Expert Reviews
org
The use of intrapartum ultrasound to diagnose
malpositions and cephalic malpresentations
Federica Bellussi, MD; Tullio Ghi, MD, PhD; Aly Youssef, MD, PhD; Ginevra Salsi, MD; Francesca Giorgetta, MD;
Dila Parma, CNM; Giuliana Simonazzi, MD, PhD; Gianluigi Pilu, MD, PhD
Introduction
Fetal malpositions and cephalic mal-
presentations are found in about 10%
of all pregnancies and continue to
present a challenge for obstetricians.
They are well-recognized causes of
failure to progress in labor, and usually
result in protracted or arrested
descent,1-6 an increasingly important
dilemma of contemporary obstetrics.7-
14
They frequently require operative
delivery, and are associated with an
increased probability of fetal and
maternal complications.3,4,6 Thus far,
the diagnosis relied entirely on digital
examination, which is notoriously
subjective and imprecise.15-21 Diffi-
culties in the prospective identification
contribute to creating uncertainties in
the management of these conditions.
Intrapartum sonography was recently
reported to be an objective and accurate
diagnostic tool.15-21 However, except for
persistent posterior occiput, the subject
of many studies, most available experi-
ence with other abnormalities of ce-
phalic position and presentation is based
on case reports and small series. The
sonographic technique and findings are
also demonstrated in a video accompa-
From the Departments of Obstetrics and
Gynecology at the University of Bologna,
Policlinico S Orsola-Malpighi, Bologna (Drs
Bellussi, Youssef, Salsi, Giorgetta, Simonazzi,
and Pilu, and Ms Parma), and the University of
Parma, Ospedale Maggiore, Parma (Dr Ghi),
Italy.
Received June 24, 2017; revised July 17, 2017;
accepted July 18, 2017.
The authors report no conflict of interest.
Corresponding author: Federica Bellussi, MD.
bellussi.federica@gmail.com
0002-9378/$36.00
ª 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2017.07.025
ajog.
Fetal malpositions and cephalic malpresentations are well-recognized causes of failure
to progress in labor. They frequently require operative delivery, and are associated with
an increased probability of fetal and maternal complications. Traditional obstetrics
emphasizes the role of digital examinations, but recent studies demonstrated that this
approach is inaccurate and intrapartum ultrasound is far more precise. The objective of
this review is to summarize the current body of literature and provide recommendations
to identify malpositions and cephalic malpresentations with ultrasound. We propose a
systematic approach consisting of a combination of transabdominal and transperineal
scans and describe the findings that allow an accurate diagnosis of normal and abnormal
position, flexion, and synclitism of the fetal head. The management of malpositions and
cephalic malpresentation is currently a matter of debate, and individualized depending on
the general clinical picture and expertise of the provider. Intrapartum sonography allows
a precise diagnosis and therefore offers the best opportunity to design prospective
studies with the aim of establishing evidence-based treatment. The article is accom-
panied by a video that demonstrates the sonographic technique and findings.
Key words: asynclitism, brow presentation, deep transverse arrest, dysfunctional labor,
dystocia, face presentation, fetal attitude, fetal malpositions, fetal malpresentations,
instrumental delivery, labor, obstructed labor, parturition, persistent occiput posterior,
sinciput presentation
nying the article. Furthermore, the We combined information from
approach to diagnosis is variable, as these articles with our own personal
transabdominal, transperineal, and experience collected over a decade of
transvaginal sonography, or a combina- intensive use of ultrasound in labor.
tion of methods, were used.16,17,20-23 The following discussion focuses on
The objective of this review is to the second stage of labor, as this is
summarize the current body of liter- the most optimal time for the diag-
ature and provide recommendations nosis of malpositions and cephalic
to identify malpositions and malpresentations.
cephalic malpresentations with ultra-
sound. The review was performed Technique of intrapartum
according to the Meta-analysis of sonography and findings of vertex
Observational Studies in Epidemi- presentation with anterior occiput
ology guidelines.24 We systematically Sonographic diagnosis of presentation
searched PubMed for the following and position in patients in labor with
terms: “malpositions,” “malpresenta- cephalic fetuses requires both a
tions,” “occiput posterior,” “deep transabdominal and a transperineal43
transverse arrest,” “deflexed presenta- (also referred to as translabial)44
tion,” “face,” “brow,” “sinciput,” and approach (Figure 1).17,28,44 Fetal po-
“asynclitism” as related to “intra- sition is best assessed by identifying
partum sonography.” the spine in the transabdominal scan
The initial yield included 172 arti- and following its course to the
cles; 23 of these provided details on conjunction with the occiput, which
the methodology and findings of in anterior presentations is found be-
intrapartum sonography.5,17,21-23,25-42 tween 10.30-1.30 hours. Vertex
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posterior and transverse (Table 2).

FIGURE 1
Diagnosis is made at the time of de-
Sonography of vertex presentation with anterior occiput after livery because, in normal labor, the
engagement of fetal head fetal occiput is frequently directed
posteriorly or laterally in the first and
even early second stage of labor and
spontaneously rotates to an anterior
position later. In the largest available
sonographic studies, posterior and
lateral occiput were found, respec-
tively, in 33% and 37% of patients in
the first stage; 19% and 28% at full
dilatation; and 7% and 5% at
delivery.16,25,45
Persistent malpositions are a major
cause of prolonged or obstructed la-
bor, and are associated with operative
delivery and complications, including
perineal lesions, febrile morbidities,
and low 5-minute Apgar test
scores.2,6,42,46-50 Posterior occiput was
also associated with a 4-fold increase
A, Schematic representation of ultrasound technique to identify fetal position and presentation: in neonatal encephalopathy.51
transabdominal scan is first obtained to demonstrate spine and occiput (1), and transperineal scan is Clinical diagnosis is inaccurate and
then performed to identify cerebral midline echo (2). B, Schematic representation of direction of there is little doubt that sonography is
sagittal suture prior to internal rotation. C, Sonogram corresponding to section plane (1): wide angle the method of choice.15,18-21,52 Poste-
between fetal spine and occiput indicates normal flexion. D, Sonogram corresponding to section rior occiput is easily diagnosed with a
plane (2): following engagement and prior to internal rotation cerebral midline echo has angle of transabdominal scan oriented trans-
about 45 degrees to anteroposterior axis of maternal pelvis. versely above the pubic symphysis,
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
demonstrating that the fetal eyes are
oriented upwards (Figure 2).41 The
transperineal scan is usually less
informative in these cases. Attention
presentation is inferred by demon- when close to engagement, and it has to the details of intracranial anatomy
strating a wide angle between the been found that the larger the angle, allow the inference of the posterior
cervical spine and the occiput the greater the probability of a spon- position of the occiput by demon-
(occiput-spine angle) that reflects the taneous vaginal delivery.28 Rotation is strating brain structures such as the
flexion of the fetal head.28 The angle assessed clinically by palpating the atria of the lateral ventricles, but this
typically increases as the head de- sagittal suture. The midline of the requires specific knowledge of sonog-
scends into the maternal pelvis fetal brain is easily demonstrated with raphy of intracranial anatomy.53
(Table 1). It is on average 133 degrees sonography and is a convenient proxy Demonstrating the fetal eyes, which
of the sagittal suture. When the head remain visible above the pubic sym-
is engaged, the midline echo is best physis until late in the second stage,
seen in a transverse transperineal when the head is very close to be
TABLE 1 scan.44 In normal labor, the angle delivered, is far simpler. When the
Measurement of occiput-spinal formed between the midline of the occiput is posterior, head deflexion is
angle according to fetal station fetal brain and the anteroposterior not infrequent and has a major
Occiput-spine angle, axis of the maternal pelvis is most influence on the progress of labor.17
Station, cm mean – SD frequently close to 45 degrees at the Deflexion can be ruled out by
e3 118.7  11.0 time of engagement. Internal rotation, demonstrating in a longitudinal view
e2 126.0  8.76 inferred by an angle close to 0, usually of the fetal head that the chin is
occurs at a station of >3 cm.44 tucked on the chest (Figure 2).17
e1 133.8  8.3 The transverse position of the
Bellussi. Intrapartum ultrasound diagnosis of Cephalic malpositions occiput is best recognized by visual-
malpositions and cephalic malpresentations. Am J
Obstet Gynecol 2017. Cephalic malpositions include persis- izing the horizontal direction of the
tent vertex presentation with occiput midline of the fetal brain in a

634 American Journal of Obstetrics & Gynecology DECEMBER 2017

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TABLE 2
Clinical and sonographic findings of fetal malpositions
Malposition Clinical examination
Occiput posterior Posterior fontanelle is in posterior pelvis;
orientation of sagittal suture is variable
Occiput transverse Sagittal suture is horizontal and fontanelles
are palpable laterally; if fetal head is in lower
pelvis, helix of fetal ear may be palpable
below pubic symphysis
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
Sonographic findings
Transabdominal scan: eyes are directed upwards; flexion is inferred
by profile view of face demonstrating chin resting on chest;
fetal spine is in variable position
Transperineal scan: when head is engaged, in coronal scan
choroid plexuses diverge posteriorly; ovoid of fetal head is larger
towards hollow of sacrum, and in sagittal scan, third ventricle and
corpus callosum may be seen; orientation of midline is variable
Transabdominal scan: fetal spine is often lateral; if head is not
engaged, fetal eyes are directed laterally
Transperineal scan: horizontal direction of midline can be seen
when head in engaged

transverse scan. When the head is reported that knowing the position of and face presentation, in which the
engaged, the transabdominal the fetal spine facilitates manual head is partially or completely
approach is scarcely informative due rotation of the occiput.62 extended.3,4,6 Some authors recognize
to shadowing from the bones of the a third variety: sinciput presentation,
maternal pelvis, and a transperineal Deflexed presentations: sinciput, in which the fetus has a military atti-
approach is usually more effective brow, and face tude and the head is neither flexed or
(Figure 3).23 In normal labor, the fetal head un- extended (Figure 4 and Table 3). The
There is an ongoing debate around dergoes maximal flexion, forcing the clinical diagnosis relies on palpation of
the management of malpositions. The chin against the chest. Incomplete the leading parts, the anterior fonta-
discussion includes the role of flexion or extension results in nelle, the superior orbital ridge and
manual54-56 and instrumental2 rota- increased diameters of the presenting the mouth with sinciput, brow, and
tion of the fetal head, and maternal part, which in turn may lead to ceph- face presentation, respectively. With
positioning.57,58 Several studies alopelvic disproportion. Two types of the exception of face presentation,
suggest that manual rotation is asso- deflexed cephalic malpresentations the other types of deflexion are
ciated with a higher probability of are traditionally acknowledged: brow frequently misdiagnosed clinically
spontaneous vaginal delivery.55,56,59
However, interpreting the data is
difficult because experience with FIGURE 2
intrapartum sonography suggests that Sonography of vertex presentation with posterior occiput
most fetuses with a posterior or
transverse occiput at full cervical
dilatation will rotate spontaneously to
an anterior position during the second
stage. To our knowledge, only 1 ran-
domized controlled trial has been
published, but this was underpowered
to demonstrate the effect of the ma-
neuver.54 Two larger trials have been
announced and are ongoing at the
time of this writing.60,61 It is of in-
terest that sonography was found to
predict spontaneous anterior rotation.
In 1 study, fetuses with an anterior or
A, Schematic representation of ultrasound technique; transducer is initially positioned transversely in
lateral spine were more likely to rotate
lower maternal abdomen immediately above pubic symphysis (1) and is then rotated 90 degrees (2).
anteriorly than those with a posterior
B and C, Corresponding images obtained from scanning planes (1) and (2); eye directed upwards,
spine. Although the number of cases
and in profile view of face chin is seen resting on chest.
was small, the observation is Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
intriguing.27 Recently, it was also

DECEMBER 2017 American Journal of Obstetrics & Gynecology 635

Expert Reviews
FIGURE 3
Sonography of vertex presentation with lateral occiput
A, Schematic representation after engagement of fetal head. B, Corresponding transperineal
sonogram demonstrating horizontal disposition of cerebral midline echo.
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
and ultrasound has been found to continuum and we argue that the
perform far better.17,34 sonographic measurement of the
With an anterior occiput, the most occiput-spine angle may better
valuable sonographic finding is a describe the phenomenon.
longitudinal view of the fetal trunk When the occiput is posterior,
demonstrating the occiput-spine acoustic shadowing from the cranio-
angle.28 Close to engagement, the facial bones of the fetus prevents clear
angle is usually >125 degrees, and visualization and measurement of
smaller angles are associated with occiput-spine angle, but a qualitative
increased risk of obstructed labor.28 approach can be utilized.17 When the
We also found that with face and head is flexed, the chin is seen resting
brow presentations the angle is very on the chest. With deflexion, the chin
small, usually in the range of 90 de- is separate from the chest, and the
grees (Figure 5).31 Traditionally, cervical spine is curved anteriorly. The
diagnosis of deflexion was made by transperineal scan allows further
palpating the presenting part, and was definition of the type of abnormal
therefore subdivided into discrete en- presentation (Figure 6). Visualization
tities. However, deflexion is a of the fetal eyes and of details of the
face at or below the level of the pubic
symphysis has been described in
fetuses with brow17,34 and face22,33
FIGURE 4 presentations, respectively.
Schematic representation of With the exception of very small
flexed and deflexed fetuses, persistent deflexed presenta-
presentations tion is a major obstacle to the progress
of labor. In practice, only fetuses with
face presentation and an anterior chin
can be consistently delivered vagi-
nally.3,4,6 The consensus is that vaginal
operations are contraindicated, with
the only possible exception being
forceps application in a face presen-
Schematic representation of flexed (vertex) and tation with an anterior chin.6 In 1
deflexed (sinciput, brow, face) presentations. series, manual rotation of brow pre-
Bellussi. Intrapartum ultrasound diagnosis of malpositions
and cephalic malpresentations. Am J Obstet Gynecol 2017.
sentation was frequently successful
and resulted in vaginal delivery.63
636 American Journal of Obstetrics & Gynecology DECEMBER 2017
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There are no available data on the
probability of remission throughout
labor. In 1 small series, the association
between prolonged labor and deflexed
presentation always required cesarean
delivery.17
Asynclitism
Asynclitism is the malalignment of
the central axes of the fetal head
and maternal pelvis (Table 4). Anterior
asynclitism results from anterior tilting
of the head, and is by far the most
common variety. Posterior asynclitism,
which occurs with posterior tilting, is
rare.5,30,32 Clinical diagnosis is based
on the palpation of the sagittal suture
in an asymmetrical position (Figure 7).
We are not aware of any precise data,
but the consensus is that the diagnosis
is difficult and imprecise. The inci-
dence of asynclitism is unknown and
the clinical implications are poorly
understood. Mild degrees of anterior
asynclitism are almost physiological
with a high station, and tend to resolve
spontaneously with further descent.50
However, the diameters of the pre-
senting cranium are increased and this
may result in or contribute
to obstructed labor although, to our
knowledge, there are no clear-cut data.
Posterior asynclitism, when persistent,
is virtually incompatible with engage-
ment except for very small fetuses.
Different approaches have been pro-
posed for the sonographic identifica-
tion of asynclitism.5,29,30,32,37-39
Anterior and posterior asynclitism
occur at the entry of the fetal head into
the birth canal and acoustic shadowing
from the maternal bones represent
a major obstacle. When the head
is engaged, we found that a trans-
perineal approach, demonstrating a
shift of the cerebral midline echo, is a
simple and effective approach
(Figure 8).30,32,39
Recently, it was suggested that
lateral asynclitism may also occur. In
the handful of cases thus far
described, the sagittal suture was
identified in a lateral position and
sonography demonstrated marked
twisting of the fetal head.29,35
Whether this is a separate entity or
ajog.org Expert Reviews

TABLE 3
Clinical and sonographic findings of deflexed presentations
Malpresentation Clinical examination Sonographic findings
Sinciput Anterior fontanelle is palpable in center of pelvis; Transabdominal scan: if occiput is anterior, main finding is decreased
direction of sagittal suture is variable OS angle (<125 degrees); if occiput is posterior, chin is distant from
chest and cervical spine is curved anteriorly
Transperineal scan: findings are similar to those described with flexed
posterior occiput
Brow Anterior fontanelle, supraorbital ridges, and root of nose Transabdominal scan: if occiput is anterior, main finding is decreased
are palpable vaginally, usually sagittal suture is not OS angle, usually around 90 degrees; if occiput is posterior, chin is
appreciated separate from chest and cervical spine is curved anteriorly
Transperineal scan: fetal orbits are seen at same level of pubic
symphysis, caput is on forehead
Face Mouth, nose, malar eminences, and orbital ridges are Transabdominal scan: if occiput is anterior, main finding is much
palpable; fontanelles and sutures are not appreciated decreased OS angle, usually <90 degrees; if occiput is posterior, chin
is separate from chest and cervical spine is curved anteriorly
Transperineal scan: fetal orbits are seen below pubic symphysis
OS, occiput-spine.
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.

a more extreme form of either ante- comprehensive approach to sono- with abnormal flexion17,31 and asyn-
rior or posterior asynclitism is graphic diagnosis of malpositions and clitism29,30,32,37-40 is far more limited.
uncertain. cephalic malpresentations. The main A well-designed prospective study to
limitation is that most of the available evaluate the full potential of intra-
Comment studies focused on single abnormal- partum ultrasound to identify
Principal findings ities. Large series are available doc- abnormal position and presentation,
Intrapartum sonography allows a umenting the accuracy of ultrasound and the precise impact of these ab-
precise diagnosis of malpositions and in identifying abnormal posi- normalities on the progress of labor, is
cephalic malpresentations, and is far tion.15,16,18,20,26,52,64,65 The experience still lacking.
more accurate than the traditional
digital examination. A combination of
a transabdominal and a transperineal
scan allows for precise identification FIGURE 5
of the position of the fetal occiput, Sonography of deflexed cephalic presentation (face) with anterior occiput
and degree of flexion and rotation of
the head. We suggest that this is a step
forward. The success of the labor
process depends fundamentally on 4
major variables: the compliance of the
cervix, the strength and efficacy of
uterine contractions, the relative size
of the fetus and the maternal pelvis,
and the way the body of the fetus
engages the birth canal. We argue that
while none of the first 3 can be
assessed with precision, the last one
can be accurately diagnosed with
intrapartum sonography.

Strengths and limitations

The main strength of our study is that,
A, Schematic representation. B, Corresponding sonogram demonstrating sharp angle between
to our knowledge, this is the first
cervical spine and occiput.
time the available literature was sys- Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
tematically reviewed to provide a

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ultrasound spanning more than a

FIGURE 6
decade, not all obstetricians
Sonography of deflexed cephalic presentation (brow) with posterior attending our labor ward master the
occiput technique. Providing intrapartum
ultrasound in any labor unit
would require a major organizational
and economic effort that is hard
to conceive at present, although in
the near future the increasing famil-
iarity of obstetric trainees with
sonography will probably be of help.
The second shortcoming is that,
once a malposition or a cephalic
malpresentation is recognized, the
decision-making process is not
straightforward. Improved diagnostic
accuracy does not necessarily imply
an improvement in the outcome.
Although the introduction of intra-
partum sonography has been
embraced by many as an important
step forward in the management of
labor,15,42,44,66-68 prospective studies
have not been encouraging thus far in
A, Schematic representation demonstrating scanning planes useful for diagnosis (1-3). B, Trans- terms of practical results. Ultrasound
abdominal scan oriented transversely immediately above pubic symphysis (1) reveals upward di- did not ameliorate the ultimate
rection of eyes. C, Transabdominal scan oriented at right angle from previous one (2) allows outcome of labor in 2 randomized
inference of deflexion by demonstrating distance between chest and chin as well as anterior cur- clinical trials,19,52 and in 1 study, the
vature of spine. D, Transperineal scan (3) reveals eye at same level as pubic symphysis suggesting incidence of operative deliveries
brow presentation; presence of caput on forehead is also demonstrated in this view. increased.52 At the heart of this issue
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017. is indeed the question: will improved
diagnosis of abnormal position/
presentation result in an unnecessary
Clinical implications Recognizing posterior occiput only increase in the cesarean delivery
We do envision 2 major limitations of requires a minimal level of compe- rate? Traditional obstetrics fore-
intrapartum sonography. First, it re- tence.65 Identifying and measuring grounds the recognition of malposi-
quires that sonographic equipment the occiput-spine angle, the angle of tions and cephalic malpresentations,
and personnel capable of operating it rotation, or visualizing deflexion in a but some have questioned the useful-
always be available in the labor ward. fetus with a posterior occiput is ness of a precise diagnosis in
The expertise required is variable certainly more demanding. Despite contemporary practice, and the debate
depending on the type of diagnosis. our keen interest in intrapartum is ongoing.52,69

TABLE 4
Clinical and sonographic findings of asynclitism
Malpresentation Clinical examination Sonographic findings
Anterior Sagittal suture is found posteriorly and leading Transabdominal scan: usually does not provide valuable information
asynclitism presenting part is anterior parietal bone Transperineal scan: when head is engaged, midline echo appears not
aligned with maternal pelvis, and anterior parietal bone is leading
presenting part
Posterior Usually head fails to engage; sagittal suture is found Transabdominal scan: usually does not provide valuable information
asynclitism anteriorly and leading presenting part is posterior Transperineal scan: midline echo is not aligned with maternal pelvis,
parietal bone and posterior parietal bone is leading presenting part
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.

638 American Journal of Obstetrics & Gynecology DECEMBER 2017

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FIGURE 7
Schematic representation of synclitic presentation, anterior asynclitism, and posterior asynclitism

Schematic representation of: A and B, synclitic presentation; C and D, anterior asynclitism; and E and F, posterior asynclitism. Red lines indicate
anteroposterior axis of upper pelvis.
Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.

We suggest that the value of intra-

FIGURE 8
partum sonography is mostly in
perspective, as a precise diagnosis is
Sonography of anterior asynclitism
the prerequisite for prospective
studies that may better elucidate
the clinical significance of malposi-
tions and cephalic malpresentations
and the implications for management.
It is obvious that the diagnosis
of these conditions should not lead
to a decision to intervene surgically.
Spontaneous conversion is known
to occur, and vaginal delivery is
possible in many cases. We do
not advocate the routine use of
ultrasound in labor with normal
progress. However, an accurate iden-
tification of abnormal position or A, Schematic representation. B, Transverse perineal scan was performed in this patient with prolonged
presentation can have important im- second stage and demonstrated shift in midline echo suggestive of mild anterior asynclitism; spontaneous
plications for the diagnosis and man- conversion ensued subsequently and spontaneous delivery occurred few minutes after sonogram.
agement of protracted or arrest Bellussi. Intrapartum ultrasound diagnosis of malpositions and cephalic malpresentations. Am J Obstet Gynecol 2017.
disorders of labor.

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Expert Reviews
Conclusions
We described a sonographic technique
that allows an accurate diagnosis of
malpositions and cephalic malpre-
sentations. At present, the manage-
ment of these conditions is
individualized, depending on other
clinical variables and provider exper-
tise. But intrapartum sonography is
an invaluable tool to strengthen the
design of prospective studies with the
aim of establishing optimal evidence-
based management recommendations
for a normal progression of labor. -
ACKNOWLEDGMENT
Graphic art by Alessandro Meggio.
REFERENCES
1. Ponkey SE, Cohen AP, Heffner LJ,
Lieberman E. Persistent fetal occiput posterior
position: obstetric outcomes. Obstet Gynecol
2003;101:915-20.
2. Aiken AR, Aiken CE, Alberry MS,
Brockelsby JC, Scott JG. Management of fetal
malposition in the second stage of labor: a
propensity score analysis. Am J Obstet Gynecol
2015;212:355.e1-7.
3. Bashiri A, Burstein E, Bar-David J, Levy A,
Mazor M. Face and brow presentation: inde-
pendent risk factors. J Matern Fetal Neonatal
Med 2008;21:357-60.
4. Gardberg M, Leonova Y, Laakkonen E.
Malpresentationseimpact on mode of delivery.
Acta Obstet Gynecol Scand 2011;90:540-2.
5. Malvasi A, Barbera A, Di Vagno G, et al.
Asynclitism: a literature review of an often
forgotten clinical condition. J Matern Fetal
Neonatal Med 2015;28:1890-4.
6. Stitely ML, Gherman RB. Labor with
abnormal presentation and position. Obstet
Gynecol Clin North Am 2005;32:165-79.
7. American College of Obstetricians and
Gynecologists, Society for Maternal-Fetal Med-
icine, Caughey AB, Cahill AG, Guise JM,
Rouse DJ. Safe prevention of the primary ce-
sarean delivery. Am J Obstet Gynecol 2014;210:
179-93.
8. Cohen WR, Friedman EA. Perils of the new
labor management guidelines. Am J Obstet
Gynecol 2015;212:420-7.
9. Leveno KJ, Nelson DB, McIntire DD. Second-
stage labor: how long is too long? Am J Obstet
Gynecol 2016;214:484-9.
10. Zhang J, Troendle JF, Yancey MK. Reas-
sessing the labor curve in nulliparous women.
Am J Obstet Gynecol 2002;187:824-8.
11. Gimovsky AC, Berghella V. Random-
ized controlled trial of prolonged second
stage: extending the time limit vs usual
guidelines. Am J Obstet Gynecol
2016;214:361.e1-6.
640 American Journal of Obstetrics & Gynecology DECEMBER 2017
12. Son M, Roy A, Grobman WA. Attempted
operative vaginal delivery vs repeat cesarean in
the second stage among women undergoing a
trial of labor after cesarean delivery. Am J Obstet
Gynecol 2017;216:407.e1-5.
13. Ducarme G, Hamel JF, Sentilhes L. Pre-
dictors of shoulder dystocia at the time of
operative vaginal delivery. Am J Obstet Gynecol
2017;216:624-5.
14. Andrews SE, Alston MJ, Allshouse AA,
Moore GS, Metz TD. Does the number of for-
ceps deliveries performed in residency predict
use in practice? Am J Obstet Gynecol
2015;213:93.e1-4.
15. Akmal S, Kametas N, Tsoi E, Hargreaves C,
Nicolaides KH. Comparison of transvaginal dig-
ital examination with intrapartum sonography to
determine fetal head position before instru-
mental delivery. Ultrasound Obstet Gynecol
2003;21:437-40.
16. Akmal S, Tsoi E, Kametas N, Howard R,
Nicolaides KH. Intrapartum sonography to
determine fetal head position. J Matern Fetal
Neonatal Med 2002;12:172-7.
17. Bellussi F, Ghi T, Youssef A, et al. Intra-
partum ultrasound to differentiate flexion and
deflexion in occipitoposterior rotation. Fetal
Diagn Ther 2017 Apr 12. http://dx.doi.org/10.
1159/000457124. [Epub ahead of print].
18. Malvasi A, Tinelli A, Barbera A, et al. Occiput
posterior position diagnosis: vaginal examination
or intrapartum sonography? A clinical review.
J Matern Fetal Neonatal Med 2014;27:520-6.
19. Ramphul M, Ooi PV, Burke G, et al. Instru-
mental delivery and ultrasound: a multicenter
randomized controlled trial of ultrasound
assessment of the fetal head position versus
standard care as an approach to prevent
morbidity at instrumental delivery. BJOG
2014;121:1029-38.
20. Chou MR, Kreiser D, Taslimi MM, Druzin ML,
El-Sayed YY. Vaginal versus ultrasound exami-
nation of fetal occiput position during the second
stage of labor. Am J Obstet Gynecol 2004;191:
521-4.
21. Zahalka N, Sadan O, Malinger G, et al.
Comparison of transvaginal sonography with
digital examination and transabdominal sonog-
raphy for the determination of fetal head position
in the second stage of labor. Am J Obstet
Gynecol 2005;193:381-6.
22. Eggebo TM, Eymundsdottir AE,
Ostborg TB. Face presentation and persistent
deep mentum transverse position diagnosed
with three-dimensional ultrasound. Ultrasound
Obstet Gynecol 2015;45:490-1.
23. Malvasi A, Giacci F, Gustapane S, Sparic R,
Barbera A, Tinelli A. Intrapartum sonographic
signs: new diagnostic tools in malposition and
malrotation. J Matern Fetal Neonatal Med
2016;29:2408-13.
24. Stroup DF, Berlin JA, Morton SC, et al.
Meta-analysis of observational studies in
epidemiology: a proposal for reporting. Meta-
analysis of observational studies in epidemi-
ology (MOOSE) group. JAMA 2000;283:
2008-12.
ajog.org
25. Akmal S, Tsoi E, Howard R, Osei E,
Nicolaides KH. Investigation of occiput posterior
delivery by intrapartum sonography. Ultrasound
Obstet Gynecol 2004;24:425-8.
26. Akmal S, Tsoi E, Nicolaides KH. Intrapartum
sonography to determine fetal occipital position:
interobserver agreement. Ultrasound Obstet
Gynecol 2004;24:421-4.
27. Blasi I, D’Amico R, Fenu V, et al. Sono-
graphic assessment of fetal spine and head
position during the first and second stages of
labor for the diagnosis of persistent occiput
posterior position: a pilot study. Ultrasound
Obstet Gynecol 2010;35:210-5.
28. Ghi T, Bellussi F, Azzarone C, et al. The
“occiput-spine angle”: a new sonographic index
of fetal head deflexion during the first stage of
labor. Am J Obstet Gynecol 2016;215:84.e1-7.
29. Ghi T, Bellussi F, Pilu G. Sonographic diag-
nosis of lateral asynclitism: a new subtype of fetal
head malposition as a main determinant of early
labor arrest. Ultrasound Obstet Gynecol
2015;45:229-31.
30. Ghi T, Dall’Asta A, Kiener A, Volpe N,
Suprani A, Frusca T. Intrapartum diagnosis of
posterior asynclitism using two-dimensional
transperineal ultrasound. Ultrasound Obstet
Gynecol 2017;49:803-4.
31. Ghi T, Maroni E, Youssef A, et al. Intra-
partum three-dimensional ultrasonographic im-
aging of face presentations: report of two cases.
Ultrasound Obstet Gynecol 2012;40:117-8.
32. Ghi T, Youssef A, Pilu G, Malvasi A,
Ragusa A. Intrapartum sonographic imaging of
fetal head asynclitism. Ultrasound Obstet
Gynecol 2012;39:238-40.
33. Lau WL, Cho LY, Leung WC. Intrapartum
translabial ultrasound demonstration of face
presentation during first stage of labor. J Obstet
Gynaecol Res 2011;37:1868-71.
34. Lau WL, Leung WC, Chin R. Intrapartum
translabial ultrasound demonstrating brow pre-
sentation during the second stage of labor. Int J
Gynaecol Obstet 2009;107:62-3.
35. Malvasi A, Barbera A, Ghi T, Tinelli A. Lateral
asynclitism: introduction of a new terminology
associated to specific fetal position of the fetal
head diagnosed by ultrasound in the second
stage of labor. J Matern Fetal Neonatal Med
2015;28:1839-41.
36. Malvasi A, Bochicchio M, Vaira L, Longo A,
Pacella E, Tinelli A. The fetal head evaluation
during labor in the occiput posterior position: the
ESA (evaluation by simulation algorithm)
approach. J Matern Fetal Neonatal Med
2014;27:1151-7.
37. Malvasi A, Stark M, Ghi T, Farine D,
Guido M, Tinelli A. Intrapartum sonography for
fetal head asynclitism and transverse position:
sonographic signs and comparison of diag-
nostic performance between transvaginal and
digital examination. J Matern Fetal Neonatal Med
2012;25:508-12.
38. Malvasi A, Tinelli A. Intrapartum sonogra-
phy: two signs to detect asynclitism degree.
J Matern Fetal Neonatal Med 2016;29:
1289-90.
ajog.org Expert Reviews

39. Malvasi A, Tinelli A. Intrapartum sonography
asynclitism diagnosis by transperineal ultrasonog-
raphy. J Matern Fetal Neonatal Med 2017;1:1-2.
40. Malvasi A, Tinelli A, Stark M. Intrapartum
sonography sign for occiput posterior asyncli-
tism diagnosis. J Matern Fetal Neonatal Med
2011;24:553-4.
41. Youssef A, Ghi T, Pilu G. How to perform
ultrasound in labor: assessment of fetal occiput
position. Ultrasound Obstet Gynecol 2013;41:
476-8.
42. Kahrs BH, Usman S, Ghi T, et al. Sono-
graphic prediction of outcome of vacuum de-
liveries: a multicenter, prospective cohort study.
Am J Obstet Gynecol 2017;217:69.e1-10.
43. Jeanty P, d’Alton M, Romero R,
Hobbins JC. Perineal scanning. Am J Perinatol
1986;3:289-95.
44. Ghi T, Farina A, Pedrazzi A, Rizzo N,
Pelusi G, Pilu G. Diagnosis of station and rotation
of the fetal head in the second stage of labor with
intrapartum translabial ultrasound. Ultrasound
Obstet Gynecol 2009;33:331-6.
45. Akmal S, Kametas N, Tsoi E, Howard R,
Nicolaides KH. Ultrasonographic occiput posi-
tion in early labor in the prediction of caesarean
section. BJOG 2004;111:532-6.
46. Damron DP, Capeless EL. Operative vaginal
delivery: a comparison of forceps and vacuum
for success rate and risk of rectal sphincter
injury. Am J Obstet Gynecol 2004;191:907-10.
47. de la Torre L, Gonzalez-Quintero VH,
Mayor-Lynn K, et al. Significance of accidental
extensions in the lower uterine segment during
cesarean delivery. Am J Obstet Gynecol
2006;194:e4-6.
48. Wu JM, Williams KS, Hundley AF,
Connolly A, Visco AG. Occiput posterior fetal
head position increases the risk of anal sphincter
injury in vacuum-assisted deliveries. Am J
Obstet Gynecol 2005;193:525-9.
49. Benavides L, Wu JM, Hundley AF,
Ivester TS, Visco AG. The impact of occiput
posterior fetal head position on the risk of anal
sphincter injury in forceps-assisted vaginal de-
liveries. Am J Obstet Gynecol 2005;192:1702-6.
50. Ben-Haroush A, Melamed N, Kaplan B,
Yogev Y. Predictors of failed operative vaginal
delivery: a single-center experience. Am J
Obstet Gynecol 2007;197:308.e1-5.
51. Badawi N, Kurinczuk JJ, Keogh JM, et al.
Intrapartum risk factors for newborn encepha-
lopathy: the Western Australian case-control
study. BMJ 1998;317:1554-8.
52. Popowski T, Porcher R, Fort J, Javoise S,
Rozenberg P. Influence of ultrasound determi-
nation of fetal head position on mode of delivery:
a pragmatic randomized trial. Ultrasound Obstet
Gynecol 2015;46:520-5.
53. Ghi T, Bellussi F, Eggebo T, et al. Sono-
graphic assessment of fetal occiput position
during the second stage of labor: how reliable is
the transperineal approach? J Matern Fetal
Neonatal Med 2015;28:1985-8.
54. Phipps H, de Vries B, Hyett J, Osborn DA.
Prophylactic manual rotation for fetal malposi-
tion to reduce operative delivery. Cochrane
Database Syst Rev 2014;12:CD009298.
55. Shaffer BL, Cheng YW, Vargas JE,
Caughey AB. Manual rotation to reduce cesar-
ean delivery in persistent occiput posterior or
transverse position. J Matern Fetal Neonatal
Med 2011;24:65-72.
56. Shaffer BL, Cheng YW, Vargas JE,
Laros RK Jr, Caughey AB. Manual rotation of the
fetal occiput: predictors of success and delivery.
Am J Obstet Gynecol 2006;194:e7-9.
57. Hunter S, Hofmeyr GJ, Kulier R. Hands and
knees posture in late pregnancy or labor for fetal
malposition (lateral or posterior). Cochrane
Database Syst Rev 2007;4:CD001063.
58. Le Ray C, Lepleux F, De La Calle A, et al.
Lateral asymmetric decubitus position for the
rotation of occipito-posterior positions: multi-
center randomized controlled trial EVADELA.
Am J Obstet Gynecol 2016;215:511.e1-7.
59. Reichman O, Gdansky E, Latinsky B, Labi S,
Samueloff A. Digital rotation from occipito-
posterior to occipito-anterior decreases the
need for cesarean section. Eur J Obstet Gynecol
Reprod Biol 2008;136:25-8.
60. de Vries B, Phipps H, Kuah S, et al. Trans-
verse occiput position: using manual rotation to
aid normal birth and improve delivery outcomes
(TURN-OUT): a study protocol for a randomized
controlled trial. Trials 2015;16:362.
61. Phipps H, Hyett JA, Kuah S, et al. Persistent
occiput posterior positioneoutcomes following
manual rotation (POP-OUT): study protocol for a
randomized controlled trial. Trials 2015;16:96.
62. Masturzo B, Farina A, Attamante L, et al.
Sonographic evaluation of the fetal spine posi-
tion and success rate of manual rotation of the
fetus in occiput posterior position: a randomized
controlled trial. J Clin Ultrasound 2017 Apr 3.
http://dx.doi.org/10.1002/jcu.22477. [Epub
ahead of print].
63. Verspyck E, Bisson V, Gromez A, Resch B,
Diguet A, Marpeau L. Prophylactic attempt at
manual rotation in brow presentation at full
dilatation. Acta Obstet Gynecol Scand 2012;91:
1342-5.
64. Dupuis O, Ruimark S, Corinne D, Simone T,
Andre D, Rene-Charles R. Fetal head position
during the second stage of labor: comparison of
digital vaginal examination and transabdominal
ultrasonographic examination. Eur J Obstet
Gynecol Reprod Biol 2005;123:193-7.
65. Rozenberg P, Porcher R, Salomon LJ,
Boirot F, Morin C, Ville Y. Comparison of the
learning curves of digital examination and
transabdominal sonography for the determina-
tion of fetal head position during labor. Ultra-
sound Obstet Gynecol 2008;31:332-7.
66. Malvasi A, Montanari Vergallo G, Tinelli A,
Marinelli E. Can the intrapartum ultrasonography
reduce the legal liability in distocic labor and
delivery? J Matern Fetal Neonatal Med 2017 Apr
2:1-2. http://dx.doi.org/10.1080/14767058.
2017.1306514. [Epub ahead of print].
67. Eggebo TM, Wilhelm-Benartzi C,
Hassan WA, Usman S, Salvesen KA, Lees CC.
A model to predict vaginal delivery in nulliparous
women based on maternal characteristics and
intrapartum ultrasound. Am J Obstet Gynecol
2015;213:362.e1-6.
68. Kasbaoui S, Severac F, Aissi G, et al.
Predicting the difficulty of operative vaginal
delivery by ultrasound measurement of fetal
head station. Am J Obstet Gynecol 2017;216:
507.e1-9.
69. Youssef A, Pilu G. Knowledge, under-
standing and fetal occiput position. Ultrasound
Obstet Gynecol 2016;47:523-4.

Glossary of terms
Malposition Fetal occiput is found either posteriorly or laterally in maternal pelvis
Cephalic malpresentation Leading presenting part is not vertex; includes sinciput, brow, and face presentation
Sinciput presentation Leading presenting part is bregmatic fontanel
Brow presentation Leading presenting part is forehead
Face presentation Leading presenting part is face
Asynclitism Axes of pelvis and fetal head are not aligned; includes anterior asynclitism (leading presenting part is anterior
parietal bone) and posterior asynclitism (leading presenting part is posterior parietal bone)

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