title: Can angle of progression in pregnant women before onset of labor predict mode of delivery?
abstract: OBJECTIVE
  The angle of progression (AOP), measured by transperineal ultrasound, has been used to assess fetal head descent during labor. Our aim was to assess whether, before onset of labor, parous women have a narrower AOP than do nulliparous women and if a narrow AOP is associated with a higher rate of Cesarean delivery.
  
  
  METHODS
  In this prospective, observational study, we performed transperineal ultrasound in pregnant women not yet in labor at ≥ 39 weeks' gestation who delivered within 1 week of sonography. The AOP was compared as follows: in nulliparous women, between those who had a Cesarean section and those who delivered vaginally; and among women who delivered vaginally, between those who were nulliparous and those who were parous.
  
  
  RESULTS
  Included in the study were 100 nulliparous and 71 parous women. Among those who delivered vaginally (n = 161), the median AOP before onset of labor was narrower in parous than in nulliparous women (98° (interquartile range (IQR)), 90-107° vs 104° (IQR, 97-113°), P < 0.001). Among the 100 nulliparous women, (1) the median AOP before onset of labor was narrower in those who went on to deliver by Cesarean section (n = 9) than in those delivered vaginally (n = 91) (90° (IQR, 85.5-93.5°) vs 104° (IQR, 97-113°), P < 0.001); (2) an AOP ≥ 95° (derived from the receiver-operating characteristics curve) was associated with vaginal delivery in 99% of women; and (3) 89% (8/9) of women who delivered by Cesarean section had an AOP < 95°. Among the 71 parous women, only one delivered by Cesarean section and all of those with an AOP < 95° delivered vaginally.
  
  
  CONCLUSIONS
  A narrow AOP (< 95°) in non-laboring nulliparous women at term is associated with a high rate of Cesarean delivery. Parous women have a narrower AOP than do nulliparous women before the onset of labor; however, unlike in nulliparous women, a narrow AOP in parous women does not appear to be associated with Cesarean delivery and most parous women with such an angle go on to deliver vaginally.
authors.affiliation: Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel, affiliated to Hebrew University and Hadassah School of Medicine, Jerusalem, Israel. ronil123@zahav.net.il
authors.forename: R
authors.initials: R
authors.lastname: Levy
authors.forename: S
authors.initials: S
authors.lastname: Zaks
authors.forename: A
authors.initials: A
authors.lastname: Ben-Arie
authors.forename: S
authors.initials: S
authors.lastname: Perlman
authors.forename: Z
authors.initials: Z
authors.lastname: Hagay
authors.forename: E
authors.initials: E
authors.lastname: Vaisbuch
mesh_terms: D000328:Adult; D002585:Cesarean Section; D005260:Female; D006801:Humans; D007746:Labor Presentation; D010298:Parity; D011247:Pregnancy; D011379:Prognosis; D011446:Prospective Studies; D016216:Ultrasonography, Prenatal / Q000379:methods*; D055815:Young Adult