Vaginal versus ultrasound examination of fetal occiput position during the second stage of labor

OBJECTIVE: The purpose of this study was to determine whether ultrasonography is more accurate than vaginal examination in the determination of fetal occiput position in the second stage of labor. STUDY DESIGN: Eighty-eight patients in the second stage of labor were evaluated by vaginal examination and by combined transabdominal and transperineal ultrasound examination to determine occiput position. These predictions of position were compared with the actual delivery position at vaginal delivery after spontaneous restitution or at cesarean delivery. Different examiners performed the vaginal examinations and the ultrasound examinations. Each examiner was blinded to the determination of the other examiner. RESULTS: Vaginal examination determined fetal occiput position correctly 71.6% of the time; ultrasound examination determined fetal occiput position correctly 92.0% of the time (P=.018). CONCLUSION: Ultrasound examination is more accurate than vaginal examination in the diagnosis of fetal occiput position in the second stage of labor.     

Determination of fetal occiput position by ultrasound during the second stage of labor

OBJECTIVE: To investigate whether ultrasonography is superior to vaginal examination for determination of fetal occiput position during the second stage of labor. METHODS: We conducted a prospective cohort study of 44 parturients. During the second stage of labor, an attending obstetrician performed a vaginal examination to detect fetal occiput position. This was followed by combined abdominal and perineal ultrasound examination. The two methods were compared to the true position. Results were analyzed using Student's t test for quantitative parameters. McNemar's and Fisher's exact tests were applied in order to examine differences between the study groups. RESULTS: The error rate in detecting fetal occiput position was significantly lower using the ultrasound technique (6.8%) compared to vaginal examination (29.6%, p = 0.011). Parity, maternal body mass index or fetal weight had no influence on the error rate. CONCLUSIONS: Ultrasonographic determination of the fetal position is an accurate technique and is superior to vaginal examination.     

Sonographic assessment of fetal occiput position during labor for the prediction of labor dystocia and perinatal outcomes

Objectives: To evaluate the effect of the occiput posterior (OP) position on dystocia and perinatal outcomes.

Methods: This was a prospective cohort study of 162 primiparous women. We performed intrapartum sonography, and fetal occiput positions were recorded. The relationships between the position of the occiput and the course of labor and perinatal outcomes were investigated. Statistical analysis was performed using SAS 9.2.

Results: Fifty-six of 162 fetuses were found to be in the OP position during the first stage of labor. Eight (80.0%) of 10 fetuses in the OP position during the second stage were among the 56 that were in OP position during the first stage. The rate of cesarean sections performed in the OP position group during the first stage was significantly higher than the rate in the non-OP position group (37.5% versus 8.5%, p?<?0.0001). The duration of the second stage of labor was longer and neonatal complications occurred more frequently in the OP position group during the second stage than in the non-OP position group (77.9 ± 33.4?min versus 52.2 ±?26.6?min, p?=?0.0104; 50.0% versus 17.2%, p?=?0.0118).

Conclusions: The OP position may be a useful predicator for labor dystocia that can lead to poor neonatal outcomes.     

Levels of agreement between clinical examination and transabdominal ultrasound evaluation of fetal head position in the second stage of labor

Aim: To compare transvaginal digital examination performed by residents and attending physicians to transabdominal suprapubic ultrasound in the evaluation of fetal head position in the second stage of labor.

Methods: A prospective study was conducted at a tertiary center and included pregnant women at term, with normal singleton cephalic presentation fetuses. All patients had ruptured membranes and were evaluated during the second stage of labor. Fetal head position was assessed consecutively by two clinicians (one resident and one attending physician). Afterwards, transabdominal suprapubic ultrasound was performed by another observer. Examiners were blinded to each other’s findings. Cohen’s kappa test was used to assess the degree of agreement between the evaluation methods.

Results: One-hundred sixty-one women were included. Transvaginal examination was consistent with the ultrasound in 45.0% of cases (95% CI: 37–53%) when the examination was performed by residents (k?=?0.349) and in 67% (95% CI: 60–74%) if the attending physician carried out the evaluation (k?=?0.604). When considering only the anterior positions, the Cohen’s kappa test was 0.426 and 0.709, respectively.

Conclusion: Transabdominal suprapubic ultrasound improved the accuracy of the evaluation of fetal head position, namely when transvaginal digital examination was performed by residents. This may be important especially when instrumental deliveries are considered.     

Evaluation of fetal heart monitoring in the first stage of labor

Objective : To evaluate the usefulness of continuous electronic fetal heart rate (FHR) monitoring in the first stage of labor. Methods : A total of 814 pregnant women in labor without identifiable risk factors was divided into two groups. In group A (468 cases), continuous FHR monitoring began in the earliest phase of the first stage of labor (cervical dilatation &#104 4 cm), while in group B (346 cases) it began when the cervical dilatation was > 4 cm. Initial FHR tracings were normal in all 814 cases. The fetal monitoring findings were analyzed at 10-min intervals, and comparisons were made between the two groups concerning FHR findings and their correlation with the state of the newborns. Results : No significant difference was found between the two groups in the incidence of repetitive variable decelerations (1.9% and 1.7%, respectively); sporadic variable decelerations (9.2% and 8.7%, respectively); persistent repetitive late decelerations that resulted in Cesarean section (1.1% and 1.4%, respectively); or sporadic late decelerations (8.3% and 8.1%, respectively). One newborn from each group required intensive neonatal care. Conclusions : The same tracing sufficiency of fetal stress was observed in the two groups. However, the manner of labor supervision in group B seemed to be more beneficial, because of greater maternal comfort, a lower necessity for personnel, lower consumption of cardiotocographic materials and the possibility of labor induction for more women. Since fetal monitoring is widely used, it is preferable to start continuous FHR monitoring when the dilatation of the cervix approximates 4-5 cm (second phase of the first stage of labor) without risk of fetal loss.     

第二产程胎心监护异常的处理及临床意义

目的 探讨第二产程胎心监护异常者的分娩方式,及其与产妇并发症和围产儿结局的关系。方法 回顾性分析我院足月单胎头位分娩产妇第二产程中胎心率（FHR）正常的111例（对照组）和胎心率异常的121例（观察组）的资料。结果 FHR异常的发生率为52.2%（121／232）,异常胎心率类型包知中、重度变异减速（VD）81例,占66.9%;晚期减速（LD）27例,占22.3%,其中仅1例发生连续LD;延长减速（PD）4例,占3.3%;VD合并LD2例,占1.7%;VD合并PD3例,占2.5%;基线变异减弱4例,占3.3%。对照组中,阴道助产13例（11.7%）,顺产98例（88.3%）;观察组中,顺产86例（71.1%）,阴道助产35例（28.9%）,其中29例（82.9%）为FHR异常而施术者,两组间比较,差异有显著性（P＜0.05）。观察组、对照组新生儿窒息的发生率（分别为5.0%、1.8%）及产伤的发生率（14.3%、15.4%）比较,差异均无显著性（P＞0.05）;观察组中有1例产妇会阴Ⅲ度撕伤。结论 第二产程中FHR异常的发生率高,多为产程中胎头受压或脐带受压而引起的迷走神经反射或暂时性子宫胎盘血流减少,并非缺氧所致,不必急于干预,以免造成母、儿损伤。     

两种体侧卧位法纠正枕后位的临床观察

目的探讨产程中产妇采用两种不同体侧卧位纠正枕后位的临床效果.方法选择潜伏期经内诊或B超确诊为枕后位的初产妇100例,按随机表法分成同侧卧位组和对侧卧位组(各50例),分别采用同侧和对侧卧位法纠正胎方位,观察两组阴道分娩率、第1产程时间.结果(1)同侧卧位组阴道分娩34例(68%),胎儿转至枕前位27例(54%),对侧卧位组阴道分娩为22例(44%),胎儿转至枕前位12例(24%),两组比较,差异有显著性(P＜0.005).(2)同侧卧位组平均第1产程时间为(13.5±6.5)h;对侧卧位组平均第1产程时间为(17.1±7.2)h,两组比较,差异有极显著性(P＜0.01).结论产程中指导产妇取同侧卧位矫正枕后位,是提高阴道分娩率、缩短第1产程的有效方法.     

Implications of incorrect determination of fetal sex by ultrasound

Objective: To assess the experiences of women following incorrect determination of fetal sex by ultrasound. Method: A 3-year prospective cohort study of 102 women with discordance between fetal sex determined by ultrasound scan and birth sex. Participants were interviewed using 2 structured pretested questionnaires. The first questionnaire was undertaken within 24 h of delivery. The women were followed up with a second questionnaire 6–9 months later. In-depth interviews were also carried out at this time. Results: Women who had received an incorrect determination of fetal sex by ultrasound experienced marital conflicts, domestic violence, negative perceptions of ultrasound, and a desire for reversal of tubal ligation. Conclusion: Incorrect determination of fetal sex by ultrasound has implications that can affect the mental and psychological health of the mother and the upbringing of the newborn.     

持续性枕后位的临床特点及分娩方式选择

目的探讨持续性枕后位的临床特点及分娩方式。方法采用回顾性分析方法，对1998年1月至2004年12月在重庆医科大学两所附属医院住院分娩的112例持续性枕后位（枕后位组）和112例枕前位（枕前位组）的临床资料进行分析，比较两组产程情况、分娩方式及母儿结局。结果两组头位分娩评分、第一产程、第二产程及总产程时间比较，差异有显著性意义（P〈0．05）。枕后位组产钳助产、剖宫产、会阴裂伤、产后出血、胎儿窘迫、新生儿窒息率等均明显高于枕前位组，差异均有显著性意义（P〈0．05）。枕后位组宫口扩张及胎头下降延缓和第二产程延长的发生率均高于枕前位组，差异均有显著性意义（P〈0．05）。剖宫产组富口扩张延缓、胎头下降停滞和第二产程延长的发生率明显高于阴道分娩组（P〈0．05）。而剖宫产组和阴道分娩组骨盆临界狭窄、潜伏期及活跃期延长的发生率比较，差异无显著性意义（P〉0．05）。结论持续性枕后位导致母儿并发症增加，及时处理并选择最佳分娩方式可减少母儿并发症的发生。     

临床早期胎心率监测的价值

对１２３例高危产妇临床早期进行胎心监护，按Ｆｉｓｃｈｅｒ评分法分高分、中分与低分３组。结果：１．３组分娩方式、Ａｐｇａｒ评分及脐带情况差异均有显著性，（Ｐ＜０．０１）；２．监测组与未监测组Ａｐｇａｒ评分＜４分者分别为０．６１％与１．４７％，未监测组新生儿死亡率为５．５墸嗖庾槲抟焕劳觯＊３．胎心率监护图象异常组中８２．６１％伴产科临床情况异常，而正常组仅１７．３９％（Ｐ＜０．００１）；４．白天与夜间均行胎心率监护，低分组分别为５．１５％与１９．２３％，（Ｐ＜０．０５）。提示不论有无高危因素，在临床早期常规行胎心率监护，对可疑者连续或反复监测，可减少胎儿重度窒息，避免新生几死亡，对促进优生有很大的价值。     

The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries

OBJECTIVE: A forceps-assisted vaginal delivery is a well-recognized risk factor for anal sphincter injury. Some studies have shown that occiput posterior (OP) fetal head position is also associated with an increased risk for third- or fourth-degree lacerations. The objective of this study was to assess whether OP position confers an incrementally increased risk for anal sphincter injury above that present with forceps deliveries. STUDY DESIGN: This was a retrospective cohort study of 588 singleton, cephalic, forceps-assisted vaginal deliveries performed at our institution between January 1996 and October 2003. Maternal demographics, labor and delivery characteristics, and neonatal factors were examined. Statistical analysis consisted of univariate statistics, Student t test, chi2, and logistic regression. RESULTS: The prevalence of occiput anterior (OA) and OP positions was 88.4% and 11.6%, respectively. The groups were similar in age, marital status, body mass index, use of epidural, frequency of inductions, episiotomies, and shoulder dystocias. The OA group had a higher frequency of rotational forceps (16.2% vs 5.9%, P = .03), greater birth weights (3304 +/- 526 g vs 3092 +/- 777 g, P = .004), and a larger percentage of white women (48.8% vs 34.3%, P = .04). Overall, 35% of forceps deliveries resulted in a third- or fourth-degree laceration. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (51.5% vs 32.9%, P = .003), giving an odds ratio of 2.2 (CI: 1.3-3.6). In a logistic regression model that controlled for occiput posterior position, maternal body mass index, race, length of second stage, episiotomy, birth weight, and rotational forceps, OP head position was 3.1 (CI: 1.6-6.2) times more likely to be associated with anal sphincter injury than OA head position. CONCLUSION: Forceps-assisted vaginal deliveries have been associated with a greater risk for anal sphincter injury. Within this population of forceps deliveries, an OP position further increases the risk of third- or fourth-degree lacerations when compared with an OA position.     

第一产程异常胎心监护图形与新生儿结局的关系

目的　探讨第一产程异常胎心监护图形与新生儿结局的关系。方法　回顾分析 2 0 0 2年 8月至 2 0 0 3年 6月在我院足月单胎头位分娩产妇 ,第一产程中胎心率 (FHR)异常图形 2 1 7例 (观察组 )和FHR正常图形的2 6 9例 (对照组 )的临床资料。结果　第一产程异常FHR图形的发生率为 4 4 7% ,常见类型为轻度变异减速(6 4 5 % )、基线变异减弱 (2 1 6 % )和轻度心动过速 (1 2 0 % )。晚期减速、基线变异减弱和重度变异减速是导致新生儿窒息的危险因素。观察组羊水过少 (5 1 % )、脐带缠绕 (2 2 6 % )、羊水粪染 (1 0 6 % )、新生儿窒息 (6 5 % )、新生儿转入NICU(1 0 1 % )的发生率和剖宫产率 (31 8% )明显高于对照组 (P <0 0 5 )。结论　第一产程异常FHR图形的发生率较高 ,其中晚期减速、基线变异减弱、重度变异减速与新生儿窒息的发生相关 ,其他图形可在严密监护下继续试产     

Comparison of perinatal grief after dilation and evacuation or labor induction in second trimester terminations for fetal anomalies

OBJECTIVE: This study was undertaken to compare grief resolution after dilation and evacuation (D&E) or induction of labor (IOL) for second-trimester pregnancy termination. STUDY DESIGN: A prospective cohort of 49 women choosing second-trimester abortion caused by fetal anomalies by either medical IOL or D&E. Depression was evaluated by using the Edinburgh Postnatal Depression Scale and bereavement was assessed by using the Perinatal Grief Scale with follow-up to 12 months after pregnancy termination. Data were analyzed with chi 2 tests, Mann-Whitney U tests, and independent and paired sample t tests. RESULTS: There was no significant difference in depression incidence on enrollment (61.9% D&E, 53.8% IOL, P = .579), at 4 months (23.5% D&E, 14.3% IOL, P = .252) or 12 months (27.3% D&E, 20.0% IOL, P = .696) or on the PGS at 4 months (74.1 vs 90.2, P = .351) or 12 months (73.3 vs 86.4, P = .658). CONCLUSION: There is no significant difference in grief resolution among women who terminate a desired pregnancy by either medical or surgical abortion.     

Positions during the first stage and the passive second stage of labor: A survey of French midwives

Objectivethe objective of our study was to describe the practices reported by French midwives during labor (first stage and passive phase of the second stage).Designthis cross-sectional internet questionnaire surveyed French midwives who attended at least one delivery in 2013.Settingthis open survey was posted on a website from June 15 through December 1, 2014.Participants1496 midwives from 377 maternity units participated in the study. Nearly 93% of the midwives worked in an obstetric unit, 5.9% had a mixed practice, and 1.3% worked in private practice.Measurements and findingsduring the first stage of labor, midwives reported suggesting that women without epidural analgesia use a birthing ball (98.1%) and that they walk around (97.4%). For women with epidural analgesia, most suggested motion in horizontal positions. Epidural analgesia was proposed more often by midwives from level II (75.7%) and level III (73.5%) maternity wards than by those at level 1 units (57.7%) (p<0.0001). The midwives preferred a lateral position during the first stage for women with epidural analgesia and during the second stage for women both with and without it. Midwives in practice for 5 years or less suggested a kneeling position for women with epidural analgesia more often than more experienced midwives.Key conclusionthe practices of French midwives vary with their place of practice and their experience.Implications for practiceto promote normal labor, French midwives must reappropriate vertical positions and analgesic alternatives to epidurals.     

Maternal half-sitting position in the second stage of labor

The maternal half-sitting and supine position during the second stage of fullterm labor was compared in 100 women who, after identical opening phases in supine position, randomly delivered in half-sitting (50 degrees, n = 50) or supine position (n = 50). The whole duration of the second stage of labor or the time spent in active pushing did not differ between the groups. Vacuum extraction was needed twice (4%) in the group delivering in half-sitting and six times (12%) in the group delivering in supine position. Vaginal tear occurred in one mother in both groups. Early decelerations in fetal cardiotocography were seen 22 times in half-sitting and 14 times in supine group (p less than 0.05). However, late decelerations were seen in only one mother with half-sitting, as compared to five mothers with supine position. Four infants of mothers giving birth in supine position had 1 minute APGAR scores 7 or less, whereas all infants of mothers delivering in half-sitting position had APGAR scores higher than 7. Subjectively the mothers liked more the half-sitting position. We conclude that a women can deliver in half-sitting position without maternal or fetal risks.