الفهرس 
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Abstract
The main aim of this study was to assess role of intrapartum trans-perineal ultrasonography parameters as a quantitative and objective tool in prediction of successful vaginal delivery and in making more reliable clinical decisions aiming to improve obstetric outcome of both the mother and the fetus.
This diagnostic test accuracy study was conducted at Ain Shams University Maternity Hospital including 200 pregnant women admitted in first stage of labor. The study duration was one and half year from September 2019 to March 2021.
All pregnant women admitted to Ain Shams maternity hospital emergency unit meeting the inclusion and exclusion criteria till the sample size was reached. Suitable women were invited to participate in the study then a verbal and informed consent was obtained from them. When the patient’s consent was obtained, they were considered to be included into the study.
All included women were subjected to full history taking and full physical examination including general, abdominal and digital vaginal examination.
Complete real time trans-abdominal ultrasonographic examination was done.
Trans-abdominal and trans-perineal ultrasonography was performed by a single operator for all patients involved in the study by Samsung Midison SonoAce R5, Convex probe 2-8 MHz, made in South Korea).
Complete real time trans-abdominal ultrasonographic examination including confirmation of gestational age, fetal number, viability, presentation, estimated fetal weight, position and placental site and grading, amount of liquor biophysical profile and doppler indices umbilical artery and to exclude congenital anomalies.
Intrapartum ultrasonographic assessment of fetal head position by trasns-abdominal ultrasound and assessment of fetal head station by trans-perineal ultrasound measuring Angle of progression (AOP), Head perineal distance (HPD), Head symphysis distance (HSD) and Medlin angle (MLA).
Ultrasonographic parameters was measured in-between contractions and just before or after applying the digital vaginal examination and the cervical dilatation equal to or more than seven centimeters.
If pregnant woman admitted with cervical dilatation less than seven centimeter, the ultrasound examination was performed at time of admission and again after cervical dilatation equal to or exceeding seven centimeters.
Three groups of women based on the outcome of labour were defined: group A: women with successful vaginal delivery (VD), group B: women with operative vaginal delivery (OVD) and group C: women had undergone cesarean section (CS).
The data have been collected in a data sheet and the progress of labor and method of delivery was recorded. The women received the care as normal from the attending health professional and the management of labor was based only on the digital vaginal examination and clinical data collected routinely and physicians who are not part of the research team was blinded to the ultrasound findings to avoid research bias.
In our study, 168 pregnant women had a successful vaginal delivery while 22 pregnant women delivered by cesarean section and 10 pregnant women needed an operative vaginal delivery.
Regarding clinic-demographic characteristics. There was no statistically significant difference between the studied groups regarding age, gestational age, weight and (p>0.05). Meanwhile, vaginal delivery group had significantly higher height compared to CS group. BMI was significantly higher in CS group compared to normal vaginal delivery group and operative vaginal delivery group (p<0.05).
Regarding trans perineal US findings, the measurement of HPD and AOP were significantly correlated to the clinical parameters for assessment of progress of labor. The HPD was found to be significantly inversely proportional to each the cervical dilatation and station in whole study population (p value < 0.001). The AOP was found to be significantly directly proportional to each the cervical dilatation and fetal head station in the whole study population.
In our study when cervical dilatation less than 7 cm, normal vaginal delivery group had significantly higher AOP compared to operative vaginal delivery group and CS group while normal vaginal delivery group had significantly lower HSD compared to CS group (p<0.05). HPD was significantly higher in CS groups compared to both normal vaginal delivery group and operative vaginal delivery group sequentially. MLA was significantly lower in operative vaginal delivery group compared to both normal vaginal delivery group and CS groups respectively.
When cervical dilatation more than 7 cm, normal vaginal delivery group had significantly higher AOP compared to operative vaginal delivery group and CS group while normal vaginal delivery group had significantly lower HSD compared to CS group (p<0.05). HPD and MLA were significantly higher in CS groups compared to both normal vaginal delivery group and operative vaginal delivery group sequentially.
Validity of Intrapartum Trans perineal Ultrasound in Prediction of successful vaginal delivery when cervical dilatation less than 7 cm the has the best accuracy noticed in AOP at cutoff 92.0° with sensitivity and specificity (95.9% & 85.7%) respectively with AUC= (0.957). When cervical dilatation more than 7 cm the best accuracy was noticed in AOP at cutoff 111.0° with sensitivity and specificity (95.5% & 90.9%) respectively with AUC= (0.959) which can predict successful vaginal delivery.
We concluded that Ultrasound has become an essential tool in all fields of obstetrics. Trans-perineal ultrasound converts images to measurements of AOP, HSD, MLA and HPD to accurately predict the mode of delivery. This may improve our considerations of normal and abnormal labor, allow objective measurement of birth progress, and provide an additional scientific basis for assessing labor. This study has proved the feasibility and reliability of intrapartum trans-pereneal ultrasound measurement as a tool in prediction of successful vaginal delivery.