Editorial Comment on: M. Dębska, P. Kretowicz, R. Dębski Intrapartum sonography – eccentricity or necessity?

This article discusses an extremely significant issue of using ultrasonography in the delivery room. The authors discuss the role of ultrasonography in assessing the course of labor. Although the first reports on this subject appeared approximately 20 years ago, the mass use of such examinations has started only recently^(2–4). In some of these reports, the 2D and 3D imaging is compared⁽³⁾ whereas some of them compare a physical anorectal examination with ultrasound assessment of labor^{(5, 6)}. Nearly all authors agree that ultrasonography in the delivery room is useful and, currently, the more information is available to the obstetrician, the safer the delivery is both for the mother and child. Each article on the use of ultrasonography in the delivery room is therefore valuable. The authors of this paper preset a concise historical review as well as indications for and practical aspects of US examinations during labor, referring to 30 recent publications. One should hope that this article will resolve any doubts of obstetricians and gynecologists concerning the utility of ultrasonography during labor.

As a surgeon coloproctologist, I would like to mention another aspect of applying this modality. Namely, labor monitoring can prevent a serious complication, i.e. so-called neurogenic anal incontinence. This is a “silent disease” due to its embarrassing nature and the fact that doctors or patients rarely talk about it. The cause of this difficult-to-treat, and in many cases – untreatable condition, which makes women withdraw from social life, is prolonged labor and compression of the child's head on the pudendal nerve which is pushed against the ischial spine. Studies have demonstrated that prolonged labor of >8 hours leads to irreversible neuropathy of this nerve⁽⁷⁾.

The second application of ultrasonography, more specifically – endosonography, has been frequently discussed in “Journal of Ultrasonography” and “Ultrasonografia”^{(8, 9)}, since obstetric injury, mechanical (sphincter tear), neurogenic or mixed, is the most frequent cause of incontinence in women. 3–35% of obstetric anal sphincter injuries are occult defects⁽¹⁰⁾. In own research, the percentage of detected defects reached 3.9%⁽¹¹⁾. Such diagnoses remain undetected by obstetricians, and are identified during imaging examinations: ultrasonography or MRI. The clinical symptoms in the form of gas and stool incontinence may, in such cases, develop several or even a dozen or so years after the delivery when compensatory mechanisms, in the form of the strong puborectalis muscle, stop working. One more question needs answering: In which cases should endosonography of the anal sphincters be indicated after labor? It seems that the identification of pregnant patients at a greater risk of incontinence should be significant (i.e. women with incontinence symptoms before labor, with low perineum, with neurological diseases or after anorectal procedures involving the sphincters)^{(12, 13)}. Moreover, one should also take into account risk factors of obstetric gas and stool incontinence, both those related to the mother and the course of labor (such as: grade III and IV perineal tear, assisted delivery, mother's age, prolonged duration of the second stage of labor, application of epidural anesthesia or breech delivery), as well as those associated with the child (birth weight or head circumference). A routine transrectal ultrasound examination should be conducted particularly in patients after a forceps delivery and those with perineal tear. The occurrence of sphincter defects should be taken into account in the planning of subsequent deliveries. Such an examination would certainly be associated with additional costs. However, it must be remembered that obstetric injuries concern young, professionally active women and therefore possible social and economic costs in the case of missing anal sphincter defects can considerably exceed the cost of prophylactic ultrasound examinations.

The problem of obstetric injuries and prophylaxis is extensive, but editorial limitations do not allow for a longer discussion. All the readers interested in this issue are recommended to read the Standards of diagnostic and prophylactic management of obstetric anal sphincter defects published 3 years ago⁽¹⁴⁾.