Asynclitic birth

In obstetrics, asynclitic birth, or asynclitism, refers to the malposition of the fetal head in the uterus relative to the birth canal.^[1] Many babies enter the pelvis in an asynclitic presentation, but in most cases, it corrects itself spontaneously during labor.^[2] Asynclitic presentation is not to be confused with a shoulder presentation, where the shoulder leads first.

Fetal head asynclitism may affect the progression of labor, increase the need for obstetrical intervention, and may be associated with difficult instrumental delivery.^[3] The prevalence of asynclitism at transperineal ultrasound was common in nulliparous women at the second stage of labor and seemed more commonly associated with non occiput anterior position, suggesting an autocorrection occurs in many cases.^[3]

When the self-correction does not occur, obstetrical intervention is necessary to deliver the child. Persistence of asynclitism can cause problems with dystocia, and has often been associated with cesarean births. However, with a skilled midwife or obstetrician a complication-free vaginal birth can sometimes, though not necessarily, be achieved through movement and positioning of the birthing person, and patience and extra time to allow for movement of the baby through the pelvis and moulding of the skull during the birthing process if this is safe in the circumstances. Other options include the use of vacuum-assisted delivery and forceps.^{[medical citation needed]}^[4]^{[unreliable source?]} There is no evidence to suggest that people with previous asynclitic presentation are more likely to experience it in subsequent childbirth.^[5]^{[better source needed]}

Diagnosis

Asynclitism can be digitally diagnosed using intrapartum ultrasound through the transabdominal cavity and the transperitoneal cavity. Intrapartum ultrasonography is regularly used during pregnancy to constantly monitor the fetal position within the mother's belly.^[6] The International Society of Ultrasound in Obstetrics and Gynecology Practice Guidelines recommend the use of intrapartum ultrasound to diagnose asynclitic births during prolonged and obstructed labors.^[7]

Asynclitism is most easily diagnosed during labor when the cervix is opened allowing the orientation of the occiput, the back of the fetal head, to be visually assessed in relation to the mother's pelvis.^[8] Posterior asynclitism is when the fetal occiput is facing the mother's spine, and anterior asynclitism is when the fetal occiput is facing the mother's belly. The most common and preferred type of asynclitism is the left occiput anterior asynclitism because the baby's head enters the pelvis in such a way that it minimizes the circumference of how the baby exits the body as much as possible. In this type of asynclitism, it allows the fetus to be in the most efficient position. The back of the fetus's head is towards the carrier's left side. Meanwhile, their face is towards the mother's right side at an angle between the hip and the spine of the mother.^[9] Posterior asynclitism can lengthen the duration of labor and cause complications.^[10] Asynclitism is most commonly discovered during vaginal exams conducted in labor. During the exam, the healthcare professional may feel the parietal bone more distinctly than others. Professionals can also use ultrasound to help identify potential asynclitism.^[11]

Occurrence

Asynclitism can occur at any time during pregnancy. Most commonly, it occurs near the end of the third trimester or during labor. At this time, the fetus becomes more developed and begins moving down the birth canal.^[12]

Causes

The exact cause of asynclitism is unknown. The shape and size of the uterus, the weight of the fetus, pelvic anatomy, and multiparity can contribute to it.^[13] Factors can vary depending on the person carrying the fetus. For example, a pregnant person with rotated hips can increase the likelihood of asynclitism. Situational factors include a short umbilical cord and unevenness of the pregnant person's pelvic floor during contractions, leading to the baby's head tipping to one side.^[5]

Asynclitism can also begin at the time of the birth. This happens when the fetus quickly comes down on the pelvic floor before straightening their head when the water breaks.^[14] This can be due to the water rushing through the pelvis too quickly; once it occurs, it is difficult to correct.

Signs and symptoms

Signs of asynclitism which may be observed without medical diagnostic equipment include visual asymmetric baby bumps, caused by the baby's head being tilted asymmetrically in relation to the mother's pelvis, or by an abnormal buildup of amniotic fluid.^[15] The mother may report symptoms of abdominal discomfort, particularly on one side, or pain on one side of the hips.^[5]

Complications

Asynclitism is common as the fetus enters through and tilts the maternal pelvis. There are three types: anterior, posterior, and lateral asynclitism.^[3] Minor asynclitism generally resolves itself and results in uncomplicated births.^[8] Minor cases present mild molding and the slight deviation of the head from the midline, but are otherwise absent of major fetal head malpositioning. In cases that present with persistent occiput posterior - in which the head is in a downward position, but facing towards the front of the abdomen - or shoulder positions, this can result in prolonged and difficult delivery and may warrant surgical intervention.^[8]^[16]

Complications can occur before, during, and after birth that affect both parent and baby. Asynclitism can lead to slower and more difficult labor, increasing stress and fatigue. If the fetus' head is not optimally positioned, this can result in dystocia, necessitating an operative delivery. Complications are associated with procedures such as operational vaginal deliveries (OVD), particularly with the use of vacuum extraction, and caesarean sections (CS).^[3] Caesarean sections can increase the risk of maternal complications, which can affect future pregnancies. These include uterine ruptures, chronic pain, hemorrhages, and bladder injury. One of the more severe complications is placenta accreta, which can lead to a life-threatening hemorrhage and peripartum hysterectomy.^[3]

Complications the baby may face include cephalohematomas, hyperbilirubinemia, and intracranial hemorrhages.^[17]^[16] Asynclitic birth can also increase the risk of birth injuries such as brachial plexus injury in which the nerves responsible for sending signals to the baby's arm are damaged, resulting in temporary or permanent numbness, weakness, or even paralysis in the affected arm.^[18] In rare cases, uncorrected asynclitism can lead to neonatal asphyxia, in which the child does not receive enough oxygen before, during, or just after birth, which can result in temporary or permanent organ damage.^[19] The mother may experience complications such as vaginal or cervical tears, excessive blood loss, infection of the placental membrane, and postpartum infections.^[20] Asynclitism can also affect the development of facial structures and nerves during pregnancy, with lifelong consequences for the child. These complications can include facial malformation, Bell's palsy, deviated septum, and facial asymmetry.^[21]

Management

Various techniques have been tried to resolve an asynclitic position of the fetus. Vacuum extraction, a delivery assistance method used for prolonged or obstructed labor, has been shown to reverse the position from the less optimal one, known as occiput posterior or occiput transverse, to the more favorable position known as occiput anterior.^[22] However, it is not the primary treatment for asynclitic births, as the effectiveness rate is not very high and vacuum extraction can lead to additional complications.^[23] Possible complications include fetal morbidity and fatality, and damage to the derma layer leading to bleeding within the brain and the layer of skin on the skull, known as cephalohematomas.^[24] Facial nerve damage and immobility are permanent consequences from intracranial hemorrhage leading to a diminished quality of life. However, when it is successful, vacuum extraction can change the position from a non-occital anterior position to an occital anterior position, which is more favorable in terms of asynclitic births.^[25] Following any medical procedure to alter the occiput position or any assisted vaginal delivery, monitoring of the neonate is extremely important as intracranial hemorrhages may be imperceptible.

Non-invasive techniques are typically the first steps when dealing with asynclitic birth. Short and quick breaths synchronized with contractions are commonly suggested by the obstetrician to help with prolonged labor with asynclitism.^[26] Positioning techniques can also employed to help the baby to rotate or descend.^[27] Examples of these techniques include the hands-on-knees position, lunging, kneeling lunge, side-lying release, and use of a birth ball. If positioning techniques do not work, healthcare professionals may attempt manual rotation, attempting to adjust the baby's position manually via the vagina.^[28]

If none of these methods are successful, the physician may consider a caesarean section to deliver the baby safely.^[29]

Along with procedural interventions, there are supportive measures that are taken to alleviate the physical and psychological trauma associated with childbirth. Supportive measures come in both non-pharmacological and pharmacological forms.^[8] For pain management, labor analgesia has been shown to be effective. Depending on the procedure, different types of anesthesia, such as pudendal block anesthesia, may be used.^[16]

References

^ Vlasyuk, Vasily (2022). "The importance of asynclitism in birth trauma and intrapartum sonography". The Journal of Maternal-Fetal & Neonatal Medicine. 35 (11): 2188–2194. doi:10.1080/14767058.2020.1777270. PMID 32538217. S2CID 219706630.
^ Hung, Catherine M.W.; Chan, Viola Y.T.; Ghi, Tullio; Lau, Wailam (September 2021). "Asynclitism in the second stage of labor: prevalence, associations, and outcome". American Journal of Obstetrics & Gynecology MFM. 3 (5): 100437. doi:10.1016/j.ajogmf.2021.100437. ISSN 2589-9333.
^ ^a ^b ^c ^d ^e Hung CM, Chan VY, Ghi T, Lau W (September 2021). "Asynclitism in the second stage of labor: prevalence, associations, and outcome". American Journal of Obstetrics & Gynecology MFM. 3 (5): 100437. doi:10.1016/j.ajogmf.2021.100437. PMID 34217855.
^ "Asynclitism - A Helpful Guide and Solutions". Spinning Babies. 23 June 2020. Retrieved 2023-07-25.
^ ^a ^b ^c ^{[better source needed]} Herbert C. "What is asynclitic presentation?". BabyCentre UK. Retrieved 2023-07-25.
^ Malvasi A, Giacci F, Gustapane S, Sparic R, Barbera A, Tinelli A (2016). "Intrapartum sonographic signs: new diagnostic tools in malposition and malrotation". The Journal of Maternal-Fetal & Neonatal Medicine. 29 (15): 2408–2413. doi:10.3109/14767058.2015.1092137. PMID 26444321. S2CID 46126409.
^ Beck R, Malvasi A, Kuczkowski KM, Marinelli E, Zaami S (April 2019). "Intrapartum sonography of fetal head in second stage of labor with neuraxial analgesia: a literature review and possible medicolegal aftermath". European Review for Medical and Pharmacological Sciences. 23 (8): 3159–3166. doi:10.26355/eurrev_201904_17673. PMID 31081066. S2CID 153308972.
^ ^a ^b ^c ^d Malvasi A, Barbera A, Di Vagno G, Gimovsky A, Berghella V, Ghi T, et al. (November 2015). "Asynclitism: a literature review of an often forgotten clinical condition". The Journal of Maternal-Fetal & Neonatal Medicine. 28 (16): 1890–1894. doi:10.3109/14767058.2014.972925. PMID 25283847. S2CID 24295521.
^ Ghi T, Conversano F, Ramirez Zegarra R, Pisani P, Dall'Asta A, Lanzone A, et al. (January 2022). "Novel artificial intelligence approach for automatic differentiation of fetal occiput anterior and non-occiput anterior positions during labor". Ultrasound in Obstetrics & Gynecology. 59 (1): 93–99. doi:10.1002/uog.23739. PMID 34309926. S2CID 236432509.
^ Ghi T, Youssef A, Pilu G, Malvasi A, Ragusa A (February 2012). "Intrapartum sonographic imaging of fetal head asynclitism". Ultrasound in Obstetrics & Gynecology. 39 (2): 238–240. doi:10.1002/uog.9034. PMID 21523842. S2CID 206543816.
^ Copel JA, D'Alton ME, Feltovich H, Gratacós E, Krakow D, Odibo AO, et al. (2017-01-01). Obstetric imaging: Fetal diagnosis and care (2nd ed.). Elsevier. doi:10.1016/C2014-0-00100-1. ISBN 978-0-323-44548-1. {{cite book}}: |journal= ignored (help)
^ "Your baby in the birth canal". MedlinePlus Medical Encyclopedia. Retrieved 2023-07-31.
^ Dasa TT, Okunlola MA, Dessie Y (2022). "Effect of grand multiparity on adverse maternal outcomes: A prospective cohort study". Frontiers in Public Health. 10: 959633. doi:10.3389/fpubh.2022.959633. PMC 9608575. PMID 36311606.
^ Tully, G (19 July 2019). "What Causes Asynclitism". Spinning Babies. Retrieved 26 July 2023.
^ Shamsnajafabadi H, Soheili ZS (August 2022). "Amniotic fluid characteristics and its application in stem cell therapy: A review". International Journal of Reproductive Biomedicine. 20 (8): 627–643. doi:10.18502/ijrm.v20i8.11752. PMC 9596929. PMID 36313262.
^ ^a ^b ^c Malvasi A, Vinciguerra M, Lamanna B, Cascardi E, Damiani GR, Muzzupapa G, et al. (November 2022). "Asynclitism and Its Ultrasonographic Rediscovery in Labor Room to Date: A Systematic Review". Diagnostics. 12 (12): 2998. doi:10.3390/diagnostics12122998. PMC 9776610. PMID 36553005.
^ Jacob K, Hoerter JE (2023). Caput Succedaneum. Treasure Island (FL): StatPearls Publishing. PMID 34662048. Retrieved 2023-07-27. {{cite book}}: |work= ignored (help)
^ Althaus JE, Petersen S, Driggers R, Cootauco A, Bienstock JL, Blakemore KJ (September 2006). "Cephalopelvic disproportion is associated with an altered uterine contraction shape in the active phase of labor". American Journal of Obstetrics and Gynecology. 195 (3): 739–742. doi:10.1016/j.ajog.2006.05.053. PMID 16949406.
^ American Academy of Pediatrics; American Heart Association (2016-04-16). Textbook of Neonatal Resuscitation (NRP) (7th ed.). American Academy of Pediatrics. ISBN 978-1-61002-025-1.
^ Simkin P (March 2010). "The fetal occiput posterior position: state of the science and a new perspective". Birth. 37 (1): 61–71. doi:10.1111/j.1523-536X.2009.00380.x. PMID 20402724.
^ Sapin SO, Miller AA, Bass HN (March 2005). "Neonatal asymmetric crying facies: a new look at an old problem". Clinical Pediatrics. 44 (2): 109–119. doi:10.1177/000992280504400202. PMID 15735828. S2CID 25670821.
^ Jeon J, Na S (November 2017). "Vacuum extraction vaginal delivery: current trend and safety". Obstetrics & Gynecology Science. 60 (6): 499–505. doi:10.5468/ogs.2017.60.6.499. PMC 5694723. PMID 29184857.
^ Kettle C, Tohill S (April 2011). "Perineal care". BMJ Clinical Evidence. 2011: 1401. PMC 3275301. PMID 21481287.
^ Ali UA, Norwitz ER (2009). "Vacuum-assisted vaginal delivery". Reviews in Obstetrics & Gynecology. 2 (1): 5–17. PMC 2672989. PMID 19399290.
^ Kahrs BH, Usman S, Ghi T, Youssef A, Torkildsen EA, Lindtjørn E, et al. (August 2018). "Fetal rotation during vacuum extractions for prolonged labor: a prospective cohort study". Acta Obstetricia et Gynecologica Scandinavica. 97 (8): 998–1005. doi:10.1111/aogs.13372. hdl:10044/1/61107. PMID 29770435. S2CID 21721014.
^ Hanson L (January 2009). "Second-stage labor care: challenges in spontaneous bearing down". The Journal of Perinatal & Neonatal Nursing. 23 (1): 31–39. doi:10.1097/JPN.0b013e318196526b. PMID 19209057. S2CID 9830451.
^ Simkin P, Hanson L, Ancheta R (2017). The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia (Fourth ed.). Hoboken, New Jersey: Wiley Blackwell. ISBN 978-1-119-17046-4.
^ Williams Obstetrics (24th ed.). New York: McGraw-Hill education. 2014. ISBN 978-0-07-179893-8.
^ Birsner, Meredith; Porter, Flint (April 2013). "Cesarean Delivery on Maternal Request". American College of Obstetricians and Gynecologists. Retrieved 2023-07-31.