DISCUSSION

Labor progress monitoring is important to avoid embryonic and maternal complications. There are massive variations in the period of labour between females. It is suggested that females must be permitted to labour for extended periods so that vaginal birth can be done. ⁷

Conventionally, the evaluation and management of a female in labour is built on clinical results. The labour arrest diagnosis and decisions concerning the timing or type of intervention rely mostly on digital evaluation of cervical dilatation and embryonic head station and location. But, clinical examinations of the head station and location are inexact and particular, especially when head succedaneum harms palpation of the joints and fontanelles. ⁵

US examinations could, somewhat, differentiate between those females intended for unprompted vaginal birth and those intended for operational deliveries. Moreover, there is a rising suggestion that US labour can expect the outcomes of instrumentally vaginal deliveries. ⁸

The current work aimed to assess the role of the US in labour to find out about embryonic head station, dilatation, location and attitudes.

This was a prospective observational investigation was done at the obstetrics and gynecology department at Bab el-sharia, Al-Azhar University Hospital on 85 women with singleton term (37-40 weeks) pregnancies.

This comes in comparison with the study of Mohan et al., ⁷ in which 215-cases were involved. Amongst these cases, 20 were born after the 1^st labour evaluation, 162 afterward the 2^nd, 18 afterward the 3^rd, and 15 afterward the 4^th. Consequently, a number of 458 observations have been attained by DVE as well as the US. The age mean was 23.1 2.7-yrs, and the mean pregnancy age was 383-wks. It was unprompted for 173 (80.4%) cases and persuaded because of motherly and embryonic indications for 42 (19.5%) females. BMI was 18.5–22.9 in 148 (68.8), and was 23.0–24.9 in 57 (26.5). There were 11 (5.1%) operational vaginal births and 6 (2.7%) cesarean births. The percentage of cesarean deliveries was less than that of the studied group (28%) because of the studied cases of low-risk nulliparous females in active labour, whereas 159 (74.0) were from 2.5 to 3.5-kg, and 6 (2.8) were > 3.5 kg.

In another study, Khalil et al., ⁹ reported that the age mean of cases was 24.8 5.1-yrs. The median pregnancy was 2, ranging between G1 & G7. The mean pregnancy age depending on the ultimate menstrual period was 39.3-wks, ranging between 37 and 41-wks of amenorrhea. The mean embryonic delivery mass was 3.2232 0.4235-kg Closely 82% of cases were born vaginally, in comparison with 17% who were born via CS, and one woman was born vaginally via obstetric forceps.

Furthermore, Mittal et al., ¹⁰ reported that a total of 335-cases have been involved in the report and have been monitored by DVE and trans-abdominal sonography to find out the FHP in the active 1^st-stage (cervical dilation 40–60 mm) and in the 2^nd-stage of labour. The age mean of cases was 22.81 2.91-yrs. The majority of cases (60.0%) had a mean BMI of 23.25 11.85 kg/m2. The mean pregnancy age was 39.07 0.79-wks (37–42-wks). The interval of pregnancy was 39–39+6 in 54.39% of females. The majority of delivered babies were from 2.5 to 3.5 kg [236 (70.45%)], and 20.30% of delivered babies were of small birth mass.

In the current work, we revealed that the embryonic head position distribution in the study group females according to ultrasonography and DVE examination and the agreement between them. The embryonic head position couldn't be identified in 21 (24.7%) of the females by the DVE examination. There was high agreement (78.1%) between the two methods when the embryonic head location was LOA-Left Occiput Frontal. The intra ICC for both the US and DVE as regards embryonic head position revealed a high correlation (ICC, 0.669 95% confidence interval, 0.492-0.785) and the accordance between DVE and the US was substantial (=0.635, P-value 0.001).

Indeed, Mohan et al., ⁷ reported that the embryonic head location couldn’t be assessed by DVE in 44 out of 458 (9.6%) observations because of the existence of a head. On the other hand, embryonic head location was assessed by trans-abdominal US in all patients. In 376 out of458 (82.1%) observations, the head location on the US was at 45° of the DVE evaluation (Table 3). The accordance between the 2 methods was non-significantly associated (=0.554; P 0.001).

A local report in addition to a new multicenter random controlled study by Ramphul et al., ¹¹ have concluded that, in comparison to DVE, determining embryonic head position with US prior to instrumental birth decreases mis-placement of the vacuum cup. The prophecy of continual OP position at birth is also probable with a sensitivity of about 70-80%.

Chou et al., ¹² concluded finding embryonic head location precisely in 71.6% of DVE vs. 92.0% of US assessments.

Hassan et al., ¹³ found embryonic head location in 98 % of US assessments but only 46 % of DVE assessments.

Akmal et al., ¹⁴ and Souka et al., ¹⁵ were unsuccessful in determining embryonic head location in 33.5% and 60.7% of DVEs, respectively. In the current work, embryonic head position was defined in a high percentage of DVEs in comparison to preceding research, perhaps as the mainstream of examinations in preceding reports have been done via midwifes, while all DVEs have been done via obstetricians in the current work. This is in accordance with research concluding that the rate of precise determination of embryonic location via DVE was high for obstetricians in comparison to midwives (50% versus 30%).

Moreover, digital pelvic examinations are minor in the US for examining the embryonic head crosswise location throughout labour. In particular, the head succedaneum connected to the deep crosswise location reduces the diagnosing exactness of DVE. The crosswise location of the embryonic head could disturb the descent of the fetus via asynclitism. ¹⁶

A new report by Malvasi et al., ¹⁷ revealed that "squint signs" and "sun-set of thalamus and cerebellum signs" are two simple US signs for frontal and backward asynclitism, correspondingly. The commonest crosswise location was the left, whereas the commonest asynclitism was the frontal. The crosswise head locating with frontal or backward asynclitism is improbable to be indorsed by medication-or performance-connected mechanisms but must somewhat be a result of cephalopelvic dis-proportion. Moreover, epidural numbness doesn’t increase the dystocic labour rate.¹⁸

In accordance with the classifications of the American College of Obstetricians and Gynecologists, the station splits the pelvis above and under the ischial spines into 5th at 10-mm pauses. Zero station means that the lowest embryonic giving part is at the plane of the spines. In the meantime, station +5 is the condition of the embryonic head being observable at the introitus. But, the digital examinations of embryonic head stations are undependable. ¹⁶

et al., ¹⁹ studied the dependability of digital examinations of embryonic head stations evaluated by 32 residents and 25 attending physicians utilizing a recently designed delivery simulator mannequin. The mistake rates of residents and attending physicians were 50-88% and 36-80%, correspondingly. Moreover, head succedaneum, a procedure throughout labour, could as well delay precise digital assessment of the embryonic station. Consequently, objective measurements for the appointment and station in labour are needed.

On the other hand, in the current study, as regards the embryonic head station distribution in the studied group according to ultrasonography and DVE examination and the agreement between them, there was high agreement (95%) between the two methods when the embryonic head station was 20-mm. The ICC for both US and DVE as regards embryonic head station revealed a high correlation (ICC, 0.980 95% CI, 0.969-0.987) and the accordance between DVE and US was reasonable (=0.378, P-value 0.001).

CONCLUSION

The Intrapartum US is a simple method that expands the identification of ordinary and non-ordinary labour, permits objective measurements of delivery progress and provides a more systematic foundation for labour assessment. Moreover, the usage of the US is of crucial significance in the execution of a secure operative birth and could aid in predicting whether a vaginal birth will be successful or not. Additionally, intra-partum US was revealed to be an advantageous device for diagnosing labour progress in the active phase among term females. The accordance between DVE and US results was powerful for cervical expansion, and fair for embryonic head station and head location. The majority of labouring females concluded that the US is less upsetting and favored it over DVE for assessments of labour.