ISUOG practice guidelines for intrapartum ultrasound: application in obstetric practice and medicolegal issues

The recent ISUOG Practice Guidelines represent a valuable frame of reference for the application of intrapartum ultrasound1. However, they raise several new obstetric and medicolegal questions. Although they highlighted high levels of evidence and grades of recommendation, in particular for the sonographic confirmation of fetal head position in the birth canal before vacuum extraction or delivery using forceps, intrapartum ultrasound is not currently considered mandatory in obstetric practice. Relatively few labor wards are equipped with ultrasound machines and there is a paucity of training for birth attendants in maternity units. Provision of intrapartum ultrasound on a large scale would require input from an organization with the specific aim of setting up accredited courses, run by qualified trainers, making use of the new generation of simulators for teaching purposes. However, as clearly stated in the Guidelines1, digital examination cannot be replaced by intrapartum ultrasound. Rather, the two should be considered complementary approaches. The use of intrapartum ultrasound in the labor ward should thus be promoted as ancillary and not as a substitute for clinical examination. Moreover, it is worth remembering that the impact of intrapartum ultrasound on maternal and neonatal outcome is, as yet, undetermined; multicenter randomized studies will be needed to ascertain that there is indeed benefit from the procedure2. The use of intrapartum ultrasound has important medicolegal implications. It allows objective documentation of the intrapartum findings leading to a clinical decision or a particular obstetric intervention. In case of litigation, the ability to produce incontrovertible evidence may prove essential for defendant doctors to justify their choices3. There are, however, also certain practical and not insignificant issues that need to be weighed when applying these new intrapartum ultrasound1 guidelines–issues stemming from the growing importance of guidelines in court trials for the purpose of distinguishing good practice from malpractice4. First, there must be an awareness that, whenever, within official guidelines, a given procedure is rated highly in terms of scientific evidence and is strongly recommended, it takes on the value of a technical rule. Consequently, failure of an operator to comply with it is likely to be viewed by a court as malpractice. It is bordering on paradoxical that a procedure which is strongly recommended in ISUOG guidelines is still considered non-mandatory in clinical practice and is not explicitly acknowledged in most scientific societies’ guidelines. Finally, it must be taken into account that several aspects of intrapartum ultrasound, such as its use in the administration of analgesia during labor5, require further investigation and need to be included within relevant future guidelines.