A Simple Model Based on Fetal Head Circumference, Fetal Abdominal Circumference and Angle of Progression to Predict the Difficulty of Operative Vaginal Delivery

doi:10.12280/gjfckx.20230209

Abstract

Abstract:

Objective: To investigate the predictive value of joint use of fetal head circumference, fetal abdominal circumference and angle of progression (AOP) for the difficulty of operative vaginal delivery (forceps and vaccum). Methods: This prospective observational study was carried out in Department of Obstetrics of the People′s Hospital of Guangxi Zhuang Autonomous Region from May 2017 to July 2022. A total of 64 nulliparous women with singleton term pregnancies who required instrumentation to expedite vaginal delivery during the second stage of labor were included. Clinical data of pregnant women were collected after admission to the hospital. Fetal head circumference and fetal abdominal circumference were measured. Before performing operative vaginal delivery, AOP at rest and that during uterine contraction were measured by transperineal ultrasound (AOP1: mean of AOPs at rest, AOP2: mean of AOPs during uterine contraction). According to the outcomes of operative vaginal delivery, a case was included into "difficult or failed group" (Group A) when one or more of the following situations occurred: three or more tractions needed; successful operative vaginal delivery requiring sequential instruments (change vacuum to forceps); failed operative vaginal delivery; cesarean delivery due to a subjective impression of a difficult or failed traction; birth injury and the third- or the fourth-degree perineal tear. The rest cases were included into "successful and easy group" (Group B). Fetal head circumference, fetal abdominal circumference, AOP1 and AOP2 were used to establish four different predictive models by employing multivariable logistic regression. Receiver operator characteristic (ROC) curve was used to evaluate the discrimination of four models and the model with the largest area under ROC curve (AUC) was considered as the best one. Hosmer-Lemeshow test assessed the calibration of the optimal model. The optimal one was internally validated by using Bootstrap replicated sampling (1 000 times) method. Results: Statistically significant differences were revealed with regard to fetal head station by vaginal digital examination, duration of the last traction, initial direction of pulling in the last traction, fetal abdominal circumference, AOP1, AOP2, umbilical cord artery pH and rate of neonatal asphyxia (all P<0.05). A predictive model basing on the combination of fetal head circumference, fetal abdominal circumference, AOP1 and AOP2 showed the largest AUC (AUC=0.917, 95%CI: 0.821-0.972, Z=11.676, P<0.001). The Hosmer-Lemeshow test showed that χ²=5.873, P=0.661. Both of discrimination and calibration were good. The model showed good consistency in the internal validation. Conclusions: The simple model based on the combination of fetal head circumference, fetal abdominal circumference, AOP1 and AOP2 showed a predictive value for the difficulty of operative vaginal delivery and provided some basis for clinical decision-making.

Key words: Logistic models, Transperineal ultrasound, Intrapartum ultrasound, Angle of progression, Operative vaginal delivery

CHEN Hui, WU Su-qing, LIANG Xu-xia, ZHANG Shan-shan, MA Yan-hua, HU Qiong-yan. A Simple Model Based on Fetal Head Circumference, Fetal Abdominal Circumference and Angle of Progression to Predict the Difficulty of Operative Vaginal Delivery[J]. Journal of International Obstetrics and Gynecology, 2023, 50(5): 507-513.

Figures/Tables 12

References 20

[1]	Martin JA, Hamilton BE, Osterman MJ, et al. Births: Final Data for 2015[J]. Natl Vital Stat Rep, 2017, 66(1):1. pmid: 28135188
[2]	Wang X, Hellerstein S, Hou L, et al. Caesarean deliveries in China[J]. BMC Pregnancy Childbirth, 2017, 17(1):54. doi: 10.1186/s12884-017-1233-8.
[3]	Harrison MS, Saleem S, Ali S, et al. A Prospective, Population-Based Study of Trends in Operative Vaginal Delivery Compared to Cesarean Delivery Rates in Low- and Middle-Income Countries, 2010-2016[J]. Am J Perinatol, 2019, 36(7):730-736. doi: 10.1055/s-0038-1673656. pmid: 30372772
[4]	Miller ES, Lai Y, Bailit J, et al. Duration of Operative Vaginal Delivery and Adverse Obstetric Outcomes[J]. Am J Perinatol, 2020, 37(5):503-510. doi: 10.1055/s-0039-1683439. pmid: 30895577
[5]	Muraca GM, Lisonkova S, Skoll A, et al. Ecological association between operative vaginal delivery and obstetric and birth trauma[J]. CMAJ, 2018, 190(24):E734-E741. doi: 10.1503/cmaj.171076.
[6]	Attali E, Reicher L, Many A, et al. Pregnancy outcome after cesarean section following a failed vacuum attempt[J]. J Matern Fetal Neonatal Med, 2022, 35(22):4375-4380. doi: 10.1080/14767058.2020.1849122.
[7]	Tsakiridis I, Giouleka S, Mamopoulos A, et al. Operative vaginal delivery: a review of four national guidelines[J]. J Perinat Med, 2020, 48(3):189-198. doi: 10.1515/jpm-2019-0433. pmid: 31926101
[8]	Dupuis O, Silveira R, Zentner A, et al. Birth simulator: reliability of transvaginal assessment of fetal head station as defined by the American College of Obstetricians and Gynecologists classification[J]. Am J Obstet Gynecol, 2005, 192(3):868-874. doi: 10.1016/j.ajog.2004.09.028. pmid: 15746684
[9]	Ghi T, Eggebø T, Lees C, et al. ISUOG Practice Guidelines: intrapartum ultrasound[J]. Ultrasound Obstet Gynecol, 2018, 52(1):128-139. doi: 10.1002/uog.19072. pmid: 29974596
[10]	Cuerva MJ, Bamberg C, Tobias P, et al. Use of intrapartum ultrasound in the prediction of complicated operative forceps delivery of fetuses in non-occiput posterior position[J]. Ultrasound Obstet Gynecol, 2014, 43(6):687-692. doi: 10.1002/uog.13256. pmid: 24265172
[11]	Sainz JA, García-Mejido JA, Aquise A, et al. Intrapartum transperineal ultrasound used to predict cases of complicated operative (vacuum and forceps) deliveries in nulliparous women[J]. Acta Obstet Gynecol Scand, 2017, 96(12):1490-1497. doi: 10.1111/aogs.13230.
[12]	Chan V, Lau WL, So M, et al. Measuring angle of progression by transperineal ultrasonography to predict successful instrumental and cesarean deliveries during prolonged second stage of labor[J]. Int J Gynaecol Obstet, 2019, 144(2):192-198. doi: 10.1002/ijgo.12712. pmid: 30430566
[13]	Sainz JA, Fernández-Palacín A, Borrero C, et al. Intra and interobserver variability of intrapartum transperineal ultrasound measurements with contraction and pushing[J]. J Obstet Gynaecol, 2018, 38(3):333-338. doi: 10.1080/01443615.2017.1354179. pmid: 29022481
[14]	Elfituri A, Datta T, Hubbard HR, et al. Successful versus unsuccessful instrumental deliveries-Predictors and obstetric outcomes[J]. Eur J Obstet Gynecol Reprod Biol, 2020, 244:21-24. doi: 10.1016/j.ejogrb.2019.10.050. pmid: 31711005
[15]	Lipschuetz M, Cohen SM, Ein-Mor E, et al. A large head circumference is more strongly associated with unplanned cesarean or instrumental delivery and neonatal complications than high birthweight[J]. Am J Obstet Gynecol, 2015, 213(6):833.e1-833.e12. doi: 10.1016/j.ajog.2015.07.045.
[16]	Hadlock FP, Harrist RB, Sharman RS, et al. Estimation of fetal weight with the use of head, body, and femur measurements--a prospective study[J]. Am J Obstet Gynecol, 1985, 151(3):333-337. doi: 10.1016/0002-9378(85)90298-4. pmid: 3881966
[17]	ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles[J]. Obstet Gynecol, 2009, 114(1):192-202. doi: 10.1097/AOG.0b013e3181aef106. pmid: 19546798
[18]	Bultez T, Quibel T, Bouhanna P, et al. Angle of fetal head progression measured using transperineal ultrasound as a predictive factor of vacuum extraction failure[J]. Ultrasound Obstet Gynecol, 2016, 48(1):86-91. doi: 10.1002/uog.14951. pmid: 26183426
[19]	Sainz JA, García-Mejido JA, Aquise A, et al. A simple model to predict the complicated operative vaginal deliveries using vacuum or forceps[J]. Am J Obstet Gynecol, 2019, 220(2):193.e1-193.e12. doi: 10.1016/j.ajog.2018.10.035.
[20]	Rizzo G, Mattioli C, Mappa I, et al. Antepartum ultrasound prediction of failed vacuum-assisted operative delivery: a prospective cohort study[J]. J Matern Fetal Neonatal Med, 2021, 34(20):3323-3329. doi: 10.1080/14767058.2019.1683540.

预测模型	纳入的变量
模型1	AOP1+AOP2
模型2	AOP1+AOP2+HC
模型3	AOP1+AOP2+AC
模型4	AOP1+AOP2+HC+AC

预测模型	纳入的变量
模型1	AOP1+AOP2
模型2	AOP1+AOP2+HC
模型3	AOP1+AOP2+AC
模型4	AOP1+AOP2+HC+AC

组别	n	年龄（岁）	孕周（周）	身高（cm）	BMI （kg/m²）	孕次	催产	无痛分娩	第一产程时长（min）	阴道指检胎头位置（cm）	助产指征（胎儿窘迫）
A组	17	30.35±2.00	39.98±0.86	158.00±2.96	28.03±3.13	1.0（1.0，2.0）	5（29.4）	7（41.2）	420.0（340.0，775.0）	2.50（2.00，2.75）	14（82.4）
B组	47	30.85±4.21	39.63±0.98	159.36±5.01	26.76±3.01	1.0（1.0，2.0）	14（29.8）	13（27.7）	355.0（250.0，570.0）	3.00（2.50，3.00）	37（78.7）
t或Z或χ²		-0.637	1.303	-1.330	1.475	-0.589	0.001	1.062	-1.125	-2.508	0.000
P		0.527	0.197	0.190	0.145	0.556	0.977	0.303	0.261	0.012	1.000

组别	n	年龄（岁）	孕周（周）	身高（cm）	BMI （kg/m²）	孕次	催产	无痛分娩	第一产程时长（min）	阴道指检胎头位置（cm）	助产指征（胎儿窘迫）
A组	17	30.35±2.00	39.98±0.86	158.00±2.96	28.03±3.13	1.0（1.0，2.0）	5（29.4）	7（41.2）	420.0（340.0，775.0）	2.50（2.00，2.75）	14（82.4）
B组	47	30.85±4.21	39.63±0.98	159.36±5.01	26.76±3.01	1.0（1.0，2.0）	14（29.8）	13（27.7）	355.0（250.0，570.0）	3.00（2.50，3.00）	37（78.7）
t或Z或χ²		-0.637	1.303	-1.330	1.475	-0.589	0.001	1.062	-1.125	-2.508	0.000
P		0.527	0.197	0.190	0.145	0.556	0.977	0.303	0.261	0.012	1.000

组别	n	第二产程时长（min）	会阴侧切	牵引次数	末次牵引时长（s）	末次牵引初始牵引方向
组别	n	第二产程时长（min）	会阴侧切	牵引次数	末次牵引时长（s）	向上或水平	向下
A组	16*	60.00（31.75，138.00）	13（81.3）	2.0（1.0，3.0）	40.00（32.75，60.00）	2（12.5）	14（87.5）
B组	47	52.00（29.00，107.00）	38（80.9）	1.0（1.0，1.0）	25.00（13.00，30.00）	29（61.7）	18（38.3）
Z或χ²		-0.679	0.000	-4.127	-3.755	11.562
P		0.497	1.000	<0.001	<0.001	0.001