Ultrasound Obstet Gynecol 2015; 46: 520–525
Published online 28 September 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.14785
Influence of ultrasound determination of fetal head position
on mode of delivery: a pragmatic randomized trial
T. POPOWSKI*, R. PORCHER†, J. FORT*, S. JAVOISE* and P. ROZENBERG*‡
*Department of Obstetrics and Gynecology, Poissy-St-Germain Hospital, Poissy, France; †Department of Biostatistics, Saint-Louis
Hospital, UMR-S 717 Paris Diderot University and INSERM, Paris, France; ‡EA7285, Versailles Saint-Quentin University (UVSQ), France
K E Y W O R D S: Cesarean delivery; digital vaginal examination; fetal occiput position; obstetric care; ultrasound
ABSTRACT
Objective To evaluate the influence of ultrasound
determination of fetal head position on mode of delivery.
Methods This was a pragmatic open-label randomized
controlled trial that included women with a singleton
pregnancy in the vertex presentation at ≥ 37 weeks’
gestation, cervical dilation ≥ 8 cm and who received
epidural anesthesia. Women were assigned randomly to
undergo either digital vaginal examination (VE group)
or both digital vaginal and ultrasound examinations
(VE+US group) to determine fetal head position.
When the ultrasound and digital vaginal findings were
inconsistent in the VE+US group, the ultrasound result
was used for clinical management. The primary outcome
assessed was operative delivery (Cesarean or instrumental
vaginal delivery), and maternal and fetal morbidity were
also assessed.
Results The VE and VE+US groups included 959 and
944 women, respectively. The overall rate of operative
delivery was significantly higher in the VE+US group
than in the VE group: 33.7% vs 27.1%, respectively
(relative risk (RR), 1.24 (95% CI, 1.08–1.43)), as was
the rate of Cesarean delivery: 7.8% vs 4.9%, respectively
(RR, 1.60 (95% CI, 1.12–2.28)). The rate of instrumental
vaginal delivery was also higher, albeit not significantly:
25.8% in the VE+US group vs 22.2% in the VE group
(RR, 1.16 (95% CI, 0.99–1.37)). Neonatal outcomes did
not differ between the two groups. When analysis was
restricted to instrumental vaginal deliveries only, maternal
and neonatal morbidity outcomes were similar in both
groups.
Conclusion Correction of fetal occiput position, deter-
mined initially by digital vaginal examination, using
systematic ultrasound examination did not improve man-
agement of labor and increased the rate of operative
Correspondence to: Dr P. Rozenberg, Centre Hospitalier Poissy-St-Germain, Rue du Champ Gaillard, 78303 Poissy, Cedex, France (e-mail:
prozenberg@chi-poissy-st-germain.fr)
Accepted: 2 January 2015
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
delivery without decreasing maternal and neonatal mor-
bidity. Copyright © 2015 ISUOG. Published by John
Wiley & Sons Ltd.
INTRODUCTION
Fetal head position is assessed usually during labor by
digital vaginal examination. Palpation of the sagittal
sutures and fontanels defines the occiput position in
relation to the maternal pelvis1,2 . This information has
always been considered essential for managing labor
and determining the need for operative delivery3 – 5 .
Occiput posterior and transverse positions are associated
with a high rate of maternal complications such as
instrumental vaginal delivery, third- and fourth-degree
perineal lacerations and Cesarean delivery3,4 . Neonatal
complications are also more frequent, including high
rates of 5-min Apgar score < 7, acidemic umbilical
cord gases, meconium-stained amniotic fluid, neonatal
trauma and admission to the neonatal intensive care
unit (NICU)5 . Manual rotation of the fetal head can be
attempted when either an occiput posterior or transverse
position is associated with dystocia; when successful, it
appears reliably to prevent complications owing to these
positions6,7 .
Until recently, digital vaginal examination was the only
way to determine the position of the fetal head. The
advent of mobile compact ultrasound units has facilitated
the use of ultrasound examination in the delivery
room, and studies comparing ultrasound examination
with digital vaginal examination for determination of
the fetal head position during labor have cast serious
doubt on the accuracy of digital examination. Indeed,
several studies have shown that prediction of fetal head
position by digital vaginal examination is inaccurate in
20–40% of cases, regardless of examiner experience8 – 13 .
One study found that the accuracy of digital vaginal
RANDOMIZED CONTROLLED TRIAL
Systematic ultrasound determination of fetal head position in labor
examination for occiput posterior and transverse positions
was only 50%13 . These authors suggested that ultrasound
examination should become the standard of care for
determination of fetal head position and concluded that
ultrasound is useful in the delivery room, especially when
instrumental delivery is needed.
Although these studies have highlighted the increased
accuracy of ultrasound examination for fetal head
determination, no study has examined the potential
benefits of routine ultrasound examination for improving
the management of labor and delivery, in particular when
occiput posterior or transverse positions are associated
with labor dystocia. Our aim was therefore to evaluate
the influence of ultrasound determination of fetal head
position on mode of delivery.
SUBJECTS AND METHODS
This pragmatic open-label randomized controlled trial
took place at the Poissy Saint-Germain university hospital.
The study protocol was approved by the Institutional
Review Board of Poissy Saint-Germain Hospital (Comité
de Protection des Personnes de Saint-Germain en Laye).
All women received detailed information about the study
before entering the labor and delivery unit. The trial
was registered at ClinicalTrials.gov (NCT01436409).
Women were included in the trial if they were at least
18 years old, had entered labor with a singleton fetus in
the vertex presentation at ≥ 37 weeks of gestation, with
cervical dilation ≥ 8 cm, had received epidural anesthesia
and provided written informed consent. Exclusion
criteria were previous Cesarean delivery, pre-eclampsia,
placenta previa or other obstetric disorder, participation
in another trial and refusal to sign the informed
consent.
After verification of the inclusion and exclusion
criteria, eligible women were assigned randomly in the
labor room to one of two groups, at a 1:1 ratio.
Allocation to one of the two groups was performed by
the distribution of opaque envelopes, each containing
one allocation. The random allocation sequences were
generated with a computer random-number generator
by the study statistician, according to a permuted
block method. To determine the fetal head position,
the first group underwent digital vaginal examination
only (VE group) and the second underwent a digital
vaginal examination followed by a systematic ultrasound
verification examination (VE + US group). In accordance
with standard clinical practice, the digital vaginal
determination classified fetal head position as left, right
or direct occiput anterior (LOA, ROA, DOA), left, right
or direct occiput posterior (LOP, ROP, DOP), or left or
right occiput transverse (LOT or ROT).
A portable Voluson-i ultrasound machine (GE Medical
Systems, Vélizy, France) with a 3.5-MHz transducer was
used to perform the ultrasound examinations. A two-step
procedure was used for ultrasound determination in
the VE + US group. The position of the fetal spine
was determined, at the level of the fetal heart and in
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
521
relation to the maternal abdomen. The position of the
fetal occiput was restricted to within 90◦ clockwise or
counterclockwise of the spine position. The ultrasound
transducer followed the spine downwards and was then
placed on the pubic symphysis to obtain a transverse view
relative to the maternal anatomy. An attempt was made
to identify the fetal cranial contour, cranial midline, and
fetal orbits or superciliary arch in the same plane14 . When
identified, other anatomical features (nose, cheeks, ears,
thalami, cavum septi pellucidi) also assisted in determining
the fetal position. The fetal head position was classified
as one of the eight standard clinical positions mentioned
above. The fetus was considered to be in the occiput
transverse position when the anteroposterior diameter
of the fetal head was within 45◦ of transverse. The
fetus was considered either DOA or DOP, depending
on the position of the fetal occiput, if the anteroposterior
diameter was within 45◦ of an anteroposterior position.
The same classification was used for the LOA, ROA,
LOP and ROP positions. All digital vaginal examinations
were performed by the midwife responsible for the
follow-up after rupture of the membranes during the first
stage of labor and were not performed during a uterine
contraction. In the VE + US group, ultrasonography was
performed by a midwife or physician within 15 min
after the vaginal examination. All sonographers (T.P.,
J.F., S.J., P.R.) had completed previously the learning
curve for this ultrasound examination, as described
by Rozenberg et al.14 . The fetal position determined
by vaginal examination was considered correct if
the anteroposterior diameter on the digital vaginal
examination was within ± 45◦ of the ultrasonographic
anteroposterior diameter. When the ultrasound and
digital vaginal findings in the VE + US group were not
in agreement, the ultrasound result was used for clinical
management.
Attempts at manual rotation were at the discretion
of the healthcare professional managing the delivery and
performed by attending midwives, physicians, or residents
supervised by the attending physician, with a technique
based essentially on that described by Le Ray et al.15 . The
patient was placed in a dorsal recumbent position after
emptying her bladder. When the uterus was relaxed, the
operator gently placed two fingers or, if possible, the entire
hand (right hand for the LOP and LOT positions and left
hand for the ROP and ROT positions) behind the fetal
ear (right for left positions and left for right positions)16 .
During the uterine contraction, while the patient was
pushing, the operator used the pressure of the fingers to
rotate the anterior fetal head, moving the occiput toward
the anterior pelvic girdle. The indications for manual
rotation of the fetus were lack of progress for at least
2 hours in women with dilation ≥ 8 cm, non-engagement
or fetal head engaged in posterior position.
The prespecified primary outcome was operative deliv-
ery, including Cesarean delivery after cervical dilation
≥ 8 cm and instrumental vaginal delivery. Prespecified
secondary outcomes were (i) delivery criteria (separate
Cesarean and instrumental vaginal delivery rates);
Ultrasound Obstet Gynecol 2015; 46: 520–525.
522 Popowski et al.

(ii) maternal morbidity (postpartum hemorrhage, epi- 1903 women enrolled and
siotomy, perineal lacerations or intrapartum fever); and randomized
(iii) neonatal morbidity (1-min and 5-min Apgar scores
< 7, umbilical cord pH < 7.20, meconium aspiration
syndrome, neonatal trauma or transfer to NICU).
Allocated to VE group Allocated to VE+US group
(n = 959) (n = 944)
Statistical analysis Did not meet inclusion Did not meet inclusion
criteria (n = 0) criteria (n = 0)
A total sample size of 1900 women (950 in each group)
was planned to demonstrate a 25% relative reduction in
Failed to determine head Failed to determine head
the rate of operative deliveries in the experimental group position by US (n = 56)
position by VE (n = 53)
(VE + US group) compared with the control group (VE
group), i.e. a decrease in absolute rate from 20% to 15%,
with at least 80% power and a two-sided Type I error Analyzed (n = 959) Analyzed (n = 944)
rate of 5%. The anticipation of lower operative delivery Excluded from analysis (n = 0) Excluded from analysis (n = 0)
rates in the VE + US group was based on the assumption
that a better determination of the fetal head position Figure 1 Flowchart summarizing enrollment, randomization and
during labor by ultrasound examination could reduce the follow-up of study population of pregnant women who had fetal
rate of operative delivery by increasing the rate of manual head position determined by digital vaginal examination (VE) only
rotation of the head or of expectant management during and those with subsequent verification by ultrasound (US)
examination (VE + US).
the second stage of labor, when an occiput posterior or
transverse position of the fetal head was associated with Table 1 General characteristics of 1903 pregnant women
dystocia. randomized to determination of fetal head position by digital
Fisher’s exact test was used to compare the primary and vaginal examination (VE) only or by VE and subsequent ultrasound
other binary outcomes between the two study groups. examination (VE + US)
An ancillary study planned in the protocol evaluated
VE VE + US
the agreement of the two examinations in the VE + US Characteristic (n = 959) (n = 944)
group for whom fetal head position was determined by
both digital and US examination. The observed agreement Maternal age (years) 30 (27–34) 30 (27–33)
Gestational age 40 + 1 40 + 1
was reported, as was the kappa statistic. An unplanned
(weeks) (39 + 1 to 40 + 6) (39 + 2 to 40 + 6)
exploratory analysis was conducted in the subgroup of Nulliparous 533 (55.6) 572 (60.6)
women with instrumental vaginal deliveries. All tests Birth weight (g) 3380 (3120–3680) 3420 (3170–3720)
were two-sided and P < 0.05 was considered statistically Fetal head position*
significant. Statistical analyses were performed with R Occiput anterior
statistical software, version 2.13.2. Direct 143 (14.9) 154 (16.3)
Left 392 (40.9) 196 (20.8)
Right 142 (14.8) 107 (11.3)
RESULTS Total 677 (70.6) 457 (48.4)
Occiput posterior
The study took place from December 2005 to November Direct 10 (1.0) 41 (4.3)
Left 53 (5.5) 92 (9.7)
2010 and included 1903 women (Figure 1). All women
Right 89 (9.3) 130 (13.8)
met the inclusion criteria and none was excluded. Table 1 Total 152 (15.8) 263 (27.9)
summarizes the characteristics and fetal head position of Occiput transverse
the 959 pregnant women in the VE group and the 944 Left 29 (3.0) 94 (10.0)
pregnant women in the VE + US group. Right 48 (5.0) 74 (7.8)
The rates of overall occiput anterior and posterior Total 77 (8.0) 168 (17.8)
Unknown 53 (5.5) 56 (5.9)
positions diagnosed by digital vaginal examination in
the VE group were 70.6% and 15.8%, respectively. In Data are given as median (interquartile range) or n (%). *Fetal head
the VE + US group, the corresponding rates of fetal head position in VE + US group determined by ultrasound examination.
positions were 48.4% and 27.9%, respectively (Table 1).
Fetal head position could not be determined in 53 women of 65.4%. Agreement according to the kappa coefficient
in the VE group. In the VE + US group, head position (κ) was poor (κ, 0.38 (95% CI, 0.33–0.44)). Furthermore,
could not be determined by digital vaginal examination in measurement errors of 180◦ or more were found in 86
26 women and by ultrasound in 56. For the 862 women (10.0%) of the 862 cases, representing 20% of all errors.
in the VE + US group with fetal head position determined Manual rotation was attempted in 7.8% (75/959) of the
by both a vaginal and an ultrasound examination before VE group and in 9.6% (91/944) of the VE + US group
manual rotation of the fetus, the agreement between (P = 0.17).
the digital vaginal and the ultrasound examinations was The rate for the primary outcome of operative delivery
67.9% for occiput anterior positions and 66.3% for (Cesarean or instrumental vaginal delivery) was signifi-
posterior positions (Table 2), with an overall agreement cantly higher in the VE + US group than in the VE group

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 520–525.
Systematic ultrasound determination of fetal head position in labor 523

Table 2 Agreement of fetal head position determined by digital vaginal examination (VE) and by ultrasound examination (US) in 862
women who underwent both examinations

Fetal head position on US

Fetal head position on VE Occiput anterior Occiput posterior Occiput transverse

Occiput anterior (n = 586) 398 (67.9) 105 (17.9) 83 (14 .2)

Occiput posterior (n = 193) 26 (13.5) 128 (66.3) 39 (20.2)
Occiput transverse (n = 83) 26 (31.3) 19 (22.9) 38 (45.8)
Data are given as n (%).

Table 3 Pregnancy outcome in women randomized to fetal head position determination by digital vaginal examination (VE) or by VE and
subsequent ultrasound examination (VE + US)

Outcome VE (n = 959) VE + US (n = 944) RR (95% CI) P

Operative delivery 260 (27.1) 318 (33.7) 1.24 (1.08–1.43) 0.002

Cesarean delivery 47 (4.9) 74 (7.8) 1.60 (1.12–2.28) 0.01
Fetal distress 16 (34.0) 34 (45.9) — —
Failure to progress from 8 cm to full cervical dilatation 8 (17.0) 17 (23.0) — —
Failure to progress in second stage of labor 23 (48.9) 23 (31.1) — —
Instrumental vaginal delivery 213 (22.2) 244 (25.8) 1.16 (0.99–1.37) 0.07
Fetal distress 113 (53.1) 121 (49.6) — —
Failure to progress 100 (46.9) 123 (50.4) — —
Episiotomy 296 (30.9) 334 (35.4) 1.15 (1.01–1.30) 0.04
Postpartum hemorrhage 81 (8.4) 92 (9.8) 1.16 (0.87–1.54) 0.34
First- or second-degree perineal lacerations 426 (44.4) 388 (41.1) 0.93 (0.83–1.03) 0.15
Third- or fourth-degree perineal lacerations 10 (1.0) 7 (0.7) 0.71 (0.27–1.86) 0.63
Intrapartum fever 44 (4.6) 60 (6.4) 1.39 (0.95–2.02) 0.11
Data are given as n (%). RR, relative risk.

(33.7% vs 27.1%, respectively; P = 0.002), with a relative
risk (RR) of 1.24 (95% CI, 1.08–1.43) (Table 3). Opera-
tive delivery stratified according to Cesarean or instrumen-
tal vaginal delivery identified a significantly higher rate of
Cesarean delivery in the VE + US group (7.8% vs 4.9%,
respectively; P = 0.01), with an RR of 1.60 (95% CI,
1.12–2.28). The rate of instrumental vaginal delivery was
also higher in the VE + US group, but this difference was
not significant (25.8% vs 22.2%, respectively; P = 0.07),
with an RR of 1.16 (95% CI, 0.99–1.37). The rate of
episiotomy was also significantly higher in the VE + US
group than in the VE group (35.4% vs 30.9%; P = 0.04),
with an RR of 1.15 (95% CI, 1.01–1.30).
Table 4 shows the operative delivery rates according to
the fetal head position as determined by the digital vaginal
examination in both study groups. The rate of operative
delivery differed significantly between study groups for
the total anterior position subgroup only (31.3% in the
VE + US vs 23.0% in the VE group), with an RR of 1.34
(95% CI, 1.11–1.63).
There was no difference in neonatal outcomes between
the two groups (Table 5). When analysis was restricted to
women who underwent an instrumental vaginal delivery,
no difference was found in maternal and neonatal
morbidity outcomes between both groups (Table 6).
DISCUSSION
This study focused on the effect of verifying fetal head
position in labor by ultrasound examination on mode
of delivery and maternal and neonatal outcome. The
principal findings of the study were that (1) correction
of digital vaginal determination of fetal occiput positions
by systematic ultrasound examination increased the rate
of operative delivery without decreasing maternal and
neonatal morbidity, and (2) digital vaginal examination
for determination of fetal head position was inaccurate
in 35% of cases.
The main result is disappointing from a clinical
perspective, but not surprising. Clinicians are aware
that malpositions are associated with complicated
deliveries3 – 5 , and clinical examinations underestimate the
frequency of malpositions13 . More accurate knowledge
led to an increase in interventions and explained the
deleterious effect of systematic correction of digital
vaginal examination errors by ultrasound, mainly in
pregnancies with an anterior fetal position (Table 4).
Indeed, and unsurprisingly, 105 of the 586 patients
in the VE + US group who had been diagnosed with
occiput anterior position by digital vaginal examination
were reclassified as occiput posterior by subsequent
ultrasound examination, while only 26 of the 193 patients
diagnosed with occiput posterior position by digital
vaginal examination were reclassified as occiput anterior
by subsequent ultrasound examination (Table 2).
The aim of the ancillary study in our protocol was to
evaluate the rates of different fetal head positions and
the discordance between ultrasound and digital vaginal
determination in women with cervical dilation ≥ 8 cm.
Therefore we chose to use ultrasound systematically in
the experimental arm rather than selectively in cases of
labor dystocia. Unfortunately, this strategy induced a

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 520–525.
524 Popowski et al.

Table 4 Operative delivery (Cesarean section or instrumental vaginal delivery) rates in pregnant women with fetal head position determined
by digital vaginal examination only (VE) or by VE and subsequent ultrasound examination (VE + US), according to results of VE

Operative delivery
Fetal head position on VE VE VE + US RR (95% CI)
Total occiput anterior 156/677 (23.0) 194/620 (31.3) 1.34 (1.11–1.63)
Total occiput posterior 65/152 (42.8) 84/204 (41.2) 0.96 (0.73–1.26)
Total occiput transverse 24/77 (31.2) 29/88 (33.0) 1.06 (0.67–1.67)
Not determined 15/53 (28.3) 11/32 (34.3) 1.10 (0.55–2.18)

Data are given as n/N (%). RR, relative risk.

Table 5 Neonatal outcomes in women with fetal head position determined by digital vaginal examination (VE) only or by VE and
subsequent ultrasound examination (VE + US)

VE VE + US
Outcome (n = 959) (n = 944) RR (95% CI) P
1-min Apgar score < 7 101 (10.5) 105 (11.1) 1.06 (0.82–1.37) 0.71
5-min Apgar score < 7 12 (1.3) 9 (1.0) 0.76 (0.32–1.80) 0.66
Umbilical cord pH < 7.2 100 (10.4) 117 (12.4) 1.19 (0.92–1.53) 0.19
Meconium aspiration syndrome 2 (0.2) 2 (0.2) 1.02 (0.07–14.0) 1.00
Transfer to NICU 6 (0.6) 4 (0.4) 0.68 (0.14–2.86) 0.75
Neonatal trauma 8 (0.8) 16 (1.7) 2.04 (0.88–4.73) 0.10

Data are given as n (%). NICU, neonatal intensive care unit.

Table 6 Maternal and neonatal outcomes in 457 women who had Several studies have shown that digital examination is
an instrumental vaginal delivery, according to determination of less accurate than is ultrasound9,10 , particularly in cases
fetal head position by digital vaginal examination (VE) only or by
VE and subsequent ultrasound examination (VE + US)
of obstructed labor for which medical intervention is
more likely to be needed17 . Four studies that defined
VE VE + US agreement between examinations as a difference in head
Outcome (n = 213) (n = 244) P rotation of up to 45◦ found the agreement rate between
clinical and ultrasound examinations to range from
Episiotomy 166 (77.9) 147 (60.2) 0.84
First- or second-degree perineal 84 (39.4) 66 (27.1) 0.48 47% to 80%9,10,13,18 . Chou et al. reported that digital
lacerations vaginal and ultrasound examinations determined fetal
Third- or fourth-degree perineal 2 (0.9) 4 (1.6) 0.42 occiput position correctly 71.6% and 92.0% of the time,
lacerations respectively (P = 0.018)12 . The findings of our ancillary
1-min Apgar score < 7 39 (18.3) 37 (15.2) 0.38
study are in agreement with these results. Recently,
5-min Apgar score < 7 3 (1.4) 5 (2.0) 0.73
Umbilical cord pH < 7.2 39 (18.3) 39 (16.0) 0.80 Ramphul et al. randomized 514 nulliparous women
Meconium aspiration syndrome 0 (0) 1 (0.4) 1 who were at ≥ 37 weeks of gestation with a singleton
Transfer to NICU 2 (0.9) 1 (0.4) 0.60 cephalic pregnancy to receive clinical assessment or
Neonatal trauma 5 (2.3) 13 (5.3) 0.15 both an ultrasound scan and clinical assessment before
Data are given as n (%). NICU, neonatal intensive care unit.
instrumental delivery19 . The incidence of incorrect
diagnosis was significantly lower in the ultrasound
performance bias with a significant increase in Cesarean group than the standard care group (1.6% vs 20.2%;
delivery in the experimental arm. P < 0.001). However, the incidence of maternal and
Interestingly, even when analysis was restricted to the neonatal complications, failed instrumental delivery and
subgroup of 457 women who had an instrumental vaginal Cesarean delivery did not differ significantly between the
delivery, there were no maternal or neonatal benefits two groups. These results are also in agreement with our
of the ultrasound verification examination, as seen in findings when the analysis was restricted to instrumental
the VE + US group. This negative result raises a serious vaginal deliveries. As pointed out by Ramphul et al., a
concern about the potential benefit of systematic use of more integrated clinical skills-based approach is likely to
ultrasound before instrumental vaginal delivery11 . We be required to prevent adverse outcomes at instrumental
were surprised that the enhanced diagnosis of occiput delivery19 . Finally, head position could not be determined
posterior or transverse position in the ultrasound group by transabdominal ultrasound in 5.9% (56/944) of
did not increase attempts at manual rotation. One women in the VE + US group. Transabdominal imaging is
potential explanation for these disappointing results difficult technically in pregnancies with a deeply engaged
is that ultrasound facilitates the diagnosis of fetal fetal head in the second stage of labor. In such cases,
malpositions but not the operators’ ability to deal with it. Zahalka et al. reported that the accuracy of ultrasound is
These results highlight the need to improve training in the increased by using a transvaginal approach20 .
management of fetal malpositions once they have been The main strength of this study was the large size
identified. of the randomized trial. Furthermore, all obstetricians

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 46: 520–525.
Systematic ultrasound determination of fetal head position in labor
and midwives who performed this limited ultrasound
examination had completed the individual learning curve
for ultrasound determination of fetal head position, as
described by Rozenberg et al.14 . This quality process
ensured internal validity of our results.
Nonetheless, our study has some limitations. Despite
randomization, as no ultrasound examinations were
performed in the VE group, we cannot confirm that
the occiput posterior position rates were similar in
both groups. A study design in which an ultrasound
examination was performed in both groups with the
clinicians blinded to the result in the VE group would
have been preferable from this perspective. Our initial
protocol proposed this design, but our local institutional
review board considered it was unethical not to inform the
attending obstetrician of the ultrasound findings before
vacuum extraction or forceps delivery when the clinical
examination was incorrect. Such unblinding, however,
would have introduced severe contamination bias into
our study, compromising its internal validity. Therefore,
in agreement with our local institutional review board, we
proposed that fetal head position would be determined
by digital vaginal examination only in one group and
by digital vaginal examination followed by systematic
ultrasound verification in the other.
Lieberman et al. demonstrated a strong association of
administration of epidural analgesia with fetal occiput
posterior position at delivery. This association may
contribute to the lower rate of spontaneous vaginal
delivery observed consistently in women with an epidural,
especially in our study21 . Therefore, inclusion only of
women who received epidural analgesia limited the
external validity of our study. Finally, the study was
underpowered to assess neonatal complications, due to
the rarity of their occurrence.
In conclusion, we do not believe that the study
limitations override our finding that correction of digital
vaginal determination of fetal occiput positions by sys-
tematic ultrasound examination conveys no improvement
on management of labor. This pragmatic trial provides
evidence that, if the rate of manual rotation of the fetus
remains unaffected, precise knowledge of fetal occiput
position determined by ultrasound is associated with an
increase in operative delivery.
This article has been selected for Journal Club.
A slide presentation, prepared by Dr Katherine Goetzinger,
one of UOG's Editors for Trainees, is available online.
Chinese translation by Dr Yang Fang. Spanish translation by Dr Masami Yamamoto.
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
525
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