Ultrasound Obstet Gynecol 2013; 41: 419–424

Published online 6 March 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.12335

Fetal head–symphysis distance: a simple and reliable

ultrasound index of fetal head station in labor
A. YOUSSEF*, E. MARONI*, A. RAGUSA†, F. DE MUSSO*, G. SALSI*, M. T. IAMMARINO‡,
A. PACCAPELO‡, N. RIZZO*, G. PILU* and T. GHI*
*Department of Obstetrics and Gynecology, Sant’Orsola Malpighi University Hospital, University of Bologna, Bologna, Italy; †Department
of Obstetrics and Gynecology, Niguarda Hospital, Milan, Italy; ‡Department of Clinical Medicine, Alma Mater Studiorum - University of
Bologna, Bologna, Italy

K E Y W O R D S: fetal head–symphysis distance; intrapartum; labor; three-dimensional; translabial; ultrasound

ABSTRACT INTRODUCTION
Objectives To assess the reproducibility of measurement Fetal head descent, a cardinal labor movement, is tra-
of a new sonographic index of fetal head station in labor, ditionally assessed using digital examination1 . However,
the fetal head–symphysis distance (HSD), using three- such evaluation is inaccurate2 – 4 . Intrapartum transperi-
dimensional ultrasound, and its correlation with digital neal ultrasound (ITU) has been suggested recently as an
assessment of fetal head descent and with the angle of adjuvant tool in determining the progress of the fetal
progression (AoP). head5 – 9 . Different approaches have been suggested, but
the best sonographic method to evaluate fetal station
Methods Three-dimensional (3D) ultrasound volumes remains uncertain10 – 13 .
were acquired from 47 nulliparous women in active In the present study we provide data on a new, simple
labor following assessment of fetal head station with ITU parameter: the fetal head–symphysis distance (HSD).
digital examination. The HSD (the distance between The aim of our study was to assess the reproducibility
the lower edge of the pubic symphysis and the nearest of measurement of HSD using three-dimensional (3D)
point of the fetal skull) was measured independently ultrasound, and the correlation of HSD with digital
by two operators in order to evaluate intra- and assessment of fetal station and with the angle of
interobserver reproducibility. The correlation between progression (AoP).
HSD, AoP and fetal head station was evaluated using
regression analysis. Using 3D tomographic ultrasound
METHODS
imaging (TUI), measurements of the HSD were obtained
in different parasagittal planes to evaluate the influence From August 2010 to January 2011, a series of nulliparous
of inaccurate alignment of the probe with the midline of women in active labor with a singleton uncomplicated
the pelvis. term (37–42 weeks) pregnancy and fetuses in the vertex
presentation were recruited to the study. The study
Results Measurement of HSD showed high intraobserver protocol was approved by the local Ethics Committee
(intraclass correlation coefficient (ICC) = 0.995; 95% CI, and informed consent was obtained from each patient
0.991–0.997) and interobserver (ICC = 0.991; 95% CI, before scanning.
0.984–0.995) reliability. In addition, a high correlation The fetal head station in relation to the ischial spines
was demonstrated between mid-sagittal and parasagittal was digitally assessed, as suggested by the American
HSD measurements. HSD showed significant negative College of Obstetricians and Gynecologists14 , in the
correlation with both fetal head station and AoP. absence of uterine contractions or maternal pushing.
A transabdominal ultrasound examination was then
Conclusion Fetal HSD is a simple and reliable method for
performed in order to detect the fetal occiput position, as
the assessment of fetal head descent in labor. Copyright
previously described15 , and women with occipitoposterior
 2012 ISUOG. Published by John Wiley & Sons, Ltd.

Correspondence to: Dr A. Youssef, Department of Obstetrics and Gynecology, Sant’Orsola-Malpighi University Hospital, University of
Bologna, Via Massarenti 13, 40138 Bologna, Italy (e-mail: [email protected])
Accepted: 22 October 2012

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
 14690705, 2013, 4, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.12335 by CochraneChina, Wiley Online Library on [08/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
420 Youssef et al.

Figure 1 Three-dimensional graphic (a) and ultrasound image (b) showing fetal head–symphysis distance (HSD) measurement. This is the
distance between the lowest edge of the symphysis pubis and the nearest point of the fetal skull along a line passing perpendicular to the long
axis of the symphysis pubis.

Figure 2 Ultrasound images showing fetal head–symphysis distance (HSD) measurements at fetal head stations of: (a) −3 (HSD = 42 mm),
(b) 0 (HSD = 18 mm) and (c) +2 (HSD = 11 mm).

position were not included in the study. Subsequently, both blinded to the results of clinical evaluation. The two
a transperineal 3D ultrasound volume was acquired in measurements obtained by Operator 1 were performed
the mid-sagittal plane using a portable machine (Voluson with an intervening time interval of at least 1 week in
i; GE Medical Systems, Zipf, Austria) equipped with a order to avoid bias. Cases in which the HSD could
volumetric probe covered by a sterile glove, as previously not be measured were subsequently excluded from the
described12 . All volumes were subsequently analyzed study. In the case of overlapping skull bones at the lower
offline using specific software, as previously described (4D end of the HSD, the outer skull edge was considered
view 9.0 with Sono VCAD labor; GE Medical Systems)12 . for the measurement. The AoP (the angle between the
On the mid-sagittal plane the fetal HSD (defined as the longitudinal axis of the pubic bone and a line joining the
distance between the lowest edge of the symphysis pubis lowest edge of the pubis to the lowest convexity of the
and the nearest point of the fetal skull along a line passing fetal skull)6,16 , was then measured on the mid-sagittal
perpendicular to the long axis of the pubic symphysis, plane.
the so-called infrapubic line7 ) (Figures 1 and 2; Videoclip HSD was later measured in the right and left
S1) was measured twice by one operator (Operator 1: parasagittal planes (± 5 mm) using a 3D Tomographic
A.Y.) and once by another operator (Operator 2: T.G.), Ultrasound Imaging algorithm (TUI; GE Medical

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 419–424.
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Head–symphysis distance 421

Figure 3 Tomographic ultrasound imaging technique used to assess fetal head–symphysis distance in midsagittal plane (a) and on right (b)
and left (c) parasagittal planes (5 mm).

Systems) by Operator 1 in order to evaluate the Table 1 Characteristics of 47 nulliparous women with a singleton
repeatability of parasagittal vs mid-sagittal measurements uncomplicated term pregnancy who underwent three-dimensional
ultrasound for assessment of fetal head station
(Figure 3).
Characteristic Value
Statistical analysis Maternal age (years) 32 (17–42)
Body mass index (kg/m2 ) 26.5 (20.8–34.9)
Mean, median, SD, range and frequencies were used Gestational age (weeks) 39.2 (37.0–41.0)
as descriptive statistics. Agreement between the two Birth weight (g) 3270 (2790–4100)
operators and between the two measurements made Epidural analgesia 22 (46.8)
Instrumental vaginal delivery 4 (8.5)
by the first operator, as well as the agreement between
Cesarean section 3 (6.4)
parasagittal vs mid-sagittal measurements, was expressed Stage
using intraclass correlation coefficients (ICCs) for single First stage 29 (61.7)
measurements and 95% CI for the ICC17 . The systematic Second stage 18 (38.3)
differences were also computed using the paired Student’s
Data are given as median (range) or n (%).
t-test.
As far as repeatability is concerned, in order to assess
systematic bias between intraobserver measurements, RESULTS
interobserver measurements and mid-sagittal vs parasagit-
tal measurements, differences between values were plotted Fifty-five women were enrolled into the study. Measure-
against means of the measurements, as described by Bland ment of HSD was not possible in eight, all with a station
and Altman18 , and the limits of agreement were evaluated of −3 or higher7 . The characteristics of the 47 women
together with their 95% CI18 . The repeatability coeffi- included in the analysis are shown in Table 1.
cients were also computed19 . For comparisons other than Bland–Altman plots are shown in Figure 4. No
the analysis of intraobserver repeatability, only the first of significant relationship was found between the differences
the two midsagittal measurements obtained by Operator and the mean values of the two measurements made in
1 was used in each case. The correlations between average all the study conditions. The results of the analyses of
values and differences, as well as the correlations between agreement are shown in Table 2. A systematic difference
HSD and AoP and digital examination, were tested using was only observed between the two observers and between
Pearson’s r coefficient. the mid-sagittal vs the right parasagittal evaluations.
The statistical analyses were performed using SPSS HSD showed high intraobserver (ICC = 0.995; 95% CI,
version 13.0 (SPSS Inc., Chicago, IL, USA), and two-tailed 0.991–0.997) and interobserver (ICC = 0.991; 95% CI,
P-values < 0.05 were considered statistically significant. 0.984–0.995) reliability. In addition, mid-sagittal HSD

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 419–424.
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422 Youssef et al.

(a) 3 (b) 3
+1.96 SD = 2.15 mm
Intraobserver HSD difference (mm)

2 +1.96 SD = 1.72 mm 2

Interobserver difference (mm)

1
1
0
0
−1
−1
−2
−2
−1.96 SD = −2.24 mm
−3
−1.96 SD = −2.92 mm
−3 −4

−4 −5
5 10 15 20 25 30 35 40 45 50 55 5 10 15 20 25 30 35 40 45 50 55
Intraobserver HSD mean (mm) Interobserver HSD mean (mm)

(c) 4 (d) 4
+1.96 SD = 2.89 mm +1.96 SD = 2.80 mm
Mid-sagittal vs right parasagittal

3 3

Mid-sagittal vs left parasagittal

2 2
HSD difference (mm)

HSD difference (mm)

1
1
0
0
−1
−1
−2
−2
−1.96 SD = −2.12 mm −3 −1.96 SD = −2.50 mm

−3 −4
−4 −5
5 10 15 20 25 30 35 40 45 50 55 5 10 15 20 25 30 35 40 45 50 55
Mid-sagittal and right parasagittal HSD mean (mm) Mid-sagittal and right parasagittal HSD mean (mm)

Figure 4 Bland–Altman plots of first measurement of fetal head–symphysis distance (HSD) obtained by Operator 1 vs: (a) second
measurement by Operator 1 (intraobserver) (correlation between average values and differences: r = 0.003, P = 0.986); (b) measurement by
Operator 2 (interobserver) (r = 0.047, P = 0.755); (c) measurement at 5-mm right parasagittal plane (r = −0.073, P = 0.626); and (d)
measurement at 5-mm left parasagittal plane (r = −0.220, P = 0.137). Solid line represents mean difference, and broken lines represent 95%
limits of agreement (calculated as mean difference ±1.96 SD).

Table 2 Summary of intra- and interobserver reliability, as well as mid-sagittal vs left and right parasagittal (5 mm) measurement reliability,
of fetal head–symphysis distance

Mid-sagittal Mid-sagittal
vs vs
Parameter Intraobserver Interobserver right parasagittal left parasagittal

Mean difference (95% CI) (mm) −0.255 (−0.544 to 0.033) −0.383 (−0.753 to −0.013) 0.383 (0.018 to 0.748) 0.149 (−0.237 to 0.535)
Range of differences (mm) −3 to 2 −4 to 2 −3 to 3 −4 to 2
Systematic difference* P = 0.090 P = 0.048 P = 0.046 P = 0.454
ICC (95% CI) 0.995† (0.991 to 0.997) 0.991† (0.984 to 0.995) 0.991† (0.984 to 0.995) 0.991† (0.984 to 0.995)
95% LOA (95% CI) (mm)
Upper 1.72 (1.22 to 2.23) 2.15 (1.51 to 2.80) 2.89 (2.25 to 3.53) 2.80 (2.12 to 3.47)
Lower −2.24 (−2.74 to −1.73) −2.92 (−3.57 to −2.27) −2.12 (−2.76 to −1.48) −2.50 (−3.18 to −1.82)
Repeatability coefficient (mm) ± 1.98 ± 2.54 ± 2.50 ± 2.65

ICC, intraclass correlation coefficient; LOA, limits of agreement. *Student’s t-test. †P < 0.001 vs 0.

measurements showed a high agreement with parasagittal 1.7 mm to 2.9 mm for the upper limit. The repeatability
measurements, reflecting very little effect of parasagittal coefficients were relatively small in all the comparisons
acquisition. The ICC values show that the measurement made, ranging between 1.98 and 2.65 mm.
error variability was lower than 0.9% of the total HSD showed significant negative correlation both
variability in all the conditions tested and the four with the digital examination (r = −0.894; P < 0.001)
conditions showed similar limits of agreement, ranging (Figure 5a) and with the AoP (r = −0.883; P < 0.001)
from −2.9 mm to −2.1 mm for the lower limit and from (Figure 5b).

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 419–424.
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Head–symphysis distance 423

(a) 60 (MRI) observation of human birth, Bamberg et al. demon-

strated that fetal head extension occurred as soon as the
50
occiput was in close contact with the inferior margin of the
40 symphysis pubis, highlighting the critical role of the fetal
HSD (mm)

head–symphysis pubis relationship in human labor27 .

30
The reason that we chose 5 mm on either side to test for
20 the effect of parasagittal acquisition is that more laterally
the pubic bone changes shape considerably, making
10
errors in acquisition beyond this distance unlikely in our
0 opinion. This is illustrated in two videoclips (available
−4 −3 −2 −1 0 1 2 3 4 online), showing how the pubic bone changes shape from
Station at digital examination the mid-sagittal to 5-mm parasagittal plane (Videoclip
(b) 60
S2), and from the midsagittal to 10-mm parasagittal
plane (Videoclip S3).
50
It is worth mentioning that HSD measurement was not
40 feasible if fetal head station at digital examination was
HSD (mm)

30 above −3 cm from the ischial spines. This is not surprising,

as the infrapubic line, along which we measured our
20
distance, corresponds to 3 cm above the plane of the
10 ischial spines (0 station)7 . However, we do not think that
0 this should be regarded as a limitation of our parameter.
We believe it is unlikely that a station of −3 cm or higher
−10
80 100 120 140 160 180 200 will be clinically misinterpreted.
Angle of progression (°) We would like to highlight that fetuses with posterior
occiput position were excluded in our study. This latter
Figure 5 Scatterplots with linear regression lines showing subgroup is acknowledged to have a different progression
correlation of fetal head–symphysis distance (HSD) with: (a) fetal mechanism in labor and warrants separate evaluation7 .
head station determined by digital examination (HSD = 22.36 – We do recognize the limitations of our study. Intra- and
6.15 × station; r = − 0.894, P < 0.001) and (b) angle of progression
interobserver reproducibility were evaluated analyzing
(AoP) (HSD = 84.15 – 0.49 × AoP; r = −0.883, P < 0.001).
the same 3D volumes by experienced operators. Ideally,
two different 3D acquisitions should have been analyzed,
DISCUSSION but we decided to shorten the scanning time to avoid
Evaluation of fetal head station in labor is required to discomfort for the women. In addition, recent studies
diagnose obstructed labor and to decide the mode of demonstrated good agreement between two-dimensional
operative delivery1,20 . Station is traditionally assessed (2D) and 3D ultrasound assessment of another ITU
parameter and suggested that the two methods can be
using digital examination but this approach is inac-
used interchangeably13 . This issue was not addressed in
curate and poorly reproducible2,3,21,22 . ITU has been
our study and remains to be demonstrated with regard to
recently suggested as an adjuvant tool to the clinical
HSD.
examination5 – 9,16 . Different approaches have been pro-
In the present study we provided original data on a new
posed; however, the best sonographic parameter with
ITU parameter, the fetal HSD. Further studies are needed
which to assess the descent of the fetal head remains
to explore its usefulness in labor management. However,
unclear13 . Several investigators have stressed the role
we do believe that our results suggest a potential role
of the ‘angle of progression’11,12,16 . However, conflict-
for HSD, which is a reliable parameter of fetal head
ing results have been reported recently6,23 , and it has
descent in labor, simple to obtain and sufficiently robust
been suggested that difficulties in identifying a strict mid-
to withstand inaccuracies in transducer positioning.
sagittal plane are reflected in excessive variations in the
measurements24 . In general, the sonographic parameters
thus far suggested suffer from considerable complexity
REFERENCES
and there has been a plea for more simple methods25,26 .
The HSD is a simple linear measurement between two 1. Louis LS, Warren R. Pelvic and fetal cranial anatomy and
well-defined anatomic landmarks: the pubic symphysis mechanism of labour. In Best Practice in Labour and Delivery,
Warren R, Arulkumaran S (eds). Cambridge University Press:
and the fetal skull. It is a reproducible measurement that New York, NY, 2009; 10.
furthermore is quite robust, tolerating even significant 2. Dupuis O, Silveira R, Zentner A, Dittmar A, Gaucherand P,
displacement of the transducer from the midsagittal plane Cucherat M, Redarce T, Rudigoz RC. Birth simulator: reliability
of the pelvis. of transvaginal assessment of fetal head station as defined
The evaluation of the relationship between the fetal by the American College of Obstetricians and Gynecologists
classification. Am J Obstet Gynecol 2005; 192: 868–874.
head and the maternal symphysis pubis assessed digitally 3. Buchmann E, Libhaber E. Interobserver agreement in intra-
has previously been suggested for the evaluation of labor partum estimation of fetal head station. Int J Gynaecol Obstet
progress. Very recently, in a magnetic resonance imaging 2008; 101: 285–289.

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 419–424.
 14690705, 2013, 4, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.12335 by CochraneChina, Wiley Online Library on [08/06/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
424 Youssef et al.

4. Baskett TF, Calder AA, Arulkumaran S. Assessment and Cichon G, Dudenhausen JW. Transperineal ultrasound imaging
management of labour. In Munro Kerr’s Operative Obstetrics in prolonged second stage of labor with occipitoanterior
(11th edn). Baskett TF, Calder AA, Arulkumaran S (eds). presenting fetuses: how well does the ’angle of progression’
Saunders Elsevier: London, 2007; 19–29. predict the mode of delivery? Ultrasound Obstet Gynecol 2009;
5. Ghi T, Farina A, Pedrazzi A, Rizzo N, Pelusi G, Pilu G. Diagnosis 33: 326–330.
of station and rotation of the fetal head in the second stage 17. Rankin G, Stokes M. Reliability of assessment tools in
of labor with intrapartum translabial ultrasound. Ultrasound rehabilitation: an illustration of appropriate statistical analyses.
Obstet Gynecol 2009; 33: 331–336. Clin Rehabil 1998; 12: 187–199.
6. Barbera AF, Pombar X, Perugino G, Lezotte DC, Hobbins 18. Bland JM, Altman DG. Applying the right statistics: analyses
JC. A new method to assess fetal head descent in labor with of measurement studies. Ultrasound Obstet Gynecol 2003; 22:
transperineal ultrasound. Ultrasound Obstet Gynecol 2009; 33: 85–93.
313–319. 19. Bland JM, Altman DG. Measuring agreement in method
7. Henrich W, Dudenhausen J, Fuchs I, Kamena A, Tutschek comparison studies. Stat Methods Med Res 1999; 8: 135–160.
B. Intrapartum translabial ultrasound (ITU): sonographic 20. Cunningham FG, Hauth JC, Leveno KJ, Gilstrap LC III, Bloom
landmarks and correlation with successful vacuum extraction. SL, Wenstrom KD. Maternal anatomy. In Williams Obstetrics
Ultrasound Obstet Gynecol 2006; 28: 753–760. (22nd edn), Cunningham FG, Hauth JC, Leveno KJ, Gilstrap LC
8. Eggebo TM, Gjessing LK, Heien C, Smedvig E, Okland I, III, Bloom SL, Wenstrom KD (eds). McGraw-Hill: New York,
Romundstad P, Salvesen KA. Prediction of labor and delivery by NY, 2005: 13–38.
transperineal ultrasound in pregnancies with prelabor rupture 21. Sherer DM, Miodovnik M, Bradley KS, Langer O. Intrapartum
of membranes at term. Ultrasound Obstet Gynecol 2006; 27: fetal head position I: comparison between transvaginal digital
387–391. examination and transabdominal ultrasound assessment during
9. Dietz HP, Lanzarone V. Measuring engagement of the the active stage of labor. Ultrasound Obstet Gynecol 2002; 19:
fetal head: validity and reproducibility of a new ultrasound 258–263.
technique. Ultrasound Obstet Gynecol 2005; 25: 165–168. 22. Sherer DM, Miodovnik M, Bradley KS, Langer O. Intrapartum
10. Duckelmann AM, Bamberg C, Michaelis SA, Lange J, Nonnen- fetal head position II: comparison between transvaginal digital
macher A, Dudenhausen JW, Kalache KD. Measurement of fetal examination and transabdominal ultrasound assessment during
head descent using the ’angle of progression’ on transperineal the second stage of labor. Ultrasound Obstet Gynecol 2002;
ultrasound imaging is reliable regardless of fetal head station 19: 264–268.
or ultrasound expertise. Ultrasound Obstet Gynecol 2010; 35: 23. Bamberg C, Scheuermann S, Slowinski T, Duckelmann AM,
216–222. Vogt M, Nguyen-Dobinsky TN, Streitparth F, Teichgraber
11. Molina FS, Terra R, Carrillo MP, Puertas A, Nicolaides KH. U, Henrich W, Dudenhausen JW, Kalache KD. Relationship
What is the most reliable ultrasound parameter for assessment between fetal head station established using an open magnetic
of fetal head descent? Ultrasound Obstet Gynecol 2010; 36: resonance imaging scanner and the angle of progression
493–499. determined by transperineal ultrasound. Ultrasound Obstet
12. Ghi T, Contro E, Farina A, Nobile M, Pilu G. Three-dimensional Gynecol 2011; 37: 712–716.
ultrasound in monitoring progression of labor: a reproducibility 24. Paltieli Y, Nizard J. A question of angle of view. Ultrasound
study. Ultrasound Obstet Gynecol 2010; 36: 500–506. Obstet Gynecol 2009; 34: 363–364; author reply 364–366.
13. Torkildsen EA, Salvesen KA, Eggebo TM. Agreement between 25. Sherer DM. Can sonographic depiction of fetal head position
2D and 3D transperineal ultrasound methods in assessing fetal prior to or at the onset of labor predict mode of delivery?
head descent in the first stage of labour. Ultrasound Obstet Ultrasound Obstet Gynecol 2012; 40: 1–6.
Gynecol 2012; 39: 310–315. 26. Youssef A, Ghi T, Awad EE, Maroni E, Montaguti E, Rizzo
14. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth N, Pilu G. Ultrasound in labor: a caregiver’s perspective.
JC, Wenstrom KD. Mechanisms of normal labor. In Williams Ultrasound Obstet Gynecol 2013; 41: 469–470.
Obstetrics (21st edn), Cunningham FG, MacDonald PC, Gant 27. Bamberg C, Scheuermann S, Fotopoulou C, Slowinski T,
NF, Leveno KJ, Gilstrap LC, Hankins GDV, Clark SL (eds). Duckelmann AM, Teichgraber U, Streitparth F, Henrich
McGraw-Hill: New York, NY, 2001: 291–307. W, Dudenhausen JW, Kalache KD. Angle of progression
15. Akmal S, Tsoi E, Kametas N, Howard R, Nicolaides KH. measurements of fetal head at term: a systematic com-
Intrapartum sonography to determine fetal head position. J parison between open magnetic resonance imaging and
Matern Fetal Neonatal Med 2002; 12: 172–177. transperineal ultrasound. Am J Obstet Gynecol 2012; 206:
16. Kalache KD, Duckelmann AM, Michaelis SA, Lange J, 161 e161–165.

SUPPORTING INFORMATION ON THE INTERNET

The following supporting information may be found in the online version of this article:
Videoclip S1 Clip demonstrating the method for measurement of the fetal head–symphysis distance (HSD).
Throughout the clip, the left-hand side shows a graphic animation of the fetus in relation to the maternal
pelvis, while the right-hand side shows the corresponding ultrasonographic images. The convex probe
(covered by a sterile glove) is placed transperineally in the mid-sagittal plane visualizing the fetal head and
the maternal symphysis. The HSD is then measured between the lower edge of the symphysis pubis and the
fetal skull.
Videoclip S2 Clip showing how the pubic bone changes shape from the midsagittal plane (first frame) to a
5-mm parasagittal plane (last frame).
Videoclip S3 Clip showing how the pubic bone changes shape from the midsagittal plane (first frame) to a
10-mm parasagittal plane (last frame).

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 419–424.