الفهرس 
prolonged second stageOnly 14 pages are availabe for public view
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Abstract
This study asses is intrapartum fetal head circumference a sensitive major for diagnosis of prolonged second stage.
The second stage begins with complete cervical dilatation and end with delivery of fetus, prolonged second stage of labor should be considered when the second stage of labor exceeds 3 hours if regional anesthesia is administered or 2 hours in the absence of regional anesthesia for nulliparas. In multiparous women, such a diagnosis can be made if the second stage of labor exceeds 2 hours with regional anesthesia or 1 hour without it (Cunningham et al., 2010) .
Studies performed to examine perinatal outcomes associated with a prolonged second stage of labor revealed increased risks of operative deliveries and maternal morbidities but no differences in neonatal outcomes( cheng et al., 2004 / janni et al., 2002) .
Maternal risk factors associated with a prolonged second stage include nulliparity, increasing maternal weight and/or weight gain, use of regional anesthesia, induction of labor, fetal occiput in a posterior or transverse
position, and increased birth weight. (O’Connell et al., 2003 / Senécal et al., 2005).
Although the 2003 ACOG practice guidelines state that the duration of the second stage alone does not mandate intervention by operative vaginal delivery or cesarean delivery if progress is being made, the clinician has several management options (continuing observation/expectant management, operative vaginal delivery by forceps or vacuum-assisted vaginal delivery, or cesarean delivery) when second-stage arrest is diagnosed.
The association between a prolonged second stage of labor and adverse maternal or neonatal outcome has been examined. While a prolonged second stage is not associated with adverse neonatal outcomes in nulliparas, possibly because of close fetal surveillance during labor, but it is associated with increased maternal morbidity, including higher likelihood of operative vaginal delivery and cesarean delivery, postpartum hemorrhage, third- or fourth-degree perineal lacerations, and peripartum infection (Martin et al., 2000).
Not much work has been done in the area of attempting to predict labor outcome using dimensions of the fetal head. This study was aimed at determining
whether intrapartum (sonographic) head circumference has relationship with the second stage duration. Large FHC relative to maternal pelvic diameter, is the main cause of prolonged labor (Konje &Ladipo, 2000). And there for increased risk of operative delivery (primary cesarean section, vacuum assisted and forceps-assisted vaginal delivery) (Elvander et al., 2012) .
Intra partum head circumference Is an integral part of sonographic models and important fo the purpose of fetal weight estimation (Hadlock et al., 1982) as well as in cases which abnormal fetal head growth is suspected (Hadlock et al., 1982) with some reviews suggesting that it can replace biparietal diameter (Weiner et al., 1985) .
Large study by Chervenak et al that evaluated pregnancies conceived by in vitro fertilization and thus had known conception dates, head circumference was found to be the best predictor of gestational age compared with other commonly used parameters (Chervenak et al., 1991). This finding is in agreement with that of Hadlock (Hadlock et al., 1984), (Ott et al., 1994) and Benson (Benson et al., 1991) who compared the performance of HC, BPD, FL and AC in different populations.
The study included 520 women with the diagnosis of the first of labor with at least cervical dilatation 4cm.
Each woman will be subject to:-
1. Careful and detailed history taking regarding personal history, complaint, past history, menstrual history and history of present pregnancy.
2. Abdominal examination is done to asses fetal movements the fundal height, number of fetuses, fetal lie, frequency and duration of uterine contraction if present. Auscultation of fetal heart sound was done by pinard’s stethoscope or sonicaid.
3. Local vaginal examination for assessment of. Presenting part for descent (station) presentation and position, state of membranes (intact or ruptured) and pelvic adequacy.
4. Ultrasound examination to fetal life, fetal lie and presentation, biometry for estimation of gestational age, amniotic fluid volume and turbidity.
Determination of fetal head circumference (primary outcome).
5. When the women is fully dilated. She transferred to operating room and determination of the second stage length (second outcome).
6. Assessment of any vaginal laceration or perinatal tears.
7. Rate of caesarean section.
8. Rate of instrumental delivery.
The result showed there was significant association between intra partum fetal head circumference (IPFHC) with gestational age, postpartum fetal head circumference and fetal weight. And no significant association between intra partum fetal head circumference and age, body mass index.
Receiver Operator characteristics curves (ROC) indicated that (IPFHC) ≤ 35.8 cm the best cut of level for predicting the prolonged second stage.
Cesarean delivery rate was 24.5% among 121 women with small fetal head circumference (≤ 35.8 cm) and 66.6 % among 42 women with large fetal head circumference (≥ 35.8 cm).
Small fetal head circumference (≤ 35.8 cm) showed short second stage with mean 35.12 minute and large fetal head circumference (≥ 35.8 cm) show long second stage with mean 109 minute.