1. UOG Journal Club: April 2013
Intrapartum transperineal ultrasound assessment of fetal head progression
in active second stage of labor and mode of delivery
T. Ghi, A. Youssef, E. Maroni, T. Arcangeli, F. De Musso, F. Bellussi, M. Nanni,
F. Giorgetta, A. M. Morselli-Labate, M. T. Iammarino, A. Paccapelo, L. Cariello,
N. Rizzo, G. Pilu
Volume 41, Issue 4, Date: April 2013, pages 430–435
Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Y. Gilboa, Z. Kivilevich, M. Spira, E. Katorza, O. Moran, R. Achiron
Volume 41, Issue 4, Date: April 2013, pages 436–441
Journal Club slides prepared by Dr Aly Youssef
(UOG Editor for Trainees)

2. UOG Journal Club: April 2013
Intrapartum transperineal ultrasound assessment of the fetal head
progression in the active second stage and the mode of delivery
T. Ghi, A. Youssef, E. Maroni, T. Arcangeli, F. De Musso, F. Bellussi, M. Nanni,
F. Giorgetta, A. M. Morselli-Labate, M. T. Iammarino, A. Paccapelo, L. Cariello,
N. Rizzo, G. Pilu
Volume 41, Issue 4, Date: April 2013, pages 430–435

3. • Digital examination in labor is inaccurate and poorly
reproducible
• Intrapartum transperineal ultrasonography has been
suggested as an objective and reliable method in
assessing fetal head descent and rotation
• Many transperineal ultrasound parameters have been
studied. However, very little is known about the dynamic
changes and clinical usefulness of these parameters in the
second stage of labor

4. Two transperineal ultrasound parameters
were assessed in the present study
Fetal skull
Maternal
symphysis
pubis ANGLE OF MIDLINE
PROGRESSION ANGLE
Fetal head
midline
Angle of progression Midline angle
(AoP) (MLA)
• The angle between the pubic symphysis • The angle between the antero-posterior axis
and a line tangential to the fetal skull of maternal pelvis and the head midline
• Assessed in a mid-sagittal view • Assessed in a transverse view

5. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Objectives
1. Evaluate by 3D ultrasound the longitudinal changes of two
transperineal parameters (AoP and MLA) during the active second
stage of labor.
2. To assess if the sonographic changes of these two parameters are
affected by the mode of delivery.

6. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Methods
Transperineal ultrasound volumes were acquired from a series of nulliparous
women at term in the active second stage of labor
Inclusion criteria Exclusion criteria
1. Uncomplicated singleton 1) Cesarean delivery during the first
pregnancies at term gestation (37 stage of labor
weeks or more) 2) Cesarean or instrumental vaginal
2. Fetuses in cephalic presentation delivery performed in the second
stage purely due to an abnormal fetal
heart trace

7. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Methods
• 3D volumes were acquired at the beginning of the active second
stage (T1), and every 20 minutes thereafter (T2, T3, T4, T5, and T6)
until delivery
• Both AoP and MLA were calculated after delivery and compared
between patients who underwent spontaneous vaginal vs operative
delivery (instrumental or Cesarean delivery)
• Univariate and multivariate regression analyses were performed
including the two ultrasound parameters in addition to various
intrapartum and maternal variables to determine independent
predictors of operative delivery in the second stage

8. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Results
76 recruited women
3 excluded due to operative delivery for abnormal
fetal heart trace
2 excluded due to Cesarean delivery in
the first stage of labor
71 women
(174 acquired 3D volumes)
58 (81.7%) 13 (18.3%)
spontaneous vaginal delivery operative delivery
8 5
vacuum Cesarean

9. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Results
• Women who underwent a spontaneous vaginal delivery had a wider
angle of progression at T1 and T2 when compared with women who
underwent operative delivery
• On the other hand, women who underwent spontaneous vaginal
delivery had a narrower midline angle at T3, T4 and T5

10. Intrapartum transperineal ultrasound assessment of fetal head progression in
active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Results
• On univariate regression analysis, all parameters (including epidural
analgesia, maternal age, BMI and oxytocin use) except gestational
age were significantly associated with operative delivery
• On multivariate analysis of only ultrasound parameters, both AoP and
MLA were independently associated with operative delivery
• When maternal and intrapartum variables were also considered in
the multivariate analysis, only AoP, epidural analgesia and
maternal age were significantly associated with operative delivery

11. Intrapartum transperineal ultrasound assessment of fetal head progression in
the active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Discussion
• Ultrasonographic evidence of poor fetal head descent (as assessed by
the angle of progression) can be detected as early as the beginning of
the active second stage in cases undergoing operative delivery
• A slower head rotation in these cases (as assessed by midline angle)
seems to be a late finding (at least 40 minutes from the beginning of the
active second stage)
• The evaluated ultrasonographic parameters may help predict the mode
of delivery together with factors such as epidural analgesia and maternal
age

12. Intrapartum transperineal ultrasound assessment of fetal head progression in
the active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Limitations
• The limited number of patients who underwent operative delivery did not
permit a separate analysis of the women who underwent vacuum from
those who were submitted to cesarean delivery
• As all vacuum extractions were successful, no data on the prediction of
instrumental delivery success could be provided
• The fetal occiput position was not sonographically determined at the
beginning of the second stage so the data could not be stratified
according to the fetal head position
• All ultrasound evaluations were performed in the absence of uterine
contractions and maternal pushing

13. Intrapartum transperineal ultrasound assessment of fetal head progression in
the active second stage of labor and mode of delivery
Ghi et al., UOG 2013
Future perspectives
• Larger studies are needed to evaluate the predictive value of
ultrasound for the type of operative delivery (vacuum or forceps vs
Cesarean delivery)
• Further studies are needed to investigate the value of the dynamic
changes during uterine contractions and maternal pushing in the
prediction of the mode of delivery
• The role of ultrasound in the subset of fetuses with posterior occiput
remain to be elucidated

14. UOG Journal Club: April 2013
Head progression distance in prolonged second stage of
labor: relationship with mode of delivery and fetal head
station
Y. Gilboa, Z. Kivilevich, M. Spira, E. Katorza, O. Moran, R. Achiron
Volume 41, Issue 4, Date: April 2013, pages 436–441

15. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Maternal
symphysis pubis
Fetal head
progression
distance (HPD)
The fetal head progression distance (HPD) represents a line connecting the most distally presenting part of
the fetal head to the infra-pubic line (-----), a vertical line from the lower edge of the pubic symphysis

16. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
The aim of this study was to assess the clinical significance, and
utility, of the fetal head progression distance in predicting the
mode of delivery during prolonged second stage

17. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Methods
65 term women with prolonged second stage of labor were included
Inclusion criteria
1. Fetal head station below the ischial spines
2. Normal fetal heart rate monitoring
• Following digital evaluation of fetal head station, HPD was measured during
maternal pushing by an operator blinded to clinical examination
• The mode of delivery was decided by an obstetrician blinded to ultrasound findings
• Binary logistic regression analysis was performed to evaluate the predictive value
of the fetal head progression distance for the mode of delivery

18. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Results
65 women with prolonged second stage
(174 acquired 3D volumes)
17 (26.2%) 48 (73.8%)
Spontaneous vaginal delivery Operative delivery
32 5 11
vacuum forceps Cesarean

19. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Results
• A positive correlation was demonstrated between mean HPD and
fetal head station, and between HPD and neonatal head
circumference
• No statistically significant differences between HPD for the
various modes of delivery
• Multivariate analysis adjusted for maternal age, gestational age,
maternal BMI, parity, previous CS, fetal gender, neonatal head
circumference and head position did not show a significant
association between HPD and mode of delivery

20. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
No correlation was found between HPD and various
classification the mode of delivery
MOD1 MOD 2 MOD 3
Spearman's correlation
coefficient
-0.077 -0.037 -0.121
P value (2-tailed) 0.541 0.771 0.364
MOD1 : Spontaneous vaginal delivery, vacuum, forceps, and Cesarean section
delivery as four separated groups
MOD2 : Spontaneous vaginal delivery vs operative deliveries (vacuum, forceps,
and Cesarean section delivery) as two separated groups
MOD3 : Spontaneous vaginal delivery, instrumental deliveries (vacuum,
forceps) and Cesarean section delivery, as three separated groups

21. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Discussion
• The present study confirms the correlation between clinical
assessment of fetal head station and HPD during labor
• Despite this positive correlation, no statistically significant
correlation, or predictive value, was found between HPD and
mode of delivery
• Despite the lack of predictive value for HPD measurement in
determining mode of delivery, the finding that HPD correlates well
with fetal head station suggests its usefulness as an ancillary tool
for assessing fetal head descent during labor

22. Head progression distance in prolonged second stage of labor: relationship
with mode of delivery and fetal head station
Gilboa et al., UOG 2013
Limitations
• Small sample size, due to the relatively low number of women who
reach prolonged second stage
• Lack of comparison to women in the first stage of labor
Future perspectives
A larger prospective study, including patients evaluated during the first
stage of labor, as well as the second, is required to further assess the
HPD measurement in the clinical management of labor

23. Intrapartum transperineal ultrasound Head progression distance in
assessment of fetal head progression prolonged second stage of labor:
in active second stage of labor and relationship with mode of delivery
mode of delivery and fetal head station
Ghi et al., UOG 2013 Gilboa et al., UOG 2013
Discussion points
• Should ultrasound be routinely used in the labor ward for fetal head
progression assessment?
• What are the most reliable ultrasound parameters for monitoring fetal
head descent?
• What is the clinical situation in which ultrasound may have a role in
labor?
• How should ultrasound be included in the algorithms of different clinical
scenarios?