Assessment of labor progress by ultrasound vs manual examination: a randomized controlled trial.

BACKGROUND: Assessment of labor progress via digital examination is considered the standard of care in most delivery rooms. However, this method can be stressful, painful, and imprecise, and multiple examinations increase the risk for chorioamnionitis. Intrapartum ultrasound was found to be an objective, noninvasive tool to monitor labor progression. OBJECTIVE: This study aimed to investigate whether, among nulliparous women, the use of intrapartum ultrasound can reduce the rate of intrapartum fever by reducing the number of digital examinations. STUDY DESIGN: This was a prospective, randomized controlled trial in term nulliparas admitted with prelabor rupture of membranes, induction of labor, or in latent phase of labor with a cervical dilation of <4 cm. Women were randomized into 1 of the following 2 arms: (1) labor progress assessed by ultrasound, avoiding digital examinations as much as possible; and (2) control group in which labor progression was assessed according to the regular protocol. Before the study, all labor ward physicians underwent training in intrapartum ultrasound. RESULTS: A total of 90 women were randomized to the ultrasound group and 92 were randomized to the control group. When compared with the control group, the ultrasound group had significantly lower rates of intrapartum fever (11.1% vs 26.1%; P=.01), clinical chorioamnionitis (3.3% vs 16.5%; P>.01), and histologic chorioamnionitis (2.2% vs 9.8%; P=.03). The median number of digital examinations was significantly lower in the ultrasound group (5; interquartile range, 4-6) than in the control group (8; interquartile range, 6-10; P<.01). The median number of digital examinations per hour in the ultrasound group was significantly lower than in the control group (0.2 vs 0.4; P<.01). The induction rates, time from admission to delivery, mode of delivery, Apgar score at 5 minutes, and neonatal intensive care unit admission rates did not differ significantly between the groups. CONCLUSION: The use of intrapartum ultrasound lessens the total number of digital examinations needed to be performed during labor and, consequently, the incidence of intrapartum fever and chorioamnionitis are reduced. No adverse effects on labor progression and short-term maternal or neonatal outcomes were noted.

Prediabetes in pregnancy - follow-up, treatment, and outcomes compared to overt pregestational diabetes.

OBJECTIVE: There are limited data on follow-up, treatment, and maternal and fetal outcomes in women with prediabetes before or at the beginning of pregnancy. The aim of this study was to comprehensively characterize women with prediabetes compared to women with type 2 diabetes mellitus. STUDY DESIGN: This was a retrospective cohort data from a single medical center treating women with pregestational prediabetes mellitus (PDM). Women were compared to pregestational overt type 2 diabetes mellitus (T2DM). RESULTS: Data were collected from 120 women in the PDM group and 86 women in the T2DM group. Baseline characteristics were comparable, albeit women in the PDM group arrived at medical attention significantly later, 55% after 15 weeks gestation. Women with PDM needed significantly less treatment to achieve glycemic control and glycated hemoglobin remained lower throughout pregnancy. Maternal and fetal outcomes were similar between groups, although significantly higher rates of macrosomia and neonatal jaundice were observed in the T2DM group. CONCLUSIONS: The lack of clear guidelines causes a delay in the first prenatal visit of women with PDM. Comparable pregnancy outcomes may tip the balance toward acceptance of early treatment. Establishing clear guidelines will enable primary caregivers to refer prediabetic women sooner for lifestyle modifications and treatment if needed.

Intrapartum ultrasound at the initiation of the active second stage of labor predicts spontaneous vaginal delivery.

BACKGROUND: Longer duration of active pushing during labor is associated with a higher rate of operative delivery and an increased risk of maternal and neonatal complications. Although immediate pushing at complete dilatation is associated with lower rates of chorioamnionitis and postpartum hemorrhage, it is also associated with a longer duration of pushing. OBJECTIVE: This study aimed to evaluate whether fetal head station and position, as assessed by ultrasound at the beginning of the pushing process, can predict the mode of delivery and duration of pushing in nulliparous women. STUDY DESIGN: This prospective observational study included nulliparous women with neuraxial analgesia and complete cervical dilatation. The following sonographic parameters were assessed just before the beginning of the pushing process, at rest, and while pushing during contraction: head position, angle of progression, head-perineum distance, and head-symphysis distance. The change between rest and pushing was designated as delta angle of progression, delta head-perineum distance, and delta head-symphysis distance. The sonographic measurements and fetal head station assessed by vaginal examination were compared between women who had a spontaneous vaginal delivery to those who underwent an operative delivery, and between those who pushed for more or less than 1 hour. RESULTS: Of the 197 women included in this study, 166 (84.3%) had a spontaneous vaginal delivery, 31 (15.7%) had an operative delivery, 23 (11.6%) had a vacuum delivery, and 8 (4.0%) had a cesarean delivery. Spontaneous vaginal delivery and shorter duration of pushing (less than an hour) were significantly more common with a nonocciput posterior position (10.6% vs 47.3%; P<.005), a wider angle of progression, a shorter head-perineum distance and head-symphysis distance (both during rest and while pushing), and a lower fetal head station as assessed by digital vaginal examination. However, a logistic regression model revealed that only the angle of progression at rest and the delta angle of progression were independently associated with a spontaneous vaginal delivery with an area under the curve of 0.82 (95% confidence interval, 0.76-0.87; P<.0001) and 0.75 (95% confidence interval, 0.67-0.79; P<.0001), respectively. CONCLUSION: Ultrasound performed at the beginning of the active second stage of labor can assist in predicting the mode of delivery and duration of pushing and perform better than the traditional digital examination, with the angle of progression at rest and delta angle of progression being the best predictors.