General Intrapartum Sonography Setup and Use in Labor

Transcription

1 Generl Intrprtum Sonogrphy Setup nd Use in Lor 2 Miguel Angel Brer, Frncisc S. Molin, Mrgrit Medin, Azhr Romero, nd Jose A. Grci-Hernndez 2.1 Introduction We re currently witnessing chnge in ostetrics. For more thn 10 yers, ostetric sonogrphy hs een the min dignostic tool ville to specilists. Currently, the prediction of conditions such s preeclmpsi, preterm lor, or plcentl insuf fi ciency within the context of intruterine growth restriction is sed on ultrsound use. It is logicl to hypothesize tht sonogrphy could ply signi fi cnt, expnded role in lor mngement nd ssistnce, prticulrly in situtions tht require quick ostetric decisions sed on clinicl explortions tht re sujective nd hve considerle lerning curve. M.A. Brer, M.D., Ph.D. ( ) Prentl Dignosis nd Fetl Therpy Unit, Deprtment of Ostetrics nd Gynecology, Insulr nd Mternl Universitry Hospitlry Complex (CHUIMIC), Ls Plms of Grnd Cnry, Spin Deprtment of Ostetrics nd Gynecology, Cnries University Hospitl Mternity Wrd, Avenid mritim del sur sn., Ls Plms de Grn Cnri, Spin e-mil: [email protected] F.S. Molin, M.D., Ph.D. Mternl-Fetl Medicine Unit, Deprtment of Ostetrics nd Gynecology, Sn Cecilio University Hospitl (HUSC), Grnd, Spin M. Medin, M.D. A. Romero, M.D. J.A. Grci-Hernndez, M.D., Ph.D. Prentl Dignosis nd Fetl Therpy Unit, Deprtment of Ostetrics nd Gynecology, Insulr nd Mternl Universitry Hospitlry Complex (CHUIMIC), Ls Plms of Grnd Cnry, Spin 2.2 Generl Intrprtum Ultrsound Setup Portle Ultrsound Recent chnges in the pro fi le of the ultrsound mchine hve een fundmentl for its more generl use in the delivery room nd hve mde sonogrphy much more effective in smll nd dynmic spce, compred to the lrge ultrsound mchines used during consulttion. While the use of ultrsound is the prerogtive of ech individul exminer nd depends on the mchine t hnd, we hve used this type of mchine in our center to conduct studies relted to sonogrphic pplictions in the delivery room [ 1 ] Ultrsound Proes Ultrsound explortions cn e performed either trnsdominlly nd/or trnsperinelly. We recommend the use of convex dominl proe nd dominl 3D-4D ultrsound. Our group generlly uses the RIC5-9H proe y Generl Electric. During intrprtum sonogrphy, we generlly do not use proes for vginl explortion Exminer The use of sonogrphy in the delivery room is not yet routine for ll ostetric services. A. Mlvsi (ed.), Intrprtum Ultrsonogrphy for Lor Mngement, DOI / _2, Springer-Verlg Berlin Heidelerg

2 16 M.A. Brer et l. Historiclly, there hs een gp etween ostetricins with delivery room trining nd ostetricins with greter sonogrphy skills. Consequently, numer of ultrsound pplictions re not used in the delivery room ecuse of the delivering ostetricin s lck of experience with their use. Intrprtum ultrsound explortions must e conducted y experts in sonogrphy or y ostetricins who re experts in lor ssistnce nd who hve received the necessry sonogrphy trining ecuse decisions out the delivery route re often sed on sonogrphy results Explortion Techniques Bsed on our experience, the most pproprite mternl position for determining the fetl hed descent in the mternl pelvis is the dorsl lithotomy position [ 2 ] ; to determine the fetl hed position with respect to the pelvis in the nterior or posterior position, one cn opt for the decuitus supine position [ 3 ]. Prior ldder-emptying fcilittes visuliztion nd stndrdizes the mesurements. For dominl explortion, the dominl proe (convex or 3D) must e plced trnsverslly in the suprpuic region of the mternl domen; for trnslil or trnsperinel explortion, the dominl proe must e plced inside ruer glove covered with ultrsound gel nd then plced longitudinlly in the medil sgittl position etween oth li mjor, elow the symphysis puis (Fig. 2.1 d ). If mesurements re needed during studies conducted with 3D proe, it is very importnt to keep the ptient still during the procedure; to identify the medil sgittl plne, where the long xis of the symphysis puis nd the fetl hed cn e identi fi ed prior to strting; nd to lightly tilt the proe to prevent shdow from eing produced y the symphysis puis over the fetl hed [ 4 ]. The imge otined is shown in Fig. 2.2,, in which recognizle mternl nd fetl structures re indicted. Fig. 2.1 The ultrsound scn of fetl hed During the lor, in longitudinl nd trnsverse section nd in soprpuic (or trnsdominl) supuis (or trnslil) scn. ( ) The figures shows the soprpuic sgittl scn of the fetl hed. ( ) The figures shows trnsverse scn of fetl hed sovpruic. ( c ) The figures show the supuic sgittl (or trnslil) scn of fetl hed. ( d ) The figures show the trnsversl sonogrm of fetl hed (or trnslil) under the simphisis

3 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor 17 c d Fig. 2.1 (continued) Fig. 2.2 ( ) Sgittl section of femle pelvis t term of pregnncy in the fi rst stge of lor nd trnsvginl sonogrphy: the lines pssing through the scn represent the min longitudinl nd trnsverse scns. ( ) Imge otined fter intrprtum sgittl medil trnslil explortion; indictes the mternl puis, indictes the fetl hed, nd c indictes the fetl cput succedneum Tle 2.1 Recommended ultrsound settings [4] 1 Lowest possile ngle of insontion 2 Lower output frequency 3 Highest insontion depth 4 Wide volumetric re with low sound volume Ghi et l. [ 4 ] suggest series of settings for the cquisition of dequte intrprtum fetl hed nd mternl pelvis volumes (Tle 2.1 ) Determining the Type of Explortion Ultrsound explortion in the delivery room cn e useful for two purposes: fi rst, to document the fetl hed position in reltion to the mternl pelvis (e.g., efore n instrumentl delivery), nd second, to determine lor progression. These two purposes re undoutedly the prmeters of most interest in the intrprtum study.

4 18 M.A. Brer et l. Fetl hed descent in the mternl pelvis, rottion, nd fetl hed direction cn e evluted to determine whether lor is progressing dequtely. summrized s serving two purposes: determining fetl hed position in reltion to the mternl pelvis nd ojectively documenting indequte progression of lor. 2.3 Ultrsound Use in Lor The use of intrprtum ultrsound hs een widely discussed in the lst fi ve yers. Different studies discuss the uses of ultrsound in the delivery room [ 1, 5 ]. Some of these uses re considered sic nd do not require signi fi cnt level of speciliztion in ostetric sonogrphy [ 1 ], such s with excluding or con fi rming fetl deth, determining fetl sttus, determining fetl iometry to estimte pproximte weight, nd determining the degree of fl exion of the fetl hed. When descriing the uses of ultrsound in the delivery room, these indictions cnnot e forgotten; however, they will not e the most importnt indictions when ptient is in lor [ 1 ]. Other uses of intrprtum sonogrphy, such s mniotic fl uid evlution nd plcent locliztion, should e conducted within fetl pthophysiology nd not within the delivery room [ 1 ]. In Tle 2.2, we provide clssi fi ction system tht we creted to clssify the uses of intrprtum sonogrphy [ 1 ]. Prcticlly speking nd to the est of our knowledge, ultrsound use during lor cn e Tle 2.2 Clssi fi ction of ultrsound uses in the intrprtum setting [ 1 ] 1. Bsic uses Identifiction of fetl hertet Determintion of fetl presenttion Attinment of somtometry; determintion of estimted fetl weight (to detect fetl mcrosomi) Plcentl loction Determintion of the degree of cephlic fl exion (podlic irth) Assistnce in the irth of the second twin Postprtum metrorrhgi 2. Advnced uses Determintion of fetl hed position Dignosis of stlled lor Assessment of intrprtum fetl well-eing (intrprtum Doppler) Ultrsound Use to Determine Fetl Hed Position The digitl determintion of the fetl hed position using n ostetric explortion tht requires trining is gretly in fl uenced y the loring womn s degree of cervicl diltion nd hs dded dif fi culties with the presence of cput succedneum or synclitism. Some studies hve shown tht the digitl determintion of fetl hed position with respect to the mternl pelvis during lor is not exct [ 6, 7 ]. Likewise, Akml et l. [ 8 ] conducted study of 496 dominl ultrsounds fter digitl explortion nd found tht fetl hed position could not e determined vi vginl touch in 33% of the cses, especilly in cses with occipitoposterior positions [ 9 ]. Souk et l. [ 10 ] could not determine fetl hed position in 61% of sujects during the fi rst stge of lor nd in 31% during the second stge. In study of 44 pregnnt women in the intrprtum setting, Kreise et l. [ 11 ] found erroneous interprettions of fetl hed position in 30% of cses fter digitl explortion. Dupuis et l. [ 12 ] found 70% concordnce of oth methods in determining fetl hed position, with more dif fi culties oserved in cses with cput succedneum nd posterior positions. Chou et l. [ 13 ] found greter precision for determining occipitoposterior positions with trnsdominl ultrsound thn with vginl touch (92% vs. 72%, respectively). Zhlk et l. [ 14 ] compred the use of vginl touch, trnsdominl ultrsound, nd trnsvginl ultrsound to determine fetl hed position nd found tht trnsvginl ultrsound ws the most exct method. In our center, which hd n verge of 7,900 irths in the lst 10 yers nd n verge C-section rte lower thn 12%, we elieve tht there is no sustitute for dequte clinicl mngement; however, the mjority of

5 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor 19 Fig. 2.3 ( ) 2D trnsdominl ultrsound in cross section during lor with fetl hed in medin occiput posterior position. ( ) Intrprtum trnsdominl ultrsound (suprpuic trnsverse) of ptient in the second stge of lor with the fetus in the occipitoposterior position. Note tht oth orits re directed towrd the ultrsound trnsducer delivering ostetricins fi nd tht trnsdominl or trnslil ultrsound is useful for determining fetl hed position, primrily t the point t which n instrumentl delivery is indicted [ 15 ]. In other centers with perhps less clinicl experience, ultrsound could e useful for decresing the numer of C-sections performed defensively y ostetricins who wish to void the possiility of complicted delivery [ 16 ]. In recently pulished rticle, we evluted the usefulness of trnsdominl ultrsound to determine fetl hed position during the fi rst nd second stges of lor in 86 consecutive ptients [1 ]. With the ptient in the decuitus supine position or the dorsl lithotomy position fter ldderemptying, we plced the dominl proe trnsverslly in the suprpuic re. The fetl hed position ws de fi ned y the identi fi ction of the orits (occipitoposterior), midline echo (occipitotrnsverse), nd cereellum or column (occipitonterior) [17 ] (Fig. 2.3, ). Using trnsvginl explortion followed y trnsdominl ultrsound, we did not fi nd signi fi cnt differences etween these methods ility to determine the fetl hed position. Cliniclly, it ws possile to determine fetl hed position in 93% of the ptients in the fi rst stge of lor nd in 96% of the ptients in the second stge of lor, nd there ws concordnce with the ultrsound results in 98% of the cses. A ody mss index in the top 15% of women ws the only signi fi cnt fctor tht mde trnsdominl ultrsound explortion dif fi cult, while the presence of cput succedneum ws importnt for determining fetl hed position [1 ]. Instrumentl delivery with forceps or vcuum requires wreness of the fetl hed position ecuse the incorrect ppliction of these instruments cn led to dverse results. Wong et l. [ 18 ] rndomized 50 ptients with prolonged second stge of lor prior to vcuum extrction to digitl pelvic explortion only or trnsdominl ultrsound explortion in conjunction with digitl explortion. The uthors showed tht including ultrsound llowed more

6 20 M.A. Brer et l. precise ppliction of the vcuum extrctor. In our studies, we determined the exct clinicl nd ultrsound fetl hed position prior to the ppliction of forceps in 13 cses. In our center, which hs C-section rte of pproximtely 12% nd forceps delivery rte of 14%, it is impertive to determine the fetl hed position for etter lor mngement. In contrst, Akml et l. [ 19 ] studied 64 lors prior to instrumentl delivery nd found tht digitl explortion filed to determine the fetl hed position in 26% of the cses. The existence of higher C-section rte or the use of vcuum extrction s the instrumentl technique of choice my e responsile for the inccurcy of fetl hed position determintion vi trnsvginl explortion. The differences in the pulished dt demonstrte the need for prospective study to more precisely specify the usefulness of ultrsound to determine the fetl hed position prior to n instrumentl delivery. To lesser extent, studies hve lso descried the determintion of fetl hed position using 3D trnsperinel ultrsound [ 20 ]. In our center, we otined 20 cptures of sutures nd fontnels using trnslil ultrsound with trnsdominl proe. Such volumetric cptures llow us to identify the sutures nd fontnels of the fetl hed, which is useful prior to n instrumentl delivery or when deciding whether to llow vginl delivery ttempt or perform C-section (Fig. 2.4, ). The ojective informtion out the fetl hed position tht 2D or 3D ultrsound provides prior to n instrumentl delivery ppers to e mong the most useful dt for decresing the numer of C-sections or dverse results fter the indequte performnce of instrumentl deliveries Ultrsound Use for Dignosing Stlled Lor If the fetl hed position is nterior, posterior, or trnsverse, ultrsound is clerly wrrnted to determine the exct fetl position efore delivery; however, using ultrsound during delivery cn lso provide ojective dt for dignosing indequte progression of lor [ 8, 21 ]. Currently, the numer of C-sections is incresing in n unjusti fi ed mnner, often due to the prctice of defensive medicine. We commented previously on the impreciseness of digitl touch for the evlution of the fetl hed position reltive to the mternl pelvis [22]; the comintion of ultrsound explortion with clinicl explortion could e useful for decresing the numer of C-sections. The inccurcy of clinicl exmintion during lor hs lso een demonstrted regrding the descent of the hed cross the different plnes of the mternl pelvis. Dupuis et l. [ 23 ] investigted the reliility of trnsvginl ssessment of fetl hed sttion using newly designed irth simultor. A fetl hed mnnequin ws plced in one of the 11 Americn College of Ostetricins nd Gynecologists (ACOG) sttions in irth simultor equipped with rel-time miniturized sensor. The opertors (32 residents nd 25 ostetricins) then determined the hed position cliniclly. The ACOG position ws incorrectly determined in 50 88% of cses for residents nd in 36 80% of cses for ostetricins, depending on the position. When the sttions were exmined in groups (high, midpelvis, low, nd outlet), the men group error ws 30% (95% CI: 25 35%) for residents nd 34% (95% CI: 27 41%) for ostetricins. Alrmingly, the group errors show tht the misdignosis of sttion s midpelvic rther thn high-pelvic ccounted for 88% nd 67% of the errors mde y residents nd ostetricins, respectively. This misdignosis cn hve serious implictions for the mngement of ptients in lor. To determine the progression of lor using either 2D or 3D sonogrphy, the explortion must e performed trnslilly. The ptient must e plced in semicurved position with fl exed legs, nd mniotomy is recommended [ 24 ]. The ultrsound trnsducer is plced in the medil sgittl plne, etween the li mjor nd precisely elow the symphysis puis. Severl studies hve used ultrsound to provide n ojective mesure of hed progression in lor: The most importnt mesurement is the ngle of progression of the fetl hed, descried s the ngle etween line through the midline of the puic symphysis nd line from the infe-

7 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor 21 Fig. 2.4 Drwing of sutures nd fontnels nd ours digitl plptions: ( A ) coronl sutures; ( B ) frontl sutures; ( C ) nterior fontnel (regm or mjor fontnel); ( D ) occipitl sutures; ( E ) circumference posterior fontnel or lmdoid suture or smll fontnel; ( F ) prietl suture (or sgittl suture). O occiput, S sinciput. ( ) Identifiction of sutures nd fontnels using 3D ultrsound in ptient during the second stge of lor. Note tht the lmdoid fontnels re to the right in fetus with n occipitonterior position

8 22 M.A. Brer et l. Fig. 2.5 ( ) Ultrsound imge nd drwing demonstrting the ngle of fetl hed progression, descried s the ngle etween line through the midline of the puic symphysis ( continuous yellow line ) nd line from the inferior pex of the symphysis to the leding prt of the fetl skull ( interrupted red line ). ( ) The imge shows the equivlent digrm of the ngle of the progression of the fetl hed rior pex of the symphysis to the leding prt of the fetl skull (Fig. 2.5, ). An ngle of progression of 120 or greter is n excellent predictor of successful vginl delivery. Klche et l. [ 25 ] evluted this mesurement prospectively in women t term with filure to progress in the second stge of lor. Logistic regression nlysis showed strong reltionship etween the ngle of progression nd the need for cesren delivery. When the ngle of progression ws 120, the fi tted proility of either n esy nd successful vcuum extrction or spontneous vginl delivery ws 90%. The sme ngle ws mesured y Brer et l. [ 2, 26 ] in 88 term loring ptients. The uthors descried good intr- nd interoserver vriility for mesurements tht were less thn 3. Their dt showed tht n ngle of t lest 120 ws lwys ssocited with susequent spontneous vginl delivery. Hed direction : Defined y Hernich [27 ] s the ngle etween the infrpuic line of the pelvis ( line perpendiculr to the longer dimeter of the puis strting from the inferior order) nd nother line drwn perpendiculr to the widest dimeter of the fetl hed (Fig. 2.6, ). Using this technique, three types of hed directions were determined: hed down, horizontl, nd hed up. Hed up is when the line perpendiculr to the widest dimeter of the fetl hed points ventrlly t n ngle of ³ 30 ; hed down is when this ngle is <0 ; ll other ngles re considered horizontl. The hed direction, together with the descent in the mternl pelvis, is good indictor of successful vginl delivery. An upwrd direction of the fetl hed is good prognostic sign for vginl delivery, in contrst with downwrd or horizontl hed direction [22 ]. Progression distnce : De fi ned y Dietz et l. [28 ] s the minimum distnce etween line through the inferoposterior mrgin of the symphysis puis nd the order of the fetl skullcp (Fig. 2.7, ). This indictor is useful mrker for the determintion of fetl hed sttion. Informtion out the degree of fetl hed descent is necessry prior to the use of forceps or vcuum. It my e helpful to determine these mesurements when determining fetl hed sttion [ 29, 30 ]. The results of one of our studies compring ll the mesurements of 50

9 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor 23 Fig. 2.6 ( ) Ultrsound imge nd drwing demonstrting the fetl hed direction, descried s the ngle etween verticl line from the inferior pex of the symphysis ( yellow line ) nd line drwn perpendiculr to the widest dimeter of the fetl hed ( red rrow ). ( ) The ultrsound imge shows the corresponding ngle of the direction of the fetl hed in the irth cnl Fig. 2.7 ( ) Ultrsound imge nd drwing demonstrting the progression distnce of the hed, descried s the distnce ( red line ) etween verticl line from the inferior pex of the symphysis ( yellow line ) to the leding edge of the fetl skull. ( ) The ultrsound imge shows the distnce of progression of the fetl hed in the irth cnl women in the second stge of lor indicted tht ngle progression hs the est intr- nd interoserver reproduciility when studying fetl hed progression during lor [ 31 ]. With the systemtic use of these prmeters in women for whom no or indequte progression of lor is dignosticlly suspected, we could ojectively demonstrte the presence of such

10 24 M.A. Brer et l. Fig. 2.8 The drwing schemtizes the rottion ngle of 45, from 1 (inlet pelvis) to 2 (midpelvis), of the fetl hed during lor in childirth y ultrsound trnsdominl dignoses. These prmeters would result in more ccurte dignoses nd more exct indictioplens for C-sections. The determintion of fetl hed position my e of interest in cses of stlled lor [ ]. We know tht posterior positions present higher risk of indequte lor progression (with episiotomy, instrumentl delivery, C-section delivery, nd oxytocin nd ergotmine derivtive infusion), perinel ter, nd puerperl leeding [36 ]. Furthermore, the degree of cephlic rottion cn e comined with fetl hed sttion. In our center, we evluted 80 cses during the expulsive period to determine cephlic rottions in comprison with the ctive phse of lor. We considered the existence of rottion when trnsdominl ultrsound reveled progressions from the rin midline greter thn 45º compred with the nteroposterior dimeter of the mternl pelvis. Vginl deliveries were chieved in 95% of the cses in which we were le to demonstrte rottion greter thn 45º. In contrst, only 60% of the cses in which it ws impossile to demonstrte such rottion delivered vginlly. Evidently, when such rottions resulted in nterior positions, the sitution ws more fvorle, producing vginl irths in 87% of the cses [ 1 ] (Fig. 2.8, ). Ghi et l. [ 30 ] recommend not llowing vginl irth nd evluting the possiility of C-section in cses without rottions or with rottions greter thn 45º from the nteroposterior dimeter of the midline. The cretion of the SonoVCAD TM Lor softwre hs llowed us to otin three simultneous mesurements: hed direction, ngle of progression, nd progression distnce. This evlution is conducted in the intrprtum setting nd cn e used to ojectively demonstrte cses with n indequte progression of lor. No retrospective studies hve yet evluted this tool or indicted which prmeter is the est predictor of vginl irth. In study y Molin et l. [ 22 ], the ngle of progression ws descried s the most esily reproducile mesurement. This mesurement seems to e the est option to e comined with clinicl explortion to more precisely determine which C-sections result from the indequte progression of lor. One inconvenience such mesurements present is the technicl need for portle ultrsound mchine nd speci fi c softwre, which represent dditionl costs. Another spect to resolve is the need for posteriori or of fl ine evlutions long with the need for sonogrphic skills, prticulrly the use of 3D ultrsound, which not ll ostetricins hve. It is very prole tht once these technicl dif fi culties re eliminted, the ojective dignosis of indequte lor progression could ecome the min use of intrprtum sonogrphy Other Uses There re vrious sic ultrsound uses tht do not require signi fi cnt level of speciliztion in ostetric sonogrphy [ 1 ] (Tle 2.2 ). These uses include ruling out or con fi rming fetl deth when the womn in lor does not report fetl movements or when the fetl hert rte cnnot e detected; determining fetl position, which is

11 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor 25 prticulrly importnt in multiple irths; con fi rming the fetl sttion or presenttion; determining fetl iometry to estimte weight in cses of clinicl suspicion of mcrosomy; nd determining the degree of fetl hed fl exion, primrily in cses with reech presenttions [ 37, 38 ]. Shipp et l. [ 39 ] de fi ne fetl hed hyperextension s the persistence of the cervicl column in mximl extension (greter thn 150º). In our center, we evluted cephlic fl exion prior to podlic irth using dominl rdiology. In 26 ultrsound evlutions, we were le to identify the existence or sence of cervicl fl exion in reech presenttion deliveries, demonstrting tht dominl rdiology ws useful option [ 1 ]. In such cses, we considered the existence of cephlic fl exion when we found n ngle of 90º or less etween the fetl column nd the se of the skull. Other uses of intrprtum sonogrphy should e included in the fetl pthophysiology nd not conducted in the delivery room, lthough such uses my hve indictions in speci fi c situtions in the delivery room, such s mniotic fl uid evlution or determining plcentl loction [ 40 ]. In cses of intrprtum or postprtum metrorrhgi, ultrsound studies cn help determine plcentl loction or the retention of plcentl remins nd cn help dignose plcentl cretism [ 41, 42 ]. Among the previously discussed dvnced uses of intrprtum sonogrphy, the determintion of fetl hed position nd the dignosis of indequte progression of lor re undoutedly the most importnt; s such, they re the focus of the mjority of the studies [ 43 ]. However, we must lso consider those studies conducted with Doppler ultrsound. We support the ssurnce of the fetus intrprtum well-eing with electronic fetl monitoring nd cid se equilirium mesurement. Accordingly, we hve evluted the use of fetl vsculr Doppler studies for such purposes nd hve studied the following structures: the uterine rteries, umilicl rtery, medil cererl rtery, nd the ductus venosus. We know tht the uterine rteries nd the medil cererl rtery undergo modi fi ctions in reltion to uterine contrctions; in contrst, the umilicl rtery does not chnge in reltion to the uterine dynmic. It is unknown whether the ductus venosus undergoes intrprtum chnges [ ]. The explortion of fetl vessels cn e very dif fi cult in the intrprtum setting ecuse in mny cses, our ptients re experiencing intense pin or re under the effects of epidurl nlgesi. The fetl hed my e very engged or in n unfvorle position for the study of the cererl medil rtery. We used Doppler to mesure the cererl medil rtery during the fi rst nd second stges of lor in 78 cses, nd it ws impossile for us to determine differences etween oth men mesurements. We could not demonstrte chnge in rin perfusion when we compred oth stges of lor. In contrst, the explortions were highly complex, nd we experienced gret dif fi culty with otining wves of suf fi cient qulity to otin pproprite pulstility indices. Currently, there is no evidence of the usefulness of intrprtum Doppler ultrsound to mnge fetl well-eing [ 1 ]. Different pulictions hve exmined the possile usefulness of color Doppler to detect nuchl cord [48 ] ; however, we find this informtion somewht limited ecuse no possiilities for intervention exist, nd detection could crete unnecessry lrm. Likewise, studies continue to present new possiilities for ultrsound use in the delivery room [ 49 ], thus positioning this suject s mjor topic for future ostetrics reserch. Conclusions Ultrsound is n essentil tool in contemporry ostetrics. Its use hs een generlized to the point tht we hve trnsitioned from ostetrics ultrsound to ultrsonogrphic ostetrics [50 ]. The screening of diseses such s preeclmpsi or premturity is currently sustntited y ultrsound. This generliztion of ultrsound use coincides with focus on the use of ultrsound t the time of delivery. In the lst fi ve yers, different pulictions hve ttempted to clrify the possile uses of ultrsound in the delivery room [51, 52 ] nd fi nd ojective dt tht cn provide guidnce during lor progression [ 53 ]. Ostetricin interest hs fvored the development of intrprtum sonogrphy, nd the development of esily portle mchines, 3D technologies, nd explortion softwre hs

12 26 M.A. Brer et l. Fig. 2.9 Sonogrphic dignosis of fetl presenttion in lor ( ) sonogrphic dignosis of rech presenttion. ( ) n ultrsonogrphic dignosis of twin pregnncy in fcilitted more in-depth intrprtum studies nd more frequent pulictions regrding intrprtum sonogrphy. Despite these dvnces, the mjority of hospitls do not provide ultrsound mchines to delivery room doctors, nd in mny cses, delivering physicins do not hve the trining necessry to conduct n ultrsound explortion under such conditions. The ppropriteness of mny of the indictions ttriuted to intrprtum sonogrphy hs not yet een vlidted with prospective studies. Nevertheless, the possiilities of intrprtum sonogrphy hve een gining cceptnce with the ppernce of stndrdized pplictions nd the incorportion of ojective dt, such s the ngle of progression, tht hve pplictions for dily clinicl use. It is necessry to de fi nitively stndrdize these dt nd methods for using ultrsound explortion in the delivery room with loring women. Studies hve exmined the use of oth the dominl route nd the trnslil route to evlute the position nd descent of the fetl hed. To the est of our knowledge, fetl hed position should e evluted trnsdominlly, nd descent nd enggement should e evluted trnslilly. The mesurement of the ngle of progression with trnslil ultrsound in the second stge of lor is the most lor, with the fi rst fetus in rech presenttion nd second fetus in cephlic presenttion useful wy to evlute the fetl hed s descent into the irth cnl. Three-dimensionl sonogrphy is incresingly used in ostetrics, nd intrprtum sonogrphy is no exception. The identi fi ction of sutures nd fontnels through the rendering mode cn e used to clssify the fetl hed position. SonoVCAD TM Lor softwre for volume clcultion uses volumes cquired through trnslil ultrsound. These volumes llow for the dequte evlution of lor progression nd enle the clinicin to tke pertinent clinicl ction. References 1. Brer M, Gutierrez L, Plsenci W, Vlle L, Grci-Hernndez JA (2010) Role of ultrsound in the lor wrd. J Mtern Fetl Neontl Med 30(3): Brer AF, Pomr X, Perugino G, Lezotte DC, Hoins JC (2009) A new method to ssess fetl hed descent in lor with trnsperinel ultrsound. Ultrsound Ostet Gynecol 33(3): Eggeo T, Slvesen K (2010) Ultrsound ssessment of fetl hed position. Ultrsound Ostet Gynecol 36: Ghi T, Contro E, Frin A, Noile M, Pilu G (2010) Three-dimensionl ultrsound in monitoring progression of lor: reproduciility study. Ultrsound Ostet Gynecol 36(4):

13 2 Generl Intrprtum Sonogrphy Setup nd Use in Lor Vintzileos AM, Chvez MR, Kinzler WL (2010) Use of ultrsound in the lor nd delivery. J Mtern Fetl Neontl Med 23(6): Sherer D, Miodovnik M, Brdley K, Lnger O (2002) Intrprtum fetl hed position II: comprison etween trnsvginl digitl exmintion nd trnsdominl ultrsound ssessment during the second stge of lor. Ultrsound Ostet Gynecol 19(3): Sherer D, Miodovnik M, Brdley K, Lnger O (2002) Intrprtum fetl hed position I: comprison etween trnsvginl digitl exmintion nd trnsdominl ultrsound ssessment during the ctive stge of lor. Ultrsound Ostet Gynecol 19(3): Akml S, Tsoi E, Kmets N, Howrd R, Nicolides K (2002) Intrprtum sonogrphy to determine fetl hed position. J Mtern Fetl Neontl Med 12(3): Akml S, Tsoi E, Nicolides K (2004) Intrprtum sonogrphy to determine fetl occipitl position: interoserver greement. Ultrsound Ostet Gynecol 24(4): Souk A, Hritos T, Bsyinnis K, Noikokyri N, Antsklis A (2003) Intrprtum ultrsound for the exmintion of the fetl hed position in norml nd ostructed lor. J Mtern Fetl Neontl Med 13(1): Kreiser D, Schiff E, Lipitz S, Kym Z, Avrhm A, Achiron R (2001) Determintion of fetl occiput position y ultrsound during the second stge of lor. J Mtern Fetl Med 10(4): Dupuis O, Ruimrk S, Corinne D, Simone T, André D, René-Chrles R (2005) Fetl hed position during the second stge of lor: comprison of digitl vginl exmintion nd trnsdominl ultrsonogrphic exmintion. Eur J Ostet Gynecol Reprod Biol 123(2): Chou M, Kreiser D, Tslimi M, Druzin M, El-Syed Y (2004) Vginl versus ultrsound exmintion of fetl occiput position during the second stge of lor. Am J Ostet Gynecol 191(2): Zhlk N, Sdn O, Mlinger G, Lierti M, Boz M, Glezermn M et l (2005) Comprison of trnsvginl sonogrphy with digitl exmintion nd trnsdominl sonogrphy for the determintion of fetl hed position in the second stge of lor. Am J Ostet Gynecol 193(2): Agrwl U, Bricker L, Alfirevic Z (2011) The use of 3D ultrsound for the prediction of success of vginl irth prior to instrumentl delivery. Arch Dis Child Fetl Neontl Ed 96:F Dückelmnn AM, Michelis SA, Bmerg C, Dudenhusen JW, Klche KD (2011) Impct of intrprtl ultrsound to ssess fetl hed position nd sttion on the type of ostetricl interventions t full cervicl dilttion. J Mtern Fetl Neontl Med 25(5): Ryurn W, Siemers K, Legino L, Nity M, Anderson J, Ptil K (1989) Dystoci in lte lor: determining fetl position y clinicl nd ultrsonic techniques. Am J Perintol 6(3): Wong G, Mok Y, Wong S (2007) Trnsdominl ultrsound ssessment of the fetl hed nd the ccurcy of vcuum cup ppliction. Int J Gynecol Ostet 98(2): Akml S, Kmets N, Tsoi E, Hrgreves C, Nicolides K (2003) Comprison of trnsvginl digitl exmintion with intrprtum sonogrphy to determine fetl hed position efore instrumentl delivery. Ultrsound Ostet Gynecol 21(5): Fuchs I, Tutschek B, Henrich W (2008) Visuliztion of the fetl fontnels nd skull y three-dimensionl trnslil ultrsound during the second stge of lor. Ultrsound Ostet Gynecol 31: Sherer D, Aulfi O (2003) Intrprtum ssessment of fetl hed enggement: comprison etween trnsvginl digitl nd trnsdominl ultrsound determintions. Ultrsound Ostet Gynecol 21(5): Molin F, Nicolides K (2010) Ultrsound in lor nd delivery. Fetl Dign Ther 27: Dupuis O, Silveir R, Zentner A, Dittmr A, Guchernd P, Cuchert M, Redrce T, Rudigoz RC (2005) Birth simultor: reliility of trnsvginl ssessment of fetl hed sttion s de fi ned y the Americn College of Ostetricins nd Gynecologists clssi fi ction. Am J Ostet Gynecol 192: Torkildsen EA, Slvesen KÅ, Eggeø TM (2011) Prediction of delivery mode with trnsperinel ultrsound in women with prolonged fi rst stge of lor. Ultrsound Ostet Gynecol 37(6): Klche K, Dückelmnn A, Michelis S, Lnge J, Cichon G, Dudenhusen J (2009) Trnsperinel ultrsound imging in prolonged second stge of lor with occipitonterior presenting fetuses: how well does the ngle of progression predict the mode of delivery? Ultrsound Ostet Gynecol 33(3): Brer A, Imni F, Becker T, Lezotte D, Hoins J (2009) Antomic reltionship etween the puic symphysis nd ischil spines nd its clinicl signi fi cnce in the ssessment of fetl hed enggement nd sttion during lor. Ultrsound Ostet Gynecol 33(3): Henrich W, Dudenhusen J, Fuchs I, Kämen A, Tutschek B (2006) Intrprtum trnslil ultrsound (ITU): sonogrphic lndmrks nd correltion with successful vcuum extrction. Ultrsoxund Ostet Gynecol 28(6): Dietz H, Lnzrone V (2005) Mesuring enggement of the fetl hed: vlidity nd reproduciility of new ultrsound technique. Ultrsound Ostet Gynecol 25(2): Dückelmnn AM, Bmerg C, Michelis SA, Lnge J, Nonnenmcher A, Dudenhusen JW, Klche KD (2010) Mesurement of fetl hed descent using the ngle of progression on trnsperinel ultrsound imging is relile regrdless of fetl hed sttion or ultrsound expertise. Ultrsound Ostet Gynecol 35(2): Ghi T, Frin A, Pedrzzi A, Rizzo N, Pelusi G, Pilu G (2009) Dignosis of sttion nd rottion of the fetl hed in the second stge of lor with intrprtum

14 28 M.A. Brer et l. trnslil ultrsound. Ultrsound Ostet Gynecol 33(3): Molin FS, Terr R, Crrillo MP, Puerts A, Nicolides KH (2010) Wht is the most relile ultrsound prmeter for ssessment of fetl hed descent? Ultrsound Ostet Gynecol 36(4): Dietz H, Bennet M (2002) Cn we predict the course of lour? Aust N Z J Ostet Gynecol 42:S Senécl J, Xiong X, Frser W (2005) Effect of fetl position on second-stge durtion nd lor outcome. Ostet Gynecol 105(4): Dietz H, Lnzrone V, Simpson J (2006) Predicting opertive delivery. Ultrsound Ostet Gynecol 27(4): Dietz H, Lnzrone V (2004) Predicting delivery mode. Ultrsound Ostet Gynecol 24: Akml S, Tsoi E, Howrd R, Osei E, Nicolides K (2004) Investigtion of occiput posterior delivery y intrprtum sonogrphy. Ultrsound Ostet Gynecol 24(4): Hezell A, Rouf S, Bhtti N, Smewing S (2004) A prospective study of the use of ultrsound scnning on the delivery suite. Ultrsound Ostet Gynecol 24(3): Sen S, Mjumdr A (2006) Is there ny role of ultrsound in the lor wrd nd delivery suite? Ultrsound Ostet Gynecol 26(4): Shipp T, Bromley B, Bencerrf B (2000) The prognostic signi fi cnce of hyperextension of the fetl hed detected ntentlly with ultrsound. Ultrsound Ostet Gynecol 15(5): Sherer D (2007) Intrprtum ultrsound. Ultrsound Ostet Gynecol 30(2): McEwing R (2007) Prentl dignosis of plcent ccret: new sonogrphic mrker? Ultrsound Ostet Gynecol 30(4): Dens R, Dietz H (2006) Ultrsound of the post-prtum uterus. Aust N Z J Ostet Gynecol 46(4): Verhoeven CJ, Rückert ME, Opmeer BC, Pjkrt E, Mol BW (2012) Ultrsonogrphic fetl hed position to predict mode of delivery: systemtic review nd ivrite met-nlysis. Ultrsound Ostet Gynecol 40(1): Jnu T, Nesheim B (1987) Uterine rtery lood velocities during contrctions in pregnncy nd lour relted to intruterine pressure. Br J Ostet Gynecol 94: Kssnos D, Siristtidis C, Vitortos N, Slmlekis E, Cretss G (2003) The clinicl signi fi cnce of Doppler fi ndings in fetl middle cererl rtery during lor. Eur J Ostet Gynecol Reprod Biol 109(1): Fleischer A, Anyegunm A, Schulmn H, Frmkides G, Rndolph G (1987) Uterine nd umilicl rtery velocimetry during norml lor. Am J Ostet Gynecol 157(1): Krpp M, Denzel S, Ktlinic A, Berg C, Smrcek J, Geipel A et l (2002) Norml vlues of fetl ductus venosus lood fl ow wveforms during the fi rst stge of lor. Ultrsound Ostet Gynecol 19: Qin Y, Wng C, Lu T, Rogers M (2000) Color ultrsonogrphy: useful technique in the identi fi ction of nuchl cord during lor. Ultrsound Ostet Gynecol 15(5): Ghi T, Youssef A, Pilu G, Mlvsi A, Rgus A (2012) Intrprtum sonogrphic imging of fetl hed synclitism. Ultrsound Ostet Gynecol 39(2): Ville Y (2006) From ostetrics ultrsound to ultrsonogrphic ostetrics. Ultrsound Ostet Gynecol 27(1): Ugwumdu A (2002) The role of ultrsound on the lor wrd. Ultrsound Ostet Gynecol 19(3): Sherer D, Onyeije C, Bernstein P, Kovcs P, Mnning F (1999) Utiliztion of rel-time ultrsound on lor nd delivery in n ctive cdemic teching hospitl. Am J Perintol 16(6): Yeo L, Romero R (2009) Sonogrphic evlution in the second stge of lor to improve the ssessment of lor progress nd its outcome. Ultrsound Ostet Gynecol 33(3):

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