CONGRESSO AOGOI - RIMINI

Transcript

1 1 CONGRESSO AOGOI - RIMINI

2 CORSI PRE CONGRESSUALI CORSO PRECONGRESSUALE SEMEIOTICA OSTETRICA Il travaglio e il parto Impegno e progressione. Mani o eco? Paolo Accorsi 2

3 Il Contesto Paolo Accorsi: Anno di laurea 1979 Specialista dal 1983 Indice di posizione: vietato fare diagnosi... 3

4 Il Contesto La regione occipitale per prima contrae rapporti con l ingresso pelvico: presentazione di vertice. La testa può assumere un atteggiamento anomalo: - le bozze frontali per prime si rapportano con l ingresso del bacino (fronte) - a volte la prima regione a contrarre rapporti con l ingresso pelvico è quella la facciale (faccia.) A testa fetale non completamente flessa, diversi sono i diametri che si confrontano... 4

5 Il Contesto I due diametri obliqui dell ingresso pelvico (stretto superiore della pelvi) nel bacino normoconformato rappresentano gli assi di due aree ovoidali, dette aree di impegno. 5

6 Livello parte presentata Impegno della p.p.: esprimere in centimetri la distanza tra l indice della parte presentata ed il piano delle spine ischiatiche. Livello 0: impegno 6

7 Impegno della parte presentata Impegno della parte presentata: il passaggio della maggior circonferenza della parte presentata al di là del piano dello stretto superiore e l indice di presentazione viene a trovarsi a livello delle spine ischiatiche. 7

8 Progressione della p.p. Progressione della p.p. è la fase nella quale la parte presentata avanza lungo il canale del parto sotto l azione delle contrazioni-spinte 8

9 Sonographic assessment Ecografia trans addominale I. Blasi. Ultrasound Obstet Gynecol 2010; 35:

10 Sonographic assessment Ecografia trans addominale Conclusions The results of this study suggest that the position of the head and spine during the second stage of labor could be useful indicators for predicting the OP position at delivery. I. Blasi. Ultrasound Obstet Gynecol 2010; 35:

11 11 Intrapartum Translabial Ultrasound

12 12 Intrapartum Translabial Ultrasound

13 13 Intrapartum Translabial Ultrasound

14 Impegno della p.p. A three-dimensional reconstruction from a computed tomographic 14 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

15 Impegno della p.p. Gli stessi piani con gli ultrasuoni Infrapubic line 15 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

16 Sonographic Landmarks The infrapubic line Infrapubic line 16 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

17 QUESTIONS Per infrapubic line si intende: 1) la linea che idealmente il margine inferiore del pube e il promontorio 2) la linea che unisce le spine ischiatiche 3) la linea ideale che partendo dal margine inferiore del pube si stacca da questo, perpendicolare all asse maggiore del pube stesso 17

18 Sonographic Landmarks The infrapubic line caput head direction infrapubic line 18 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

19 Sonographic Landmarks With the transducer placed infrapubically: (i) the infrapubic line is perpendicular to the long axis of the pubic joint (ii) the widest fetal head diameter and its movement with regard to the infrapubic line during pushing (iii) the head direction with respect to the long axis of the symphysis 19 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

20 20 Caput succedaneum...

21 Head Direction Is defined as the direction of a line perpendicular to the widest diameter of the fetal head in the infrapubic plane, with respect to the infrapubic line. -When this line pointed ventrally at an angle of 30 or more, it was considered head up -For lines below 0, the direction was termed head down -All other angles were considered horizontal 21 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

22 Sonographic Landmarks head up. caput head direction infrapubic line 22 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

23 Head Direction horizontal head. 23 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

24 Head Direction head down. 24 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

25 Sonographic Landmarks 20 pregnant women in spontaneous term labor with normal singleton fetuses in cephalic presentation and clinical indication for vacuum extraction caputwere studied by ITU immediately before operative vaginal delivery Lack of descent or lack of passage below the infrapubic line and horizontal or downward head direction were poor prognostic signs Conclusions. ITU provides objective information on the dynamics of the second stage of labor, head station and head direction. ITU may be used to assess the prognosis for operative vaginal delivery. 25 W. Henrich. Ultrasound Obstet Gynecol 2006; 28:

26 QUESTIONS Quando la testa fetale ha un orientamento caputdefinito all ecografia translabiale: head down, la probabilità per il parto vaginale è: 1) maggiore 2) minore 3) indifferente 26

27 Head Direction -When the fetal head was directed downward, the station assessed clinically was most frequently +1 cm from the ischial spines -When the direction was horizontal, the station was most frequently +2 cm -When the fetal head was directed upward, the station was usually +3 cm All comparisons between clinical and sonographic findings demonstrated a statistically significant relationship (P < ). 27 T. Ghi. Ultrasound Obstet Gynecol 2009; 33:

28 Head Direction: down 28 T. Ghi. Ultrasound Obstet Gynecol 2009; 33:

29 Head Direction: horizontal 29 T. Ghi. Ultrasound Obstet Gynecol 2009; 33:

30 Head Direction: upward 30 T. Ghi. Ultrasound Obstet Gynecol 2009; 33:

31 Discesa p.p e modalità di parto Objectives. To assess the feasibility and reproducibility of measuring fetal head station and descent during labor using transperineal ultrasound (TPU) To assess its utility in distinguishing patients whose pregnancy will result in spontaneous vaginal delivery from those who will require operative vaginal delivery or Cesarean section for failure to progress 31 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

32 Discesa p.p e modalità di parto TPU imaging was used to measure the angle of head descent during the second stage of labor in 23 women. Head descent was quantified by measuring the angle between the long axis of the pubic symphysis and a line extending from its most inferior portion tangentially to the fetal skull Intraobserver and interobserver variability were calculated using variance component analysis. 32 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

33 Discesa p.p e modalità di parto 33 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

34 Discesa p.p e modalità di parto 34 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

35 Discesa p.p e modalità di parto 35 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

36 Discesa p.p e modalità di parto 36 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

37 Discesa p.p e modalità di parto 37 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

38 Angolo di discesa e tempo del parto 38 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

39 Angolo di discesa e tempo del parto 39 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

40 Discesa p.p e modalità di parto Results Spontaneous delivery occurred in all cases in which the TPU angle exceeded 120. Among the six patients who had Cesarean Sections for failure to progress (26%), clinical digital assessment of fetal head station was +2 or more. Conclusions The angle of head descent measured by TPU imaging provides an objective, accurate and reproducible means for assessing descent of the fetal head during labor 40 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

41 Discesa p.p e modalità di parto Conclusions The low intraobserver and interobserver variability validates the accuracy of this technique. The relationship between fetal head descent assessed by digital examination and by TPU imaging clearly shows a particularly poor correlation in mid-station (clinical station, 2 to 0), reflecting how difficult it is for clinicians to accurately quantify clinical head station using the more subjective method of digital examination. 41 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

42 Discesa p.p e modalità di parto Conclusions We are hoping that, after further investigation, TPU imaging may have the potential to be used as a more accurate tool in decision making in the event of true failure to progress in labor and that it may aid in guiding clinicians with regards to operative vaginal delivery 42 A.F. Barbera. Ultrasound Obstet Gynecol 2009; 33:

43 A study of progress of labour Objectives. Intrapartum translabial ultrasound measurements for head station, head direction, and angle of descent (AoD) in 50 labouring women, compared, studied for repeatability, and correlated with the progress of labour Main outcome measures. Reproducibility and correlation of ITU parameters and their pattern of changes during labour. 43 B. Tutschek, W. Henrich BJOG 2011;118:62 69

44 A study of progress of labour The infrapubic line is perpendicular to the long axis of the pubic symphysis. The parallel plane through the ischial spines is 3 cm below the infrapubic line, and is used to measure true head station ( ITU station ). 44 B. Tutschek, W. Henrich BJOG 2011;118:62 69

45 A study of progress of labour Intrapartum translabial ultrasound parameters were recorded at the height of pushing. Results Vaginal delivery (either spontaneous or operative) occurred in: 33 of 34 (97%) women for an ITU station greater than +2.0 cm, 32 of 34 (94%), for a head direction >22, and 34 of 36 (94%) women with angle of descent > B. Tutschek, W. Henrich BJOG 2011;118:62 69

46 A study of progress of labour Results 46 B. Tutschek, W. Henrich BJOG 2011;118:62 69

47 A study of progress of labour Results There was good repeatability for ITU head station, AoD, and head direction, both for the same and for two different examiners. 50 pregnant women with normal singleton term pregnancies, mostly in the second stage of normal spontaneous labour, were included: there were 28 normal vaginal birth, 13 attempted and successful instrumental, and nine caesarean deliveries (18%) 47 B. Tutschek, W. Henrich BJOG 2011;118:62 69

48 A study of progress of labour Results The changes of ITU-measured head station and head direction during a contraction with pushing differed with head station: at stations between -3 and -2 cm, the average descent during a contraction was 2.5 cm, between -2 and +2 cm it was 1 cm, and at stations between +2 and +3 cm it was 2.2 cm. In the upper part of the birth canal and down to head station +2 cm, head directions varied, but mostly changed from down to horizontal. The average change of head direction during a contraction per 1 cm of head descent overall was +10, but between head station +2 and +3 cm there was a markedly increased change of head direction during a contraction (on average +18 ) 48 B. Tutschek, W. Henrich BJOG 2011;118:62 69

49 A study of progress of labour Conclusions Vaginal birth is a natural process, but occasionally requires urgent medical intervention. Our new data may improve our understanding of normal and abnormal labour, enable objective measurement of birth progress, and provide a more scientific basis for assessing labour. We speculate that ITU may reduce the risks of assisted labour, and that it might even avoid unnecessary caesarean deliveries (18% TC!!) 49 B. Tutschek, W. Henrich BJOG 2011;118:62 69

50 Roberto Romero One of the most difficult dilemmas in clinical obstetrics is that presented by a nulliparous woman at term who had a protracted active phase of labor, received an epidural, and now has a prolonged second stage of labor. The head appears to be low, but there is always uncertainty as to whether this reflects caput. Should this situation be handled with an operative vaginal delivery (forceps or vacuum) or a Cesarean section? 50 R. Romero Ultrasound Obstet Gynecol 2009; 33:

51 Roberto Romero Ultrasound can play a role by: 1) identifying precisely the fetal position; 2) diagnosing whether caput is present and its extent; 3) assessing the fetal station; and 4) when ultrasound has been used serially, documenting the degree of progress that has been made during the second stage 51 R. Romero Ultrasound Obstet Gynecol 2009; 33:

52 Conclusioni Conclusioni: A) Serve un matrimonio tra ecografisti e clinici in sala parto (vedi 18 e 26 % di TC nel secondo stadio) B) Cerchiamo di capire il parto, anche con gli ultrasuoni C) Non interferire negativamente con il parto introducendo metodiche non standardizzate e non EBM 52

53 Conclusioni Conclusioni: D) Utilizzare la metodica (standardizzata) in situazioni di necessità e non generalizzate (la > parte partorisce bene senza interferenze!) E) Maggiore possibilità di corretto utilizzo del vacuum F)... Poi occorre un ecografo in sala parto 53

54 54 Grazie dell attenzione