Intrapartum Sonographic Diagnosis of Compound Hand-Cephalic Presentation

Dear Editor,

We have recently shown that intrapartum ultrasound is a useful tool in the diagnosis of fetal head malposition [1]. Compound presentation (CP) is a rare malpresentation occurring when an extremity prolapses alongside the presenting part, with both parts presenting simultaneously. We report herein the first case of compound hand-cephalic presentation diagnosed at intrapartum sonography.

In a 42-year-old nullipara with an unfavorable Bishop score, labor was induced at 38 weeks by means of Dinoprostone pessary due to severe gestational hypertension. One day later oxytocin infusion was started as per protocol because of unchanged cervical findings. After eight hours, despite augmentation and amniotomy, no progression of cervical dilatation and a lack of fetal head descent were noted at clinical examination. At transabdominal suprapubic ultrasound, a right occiput anterior position with anterior spine was diagnosed and a hand of the fetus lying between the presenting part and the cervix was suspected ([Fig. 1]). At transperineal ultrasound ([Fig. 2b]), hand-cephalic CP with the right hand preceding the leading part of the fetal skull was documented. Given the persistently unfavorable Bishop score, manual resolution of the malpresentation could not be attempted and due to the lack of cervical changes despite adequate uterine contractions Cesarean delivery for failed induction was performed.

Fig. 1 Hand-cephalic compound presentation. The right hand is lying in front of the vertex. Image devised by Andrea Dall’Asta, MD, University of Parma, and drawn by Stefano Gobbi, project designer, University of Parma, Italy.

Fig. 2 a Transabdominal sagittal view showing the fingers prolapsed beyond the fetal head; b transperineal midsagittal view demonstrating the fingers of the fetus lying in front of the fetal head (ps: pubic symphysis).

CP occurs in approximately 1/700 deliveries [2]. Preterm delivery and external cephalic version are acknowledged as being among the predisposing factors, although most cases of CP occur in low-risk term cephalic presenting fetuses [2] [3].

The diagnosis of CP involves the palpation of a small part of the limb along with the major presenting part during vaginal examination. In early labor, the fetus may retract the extremity allowing for the spontaneous resolution of this malpresentation. On the other hand, if the extremity fails to retract spontaneously and prolapses below the fetal head, the correction of the malpresentation can be manually attempted by gently pushing the prolapsed arm upward and the head simultaneously downward by fundal pressure [2].

CP persisting despite multiple attempts of manual resolution should be closely observed given that the prolapsed limb may interfere with labor progression causing dystocia. The persistence of this malpresentation has been associated with a higher rate of obstetric intervention and a lack of fetal head descent during vacuum-assisted delivery, with a greater number of pulls and higher traction force required to overcome the entrapment of the presenting part [2] [4]. Additionally, soft tissue injury with ischemic necrosis of the limb may occur if no intervention is undertaken [3].

By reporting this first case of sonographic diagnosis of CP, we have further demonstrated that intrapartum ultrasound represents a useful tool to disclose or clarify the underlying cause of dystocia in the case of labor arrest [1] [5]. This can reduce the likelihood of incorrect diagnosis, therefore improving overall intrapartum care.

• References

• 1 Ghi T, Dall'Asta A, Kiener A. et al. Intrapartum sonographic diagnosis of posterior asynclitism by two-dimensional transperineal ultrasound. Ultrasound Obstet Gynecol 2016; DOI: 10.1002/uog.17302. [Epub ahead of print] No abstract available
• 2 Labor and delivery. In: Cunningham FG, Hauth JC, Leveno KJ. et al. (eds) Williams Obstetrics (22nd edition). 414. New York: McGraw-Hill; 2005
• 3 Sharshiner R, Silver RM. Management of fetal malpresentation. Clin Obstet Gynecol 2015; 58: 246-255
• 4 Vacca A. The 'sacral hand wedge': a cause of arrest of descent of the fetal head during vacuum assisted delivery. BJOG 2002; 109: 1063-1065
• 5 Ghi T, Youssef A, Pilu G. et al. Intrapartum sonographic imaging of fetal head asynclitism. Ultrasound Obstet Gynecol 2012; 39: 238-240