Anaesth Crit Care Pain Med 41 (2022) 100993

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Anaesthesia Critical Care & Pain Medicine

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Original Article

Ultrasound assessment of gastric contents prior to placental delivery:

A prospective multicentre cohort study
François-Pierrick Desgranges a,*, Florence Vial b, Laurent Zieleskiewicz c,
Marie-Caroline Boghossian c, Hervé Bouaziz b, Marc Leone c, Dominique Chassard d,e,
Lionel Bouvet d,e
a
Department of Anaesthesiology, L’Hôpital Nord-Ouest, Villefranche-sur-Saône, France
b
Department of Anaesthesiology and Intensive Care, University Hospital of Nancy, Nancy, France
c
Department of Anaesthesiology and Intensive Care, University Hospital of Marseille, Aix Marseille University, Marseille, France
d
Department of Anaesthesiology and Intensive Care, Femme Mère Enfant Hospital, Hospices Civils de Lyon, Bron, France
e
Research Unit APCSe VetAgro Sup UPSP 2016.A101, Claude Bernard Lyon 1 University, Marcy-l’Etoile, France

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is ongoing debate regarding the optimal general anaesthetic technique for manual
Available online removal of the placenta after vaginal delivery. Using ultrasound examination of the gastric antrum, this
study aimed to assess the change in gastric contents during vaginal delivery and to determine the
Keywords: prevalence of stomach at risk for pulmonary aspiration in the immediate postpartum period before
Gastric antrum placental delivery.
Gastric contents Methods: In this prospective multicentre cohort study, antral ultrasonography was performed at full
Obstetric anaesthesia
cervical dilatation within the thirty minutes preceding the beginning of expulsive efforts and after
Postpartum
Pulmonary aspiration
vaginal birth, before placental delivery. High-risk gastric content was defined as the visualisation of any
Ultrasound solid content in the antrum or antral cross-sectional area in the semi-recumbent position (SR-
CSA) > 608 mm2.
Results: Twenty-six women were included and analysed. There was a significant decrease in both the
proportion of patients with solid gastric content and the SR-CSA between the two-ultrasound
examinations. Twenty-one patients (80.8%) exhibited a decrease in the SR-CSA during vaginal delivery.
The prevalence of stomach at risk for pulmonary aspiration was significantly lower after vaginal delivery
than before vaginal delivery (23.1% vs. 57.7%, P = 0.0004).
Conclusion: Our results suggest that gastric emptying is at least partially preserved during vaginal birth.
Nevertheless, almost a quarter of women did have high-risk gastric content in the immediate
postpartum period. Point-of-care antral ultrasonography may be of interest for the fast assessment of the
gastric content status when a general anaesthesia is required for manual removal of retained placenta.
C 2021 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All

rights reserved.

1. Introduction failure of epidural analgesia or when neuraxial anaesthesia is

Manual removal of the placenta and exploration of the uterine
cavity are the first obstetric procedures to perform after vaginal
birth in case of immediate postpartum haemorrhage [1]. General
anaesthesia may be performed for alleviating pain and discomfort
during manual removal of retained placenta, notably in cases of
* Corresponding author at: Department of Anaesthesiology, L’Hôpital Nord-
Ouest, plateau d’Ouilly-Gleizé, 69655 Villefranche sur Saône, France.
E-mail address: fp_desgranges@yahoo.fr (F. P. Desgranges).
contraindicated [2,3].
Since the middle of the twentieth century, pregnant women,
especially women in labour, have been considered at increased risk
of high gastric volume, requiring rapid sequence induction with
tracheal intubation to be performed in case of general anaesthesia
[3–5]. However, there is ongoing debate regarding the optimal
general anaesthetic technique for manual removal of the placenta
after vaginal delivery [6]. Despite the potential risk of significant
residual gastric contents in this context, several practice surveys
and case series reported that, in different countries, general
anaesthesia without intubation was often preferred by clinicians

https://doi.org/10.1016/j.accpm.2021.100993
2352-5568/ C 2021 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

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F.-P. Desgranges, F. Vial, L. Zieleskiewicz et al.
for manual removal of a retained placenta and exploration of the
uterine cavity rather than rapid sequence induction with tracheal
intubation when neuraxial anaesthesia was contraindicated [7–
10]. Moreover, the American Society of Anesthesiologists task force
on obstetric anaesthesia states that a carefully titrated sedation/
analgesia may be considered as an anaesthetic option for removal
of retained placenta in patients presenting with postpartum
haemorrhage without haemodynamic instability [2].
Point-of-care ultrasound examination of the gastric antrum has
been proposed for the rapid and non-invasive qualitative and
quantitative assessment of gastric contents and volume in term
pregnant labouring women and in the postpartum period [11–
16]. In particular, antral ultrasonography allows for determination
of both the nature of gastric contents and the gastric volume using
measurement of the antral cross-sectional area. In fact, no previous
study has assessed the change in the gastric contents during
vaginal delivery, immediately before placental delivery.
Using point-of-care ultrasound examination of the gastric
antrum, we performed a prospective multicentre cohort study that
aimed to assess the change in gastric contents during vaginal
delivery and to determine the prevalence of stomach at risk for
pulmonary aspiration in the immediate postpartum period before
placental delivery.
2. Material and methods
2.1. Study setting and participants
This prospective cohort study was conducted between August
2018 and August 2020 in three level-3 maternity units, after
approval from the Institutional Review Board (Comité de Protec-
tion des Personnes Sud-Est IV, Groupement Hospitalier Est, IRB
number L16-113). The methodology followed the recommenda-
tions of the Strengthening the Reporting of Observational studies in
Epidemiology statement [17].
After receiving informed consent, adult women in active labour
with effective patient-controlled epidural analgesia were consec-
utively enrolled according to ultrasound operator availability (four
physicians, each with a practice of at least 100 gastric ultrasound
examinations in term pregnant women). Patients with a history of
previous upper gastrointestinal surgery, multiple pregnancy,
obesity (body mass index before pregnancy  35 kg/m2) and
underlying diseases with potential impact on gastric emptying
(diabetes mellitus or gestational diabetes, hypothyroidism and
chronic opioid consumption) were not included in the study.
Parturients were allowed to drink clear liquids during labour until
full cervical dilatation but they were not allowed to eat any solid
food. For each woman, patient-controlled epidural analgesia was
set up using ropivacaine (1 mg/mL) or levobupivacaine (1.25 mg/
mL) with sufentanil (0.5 mg/mL). After administration of an initial
bolus immediately after insertion of the epidural catheter,
analgesia was maintained using pump settings of 5 mL bolus,
10 min lockout interval, and 5-mL/h basal infusion.
2.2. Study protocol and ultrasound assessment of gastric content
For each patient, ultrasound examination of the antrum was
performed at two predefined time points: (1) at full cervical
dilatation, within the thirty minutes preceding the beginning of
expulsive efforts, and (2) after vaginal birth, before placental
delivery. Each ultrasound examination was performed with the
patient placed in the semi-recumbent position (supine position
with the head of the bed raised to 458), using a portable
sonographic device (SonoSite Inc., Bothell, WA, USA) fitted with
an abdominal 2–5 MHz probe. The gastric antrum was scanned in a
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Anaesth Crit Care Pain Med 41 (2022) 100993
standardised sagittal plane in the epigastric area, including the left
lobe of the liver and the aorta, as previously described [11,12]. The
maximal anteroposterior (D1) and longitudinal diameters (D2) of
the antrum were measured, from serosa to serosa, allowing the
calculation of the antral cross-sectional area in the semi-
recumbent position (SR-CSA) according to the following formula:
SR-CSA = (p  D1  D2)/4 [18,19]. The shortest distance between
the anterior wall of the abdominal aorta and the centre of the
antrum, and the shortest distance between the skin and the centre
of the antrum, were also measured and reported [20]. The presence
or the absence of solid content in the antrum was also recorded.
Solid gastric content was defined as the visualisation of hyper-
echoic content in the antrum. Patients were considered as having a
stomach at risk for pulmonary aspiration if any solid content was
observed in the antrum or if the SR-CSA was > 608 mm2 (cut-off
value of SR-CSA to detect gastric fluid volume  1.5 mL/kg) [14].
2.3. Statistical analysis
All continuous data were verified for normality using the
D’Agostino Pearson test. Normally distributed quantitative data
were expressed as mean  standard deviation. Skewed data were
expressed as median [interquartile range]. Incidence data were
expressed as number (proportion), with 95% confidence interval (95%
CI) calculated according to the Wilson method with continuity
correction. Ultrasound data between the first ultrasound examination
(at full cervical dilatation, before the beginning of expulsive efforts)
and the second ultrasound examination (after vaginal birth, before
placental delivery) were compared using McNemar test for categori-
cal variables, and using paired Student’s t-test for quantitative
parameters, as appropriate. The relationship between the SR-CSA
measured before and after vaginal delivery was analysed using
Pearson’s correlation. For each test, P < 0.05 was considered as
statistically significant. Statistical analysis was performed using
MedCalc1 version 12.1.4.0 for Windows (MedCalc Software, Ostend,
Belgium).
Assuming that 75% of women would have high risk gastric
content status at full cervical dilatation, the inclusion of 28 women
was required in order to show a 35% decrease in the prevalence of
high-risk gastric content after delivery, with a = 0.05 and b = 0.2.
We decided to include 30 women to account for the risk of
inconclusive examinations.
3. Results
Thirty patients were recruited as shown in Fig. 1.
The antrum was not identified in two patients (6.7%) during the
first ultrasound assessment and in one patient (3.7%) during the
second ultrasound assessment (P = 0.44). A total of 26 patients
were included in the final analysis. The baseline characteristics of
these patients are presented in Table 1.
Six patients (23%) underwent instrumental vaginal delivery
between the two-ultrasound examinations. Four patients (15.4%)
underwent manual exploration of the uterus after the second
ultrasound examination. None of the included patients required a
general anaesthesia until the completion of the study.
The mean time interval between the first and the second
ultrasound examination was 47  20 min. Qualitative and quanti-
tative ultrasound assessments of gastric contents, and distances
between antrum and skin and antrum and aorta, before and after
vaginal delivery, are shown in Table 2.
The SR-CSA, the proportion of patients with solid gastric
content and the skin-antrum distance decreased significantly after
vaginal delivery (Table 2). The difference in the proportion of
patients with solid gastric content between the two-ultrasound
F.-P. Desgranges, F. Vial, L. Zieleskiewicz et al. Anaesth Crit Care Pain Med 41 (2022) 100993

Fig. 1. Study flow diagram.

Table 1
Baseline characteristics of the patients included in the study.
Age (years) 28  4
Body mass index before pregnancy (kg/m2) 25  4
ASA physical status
ASA 2 26 (100%)
Gestational age (weeks) 39.5 [38.5–40.5]
Parity 1 [0–1]
Gastro-oesophageal reflux during the last month of pregnancy 16 (61.5%)
Vomiting during labour 6 (23.1%)
Duration of fasting for clear fluids at first ultrasound examination (hours) 45
Duration of fasting for solids at first ultrasound examination (hours) 15  4
Level of pain at first ultrasound examination (/10)a 1 [0–3]
Duration of epidural analgesia at first ultrasound examination (hours) 62

Normally distributed quantitative data are expressed as mean  standard deviation. Skewed data are expressed as median [interquartile range]. Qualitative data are expressed as
number (%). ASA: American Society of Anesthesiologists.
a
Level of pain assessed by using a 0–10 numerical verbal rating scale (0 = no pain and 10 = worst pain imaginable).

Table 2
Qualitative and quantitative assessment of gastric contents before and after vaginal delivery.

Before vaginal delivery After vaginal delivery P value

Solid gastric content (n) 9 (34.6%) 2 (7.7%) 0.02

SR-CSA (mm2) 559  182 464  186 0.005
High gastric contenta (n) 15 (57.7%) 6 (23.1%) 0.004
Skin-antrum distance (mm) 51.4  11.7 46.8  10.2 0.04
Aorta-antrum distance (mm) 36.2  7.1 36.6  9.9 0.71

Data are expressed as number (%) or mean  standard deviation. SR-CSA: antral cross-sectional area in the semi-recumbent position.
a
High gastric content defined as solid gastric content or SR-CSA > 608 mm2.

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F.-P. Desgranges, F. Vial, L. Zieleskiewicz et al.
Fig. 2. Individual data graph showing the changes in antral cross-sectional area
measured in the semi-recumbent position (SR-CSA) between the two ultrasound
examinations (at full cervical dilatation before the beginning of expulsive efforts
and in the immediate postpartum period before placental delivery). The dotted line
indicates the cut-off value of 608 mm2 for the diagnosis of a stomach at risk for
pulmonary aspiration.
examinations was 26.9% [95% CI: 2.3–49%]. The mean percentage
change in SR-CSA between the two-ultrasound examinations was
14.3% [95% CI: 3.2–25.4%]. There was a significant correlation
between the SR-CSA before vaginal delivery and the SR-CSA after
vaginal delivery (r = 0.65 [95% CI: 0.34–0.83], P = 0.0004). The
prevalence of stomach at risk for pulmonary aspiration was
significantly lower after vaginal delivery than before vaginal
delivery (23.1% [95% CI: 9.8–44.1%] vs. 57.7% [95% CI: 37.2–76.0%],
P = 0.0004) (Table 2).
The SR-CSA was above 608 mm2 in 10 patients (38.5%) before
vaginal delivery and five patients (19.2%) after vaginal delivery
(P = 0.12) (Fig. 2).
Twenty-one patients (80.8%) had a decrease in the SR-CSA
between the two ultrasounds. Among the 10 women with a SR-
CSA > 608 mm2 before vaginal delivery, six (60%) had a SR-
CSA < 608 mm2 after vaginal delivery.
Among the six patients with high-risk gastric content after
vaginal delivery, two patients (33%) presented with solid gastric
content and four patients (67%) presented without solid gastric
content but with a SR-CSA > 608 mm2.
4. Discussion
Our study is the first to analyse the impact of vaginal birth on
gastric content status in the immediate postpartum, before
placental delivery. In our study, we have reported a significant
decrease in the proportion of patients with solid gastric content as
well as in the SR-CSA during vaginal delivery. Most of the patients
presented a decrease in the SR-CSA between the two-ultrasound
examinations. Thus, the proportion of patients with high-risk
gastric content was significantly lower after vaginal delivery than
before vaginal delivery. Therefore, our results suggest that gastric
emptying is at least partially preserved during the course of vaginal
delivery. As previously reported in patients undergoing caesarean
delivery [20], there was a significant decrease in the depth of the
antrum during vaginal delivery in our study, indicating a
significant change in the anatomical position of the antrum
between the two measurement periods that did nevertheless not
affect the qualitative assessment of gastric antrum content.
Nonetheless, contrary to previously described results in patients
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Anaesth Crit Care Pain Med 41 (2022) 100993
undergoing caesarean section [20], there was no significant
difference in the distance between the antrum and the aorta
during the course of delivery in our study. The discrepancy
between these findings may reflect differences regarding the
change in the anatomical position of the antrum between patients
undergoing vaginal birth and patients undergoing caesarean
delivery. One can assume that, before the beginning of expulsive
efforts, the gravid uterus could alter gastric emptying through
direct compression on the gastro-intestinal tract. The abrupt stop
in the mechanical obstruction of the gastric outlet during the
course of delivery may promote resumption of gastric emptying
after vaginal birth. Nevertheless, in our study, one cannot rule out a
potential influence of the release of the mechanical obstruction
from the uterus in the SR-CSA measurement as a confounder while
scanning. The measurements might be influenced by anatomical
disposition of the antrum under different scanning conditions,
rather than real changes in the size of the antrum between the two
measurement periods.
Currently, most authors define a patient at risk for pulmonary
aspiration by the presence of solid material in the stomach and/or
a gastric content volume >1.5 mL/kg [13,21–24]. Two mathe-
matical models have been described and validated for the
calculation of gastric content volume in third-trimester pregnant
women [25,26]. However, these models require placing the
patient in the right lateral position, which may be not easily
feasible and may have harmful consequences for the mother or
the foetus [27]. Therefore, we decided not to calculate the volume
of stomach contents and to use the measurement of the SR-CSA as
a surrogate of the gastric content volume. Several previous
studies have reported that the SR-CSA correlated with gastric
volume and showed good performance to discriminate between
high and low gastric contents in adult surgical patients and term
pregnant women [14,22,26,28]. The cut-off value of SR-CSA of
608 mm2 used in our study to discriminate between patients
with high estimated gastric volumes and those with low
estimated gastric volumes is based on one single study including
40 patients [14], which may limit its use in current practice.
Nevertheless, this cut-off value has been reported as predictive of
a gastric content volume >1.5 mL/kg with a sensitivity of 75% and
a specificity of 94% in labouring women [14]. Composite
ultrasound scales combining semi-quantitative grading scale
and the measurement of the antral cross-sectional area have been
proposed for the discrimination between low and high gastric
content volumes, both in term pregnant women and in the adult
non-pregnant population [26,29]. Although such composite
scales could be of particular interest for the stratification of
the risk of pulmonary aspiration at the bedside, they have not
been used for the estimation of gastric content volume in our
study because they require turning the parturient into the right
lateral decubitus.
Previous studies have reported that, in clinical practice,
tracheal intubation is performed in a minority of patients
requiring general anaesthesia in the immediate postpartum
period, notably for placenta removal after vaginal delivery [7–
9]. However, in our study, the prevalence of stomach at risk for
pulmonary aspiration was somewhat high in this context, since
23.1% of postpartum women who have delivered vaginally had
high-risk gastric content before placental delivery. Our study
confirms the feasibility of antral ultrasound in the immediate
postpartum period, already reported in a previous work [16]. For
these reasons, point-of-care ultrasound assessment of gastric
contents may be of interest to individualise the anaesthetic
management according to the gastric content status in cases of
emergent obstetrical procedures requiring general anaesthesia
after vaginal delivery, and could be included in future clinical
decision-making algorithms. In particular, when a general
F.-P. Desgranges, F. Vial, L. Zieleskiewicz et al.
anaesthesia is required for manual removal of retained placenta,
antral ultrasound could be a useful tool to rapidly estimate the
risk of pulmonary aspiration and to choose between a titrated
sedation/analgesia without tracheal intubation, as suggested by
the American Society of Anesthesiologists Task Force report on
obstetric anaesthesia [2], or a general anaesthesia with rapid
sequence induction and endotracheal intubation. Further studies
could be of interest to assess the impact of ultrasound assessment
of gastric contents on the choice of the anaesthetic strategy and
on maternal morbidity in this setting.
A limitation of the present study is related to our inclusion
criteria. This may have an effect on the externalisation of our
findings. In fact, we have examined a specific cohort of healthy
patients without any underlying conditions with potential
influence on gastric volume and emptying. One cannot exclude
the possibility that various diseases like diabetes mellitus or
obesity would have contributed to impair gastric emptying during
vaginal delivery and to increase gastric content volume in the
immediate postpartum period [30]. Moreover, our study was
performed in women with effective epidural analgesia. Therefore,
we could not investigate the effects of the mode of analgesia during
labour (epidural analgesia, intravenous opioids, or no analgesia) on
the prevalence of patients with high-risk gastric content after
vaginal birth in our study. This should be assessed specifically in
further studies. Another limitation of this study is related to the
number of patients included. In fact, for sample size calculation, we
assumed that 75% of women would have high-risk gastric content
status at full cervical dilatation, while only 57.7% of the patients
presented a stomach at risk for pulmonary aspiration before
vaginal delivery in our cohort. Nevertheless, despite our relatively
low sample size, we were able to show a significant decrease in the
proportion of patients with high-risk gastric content during
vaginal delivery. Because of the relative small sample size, we
observed a wide CI for the prevalence of stomach at risk for
pulmonary aspiration in our study, limiting the interpretation of
the clinical implications of our results. External validation using
large sample sizes may be of interest to assess the generalisability
of our findings.
5. Conclusion
In our cohort, both the SR-CSA and the proportion of patients
with solid gastric content decreased significantly after vaginal
birth, suggesting that gastric emptying is at least partially
preserved during the course of vaginal delivery. Although the
prevalence of stomach at risk for pulmonary aspiration was
significantly lower after vaginal delivery than before vaginal
delivery, almost a quarter of women who has delivered vaginally
presented with high-risk gastric content in the immediate
postpartum period. Point-of-care antral ultrasound may be of
interest for the fast assessment of the gastric content status when a
general anaesthesia is required for manual removal of retained
placenta in case of immediate postpartum haemorrhage, and could
have an impact on the choice of the anaesthetic strategy in this
setting.
Human and animal rights
The authors declare that the work described has been carried out in
accordance with the Declaration of Helsinki of the World Medical
Association revised in 2013 for experiments involving humans as well as
in accordance with the EU Directive 2010/63/EU for animal experiments.
Informed consent and patient details
The authors declare that this report does not contain any personal
information that could lead to the identification of the patient(s).
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Anaesth Crit Care Pain Med 41 (2022) 100993
Disclosure of interest
Laurent Zieleskiewicz and Lionel Bouvet received fees from GE Healthcare for
ultrasound teaching to GE Healthcare costumers.
Marc Leone received fees from Aspen, MSD for lectures and from Gilead, Amomed
and Ambu for consulting.
The other authors have no competing interests to declare.
Funding
This work did not receive any grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Author contributions
All authors contributed to the conception and design of the study. FPD,
FV, MCB and LB contributed to the acquisition of the data. FPD and LB
performed statistical analysis and wrote the first draft of the manuscript. All
authors made substantial contributions to the interpretation of the results,
and to the critical revision of the manuscript for important intellectual
content. All authors approved the version to be submitted.
Acknowledgements
None.
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