Structured clinical examinations in labor: rekindling the craft of obstetrics

Abstract

Objectives: Exact knowledge of fetal station and position is of paramount importance for reliable surveillance of labor progress and a prerequisite for safe operative vaginal procedures. Detailed clinical assessments are thoroughly described in old textbooks, but almost forgotten in contemporary obstetrics. Ultrasound is suggested as an objective diagnostic tool in active labor. Several publications have demonstrated a low correlation between ultrasound and clinical assessment of fetal head station and position, but the methods of clinical assessment in these studies are poorly described. We wanted to explore if a quality clinical assessment could perform better than clinical assessment in previous publications, by analysing the correlation between a structured method of clinical assessment and intrapartum ultrasound.Methods: In all, 100 laboring women with cervical dilatation ≥7 cm were included in a prospective cohort study at Oslo University Hospital from October to December 2016. The study design was cross sectional. Clinical examinations were performed by one special educated consultant (JKI), and transabdominal and transperineal ultrasound clips were recorded and examined by a blinded expert in intrapartum ultrasound (TME). Fetal position was classified as a clock face with 12 units (hourly divisions) and thereafter categorized as occiput anterior (OA), left occiput transverse (LOT), occiput posterior (OP) and right occiput transverse (ROT) positions. Fetal station was categorized clinically from -5 to + 5 and measured with ultrasound as angle of progression (AoP) and head-perineum distance (HPD).AoP is the angle between a longitudinal line through the symphysis and a tangent to the head contour. HPD is the shortest distance between the fetal skull and the perineum.Results: Eight women were excluded due to strong contractions between clinical assessments and ultrasound measurements, fetal distress or incomplete examinations. Fetal position assessed by ultrasound and clinical examination agreed exactly in 48/92 (52%) cases, within one unit (hour) in 87/92 (95%) of cases and within two units in 90/92 (98%) of cases.It differed by three units in one case and by five units in one case. The agreement categorized into OA, LOT, OP and ROT was good (Cohen's kappa 0.72; 95% CI 0.61-0.84). For station, the agreement was very good for both head-perineum distance (Pearson correlation coefficient r=0.86; 95% CI 0.80-0.91) and angle of progression (r=0.77; 95% CI to 0.67-0.84). The correlation between HPD and AoP was good (r =0.76; 95% CI 0.65-0.84). Conclusion:We found very good correlations between structured clinical assessments and ultrasound examinations, suggesting that an objective quality in clinical examinations is possible to achieve. More focus on clinical skills training may improve accuracy for clinicians.

When does fetal head rotation occur in spontaneous labor at term: results of an ultrasound-based longitudinal study in nulliparous women

“…33 We observed that the fetal head position could only be correctly identified in a minority of cases at inclusion, but even at the last examination, only around two-thirds of the clinical staff felt they could determine the position but with increasing accuracy. This is very much in agreement with other studies, 6e8,34,35 but Iversen et al 4 have shown that this can be improved with structured clinical assessment.…”

“…Occiput posterior (OP) and transverse positions have been associated with poorer outcomes of labor for both the mother and fetus. 1e3 At present, position is predominantly assessed clinically, and although some obstetricians become skilled at this examination, 4,5 many operators never acquire it fully. The use of ultrasound has been shown to be more accurate in determining fetal head position 6e11 and has a shorter learning curve than clinical examinations, 12 and the introduction of this skill has been encouraged.…”

The use of a novel sensorized simulation platform for real‐time labor progression assessment

“…12 A revival of digital examination with sustainable technologic strategies to improve its objectivity may therefore be an optimal development both for training purposes and possibly for future clinical use in labor wards. 13 Our study demonstrates that the use of a sensorized platform- use of the NAV system while conducting a gynecologic examination and, in turn, to evaluate the usefulness of introducing such a system to the training program of medical students. Future studies will be conducted by organizing the operators into two groups, one using the SIM and one using the NAV system, to evaluate the difference between the learning curves of the two groups.…”

“…Although the abandonment of basic obstetrical skills in favor of more technologic approaches is unrealistic for a number of economical and logistical reasons, it would also carry a loss of the basic “know‐how” for following generations 12 . A revival of digital examination with sustainable technologic strategies to improve its objectivity may therefore be an optimal development both for training purposes and possibly for future clinical use in labor wards 13 …”

Obstetric factors and neonatal outcomes of depressed skull fractures in newborns

“…The cardinal movements mostly occur during the second stage of labor and accordingly disproportion or resistance of the maternal pelvic cavity and the fetus becomes apparent [15]. In general, the vertex or cephalic presentation of fetuses enter the pelvis with the sagittal suture lying in the transverse diameter of pelvis [16]. When fetal head engages into the pelvic cavity, occiput usually comes in the left side, resulting in the right parietal bone exposed to the anterior pelvic bones, which are narrower than the posterior structures [17,18].…”