Fetal head position during the second stage of labor: comparison of digital vaginal examination and transabdominal ultrasonographic examination. Eur J Obstet Gynecol Reprod Biol
To study the correlation between digital vaginal and transabdominal ultrasonographic examination of the fetal head position during the second stage of labor.
Patients (n = 110) carrying a singleton fetus in a vertex position were included. Every patient had ruptured membranes and a fully dilated cervix. Transvaginal examination was randomly performed either by a senior resident or an attending consultant. Immediately afterwards, transabdominal ultrasonography was performed by the same sonographer (OD). Both examiners were blind to each other's results. Sample size was determined by power analysis. Confidence intervals around observed rates were compared using chi-square analysis and Cohen's Kappa test. Logistic regression analysis was performed.
In 70% of cases, both clinical and ultrasound examinations indicated the same position of the fetal head (95% confidence interval, 66-78). Agreement between the two methods reached 80% (95% CI, 71.3-87) when allowing a difference of up to 45 degrees in the head rotation. Logistic regression analysis revealed that gestational age, parity, birth weight, pelvic station and examiner's experience did not significantly affect the accuracy of the examination. Caput succedaneum tended to diminish (p = 0.09) the accuracy of clinical examination. The type of fetal head position significantly affected the results. Occiput posterior and transverse head locations were associated with a significantly higher rate of clinical error (p = 0.001).
In 20% of the cases, ultrasonographic and clinical results differed significantly (i.e., >45 degrees). This rate reached 50% for occiput posterior and transverse locations. Transabdominal ultrasonography is a simple, quick and efficient way of increasing the accuracy of the assessment of fetal head position during the second stage of labor.
Available from: Asha Kamath
- "Ultrasonography is noninvasive and has been found to be more accurate for assessing position of the fetal head, during labor  . Recent studies by Sherer et al. , Chou et al. , Dupuis et al. , and Zahalka et al.  have shown that ultrasound scanning is a quick and efficient way of increasing the accuracy of the assessment of fetal head position during the second stage of labor. We would also like to highlight that ultrasound determination of fetal head may allow safe instrumental delivery if required in second stage. "
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ABSTRACT: Introduction. Recent evidence indicates that clinical examination, for determination of fetal head position, is subjective and inaccurate. Present study was aimed to compare transabdominal ultrasound for fetal head position with vaginal examination during first stage of labor. Material and Methods. This prospective study was performed at a tertiary center during a two-year period. Before or after clinically indicated vaginal examinations, transverse suprapubic transabdominal real-time ultrasound fetal head position assessment was done. Frequencies of various ultrasound depicted fetal head positions were compared with position determined at vaginal examination. Results. In only 31.5% of patients, fetal head position determinations by vaginal examinations were consistent with those obtained by ultrasound. Cohen’s Kappa test of concordance indicated a poor concordance of 0.15. Accuracy of vaginal examination increased to 66% when fetal head position at vaginal examination was recorded correct if reported within +45° of the ultrasound assessment. Rate of agreement between the two assessment methods for consultants versus residents was 36% and 26%, respectively (
). Conclusion. We found that vaginal examination was associated with a high error rate in fetal head position determination. Data supports the idea that intrapartum transabdominal ultrasound enhances correct determination of fetal head position during first stage of labor.
Available from: Marie-Julia Guittier
- "Clinical diagnosis of the OP position is difficult as it is often associated with a deflection of the fetal head, and/or fetal head swelling, and oedema of the maternal cervix [14,15]. Several studies recommend verifying the clinical diagnosis of the fetal head position with ultrasound to increase the diagnosis of OP position early in labour [16,17]. "
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ABSTRACT: To evaluate the efficacy of the hands and knees position during the first stage of labour to facilitate the rotation of the fetal head to the occiput anterior position. Randomised controlled trial. Geneva University Hospitals, Switzerland. A total of 439 women with a fetus in the occiput posterior position during the first stage of labour. The women in the intervention group were invited to take a hands and knees position for at least for 10 minutes. Women allocated to the control group received the usual care. For both groups, 15 minutes after randomisation, women completed a short questionnaire to report their perceived pain and the comfort of their position. The rotation of the fetal head in occiput anterior position confirmed by ultrasonography 1 hour after randomisation. One hour after the randomisation, 35 of 203 (17%) fetuses were diagnosed as being in the occiput anterior position in the intervention group compared with 24 of 209 (12%) in the control group. This difference was not statistically significant (relative risk 1.50; 95% CI 0.93–2.43; P = 0.13). The change in the evaluation of comfort between the randomisation and 15 minutes after showed an improvement in 70 and 39 women, no change in 82 and 78 women and a decrease in 56 and 86 women in the intervention and control groups, respectively (P = 0.02). This study could not demonstrate a benefit of the hands and knees position to correct the occiput posterior position of the fetus during the first stage of labour, but the women reported an increase in their comfort level. Hands and knees position does not facilitate rotation into occiput anterior but increases the comfort level of women.
Available from: Emmanuel Gilles Simon
- "L'e ´ valuation de la position de la tête foetale semble plus difficile dans les varié té s posté rieures et transverses par rapport aux varié té s anté rieures. De même pour les varié té s droites en comparaison aux gauches  . L'erreur la plus fré quente au toucher vaginal est de se tromper de 1808. "
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ABSTRACT: In the second stage of labor, fetal head rotation and fetal head position are determinant for the management of labor to attempt a vaginal delivery or a cesarean section. However, digital examination is highly subjective. Nowadays, delivery rooms are often equipped with compact and high performance ultrasound systems. The clinical examination can be easily completed by quantified and reproducible methods. Transabdominal ultrasonography is a well-known and efficient way to determine the fetal head position. Nevertheless, ultrasound approach to assess fetal head descent is less widespread. We can use translabial or transperineal way to evaluate fetal head position. We describe precisely two different types of methods: the linear methods (3 different types) and the angles of progression (4 different types of measurement). Among all those methods, the main pelvic landmarks are the symphysis pubis and the fetal skull. The angle of progression appears promising but the assessment was restricted to occipitoanterior fetal position cases. In the coming years, ultrasound will likely play a greater role in the management of labor.
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