1. The prediction of vaginal birth with transperineal ultrasound in women induced with dinoprostone
Hale GÖKSEVER ÇELİK, Engin ÇELİK, Gökhan YILDIRIM
Istanbul Health Sciences University Kanuni Sultan Suleyman Training and Research Hospital

2. ıntroductıon
The rate of incidence of cesarean section is steadily increasing all over the world
The most important point is the distinction between necessary and unnecessary cesarean sections
Because postponing the decision of cesarean section could cause undesirable results for the baby and the mother herself.

3. Digital cervical evaluation is used to determine the likelihood of vaginal birth which is considered by many women to be non- tolerable
Transperineal ultrasound allowing direct visualization of the fetal skull, first described in the mid-1990s, has been using for the evaluation of labor progress
Eggebo et al, 2015

4. Head-perineum distance: the distance between the presenting point of fetal head and the perineum
Head-pubis distance: the distance between the lower edge of the symphysis pubis and the fetal head
Angle of progression: the angle between the long axis of the symphysis pubis and the line in midsagittal plane passing through the lowest point of the symphysis pubis and tangent to the skull of the fetus
Barbera et al, 2009

5. A B C D

6. Aım…
to understand whether the transperineal ultrasound during the first stage of labor is a good model for the prediction of labor route in women induced with dinoprostone
to compare the predictive values of the head-perineum distance, the head-pubis distance and the angle of progression of fetal head

7. Method
A total of 55 pregnant women at gestational weeks were enrolled in this prospective observational study from August 2015 to July 2016
All participated women were examined before the admission to measure HPD, the head-pubis distance and AOP with transperineal ultrasound
Then Propess ovule was applied to all of the patients

8. Findings in nulliparous women…
Mean duration of Propess ovule application was significantly longer
The greater AOP, the shorter HPD, head-pubis distance and cervical length were associated with vaginal birth

9. Characteristics
Vaginal birth (n=14)
Cesarean section (n=18)
Mean±SD p
Age
25,8±5,3
27,3±5,6
0.451
BMI (kg/m2)
28,21±4,60
28,77±3,64
0.704
Weight gain (kg)
15,3±5,3
14,4±5,2
0.636
Gestational weeks
40,9±,3
41,0±,3
0.501
First Bishop score
2,9±1,1
3,3±1,2
0.350
EFW (grams)
3276±245
3318±265
0.651
Cervical length (mm)
38,4±8,6
41,2±9,3
0.390
Head-perineum distance (mm)
54,38±12,83
56,95±16,57
0.006
Head-pubis distance (mm)
43,48±11,29
46,08±8,33
0.045
Angle of progression of fetal head
118,1±15,8
112,4±13,7
0.028
Propess duration (hours)
12,8±4,8
15,9±9,8
Last Bishop score
7,3±0,8
5,0±1,3
0.001
Birth weight (grams)
3282±241
3346±305
0.526
Apgar score on 1st min
8,9±0,3
0.713
Apgar score on 5th min
9,9±0,3

10. Findings in multiparous women
Younger age, less gravida and BMI in vaginal birth group
HPD and the head-pubis distance were shorter, whereas cervical length was longer and AOP was greater in the vaginal birth group

11. Characteristics
Vaginal birth (n=19)
Cesarean section (n=4)
Mean±SD p
Age
29,8±5,3
33,2±5,6
0.027
Gravida
3,2±1,1
4,7±2,1
0,037
BMI (kg/m2)
30,67±3,28
35,05±3,69
Weight gain (kg)
12,8±4,3
11,5±3,1
0.561
Gestational weeks
40,6±0,6
41,4±,5
0.028
First Bishop score
3,6±0,8
4,0±0,0
0.294
EFW (grams)
3427±356
3551±407
0.542
Cervical length (mm)
46,8±7,0
45,3±6,2
0.682
Head-perineum distance (mm)
56,84±17,04
57,97±4,44
0.006
Head-pubis distance (mm)
53,98±12,46
54,95±5,87
0.882
Angle of progression of fetal head
110,5±17,2
99,9±19,5
Propess duration (hours)
8,6±6,8
7,4±4,7
0.732
Last Bishop score
6,9±0,8
5,7±1,5
0.038
Birth weight (grams)
3478±383
3721±769
0.348
Apgar score on 1st min
8,9±0,2
7,5±3,0
0.033
Apgar score on 5th min
9,9±0,2
9,2±1,5
0.049

12. nulliparous women vs multiparous women
Gravidity, BMI and birth weight were significantly higher in the multiparous group
Cesarean rates were higher in the nulliparous group
Mean duration of Propess ovule application was longer in the nulliparous group
Cervical length and head-pubis distance were significantly longer in the multiparous group

13. 0.004 0.001 0.008 0.002 0.046 Characteristics Nulliparous (n=32)
Multiparous (n=23) p
n (%)
Birth way
Vaginal birth
14 (42,4)
19 (57,6)
0.004
Cesarean section
18 (81,8)
4 (18,2)
Gender
Female
15 (71,4)
6 (28,6)
0.118
Male
17 (50,0)
Mean±SD
Age
26,6±5,4
31,4±5,9
0.074
Gravida
1,3±,6
3,4±1,4
0.001
BMI (kg/m2)
28,53±4,03
31,43±3,67
0.008
Weight gain (kg)
14,8±5,2
12,6±4,1
0.101
Gestational weeks
41,0±,3
40,8±,6
0.119
First Bishop score
3,2±1,2
3,6±,7
0.060
EFW (grams)
3299,8±253,6
3448,6±359,1
0.077
Cervical length (mm)
39,9±8,9
46,7±6,8
Head-perineum distance (mm)
55,82±14,87
57,86±15,50
0.624
Head-pubis distance (mm)
44,94±9,65
54,15±11,48
0.002
Angle of progression of fetal head
114,9±14,7
108,7±17,6
0.164
Propess duration (hours)
14,6±8,1
8,4±6,4
Last Bishop score
6,0±1,6
6,7±1,0
0.073
Birth weight (grams)
3318.7±276.4
3521.1±457.8
0.046
Apgar score on 1st min
8,9±,3
8,7±1,2
0.364
Apgar score on 5th min
9,9±,3
9,8±,6
0.541
There were differences between nulliparous and multiparous women when they were analyzed according to delivery route. The mean Bishop score after induction with Propess ovule was significantly higher in the vaginal birth group in the nulliparous women (p=0.001). The greater AOP, the shorter HPD, head-pubis distance and cervical length were associated with vaginal birth in the nulliparous women (Table 3).

14. Thresholds for the association of delivery route with ultrasonographic parameters were determined by using ROC curves to ascertain the optimal cut-off value
When a significant cut-off value was observed,
the sensitivity, specifity, positive likelihood ratio values were presented

15. Vaginal birth occurred with cut-off values for HPD≤54.5 mm and AOP≥115.5º in nulliparous women
Vaginal birth occurred with cut-off values for HPD≤58.5 mm and AOP≥93.2º in multiparous women

16. Cut-off value
Area under curve
Sensitivity (%)
Specifity (%)
Positive likelihood ratio
Nulliparous women
HPD (mm)
54,5
0.48
50.0
61.1
1.28
AOP (°)
115.5
0.62
57.1
66.7
1.71
Multiparous women
58.5
0.51
52.6 50
1.05
93.2
0.75
89.5 75
3.58

17. DISCUSSION
Pregnant women with shorter HPD and wider AOP might have a high possibility to achieve vaginal birth
Narrower AOP or greater HPD may caution doctors about the unsuccessful vaginal birth

18. Barbera et al, 2009; Ciaciura-Jarne et al, 2016
The angle greater than 120º-126º was associated with vaginal birth in many publications
The prediction of success of vaginal delivery in vacuum extraction attempt was also in another study and AOP is an important measurement associated with successful vaginal delivery
Barbera et al, 2009; Ciaciura-Jarne et al, 2016
Sainz et al, 2016

19. no practical clinical differences between them
Two-dimensional and three-dimensional transperineal ultrasound methods were compared to predict the delivery mode
no practical clinical differences between them
both of them seemed to perform better than digital cervical examination
two-dimensional transperineal ultrasound is cheaper than three- dimensional transperineal ultrasound
Torkildsen et al, 2011

20. According to our results…
nulliparous women with HPD≤54.5 mm or AOP≥115.5º
multiparous women with HPD≤58.5 mm or AOP≥93.2º
HIGH POSSIBILITY FOR VAGINAL BIRTH
If narrower AOP or greater HPD are encountered, it does not mean that the delivery will definitely occur with cesarean section, but may caution doctors that the chance of successful vaginal birth is slim

21. Transperineal ultrasound will be used as an alternative to traditional clinical examinations, because it is significantly better tolerated by mothers
Especially the patients with prolonged first stage of labor will receive biggest benefit from transperineal ultrasound
Further studies should be carried out to prove the utility of intrapartum transperineal ultrasound in the prediction of vaginal birth

22. THANK YOU FOR YOUR ATTENTION