Sherer D M, Miodovnik M, Bradley K S, Langer O
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, St Luke's Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, NY 10019, USA.
Ultrasound Obstet Gynecol. 2002 Mar;19(3):258-63. doi: 10.1046/j.1469-0705.2002.00641.x.
To test the null hypothesis that no correlation exists between transvaginal digital and the gold standard technique of transabdominal suprapubic ultrasound assessments of fetal head position during labor. A secondary objective was to compare the performance of attending physicians vs. senior residents in depicting fetal head position by transvaginal digital examination in comparison with ultrasound, respectively.
Consecutive patients in active labor at term with normal singleton cephalic-presenting fetuses were included. All participants had ruptured membranes, cervical dilation > or = 4 cm and fetal head at ischial spine station -2 or lower. Transvaginal sterile digital examinations were performed by either senior residents or attending physicians and followed immediately by transverse suprapubic transabdominal ultrasound assessments. Examiners were blinded to each other's findings. Power-analyses dictated number of subjects required. Statistical analyses included Chi-square, Cohen's Kappa test and logistic regression analysis. P < 0.05 was considered statistically significant.
One hundred and two patients were studied (n = 102). In only 24% of patients (n = 24), transvaginal digital examinations were consistent with ultrasound assessments (P = 0.002, 95% confidence interval, 16-33). Logistic regression revealed that cervical effacement (P = 0.03) and ischial spine station (P = 0.01) significantly affected the accuracy of transvaginal digital examination. Parity, gestational age, combined spinal epidural anesthesia, cervical dilation, birth weight and examiner experience did not significantly affect accuracy of the examination. The accuracy of the transvaginal digital exams was increased to 47% (n = 48) (95% confidence interval, 37-57) when fetal head position at transvaginal digital examination was recorded as correct if reported within +/- 45 degrees of the ultrasound assessment. The rate of agreement between the two assessment methods for attending physicians vs. residents was 58% vs. 33%, respectively (P = 0.02) with the +/- 45 degrees analysis.
Using ultrasound assessment as the gold standard, our data demonstrate an overall high rate of error (76%) in transvaginal digital determination of fetal head position during active labor, consistent with the null hypothesis. Attending physicians exhibited an almost two-fold higher success rate in depicting correct fetal head position by physical examination vs. residents in the +/- 45 degrees analysis. Intrapartum ultrasound increases the accuracy of fetal head position assessment during active labor and may serve as an educational tool for physicians in training.
检验无效假设，即在分娩过程中，经阴道指诊与经腹耻骨上超声评估胎儿头部位置的金标准技术之间不存在相关性。次要目的是比较主治医师与高年资住院医师分别通过经阴道指诊与超声描绘胎儿头部位置的表现。
纳入足月单胎头先露、处于活跃期分娩的连续患者。所有参与者胎膜已破，宫颈扩张≥4cm，胎儿头部位于坐骨棘水平-2或更低。由高年资住院医师或主治医师进行经阴道无菌指诊，随后立即进行耻骨上经腹横向超声评估。检查者对彼此的检查结果不知情。通过功效分析确定所需的受试者数量。统计分析包括卡方检验、科恩kappa检验和逻辑回归分析。P<0.05被认为具有统计学意义。
共研究了102例患者（n = 102）。仅24%的患者（n = 24）经阴道指诊与超声评估结果一致（P = 0.002，95%置信区间，16 - 33）。逻辑回归显示，宫颈消退（P = 0.03）和坐骨棘水平（P = 0.01）显著影响经阴道指诊的准确性。产次、孕周、腰硬联合麻醉、宫颈扩张、出生体重和检查者经验对检查准确性无显著影响。如果经阴道指诊时胎儿头部位置报告在超声评估的±45度范围内被记录为正确，则经阴道指诊的准确性提高到47%（n = 48）（95%置信区间，37 - 57）。在±45度分析中，主治医师与住院医师两种评估方法之间的一致率分别为58%和33%（P = 0.02）。
以超声评估作为金标准，我们的数据表明，在活跃期分娩期间，经阴道指诊确定胎儿头部位置的总体错误率较高（76%），与无效假设一致。在±45度分析中，主治医师通过体格检查描绘正确胎儿头部位置的成功率比住院医师高出近两倍。产时超声可提高活跃期分娩期间胎儿头部位置评估的准确性，并可作为培训医师的教育工具。
