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Human birth observed in real-time open magnetic resonance imaging

Christian Bamberg, MD; Grit Rademacher; Felix Gttler; Ulf Teichgrber, PhD; Malte Cremer, MD; Christoph Bhrer, PhD; Claudia Spies, PhD; Larry Hinkson, MD; Wolfgang Henrich, PhD; Karim D. Kalache, PhD; Joachim W. Dudenhausen, PhD
OBJECTIVE: Knowledge about the mechanism of labor is based on asRESULTS: Delivery occurred by progressive head extension. However,

sumptions and radiographic studies performed decades ago. The goal of this study was to describe the relationship between the fetus and the pelvis as the fetus travels through the birth canal, using an open magnetic resonance imaging (MRI) scanner. STUDY DESIGN: The design of the study used a real-time MRI series during delivery of the fetal head.

extension was a very late movement that was observed when the occiput was in close contact with the inferior margin of the symphysis pubis, occurring simultaneously with gliding downward of the fetal head. CONCLUSION: This observational study shows, for the rst time, that birth can be analyzed with real-time MRI. MRI technology allows assessment of maternal and fetal anatomy during labor and delivery.

Cite this article as: Bamberg C, Rademacher G, Gttler F, et al. Human birth observed in real-time open magnetic resonance imaging. Am J Obstet Gynecol 2012;206:505.e1-6.

B ACKGROUND AND O BJECTIVE

We used an open magnetic resonance imaging (MRI) scanner to capture images of human delivery. Our main goal was to describe the relationship between fetal movements and position as the fetus passes through the birth canal.

M ATERIALS AND M ETHODS

We designed an observational study to maximize safety for the mother and feFrom the Departments of Obstetrics (Drs Bamberg, Hinkson, Henrich, Kalache, and Dudenhausen and Ms Rademacher), Radiology (Mr Gttler and Dr Teichgrber), Neonatology (Drs Cremer and Bhrer), and Anesthesiology and Intensive Care Medicine (Dr Spies), Charit University Hospital Berlin, Berlin, Germany. This study was supported by a public grant (TSB Technologiestiftung BerlinZukunftsfonds Berlin). The authors report no conict of interest. Presented at Birth: Clinical Challenges in Labor and Delivery, presented by the Division of Continuing Medical Education, Wayne State University School of Medicine, Chicago, IL, Sept. 9-11, 2011.
0002-9378/free 2012 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2012.01.011

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tus. The patient underwent intermittent electronic fetal heart rate (FHR) monitoring with a prototype of a wireless MRI-compatible telemetric system with the exception of image acquisition time. This system, developed by us and modied from the Philips Avalon Cordless Transducer System (Philips Healthcare, Best, The Netherlands), allows for continuous cardiotocograph tracing with few artifacts. MRI was performed on a 1.0 Tesla open high-eld MRI scanner with vertical-eld orientation. A T2-weighted multislice TSE single-shot sequence was used to visualize the midsagittal, coronal, and axial planes with the following settings: 1000 millisecond time of repetition (TR), 100 millisecond time of echo (TE), ip angle 90, 40 slices of 6 mm with 1 mm gap, voxel size 1.4 1.6 mm, and eld of view (FOV) 300 262 mm, with constant level appearance (CLEAR) correction. Real-time cinematic MRI series were acquired from the midsagittal plane for representation of the extension phase with use of an interactive TSE singleshot sequence (TR 1600 milliseconds, TE 150 milliseconds, ip angle 90, single slice of 6 mm, voxel size 1.4 1.5 mm, and FOV 380 285 mm, with CLEAR correction). A nal MRI sequence was performed immediately after childbirth in a BFFE sequence (TR 6

milliseconds, TE 3 milliseconds, ip angle 60, 26 slices of 6 mm with no gap, voxel size 2.0 2.03 mm, FOV 340 340 mm) to evaluate the third stage of labor with regard to placental separation and uterus involution.

R ESULTS
In November 2010, a 24 year old gravida 2, para 2 at 37 5/7 weeks of gestation was admitted with regular contractions to the Department of Obstetrics of the Charit University Hospital in Berlin, Germany. The patient received an epidural injection and was transferred to the open MRI suite. In addition, the cervix was fully dilated and the presenting part was engaged (Figure). In the active second stage, when the mother began expulsive efforts with the Valsalva maneuver, her legs were slightly abducted and supported by padding. This period was evaluated by real-time cinematic MRI series. She gave birth to a 2585 gram boy at an appropriate size for gestational age with Apgar scores of 9, 9, and 10 at 1, 5, and 10 minutes, respectively. Umbilical artery and umbilical vein pH measurements are routinely assessed in our routine practice; however, because of technical difculties with the umbilical artery blood sample in this case, only the umbilical vein pH was available: 7.32. A neonatologist assessed the babys condition. 505

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www.AJOG.org
ing during the MRI examination without interference. Arrest of labor, necessitating cesarean delivery, is a major cause of maternal morbidity and mortality. An improved understanding of the mechanism of labor will help clinicians toward a more individualized approach, allowing them to more easily distinguish normal from abnormal courses of labor and intervene in a timely, effective fashion to ensure a favorable outcome. Furthermore, a basic knowledge of the attitude of the fetal head at the time of its passage through the lower birth canal is of practical value in operative vaginal deliveries. The shape and direction of the birth canal have generally been investigated by palpation during labor and in frozen sections from women who died during labor. There is no doubt that the human fetus must negotiate a curve to be born. Collecting images of the fetus during delivery using an open MRI is feasible. We have demonstrated that MRI technology is useful for visualizing normal maternal and fetal anatomy during labor. This observation reveals a new way to study the mechanism of birth. CLINICAL IMPLICATIONS

View of the midsagittal MRI plane of the maternal pelvis before the expulsion phase without pushing

The fetal head station is midpelvis (in comparison with standard obstetric textbooks) and the membranes are intact.
MRI, magnetic resonance imaging. Bamberg. Birth in real-time MRI. Am J Obstet Gynecol 2012.

Immediately after childbirth, the maternal anatomy was imaged before and after expulsion of the placenta in a BFFE sequence. The total individual study time in the magnet room was less than 1 hour. The woman tolerated the discomfort during labor well and her postpartum course was uneventful. She was discharged with her newborn 2 days after delivery. The pediatric screening examinations, including auditory tests, did not reveal any abnormalities.

C OMMENT
For many years, digital examination was the only method used during labor to provide information about the mothers

bony pelvis and soft tissue and the fetus. Our visualization of the normal mechanism of late second-stage labor by MRI shows that extension started as soon as the occiput came into close contact with the inferior margin of the symphysis pubis. Thereafter extension was simultaneous, with a downward gliding of the fetal head. At this point, the birth canal curved 90 upward and the fetal head was delivered by extension and rotated around the symphysis pubis. To our knowledge, this is the rst time this mechanism has been clearly visualized. We used the same approach for cardiotocography, removing ferromagnetic parts to allow FHR monitor-

The mechanism of labor can be studied with real-time open magnetic resonance imaging. An improved understanding of the mechanism of labor will help clinicians toward a more individualized approach to labor, allowing them to more easily distinguish normal from abnormal courses of labor. Understanding the attitude of the fetal head at the time of its passage through the lower birth canal is of practical value in operative vaginal deliveries as well. f

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