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Original Research ajog.


The occiputespine angle: a new sonographic index
of fetal head deflexion during the first stage of labor
Tullio Ghi, MD, PhD; Federica Bellussi, MD; Carlotta Azzarone, MD; Jovana Krsmanovic, MD;
Laura Franchi, MD; Aly Youssef, MD; Jacopo Lenzi, MD; Maria Pia Fantini, MD;
Tiziana Frusca, MD; Gianluigi Pilu, MD

BACKGROUND: Fetal head attitude (relationship of fetal head to RESULTS: A total of 108 pregnant women were recruited, 79 of which
spine) in the first stage of labor may have a substantial impact on labor underwent a spontaneous vaginal delivery and 29 were submitted to ob-
outcome. The diagnosis of fetal head deflexion traditionally is based on stetric intervention (19 cesarean delivery and 10 instrumental vaginal de-
digital examination in labor, although the use of ultrasound to support liveries). The mean value of the occiput-spine angle measured in the active
clinical diagnosis has been recently reported. phase of the first stage was 126  9.8 (SD). The occiput-spine angle
OBJECTIVES: The aims of this study were: (1) to quantify the degree of measurement showed a very good intraobserver (r 0.86; 95% confi-
fetal head deflection via the use of sonography during the first stage of dence interval [95% CI] 0.80e0.90) and a fair-to-good interobserver (r
labor; and (2) to determine whether a parameter derived from ultrasound 0.64; 95% CI 0.51e0.74) agreement. The occiput-spine angle was
examination (the occiput-spine angle) has a relationship with the course significantly narrower in women who underwent obstetric intervention
and outcome of labor. (cesarean or vacuum delivery) due to labor arrest (121  10.5 vs
STUDY DESIGN: This was a prospective multicentric, cross- 127  9.4 , P .03). Multivariable logistic regression analysis showed
sectional study conducted at the Maternity Unit of the University of that narrow occiput-spine angle values (OR 1.08; 95% CI 1.001.16; P
Bologna and Parma from January 2014 to April 2015. A noncon- .04) and nulliparity (OR 16.06; 95% CI 1.71150.65; P .02) were in-
secutive series of women with uncomplicated singleton pregnancies at dependent risk factors for operative delivery. A larger occiput-spine angle
term gestation (37 weeks or more) were submitted to transabdominal width (i.e., >125 ) showed to be significantly associated with a shorter
ultrasound during the first stage of labor. If fetal position was occiput duration of labor (hazard ratio 1.62; 95% CI 1.072.45; P .02).
anterior or transverse, the angle between the fetal occiput and the CONCLUSION: We described herein the occiput-spine angle, a new
cervical spine (the occiput-spine angle) was sonographically obtained sonographic parameter to assess fetal head deflection during labor. Fe-
on the sagittal plane. The measurements of the occiput spine-angle tuses with smaller occiput-spine angle (<125 ) are at increased risk for
were performed offline by 2 operators who were blinded to the labor operative delivery.
outcome. The intra- and interobserver reproducibility and the corre-
lation between the occiput-spine angle and the mode of delivery were Key words: dystocia, failure to progress, fetal attitude, first stage of
evaluated. labor, intrapartum ultrasound, labor, malpresentation, reproducibility

T he arrest of labor progression is the

leading cause of obstetric in-
terventions, including cesarean delivery more in parous with epidural).9 Some
than the widest diameter of the birth canal
(obstetric conjugate 11 cm).19-21 The
diagnosis traditionally is based on digital
and instrumental vaginal delivery.1,2 In authors, however, have challenged this examination during labor, although
the attempt to decrease the incidence of new statement claiming that, based on the use of ultrasound to support clinical
primary cesarean delivery, the classical the available evidence, a second stage of diagnosis has been reported recently.22-25
denition of abnormal labor course3-6 labor beyond 3 hours is unsafe for the Apart from these 3 varieties, minor
has been revised recently,7-9 and a unborn infant.10,11 degrees of fetal head deexion in respect
longer duration of the second stage has Deexed cephalic presentations are of the trunk but not clinically detectable
been declared as acceptable before diag- an important cause of obstructed may be sonographically documented at
nosing a labor arrest (up to 4 hours or labor12,13 and account for one third suprapubic ultrasound. It has never been
more in nulliparous and to 3 hours or of cesarean deliveries as the result of labor established whether minor degrees of
arrest.1,2,7-9,14-17 Three varieties of fetal head deection are associated with
Cite this article as: Ghi T, Bellussi F, Azzarone C, et al. deexed cephalic malpresentations tradi- disorders of labor progression. The aims
The occiputespine angle: a new sonographic index of tionally are described according to the of this study were: (1) to quantify the
fetal head deflexion during the first stage of labor. Am J degree of head extension, including degree of fetal head deection by the use
Obstet Gynecol 2016;215:84.e1-7. sinciput, brow, and face.18 In some of of sonography during the rst stage of
0002-9378/free these cases, such as brow presentation, the labor; and (2) to determine whether a
2016 Elsevier Inc. All rights reserved. achievement of vaginal delivery is not parameter derived from ultrasound ex-
possible because the mean fetal head amination (the occiput-spine angle) has
presenting diameter (mento-occipital a relationship with the course and
diameter) is 13 cm, which is larger outcome of labor.

84.e1 American Journal of Obstetrics & Gynecology JULY 2016 OBSTETRICS Original Research

position, a 2-dimensional sagittal picture

of the fetal head and upper spine was
The technique for the The angle formed by the fetal
acquired (Figure 1) and stored in the
measurement of the occiput occiput and the cervical spine
spine angle by means of ultrasound machine. On this image, the (the occiput-spine angle) is
transabdominal ultrasound ofine measurement of the angle formed measured on the sagittal plane at
by a line tangential to the occipital bone transabdominal ultrasound: the
and a line tangential to the rst vertebral fetal head is almost completely
body of the cervical spine (occiput-spine flexed on the chest
angle) was performed to quantify the
degree of fetal head deexion in respect
of the trunk (Figures 2 and 3). For each
case, the angle was calculated twice and
independently by the 3 main in-
vestigators (J.M.K., F.B., and T.G.) to
Image devised by Tullio Ghi, MD, University of evaluate the intra- and interobserver
Parma, and drawn by Simona Morselli, graphic agreement of this measurement.
designer, Bologna, Italy. Ultrasound did not alter labor man-
Ghi et al. A new sonographic parameter to diagnose fetal agement because the examiner was not
head deexion. Am J Obstet Gynecol 2016.
involved in the patients care. Further-
more, the results of ultrasound were not Ghi et al. A new sonographic parameter to diagnose fetal
Materials and Methods made available to the clinicians man- head deexion. Am J Obstet Gynecol 2016.
A prospective, multicentric observa- aging the patient. For each patient of the
tional study with a sample of conve- study group, the labor outcome and the measurements by the same observer will
nience was carried out at the Maternity mode of delivery was assessed retro- fall for 95% of subjects. Interobserver
Unit of the University Hospital of spectively. Women submitted to obstetric agreement in occiput-spine angle mea-
Bologna and Parma. The study was interventions only due to nonreassuring surements was expressed as the Pearson
approved by the Institutional Review fetal heart rate were eventually excluded correlation coefcient (Pearson r) and the
Board of the 2 istitutions. From January because we sought to assess the rela- 2-way mixed-effects intraclass correlation
2014 to April 2015 a nonconsecutive tionship of the ultrasound ndings with coefcient, with variance components
series of low-risk pregnant women in the the risk of operative delivery due to being estimated by analysis of variance of
rst active stage of labor at or beyond 37 prolonged or arrested labor. Prolonged replicate measurements. Agreement be-
weeks of gestation were enrolled in this rst stage of labor was dened as cervical tween the 2 observers also was assessed
study. Patients were considered eligible dilatation <1.2 cm/h in nullipara and 1.5
for the study if 1 of the main in- cm/h in multipara; arrest of the rst stage
vestigators (T.G., F.B., or J.M.K.) was was dened as nonprogression of cervical FIGURE 3
available in labor ward and if cervical dilatation for >4 hours despite adequate The angle formed by the fetal
dilatation was between 3 and 6 cm, the uterine activity (35 contractions every occiput and the cervical spine
fetal head station was above the ischial 10 minutes) and rupture of membranes; (the occiput-spine angle) is
spine (level 0), and regular uterine con- prolonged second stage of labor was measured on the sagittal plane at
tractions were present. The patients dened as fetal head descent <1 cm/h in transabdominal ultrasound: the
provided a written informed consent to nullipara and <2 cm/h in multipara; ar- fetal head shows a mild degree of
participate the study. rest of the second stage was dened as
posterior deflexion in respect of
the chest
In these cases, the fetal head position lack of fetal head descent after 2 or 3
was ascertained by mean of trans- hours of active pushing in nullipara
abdominal sonography and described as (respectively without or with epidural)
on a clock face, as elsewhere reported 26 and after 1 or 2 hours in multipara
Cases in which fetal occiput was poste- (respectively without or with epidural).12
rior (between the 4- and 8-clock posi-
tion) were excluded. Additional Statistics
exclusion criteria were prelabor rupture Intraobserver agreement in occiput-spine
of membranes lasting more than 24 angle measurements was determined with
hours, obvious signs of deexed presen- the use of the Pearson correlation coef-
tation or asynclitism at digital examina- cient (Pearson r); in addition, the repeat-
tion, or abnormal cardiotocography at ability coefcient was calculated as
enrollment. In fetuses with anterior described by Bland and Altman27this Ghi et al. A new sonographic parameter to diagnose fetal
head deexion. Am J Obstet Gynecol 2016.
(right or left) or transverse (right or left) denes the range within which 2

JULY 2016 American Journal of Obstetrics & Gynecology 84.e2

Original Research OBSTETRICS

A box plot showing the Maternal, obstetric, and newborn characteristics stratified by type of
distribution of occiput-spine delivery, after exclusion of cases in which obstetric intervention
angle values according to the was performed due to nonreassuring fetal heart rate
fetal head station
Maternal, obstetric Spontaneous Operative
and newborn All, delivery delivery P
characteristics n 98 (n 79) (n 19) value
Maternal age, meanSD 32.6  5.8y 32.3  5.9y 34.2  5.4y .22
Race (%) >.99
White 88 (89.8%) 70 (88.6%) 18 (94.7%)
Asian 8 (8.2%) 7 (8.9%) 1 (5.3%)
African 2 (2.0%) 2 (2.5%) 0 (0.0%)
Body mass index, mean 26.9  3.6 kg/ 26.7  3.6 27.9  3.7 .16
The distribution of OSA values is described by Multiparity 35 (35.7%) 34 (43.0%) 1 (5.3%) <.01
displaying 5-number summary statistics. Any
observation not included between the whiskers Gestational age, wk 39.6  1.2 39.5  1.2 39.7  1.3 .44
is represented as a dot. Premature rupture of 31 (31.6%) 22 (27.8%) 9 (47.4%) .11
OSA, occiput-spine angle. membranes
Ghi et al. A new sonographic parameter to diagnose fetal
head deexion. Am J Obstet Gynecol 2016. Epidural analgesia 49 (50.0%) 37 (46.8%) 12 (63.2%) .31
Induction of labor 56 (57.1%) 42 (53.2%) 14 (73.7%) .13

by calculating the limits of agreement as By

described by Bland and Altman28; the Vaginal 11 (1.6%) 10 (23.8%) 1 (7.1%)
limits of agreement dene the range prostaglandines
within which 95% of the differences be- Endovenous oxytocin 53 (94.6%) 39 (92.9%) 14 (100.0%)
tween 2 observers are likely to fall. Length of stage 1, min 318.8  209.2 274.1  168.6 505.0  259.4 <.001
The rst measurement by the expert
Length of stage 2, min 44.2  42.0 40.4  32.9 60.4  66.9 .69
operator was used for all subsequent
analyses. The association between Time between 234.5  170.9 199.8  139.8 378.5  213.2 <.001
occiput-spine angle values and fetal head ultrasound
and delivery (min)
station was assessed graphically with the
use of box plots (Figure 4). The c2 test, Occiput-spine angle,  126  9.8 127  9.4 121  10.5 .03
Fisher exact test, and MannWhitney U Station of the fetal head e2.0  0.1 e1.9  0.1 e2.2  0.1 .11
test were used, where appropriate, to Birthweight, g 3393.3  476.9 3335.1  479.4 3635.0  391.3 .01
compare the distribution of de-
Apgar score, 1 min 9.0  0.8 9.1  0.8 8.7  1.0 .17
mographic and clinical characteristics of
women who underwent spontaneous Apgar score, 5 min 9.9  0.3 9.9  0.2 9.7  0.6 .04
vaginal delivery with those of women Apgar score <7 at 1 or 4 (4.1%) 2 (2.6%) 2 (10.5%) .17
submitted to an operative delivery 5 min
(dened as caesarean delivery or instru- pHa 7.2  0.8 7.2  0.9 7.3  0.1 .70
mental vaginal delivery).
Base excess b
5.2  3.4 5.3  3.3 4.7  3.9 .23
A multivariable logistic regression a
n 89; b n 88. y, years.
model was used to assess whether the
Ghi et al. A new sonographic parameter to diagnose fetal head deexion. Am J Obstet Gynecol 2016.
occiput-spine angle affected the mode of
delivery (spontaneous vaginal delivery vs
operative delivery) after we accounted duration using a multivariable Cox vaginal delivery occurred in 79, whereas
for possible confounding variables. The proportional hazards model. We tested cesarean delivery or vacuum were per-
area under the receiver operating char- proportionality of the hazards using the formed in 19 and 10, respectively. The
acteristic curve was calculated to assess method of Schoenfeld.29 indications for obstetric intervention
the discriminatory power of occiput- were labor arrest in 19 patients and
spine angle. Lastly, we investigated in a Results nonreassuring fetal heart rate in 10
secondary analysis the association of Overall, 108 patients were included in the patients. The mean value of the occiput-
occiput-spine angle with overall labor study group. Among these, spontaneous spine angle was 126  9.8 with

84.e3 American Journal of Obstetrics & Gynecology JULY 2016 OBSTETRICS Original Research

risk of operative delivery due to labor ar-

rest (OR 2.21, 95% CI 0.83e5.85,
Results of the multivariable logistic regression in the prediction of
P .11).
operative delivery due to labor arrest
Narrow occiput-spine angle values
Maternal and obstetric characteristics Odds ratio P value 95% confidence interval were associated with a greater risk of
Narrower occiput-spine angle 1.08 .04 1.001.16 operative delivery (OR 1.07; 95% CI
1.011.13; P .02). Multivariable
Nulliparity 16.06 .02 1.71150.65
logistic regression analysis (Table 2)
Maternal age 1.09 .13 0.971.22 conrmed this result (OR 1.08; 95% CI
Body mass index 1.13 .17 0.951.34 1.001.16; P .04); more specically,
for each degree of decrease of the
Premature rupture of membranes 2.66 .15 0.7110.0
occiput-spine angle, an 8% increase of
Induction of labor 0.76 .71 0.193.10 the risk of obstetric intervention due to
Station of the fetal head 0.72 .64 0.182.91 dystocia was documented.
Ghi et al. A new sonographic parameter to diagnose fetal head deexion. Am J Obstet Gynecol 2016. The receiver operator curve showed a
fair accuracy of occiput-spine angle (area
under the curve 0.6566) in identifying
comparable measurements among the these groups (analysis of variance the women who underwent operative
different subtypes of fetal occiput posi- F-test 0.78, P .5). The occiput-spine delivery because of labor arrest
tion: anterior 9.3%; right-transverse angle measurement yielded very good (Figure 5). Univariable and multivari-
14.8%; right-anterior 7.4%; anterior-left intraobserver agreement (Pearson able Cox regression analysis (Table 3)
31.5%; and anterior-left transverse 0.86, 95% condence interval [95% CI] showed that occiput-spine angle values
37.0%. There was no signicant differ- 0.80e0.90; repeatability coefcient greater than 125 were signicantly
ence in the occiput-spine angle among 10.1 ) and fair-to-good interobserver associated with a shorter duration of la-
agreement (Pearson 0.64, 95% CI bor (crude hazard ratio 1.46; 95% CI
0.51e0.74; intraclass correlation coef- 1.002.14; P .05; adjusted hazard ratio
FIGURE 5 cient 0.63, 95% CI 0.50e0.73). The mean 1.62; 95% CI 1.072.45; P .02). There
ROC for occiput-spine angle in interobserver difference was 2.1 , and the was no evidence that the proportional-
identifying the women submitted limits of agreement were e15.7 to 20.0 . hazards assumption was violated
to operative delivery because of A signicant direct correlation between (c2 7.48, P .381).
labor arrest the occiput-spine angle value and the fetal
head station as assessed by digital exami- Comment
nation was found. More specically, the Principal findings
lower the fetal station was at the time of Our study demonstrates that (1) the
ultrasound assessment the wider the sonographic measurement of the angle
occiput-spine angle value appeared formed by the fetal occiput and the spine
(Figure 4). A comparison between women (occiput-spine angle) is feasible and
who underwent an obstetric intervention reproducible; (2) the occiput-spine angle
(caesarean or vacuum delivery) as the in the rst stage of labor is positively
result of labor arrest and those who un- correlated with the clinically established
derwent spontaneous vaginal delivery is station; and (3) the occiput-spine angle
The ROC curve is a plot of sensitivity vs shown on Table 1. In the operative group measured in the rst stage of labor cor-
1specificity that offers a summary of sensi- due to labor arrest, the following variables relates signicantly with the risk of
tivity and specificity across a range of cut points were signicantly different in comparison obstructed labor requiring an operative
for a continuous predictor. The AUC ranges from with the women who underwent sponta- delivery.
0.5 (no discrimination) to a theoretical maximum neous vaginal delivery: lower parity (5.3%
of 1 (perfect discrimination). Model 1: AUC, area vs 43.0% P < .01), smaller occiput-spine Clinical and research implications
under curve for model based on HDR variables; angle (121  10.5 vs 127  9.4 , Fetal head attitude (the relationship of
Model 2: AUC, area under curve for model based P .03), lower 5-minute Apgar score fetal head to spine) in the rst stage of
on HDR plus OPD plus medical charts variables.
(9.9  0.2 vs. 9.7  0.6 P .04), increased labor has a substantial impact on labor
Dashed line refers to ROC curve analysis; dotted
line refers to the reference line.
duration of the rst stage (8.4  4.3 vs outcome, and this is the rst study which
AUC, area under the curve; HDR, high dynamic range; OPD,
4.6  2.8 hours, P < .001), and increased has attempted to assess objectively the
observed predictive distribution; ROC, receiver operating birth weight (3635.0  391.3 vs 3335.1  degree of fetal head exion. The
479.4 g, P .01). Interestingly, a higher degree of fetal head deexion was quan-
Ghi et al. A new sonographic parameter to diagnose fetal
head deexion. Am J Obstet Gynecol 2016. fetal station at clinical assessment was tied accurately with the use of trans-
not signicantly associated to an increased abdominal 2-dimensional ultrasound

JULY 2016 American Journal of Obstetrics & Gynecology 84.e4

Original Research OBSTETRICS

and by measuring the angle formed by

the occiput and the spine (occiput-spine
Results of the Cox model on time of delivery
angle). This new sonographic parameter
has proven to be easy to obtain and Final model
highly reproducible. Moreover, in our
Variables Hazard ratio P value 95% confidence interval
series, the occiput-spine angle width in
the rst stage of labor seemed directly Occiput-spine angle >125 1.62 .02 1.07e2.45
related to the clinically established sta- Multiparity 4.44 <.001 2.52e7.83
tion, being greater the deeper was the Maternal age 0.98 .322 0.94e1.02
level of the head in the birth canal. These
Body mass index 1.34 .246 0.97e1.11
data are well correlated with the tradi-
tional obstetric concept that the fetal Premature rupture of membranes 1.17 .514 0.73e1.88
head descending through the birth canal Epidural analgesia 0.89 .627 0.55e1.44
undergoes a modication of attitude by Station of the fetal head 1.58 .06 1.00e2.48
progressively exing towards the chest.19
Ghi et al. A new sonographic parameter to diagnose fetal head deexion. Am J Obstet Gynecol 2016.
Finally, we have noticed that the
occiput-spine angle in the rst stage of
labor correlates signicantly with the increase the risk of labor arrest and ob- 90 ) among a group of women at term
risk of obstructed labor requiring an stetric intervention. We also found a gestation with prelabor rupture of
operative delivery. Compared with signicant inverse relationship between membranes.32 In this specic context, the
spontaneous vaginal deliveries, cases the occiput-spine angle and the duration fetal head attitude was not proven to be
that require obstetric intervention of labor. More specically, in fetuses with clinically useful in predicting the occur-
demonstrated a smaller occiput-spine an occiput-spine angle <125 , the dura- rence of vaginal delivery; however,
angle at a similar station, suggesting tion of labor was increased compared different from that study, we quantied
diminished exion of the fetal head. For with those fetuses with an angle greater the occiput-spine angle in each fetus and
nonocciput posterior fetuses, the greater than that threshold. did not dichotomize the population in 2
the degree of fetal head deexion, the groups according the degree of exion.
greater risk of operative delivery it Previous studies This difference may have allowed us to
seemed due to labor arrest. Our data Other authors have consistently shown assess more genuinely the impact of the
seem to support the obstetric notion that that among women with a prolonged minor degree of fetal head deexion on
a deexed fetal attitude may interfere rst stage of labor, the risk of caesarean the fetal head descent and on the labor
with the fetal head descent because of an delivery is inversely related to the depth outcome. Furthermore, because the pre-
increase of the presenting diameter and a of the fetal head level in the birth canal, vious study included only women with
relative cephalopelvic disproportion, as assessed by transperineal ultrasound. prelabor rupture of membranes, we sus-
and this may ultimately increase the risk More specically in this group of pa- pect that the degree of fetal head exion
of arrested labor and obstetric inter- tients, either a greater distance between in this series may have been to some
vention.11,20 Lack of fetal head progres- the fetal head and the perineum (head extent conditioned by the decreased
sion may actually present as a secondary perineum distance) or a smaller angle of amount of amniotic uid rather than
arrest of cervical dilatation in the rst progression seem more accurate than reecting the primary fetal attitude in
stage or as an arrest of the second stage digital assessment of fetal station in spontaneous active labor. Finally, the de-
during active maternal pushing. predicting the chance of abdominal de- gree of fetal exion also was evaluated
The relationship between the fetal livery.31 On the other hand, the accuracy among those fetuses in direct occiput
head descent and the cervical dilatation and reproducibility of digital examina- posterior position, but the reproduc-
in the active rst stage of a normal labor tion in assessing the fetal head station in ibility of the sonographic ndings in such
has been mathematically described as the birth canal has been clearly shown to cases has not been reported. This may
linear in a very recent publication.30 In be poor.25 We think that our data are contribute toward explaining why in that
obstetric textbooks, 3 main types of consistent with the aforementioned ob- study the fetal head attitude assessed by
deexed fetal attitude are described based servations31 because a minor degree of suprapubic ultrasound did not prove to
on digital ndings at vaginal examina- fetal head deexion in the rst stage re- be predictive of labor outcome.
tion, including sinciput, brow and face.19 ected by a smaller occiput-spine angle It would be necessary to assess whether
Our data seem to suggest that in the rst may in fact be expressed also by a greater and to what extent the occiputspine
stage of labor, a minor degree of fetal head perineum distance or a smaller angle and the other parameters measured
head deexion, reected by a smaller angle of progression. by transperineal ultrasound such as the
occiput-spine angle width, is able to be The degree of fetal exion had been head perineum distance or the angle of
detected on transabdominal ultrasound sonographically assessed in a semi- progression are related to each other.32,33
but not clinical exploration that could quantiative fashion (more or less than Furthermore, it would be interesting to

84.e5 American Journal of Obstetrics & Gynecology JULY 2016 OBSTETRICS Original Research

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JULY 2016 American Journal of Obstetrics & Gynecology 84.e6

Original Research OBSTETRICS

occiput posterior position: a study of 408 instrumental delivery. Ultrasound Obstet Gyne- Franchi, and Frusca); Department of Obstetrics and Gyne-
deliveries. Obstet Gynecol 1998;91:746-9. col 2003;21:437-40. cology, St. Orsola Malpighi University Hospital, University of
36. Akmal S, Kametas N, Tsoi E, Howard R, 38. Popowski T, Porcher R, Fort J, Javoise S, Bologna, Bologna, Italy (Drs Bellussi, Azzarone, Krsmanovic,
Nicolaides KH. Ultrasonographic occiput Rozenberg P. Inuence of ultrasound determi- Youssef, and Pilu); and Department of Biomedical and
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532-6. Gynecol 2015;46:520-5. Received Jan. 16, 2016; revised Feb. 1, 2016;
37. Akmal S, Kametas N, Tsoi E, Hargreaves C, accepted Feb. 8, 2016.
Nicolaides KH. Comparison of transvaginal dig- Author and article information The authors report no conflict of interest.
ital examination with intrapartum sonography From the Department of Obstetrics and Gynecology, Mag- Corresponding author: Professor Tullio Ghi. tullioghi@
to determine fetal head position before giore Hospital, University of Parma, Parma, Italy (Drs Ghi,

84.e7 American Journal of Obstetrics & Gynecology JULY 2016