcomes. Mean
neling (Figs. 10.2 and 10.3). gestational age (GA) at inclusion among the
For best results, the internal os should be either studies varied between 21.6 and 33.1 weeks.
flat or at an isosceles angle with respect to the TVU CL cutoff also varied between 15 and
uterus, the whole length of the cervix should be 30 mm among these studies. Pooled data sug-
visualized, a symmetric image of the external os gested that TVU CL < 15 mm, predicted
should be obtained, and the distance from the PTB < 34 weeks with sensitivity, specificity, and
10
Table 10.1 Prediction of PTB by TVU CL in patients with symptoms of preterm labor (singleton pregnancies)
Number of PTB defined GA studied TVU CL cutoff
Author patients PTB (%) (weeks) (weeks) (mm) % abn Sens Spec PPV NPV RR
a
Murakawa [6] 32 34 N/A 25–35 <30 53 100 71 65 100
<25 31 64 86 70 82 3.9
a
Iams [4]b 60 40 <36 24–34 <30 73 100 44 55 100
Gomez [3] 59 37 <37 20–35 <18 41 73 78 67 83 3.9
>0.52c 31 76 94 89 86 6.9
a
Timor-Tritsch [7] 70 27 <37 20–35 Wedging 54 100 75 59 100
Rizzo [8] 108 44 <37 26–30 <20 N/A 68 79 71 76 3
Rozenberg [9] 76 26 <37 24–39 <26 39 75 73 50 89 4.6
Crane [5] 136 27 <37 23–33 <30 50 81 65 46 90 2.3
Venditelli ([10])b 200 41 <37 19–36 <30 64 83 88 54 80 2.8
Tekesin [11] 68 41 <37 20–35 <26 N/A 82 63 63 83 7.7d
Use of Cervical Length in Labor and Delivery
Tsoi [12] 216 8 £7d 24–36 <15 20 94 89 37 99 101d

Fuchs [13] 253 8 £7d 24–35 <15 14 81 92 47 98 4
Volumenie [14] 59 39 <37 18–34 <27 49 70 64 55 77 4d
Tsoi [15] 510 15 <35 24–34 <20 34 76 N/A N/A N/A N/A
Gomez [16] 401 21 <35 22–35 <15 67 46 94 67 87 N/A
Daskalakis [17] 172 37 <34 24–34 <20 N/A N/A
70e 60e 54e 94e 81e
102f 98f 95f 87f 77f
Jenkins [18] 66 27 <37 23–34 <20 47 N/A N/A N/A N/A 7.8d
Holst [19] 87 39 <34 22–34 <15 62 72 83 78 78 3.6
Palacio [20] 333 23 <34 24–36
116g <25g 16g 50g 87g 32g 94g N/A
217h <15h 4h 33h 97h 25h 98h N/A
(continued)
121
Table 10.1 (continued)
122
Number of PTB defined GA studied TVU CL cutoff

Author patients PTB (%) (weeks) (weeks) (mm) % abn Sens Spec PPV NPV RR
Gramellini [21] 108 23 <34 20–33 <15 78 24 94 54 80 4.9d
<25 77 56 83 50 86 6.3d
Alfirevic [22] 41 12 £7d N/A <15 17 N/A N/A N/A N/A 0.2
Schmitz [23] 395 8 £7d 24–35 <30 N/A 94 42 12 99 11.0d
Adhikari [24] 100 55 £7d 26–36 <25 23 60 97 91 82 4.2d
Names in italics indicate clinicians were blinded to the results of TVU
For studies listing two sets of numbers for predictive accuracy, different CL cutoffs were used
Abbreviations: PTB preterm birth, PTB% incidence of preterm birth, GA gestational age, TVU CL transvaginal ultrasound cervical length, % abn percent abnormal, sens sensitiv-
ity, spec specificity, PPV positive predictive value, NPV negative predictive value, RR relative risk, N/A not applicable
a
Infinity, since one of the boxes was zero
b
Twin pregnancies included
c
Cervical index
d
Odds ratio
e
Nulliparous
f
Multiparous
g
Admission at < 32 weeks
h
Admission at ³ 32 weeks
S. Potti et al.
10 Use of Cervical Length in Labor and Delivery 123
LR + and LR– of 46.2%, 93.7%, 4.31, and 0.63 10.2.1 Preterm Premature Rupture
respectively. of Membranes (PPROM)
For the prediction of PTB within 1 week of
presentation, TVU CL < 15 mm had sensitivity, Preterm premature rupture of membranes
specificity, and LR + and LR– of 59.9%, 90.5%, (PPROM) is defined as rupture of membranes at
5.71, and 0.51 respectively. least one hour prior to the onset of labor, occurring
These authors also reported that TVU at <37 weeks. Three percent of all pregnancies
CL < 15 mm was present in <10% of women pre- [27] and 30% to 45% of all spontaneous preterm
senting with symptoms of PTL and predicts deliveries [28] are associated with PPROM.
approximately 60% of women who will deliver The time interval between rupture of mem-
within the next one week. The likelihood of deliv- branes and delivery is referred to as latency
ering within one week of presentation is increased period. About 57% of pregnancies complicated
by 5.7 times when TVU CL cutoff of <15 mm was by PPROM < 24 weeks deliver within 1 week [28,
used. Conversely, if TVU CL was > 15 mm, the 29] and 73% deliver within 2 weeks [29].
vast majority of such women presenting with If PPROM occurs between 24 and 34 weeks,
symptoms before 34 weeks will not deliver within 50% deliver within 48 hours and 80% within
the next one week (i.e., for women presenting at 1 week.
<34 weeks with PTL symptoms and with TVU Following PPROM, prediction of this latency
CL > 15 mm, NPV of TVU CL for predicting period can help to plan administration of ante-
delivery within the next one week was 96%. In natal corticosteroids for fetal lung maturity [30]
other words, only 4% of women presenting with and also for transferring patients to a tertiary
PTL symptoms before 34 weeks will deliver within care center. Moreover, in cases of PPROM
the following week if TVU CL was >15 mm.). between 24 and 27 weeks, for each additional
These findings may be helpful in avoiding admis- day of in utero maturation, survival probability
sion of patients who are at very low risk for PTB is enhanced by approximately 2% [31].
and hence resulting in cost savings. Likewise, survival probability is improved by
approximately 10% for each additional week of
in utero maturation in cases of PPROM at
10.2 Management of PTL Based 30 weeks [31, 32].
on TVU CL Several factors like parity [33], uterine con-
tractions [33], amniotic fluid index [34–36], and
There are randomized controlled trials that have maternal white blood cell count [37] have been
been performed incorporating TVU CL in the proven to be poor predictors of duration of latency
management of PTL [26]. period between PPROM and preterm delivery. In
One of the suggested algorithms for manage- the absence of active labor, digital examination
ment of patients presenting with symptoms of for cervical assessment is contraindicated in
PTL using TVU CL and FFN is depicted in PPROM due to risk of infection and it had been
Fig. 10.4. shown to shorten the latency period [38–40].
This algorithm is based on high sensitivity and In contrast, TVU CL measurement has been
negative predictive value of TVU CL of 30 mm, shown to be safe in the presence of PPROM [41].
high positive predictive value of TVU CL of 20 mm As shown in Table 10.2, TVU CL measure-
(Table 10.1), and the high specificity of FFN. ment had been investigated by few studies in pre-
In summary, TVU CL is a very good predictor dicting latency period for preterm delivery
of PTB among women presenting with symptoms following PPROM [33, 41–43].
of PTL. An algorithm such as that shown in One study with small sample size showed that
Fig. 10.4 can be used for management of PTL there is no significant difference in the latency
according to TVU CL. period among those with and without short cervix,
124 S. Potti et al.
Threatened PTL
at 24−34 weeks
Obtain FFN prior to

manual exam and TVU
TVU CL
CL< 20mm CL< 30mm

CL =20-30 mm
FFN Positive FFN Negative
Discharge
If persistent contractions (Repeat CL for
treat with tocolysis and Repeat TVU CL in 4-6hrs persistent/recurrent
steroids if persistent contractions contractions)
Shortening >5mm Stable CL > 25 mm and no prior PTB

Consider tocolysis and Routine care
steroids especially if prior Stable CL ≤ 25mm and/or prior PTB
PTB Repeat CL in 1 week
FFN, fetal fibronectin; NEG, negative; POS, positive; PTB, preterm birth; PTL,
preterm labor; TVU CL, transvaginal ultrasound cervical length
Fig. 10.4 Suggested algorithm for use of TVU CL and FFN in women with PTL symptoms
but they showed a trend towards longer latency Cervical index (funnel length + 1/cervical
period in women with a longer cervix [41]. length) improves prediction of PTB among
TVU CL is shown to be significantly shorter women with intact membranes as compared to
in women with PPROM occurring after 28 weeks cervical length alone since it takes funneling also
[42], with uterine contractions [33, 42, 43], cervi- into account [3, 8]. Similarly, cervical index
cal funneling [33, 42], and vaginal delivery [42] shows higher diagnostic efficacy in predicting
but not with chorioamnionitis [33, 42]. PTB following PPROM as well [33].
Table 10.2 Prediction of PTB by TVU CL in patients with PPROM (singleton pregnancies)
GA at TVU CL Likelihood
Number measurement TVU CL Median latency period of PTB within
Author of patients (weeks) (mm) days (range) P value 7 days
Carlan [41] 45 24–34 £30 vs. >30 9 ± 5.4 vs. 11 ± 8.6 NS N/A
Rizzo[33] 92 24–32 £20 vs. >20 2 (0–14) vs. 6 (0–36) £0.0001 N/A
Gire [42] 101 20–34 £20 vs. >20 2.5 ± 6.6 vs. 10.0 ± 15.1 0.0029 N/A
Tsoi [43] 101 24–36 30 N/A N/A 6%
28 32%
14 64%
Latency period: is defined as the time interval between rupture of membranes and delivery
PTB preterm birth, TVU CL transvaginal ultrasound cervical length, PPROM preterm premature rupture of membranes,
GA gestational age, NS not significant, N/A not applicable
In summary, TVU CL in women with PPROM angle, cervical position, etc., as well as different
is safe and does predict PTB, but no intervention outcomes, e.g., vaginal delivery, vaginal delivery
trials have been done based on this information. less than 24 hours, duration from induction to
Therefore, the clinical use of TVU CL in women active labor, failed induction, cesarean, etc.,
with PPROM is limited and of unclear which makes it very difficult to compare studies
significance. It certainly deserves further study. and to come up with clinical recommendations.
Some studies reported TVU CL as a better
predictor [44, 48–54] of successful induction
10.2.2 Induction of Labor than Bishop score, while others did not [55–60]
(Table 10.3).
Induction of the labor is one of the frequently Primary outcome in most of the studies evalu-
performed interventions in obstetrics. Availability ating TVU CL as a predictive tool for successful
of tools for predicting which patients will have a induction of labor was mode of delivery or total
successful induction will help to reduce the cesar- duration of labor. Short TVU CL [£ 31 mm [50],
ean deliveries due to failed induction. Clinical <30 mm [49], <28 mm [51], <26 mm [52],
history of prior vaginal delivery, digital examina- <16.5 mm [53], or wedging [44]] was associated
tion (Bishop score), TVU CL measurement [44], with a shorter duration of labor and a higher inci-
and fetal fibronectin assay [45] are some of the dence of vaginal delivery compared to long cer-
tools that have been studied to predict successful vix. A TVU CL £31 mm is associated with a 97%
induction of labor at term. chance of vaginal delivery in women being
Traditionally, Bishop score [46] has been used induced, in a study [50].
for preinduction cervical assessment and to deter- One study reported that the presence of fun-
mine the need for cervical-ripening agents. neling is a favorable predictor [61] of successful
Accuracy of Bishop score has been questioned by induction of labor, whereas other studies did not
some due to its subjective nature [1, 47] and [50, 59, 62].
wide inter- and intraobserver variations [47]. In summary, TVU CL predicts length of labor
In recent years, objectively measuring CL and delivery outcomes in women undergoing
using TVU has been evaluated in various studies, induction of labor.
as a possible tool to predict outcome of labor
induction. Moreover, TVU CL measurement has
been shown to be better tolerated than digital 10.2.3 Spontaneous Onset of Labor
examination [48].
Several studies evaluating TVU prediction of Few studies suggested TVU CL as an indepen-
outcome for induction have looked at different dent predictor for onset of spontaneous labor
predictive variables, e.g., CL, funneling, cervical [63–67] (Table 10.4).
126
Table 10.3 Prediction of successful induction at/near term using Bishop score vs. TVU CL in singleton pregnancies
Bishop score TVU CL
Number Bishop GA at TVU CL
of patients score TVU CL measurement
Author (% success) cutoff (mm) (weeks) Sens Spec PPV NPV Sens Spec PPV NPV
Chandra [57]a 122 (80) >7 N\A ³41 40 96 97 29 56 54 82 23
Reis [59]b 134 (64) ³2g £20 Term 84 68 85 66 43 73 79 36
Roman [56]c 106 (15)f £4 ³30 38–41 87 46 22 95 56 66 22 89
Paterson-Brown [54]a 50 (86) >5 >70h 37–42 47 100 100 23 77 100 100 41
Ware [49]a 77 (69) >4 <30 ³37 N/A N/A N/A N/A 91 92 N/A N/A
Pandis [51]b 240 (73) >3 <28 37–42 58 77 N/A N/A 87 71 N/A N/A
Gabriel [52]d 179 (30) >5 <26 >37 66 49 N/A N/A 62 61 N/A N/A
Soon Ha Yang [50]e 105 (89) ³4 £31 37–42 51 75 94 16 75 83 97 27
Rane [53]b 604 (64) N/A <16.5 35–42 65 75 N/A N/A 89 75 N/A N/A
Tan [48]c 249 (54)f >5 >20 37–42 60 51 16 89 80 47 19 94
% Success: percentage of successful primary outcome
TVU CL transvaginal ultrasound cervical length, Sens sensitivity, Spec specificity, PPV positive predictive value, NPV negative predictive value, N/A not applicable
Definition of successful induction:
a
Vaginal delivery
b
Vaginal delivery < 24 h
c
Prediction of failure of labor induction
d
Risk of cesarean section
e
Active labor within 2 days
f
Percent failure of induction
g
Abbreviated Bishop score (dilatation + effacement) ³ 2
h
Cervical angle in degrees
S. Potti et al.
10
Table 10.4 Prediction of spontaneous onset of labor at/near term using Bishop score vs. TVU CL in singleton pregnancies
Bishop score TVU CL
Number of patients GA at TVU CL
Use of Cervical Length in Labor and Delivery
(% spontaneous Bishop TVU CL measurement

Author onset of labor) score cutoff (mm) (weeks) Sens Spec PPV NPV Sens Spec PPV NPV
Meijer-Hoogeveen [64]a 162 (76) N/A <30 37–38 N/A N/A N/A N/A 46 78 82 40
Rozenberg [65]b 128 (59) ³6 £26 39–40 45 76 76 46 56 71 76 50
Vankayalapati [63] 206 (54) N/A <25 41–42 N/A N/A N/A N/A N/A N/A N/A 1.07c
TVU CL Transvaginal ultrasound cervical length, Sens sensitivity, Spec specificity, PPV positive predictive value, NPV negative predictive value, N/A not applicable
a
Spontaneous onset of labor < 12 days
b
Spontaneous onset of labor < 7 days
c
Adjusted odds ratio
127
128 S. Potti et al.
For example, a TVU CL of about <26 or

<30 mm at 37–40 weeks is associated with an
approximately 76–82% of spontaneous onset of
labor within the next 7–12 days.
In summary, TVU CL can be used to predict
spontaneous onset of labor.
10.2.4 Need for Prostaglandin

Induction Agent
TVU CL was also compared to Bishop score in

determining the need for prostaglandin admin-
istration for preinduction cervical ripening at
term. In a randomized controlled trial, TVU CL
measurement prior to term induction of labor in
nulliparae reduced the need of prostaglandin
Fig. 10.6 Cervical ripening in the first stage of labor in

primipara: LUS = lower uterine segment (X = LUS upper
limit, Y = LUS lower limit).
Fig. 10.5 Digital examination of external uterine orifice

in primipara during early labor (Y= external uterine ori- Fig. 10.7 Cervical dilatation in labor during vaginal
fice, X= inner uterine orifice). examination in primipara.
administration by 50%. This study demon-

strated that the use of TVU CL of ³ 28 mm is as
effective as Bishop score of £ 4 for determining
the need for prostaglandin administration for
preinduction cervical ripening in nulliparae at
term [68].
Another randomized controlled trial sug-
gested that a cutoff of Bishop score < 6 or TVU
CL > 30 mm and wedging < 30% significantly
reduced the need for intracervical prostaglandin
treatment without adversely affecting the suc-
cess of induction when TVU CL was used
instead of Bishop score for preinduction cervical
assessment [69].
In summary, assessment of TVU CL prior to
induction of labor significantly reduces the need
for prostaglandin administration by providing
guidance in the proper selection of patients for
prostaglandin administration.
Fig. 10.8 Digital examination of external uterine orifice

in multipara during early labor (Y= external uterine ori-
fice, X= inner uterine orifice).
a b
Fig. 10.9 Cervical ripening in the first stage of labor in multipara: LUS = lower uterine segment (X = LUS upper limit,
Y = LUS lower limit).
130 S. Potti et al.
tion of the uterine cervix is better than cervical digital

examination as a predictor of the likelihood of prema-
ture delivery in patients with preterm labor and intact
membranes. Am J Obstet Gynecol 171(4):956–964
4. Iams JD, Paraskos J, Landon MB, Teteris JN, Johnson
FF (1994) Cervical sonography in preterm labor.
Obstet Gynecol 84(1):40–46
5. Crane JM, Van den Hof M, Armson BA, Liston R
(1997) Transvaginal ultrasound in the prediction of
preterm delivery: singleton and twin gestations. Obstet
Gynecol 90(3):357–363
6. Murakawa H, Utumi T, Hasegawa I, Tanaka K, Fuzimori
R (1993) Evaluation of threatened preterm delivery by
transvaginal ultrasonographic measurement of cervical
length. Obstet Gynecol 82(5):829–832
7. Timor-Tritsch IE, Boozarjomehri F, Masakowski Y,
Monteagudo A, Chao CR (1996) Can a “snapshot”
sagittal view of the cervix by transvaginal ultrasonog-
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8. Rizzo G, Capponi A, Arduini D, Lorido C, Romanini
C (1996) The value of fetal fibronectin in cervical and
vaginal secretions and of ultrasonographic examina-
tion of the uterine cervix in predicting premature
delivery for patients with preterm labor and
intact membranes. Am J Obstet Gynecol 175(5):
1146–1151
9. Rozenberg P, Goffinet F, Malagrida L, Giudicelli Y,
Fig. 10.10 Cervical repening in the first stages of labor Perdu M, Houssin I et al (1997) Evaluating the risk of
in multipara: LUS = lower uterine segment (LUS upper preterm delivery: a comparison of fetal fibronectin and
limit X =, Y = lower limit, without membranes and fetus in transvaginal ultrasonographic measurement of cervical
the left, with membranes and the fetus in the rigth) length. Am J Obstet Gynecol 176(1 Pt 1):196–199
10. Vendittelli F, Mamelle N, Munoz F, Janky E (2001)
Conclusions Transvaginal ultrasonography of the uterine cervix in
hospitalized women with preterm labor. Int J Gynaecol
Overall, TVU CL is a useful tool with many
Obstet 72(2):117–125
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according to a proven algorithm (Fig. 10.4).
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Intrapartum Sonography and
Clinical Risk Management 11
Andrea Tinelli, Sarah Gustapane, Francesco Giacci,
Domenico Dell’Edera, and Antonio Malvasi
Dystocia is the leading cause of caesarean sec- More recently, Tampakoudis et al. [3] have
tion in nulliparae. In 1998, Gregory et al. reported confirmed this evidence, in particular, have
that the main indication for performing a caesar- identified three factors causing dystocia: the
ean section is dystocia [1]. obstructed labor, the malposition of the fetus and
Subsequently, Gifford et al. [2] have confirmed the fetal-pelvic disproportion, as confirmed by
that the dystocia was 36% of cases of caesarean Kjaergaard in 2007 [4].
section, although the rate reported by the authors In 2009, a group of Swedes reported that the
at the time of the study was 18%. Gregory in incidence of dystocia in caesarean sections is up to
1998 reported that the main indication for per- 37% in nulliparous women at term without indica-
forming a caesarean section is dystocia [1]. tions for labor induction or caesarean section [5].
Subsequently, Gifford et al. [2] have confirmed In developing countries, where you cannot
that the dystocia was 36% of cases of caesarean access easily to a caesarean section and the birth
section, although the rate reported by the authors points are inferior to the needs of the population,
at the time of the study was 18%. clinical evaluations were performed on the dysto-
cia and caesarean section.
In Nigeria, for example, the most common
indication for performing a caesarean section is
dystocia in 76.8% [6], while in Singapore, this
A. Tinelli, M.D. ()
Division of Experimental Endoscopic Surgery, Imaging, percentage stood at 34.2% [7].
Minimally Invasive Therapy and Technology, In Pakistan, a retrospective analysis of 10,863
Department of Obstetric and Gynecology, caesarean sections in a level III hospital showed
Vito Fazzi Hospital, Piazza Muratore, 73100 Lecce, Italy
that in 11 years of caesarean sections, the per-
centage stood at 24.1%, but the emergency cae-
S. Gustapane, M.D. • F. Giacci, M.D.
sarean section was performed in 78% of cases of
SS. Annunziata Hospital, Chieti, Italy operative delivery [8].
e-mail: [email protected]; Leeman et al. analyzing data about dystocia as
[email protected] the main cause of as caesarean section stressed
D. Dell’Edera, Ph.D. the importance of the perinatal medicine, the
Unit of Cytogenetic and Molecular Genetics, management of labor and birth, and the develop-
“Madonna delle Grazie” Hospital, Matera, Italy
mental-genetic factors, in order to reduce the cae-
sarean section [9].
A. Malvasi, M.D.
Rosenberg, through his studies of comparative
Santa Maria Hospital, Bari, Italy anatomy, has shown that the high incidence
e-mail: [email protected] of dystocia in the human species is a typical

134 A. Tinelli et al.
occurrence and, instead, is more limited in other and the obstetric vacuum, instead of Kristeller
species, such as primates [10–12]. maneuvers on the perineal floor (only one is tol-
The most important factors occurring during erated in the medical contentious procedures).
labor dystocia in the human species are the Throughout his life, eight out of ten doctors
increase of the volume of the fetal head and the will receive a claim and that is what emerged
shape of the female pelvis as a result of phyloge- from a conference organized by the Italian
netic changes, such as the upright position. Society of Surgery (SIC) in 2010.
In fact, while in primates the pelvis is a short The World Health Organization recommends
loop in which the head passes easily, in humans a number of caesarean deliveries within 15%, but
the largest volume of the fetal head must adapt to this data is now overemphasized. This data
a birth canal longer, curved, with narrow points emerged from a WHO meeting in 1985 at the
that require the head to a movement of rotation Joint Interregional Conference on Appropriate
than that of descent. Technology for Birth, in Brazil. This percentage
In this complex mechanism, which involves a of 15% was decided for nonscientific reasons, but
series of human and social factors, arises the dis- only on the assumption that in countries where
course of “defensive medicine,” which involves perinatal mortality was very low, for example,
the people custom, involved in medical responsi- Ireland in those years, the number of caesarean
bility, to abuse of the procedures or tests in order sections did not exceed 15%. Really, this number
to protect themselves from any negligent. was a statistical point of reference due to very
Obstetricians seem to be the most predisposed to different reasons. Essentially in those countries,
such defensiveness, probably due to the high there were few caesarean section because they
number of processes that are involved. The spec- did not have enough specialists able to perform
trum of legal dispute affects the obstetric art caesarean sections, then tried to avoid them. In
because in every negative event that accompanies developing countries such as Africa, the percent-
a spontaneous delivery or operative vaginal route age of caesarean sections was and is undeniably
always invokes the failure to caesarean section, low, although there was and remains a very high
as a means of inevitable preventing. These judi- percentage of stillbirths or perinatal deaths, as
cial charges continue to exist, although, in reality, well as neonatal neurological sequelae (paralysis
there was no a correlation between increased obstetric, neurological damage from asphyxia-
incidence of TC with a reduction of newborn tion) and maternal physical injuries (such as
neurologic injury [13], or with lower rates of fistulas, prolapse).
trauma in cases of fetal macrosomia [14]. In conclusion, many deliveries that would
The caesarean section thus occupies a require operative action happen spontaneously in
significant place in the defensive medicine, reach- a few countries. Even so, the 15% became a ref-
ing in Italy above 38% [15, 16], representing a erence data without regard to maternal and neo-
legal defense against the potential risks of vagi- natal morbidity and mortality.
nal delivery [17]. Today, the European data shows that Italy per-
The rate of caesarean sections in the USA forms the largest number of caesarean sections,
stood at 30.5%, with 31.2% of nulliparous women but the best obstetrics in Europe because the rates
undergoing caesarean section and 50% of the of maternal mortality and maternal-fetal morbid-
caesareans performed for dystocia after induction ity are reduced to a total of 5–6%, less than Great
of labor with 6 cm of cervical dilation; this data Britain, where the number of caesarean sections
not only shows the growth of caesarean sections is inferior compared to Italy [19]. To confirm this
in recent years, but it sets to the US government data, a recent publication has pointed out that the
the goal to reduce caesarean sections in primipa- number of caesarean sections is not the best indi-
rous [18]. cator for evaluating the obstetric performance
Especially for forensic reasons, many obstetri- [19]. In fact, the victims of complications during
cians gave up the application of “high” forceps pregnancy and childbirth have declined by over a
11 Intrapartum Sonography and Clinical Risk Management 135
third (34%) in the last twenty years around the all labors at risk of dystocia, a safe and effective
world. This was revealed by a new WHO report tool for diagnosis of fetal head position which is
released in September in Geneva. From the world the intrapartum sonography.
“picture,” Italy is confirmed at the top for the A possible reduction in the percentage of cae-
number of caesarean sections, but especially for sarean section is then represented by a better
mother’s safety, with a reduced mortality rate of diagnostic accuracy of labor dystocia and, there-
4.2% per year from 1990 to 2008, and an overall fore, the echo intrapartum has a fundamental role
−53% in the two decades examined. In Italy also, in order to better assess the possibility of an oper-
according to WHO estimates, the maternal mor- ative vaginal delivery instead of a caesarean sec-
tality ratio per 100,000 live births is equal to 5%, tion in labor dystocia. The major indication for
as in Austria, Belgium, Denmark, and Iceland, caesarean section is therefore dystocia, which
this percentage is higher than Greece [2] and can occur at any stage of labor and, according to
Ireland [3], but less compared to France and the malposition of the fetal head, needs operative
Germany [7, 8]. Outside Europe, however, the assistance to carry out delivery.
situation is worse: in poor countries, women are The incidence of dystocia is on average
36 times more at risk of dying for these reasons 35–40% of the labors (Fig. 11.1); the diagnosis of
than their own peers who live in rich nations. And dystocia should indicate how many deliveries
still a thousand women worldwide die every day will be possible by Caesarean section and those
due to pregnancy or childbirth. However, if inter- with vaginal operative delivery. It is estimated
national organizations report significant progress, that about half of all deliveries require an opera-
much remains to be done because the rate of tive intervention. Depending on your needs, the
improvement is far below expectations. And if delivery can be carry out by abdominal or vaginal
1,000 women die every day in the world due to route. Hanley et al. reported that an incidence of
these complications, 570 of them live in sub-Sa- caesarean section or operative delivery in the
haran Africa, 300 in South Asia, and only 5 in USA is variable in different geographical areas in
developed countries. According to experts, the relation to several factors, but especially com-
improvement seen in recent decades is due to the pared to the attitude of gynecologists to practice
training of midwives, the improvement of the a kind of delivery over another [20].
family planning, the emergency treatment, and However, it shows that on average the two types
the postnatal monitoring. of delivery amounted to around 35.4% (Fig. 11.2).
Therefore, from those discussions, we should The different types of delivery have undergone
emphasize the hypothetical forensic medical role an interesting evolution over the past twenty
of intrapartum sonography about the evolution of years.
labor. The inexorable increase of caesarean section
Indeed, the increasing growth of forensic liti- is associated with a considerable reduction in the
gation in our country makes very timely more use of the obstetric vacuum and especially of the
accurate diagnostic procedures for the diagnosis forceps (Fig. 11.3).
of dystocia. Additional documentation of the One reason for the increase in the caesarean
progress of labor could be further protected from section was the patient’s request, even in the
any claims in case of maternal and fetal compli- absence of traditional indications. The reasons
cations. In this sense, while the classic parto- for these requests are the fear of perineum dam-
gramma, however, is the result of subjective ages (urinary and fecal incontinence, genital pro-
obstetric visits, as demonstrated by the literature, lapse), but also the reduction of fetal risks due to
poorly reliable [2], an ultrasound evaluation of vaginal delivery.
intrapartum with photographic documentation Regarding the use of forceps and the obstetric
can be ascertained by a wide margin of safety to vacuum, while the effectiveness of these instru-
the position of the fetal head in labor. Revealed ments is still recognized, but considering the
once again the importance of having available, in severity of maternal and fetal injuries resulting
a c
Fig. 11.1 Incidence of dystocia reported in the literature the obstetrical diagnostic, which is a mental synthesis (c)
came from 36% to 39%; the graph shows the incidence, in of obstetric palpation and of the ultrasound images that
the series. The intrapartum sonography (a) does not cur- produce the fetal image in labor by Gifford et al. [2]
rently replace visiting midwife (b) but it is integrated in
30
Min Max
25
20
15
10
Fig. 11.2 Incidence of
caesarean section in the
USA (first CS delivery) and 5
operative delivery (assisted
vaginal delivery in the
USA): the columns indicate
0
the minimum and maximum
of the two types of delivery First CS delivery Assisted vaginal
(Hanley et al. [20]) delivery
Fig. 11.3 Application of

forceps direct and symmetric
in occipital-anterior under
ultrasound guidance
from their use, many practitioners prefer to limit the survived infants does not have adverse neu-
their use without very clear indications. rological outcomes.
The clinical risk management in relation to In contrast, chronic asphyxia has greater inci-
fetal distress due to hypoxia or asphyxia during dence of permanent damages [22].
birth remains a central point as a major cause of In order to quickly resolve the dystocial labors
coroner’s action and increased costs for operators at risk of acute asphyxia is therefore crucial to the
and health facilities. proper use of forceps or vacuum cup, especially
The incidence of encephalopathy and cerebral in cases of dystocia.
palsy remains unchanged in industrialized coun- The placement of the cup in case of applica-
tries than in developing countries despite the tion of the vacuum or the application of forceps,
obstetricians’ progress, such as continuous car- in cases of asynclitism are two situations in which
diotocographic monitoring [21]. the operator finds good help with intrapartum
The ACOG (American College of Obstetricians sonography (Fig. 11.4).
and Gynaecologists) reports that the percentage The application of the obstetric vacuum is
of cerebral palsy associated with intrapartum closely related to the correct determination of the
events is around 10%. Acute fetal asphyxia is position of the fetal head because otherwise it
less associated with adverse neonatal outcomes causes a deflection of the fetal head with conse-
compared to prolonged intrauterine hypoxia. quent probable detachment of the cup itself and
The current opinion is that severe perinatal increase in neonatal morbidity.
asphyxia has not poor prognosis because an The application of the obstetric vacuum on
adequate neonatal resuscitation can avoid most deflected occiput increases by 4–5 times the
of the brain damage in babies and that most of probability of failure, while its application on
Fig. 11.4 Application of forceps under ultrasound guid- terior position of the median; (c) direct, and symmetrical
ance: (a) straight, and symmetrical in occipitoposterior occipitotransverse left position
right position; (b), straight, and symmetrical occipitopos-
posterior or lateral occiput increases two times the vacuum, in particular for the latest dispos-
the chances of failure [23]. able cups (Kiwi), which, if not positioned
If the fetal head is deflected at the time of the properly, can easily detach especially in case
application of the obstetric vacuum, the probabil- of misapplication over caput succedaneum
ity of a low Apgar score (less than 6) increases by (Fig. 11.5).
3.2 times and the probability of severe trauma of The intrapartum sonography is particularly
the scalp of 5.2 times and increases 12 times the important in cases of dystocia delivery, as it pro-
probability of admission to neonatal intensive vides an image that guides the application of the
care [24, 25]. branches of the forceps.
Since the lateral and posterior positions of the In particular, in anterior or posterior asyncli-
most difficult to diagnose with an obstetric tism, if you decide to apply the forceps, intra-
examination, and as reported in the literature partum transabdominal ultrasound can guide
these situations have a higher frequency with the direct and symmetrical application on the
epidural analgesia, the use of ultrasound gets parietal bones, avoiding improper application
more important with operative delivery during of the branches on the face. The trans-labial
labor analgesia [26]. ultrasound instead allows assessing the level of
In case of vaginal operating delivery, the the presenting part, letting you to decide if there
intrapartum sonography can therefore allow a are the conditions for the application of the for-
more precise application of the forceps and of ceps or not.
a b
Fig. 11.5 Application of obstetric vacuum with ultra- on the fetal head (b). If possible, the obstetric vacuum
sound guide (a). Application of the obstetric vacuum on should be applied far away from the caput succedaneum,
caput succedaneum and subsequent depression of the cup under ultrasound guidance
In particular, in anterior or posterior asyncli- cuts on the face. Nevertheless, in case of greatly
tism, if you decide to apply the forceps, intra- flexed head, a pre\operative ultrasound evalua-
partum transabdominal ultrasound, can guide tion is useful in order to prevent incongruous
the direct and symmetrical application on the maneuvers during the extraction of the head
parietal bones, avoiding improper application (Fig. 11.6).
of the branches on the face. The trans-labial The intrapartum use of ultrasound is very
ultrasound instead allows to assess the level of important in early diagnosis of dystocia, which
the presenting part, letting you to decide if there avoids unnecessary prolonged labors that often
are the conditions for the application of the for- end with emergency caesarean sections (with a
ceps or not. higher percentage of intra- and postoperative
Similarly, the application of the cup can be complications).
performed under ultrasound guidance highlight- In particular, significant intraoperative bleed-
ing the position of the fetal head and the local- ing complications may be due to an excessive
ization of the caput succedaneum, avoiding the distension of the lower uterine segment [29–36].
positioning of the cup on the tumors and prevent Postoperative complications may also occur after
failures, as reported in different studies by an inadequate hemostasis, but also as a consequence
Molina and Nicolaides [26], Sentilhes et al. [27], of hypotension caused by spinal anesthesia
and Lau et al. [28]. (Fig. 11.7) which is followed by a normalization
Even in the case of caesarean sections, intra- of blood pressure that could generate a bleeding
partum sonography is also useful to consider site if eschars fall from the vessels treated with
other important intra- and postoperative data. For electrocoagulation. This phenomenon could
example, in occiput-posterior presentations, with mainly happen in hypertensive or preeclamptic
ruptured membranes and with fixed head in the patients [37, 38].
pelvic cavity, we should consider the position of Recent studies have shown that prolonged
the fetal head in order to avoid fetal injuries by dystocial labor is caused not only by mechanical
a b
c d
Fig. 11.6 Caesarean section with fetal median occiput- tion and ruptured membranes iatrogenic injuries over the
posterior position. Image diagnosed with transabdominal fetal head are possible when the uterine incision is not
intrapartum ultrasound (a) and intraoperative correspond- made with great caution: cold knife scalpel lesion on the
ing after the hysterotomy (b). In occiput-posterior posi- scalp (c), scarring on the face of the fetus (d)
fetus-pelvic causes but also by dysfunctions of the neurotransmitters creating a vicious cycle that
the uterine contractility that are associated with increases the degree of dystocia, causes pain, and
dynamic dystocia. In particular, the dystocial increases blood circulation. This provokes a more
labor is also associated with an alteration of neu- vascularized uterine segment, with possible intra-
rotransmitters that modulate the activity of the operative difficulties, and a reduction of neu-
upper and lower uterine segment. rotransmitters that accentuate the dystocia. In the
Also, excessive distension of the lower uterine uterine scar that is created, we have a reduced
segment by the presented part of the fetus changes function of neurotransmitters in a subsequent
Fig. 11.7 The spinal and epidural anesthesia (a) or com- of uterine suture as a “bladder flap hematoma” (d).
bined spinal epidural – CSE (b), commonly used for cae- Ultrasound image of bladder flap haematoma (from
sarean section, cause hypotension; therefore, inaccurate Tinelli A et al, Gynecol Surg (2007) 4: 53–56. DOI 10.1007/
hemostasis may develop a later bleeding when the pres- s10397-006-0212-2.)
sure returns to normal (c), causing possible complications
c In particular, the suturing of the visceral peri-

toneum in the case of bleeding causes the “blad-
der flap hematoma” but in case of bleeding
without suturing, the bladder fold can cause a
hemoperitoneum [29–32] (Fig. 11.8).
Similarly, in case of bleeding with suture of
the parietal peritoneum, a subfascial hematoma
can develop (Fig. 11.9), but without the suture
of the peritoneum, leaving the Retzius space
open, the hemoperitoneum can form [33, 40].
11.1 Management of Obstetric Risk

in Thrombophilic Patients
The use of intrapartum sonography and in par-

ticular the trans-labial reduces the number of cae-
sarian sections in favor of vaginal operative
deliveries with the vacuum cup, as reported in a
study of Dukelman et al. [41].
The intrapartum sonography always improves
the diagnosis, especially of the position of the
fetal head, but also of its descent and rotation. It
is also particularly useful in labors of pregnant
women with systemic diseases, such as hyperten-
sion and diabetes.
Another interesting aspect of intrapartum
ultrasonography is in the management of labor in
patients with thrombophilia, where a spontane-
d ous delivery is indicated (that has less risk than
operative delivery).
The Enquiry Maternal Death 2005–2008 [42]
has demonstrated over the previous three years
that a screening action and therapy in thrombo-
philic patients has reduced maternal deaths at
delivery and puerperium.
In fact, thrombosis is a potentially serious
complication that can occur during pregnancy.
It can manifest against the mother, in the form
of venous thromboembolic disease, or it can
develop an obstetrical complication (placental
thrombosis).
The relative risk of thromboembolism during
labor, especially if you program a vaginal birth pregnancy has increased about 10 times. This
after caesarean section (VBACS) [39]. number must be taken with extreme caution
Another aspect of bleeding complications in the because this is compared with a very low abso-
course of CS, the postpartum and early puerperium lute incidence data of venous thromboembolism
are related to the surgical technique used. in nonpregnant women of similar age.
a a
Fig. 11.8 Hemoperitoneum in postpartum after caesar-

ean section without suturing the parietal peritoneum. (a)
Drawing representing hemoperitoneum after caesarean
section, (b) corresponding US image (Amended by
Malvasi et al. [34])
In fact, if a case of thromboembolism occurs

every 10,000 women in this age group, during Fig. 11.9 Subfascial hematoma after caesarean section
pregnancy the incidence rises to about one in with the parietal peritoneum sutured. (a) Drawing repre-
1,000 pregnant women. So, in absolute terms, we senting subfascial hematoma after caesarean section, (b)
corresponding US image (Amended by Malvasi et al. [33])
cannot speak about a common complication [43]
(Fig. 11.10).
However, we have to keep in mind that pulmo- The clinical presentation of VTE during preg-
nary embolism remains the most important and nancy is unusual, especially for what concerns
most frequent causes of maternal death. the deep vein thrombosis.
a b
Fig. 11.10 Femoral vein thrombosis in pregnancy and trophic changes of the leg and foot. (a) Image representing
Scarpa’s triangle, which runs the femoral vein. (b) Image representing the altered trophism of the lower limb
The location of deep venous thrombosis in a tendency to recur. Thrombophilia is also a hyper-
high percentage of cases, about 85%, occurs coagulable prothrombotic condition. The throm-
against the left lower limb. Furthermore, it is botic episodes are more frequent in venous
much more frequent that the thrombosis is districts than arterial.
localized to the femoral iliac district affecting A condition of hereditary thrombophilia is pres-
distal veins, then the veins of the leg in only about ent in 5–10% of healthy western population, a per-
10% of cases [44]. centage that reaches 40% in patients with venous
This is attributable to the effect of stasis thromboembolism (VTE). Although a hereditary-
related to mechanical compression of the gravid familial thrombophilic condition is itself charac-
uterus. terized by a higher risk of VTE, we should keep in
Semiotics of deep vein thrombosis in preg- mind that a thrombotic event is caused in more
nancy may be unusual. than 40% of cases by the interaction between con-
In fact, it can manifest as abdominal pain in genital and acquired factors, confirming the multi-
the lower quadrants and fever. factorial genesis of the disease [45].
In a high percentage of cases, episodes of This condition depends on defects that cause
venous thromboembolism in pregnancy are asso- a reduction in quantity and/or quality of anticoagu-
ciated with the presence of risk factors. lant or fibrinolytic mechanisms or by the presence
These risk factors have been identified with of specific molecular variants or polymorphisms
age of women during pregnancy (over 35), the of some clotting factors. Therefore, in cases where
need to perform a caesarean section, obesity, fam- there is evidence of a condition of primary or sec-
ily history, and even more with the personal his- ondary thrombophilia, it is useful to make first the
tory of venous thromboembolism. Also, venous following tests reported in Table 11.1.
thromboembolism seems to be more frequent in The purpose of these tests can be summarized
multiparous women, compared with primiparous. as follows:
Other risk factors include ovarian hyperstimu- • Explanation or a tendency to thrombosis,
lation in cases of medically assisted procreation which occurred previously
(MAP), prolonged immobility during pregnancy, • Explanation of thrombosis occurring in mem-
and the presence of varicose veins. bers of the same family
For inherited thrombophilia, we mean a high • Preventive identification of risk factors
risk of developing venous and/or arterial throm- • Definition of an appropriate therapeutic course
bosis, mostly at a young age (<50 years), not eas- The screening is strongly recommended in the
ily linked with obvious risk factors, with a following cases listed in Table 11.2.
Table 11.1 Screening of inherited thrombophilia Table 11.3 The dosages of low-molecular-weight
heparin
G1691A mutation in the gene for factor V Leiden
G20210A prothrombin gene mutation Prophylactic doses Deltaparin 5,000 IU each 24 h
844ins68 mutation of the gene for the cystathionine Or enoxaparin 4,000 IU each 24 h
beta synthase Or nadroparin 3,800 IU each 24 h
Activated partial thromboplastin time (aPTT) Intermediate doses Deltaparin 5,000 IU each 12 h
Fibrinogen Or enoxaparin 4,000 IU each 12 h
Protein C resistance coagulative Or nadroparin 3,800 IU each 12 h
Antithrombin (AT) Therapeutic doses Deltaparin 100 IU/kg each 12 h
Protein C (PCA) Or enoxaparin 1 mg/kg IU each 12 h
Protein S (PS) Or nadroparin 180 IU/kg each 24 h
Search for lupus anticoagulant (LAC) The dose of aspirin to which it refers is 100 mg/day
Search for antiphospholipid antibodies
Anticardiolipin antibodies
Baseline homocysteine assay the presence of FV Leiden, LAC, high levels of
FVIII (if you use a method based on aPTT) or
Table 11.2 Directions to screening of inherited FVII (PT-based method) and is therefore advis-
thrombophilia able to associate the immunological method for
Before pregnancy the determination of free fraction. The research
Thrombotic event onset at a young age (<50 years) on DNA of genetic polymorphisms (FV
Thromboembolism without causing Arg506Gln, FIIG20210A) can instead be done at
Recurrent venous thrombosis any time:
Recurrent superficial venous thrombosis • In the presence of a thrombophilia, the drug
Asymptomatic individuals with family history of that is commonly used in pregnancy is repre-
recurrent thromboembolic events sented by low-molecular-weight heparins
The degree of family members of subjects with (LMWH) (Table 11.3). The LMWHs are cho-
hereditary thrombophilia
sen for the following reasons: do not pass the
Association of thrombosis/fetal loss
Anatomic localization of abnormal thromboembolism
placental barrier and can thus be administered
(mesenteric vein, portal vein, cerebral veins) both during pregnancy and puerperium.
Thrombosis following treatment with progestogens • The unfractionated heparin (UFH) seems to
Recurrent miscarriages (defined as >3, or 2 in the have a modestly increased risk of bleeding
presence of at least 1 normal fetal karyotype) compared with LMWH [46].
Intrauterine fetal death (MEF) • The risk of heparin-induced thrombocythemia in
Intrauterine growth retardation (IUGR) pregnancy with LMWH seems to be extremely
Pre/eclampsia low or zero, but it is advisable to monitor the
HELLP syndrome
platelet count after initiation of prophylaxis [47].
Abruptio placentae
The treatment depends on the coagulation
found in pregnant women. The Italian Society of
The dosage of the inhibitor is preferably carried Thrombosis and Haemostasis has drafted a guide-
out with physiological functional tests, bearing in line for the proper use of antiplatelet drugs during
mind that we do not recommend them: pregnancy [48].
• During the acute phase of a thrombotic event Table 11.3 provides a brief synopsis of it.
(you should wait at least 3 months)
• During anticoagulant therapy
• In pregnancy 11.2 Pharmacological Treatment
• In presence of liver disease as they may be
altered in an undifferentiated way We suggest prophylactic doses of LMWH antena-
The coagulation method for the determination tal (that means as early as possible during preg-
of the functional PS can be falsely altered due to nancy) and for 6 weeks postpartum in women:
• Asymptomatic, which have a defect in antico- HELLP syndrome, and presence of antiphos-
agulant protein C, protein S, or double pholipid antibodies
heterozygous or homozygous for factor V In women with hyperhomocysteinemia is rec-
Leiden or for the clotting factor II. ommended to keep on the therapy with folate
• With previous thrombotic idiopathic event or throughout the course of pregnancy.
secondary to hormonal therapy or pregnancy Prophylaxis and treatment of pregnant women
and with presence of factor V Leiden or with clotting disorder, if properly done until the
heterozygous form of the prothrombin. term of pregnancy, is not a contraindication to
• Not thrombophilic women with previous epidural analgesia [49] and does not increase
thrombotic idiopathic event or secondary to complications [50, 51].
hormonal therapy or pregnancy.
• With previous obstetric complications and
acknowledgment of one of the following
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New Technologies for Monitoring
Labor Progress 12
Dan Farine, Drorith Hochner-Celnikier,
Yoav Paltieli, and Mario Bochicchio
12.1 Introduction The landmark textbook on fetal anomalies

published in 1988 by Roberto Romero [1] began
Ultrasound has been the major development in the new era of ultrasound usage in obstetrics.
obstetrics in the last three decades that allows Ultrasound made a major impact in areas such as
assessment and management of the fetus that was fetal biometry, fetal diagnosis and therapy, and
practically inconceivable prior to its invention. fetal well-being, as assessed by the biophysical
Ilan Timor Tritsch, a mentor in the field of obstet- profile developed by Manning and Platt in 1980
ric ultrasounds, repeatedly stated that there were [2]. Another contribution of ultrasound technol-
three major advancements in obstetrics: ultra- ogy was the proper evaluation of the fetal sleep
sound, ultrasound, and ultrasound. cycle by longitudinal scans [3].
Further profound development of this technol-
ogy was the decrease in the device-to-object inter-
val, through the introduction of the transvaginal
ultrasound (TVS). This allowed for better visual-
D. Farine, M.D., FRCS ()
Department of Obstetrics and Gynaecology, Mount Sinai ization of the cervix and lower segment of the
Hospital, University of Toronto, 600 University Ave., uterus, as well as the uterus in early gestation [4].
Toronto, Ontario M5G 1X5, Canada The first major textbook on TVS was pub-
lished in 1988 by Ilan Timor Tritsch [5] which
D. Hochner-Celnikier, M.D. radically changed the field of first trimester man-
agement. The use of TVS has allowed for earlier
Hadassah University Hospital,
Mount Scopus, Jerusalem 91240, Israel diagnosis of multi-fetal pregnancy, ectopic preg-
e-mail: [email protected] nancy, and placenta previa [6].
Y. Paltieli, M.D., Ph.D., LLB The TVS detection of a short cervix and its
Division of Infertility, Bnei Zion Hospital Haifa, relation to preterm labor was established by the
Haifa, Israel sentinel work of Iams et al. [7] and still remains
Trig Medical, Ridgefield Park, NJ, USA an area of much clinical research.
Trig Medical Ltd., Bldg 7, 2 Hacarmel St, 536, Despite the widespread usage of ultrasound
YoqneamIlit 20692, Israel throughout pregnancy, its role has been limited to
e-mail: [email protected] determination of fetal presentation, assessment
M. Bochicchio, Ph.D. of the amount of amniotic fluid, fetal well-being,
Software Engineering and Telemedia LAB (SET-LAB), and location of the placenta only.
Department of Innovation Engineering,
In the past 10 years, ultrasound has gained a
University of Salento,
Lecce, Italy more extensive role in assisting labor manage-
e-mail: [email protected] ment. This experience is the driving force for

150 D. Farine et al.
development of this textbook, detailing the role difference of more than 1 cm in dilatation can be
of ultrasound in labor management. noted in accordance with the timing of the contrac-
Traditionally, labor progress was determined tion relative to the examination [16]. Thus, adding an
by digital vaginal examinations of cervical efface- additional confounder to the accuracy of monitoring
ment and dilatation, station and position of the fetal labor progress by digital examination.
head, and fetal presentation. Changes of these Head’s station assessment is a subjective
parameters over time determined the progress of parameter that is the source of differences among
labor and the presence of a normal or abnormal examiners. For example, a study performed at five
labor course. Surprisingly, this low-tech approach teaching centers showed that there was a major
was practically unaffected by the extensive use of discrepancy among health-care providers as to the
ultrasound in labor and delivery and to date remains definition used to assess head station [17]. In a
the major technique of assessing labor progress. simulator model using an electronic sensor, an
The manual exam is virtually unchanged since its error rate up to 80% was noted in the assessment
inception in the sixteenth century, except for addi- of the American College of Obstetrics and
tion of gloves used by the examiner. Gynaecology (ACOG) station classification [18].
The limitations of the digital approach are Furthermore, even when the subjects were asked
numerous and have been previously reviewed [8]. to limit the head station assessment to merely
These include the following. engaged or not engaged, and high, mid, low, or
The changes in the latent phase of labor (prior outlet, there was still 30% incidence of error.
to 3 cm) are below the threshold of the examiner Determination of head presentation is also an
perception. Thus, the diagnosis of labor is gener- issue of disagreement. The works of Sherer [19]
ally made only at the active phase of labor and and Akmal [20], who compared the accuracy of
there is generally no earlier determination if the digital examination and ultrasonography in sec-
patient is indeed in true or false labor [9]. ond stage of labor, showed that the clinical exam-
The interobserver variability in assessing dilata- ination is inaccurate in 25–61% of cases
tion is usually 1–2 cm [10, 11]. The progress of cer- (depending on the definition and stage of labor
vical dilatation in the active phase of labor is thought the examination was performed). More recent
to be about 1 cm/h, and it may actually be slower as research from Modena suggests that both the
evidenced in the more recent partograms that invari- position of the trunk and the head are important
ably show a slower progress of labor [12]. This vari- in determining the outcome of labor [21].
ability may lead to the misdiagnosis of obstructed As noted, these issues demonstrate the major
labor and, therefore, may contribute to the perfor- limitations of digital vaginal examinations that
mance of unnecessary caesarean sections [12]. have been previously described [8]. If these issues
There is no consensus in the literature as to the were eliminated or controlled, our management
exact timing that the vaginal examination should be of labor progress could be improved in the fol-
performed relative to the contraction. In the sentinel lowing fashion:
paper by Friedman [13], the vaginal examination • Accurate and real-time continuous data
during labor was performed at the peak of the con- • Elimination of inter-observer variability
traction; however, most later papers on partograms • Reduction of number of vaginal examinations,
generally do not address when the examination with their associated problems, including
should be performed in relation to the contraction increased risk for chorioamnionitis and
[12, 14]. However, one study suggested that the opti- endometritis
mal time for such examination is in between con- • Eliminating discomfort for the parturients
tractions [15] possibly due to patient convenience • Reducing the need for skilled personnel
and comfort. Nowadays, the majority of laboring • Recognition of precipitous and true dysfunc-
women have effective epidural analgesia, and patient tional labors
discomfort is no longer an issue; the timing of the • Improved documentation (medical-legal aspects)
vaginal examination is not factored. This issue is of • Access to data from remote sites (e.g., central
major importance as that in 50% of contractions, a monitoring, MD’s office)
12 New Technologies for Monitoring Labor Progress 151
Fig. 12.1 Previous

cervicometers (From Ref.
[23])
Friedman
mechanical
Friedman Kok−Wladimirof
electromagnetic ultrasound
Richardson-mechanic
Improved electromechanic
using ultrasound technology used a clip-like

12.2 The History of Instrumentation attachment to the cervix, similar to scalp clip
to Improve Data Acquisition attachments for fetal ECG tracing in labor [25].
to Manage Labor As the cervix dilated and thinned out, the clip
penetrated a cervical vessel which resulted in
Quite recently, Letic outlined that vaginal major intrapartum bleeding and thus abandon-
exams are quite inaccurate and may lead to a ing any further research with the device. Other
delay of 4 h in labor management [22]. He investigators developed simple devices based
developed a simple caliper-like instrument to on currently used technology. For example,
allow for more accurate vaginal examinations there exists a US patent from 1988 that describes
[23]. The history of instrumentation to assess calibration of wires, such as a fetal scalp elec-
labor progress began more than 50 years ago trode, to assess the descent of the fetal head in
when Friedman described the first partogram labor, thus utilizing nothing but the already
[13]. He proceeded to develop several cervi- used scalp electrode [26].
cometers. Throughout the years, there have A picture of some of these instruments is
been several other investigators that developed shown [24] in Fig. 12.1.
different instruments to assess labor progress.
These were based on a variety of physical
effects such as mechanic, magnetic, electrome- 12.3 Current Technologies
chanic, and, more recently, ultrasound. A thor-
ough description of the variety of instruments is There are several technologies that are outside
beyond the scope of this chapter as they have the scope of this chapter. These include the
been reviewed quite properly [24]. However, STAN monitor that evaluates fetal cardiac ST
these instruments share one thing in common – changes along with the standard fetal heart rate
none resulted in a useful clinical tool. The monitoring to assess fetal well-being; this tech-
developers of the instruments were primarily nology is owned by Neoventa [27]. Another
concerned with assessment of dilatation and/or company that has the technology for fetal ECG
other labor parameters such as data derives, is Monica [28]; it also manufactures monitor
ease of use, and safety to patient, fetus, and for assessing uterine contractions using a uter-
operator alike. However, the feasibility of the ine EMG monitor [29]. In the rest of the chap-
instruments in the clinical setting presented ter, we will concentrate on three recent
practical problems of insertion and attachment technologies: Birmont, Barnev, and TRIG
to the cervix. One of the early experiments Medical.
Control box
Vaginal base
Camera
Inflatab lo
guard
Fig. 12.2 The Birmont cervicometer: Central Control Unit (CCUTM) linked to the Vaginal Base Unit (VBU™)
12.4 The Birmont Device
This is an optical device that obtains images of

the cervix and the presenting part and allows for
accurate measurements of cervical dilation,
effacement of the cervix, station of the head and
the response of the cervix, and the presenting
part to individual contractions. A schematic pic-
ture of the system is shown in Fig. 12.2. The
device is comprised of three components: the
Vaginal Base Unit (VBU™) Central Control
Unit (CCUTM), and the Central Processing Unit
(CPUTM). A schematic picture of the system is
shown in Fig. 12.2, depicting the Central Control Fig. 12.3 The images generated by the Birmont system
Unit (CCUTM) linked to the Vaginal Base Unit
(VBU™). The Central Processing Unit (CPUTM) of the vaginal attachment is an optical stereo-
receives the data from individual patients and typic system that allows for a 3-dimensional
links it to other labor floor parameters. The core image of the cervix and the presenting part. The
system obtains multiple frames, thus enabling a 12.5 The Barnev Device
dynamic assessment of the obstetrical parame-
ters of interest that include cervical effacement This system is based on an ultrasound GPS-like
(derived from measurement of the cervical rim system with three “satellites” placed on the
as shown in Fig. 12.3), cervical dilatation by maternal abdomen, to obtain external fetal data,
assessing the distance between the opposite sides and three probes that are placed on the cervix at
of the cervical rim, and an assessment of the sta- 3 and 9 o’clock as well as on the presenting
tion by calculating the distance between the part (Fig. 12.4). These components are similar
probe and the presenting part. The multiple to a GPS system which allows for triangulation
frames allow for dynamic changes in these of the probes and measurements of their rela-
parameters that are usually the result of individ- tions, as depicted schematically in Fig. 12.5.
ual contractions. The optical system is encased The physics and algorithms of device function
for sterilization allowing for repeated use. There have been described [32]. The output of the
a pneumatic ring that permits sealing and extend- device is an individual patient partogram as
ing the vaginal walls that are otherwise col- shown in Fig. 12.6. The image has 3 panels.
lapsed. Although a feasibility study showed The top one outlines a normal fetal heart rate
promising results, the data has not been pub- monitor tracing of the whole labor with the
lished. The function of the probe eliminates vag- fetal heart rate tracing showing on top and the
inal examinations that are as a rule unpleasant to uterine contractions below, as per convention.
the patient [30] and may cause intrapartum infec- The middle panel shows the changes in dilata-
tions. There has been extensive data linking the tion (in red) and station (in blue) in relation to
rate of such infections to the frequency of these the progress of labor. The pattern shown in this
repeated vaginal examinations in labor [31]. The panel is the common one in labor in which the
limited experience with this novel device showed changes in station keep increasing throughout
satisfaction of patients, their partners, as well as labor while the changes in dilatation initially
the obstetrical care providers, as the information increase and then become undetected as the
gained was achieved with minimal discomfort to cervix becomes fully dilated. The bottom panel
the patient. shows the partogram of the particular patient.
The measurement system
External
transmitters
External
Fetal head
anatomical marker
marker
Cervical marker
Fig. 12.4 Schematic outline
of the Barnev system
Fig. 12.5 The Barnev

system
Fig. 12.6 The output of the

Barnev system
We have described the pattern of individual labor [35, 36]. Unfortunately, the developers of
contractions and their effect on dilatation and the device were not able to complete the neces-
station [33] as well as the safety of the device sary clinical trials due to lack of funding. One
[34]. In Fig. 12.7, we demonstrate the relation- of the initial founders of the company is further
ship between dilatation and descent during exploring several other applications of the
individual contraction and their progress in system.
4
−0.2 25
3
2
−0.4
HD [cm]
HD [cm]
1
16
−0.6
0
12
end −1
−0.8 3
−2 0
beginning
−1
5.8 6.2 6.6 7.4 −3
CD [cm] 4 5 6 7 8 9
CD [cm]
Fig. 12.7 The relation between dilatation and descent caused by individual contractions
12.6 The TRIG System
Trig Medical’s LaborPro system provides profes-

sionals with accurate noninvasive image and
ruler-like measurements, increasing the data
available to make better labor management deci-
sions and lower the risks. The LaborPro system
consists of position sensors, ultrasound imaging,
a user-friendly software program, and disposable
items (Fig. 12.8). The system can use external
ultrasound input or be configured with an inte-
grated ultrasound unit. The system is also
equipped with a 3-D graphical display to enable
mothers, nurse/midwives, and physicians to visu-
alize the labor process, and a built-in data
archiving and data management program to
enhance a hospital’s obstetric risk management
system (Fig. 12.9). LaborPro answers the unmet
needs of OB/GYN physicians, nurses, and mid-
wives for accurate, noninvasive assessment and
display of labor progress, thereby supporting
labor management decision making and reducing
the risks and costs associated with childbirth. The
LaborPro main features are [1] simple ultrasound
scan for automatic determination of fetal head
position, station, and descent (Fig. 12.10); [2]
ruler-like, accurate measurements of cervical
dilatation and pelvic diameters (Fig. 12.11) [3];
real-time, 3-D monitoring of vacuum and forceps
extraction; and [4] medical record of the entire
labor procedure.
Fig. 12.8 The LaborPro system
The safety of the system was also docu- obtained a similar European approval (CE
mented [36–38]. As a result of these studies, the mark). It is currently the only commercial avail-
system has been approved by the FDA and has able system to assess labor progress [39].
Fig. 12.9 The LaborPro’s main screen shows the 3-dimentional image of head station and position
a b
Fig. 12.10 LaborPro automatic determination of head station (a), head position (b), and head descent during contrac-
tion (c), in relation to pelvic inlet and birth canal
c 6. Farine D, Fox HE, Jakobson S, Timor-Tritsch IE

(1988) Vaginal ultrasound for diagnosis of placenta
previa Am J. Obstet Gynecol 159:566–569
7. Iams JD, Goldenberg RL, Meis PJ et al (1996) The
length of the cervix and the risk of spontaneous pre-
mature delivery. N Engl J Med 334(9):567–572
8. Farine D, Shenhav M, Barnea O, Jaffa A, Fox H
(2006) The need for a new outlook on labor monitor-
ing. J Mater Fetal Neonatal Med 19(3):161–164
9. O’Driscoll K, Meagher D (1980) Active management
of labour. Mosby, London
10. Phelps JY, Higby K, Smyth MH, Ward JA, Arredondo
F, Mayer AR (1995 ) Accuracy and inter-observer
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ments. Am J Obstet Gynecol 173(3 Pt 1):942–945
11. Tuffnell DJ, Bryce F, Johnson N et al (1989)
Simulation of cervical changes in labour: reproduc-
Fig. 12.10 (continued) ibility of expert assessment. Lancet 2:1089–1090
12. Zhang J, Troendle JF, Yancey MK (2002) Reassessing
the labor curve in nulliparous women. Am J Obstet
Gynecol 187(4):824–828
13. Friedman EA (1956) Cervimetry: an objective method
for the study of cervical dilation in labour. Am J
Obstet Gynecol 71:1189–1193
14. Lavender T, Wallymahmed AH, Walkinshaw SA
(1999) Managing labor using partograms with differ-
ent action lines: a prospective study of women’s
views. Birth 26:89–96
15. Buchmann E, Libhaber E (2007) Accuracy of cervical
assessment in the active phase of labour. BJOG
144:833–837
16. Farine D, Jaffa A, Rosenn B, Kreiser D, Schiff E,
Kees S, Shenhav M (2004) The physiology of the cer-
vix in labor – the effect of individual contractions. Am
J Obstet Gynecol 191:6S–S16, Abstract N°669
17. Carollo TC, Reuter JM, Galan HL, Jones RO (2004)
Defining fetal station. Am J Obstet Gynecol 191:
Fig. 12.11 Non-radiating measurements of pelvic
1793–1796
diameters
18. Dupuis O, Silveira R, Zentner A, Dittmar A,
Gaucherand P, Cucherat M, Redarce T, Rudigoz RC
(2005) Birth simulator: reliability of transvaginal
assessment of fetal head station as defined by the
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Fetal Progression in Birth
Canal: State of the Art 13
Anna Maria Dückelmann and Karim D. Kalache
13.1 Introduction OP positioning at the onset of labor ranges

between 15 and 32 %, but this range decreases at
Spontaneous vaginal delivery is associated with delivery to between 5 and 10 % (13 % in primi-
the lowest mortality and morbidity for both gravidas with epidural analgesia at delivery) [8–
mother and child compared to operative delivery. 10]. Malpositions can lead to prolonged first and
Therefore, it is the preferred outcome for most second stages of labor, a transfer of care from
pregnancies [1–5]. Most women wish to have a midwives to obstetricians, and increased use of
spontaneous delivery without obstetric interven- medical and surgical interventions (Syntocinon
tion [6]. Obstetricians and midwifes should sup- augmentation, epidural analgesia) to expedite
port pregnant woman in achieving this goal. labor and delivery. Consequently, due to failure
However, despite intensive effort, some women to progress in labor or fetal distress (the latter
fail to progress in the second stage of labor, and often results from prolonged labor, but also occa-
thus, they require an operative delivery. sionally results from overenthusiastic oxytocin
The American College of Obstetrics and augmentation), the fetal OP position is associated
Gynecology has defined a prolonged second with an increased risk of a Cesarean delivery
stage of labor as the lack of continuing progress [11]. Furthermore, when the fetus is in the OP
for several hours, where the time depends on the position, a vaginal delivery may be complicated
anesthesia and the woman’s previous experience. by perineal tears or the need to extend an
In a nulliparous woman, labor is considered pro- episiotomy [12].
longed after 3 h with or 2 h without regional When malpositions of the vertex or malpre-
anesthesia; in a multiparous woman, labor is con- sentations ensue, the fetal head is difficult to
sidered prolonged after 2 h with or 1 h without accommodate in the maternal pelvis (cephalopel-
regional anesthesia [7]. Arrest of labor may occur vic disproportion), and this can cause problems
when the fetal head does not rotate and/or with initiating labor, progress during labor, and
descend. The most common type of malposition- delivery of the baby. A large fetal head diameter
ing is the occipitoposterior (OP) position, with an can compromise progress in labor; thus, labor
incidence of about 5 % [8–10]. The frequency of may be slow from the start (primary dystocia) or
progress may stop after previously good progress
(secondary arrest). Many cases of malpositions
A.M. Dückelmann, M.D. (*) and malpresentations can self-correct as the fetus
K.D. Kalache, M.D., Ph.D. descends through the pelvis, and a wait-and-see
Department of Obstetrics, Charité – University Hospital,
policy is appropriate. However, close maternal
Campus Charité Mitte, Charitéplatz 1, 10117 Berlin,
Germany and fetal monitoring is recommended, because in
e-mail: [email protected] some cases, labor becomes obstructed, and a

160 A.M. Dückelmann and K.D. Kalache
a b
Fig. 13.1 Image a: Digital examination of a fetus with intact membranes. Image b: Digital examination of a fetus with
ruptured membranes, X = internal uterine orifice, Y = external uterine orifice
Cesarean section is necessary. In some cases, palpation of the sagittal suture and the anterior
progression to full dilation may occur, but the and posterior fontanelles. The position of the tip
mechanics of the situation can make spontaneous of the presenting fetal scalp is estimated relative
delivery more difficult for the mother; also, to an imaginary line that connects the ischial
maternal and fetal exhaustion can occur and, spines of the mother; this position indicates which
therefore, operative delivery is preferable. Careful operative intervention is required, a primary
abdominal and vaginal examinations are neces- Cesarean section or an instrumental delivery. An
sary to establish whether instrumental delivery is instrumental delivery should only be considered
required and appropriate. In some cases, assess- or attempted when head engagement is consid-
ment can be exacerbated by molding of the baby’s ered to have occurred, that is, when the leading
head and the presence of caput succedaneum. part of the fetal head is positioned at least at the
When the operator is unsure of his/her findings, a level of the maternal ischial spine (= station 0) or
more senior clinician should be consulted [13] lower. Clinical assessment may be hindered by
(see Fig. 13.1a and b). significant elongation of the fetal head, due to
Transvaginal digital examination is the gold molding (see Fig. 13.2) and/or formation of caput
standard for obtaining information about fetal succedaneum [7] (see Fig. 13.3).
position and presentation. Traditionally, obstetri- The progress of labor can be followed, first, by
cians have determined the fetal head position by the descent of the fetal head into the maternal
13 Fetal Progression in Birth Canal: State of the Art 161
Fig. 13.2 Example of fetal No moulding Marked moulding

head molding (midsagittal
view)
of caput. In the mother, there is exhaustion,

caput = 2.5 cm pyrexia, tachycardia, and signs of dehydration. In
multiparous women, frequent, strong contrac-
tions may overcome the obstruction, but this runs
the risk of uterine rupture. In nulliparous women,
the uterine contractions may decrease in strength
and frequency, and a retraction ring (Bandl’s
ring) may be formed.
13.2 Treatment Options: Vaginal

Operative Delivery
Fig. 13.3 Example of caput succedaneum (midsagittal
view)
In the past, an essential part of obstetric practice
included knowledge of difficult vaginal operative
techniques and the ability to perform difficult
pelvis, which can be palpated on the abdomen; vaginal deliveries. Hence, the rate of operative
second, the descent of the presenting part of the vaginal deliveries declined; for example, in
fetal head relative to the ischial spines, which can Germany, the rate declined to 5.50 % in 2008
be defined in a vaginal examination; and third, from 6.9 % 10 years earlier [14]. Inevitably, this
the dilatation of the cervix. It is also crucial to decline in the rate of deliveries by vaginal opera-
take into account information regarding caput tive techniques (vacuum extraction or forceps)
and molding of the fetal head, the thinning and led to less effective training of obstetricians in
dilation of the cervix in response to the present- terms of vaginal operative deliveries. In current
ing part, and the strength and duration of the con- practice, the low acceptance of risk and high
tractions. Signs of obstructed labor include a medicolegal awareness have caused obstetricians
pause (or even reversal) in cervical dilation, due to strive to avoid difficult vaginal deliveries
to swelling of the edematous, poorly effaced (see Fig. 13.4); thus, the clinician’s skill resides
cervix; the interrupted descent of the fetal head; mainly in precisely identifying the fetal head
and an irreducible head molding that is difficult position and station to ensure that the appropriate
to feel, due to the development of a large amount technique is applied to enable a safe vaginal
Fig. 13.4 Effect of wrong placement of ventouse and forceps – cephalohematoma and injury of plexus and skin
operative delivery without complications. Thus, decline in the rate of vaginal births after Cesarean
they should know when forceps or ventouse section (28.3 % in 1996 to 8.5 % in 2006), and a
should be applied and when a Cesarean section is 42 % reduction in vaginal operative deliveries
warranted. [17]. The rates of repeat Cesarean birth following
An unsuccessful operative vaginal delivery a previous Cesarean have risen commensurately,
could have serious consequences for the fetus. A reaching 83 % in Australia [18] and nearly 90 %
study by Towner et al. reported that the incidence in the USA [19]. Repeat Cesarean currently
of intracranial hemorrhage increased from 1/860 account for 28 % of all births in the United
with vacuum delivery to 1/334 with Cesarean sec- Kingdom [20].
tion after a failed operative vaginal delivery [15]. The increases in Cesarean section rates are
explained as follows: (1) The increase in repeat
Cesarean section rate correlates with the increase
13.3 Cesarean Section in primary Cesarean section rates; (2) the involve-
ment of midwives has fallen to a low level; (3) the
On the other hand, the rising rate of Cesarean reduction in operative vaginal deliveries has led
section is an international concern. Currently, to reduced obstetrician experience; thus, they feel
nearly one third of newborns are delivered by less confident in conducting operative proce-
Cesarean section (in Germany 30.24 % in 2008) dures; and (4) the lack of effective training for
[16]. During the past decade, there was a 50 % obstetricians in vaginal operative deliveries has
increase in the Cesarean section rate, a significant caused them to abandon difficult deliveries in
favor of Cesarean sections. On the other hand, the 13.4 Assessment of Station
increased use of electronic fetal monitoring has and Position
increased our awareness of fetal distress. Thus,
despite an abnormal CTG and/or low pH at fetal In view of these risks, ultrasound studies have
blood sampling, the majority of babies are born recently been conducted to improve assessments
in good condition. of fetal head position and station (see Fig. 13.5).
Blackwell et al. [21] showed that an overesti- These studies have shown that transperineal ultra-
mation of ultrasound-derived estimated fetal sound might enable the objective quantification
weight (EFW) could influence the likelihood of of the level of fetal head descent in the birth canal
a Cesarean delivery due to the predicted risk of by measuring the distance between the outer
labor arrest. Labor outcomes of women with bony limits of the fetal skull relative to either the
EFW overestimations that were >15 % above maternal symphysis pubis or the skin surface of
the actual birth weights were compared with the perineum. In 2009, Yeo and Romero [23]
those that had accurate EFW estimations. reviewed sonographic evaluations performed in
Overestimation of EFW occurred in 9.5 % of the second stage of labor to improve assessments
cases (23/241). The rate of Cesarean delivery to of labor progression and outcome. Molina and
predicted labor arrest was higher in cases with Nikolaides also discussed this subject in 2010
EFW overestimations than in cases with accu- [24]. Thus, the obstetrics field has focused on
rate EFW estimations (34.8 % vs. 13.3 %; making the appropriate decision when there is
P = 0.01) independent of induction durations. failure to progress in either the first or second
All Cesarean section in the overestimated EFW stage of labor.
group were performed based on the predicted
risk of labor arrest.
A multicenter study at 14 Australian maternity 13.4.1 Position
hospitals [22] investigated 2,345 women with a
single prior Cesarean that were eligible to attempt It is crucial for the obstetrician to establish why
a planned vaginal birth after Cesarean section progress has become arrested and exclude
(VBAC) at more than 37 weeks of gestation. The obstructed labor before augmenting contractions
subjects were divided into two groups: one group [25]. The risk factors for arrest of descent during
with a planned VBAC, the other with a planned the second stage of labor include nulliparity, birth
elective repeat Cesarean section. They found weight >4 kg, epidural analgesia, hydramnios,
significantly more serious neonatal morbidity and hypertensive disorders, gestational diabetes, male
major hemorrhage in the VBAC group than in the fetus gender, premature rupture of maternal
Cesarean section group. This led to the recom- membranes, and induction of membranes [26].
mendation that a first Cesarean section should be Fetal malposition at full dilation increases the
avoided, unless there is a clear medical necessity. risk of a prolonged second stage of labor, and it
A Cesarean delivery may lead to serious com- increases the risk of maternal morbidity [27].
plications, particularly when the head is deep in Therefore, it is essential to make a precise
the birth canal. The complications include major diagnosis of OP position during labor (see
hemorrhage, greater risk of bladder trauma, and Fig. 13.6). Traditionally, obstetricians determine
extension tears of the uterine angle, which can the fetal head position by palpation of the sagittal
lead to a broad ligament hematoma [2]. In preg- suture and the anterior and posterior fontanelles.
nancies that occur after a Cesarean section, The fetal head position and the exact degree of
abnormal placental implantation has become a internal rotation in the second stage of labor is
common complication. The increase in primary prerequisite knowledge for a safe vaginal instru-
Cesarean section rates has also led to an increased mental delivery [28] (it assists in the optimum
risk of uterine rupture and last, but not least, an placement of the ventouse cup) and for selecting
increase in repeated Cesarean sections. the location of delivery (in the theater vs. in the
Fig. 13.5 Determination

of station and position
by ultrasound
Fig. 13.6 Occiput posterior

position. Demonstration of
fetal orbits. Transabdominal
ultrasound
labor room) [15, 29, 30]. Errors in assessments of the actual position at delivery. They found a 70 %
fetal head position may result in deflexed and agreement between the digital exam and the
asynclitic head attitudes, which may cause failure actual position at birth, but the agreement between
of a vacuum delivery. ultrasound and the actual position at birth was
above 90 %. Note, that it is possible that some
13.4.1.1 Ultrasound to Determine fetuses rotated between the time of assessment
Position and birth, because all ultrasound errors occurred
Several studies [31–35] in the last few years for patients in the +1 to +2 stations.
showed that precision and good reproducibility Clearly, noninvasive methods for detecting
are lacking in the determination of fetal head and correcting malpositions would reduce the
position. Clinical examination alone is subjec- need for medical and surgical interventions and
tive, particularly in the presence of large caput improve outcomes for mother and baby.
succedaneum. Furthermore, extensive evidence Sonographic assessment of the fetal head prior to
has suggested that digital pelvic examination is delivery is frequently applied, most likely due to
not accurate for the determination of fetal head the ready accessibility to ultrasound equipment
position during labor [36, 37]. In comparison, in outpatient clinics and delivery rooms. A study
ultrasound can provide far more precise determi- by Lieberman et al. [40] investigated how difficult
nations of fetal head position and station. In all it would be to interpret ultrasound images of fetal
studies (see Table 13.1), large discrepancies were position, particularly for ordinary maternity prac-
found between ultrasound and digital examina- titioners (with less experience than a sonologist).
tions, particularly during the first stage. Two They found that, among 4,054 ultrasonograms,
studies of second stage fetal position [38, 39] 440 (10.8 %) were uninterpretable. The rates of
compared ultrasound, digital examinations, and failed identification reported for ultrasound were
Table 13.1 Digital examinations versus ultrasound to significant difference in the two groups in terms
diagnose OP position during the second stage of labor. In of maternal and neonatal morbidities. There was
all studies, high rates of disagreement occurred between
ultrasound and digital examinations—higher during the one case of failed vacuum extraction in the no
first than the second stage ultrasound group.
% agreement with
N ultrasound (within 45°) 13.4.1.2 Asynclitism
Souka et al. [31] 133 66 Fetal head asynclitism is defined as a lateral
Sherer et al. [36] 102 47 flexion of the head. Two varieties of asynclitism
Dupuis et al. [32] 110 80 are classically recognized. The anterior type is a
Akmal et al. [34] 64 27 posterior twisting of the head, with the sagittal
suture close to the maternal sacrum; in this case,
the anterior parietal bone is the leading part of
lower than those reported for digital examina- fetal skull at vaginal examination. The posterior
tions. The rates were higher early, compared to type is an anterior twisting of the head, with the
later, in the study period. Of note, “uninterpreta- sagittal suture close to the maternal pubis; in this
ble” images may cause less harm than “mistak- case, the posterior parietal bone is the leading
enly interpreted” images, because the latter may part of the skull at vaginal examination.
lead to false certainty and inappropriate actions. Asynclitism, particularly the posterior type, is a
Sonographic techniques for determining fetal common cause of prolonged or obstructed labor
position include the abdominal approach, the [43]. Diagnosis is traditionally based upon clini-
vaginal approach, and three-dimensional (3D) cal findings in patients that experience a pause in
ultrasound. Results from various studies revealed fetal head descent during advanced first stage or
that accuracy was often improved with ultrasonic second stage of labor.
visualization, particularly when occiput anterior Malvasi et al. [44] evaluated 150 women by
(OA) and OP positions could not be readily transabdominal and transperineal ultrasound to
distinguished. The first determination of fetal detect asynclitic and deep transverse positions.
head position by transabdominal ultrasound was They found that the digital examination was
published by Rayburn et al. in 1989 [41]. They significantly less effective than ultrasound evalu-
differentiated between right OA and left OP posi- ation for the detection of either transverse posi-
tions, deflexed head, and asynclitism by defining tion or asynclitism. The left transverse position
the fetal cerebellum and orbits. According to that and the anterior asynclitism were the most fre-
study, transabdominal ultrasound could explain quently observed. The authors described two new
an arrest of labor and allow a timely Cesarean signs for diagnosing asynclitism: The “squint
delivery, or it could increase confidence in a for- sign” and the “sunset of thalamus and cerebellum
ceps placement. Wong [42] investigated whether sign.” These signs facilitated the detection of
the accuracy of vacuum cup placement might be both anterior and posterior asynclitisms (see
improved by intrapartum ultrasound assessment Fig. 13.7a and b).
of the fetal head position during the second stage
of labor. They found that the mean distance 13.4.1.3 Transvaginal Ultrasound
between the center of the chignon and the flexion As descent of the fetal head progresses, transab-
point was 2.1 ± 1.3 cm in the group with both dominal sonography becomes difficult, due to
digital examination and ultrasound assessment shadowing by the maternal symphysis. Zahalka
and 2.8 ± 1.0 cm in the group with digital exami- et al. examined the accuracy and time require-
nation alone. The difference in mean distance ments for transvaginal scans (TVS) in the second
between the two groups was statistically stage of labor for determining fetal head position
significant (P = 0.039). Thus, the accuracy of the [45]. Fetal head position could be determined in
vacuum cup placement was improved in the all cases by TVS; in contrast, seven and nine
ultrasound group. There was no statistically cases could not be determined by digital vaginal
a b
Fig. 13.7 Transabdominal intrapartum ultrasonography (orbit circumference). (b) A right transverse position,
(US). (a) An occiput posterior left position and anterior with the sagittal suture lies anteriorly, showing the right
asynclitism representing the squint sign with the orbit orbit
examination and transabdominal ultrasound eter of the pelvis [7, 47]. When a fetal OP posi-
scans (TUS), respectively (P < 0.03; P < 0.008). tion can be identified and corrected manually, the
Compared to TUS or TVS, the digital vaginal mother and baby may be spared from instrumen-
exam showed fetal head discrepancies of 60° or tal or Cesarean delivery. Various techniques for
more in 13/60 (21.7 %) or 14/60 (23.3 %) cases, digital or manual rotation are described in mid-
respectively, and a ³90° discrepancy in 9/60 wifery and obstetric textbooks. For digital rota-
(15 %) and 12/60 (20 %) cases, respectively tion, the practitioner presses the fingertips against
(P < 0.02 compared to both TUS and TVS). No the fetal head and slightly lifts and rotates the
significant differences in fetal head position were head. For manual rotation, the whole head is
detected between TUS and TVS, when the exam- inserted into the uterus or vagina, and the fetal
ination was technically feasible. TVS was the head is grasped and rotated. These techniques are
most successful method of the three studied; it not widely used and require experience. They are
was most accurate for determining fetal head considered safer than instrumental delivery by
position in the second stage of labor, and it experienced proponents [48]. Sometimes, these
required the least time for performance. In con- procedures involve umbilical cord prolapse and
clusion, the authors postulated that TVS should fetal neck injuries, but no specific studies are
be routinely performed in the labor room setting available on the incidence of these outcomes.
for the determination of fetal head position. Reichman et al. [49] studied the efficacy of digi-
Assessing the position of the fetal occiput is tal rotation for reducing persistent OP position;
difficult with transperineal ultrasound [38], they included women at term, that had exhibited,
because this method provides only a narrow ana- in the second stage of delivery, babies engaged in
tomic section of the maternal sagittal plane. an OP position. That trial was a before-and-after
Consequently, it rarely allows visualization of the comparison of medically indicated, not prophy-
orbits or cervical spine, and a suprapubic scan lactic, rotations. Group 1 comprised 30 women
may be necessary [46]. However, evaluation of that delivered in the first 6 months of the study
fetal head rotation is also of value, as an angle period and did not undergo digital rotation. Group
<45° with respect to the anteroposterior plane of 2 comprised 31 women that delivered in the sec-
the maternal pelvis would suggest that the base of ond 6 months of the study and, after receiving an
the skull is at or below the level of the ischial ultrasound-confirmed OP diagnosis, underwent
spines, which corresponds to the smallest diam- digital or manual rotation. Group 2 had a 77 %
rate of spontaneous births, compared to 26 % in evaluated in the second stage of labor. The fetal
group 1. Group 2 women were more likely than head position and spine were evaluated by intra-
group 1 women to deliver babies engaged in the partum transabdominal sonography. Women
OA position (93 % vs. 15 %) and less likely than were followed up until delivery, and OP at birth
group 1 women to have a Cesarean section (0 % was assessed. They found that, when the fetal
vs. 23 %) or a vacuum-assisted birth (22 % vs. head assumed an OA position during the second
50 %). These results suggested that digital rota- stage of labor, it was highly likely that the head
tion should be considered when managing the would be in an anterior position at delivery.
labor of a fetus in the OP position. The maneuver Conversely, when the head assumed the OP posi-
successfully rotated the fetus, and thus, it reduced tion during the second stage of labor, it was only
the occurrence of Cesarean section, instrumental 26 % (6/26) likely to be in the same position at
delivery, and other complications associated with delivery. They also found that the position of the
persistent OP position. spine during the second stage of labor could be
used as a diagnostic sign in predicting the OP
13.4.1.4 Three-Dimensional Ultrasound position at birth.
With transperineal ultrasound, one can simply The goal of ultrasonography is not simply to
rotate the transducer in the transverse plane to predict the mode of delivery by fetal head posi-
identify the midline of the fetal head, defined as tion but to detect the actual position with a reli-
the echogenic line interposed between the two able, objective measure. A review by Verhoeven
cerebral hemispheres. This approach provides [52] showed that intrapartum sonographic assess-
significant additional information, because a trans- ment of fetal head position did not increase the
verse view of the fetal head allows assessment of predictability of Cesarean section. However, the
the angle between the fetal cerebral midline and full certain knowledge of position during labor
the anteroposterior plane of the maternal pelvis may provide more time to consider therapeutic
[46]. It is nearly certain that, when the fetal head is options and facilitate earlier implementation. In
directed upward and rotated <45°, the station is fact, digital examinations may do more harm than
+3 cm or more. Three-dimensional transperineal good; they may miss many fetuses in the OP
ultrasound applied intrapartum allows clear dis- position; thus, they may miss the opportunity to
cernment of the sutures and fontanelles: thus, the intervene with noninvasive corrective measures.
exact stage of internal rotation of the head can be Once diagnosed, triage can take place. Several
determined in the second stage of labor [81]. years ago, attempts were undertaken to reduce
Furthermore, 3D ultrasound can enable the deter- the Cesarean section rate for dystocia [25].
mination of head asynclitism. In particular, a free However, first, a reliable method for routinely
cut within an ultrasound volume appears to be a determining head position must be established;
valuable technique for displaying the head mid- only then will it be possible to perform prospec-
line, despite extreme posterior flexion of the fetal tive, randomized studies to analyze the impact of
head [50]. those treatments on fetal head position.
The ability to predict accurately, during the
second stage of labor, whether the fetus will be in
the OP position at birth is important, because it 13.4.2 Station
indicates whether a pregnancy will result in spon-
taneous vaginal delivery without complications The traditional principle of applied obstetrics
or whether it will require an operative delivery holds that a correct diagnosis relies upon the
(abdominal or assisted). A study by Blasi et al. determination of the relationship between the
[51] analyzed the predictability of fetal head fetal head and the maternal pelvis or the position
position during the course of labor. They enrolled of the tip of the presenting fetal scalp relative to
100 women with singleton pregnancies during an imaginary line connecting the ischial spines.
the first or second stage of labor and 84 were This determination can indicate a normal, vaginal
delivery, or alternatively, it can indicate which fetal head station, particularly in the second stage
operative intervention is required (primary of labor.
Cesarean section or instrumental delivery).
According to international guidelines [7, 53, 54], 13.4.2.1 Ultrasound to Determine
instrumental delivery is attempted only when the Station
head is considered to be engaged. The area above In the past few years, several sonographic
and below the maternal ischial spine is divided approaches have been described for determining
into fifths. As the presenting fetal part descends the station and rotation of the fetal head. These
from the inlet toward the ischial spine, the sta- include linear measurements (distance between
tions are described as −5, −4, −3, −2, and −1; the the fetal head and the maternal perineum) [56–59],
0 station is at the ischial spine level; then, the sta- subjective assessment of the fetal head direction
tions proceed to +1, +2, +3, +4, and +5. At sta- [46, 60], and angular measurements [61–63].
tion +5, the fetal presenting part is visible at the The first sonographic attempt to assess engage-
introitus [43]. Significant elongation of the fetal ment was published by a French group [64]. They
head due to molding and/or formation of caput measured the distance between the fetal head and
succedaneum may hinder clinical assessment. the sacral tip based on echoes obtained in the A
Over the last few years, studies have shown mode. A scale was established, and the ultra-
that digital estimations of head station during sound results were correlated to clinical findings.
labor were imprecise and poorly reproducible. A The authors stated that, when the distance from
study by Dupuis et al. [32] found that vaginal the fetal head to the sacral tip was £40 mm, the
digital examinations of fetal head descent were head was always engaged. In addition, they dis-
unreliable, with errors in 50–80 % of examina- cussed whether the curved line of the pelvis might
tions, depending on the true level of the head. serve as an indication of a low station, appropri-
However, they used a birth simulator, and the ate for a low forceps approach, because, during
mannequin fetal head could not simulate molding the last period of the second stage of labor, the
or caput succedaneum; thus, the error rate is axis of the pelvis is no longer a straight line.
likely to be even higher in a clinical setting. Twenty-six years later, Sherer and Abulafia
Furthermore, a recent prospective study [55] [65] investigated the transabdominal approach to
performed with 508 women in term labor found measure the station of the fetal head. They
very poor interobserver agreement in estimating included 222 consecutive patients in labor that
fetal head station. In 446 women, the station were >37 weeks’ gestation, with normal, single-
could be estimated by both the researcher and the ton, cephalic-presenting fetuses, and with either
clinicians. However, in 131 women (29 %), the ruptured or intact membranes. First, transvaginal
researcher and clinicians did not agree on engage- digital examinations were performed; these were
ment. The kappa statistic was 0.33 (95 % CI, followed immediately by transverse suprapubic
0.24–0.43). Thus, estimation of station by digital sonographic assessments performed by a single
examination appeared to be imprecise and poorly sonographer. The fetal head was considered
reproducible. engaged when, on transvaginal digital examina-
Against this background, and in response to tion, the leading part of the fetal head was posi-
the uncertainty and lack of objectivity, recent tioned at least at the maternal ischial spine (station
studies have shown that transperineal ultrasound 0) and when, on transverse suprapubic ultra-
might provide an improved objective measure of sound, the fetal biparietal diameter was below the
fetal head progression in labor. Ultrasound scans maternal pelvic inlet. Transvaginal digital exami-
of the fetal head in the maternal pelvis were sys- nations were consistent with ultrasound determi-
tematically and prospectively evaluated. Based nations with a raw percent agreement rate of
on those results, currently, intrapartal trans- 85.6 % (95 % confidence interval [CI], 80.8–
perineal ultrasound is being intensively studied 90.3); kappa statistic = 69.5 % (95 % CI, 59.4–
and evaluated as a new method for determining 73.9; P < 0.001). This high rate of agreement
between ultrasound determination and transvagi- 13.5 Rotation

nal digital assessment of fetal head engagement
heralded the establishment of intrapartum trans- A group in Bologna, Italy [46], also used fetal head
abdominal assessment for determining fetal head direction to investigate the ability of intrapartum
engagement. transperineal sonography to diagnose station in the
second stage of labor. They found that, on the
13.4.2.2 Transperineal Ultrasound sonogram, when the fetal head was directed down-
Dietz and Lanzarone reintroduced the trans- ward, the station most frequently assessed clini-
perineal ultrasound approach in 2005. The group cally was £+1 cm from the ischial spines; when the
[66] performed transperineal ultrasound scans in direction was horizontal, the station was most fre-
139 women in the first stage of labor. They quently £+2 cm; and when the direction was
quantified fetal head descent by measuring the upward, the station was usually ³+3 cm. Failure to
minimum distance between the fetal head and a visualize the cerebral midline or a rotation ³45°
line positioned at a 90° angle from the central was associated with a station £+2 cm. Conversely,
axis of the pubic symphysis in the midsagittal a rotation of <45° was associated with a station
plane. They found that this measurement was ³+3 cm. The probability of a station ³+3 cm was
reproducible and prognostic of the course of particularly high when an upward direction of the
labor. Another study by the Dietz [58] group head was combined with a rotation <45°.
showed that head engagement measured by ultra-
sound, Bishop score, and maternal age were the
strongest single predictors of delivery mode. 13.6 Distance Measurements
These investigations were followed by Henrich
et al. [60], who were the first to use the trans- Another approach for determining station is to
perineal approach to predict the success of vac- measure the head-to-perineum distance.
uum extraction. The study included 20 women in Previously, this approach had only been per-
labor. The group performed the transperineal formed before labor or in small pilot studies.
ultrasound assessment while the woman was Eggebø et al. [56] evaluated women with prema-
actively pushing, immediately prior to vacuum ture rupture of membranes (PROM) at term to
extraction, or at the time of the ventouse determine whether either the engagement of the
application. Fetal head descent was categorized fetal head or the cervical length might be associ-
into three stages, according to fetal head direc- ated with the time from PROM to delivery or the
tion (defined as the direction, with respect to the need for operative delivery. They studied 152
infrapubic line, of a line drawn perpendicular to women with a single live fetus in cephalic pre-
the widest diameter of the fetal head below the sentation after PROM. The shortest distance from
symphysis); the directions included head up, the outer bony limit of the fetal skull to the skin
head down, and horizontal. surface of the perineum was measured in a trans-
Recently, a simpler approach to fetal head verse view. The midpoint of the pelvic canal is at
direction quantification was suggested with the the level of the ischial spine. The distance from
use of transperineal ultrasound [67]. The classi- the perineum to the ischial spine is 5 cm, accord-
cal measurement described by Henrich was ing to the WHO stages of head descent. Therefore,
shown to be equivalent to the angle formed by the a cutoff level of 45 mm was used to define head
widest biparietal fetal head diameter and the engagement; this corresponded to a fetal head
symphysis pubis long axis. Increasing values of position beneath the ischial spine, after the fetal
this angle signified progression of the fetal head, head had passed the narrowest part of the pelvic
angles less than 90° were associated with a down- canal. The time from PROM to delivery could be
ward direction, angles of 90–120° corresponded estimated from a Kaplan-Meier survival plot of
to a horizontal direction, and angles >120° women with short and long fetal head-to-
signified an upward direction of the fetal head. perineum distances (<45 mm and ³45 mm,
respectively). The difference between groups was of labor by measuring the fetal head-to-perineum
statistically significant (P < 0.001). Thus, at 24 h distance in 100 patients. A threshold of 55 mm
after PROM, 52 % of women with short and 77 % (fetal head-to-perineum distance) was associated
of women with long fetal head-to-perineum dis- with sensitivity and negative predictive values of
tances continued in labor. After 36 h, 32 % of 100 % for vaginal birth.
women with a short distance and 43 % of women
with a long distance continued in labor. The
authors concluded that women with a short fetal 13.7 Angle Measurements
head-to-perineum distance (£45 mm) have a high
probability of a rapid labor without obstetric The direction the fetal head follows as it passes
intervention; therefore, these women should be through the pelvis is a curved line, and delivery
offered expectant management when presenting occurs by deflection of the engaged head (see
with PROM. Fig. 13.8). Thus, several groups have adopted an
Subsequently, the fetal head-to-perineum dis- alternative approach, where fetal head descent is
tance was evaluated as an indicator for induction assessed by measuring the angle of progressive
of labor [68]. The study included 275 women head deflection (the so-called angle of progres-
admitted for induction of labor. That study sion), rather than linear measurements. The angle
showed that fetal head-to-perineum distance, of progression is not confounded by caput suc-
measured with transperineal ultrasound, could cedaneum, and it is simple to detect, because it
predict a vaginal delivery after induction of labor, relies on two readily discernible ultrasound mark-
with a predictive value similar to those of ultra- ers: the maternal pelvis (symphysis pubis) and a
sonographically measured cervical length and the fetal structure (the leading bony edge) (see
Bishop score. The areas under the receiver oper- Fig. 13.9). Therefore, specific training and sub-
ating characteristic curve for predicting vaginal stantial ultrasound experience might not be pre-
delivery were 62 % for fetal head-to-perineum requisites for widespread clinical use of this new
distance, 61 % for cervical length, 63 % for method.
cervical angle, 61 % for the Bishop score, and In a study by Kalache et al. [62], the prognos-
60 % for body mass index. The authors concluded tic value of measuring the angle of progression in
that this new method could be used to assess fetal the second stage of labor was examined to deter-
head descent, despite the lack of a clear relation- mine the efficacy of intrapartal ultrasound for
ship with the well-established concept of fetal predicting the mode of delivery. The goal of that
head station. study was simply to validate the feasibility of
Maticot-Baptista et al. [57] also studied the determining the angle of progression in a daily
feasibility of using ultrasound in the diagnosis of routine. The angle of progression [69] was com-
fetal head engagement during labor. They compared between different modes of birth after pro-
pared the fetal head position in the pelvic cavity longed second stage labors with fetuses in the
determined by transvaginal digital examination OA position. The angle of progression was mea-
with that determined by the ultrasound measure- sured between a line placed through the midline
ment of the fetal head-to-perineum distance in 45 of the pubic symphysis (line A) and a line run-
patients. They found that, with fetal head-to- ning from the inferior apex of the symphysis tan-
perineum distances >60 mm, the fetal head was gentially to the fetal skull (line B). Forty-one
not engaged in the pelvic cavity. They also defined women at term (³37 weeks) with a prolonged
the fetal head stations in terms of distance. A second stage of labor were enrolled in the pro-
high cavity position (station + 1) was 50 mm, a spective study. The managing obstetrician was
mid cavity position (station + 2) was 38 mm, and blinded to the transperineal ultrasound data but
a low cavity position (station + 4) was 20 mm. was aware of the transabdominal ultrasound. The
Rivaux et al. [59] also conducted a study to cases were classified into three groups: Cesarean
assess fetal head engagement in the second stage section for failure to progress, vacuum extraction
Fig. 13.8 Angle of

progression (Kalache et al.
[62])
Fig. 13.9 Correct orientation of the probe. Right side of the probe is orientated towards the anus of the patient
for failure to progress, and spontaneous delivery The aim was to analyze the correlation between an
following the prolonged second stage of labor. objective ultrasound marker (symphysis) and the
Transperineal ultrasound examination was per- mode of birth after birth arrest of fetuses in OA
formed just before digital examination and sub- position. According to that goal, Cesarean sections
sequent delivery. The angle was measured offline were sometimes conducted when the angle of pro-
by an observer blinded to delivery outcome. gression was greater than 120°. The study was not
The final analysis included 26 cases with an designed to define a particular cutoff value, where
OA fetal position (Cesarean section, n = 5; vac- an instrumental delivery would always be success-
uum extraction, n = 16; spontaneous delivery, ful. That type of study would require a systematic
n = 5). Logistic regression analysis showed a experimental design of vaginal operative deliveries
strong relationship between the angle of pro- managed by obstetricians with exactly the same
gression and the need for Cesarean delivery. experience and information. This would result in a
When the angle of progression was ³120°, the large number of failed attempts at instrumental
probability of Cesarean section was 10 %. delivery performed by obstetricians blinded to the
Moreover, the greater the angle, the higher the ultrasound results. Therefore, that study design
likelihood of a successful assisted or spontane- would not be ethically acceptable.
ous delivery. This suggested that, at a cutoff At the time of the Kalache study, another
angle of progression of 120°, there would be at group also investigated transperineal ultrasound
least a 90 % chance of safely delivering the baby, imaging to compare the fetal station evaluations
either by vacuum extraction or spontaneous made with digital examinations to those made
delivery. with concurrent transperineal ultrasound assess-
It is important to note that the relationship ments. The aim was to assess the utility of trans-
between the angle of progression and fetal head perineal ultrasound in distinguishing pregnancies
station described in the study by Kalache et al. that would result in spontaneous vaginal delivery
only applied to fetuses that were in an OA posi- from those that would fail to progress and require
tion. Thus, the angle of progression was an objec- operative vaginal delivery or Cesarean section.
tive ultrasound marker for predicting the mode of Barbera et al. [61] called the described angle of
delivery following prolonged second stage of labor progression the “angle of head descent.” They
with a fetus in the OA position (see Fig. 13.10). examined 23 term laboring patients with a single-
Kalache et al. did not analyze the correlation ton fetus in cephalic presentation during the sec-
between the measurement of an angle based on ond stage of labor. The results were similar to
transperineal ultrasound and the conventional, those of Kalache et al. An angle of at least 120°,
digital examination made at the same time to measured during the second stage of labor, was
determine the station of the fetal head. The group always associated with subsequent spontaneous
assumed that it is difficult to correlate ultrasound vaginal delivery. In six pregnancies ending in
parameters with information acquired by digital Cesarean section, the mean angle of descent,
examination or with data obtained by computed measured at the last transperineal ultrasound
tomography (CT) imaging of nonpregnant women. examination, was only 108°. A significant linear
Ultrasound measurements are based on nonosseous association was found between clinical digital
structures of the pubic bone, and data from CT assessments and angle of head descent measure-
imaging are based on osseous structures. ments by transperineal ultrasound examination
In the study of Kalache et al. [62], the appropri- (P < 0.001). They concluded that an angle of head
ateness of a Cesarean section, vacuum extraction, descent measured by transperineal ultrasound
or expectant management until spontaneous deliv- imaging provided an objective, accurate, repro-
ery in the prolonged second stage of labor was ducible means for assessing descent of the fetal
exclusively based on the digital examination by the head during labor.
managing obstetrician, who was blinded to the Lau et al. [63] compared the angle of progres-
transperineal findings and the angle of progression. sion when measured during pushing (introduced
Fig. 13.10 Elongation of

the fetal head and angle of
progression in occipito
posterior position
by Henrich) to that measured when the mother cian and the midwife. Therefore, specific train-
was at rest during the second stage of labor. They ing and substantial ultrasound experience should
found that the angles of progression measured at not be prerequisites for widespread clinical use
rest did not differ between a group that delivered of a new method. The requirements of any newly
by vacuum extraction and a group that underwent introduced method in medicine must be clini-
Cesarean section. On the other hand, the angle of cally relevant, reproducible, and related to well-
progression measured during maternal pushing established standards/methods.
differed between the two groups. With a cutoff
value of 150° for the angle of progression mea-
sured during maternal pushing, they could pre- 13.9 Reproducibility and Reliability
dict success in 80 % of vacuum extractions and
100 % of Cesarean sections. Similarly, a change Several studies on the validity of the angle of
in angle of more than 15° could predict success in progression [61] were followed by a demonstra-
73 % vacuum extractions and 100 % of the five tion of the high reproducibility and reliability of
Cesarean sections. the new method. The Kalache group examined
the reproducibility and reliability of this new
angle measurement method in comparison to the
13.8 Role of Intrapartal Ultrasound digital vaginal examination [70]. They postulated
that neither ultrasound experience nor fetal head
To ensure obstetrically relevant, identifiable ter- station would affect the reliability of the angle of
minology throughout labor, in intrapartal ultra- progression measurement of fetal head descent
sound, the digital orientation on the ischial spines based on intrapartum ultrasound images obtained
was replaced by the parameters “symphysis” and by a single experienced operator. The second
“frontal part of the fetal head,” which include the hypothesis was that the interpretation of ultra-
requirements for every method in assessing the sound images offline would be operator indepen-
level of the head. The landmarks selected must dent. One experienced obstetrician performed 44
be easy to visualize, they should not change transperineal ultrasound examinations of women
under the pressures of difficult labor on both the at term and in prolonged second stage of labor
fetal head and maternal pelvis, and they should with the fetus in the OA position. To obtain
be sufficiently intuitive to promote adoption in reproducible results, first, small lateral move-
obstetric practice. The sonographic identification ments of the probe were made until an image was
of fetal and maternal landmarks should be obtained that did not contain a shadow from the
technically straightforward for both the physi- pubic rami and showed a midsagittal view with
Fig. 13.11 (Left) Strict

midsagittal section through
the pubic symphysis. (Right)
Parasagittal section
Medial Lateral
Fig. 13.12 Effect of lateral probe displacement on the angle of progression (Dückelmann et al. [71])
clear visualization of the symphysis pubis and experience evaluated fetal head descent based on
the fetal skull. The probe was then displaced lat- the angle of progression. To assess the reliability
erally until the pubic ramus was clearly visual- of image acquisition, the angle of progression
ized within the symphyseal capsular tissue [71] was measured by two obstetricians in indepen-
(see Figs. 13.11 and 13.12). dent ultrasound examinations of 24 laboring
Three midwives without ultrasound experi- women at term with the fetus in the cephalic posi-
ence, three obstetricians with <5 year of experi- tion. Intraclass correlation coefficients (ICCs)
ence, and three obstetricians with >5 year of with 95 % confidence intervals (CI) were used to
evaluate inter- and intraobserver reliability. Labor examined. Four clinical teams used transabdom-
outcomes were compared between women with inal/transperineal ultrasound and four clinical
and without transperineal ultrasound examina- teams did not use ultrasound. Labor outcomes of
tions. A total of 444 measurements were per- women with transperineal ultrasound were com-
formed and compared. The offline image analyses pared to outcomes of those with digital exami-
showed substantial interobserver reliability. ICCs nation alone. The rate of second stage Cesarean
were 0.82, 0.81, and 0.61 for observers with section was significantly higher (P < 0.50) in the
>10 year, <5 year, and no ultrasound experience, group without ultrasound compared to the group
respectively. Thus, there were no significant dif- with ultrasound prior to operative delivery
ferences between ICCs among observer groups (20/78 vs. 7/43). Seven patients in the group
with different levels of ultrasound experience. with ultrasound delivered spontaneously, but
Furthermore, given the benchmark of 0.6 for none of the patients in the other group had spon-
clinical usefulness, the technique was considered taneous deliveries. There were no significant
clinically relevant. differences in maternal and neonatal morbidity
Fetal head station did not affect the reliability between the two groups.
of the angle of progression. Measurements on Intrapartal ultrasound in patients with a pro-
transperineal ultrasound images appeared to be longed second stage of labor may change obstet-
equally reliable at higher (above 0 station) and rical practice by reducing the number of second
lower head stations (below +1 station), despite stage Cesarean sections without increasing
the significant fetal head elongation expected to maternal and neonatal morbidity. Intrapartal
occur at lower stations, due to molding and/or ultrasound appeared to enable obstetricians to
formation of caput succedaneum. In addition, the proceed with enhanced confidence.
Bland-Altman analysis indicated reasonable
agreement between measurements obtained by
two different operators with >10 year and no 13.11 Magnetic Resonance Imaging
ultrasound experience. As expected, the degree
of concordance was lower between pairs of mea- Magnetic resonance imaging (MRI) technology
surements obtained by operators with >10 year may contribute to redefining the standard mater-
and <5 year ultrasound experience. nal and fetal anatomical parameters during active
The results of the study by Dückelmann et al. labor. To analyze the relationship between the
showed that measurement of the angle of pro- newly introduced method of angle measurement
gression on transperineal ultrasound imaging was and the well-established concept of station deter-
reliable, regardless of fetal head station or the cli- mination, Bamberg et al. [73] conducted a vali-
nician’s level of ultrasound experience. Thus, the dation study. They enrolled 31 pregnant women
parameters necessary for angle measurement are at full term with fetuses in the OA position. First,
highly reproducible. the distance between the leading part of the skull
and the interspinal plane was measured on images
acquired with an open MRI system, with the
13.10 Signiﬁcance of Ultrasound patient in a supine position. Immediately after
the MRI scan, the angle of progression was mea-
In a retrospective cohort study [72], Dückelmann sured on transperineal ultrasound images without
et al. sought to evaluate the impact of intrapartal changing the woman’s posture (see Fig. 13.13).
ultrasound on decision making by physicians A significant correlation was found between the
and on the obstetric outcome. All women that angle of progression determined by transperineal
delivered over a 1-year period were included sonography and the MRI-determined distance
when the fetus was in cephalic presentation and between the presenting fetal part and the level of
they had been diagnosed with a prolonged sec- the maternal ischial spines (y = −0.51x + 60.8,
ond stage of labor. A total of 121 deliveries were R2 = 0.38, P < 0.001). This correlation validated
Fig. 13.13 Fetal head station established using an open magnetic resonance imaging scanner (Bamberg et al. [73])
the angle of progression and that engagement digital examination and simultaneous trans-
would occur at an angle <120°. In another study perineal ultrasound. Assessments were evalu-
[74], the angle of progression assessed by open ated to compare the clinical examinations to the
MRI was compared with that assessed by trans- stations calculated from the above geometric
perineal ultrasound. A significant correlation was model. For the 70 nonpregnant subjects, a mean
found between the angles of progression mea- angle of 99° was measured between the long
sured by transperineal ultrasound (mean: 79.05°) axis of the symphysis pubis and the midpoint of
and MRI (mean: 80.48°). The intraclass correla- the line connecting the two ischial spines. They
tion coefficient between the two methods was concluded that the transperineal ultrasound
0.89. This finding confirmed the findings from angle of 99° was correlated with station 0, and
the previous comparative studies. each station above or below this station could be
Barbera et al. [75] developed a geometric assigned a specific corresponding angle for
model based on CT images of nonpregnant reference.
women to investigate which angle of progres- Recently, an open, high-field, MRI scanner
sion in a midsagittal transperineal ultrasound was used to acquire a series of real-time, cine-
image best coincided with the midpoint of a line matic MRIs as the mother began the Vasalva
drawn between the ischial spines (zero station). maneuver [76]. The midsagittal plane was visi-
Based on a geometric algorithm, the trans- ble, and the amniotic membranes were intact. A
perineal ultrasound angles were assigned to the wireless transducer system was adapted and
clinical stations (−5 to +5). Finally, the clinical modified to comply with the specific require-
station was assessed in 88 laboring patients by ments of MRI safety and compatibility. Cinematic
MRI acquisition ended in the late second stage, Molina et al. [78] evaluated the agreement
when the fetal head was extended and the between digital and ultrasound assessments of
perineum was distended. This was the first time occipital position and the repeatability of mea-
that the complex process of labor was filmed in surements for head direction, angle of the middle
3D. It displayed how the baby navigated through line, progression distance, and angle of progres-
the birth canal. The MRI visualization of a nor- sion. All four 3D ultrasound measurements per-
mal, late second stage labor showed that exten- formed in women in the second stage of labor
sion started when the occiput came into close were reproducible, but the progression angle had
contact with the inferior margin of the symphysis the highest intraclass correlation coefficient for a
pubis. From that point, extension occurred simul- single observer (0.94; 95 % CI, 0.90–0.97) and
taneous with the fetal head gliding downward. At for two different operators (0.84; 95 % CI, 0.73–
that point, the birth canal curved upward to form 0.91). Digital pelvic examination for determining
a 90° angle, and the fetal head was delivered by the fetal head position during labor was found to
extension and rotation around the symphysis be inaccurate.
pubis. In fact, the process of deflection occurred Ghi [79] also evaluated the intraobserver and
at the very last moment of birth. MRI visualiza- interobserver reproducibility of the above
tion of the ischial spine level during labor in com- described measurements. They examined stored
parison with the fetal head station during the ultrasound volumes related to fetal head
extension phase may increase our understanding progression in the birth canal. For all parameters,
of the mechanisms of labor. There is no doubt interobserver variation was significantly higher
that human fetuses must negotiate a curve to than intraobserver variation. Reproducibility was
achieve birth. Nevertheless, some controversy high for all parameters, except the midline angle.
remains to be settled. For instance, the curved Among the different ultrasound measurements,
part of the birth canal, the so-called knee, is the angle of progression exhibited the highest
widely reported in textbooks to lie at the level of reproducibility.
the ischial spines [77], but this has not been sup- Tutschek et al. [80] evaluated the relationship
ported by scientific evidence. between the different intrapartum transperineal
ultrasound parameters and their development dur-
ing normal term labor. Intrapartum transperineal
13.12 Limitations and Outlook ultrasound measurements for the “head station,”
“head direction,” and “angle of head descent”
The studies performed in the past 5 years to test were performed in 50 laboring women, compared,
the validity of transperineal intrapartal ultrasound studied for repeatability, and correlated with the
in the labor ward during the second stage of labor progression of labor. All three intrapartum trans-
aimed to establish a simple ultrasound method perineal ultrasound parameters were clinically
that could be readily and reliably applied by both reproducible. The angle of descent and the head
medical and nursing staff, regardless of experi- station were interchangeable, and could be calcu-
ence. They aimed to ensure that the methods lated from each other. Both head station and head
would be applicable to the clinical setting and direction changed in a typical pattern along the
obstetrically relevant by reflecting fetal head birth canal and correlated with time to delivery.
engagement. To date, transperineal intrapartal
ultrasound has only been used in the context of
pilot studies, and it remains unclear which 13.13 In Conclusion
approach is the best. However, two reviews in
2010 evaluated various methods of measurement It is reasonable to conclude from the current state
for predicting successful labor. In both reviews, of the field that intrapartum ultrasound is the
the angle of progression measurement showed most reliable way to detect fetal position, rota-
the most precise and reliable results. tion, and station. No study found that digital
examinations produced clinically useful or reli- 3. Bashore RA, Phillips WH Jr, Brinkman CR 3rd (1990)
able information on fetal position and station in A comparison of the morbidity of midforceps and
cesarean delivery. Am J Obstet Gynecol 162:1428–
the second stage. In fact, the digital examinations 1434; discussion 34–35
may do more harm than good: in missing many 4. Murphy DJ, Liebling RE, Patel R, Verity L, Swingler
OP fetuses, the opportunity may be missed to R (2003) Cohort study of operative delivery in the
intervene with noninvasive corrective measures. second stage of labour and standard of obstetric care.
BJOG 110:610–615
The bottom line will be to demonstrate whether 5. Bhide A, Guven M, Prefumo F, Vankalayapati P,
the use of ultrasound can improve outcomes. A Thilaganathan B (2007) Maternal and neonatal out-
transperineal ultrasound can reliably visualize come after failed ventouse delivery: comparison of
the caput succedaneum, a cephalic hematoma, or forceps versus cesarean section. J Matern Fetal
Neonatal Med 20:541–545
an abnormal molding. This may explain some 6. Kolip P (2008) Attitudes to cesarean delivery: the view of
discrepancies between the results of transperineal cesarean section mothers. Gesundheitswesen 70:e22–e28
and intrapartum ultrasound investigations. These 7. American College of Obstetricians and Gynecologists
parameters remain to be clarified in future (2000) Operative vaginal delivery. ACOG Practice
Bulletin No. 17, Washington, DC
research. Another potential research aim could be 8. Gardberg M, Laakkonen E, Salevaara M (1998) Intrapar-
to investigate the effect of fetal head position on tum sonography and persistent occiput posterior position:
intrapartum transperineal ultrasound parameters. a study of 408 deliveries. Obstet Gynecol 91:746–749
It is important to note that, to date, the relation- 9. Sizer AR, Nirmal DM (2000) Occipitoposterior posi-
tion: associated factors and obstetric outcome in nul-
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11. Akmal S, Kametas N, Tsoi E, Howard R, Nicolaides
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Index
A incidence, 133–136
Asynclitism neurotransmitter alteration, 140, 142
caput succedaneum and molding, 82, 84–85 primates, 134
fetal head engagement risk factors, 134
fetal sagittal suture palpation, 73, 74 in USA, 134
posterior and anterior fontanel palpation, 73–74 forceps and obstetric vacuum, 135, 137–138
fetal head position intrapartum sonography
anterior asynclitism, 76–77 bladder flap hematoma, 142, 143
anterior occipital positions, 75, 76 fetal median occiput-posterior position,
left occiput anterior position, 78–79 139, 140
occiput transverse position with posterior intraoperative bleeding complications, 139
asynclitism, 78 postoperative complications, 139, 141
transabdominal longitudinal section, 77 subfascial hematoma, 142, 143
vaginal digital examination, 75, 76 perineum damages, 135
left occiput anterior position, 75 Caput succedaneum, 82, 84–85, 113
occiput posterior position Central Processing Unit (CPU TM ), 152
direct OP position, 79 Cervical length. See Transvaginal ultrasound cervical
left occiput position, 79–80 length (TVU CL)
right occiput position, 80, 81 Cervical simulator model, 1
squint sign, 80, 81 Cervicometers, 151
occiput transverse position Clinical evaluation
anterior asynclitism, 80 cervical dilatation, 1–2
cephal head tumor palpation, 82 fetal head position
deep transverse head position, 81, 83 second stage of labor, 7–8
left OT position with anterior asynclitism, 82–84 transabdominal sonography (see Fetal head
posterior asynclitism, 81 position)
ROT and LOT, 80 transvaginal digital examination, 4, 7
parietal bone, 75 fetal head station
computed tomography, 2
digital examination, 2, 3
B transperineal ultrasound, 2–4
Barnev device
components, 153
dilatation and descent, 154, 155 D
output, 153–154 Doppler ultrasound, 25
Birmont cervicometer, 152–153 2D ultrasound
Bladder flap hematoma, 142, 143 head rotation, OP position
cephalic malposition, 103
digital assessment, 103–104
C fetal spine orientation, 104
Caesarean sections longitudinal assessment, 104
dystocia physiologic vertex delivery, 103
defensive medicine, 134 suprapubic OP position, 104
European data, 134–135 transabdominal
factors causing, 133 anterior occiput position, 32
human species, 133–134 axial and longitudinal, 31

DOI 10.1007/978-3-642-29939-1, © Springer-Verlag Berlin Heidelberg 2012
184 Index
2D ultrasound (cont.) anterior occiput position, 4, 5

vs. digital examination, 29–30 left posterior occiput position with anterior
fetal occipital position and indices, 34 left asynclitism, 10
head engagement, 31–32 left transverse occiput position with posterior
midline intracranial structures, 30 asynclitism, 9
translabial and transperineal ultrasound, median posterior occiput position with left
32, 34, 35 asynclitism, 11
transvaginal ultrasound, 34, 35 posterior occiput position, 12, 13
uterine cervix sonoelastography, 34, 36 right anterior occiput position with posterior
3D ultrasound right asynclitism, 11
head rotation right posterior occiput position with posterior
digital examination, 107 asynclitism, 12
midline angle measurement, 105–107 right transverse occiput position with anterior
multiplanar reconstruction, 105, 107 asynclitism, 10
reproducibility, 105 transverse occiput position, 4, 6
vs. traditional 2D US, 106 ultrasound, 164
translabial ultrasound, 36–39 asynclitism, 165
Dystocia image interpretation, 164–165
defensive medicine, 134 OA and OP positions, 165
European data, 134–135 three-dimensional, 167
factors causing, 133 transvaginal ultrasound, 165–167
human species, 133–134 Fetal head station. See also Fetal head descent
incidence, 133–136 labor progression
neurotransmitter alteration, 140, 142 angle of progression, 49, 51
primates, 134 continuous ultrasound monitoring, 51
risk factors, 134 fetal head direction, 49, 51
in USA, 134 head–perineum distance, 51–52
ischial spine, 46
midline, 46, 51
E progression distance, 49, 51
Elastography index (EI), 34 sacral tip, 46
transabdominal approach, 49
transperineal or translabial
F approaches, 49
Fetal head descent. See also Fetal head station pelvic axis, 87–88
angle of progression, TPU transperineal ultrasound
arc-like pathway, 89 angle of progression, 97–99
delivery time, 92–94 fetal head-perineum distance, 89
intraobserver variability, 90–91 linear measurements, 88
population, 89 prediction intervals, 91–92
pubic symphysis, 90–92 pubic symphysis, 88–89
pubic symphysis and ischial spines, 96–97 ultrasound probe position, 88
sagittal view, 90, 92, 93 ultrasound
suboccipitobregmatic diameter, 89 fetal head and sacral tip distance, 168
validation, 94–96 head-to-perineum distance measurement,
translabial ultrasound, 89 169–170
Fetal head position. See also Occiput transabdominal, 168
posterior (OP) position transperineal, 169
asynclitism transvaginal digital examinations, 168
anterior asynclitism, 76–77 transverse suprapubic ultrasound, 168
anterior occipital positions, 75, 76 vaginal digital examination, 87, 91–92
left occiput anterior position, 78–79 Fetal progression in birth canal. See also Labor
occiput transverse position with posterior progression
asynclitism, 78 angle measurements
transabdominal longitudinal section, 77 during maternal pushing, 172–173
vaginal digital examination, 75, 76 occipito posterior position, 172, 173
errors in, 164 probe orientation, 170, 171
internal rotation, 163–164 reproducibility and reliability, 173–175
occiput posterior position, 163, 164 second stage labors, 170
transabdominal sonography transperineal ultrasound, 170, 172
Index 185
cesarean section Intrapartum ultrasound

complications, 163 asynclitism (see Asynclitism)
increases in, 162 breach presentation, 25, 26
ultrasound-derived estimated fetal weight, 163 classification, 18
vaginal birth after, 163 Doppler studies, 25
fetal head position assessment exploration techniques
errors in, 164 abdominal exploration, 16
internal rotation, 163–164 bladder-emptying, 16
occiput posterior position, 163, 164 exploration type determination, 17–18
fetal head rotation, 169 medial sagittal plane, 16, 17
fetal head station (see Fetal head station) translabial or transperineal exploration, 16
intrapartal ultrasound, 173 fetal head descent (see Fetal head descent)
magnetic resonance imaging, 175–177 fetal head position determination (see also Fetal head
vaginal operative delivery, 161–162 position)
First stage of labor digital determination, 18
2D ultrasound (see 2D ultrasound) 3D transperineal ultrasound, 20
3D Ultrasound, 36–39 sutures and fontanels, 20, 21
Friedman’s labor partogram, 29, 30 transabdominal ultrasound, 18, 19
vacuum extraction, 19–20
vaginal touch, 18
H head rotation (see Head rotation)
Head–perineum distance, 51–52 indications, 18
Head rotation labor progression (see Labor progression)
3D ultrasound obstetricians, 15–16
digital examination, 107 portable ultrasound, 15
midline angle measurement, 105–107 recommended ultrasound settings, 17
multiplanar reconstruction, 105, 107 stalled labor (see Stalled labor)
reproducibility, 105 transabdominal ultrasound (see Transabdominal
vs. traditional 2D US, 106 ultrasound)
2D ultrasound, OP position translabial ultrasound (see Translabial ultrasound)
cephalic malposition, 103 transperineal ultrasound (see Transperineal
digital assessment, 103–104 ultrasound)
fetal spine orientation, 104 ultrasound probes, 15
longitudinal assessment, 104 Ischial spines, 111
physiologic vertex delivery, 103
suprapubic OP position, 104
dynamic changes, 101 L
midpelvis plane, internal rotation, 101, 102 Labor progression. See also Fetal progression in birth canal
translabial approach, 104–107 Barnev device
components, 153
dilatation and descent, 154, 155
I output, 153–154
Infrapubic line, 112 Birmont cervicometer, 152–153
Intrapartum translabial ultrasound (ITU) cardinal movements, 45, 46
vs. abdominal ultrasound, 109, 111 digital assessment
clinical usefulness cervical dilatation, 43
angle of descent, 113, 114 fetal station, 45
internal rotation, 113–115 digital vaginal examinations, 150
vaginal births and delivery time, 113–115 dystocia, 42–43
dynamic aspect, 110, 112 fetal station assessment
before instrumental vaginal delivery, 116 angle of progression, 49, 51
palpated head stations, 113, 114 continuous ultrasound monitoring, 51
perineal insonation, 109 fetal head direction, 49, 51
pubic symphysis and ischial spinae, 110 head–perineum distance, 51–52
quantitative parameters ischial spine, 46
angle of descent, 111–112 midline, 46, 51
caput succedaneum, 113 progression distance, 49, 51
head direction, 112–113 sacral tip, 46
infrapubic line, 110 transabdominal approach, 49
ischial spines, 111 transperineal or translabial approaches, 49
186 Index
Labor progression. See also Fetal progression vaginal digital examination

in birth canal (cont.) vs. transabdominal ultrasound, 67–68
ischial spine palpation, 43, 44 vs. transperineal ultrasound, 68
previous cervicometers, 151 vs. transvaginal ultrasound, 68
protracted labor, 43 vaginal examination, 61, 62
stages of labor, 41 vaginal operative delivery, 70
transvaginal ultrasound, 149 Occiput transverse (OT) position
TRIG system anterior asynclitism, 80
cervical dilatation and pelvic diameters, 157 cephal head tumor palpation, 82
components, 155 deep transverse head position, 81, 83
3-D graphical display, 155, 156 left OT position with anterior asynclitism, 82–84
fetal head position, station, and descent, 155–156 posterior asynclitism, 81
safety, 156 ROT and LOT, 80
ultrasound assessment
digital assessment, 55
2D or 3D ultrasound, 55–56 P
fetal head engagement, 52–53 Portable ultrasound, 15
first stage of labor, 53–54 Preterm labor (PTL)
method of choice, 55 FFN, 123, 124
pelvic floor imaging, 57–58 preterm birth
routine use, 56 definition, 119
second stage of labor, 54–55 digital cervical examination, 119
single scan or serial scans, 55 physical examination, 119
uterine EMG monitor, 151 risk factors, 119
LaborPro system. See Trig Medical’s LaborPro system TVU CL
advantages, 119–120
algorithm, 123, 124
O induction of labor, 125, 126
Occiput posterior (OP) position PPROM, 123–125
asynclitism prostaglandin induction agent, 128–129
direct OP position, 79 PTL symptoms prediction, 120–123
left occiput position, 79–80 recommendations, 120
right occiput position, 80, 81 spontaneous onset of labor, 125, 127–128
squint sign, 80, 81 Preterm premature rupture of membranes (PPROM),
digital examination, 61 119, 123–125
digital exploration, 102–103 Prostaglandin induction agent, 128–129
2D ultrasound
cephalic malposition, 103
digital assessment, 103–104 S
fetal spine orientation, 104 Scalp edema, 113
longitudinal assessment, 104 SonoVCAD TM Labor software, 24, 26
physiologic vertex delivery, 103 Stalled labor
suprapubic, 104 cephalic rotation, 24
epidural analgesia, 71 fetal head position, 20, 24
etiology of, 64–67 fetal head station, 20
induction of labor, 70 progression of labor
maternal and fetal landmark identification, 63, 64 angle of progression, 20, 22
maternal and neonatal outcomes, 66 head direction, 22, 23
normal spontaneous vaginal delivery progression distance, 22–24
anterior rotation, 68, 70 SonoVCAD TM Labor software, 24
fetal spine and head position, 70 Subfascial hematoma, 142, 143
LOP and ROP position, 68
manual rotation, 70
transabdominal ultrasound, 70 T
prevalence of, 61 Thrombophilia
transabdominal ultrasound examination intrapartum ultrasonography
longitudinal section, 61, 62 deep venous thrombosis, 144
transverse view, 61–63 femoral vein thrombosis, 143, 144
transvaginal approach, 63, 64 inherited, 144–145
Index 187
LMWH dosage, 145 arc-like pathway, 89

pulmonary embolism, 143 delivery time, 92–94
risk factors, pregnancy, 144 intraobserver variability, 90–91
pharmacological treatment, 145–146 population, 89
Transabdominal ultrasound pubic symphysis, 90–92
2D ultrasound pubic symphysis and ischial spines, 96–97
anterior occiput position, 32 sagittal view, 90, 92, 93
axial and longitudinal, 31 suboccipitobregmatic diameter, 89
vs. digital examination, 29–30 validation, 94–96
fetal occipital position and indices, 34 2D ultrasound, 32, 34, 35
head engagement, 31–32 fetal head station, 2–4
midline intracranial structures, 30 angle of progression, 97–99
fetal head position fetal head-perineum distance, 89
anterior occiput position, 4, 5 linear measurements, 88
asynclitism, 77 prediction intervals, 91–92
left posterior occiput position with anterior pubic symphysis, 88–89
left asynclitism, 10 ultrasound probe position, 88
left transverse occiput position with posterior maternal and fetal landmark identification,
asynclitism, 9 63, 64
median posterior occiput position with left Transvaginal ultrasound cervical length (TVU CL)
asynclitism, 11 advantages, 119–120
posterior occiput position, 12 algorithm, 123, 124
right anterior occiput position with posterior induction of labor, 125, 126
right asynclitism, 11 PPROM, 123–125
right posterior occiput position with posterior prostaglandin induction agent, 128–129
asynclitism, 12 PTL symptoms prediction, 120–123
right transverse occiput position with anterior recommendations, 120
asynclitism, 10 spontaneous onset of labor, 125, 127–128
transabdominal ultrasound, 18, 19 Trig Medical’s LaborPro system
transverse occiput position, 4, 6 cervical dilatation and pelvic diameters, 157
occiput posterior (OP) position components, 155
longitudinal section, 61, 62 3-D graphical display, 155, 156
normal spontaneous vaginal delivery, 70 fetal head position, station, and descent, 155–156
transverse view, 61–63 safety, 156
vs. vaginal digital examination, 67–68
Translabial ultrasound. See also Intrapartum translabial
ultrasound (ITU) U
3D acquisition, 36–39 Ultrasound probes, 15
progression angle measurement, 67
three-dimentional, 2
Transperineal ultrasound V
angle of progression, fetal head descent Vaginal birth after cesarean section (VBAC), 163
Acknowledgment
I express my personal thanks to Antonio Dell’Aquila, young great drawer, designer and artist, able to
illustrate many chapters with some beautiful and detailed pictures. I hope his future can be rewarding
and can contribute to the illustration of many other books and publications with the precision and
detail of which he is capable.
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Intrapartum Ultrasonography

for Labor Management

ISBN 978-3-642-29938-4 ISBN 978-3-642-29939-1 (eBook)

Library of Congress Control Number: 2012952508

© Springer-Verlag Berlin Heidelberg 2012

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Ultrasound has revolutionized the traditional midwife, and semiotics in par-

Bari, Italy Antonio Malvasi, M.D.

1 Clinical Evaluation of Labor and Intrapartum

10 Use of Cervical Length in Labor and Delivery. . . . . . . . . . . . . 119

Torbjørn Moe Eggebø, Ph.D. Department of Obstetrics and Gynecology,

Yoav Paltieli, M.D., Ph.D., LLB Division of Infertility,

1.1 Introduction cardboard boxes to simulate cervical examina-

The accuracy and intraobserver variability of

A. Malvasi (ed.), Intrapartum Ultrasonography for Labor Management, 1

60 74 81 88 95 102 110 115 122 160

Computed angles (°)

Fig. 1.3 Intrapartum transabdominal

Fig. 1.4 Intrapartum transabdominal

Fig. 1.5 Intrapartum transabdominal

Fig. 1.6 Intrapartum transabdominal

Fig. 1.7 Intrapartum transabdominal

Fig. 1.8 Intrapartum transabdominal

Fig. 1.9 Intrapartum transabdominal

Fig. 1.10 Intrapartum transabdominal

Fig. 1.11 Intrapartum transabdominal sonography

Fig. 1.12 Intrapartum transabdominal

Fig. 1.13 Intrapartum transabdominal

Fig. 1.14 Intrapartum transabdominal

Fig. 1.15 Intrapartum transabdominal

2.1 Introduction 2.2 General Intrapartum

A. Malvasi (ed.), Intrapartum Ultrasonography for Labor Management, 15

Fig. 2.1 (continued)

2.3 Ultrasound Use in Labor 2.3.1 Ultrasound Use to Determine

precise application of the vacuum extractor. In number of C-sections is increasing in an unjustified

Evidently, when such rotations resulted in ante-

particularly important in multiple births; intrapartum changes [44–47]. The exploration of

3.1 Background have been incorporated into routine clinical man-

A. Malvasi (ed.), Intrapartum Ultrasonography for Labor Management, 29

Latent phase Active phase

Phase of maximum slope

Sacral Occiput above

Fig. 3.3 (continued)

first stage of labor and observed a progressive

3.2.3 Transvaginal Ultrasound

Transvaginal ultrasound is widely used for the

transducers. To obtain a transperineal picture the 3.2.4 Uterine Cervix Sonoelastography

3.3 3D Ultrasound sonographic volume and the production of a rendered

Fig. 3.11 Intrapartum translabial 3D ultrasound acquisition

without vaginal penetration. We successfully 68 patients using hourly translabial 3D ultrasound

Fig. 3.12 Intrapartum translabial 3D ultrasound of uterine cervix anatomical landmarks

3.4 Conclusion – Toward a is another promising new technology that might

A. Malvasi (ed.), Intrapartum Ultrasonography for Labor Management, 41

Fig. 4.3 (a) Levels of a

accuracy of station diagnosis with digital exami- 4.4 Cardinal Movements

Fig. 4.5 (continued)

Fig. 4.5 (continued)