S. Usman

A model to predict vaginal delivery in nulliparous women based on maternal characteristics and intrapartum ultrasound

OBJECTIVEnAccurate prediction of whether a nulliparous woman will have a vaginal delivery would be a major advance in obstetrics. The objective of the study was to develop such a model based on maternal characteristics and the results of intrapartum ultrasound.nnnSTUDY DESIGNnOne hundred twenty-two nulliparous women in the first stage of labor were included in a prospective observational 2-centre study. Labor was classified as prolonged according to the respective countries national guidelines. Fetal head position was assessed with transabdominal ultrasound and cervical dilatation by digital examination, and transperineal ultrasound was used to determine head-perineum distance and the presence of caput succedaneum. The subjects were divided into a testing set (n = 61) and a validation set (n = 61) and a risk score derived using multivariable logistic regression with vaginal birth as the outcome, which was dichotomized into no/cesarean delivery and yes/vaginal birth. Covariates included head-perineum distance, caput succedaneum, and occiput posterior position, which were dichotomized respectively into the following: ≤40 mm, >40 mm, <10 mm, ≥10 mm, and no, yes. Maternal age, gestational age, and maternal body mass index were included as continuous covariates.nnnRESULTSnDichotomized score is significantly associated with vaginal delivery (P = .03). Women with a score above the median had greater than 10 times the odds of having a vaginal delivery as compared with those with a score below the median. The receiver-operating characteristic curve showed an area under the curve of 0.853 (95% confidence interval, 0.678-1.000).nnnCONCLUSIONnA risk score based on maternal characteristics and intrapartum findings can predict vaginal delivery in nulliparous women in the first stage of labor.

Sonographic prediction of outcome of vacuum deliveries: a multicenter, prospective cohort study

BACKGROUND: Safe management of the second stage of labor is of great importance. Unnecessary interventions should be avoided and correct timing of interventions should be focused. Ultrasound assessment of fetal position and station has a potential to improve the precision in diagnosing and managing prolonged or arrested labors. The decision to perform vacuum delivery is traditionally based on subjective assessment by digital vaginal examination and clinical expertise and there is currently no method of objectively quantifying the likelihood of successful delivery. Prolonged attempts at vacuum delivery are associated with neonatal morbidity and maternal trauma, especially so if the procedure is unsuccessful and a cesarean is performed. OBJECTIVE: The aim of the study was to assess if ultrasound measurements of fetal position and station can predict duration of vacuum extractions, mode of delivery, and fetal outcome in nulliparous women with prolonged second stage of labor. STUDY DESIGN: We performed a prospective cohort study in nulliparous women at term with prolonged second stage of labor in 7 European maternity units from 2013 through 2016. Fetal head position and station were determined using transabdominal and transperineal ultrasound, respectively. Our preliminary clinical experience assessing head‐perineum distance prior to vacuum delivery suggested that we should set 25 mm for the power calculation, a level corresponding roughly to +2 below the ischial spines. The main outcome was duration of vacuum extraction in relation to ultrasound measured head‐perineum distance with a predefined cut‐off of 25 mm, and 220 women were needed to discriminate between groups using a hazard ratio of 1.5 with 80% power and alpha 5%. Secondary outcomes were delivery mode and umbilical artery cord blood samples after birth. The time interval was evaluated using survival analyses, and the outcomes of delivery were evaluated using receiver operating characteristic curves and descriptive statistics. Results were analyzed according to intention to treat. RESULTS: The study population comprised 222 women. The duration of vacuum extraction was shorter in women with head‐perineum distance ≤25 mm (log rank test <0.01). The estimated median duration in women with head‐perineum distance ≤25 mm was 6.0 (95% confidence interval, 5.2–6.8) minutes vs 8.0 (95% confidence interval, 7.1–8.9) minutes in women with head‐perineum distance >25 mm. The head‐perineum distance was associated with spontaneous delivery with area under the curve 83% (95% confidence interval, 77–89%) and associated with cesarean with area under the curve 83% (95% confidence interval, 74–92%). In women with head‐perineum distance ≤35 mm, 7/181 (3.9%) were delivered by cesarean vs 9/41 (22.0%) in women with head‐perineum distance >35 mm (P <.01). Ultrasound‐assessed position was occiput anterior in 73%. Only 3/138 (2.2%) fetuses in occiput anterior position and head‐perineum distance ≤35 mm vs 6/17 (35.3%) with nonocciput anterior position and head‐perineum distance >35 mm were delivered by cesarean. Umbilical cord arterial pH <7.10 occurred in 2/144 (1.4%) women with head‐perineum distance ≤35 mm compared to 8/40 (20.0%) with head‐perineum distance >35 mm (P < .01). CONCLUSION: Ultrasound has the potential to predict labor outcome in women with prolonged second stage of labor. The information obtained could guide whether vacuum delivery should be attempted or if cesarean is preferable, whether senior staff should be in attendance, and if the vacuum attempt should be performed in the operating theater.

The feasibility and accuracy of ultrasound assessment in the labor room

Abstract Objective: Vaginal examination is widely used to assess the progress of labor; however, it is subjective and poorly reproducible. We aim to assess the feasibility and accuracy of transabdominal and transperineal ultrasound compared to vaginal examination in the assessment of labor and its progress. Methods: Women were recruited as they presented for assessment of labor to a tertiary inner city maternity service. Paired vaginal and ultrasound assessments were performed in 192 women at 24–42 weeks. Fetal head position was assessed by transabdominal ultrasound defined in relation to the occiput position transformed to a 12-hour clock face; fetal head station defined as head-perineum distance by transperineal ultrasound; cervical dilatation by anterior to posterior cervical rim measurement and caput succedaneum by skin-skull distance on transperineal ultrasound. Results: Fetal head position was recorded in 99.7% (298/299) of US and 51.5% (154/299) on vaginal examination (pu2009<u2009.00011). Bland–Altman analysis showed 95% limits of agreement, −5.31 to 4.84 clock hours. Head station was recorded in 96.3% (308/320) on vaginal examination (VE) and 95.9% (307/320) on US (pu2009=u2009.791). Head station and head perineum distance were negatively correlated (Spearman’s ru2009=u2009−.57, pu2009<u2009.0001). 54.4% (178/327) of cervical dilatation measurements were determined using US and 100% on VE/speculum (pu2009<u2009.0001). Bland–Altman analysis showed 95% limits of agreement −2.51–2.16u2009cm. The presence of caput could be assessed in 98.4% (315/320) of US and was commented in 95.3% (305/320) of VEs, with agreement for the presence of caput of 76% (pu2009<u2009.05). Fetuses with caput greater than 10u2009mm had significantly lower head station (pu2009<u2009.0001). Conclusions: We describe comprehensive ultrasound assessments in the labor room that could be translated to the assessment of women in labor. Fetal head position is unreliably determined by vaginal examination and agrees poorly with US. Head perineum distance has a moderate correlation with fetal head station in relation to the ischial spines based on vaginal examination. Cervical dilatation is not reliably assessed by ultrasound except at dilatations of less than 4u2009cm. Caput is readily quantifiable by ultrasound and its presence is associated with lower fetal head station. Transabdominal and transperineal ultrasound is feasible in the labor room with an accuracy that is generally greater than vaginal examinations.

Use of magnesium sulfate in preterm deliveries for neuroprotection of the neonate

The prevalence of preterm birth is increasing and owing to advances in neonatal care, more infants are surviving. However, in parallel with this, the incidence of cerebral palsy (CP) is also rising. Magnesium sulfate (MgSO4) is currently recommended for use in women who are at risk of giving birth at less than 30–32 weeks of gestation for neuroprotection of their infants. The exact mechanism of action remains unclear. Meta‐analyses report encouraging results that are consistent with a modest but tangible benefit for the use of MgSO4, and suggest a number needed to treat (NNT) to prevent one in 46 cases of CP in infants born preterm before 30 weeks of gestation and one in 63 cases of CP in infants born preterm before 34 weeks of gestation.

Benefits and pitfalls of the use of intrapartum ultrasound

Ultrasound in labour (intrapartum ultrasound) has come to the fore in the last decade stemming from both an increased desire for a reliable method of labour assessment coupled with increased availability of ultrasound on the delivery suite. The use of ultrasound in the delivery suite currently is predominantly for presentation, amniotic fluid and fetal heart assessment, but there is a growing acknowledgement that ultrasound parameters could be used in assessing the progress of labour, and potentially in predicting labour outcome. 1 n nThe need for an objective method of assessing labour was first recognised as early as 1977 with the first known publication on intrapartum scanning. 2 A more comprehensive review of intrapartum ultrasound, incorporating some concepts that are standard in contemporary practice was described in a Russian PhD thesis from the mid‐1990s. 3 There is the need, if not an alternative, then at least an adjunctive to digital vaginal examinations (VE). Digital VEs are associated with ascending infection to the fetus, 4 chorioamnionitis 5 and endometritis as well as reduced time to delivery in preterm labour. 5 The examination itself may also be an uncomfortable experience for the labouring woman. 6 n nIn some circumstances, digital vaginal examinations (VEs) are contraindicated, such as Placenta Praevia or Preterm Prelabour Rupture Of Membranes (PPROM). For some women with a fear of childbirth, previous sexual trauma or vaginismus, digital VEs are especially traumatic and for these women special arrangements are usually made to avoid examination except where absolutely necessary. Irrespective of these concerns, digital VE is a notoriously subjective technique and agreement between observers is frequently poor. 7 , 8

Questionnaires, Surveys, Scales in Surgical Research: Concepts and Methodology

Appropriate data gathering is the key to a successful study, and the methods employed will invariably influence the results obtained and conclusions eventually drawn. This chapter works through different methods of data gathering techniques, namely, surveys, questionnaires and scales, discussing the concepts behind the development of such tools as well as their relative merits and drawbacks.

P06.10: Prediction of emergency Caesarean sections: does umbilicocerebral ratio have a role to play?: Poster discussion hub abstracts

had a longer induction-to-delivery duration in comparison with those with non-OP position. Conclusions: Fetal occiput and spine positions are dynamic in a considerable proportion of women undergoing induction of labor. Furthermore, both assessments do not seem to correlate with the mode of delivery. Occiput and spine position assessment prior to induction of labor are unlikely to be clinically useful in women undergoing IOL.

Ultrasound is better tolerated than vaginal examination in and before labour

BACKGROUNDnIntrapartum ultrasound has been proposed as a method of assessing labour progress but its acceptability has not been comprehensively assessed.nnnAIMSnWe evaluated the acceptability of intrapartum ultrasound in women having vaginal examination (VE) and ultrasound (US) assessment (transabdominal (TA) and transperineal (TP)) prior to delivery, with and without regional analgesia (RA).nnnMATERIALS AND METHODSnWomen at 24-42xa0weeks gestation were included in a prospective observational cohort study. The acceptability of digital VE and TP US were assessed pre- and post-examination using the modified validated Wijma Delivery Experience Questionnaire. Acceptability scores ranged 6-36 (6 being most and 36 being least positive) in six domains: positive-trust and relax, negative-harmful to baby, worrying, painful, intrusive.nnnRESULTSnOf 119 women recruited, 104 completed both pre- and post-assessment questionnaires. Eighty-nine per cent of women were nulliparous with median gestation 40xa0+xa02xa0weeks (25-42+1 ). Thirty-two per cent had RA before assessment, 91% in total. The combined acceptability scores of both negative and positive experiences (6xa0=xa0most acceptable, 36xa0=xa0least acceptable) for VE and US pre-assessment were 15 and 7 respectively (Pxa0<xa00.0001: Mann-Whitney U-test). VE was associated with less positive / more negative domain scoring post-assessment 12 and 6, respectively (Pxa0<xa00.0001). Although RA made no difference to the perceived experience pre-VE (Pxa0=xa00.9), post-VE, women with RAs considered VEs more acceptable than those without RA (Pxa0=xa00.0022).nnnCONCLUSION(S)nThis is the first study to comprehensively assess the acceptability of VE and intrapartum US. US assessment prior to delivery is more acceptable than VE. RA ameliorated the negative experience of the VE post-assessment.

Fetal rotation during vacuum extractions for prolonged labor : a prospective cohort study

The aim of the study was to investigate fetal head rotation during vacuum extraction.

P04.06: Fetal rotation during vacuum extraction

of fetal distress (FD) in term nulliparous labour. There is currently no data on the timing and relationship of Doppler with the length of labour. Methods: Transabdominal ultrasound scans to assess fetal position and transperineal to assess head perineum distance(HPD) and caput were performed in early labour in 124 low risk women in a large London hospital 2015-16. The length of labour in those with vaginal birth was defined from 4cm in spontaneous labour and the start of syntocinon in induced/augmented labour. Labour and maternal characteristics, obstetric and immediate neonatal outcomes were obtained. Results: Of the 124 women, in 63, cerebral and umbilical Doppler was obtained allowing C/U ratio to be measured in early labour. There was no significant difference in maternal age, BMI or gestation between those where Dopplers could be measured and those where it was missing. The HPD was greater where the C/U ratio could be obtained(53.8mm; r45.4,58.2)compared to 46.9mm(r44.1,52.9) and lower cervical dilatation(2 vs. 4cm)indicating a higher fetal head station. The mean C/U ratio was no different in the NVD group (1.98,r0.98,4.22) compared to those with FD (1.65, r0.66, 3,13,p=0.426*). There was no relationship between length of labour and C/U ratio (r2=0.01, p=0.19). For FD deliveries, the relationship between C/U ratio and length of labour showed a non significant trend towards a positive relationship (r2=0.26,p=0.25). *Kruskal-wallis test #Spearmans Rank Correlation Coefficient. Conclusions: Cerebral and umbilical Doppler was more frequently measured at higher fetal head station in early labour. C/U ratio was not associated with time to delivery overall but in deliveries for fetal compromise there was a trend towards a relationship between C/U ratio and length of labour. This ongoing study is the first to explore the effect of length of labour on C/U ratio and delivery model.