CONGRESSO AOGOI - RIMINI · CONGRESSO AOGOI - RIMINI 1. CORSI PRE CONGRESSUALI CORSO...

CONGRESSO AOGOI - RIMINI

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CORSI PRE CONGRESSUALI

CORSO PRECONGRESSUALE

SEMEIOTICA OSTETRICA

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Il travaglio e il parto

Impegno e progressione. Mani o eco?

Paolo Accorsi

Il Contesto

Paolo Accorsi:

Anno di laurea 1979

Specialista dal 1983

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Specialista dal 1983

Indice di posizione: vietato fare diagnosi...

La regione occipitale per prima contrae rapporti conl’ingresso pelvico: presentazione di vertice.

La testa può assumere un atteggiamento anomalo:

- le bozze frontali per prime si rapportano con

Il Contesto

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- le bozze frontali per prime si rapportano conl’ingresso del bacino (fronte)

- a volte la prima regione a contrarre rapporti conl’ingresso pelvico è quella la facciale (faccia.)

A testa fetale non completamente flessa, diversi sono idiametri che si confrontano...

I due diametri obliqui dell’ingresso pelvico (stretto superiore della pelvi) nel bacino normoconformato rappresentano gli assi di due aree ovoidali, dette aree di impegno.

Il Contesto

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Livello parte presentata

Impegno della p.p.: esprimere in centimetri la distanzatra l’indice della parte presentata ed il piano delle spineischiatiche. Livello 0: impegno

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Impegno della parte presentata

Impegno della parte presentata:

il passaggio della maggior circonferenza della parte presentata al di là del piano dello stretto superiore e

l’indice di presentazione viene a trovarsi a livello delle

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l’indice di presentazione viene a trovarsi a livello delle spine ischiatiche.

Progressione della p.p.

Progressione della p.p.

è la fase nella quale la parte presentata avanza lungo il canale del parto sotto l’azione delle contrazioni-spinte

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Sonographic assessment

Ecografia trans addominale

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I. Blasi. Ultrasound Obstet Gynecol 2010; 35: 210–215

Sonographic assessment

Ecografia trans addominale

Conclusions The results of this study suggest that theposition of the head and spine during the second stage

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I. Blasi. Ultrasound Obstet Gynecol 2010; 35: 210–215

position of the head and spine during the second stageof labor could be useful indicators for predicting theOP position at delivery.

Intrapartum Translabial Ultrasound

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Impegno della p.p.

A three-dimensional reconstruction from a computedtomographic …

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W. Henrich. Ultrasound Obstet Gynecol 2006; 28: 753–760

Impegno della p.p.

Gli stessi piani con gli ultrasuoni

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Infrapubic line

Sonographic Landmarks

The ‘infrapubic line’ …

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Infrapubic line

Per “infrapubic line” si intende:

1) la linea che idealmente il margine inferiore del pube e il promontorio

QUESTIONS

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promontorio2) la linea che unisce le spine ischiatiche

3) la linea ideale che partendo dal margine inferio re del pube si stacca da questo, perpendicolare all’asse maggiore del pube stesso


The ‘infrapubic line’ …

caput

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infrapubic line

head direction


With the transducer placed infrapubically:

(i) the ‘infrapubic line’ is perpendicular to the long axisof the pubic joint

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(ii) the widest fetal head diameter and its movementwith regard to the infrapubic line during pushing

(iii) the ‘head direction’ with respect to the long axis ofthe symphysis


Caput succedaneum...

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Head Direction

Is defined as the direction of a line perpendicular tothe widest diameter of the fetal head in theinfrapubic plane, with respect to the infrapubic line.

-When this line pointed ventrally at an angle of 30° or

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-When this line pointed ventrally at an angle of 30° ormore, it was considered ‘head up’

-For lines below 0°, the direction was termed ‘headdown’

-All other angles were considered ‘horizontal’



‘head up’.

caput

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infrapubic line

head direction

Head Direction

‘horizontal head’.

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Head Direction

‘head down’.

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20 pregnant women in spontaneous term labor withnormal singleton fetuses in cephalic presentation andclinical indication for vacuum extraction were studiedby ITU immediately before operative vaginal delivery

Lack of descent or lack of passage below the

caput

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Lack of descent or lack of passage below theinfrapubic line and horizontal or downward headdirection werewere poorpoor prognosticprognostic signssigns

Conclusions. ITU provides objective information onthe dynamics of the second stage of labor, headstation and head direction. ITU may be used toassess the prognosis for operative vaginal delivery.


QUESTIONS

Quando la testa fetale ha un orientamento definito all’ecografia translabiale: “head down”, la probabilità per il parto vaginale è:

caput

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1) maggiore

2) minore

3) indifferente

-When the fetal head was directed downward, thestation assessed clinically was most frequently ≤+1 cmfrom the ischial spines

-When the direction was horizontal, the station wasmost frequently ≤+2 cm

Head Direction

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most frequently ≤+2 cm

-When the fetal head was directed upward, the stationwas usually ≥+3 cm

All comparisons between clinical and sonographicfindings demonstrated a statistically significantrelationship (P < 0.0001).

T. Ghi. Ultrasound Obstet Gynecol 2009; 33: 331–336

Head Direction: down

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Head Direction: horizontal

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Head Direction: upward

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Discesa p.p e modalità di parto

Objectives.

To assess the feasibility and reproducibility ofmeasuring fetal head station and descent during laborusing transperineal ultrasound (TPU)

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using transperineal ultrasound (TPU)

To assess its utility in distinguishing patients whosepregnancy will result in spontaneous vaginal deliveryfrom those who will require operative vaginal deliveryor Cesarean section for failure to progress

A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33: 313–319


TPU imaging was used to measure the angle of headdescent during the second stage of labor in 23women.

Head descent was quantified by measuring the angle

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Head descent was quantified by measuring the anglebetween the long axis of the pubic symphysis and a lineextending from its most inferior portion tangentially tothe fetal skull

Intraobserver and interobserver variability werecalculated using variance component analysis.



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Angolo di discesa e tempo del parto

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Angolo di discesa e tempo del parto

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Results

Spontaneous delivery occurred in all cases in which theTPU angle exceeded 120°.

Among the six patients who had Cesarean Sections forfailure to progress ((2626%%)),, clinical digital assessment of

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failure to progress ((2626%%)),, clinical digital assessment offetal head station was +2 or more.

Conclusions

The angle of head descent measured by TPU imagingprovides an objective, accurate and reproducible meansfor assessing descent of the fetal head during labor



Conclusions

The low intraobserver and interobserver variabilityvalidates the accuracy of this technique.

The relationship between fetal head descent assessed

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The relationship between fetal head descent assessedby digital examination and by TPU imaging clearlyshows a particularly poor correlation in mid-station(clinical station, −2 to 0), reflecting how difficult it isfor clinicians to accurately quantify clinical headstation using the more subjective method of digitalexamination.



Conclusions

We are hoping that, after further investigation, TPU

imaging may have the potential to be used as a more

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accurate tool in decision making in the event of true

failure to progress in labor and that it may aid in

guiding clinicians with regards to operative vaginal

delivery


A study of progress of labour

Objectives.

Intrapartum translabial ultrasound measurements for‘head station’, ‘head direction’, and ‘angle of descent’(AoD) … in 50 labouring women, compared, studied forrepeatability, and correlated with the progress of

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repeatability, and correlated with the progress oflabour

Main outcome measures.

Reproducibility and correlation of ITU parameters andtheir pattern of changes during labour.

B. Tutschek,… W. Henrich BJOG 2011;118:62–69


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The infrapubic line is perpendicular to the long axis of the pubic symphysis. The parallel plane through the ischial spines is 3 cm below the infrapubic line, and is used to measure true head station (‘ITU station’).


Intrapartum translabial ultrasound parameters wererecorded at the height of pushing.

Results

Vaginal delivery (either spontaneous or operative)

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Vaginal delivery (either spontaneous or operative)occurred in:

33 of 34 (97%) women for an ITU station greater than+2.0 cm,

32 of 34 (94%), for a head direction >22°, and

34 of 36 (94%) women with angle of descent >135°



Results

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Results

There was good repeatability for ITU head station,AoD, and head direction, both for the same and fortwo different examiners.

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two different examiners.

50 pregnant women with normal singleton termpregnancies, mostly in the second stage of normalspontaneous labour, were included: there were 28normal vaginal birth, 13 attempted and successfulinstrumental, and nine caesarean deliveries (18%)



Results

The changes of ITU-measured head station and head directionduring a contraction with pushing differed with head station: atstations between -3 and -2 cm, the average descent during acontraction was 2.5 cm, between -2 and +2 cm it was 1 cm, and atstations between +2 and +3 cm it was 2.2 cm.

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stations between +2 and +3 cm it was 2.2 cm.

In the upper part of the birth canal and down to head station +2cm, head directions varied, but mostly changed from down tohorizontal. The average change of head direction during acontraction per 1 cm of head descent overall was +10°, butbetween head station +2 and +3 cm there was a markedlyincreased change of head direction during a contraction (onaverage +18°)



Conclusions

Vaginal birth is a natural process, but occasionallyrequires urgent medical intervention.

Our new data may improve our understanding of normaland abnormal labour, enable objective measurement of

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Our new data may improve our understanding of normaland abnormal labour, enable objective measurement ofbirth progress, and provide a more scientific basisfor assessing labour.


We speculate that ITU may reduce the risks ofassisted labour, and that it might even avoidunnecessary caesarean deliveries (18% TC !!)

Roberto Romero

One of the most difficult dilemmas in clinicalobstetrics is that presented by a nulliparous woman atterm who had a protracted active phase of labor,received an epidural, and now has a prolonged secondstage of labor.

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stage of labor.

The head appears to be low, but there is alwaysuncertainty as to whether this reflects caput. Shouldthis situation be handled with an operative vaginaldelivery (forceps or vacuum) or a Cesarean section?

R. Romero Ultrasound Obstet Gynecol 2009; 33: 253–258

Roberto Romero

Ultrasound can play a role by:

1) identifying precisely the fetal position;

2) diagnosing whether caput is present and its extent;

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3) assessing the fetal station; and

4) when ultrasound has been used serially, documentingthe degree of progress that has been made during thesecond stage

R. Romero Ultrasound Obstet Gynecol 2009; 33: 253–258

Conclusioni

Conclusioni:

A) Serve un “matrimonio” tra ecografisti e clinici in sala

parto… (vedi 18 e 26 % di TC nel secondo stadio)

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B) Cerchiamo di capire il parto, anche con gli ultrasuoni

C) Non interferire negativamente con il parto

introducendo metodiche non standardizzate e non EBM

Conclusioni

Conclusioni:

D) Utilizzare la metodica (standardizzata) in situazioni

di necessità e non generalizzate (la > parte partorisce

bene senza interferenze!)

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bene senza interferenze!)

E) Maggiore possibilità di corretto utilizzo del vacuum

F) ... Poi occorre un ecografo in sala parto

Grazie dell’attenzione

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CONGRESSO AOGOI - RIMINI · CONGRESSO AOGOI - RIMINI 1. CORSI PRE CONGRESSUALI CORSO...

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