title: The "occiput-spine angle": a new sonographic index of fetal head deflexion during the first stage of labor.
abstract: BACKGROUND
  Fetal head "attitude" (relationship of fetal head to spine) in the first stage of labor may have a substantial impact on labor outcome. The diagnosis of fetal head deflexion traditionally is based on digital examination in labor, although the use of ultrasound to support clinical diagnosis has been recently reported.
  
  
  OBJECTIVE
  The aims of this study were: (1) to quantify the degree of fetal head deflection via the use of sonography during the first stage of labor; and (2) to determine whether a parameter derived from ultrasound examination (the occiput-spine angle) has a relationship with the course and outcome of labor.
  
  
  METHODS
  This was a prospective multicentric, cross-sectional study conducted at the Maternity Unit of the University of Bologna and Parma from January 2014 to April 2015. A nonconsecutive series of women with uncomplicated singleton pregnancies at term gestation (37 weeks or more) were submitted to transabdominal ultrasound during the first stage of labor. If fetal position was occiput anterior or transverse, the angle between the fetal occiput and the cervical spine (the occiput-spine angle) was sonographically obtained on the sagittal plane. The measurements of the occiput spine-angle were performed offline by 2 operators who were blinded to the labor outcome. The intra- and interobserver reproducibility and the correlation between the occiput-spine angle and the mode of delivery were evaluated.
  
  
  RESULTS
  A total of 108 pregnant women were recruited, 79 of which underwent a spontaneous vaginal delivery and 29 were submitted to obstetric intervention (19 cesarean delivery and 10 instrumental vaginal deliveries). The mean value of the occiput-spine angle measured in the active phase of the first stage was 126° ± 9.8° (SD). The occiput-spine angle measurement showed a very good intraobserver (r = 0.86; 95% confidence interval [95% CI] 0.80-0.90) and a fair-to-good interobserver (r = 0.64; 95% CI 0.51-0.74) agreement. The occiput-spine angle was significantly narrower in women who underwent obstetric intervention (cesarean or vacuum delivery) due to labor arrest (121° ± 10.5° vs 127° ± 9.4°, P = .03). Multivariable logistic regression analysis showed that narrow occiput-spine angle values (OR 1.08; 95% CI 1.00-1.16; P = .04) and nulliparity (OR 16.06; 95% CI 1.71-150.65; P = .02) were independent risk factors for operative delivery. A larger occiput-spine angle width (i.e., >125°) showed to be significantly associated with a shorter duration of labor (hazard ratio = 1.62; 95% CI 1.07-2.45; P = .02).
  
  
  CONCLUSIONS
  We described herein the "occiput-spine angle," a new sonographic parameter to assess fetal head deflection during labor. Fetuses with smaller occiput-spine angle (<125°) are at increased risk for operative delivery.
authors.affiliation: Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy. Electronic address: tullioghi@yahoo.com.
authors.forename: Tullio
authors.initials: T
authors.lastname: Ghi
authors.affiliation: Department of Obstetrics and Gynecology, St. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.
authors.forename: Federica
authors.initials: F
authors.lastname: Bellussi
authors.affiliation: Department of Obstetrics and Gynecology, St. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.
authors.forename: Carlotta
authors.initials: C
authors.lastname: Azzarone
authors.affiliation: Department of Obstetrics and Gynecology, St. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.
authors.forename: Jovana
authors.initials: J
authors.lastname: Krsmanovic
authors.affiliation: Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Franchi
authors.affiliation: Department of Obstetrics and Gynecology, St. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.
authors.forename: Aly
authors.initials: A
authors.lastname: Youssef
authors.affiliation: Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Jacopo
authors.initials: J
authors.lastname: Lenzi
authors.affiliation: Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy.
authors.forename: Maria Pia
authors.initials: MP
authors.lastname: Fantini
authors.affiliation: Department of Obstetrics and Gynecology, Maggiore Hospital, University of Parma, Parma, Italy.
authors.forename: Tiziana
authors.initials: T
authors.lastname: Frusca
authors.affiliation: Department of Obstetrics and Gynecology, St. Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy.
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Pilu
mesh_terms: D000328:Adult; D001837:Body Weights and Measures; D002574:Cervical Vertebrae / Q000000981:diagnostic imaging*; D003430:Cross-Sectional Studies; D005260:Female; D006257:Head / Q000000981:diagnostic imaging; D006801:Humans; D007746:Labor Presentation; D007747:Labor Stage, First / Q000502:physiology*; D007744:Obstetric Labor Complications / Q000000981:diagnostic imaging; D011247:Pregnancy / Q000502:physiology*; D011446:Prospective Studies; D012886:Skull / Q000000981:diagnostic imaging*; D016216:Ultrasonography, Prenatal
keywords: dystocia; failure to progress; fetal attitude; first stage of labor; intrapartum ultrasound; labor; malpresentation; reproducibility