Sonographic evaluation of the fetal head position and attitude during labor

Fetal malpresentation, malposition, and asynclitism are among the most common determinants of a protracted active phase of labor, arrest of dilatation during the first stage, and arrest of descent in the second stage. The diagnosis of these conditions is traditionally based on vaginal examination, which is subjective and poorly reproducible. Intrapartum sonography has been demonstrated to yield higher accuracy than vaginal examination in characterizing fetal malposition, and some guidelines endorse its use for the verification of the occiput position before performing an instrumental delivery. It is also useful for the objective diagnosis of the malpresentation or asynclitism of the fetal head. According to our experience, the sonographic assessment of the head position in labor is simple to perform also for clinicians with basic ultrasound skills, whereas the assessment of malpresentation and asynclitism warrants a higher level of expertise. When clinically appropriate, the fetal occiput position can be easily ascertained using transabdominal sonography combining the axial and the sagittal planes. With the transducer positioned on the maternal suprapubic region, the fetal head can be visualized, and landmarks including the fetal orbits, the midline, and the occiput itself with the cerebellum and the cervical spine (depending on the type of fetal position) can be demonstrated below the probe. Sinciput, brow, and face represent the 3 "classical" variants of cephalic malpresentation and are characterized by a progressively increasing degree of deflexion from vertex presentation. Transabdominal sonography has been recently suggested for the objective assessment of the fetal head attitude when a cephalic malpresentation is clinically suspected. Fetal attitude can be evaluated on the sagittal plane with either a subjective or an objective approach. Two different sonographic parameters such as the occiput-spine angle and the chin-chest angle have been recently described to quantify the degree of flexion in fetuses in non-occiput-posterior or occiput-posterior position, respectively. Finally, although clinical examination still represents the mainstay of diagnosis of asynclitism, the use of intrapartum sonography has been shown to confirm the digital findings. The sonographic diagnosis of asynclitism can be achieved in expert hands using a combination of transabdominal and transperineal sonography. At suprapubic sonography on the axial plane only, 1 orbit can be visualized (squint sign) while the sagittal suture appears anteriorly (posterior asynclitism) or posteriorly (anterior asynclitism) displaced. Eventually the transperineal approach does not allow the visualization of the cerebral midline on the axial plane if the probe is perpendicular to the fourchette. In this expert review we summarize the indications, technique, and clinical role of intrapartum sonographic evaluation of fetal head position and attitude.