Labor & Delivery

ISUOG
The Practiceprogression
“breech Guidelines: angle”: Intrapartuma new Ultrasound
feasible and
reliable transperineal ultrasound parameter for the
Ghi, T. , Eggebø, T. , Lees, C. , Kalache, K. , Rozenberg, P. , Youssef, A. , Salomon, L. J. and
fetal
Tutschek,breech descent
B. (2018), ISUOG PracticeinGuidelines:
the birth canalultrasound. Ultrasound
intrapartum
Obstet Gynecol, 52: 128-139. doi:10.1002/uog.19072 https://doi.org/10.1002/uog.19072
A. Youssef, E. Brunelli, M. Fiorentini, J. Lenzi, G. Pilu, A. El-Balat (2021) The “breech
progression angle”: a new feasible and reliable transperineal ultrasound parameter for
Summary
the fetal breech descent in the birth canal. Ultrasound in Obstetrics and Gynecology,
Ultrasound in active labor is not yet used widely, even though studies have shown that it is more
doi.org/10.1002/uog.23649.
precise and reproducible than clinical examination. Ultrasound allows objective measurement
https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.23649
and precise documentation of findings obtained during the examination. Several sonographic
parameters
Objective can be used during labor to assess mainly head station and position.
The aim1. of theHead
presentstation
studycan
wasbe tomeasured
assess the objectively,
feasibility andfor example
reliability of by AoP or HPD,
transperineal to assess
ultrasound in the
assessment ofcurrent
breech status
descentand as abirth
in the baseline
canal, for longitudinal
by measuring themeasurements.
“breech progression It can also
angle. ” help to
predict whether OVD is likely to be successful. Head station should be assessed
Methods
transperineally,
We recruited pregnant women not withtransabdominally.
singleton pregnancies HPD andis fetuses
straightforward to measure and
in breech presentation is
between
34 and 41 weeks’reproducible.
gestation. We AoPacquired
(in degrees) is equivalent
transperineal ultrasoundto head station
images in theexpressed
midsagittalinview for each
woman twicecentimeters,
by an operatorfrom –3 cm
and once byto +5 cm Each
another. (direct conversion
operator is possible)
measured the breech andprogression
has the angle
potential
after anonymization to link
of the ultrasound
transperineal data to traditional
ultrasound images. Breech assessment
progression by angle
palpation. HPD and
was defined as the
angle between AoP/head station
a line running alongcorrelate
the longlinearly (for
axis of the highsymphysis
pubic station, i.e.
andhigher
another than
line 0extending
to +1).2.from
the most2.inferior
Head portion
(and of the symphysis
spine) position istangentially
assessed to the accurately
more lowest recognizable fetal part in the maternal
by transabdominal
pelvis. Each operator was blinded from any other measurement
ultrasound than by digital palpation. Knowledge of head position performed for the same woman. The
in suspected delay
intra- and interobserver reproducibility were evaluated with intraclass correlation
or arrest of labor is important. Before OVD, knowledge of head position is essential. coefficient (ICC). To
investigate the presence of any bias, intra- and interobserver agreement was also analyzed using the
3. MLA is assessed by transverse transperineal ultrasound and may help to decide
Bland–Altman plot. Student’s t-test and Levene’s W0 test were used to investigate whether a number of
clinical factorswhether OVDon
had an effect cansystematic
be attempted safely.(t-test) and homogeneity (W0 test) between
differences
4. Head angle
breech progression direction is assessed by transperineal ultrasound and may help to decide
measurements.
whether OVD can be attempted safely.
Results
There are two main situations in which ultrasound assessment is likely to be of particular use in
Overall, 44 women were included in the analysis. Breech progression angle was successfully measured by
labor.
both operators on all images. Both intra- and interobserver agreement analyses showed excellent
1. Suspected delay or arrest of first or second stage. We recommend measurement of
reproducibility, with an ICC of 0.88 (95% CI, 0.80 to 0.93) and 0.83 (95% CI, 0.71 to 0.90), respectively. Mean
differences foreither AoP or HPD
intraobserver transperineally
repeatability and assessment
was 0.4 (95%CI, -1.4 to 2.2) of
andhead position
for interobserver repeatability
was -0.4 (95%CI,transabdominally.
-2.6 to 1.8). The upper limits of agreement were 12.0 (95% CI, 8.9 to 15.1) and 13.6 (95% CI,
2. forPotential
9.9 to 17.3) intraobserverneed andforinterobserver
performance of OVD. We
repeatability, recommend
respectively. assessment
The lower limits ofof head were
agreement
position
-11.2 (95% CI, -14.3 by and
to -8.1) transabdominal
-14.4 (95% CI, -ultrasound
18.2 to -10.7)and suggest measurement
for intraobserver of fetalrepeatability,
and interobserver head
respectively. Nostation by transperineal
systematic difference was ultrasound.
found bothThe most
in the reliable
intra- sonographicagreement
and interobserver parameters to
analyses.
None of the clinical factors examined (maternal body mass index, maternal
predict outcome of the procedure are HPD and AoP. MLA and/or head direction may age, gestational age at the
ultrasound scan and
also beparity)
usefulshowed
to predicta statistically
further the significant
likelihood effectof on intra- and
success interobserver
of the extraction.reliability.
Conclusions
Breech progression angle represents a new feasible and highly reproducible tool for the evaluation of fetal
breech descent in the birth canal. Future studies assessing its usefulness in the prediction of successful
external cephalic version and the success of breech vaginal delivery are needed.
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