Department of Medicine and Surgery, Obstetrics and Gynaecology Unit, University of Parma, Parma, Italy.
Department of Obstetrics and Gynecology, Sant'Anna Hospital, University of Turin, Turin, Italy.
Am J Obstet Gynecol. 2019 Dec;221(6):642.e1-642.e13. doi: 10.1016/j.ajog.2019.09.045. Epub 2019 Oct 4.
A limited number of studies have addressed the role of intrapartum ultrasound in the prediction of the mode of delivery in women with prolonged second stage of labor.
The objective of the study was to evaluate the role of transabdominal and transperineal sonographic findings in the prediction of spontaneous vaginal delivery among nulliparous women with prolonged second stage of labor.
This was a 2-center prospective study conducted at 2 tertiary maternity units. Nulliparous women with a prolonged active second stage of labor, as defined by active pushing lasting more than 120 minutes, were eligible for inclusion. Transabdominal ultrasound to evaluate the fetal head position and transperineal ultrasound for the measurement of the midline angle, the head-perineum distance, and the head-symphysis distance were performed in between uterine contractions and maternal pushes. At transperineal ultrasound the angle of progression was measured at rest and at the peak of maternal pushing effort. The delta angle of progression was defined as the difference between the angle of progression measured during active pushing at the peak of maternal effort and the angle of progression at rest. The sonographic findings of women who had spontaneous vaginal delivery vs those who required obstetric intervention, either vacuum extraction or cesarean delivery, were evaluated and compared.
Overall, 109 were women included. Spontaneous vaginal delivery and obstetric intervention were recorded in 40 (36.7%) and 69 (63.3%) patients, respectively. Spontaneous vaginal delivery was associated with a higher rate of occiput anterior position (90% vs 53.2%, P < .0001), lower head-perineum distance and head-symphysis distance (33.2 ± 7.8 mm vs 40.1 ± 9.5 mm, P = .001, and 13.1 ± 4.6 mm vs 19.5 ± 8.4 mm, P < .001, respectively), narrower midline angle (29.6° ± 15.3° vs 54.2° ± 23.6°, P < .001) and wider angle of progression at the acme of the pushing effort (153.3° ± 19.8° vs 141.8° ± 25.7°, P = .02) and delta-angle of progression (17.3° ± 12.9° vs 12.5° ± 11.0°, P = .04). At logistic regression analysis, only the midline angle and the head-symphysis distance proved to be independent predictors of spontaneous vaginal delivery. More specifically, the area under the curve for the prediction of spontaneous vaginal delivery was 0.80, 95% confidence interval (0.69-0.92), P < .001, and 0.74, 95% confidence interval (0.65-0.83), P = .002, for the midline angle and for the head-symphysis distance, respectively.
Transabdominal and transperineal intrapartum ultrasound parameters can predict the likelihood of spontaneous vaginal delivery in nulliparous women with prolonged second stage of labor.
已有少量研究探讨了产程中超声在预测第二产程延长的产妇分娩方式中的作用。
本研究旨在评估经腹和经会阴超声在预测第二产程延长的初产妇自然分娩中的作用。
这是在 2 家三级妇产医院进行的 2 中心前瞻性研究。纳入符合活跃期第二产程延长标准（定义为主动分娩持续超过 120 分钟）的初产妇。在子宫收缩和产妇推挤之间进行经腹超声评估胎儿头部位置，经会阴超声测量中线角度、头会阴距离和头耻骨距离。在经会阴超声中，测量休息时和产妇用力推挤时的进展角度。进展角差定义为最大用力推挤时测量的进展角与休息时的进展角之差。比较和评估自然分娩与需产科干预（真空抽吸或剖宫产）的产妇的经会阴超声表现。
共有 109 名产妇纳入研究。自然分娩和产科干预分别发生在 40 名（36.7%）和 69 名（63.3%）患者中。自然分娩与枕前位（90%比 53.2%，P<.0001）、较小的头会阴距离和头耻骨距离（33.2 ± 7.8 mm 比 40.1 ± 9.5 mm，P=.001，和 13.1 ± 4.6 mm 比 19.5 ± 8.4 mm，P<.001）、较小的中线角度（29.6°±15.3°比 54.2°±23.6°，P<.001）、最大用力推挤时更大的进展角（153.3°±19.8°比 141.8°±25.7°，P=.02）和更大的进展角差（17.3°±12.9°比 12.5°±11.0°，P=.04）相关。在逻辑回归分析中，只有中线角度和头耻骨距离被证明是自然分娩的独立预测因素。具体而言，预测自然分娩的曲线下面积分别为 0.80（95%置信区间为 0.69-0.92），P<.001，和 0.74（95%置信区间为 0.65-0.83），P=.002，用于中线角度和头耻骨距离。
经腹和经会阴产程超声参数可预测第二产程延长的初产妇自然分娩的可能性。
