Article

Accuracy and intraobserver variability of simulated cervical dilatation measurements

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Abstract

Objective: Our purpose was to assess the accuracy and intraobserver variability of clinical cervical diameter measurements among obstetric health care providers. Study design: Polyvinyl chloride pipes 1 to 10 cm in diameter were mounted in cardboard boxes and used to simulate cervical examinations. The boxes were designed so that the examiner had to rely solely on proprioception to determine the inner diameter. Results: A total of 1574 simulated cervical diameter measurements were obtained from 102 different examiners in a two-part study. The overall accuracy for determining the exact diameter was 56.3%, which improved to 89.5% when an error of +/- 1 cm was allowed. Intraobserver variability for a given diameter measurement was 52.1%, which decreased to 10.5% when an error of +/- 1 cm was allowed. Conclusions: Cervical diameter measurements obtained by digital examination are precise when an error of +/- 1 cm is allowed for. Intraobserver variability is > 50% and is an important consideration when evaluating dysfunctional labor.

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... It appears that variability of criteria for diagnosis is a major determinant of this increase. 4 Accurate measurement of cervical dilatation (CD) and fetal head descent (HD) is necessary in the management of labor. 4 Although digital assessment of CD is generally applied in clinical obstetrics, the intermittent nature of the procedure and its low accuracy and precision limit its usefulness for the study of cervical behavior during labor. ...
... 4 Accurate measurement of cervical dilatation (CD) and fetal head descent (HD) is necessary in the management of labor. 4 Although digital assessment of CD is generally applied in clinical obstetrics, the intermittent nature of the procedure and its low accuracy and precision limit its usefulness for the study of cervical behavior during labor. 5 A study published in the American Journal of Obstetrics and Gynacology found that estimations of CD by different care providers could vary by more than 50% and that a discrepancy of more than 1 cm is quite common. ...
... 5 A study published in the American Journal of Obstetrics and Gynacology found that estimations of CD by different care providers could vary by more than 50% and that a discrepancy of more than 1 cm is quite common. 4 Assessment of fetal head station (HS) is even more subjective and is prone to significant error. 6 Dupuis and colleagues 7 tested the reliability of clinical estimations of fetal HS using the position of the fetal head and reported that the clinical examination was incorrect one-third of the time. ...
Article
To obtain and study new data on the dynamics of the labor process and to develop a contraction-based index of labor progress. This study was carried out at the Delivery Room, Department of Obstetrics and Gynecology, Western Galilee Hospital, Nahariya, Israel, using a new device (Birth Track). We continuously monitored cervical dilatation (CD) and head descent (HD) in 30 nulliparaous women during active labor with (augmented group) and without (study group) oxytocin augmentation. This led to the development and validation of progress indices based on features extracted from continuous monitoring. There were no significant differences between the average of each parameter in the study and augmented groups, except for HD velocity. Average HD velocity was faster in the study group. Linear regression analyses demonstrated that head station (HS) amplitude and Toco amplitude were the best parameters for predicting HD velocity in both groups. In the study group, average HD velocity was also significantly related to Toco rate and contraction efficiency. In the augmented group, only a weak correlation with Toco rate was seen, and no correlation with contraction efficiency. With the assistance of the Birth Track device, we can obtain continuous data on the labor process and indices to estimate the labor progress process without the use of vaginal (manual) examination.
... Multiple studies have shown that providers" accuracy (usually defined as agreement within 1 cm) in the measurement of cervical dilation by manual examination to be about 90% (or about 50% when exactly comparable measurements are assessed), compared to cervical simulators, or to other providers (inter-observer agreement). [1][2][3][4] Since the 1800s, a variety of devices have been proposed for the intended purpose of increasing accuracy of assessment of cervical dilation in labor, yet none has proven successful in clinical use so far. 5 In fact, there is currently no commercially available device in the US for the measurement of cervical dilation in vivo. 1 Elm Tree Medical Inc. developed DilaCheck® in 2015 for the purpose of increasing inter-examiner agreement of cervical dilation measurements in women in labor. ...
... Fifty L&D providers, including medical doctors and registered nurses, participated in the trial. Each participant conducted eight cervical examinations using standard methods and eight cervical examinations using the DilaCheck device on a simulator constructed similarly to similar to that used by Phelps et al. 3 Overall, providers reported the correct dilation in 46.3% of examinations with traditional methods and 96.3% of examinations with the device. The device improved accuracy by 108% percent (p<0.001). ...
... Our results are in agreement with results of prior similar studies (Table 5). [1][2][3][4] Exact agreement using traditional manual examinations has been reported mostly at 48-54% in prior studies, but when utilizing a hard simulator. When using a soft simulator, inter-observer exact agreement fell to 19%, 4 which is similar to our results in the device group, while lower than the result in the manual exact group (43%), showing that our providers were as good as others (or better) who have investigated this issue in the past. ...
Article
Background Cervical dilation and changes in cervical dilation inform the management of labor, including decisions to admit a patient to the hospital, augment labor, or perform a cesarean section. Practitioners routinely measure cervical dilation subjectively using two fingers on manual examination; however, agreement ≤1cm between two observers has been reported as 60-91% previously in laboring women. Methods Women admitted in labor to a Labor & Delivery service were randomized to receive two cervical examinations from trained providers, either using a novel device (DilaCheck®) or the standard manual examination. This randomized controlled trial compares a novel device with the standard method of manual examination for the measurement of cervical dilation. The novel device consisted of a string measuring tape suspended between two soft plastic rings worn on the index and middle fingertips. Inter-observer agreement, defined as the agreement (exact, ≤1cm - primary outcome - or ≤2cm) in the numerical cervical dilation measurement obtained by two different examiners, was compared between the two groups. Results A total of 42 women in labor were randomized, 21 to the novel device and 21 to the standard manual examination groups. The two device examinations agreed in 19% of cases, while manual examinations agreed exactly in 42.9% of cases (p=0.10). Inter-observer agreement ≤1cm was 61.9% vs. 95.2%, respectively (p=0.008). Inter-observer agreement ≤2cm was 90.5% vs. 100%, respectively (p=0.15). Most inter-observer disagreement was seen at 5-7cm of cervical dilation. Conclusion A novel device, DilaCheck, intended for more objective cervical assessment of women in labor, did not improve inter-observer agreement; in fact, it decreased it. Standard cervical dilation examinations result in poor inter-examiner exact agreement, usually at best 50% or less. Clinical management should be based on clinical differences of >1cm because, in general, 90% of cervical examinations will agree within 1cm of each other. Given the importance of dilation measurements in the management of labor, continued innovation in this field would benefit women in labor and the providers caring for them; however, the puzzle remains unsolved.
... Studies using rigid cervical models have shown accuracy rates of approximately 49% 1 and 58% 2 and intraobserver variability of 52%. 2 Assessment of accuracy on more realistic "soft" cervices made of pillow foam has shown an even lower accuracy of only 19%. 3 Based on these assessments of health care provider accuracy, there is room for improvement in the training of this skill. In addition, the current paradigm is both anxiety-provoking for the trainee and exposes the patient to additional cervical examinations, which may cause harm. ...
... Exact accuracy and accuracy within 1 cm were assessed for both dilation and effacement because these margins of error have been investigated in other studies. 1,2,4 In addition, accuracy within 1 cm is relevant because discerning this amount of cervical change per hour is necessary to determine if labor has progressed or arrested in nulliparous women. Comparison of student performance between the polyvinyl chloride and silicone models was performed using a Mann-Whitney test. ...
... The first is the study's size, because it included 98 students, which is approximately equal to the largest prior study of cervical examination accuracy using models. 2 This prior study involved approximately 1,500 examinations, whereas the present study involved a total of approximately 4,000 examinations Fig. 3. Representative cumulative summation analyses graphs. ...
Article
Objective: To estimate whether simulation training improves medical students' cervical examination accuracy. Background: The training paradigm for the labor cervical examination exposes patients to additional examinations, lacks a gold standard, and does not objectively assess trainee competence. To address these issues and optimize training, we assessed the effectiveness of cervical examination simulation in third-year medical students. Methods: During the obstetrics and gynecology clerkship, a cohort study was performed in which third-year students were assigned to receive cervical examination simulation (n=50) or vaginal delivery simulation (n=48), with each group serving as a simulation-naive control for the other skill. As a final assessment, students performed 10 cervical examinations using task trainers. Exact accuracy and accuracy within 1 cm were compared between groups. Cumulative summation analyses were performed on the cervical examination group to assess competence and the average number of repetitions needed to achieve it. Results: Cervical examination students were significantly more accurate (Mann-Whitney, P<.001) in assessing dilation (73% exact, 98% within 1 cm) and effacement (83% and 100%) than vaginal delivery students (dilation 52% and 82%, effacement 51% and 96%). In the cumulative summation analyses, 65-100% of students attained competence during the clerkship depending on the level of accuracy and cervical parameter assessed. On average, competence was achieved with 27-44 repetitions. Conclusion: Simulation training dramatically improved student accuracy in labor cervical examinations. Because not all students achieved competence, the cumulative summation analyses suggest that more than 100 repetitions would be needed if the goal was for the entire class of students to achieve competence. Level of evidence: II.
... Performing vaginal examinations (VEs) and measuring dilatation of the cervix has been described as the 'gold standard' for measuring progress in labour. 1 Currently, there is little published research that has examined the number of VEs women receive in labour and the reasons given by health professionals for performing VEs. This study was conducted in an obstetric unit of a Scottish National Health Service (NHS) hospital where midwifery one to one care is practiced throughout labour. ...
... 24 There is little research to support this perception as the accuracy of digital examination of the cervix has been found to be inherently imprecise. The classic studies of Phelps et al. 1 and Tuffnell et al. 25 used hard cervical models in which the cervix is fixed in position to measure the accuracy of midwives and obstetricians in measuring cervical dilatation. Phelps et al. 1 found an overall accuracy for determining the exact diameter of 56.3%. ...
... The classic studies of Phelps et al. 1 and Tuffnell et al. 25 used hard cervical models in which the cervix is fixed in position to measure the accuracy of midwives and obstetricians in measuring cervical dilatation. Phelps et al. 1 found an overall accuracy for determining the exact diameter of 56.3%. Tuffnell et al. 25 found a similar overall accuracy of 48.6%. ...
Article
Objective: Vaginal examinations (VEs) in labour are a routine part of intrapartum care. Current U.K. guidelines recommend that VEs are offered to women at regular intervals of not less than 4h and only performed when justifiably necessary. However, justification may be interpreted differently by different midwives. This study aimed to investigate (i) the number of VEs performed in relation to length of labour and (ii) the reasons given by midwives for performing the VE. Methods: This study recruited a group of women (n=144) admitted in either spontaneous labour or for induction of labour from one NHS hospital in Scotland. The number of VEs performed, the reason provided by the midwife for its need and the length of labour were all recorded. Findings: The number of VEs carried out (mean 2.9, SD 1.5, range 1-7) increased as length of time in labour in hospital increased. Approximately half the sample (52%) had 3 or more VEs during labour. Almost 70% of women had more VEs than expected when the criteria of 4 hourly VEs was applied. The most common reason given by midwives for performing a VE was to assess labour progress and to assess the commencement of labour. Conclusions: Despite maternity care policy to limit interventions in normal labour, we found that a substantial number of women received more VEs than was consistent with adherence to guidelines. However, until further research is conducted to validate other measures of labour progress, the number of VEs undertaken during labour is unlikely to decrease.
... Studies comparing two analyses showed that there is usually a discrepancy of 1-2 cm between the results [30], although the difference may reach 6 centimetres. Research based on cervical models showed that clinicians were able to assess cervical dilatation to an accuracy of within 1 centimetre in only about 50% of cases [31,32]. Tufnell showed that digital examination by single observers was consistent (with the same examiner consistently providing a good estimate, overestimating or underestimating cervical dilatation) in only 33% of cases, suggesting that even repeated examinations by a single clinician are of limited value. ...
... Tufnell showed that digital examination by single observers was consistent (with the same examiner consistently providing a good estimate, overestimating or underestimating cervical dilatation) in only 33% of cases, suggesting that even repeated examinations by a single clinician are of limited value. There are additional problems with digital examinations, including the following [30][31][32]: ...
Article
Full-text available
Caesarean section (CS) rates are rising globally, though with considerable variation from country to country; in Italy the CS rate is about 38.2% and in Puglia, a region in the South-east (4 million inhabitants), the CS rate is about 47.7%, up 4.25% in the last two years. Currently, the high rate of CS and operative delivery in developed countries may be attributed to larger foetuses, an increase in the frequency of diabetes mellitus and pelvic adiposity, advanced maternal age at first pregnancy and a decrease in tissue elasticity. Moreover patients have a very low acceptance of any maternal-foetal risk in labour, and there is a significant increase of CS "on maternal request". Studies of communities with low rates of caesarean delivery may help to identify factors that lower the CS rate, such as cultural attitudes toward childbirth, design of the perinatal system, and genetic and social aspects. Also needed are biopolitical projects for the rationalisation of human and technological resources, which may lead to a reduction in legal claims and a natural decrease in defensive practices or defensive obstetrics based on doubtful diagnoses. Furthermore, the number of caesarean deliveries performed "on maternal demand " should be reduced by making sure that women are adequately informed about the safety of vaginal versus caesarean delivery. National health programs should be instituted and extended to large populations, showing the costs and benefits of vaginal versus CS delivery. This analysis reviews the current reasons for performing CS, analyzing limitations in labour management and focusing on dystocia, in order to identify possible socio-political and medical mechanisms that may reduce the CS rate in south-eastern Italy, including promising but under-used technologies.
... Several studies have shown that digital examination during labour is inaccurate, subjective and unreliable, regardless of examiner experience (5,6) . It has been reported that two doctors differed in cervical dilatation estimations by 2 cm or more on 11% of exams (7) . ...
... Assessment of cervical dilatation is an essential step in determining the progress of labour, but digital examination it is highly observer dependent (6) and uncomfortable for the patients (24) . In order to simplify ultrasound examination during labour, Hassan et al. described a two-dimensional transperineal ultrasound technique to measure cervical dilatation in labour (15) . ...
Article
Full-text available
Digital examination during labour is a subjective and inaccurate method, with high inter-examiners variability. The objective of this study was to evaluate the clinical applicability of ultrasound during labour in order to determine if it can be used as a routine method in labour management. We conducted a literature review for representative articles that studied the use of abdominal and transperineal ultrasound during labour. Intrapartum ultrasound proved to be a reliable technique for labour management and outcome prediction. Abdominal ultrasound is able to precisely determine the position of the fetal spine and head. Transperineal ultrasound can be succesufully used in determining fetal head, perineum distance, angle of progression and cervical dilatation as three markers that could predict labour remaining time and delivery mode. © 2016 Romanian Society of Ultrasonography in Obstetrics and Gynecology.
... When the cervical dilatation was 6-8cm, the accuracy of VE was 36-38 % [4,20]. In vitro studies on models Mean, median and range for cervix dilatation are calculated from the mean of the 2 methods Inter-CC interclass correlation coefficient, SD standard deviation Fig. 4 Scatter plot illustrating the association between ultrasound measurements and digital examinations of cervical dilatation confirm this [21,22]. Phelps et al. found that the overall accuracy was 56 %, however, with 1 cm error margin the accuracy improved to 90 % [22]. ...
... In vitro studies on models Mean, median and range for cervix dilatation are calculated from the mean of the 2 methods Inter-CC interclass correlation coefficient, SD standard deviation Fig. 4 Scatter plot illustrating the association between ultrasound measurements and digital examinations of cervical dilatation confirm this [21,22]. Phelps et al. found that the overall accuracy was 56 %, however, with 1 cm error margin the accuracy improved to 90 % [22]. In vitro study with soft models have poorer accuracies (19 %) [21]. ...
Article
Full-text available
Background: To compare 2D transperineal ultrasound assessment of cervical dilatation with vaginal examination and to investigate intra-observer variability of the ultrasound method. Methods: A prospective observational study was performed at Skane University Hospital, Lund, Sweden between October 2013 and June 2014. Women with one fetus in cephalic presentation at term had the cervical dilatation assessed with ultrasound and digital vaginal examinations during labor. Inter-method agreement between ultrasound and digital examinations and intra-observer repeatability of ultrasound examinations were tested. Results: Cervical dilatation was successfully assessed with ultrasound in 61/86 (71 %) women. The mean difference between cervical dilatation and ultrasound measurement was 0.9 cm (95 % CI 0.47-1.34). Interclass correlation coefficient (ICC) was 0.83 (95 % CI 0.72-0.90). Intra-observer repeatability was analysed in 26 women. The intra-observer ICC was 0.99 (95 % CI 0.97-0.99). The repeatability coefficient was ± 0.68 (95 % CI 0.45-0.91). Conclusion: The mean ultrasound measurement of cervical dilatation was approximately 1 cm less than clinical assessment. The intra-observer repeatability of ultrasound measurements was high.
... Cervical dilatation is considered an essential indicator of the progress of labour 44 . However, the assessment of cervical dilatation by digital vaginal examination can be inaccurate, inconsistent and insensitive 6,38,45 . ...
... As dilatation of the cervix is a subjective measure, it is generally recommended that ideally one person performs the vaginal examinations in labor, to avoid the interobserver error that may occur otherwise and the resultant changes in labor management (BOX 1). This interobserver variation cannot be underestimated, with studies suggesting variability in assessment of cervical dilation up to 6 cm with an average of 1-2 cm [16]. ...
Article
Full-text available
Worldwide, the rate of delivery by cesarean section is increasing, such that the cesarean section rate is often greater than 30%. The reasons for this increase are many, but a major reason for this change is related to our relatively poor ability to manage labor. This review attempts to cover the issues that contribute to this. Issues regarding definition, assessment and management of labor progress as well as critical times in labor will be examined. Types of partograms are discussed as well as the maternal and fetal factors that influence progress of labor. To be able to care for women in labor, it is important to be aware of limitations of management and how best to overcome these.
... However, most vaginal examinations are done only to assess the progress of cervical dilatation (3). Some studies have shown that the overall accuracy for cervical dilatation is between 48% to 56% with ± 1 cm error, to 89.5% to 91.7% and this accuracy is reduced with the increase of cervical dilatation (5,6). Huhn et al. noted that soft cervical models of cervical dilatation measurements were only 19% accurate and hard cervical models were 54% (7) accurate. ...
Article
Full-text available
Currently, vaginal examination is the gold standard for assessment of labor progress. The World Health Organization emphasizes that the number of vaginal examinations should be limited where it is necessary. Therefore, this study aimed to determine the diagnostic accuracy of purple line in the prediction of labor progress. In this cross-sectional study, 350 women with a single pregnancy in vertex presentation and gestational age of 38-42 weeks without any medical disorder, admitted to government hospitals of Mashhad, were selected using convenience sampling. Vaginal examination and observation of the line each hour in the active phase of labor were measured. Abnormal progress of labor was defined as cervical dilatation less than 1 centimeter/hour in the active phase for two consecutive hours and fetal head descend less than 1cm/h or duration of more than two hours for nulliparous and one hour for multiparous In the second stage of labor. Data was analyzed by SPSS version 16 using chi -square test. The purple line appeared in 75.3% of women during the active phase of labor. Appearance of the purple line in the prediction of labor progress had 90.2% sensitivity, 45.3% specificity, 88.1% positive predictive value, 51.0% negative predictive value in the first stage of labor and had 87.6% sensitivity, 52.4% specificity, 96.5% positive predictive value, 22.0% negative predictive value in the second stage of labor and has 68.57% sensitivity, 42.66% specificity, 85.32% positive predictive value, and 43.85% negative predictive value for the total labor. According to the appearance of the purple line in most of the cases and its high sensitivity and specificity, we can use it as a non-invasive complementary method for clinical assessment of labor progress.
... Manual examination of cervix is subjective, not very reproducible, and is noted to have about 52% interobserver variability. 55 Compared with manual examination, TVU has been noted to be a better predictor of PTB. 22,[56][57][58][59] About 75% of women with an asymptomatic short cervix on ultrasound have no appreciable changes by manual examination. ...
Article
Preterm birth (PTB) is a leading cause of neonatal morbidity and mortality. With research efforts, the rate of PTB decreased to 11.4% in 2013. Transvaginal ultrasound (TVU) cervical length (CL) screening predicts PTB. In asymptomatic singletons without prior spontaneous PTB (sPTB), TVU CL screening should be done. If the cervix is 20 mm or less, vaginal progesterone is indicated. In asymptomatic singletons with prior sPTB, serial CL screening is indicated. In multiple gestations, routine cervical screening is not indicated. In symptomatic women with preterm labor, TVU CL screening and fetal fibronectin testing is recommended. Copyright © 2015 Elsevier Inc. All rights reserved.
... In 1954, Friedman conceived the idea of the partogram, the principal component of which was the cervical dilatation chart (cervicograph), which later became the "Friedman curve." [11][12][13] Accurate assessment of cervical dilatation is a central component to the management of labor; however, there is long-standing evidence of inaccuracy, inconsistency, and insensitivity in obtaining the assessments by digital VE. [14][15][16] Despite being acknowledged as the "gold standard," digital VEs expose women to repeated unpleasant and unwanted examinations to monitor labor progress that is enshrined as a routine part of intrapartum care. ...
Article
Assessment of cervical dilatation by digital vaginal examination is commonly used during labor as one of the main indicators of labor progress. Despite consistent inaccuracies, this practice remains widely chosen among midwives and obstetricians. Several methods, including electromechanical and electromagnetic devices, have been trialed throughout the decades without being able to provide objective means of obtaining accurate measurements of cervical dilatation during labor. Intrapartum ultrasound in the form of transperineal or translabial applications has shown promising results in the assessment and monitoring of labor progress. Here, we described the validity of intrapartum ultrasound and its usefulness in the assessment of cervical dilatation during labor. Moreover, we highlighted the feasibility of ultrasound in obtaining these assessments.
... 10,24,35,36,[41][42][43][44][45]50,51,53,[57][58][59][60][61] Clinicians are limited in their ability to determine true protraction of fetal descent in the second stage of labor for 2 key reasons. First, the known inaccuracies of digital assessments of labor progress [62][63][64][65] are likely more pronounced in the second stage of labor when variables such as maternal position, caput succedaneum, and molding compromise the reliability of assessments of fetal descent. Second, the slowest yet statistically normal durations of time (in hours) for fetal descent to progress from one level of station to the next lower station are just coming to light through use of advanced statistical techniques. ...
Article
Contemporary labor and birth population norms should be the basis for evaluating labor progression and determining slow progress that may benefit from intervention. The aim of this article is to present guidelines for a common, evidence-based approach for determination of active labor onset and diagnosis of labor dystocia based on a synthesis of existing professional guidelines and relevant contemporary publications. A 3-point approach for diagnosing active labor onset and classifying labor dystocia-related labor aberrations into well-defined, mutually exclusive categories that can be used clinically and validated by researchers is proposed. The approach comprises identification of 1) an objective point that strictly defines active labor onset (point of active labor determination); 2) an objective point that identifies when labor progress becomes atypical, beyond which interventions aimed at correcting labor dystocia may be justified (point of protraction diagnosis); and 3) an objective point that identifies when interventions aimed at correcting labor dystocia, if used, can first be determined to be unsuccessful, beyond which assisted vaginal or cesarean birth may be justified (earliest point of arrest diagnosis). Widespread adoption of a common approach for diagnosing labor dystocia will facilitate consistent evaluation of labor progress, improve communications between clinicians and laboring women, indicate when intervention aimed at speeding labor progress or facilitating birth may be appropriate, and allow for more efficient translation of safe and effective management strategies into clinical practice. Correct application of the diagnosis of labor dystocia may lead to a decrease in the rate of cesarean birth, decreased health care costs, and improved health of childbearing women and neonates.
... 17 A short cervix is associated closely with subsequent spontaneous PTB 2 and a reliable sign of its latency. The lack of success of a digital examination in the prediction of PTB because of its subjectivity, high interobserver variability, 18 inaccuracy for evaluation of the internal os, 19 and nonspecificity 20 makes TVU CL far superior to manual examination of the cervix in PTB prediction. It is the internal os, which is visible only on ultrasound scanning, that first starts to open, and not the external os, which is the only cervical portion that is palpable by digital examination. ...
Article
A short cervix is strongly associated with preterm birth. Pharmacologic intervention with vaginal progesterone in women with a singleton pregnancy and a short cervix in the second trimester decreases the incidence of preterm birth. In this article, we explore the evidence that universal cervical length screening in women with a singleton pregnancy meets the criteria for an effective screening test for preterm birth prevention, driving it towards becoming routinely offered in prenatal care.
... These parturients reach the final stage of pregnancy in jeopardy when entering the delivery room, since an incorrect management of childbirth labor may have a crucial impact on the neonatal health regardless of the cares taken during the course of the gestation. In fact, intrapartum assessment of progression indicators (cervical dilatation, fetal head station (FHS) and rotation, progression angle (PA), etc.), essential for deciding for a surgical (i.e., CS) or an operative intervention (i.e., application of forceps or vacuum extractor), is currently performed by highly subjective transvaginal manual inspections, although relevant literature extensively reported evidence of their unreliability with errors up to 88% in FHS [14] and up to 50% in cervix dilatation [15,16] assessment. Using ultrasound (US) assessment as the standard reference, a high rate of error (65%) in transvaginal digital determination of fetal head position during the second stage of labor was also demonstrated, almost independently of the operator's experience [17][18][19][20][21]. ...
Article
Full-text available
Labor progression is routinely assessed through transvaginal digital inspections, meaning that the clinical decisions taken during the most delicate phase of pregnancy are subjective and scarcely supported by technological devices. In response to such inadequacies, we combined intrapartum echographic acquisitions with advanced tracking algorithms in a new method for noninvasive, quantitative, and automatic monitoring of labor. Aim of this work is the preliminary clinical validation and accuracy evaluation of our automatic algorithm in assessing progression angle (PA) and fetal head station (FHS). A cohort of 10 parturients underwent conventional labor management, with additional translabial echographic examinations after each uterine contraction. PA and FHS were evaluated by our automatic algorithm on the acquired images. Additionally, an experienced clinical sonographer, blinded regarding the algorithm results, quantified on the same acquisitions of the two parameters through manual contouring, which were considered as the standard reference in the evaluation of automatic algorithm and routine method accuracies. The automatic algorithm (mean error ± 2SD) provided a global accuracy of 0.9 ± 4.0 mm for FHS and 4° ± 9° for PA, which is far above the diagnostic ability shown by the routine method, and therefore it resulted in a reliable method for earlier identification of abnormal labor patterns in support of clinical decisions.
... All labors were classified by the study PI (JN) who was blinded to laboratory results when determining dilation rates. Of note, cervical exams are accurate to ± 1 cm from actual dilatation in 90% of cases (Buchmann & Libhaber, 2007;Huhn & Brost, 2004;Phelps et al., 1995;Tuffnell, Bryce, Johnson, & Lilford, 1989). ...
... Studies to assess the accuracy of the digital examination of the cervix are limited but those that do exist suggest that the assessment is imprecise. Some stu- dies [2,3] have used hard cervical models in which the cervix is fixed in position to measure the accuracy of midwives and obstetricians in measuring cervical dilatation . They reported an overall accuracy for determining the exact cervical diameter of between 48.6% and 56.3% which improved to between 89.5% and 91.7% when an error of ± 1 cm was allowed. ...
Article
Full-text available
Vaginal examination (VE) and assessment of the cervix is currently considered to be the gold standard for assessment of labour progress. It is however inherently imprecise with studies indicating an overall accuracy for determining the diameter of the cervix at between 48-56%. Furthermore, VEs can be unpleasant, intrusive and embarrassing for women, and are associated with the risk of introducing infection. In light of increasing concern world wide about the use of routine interventions in labour it may be time to consider alternative, less intrusive means of assessing progress in labour. The presence of a purple line during labour, seen to rise from the anal margin and extend between the buttocks as labour progresses has been reported. The study described in this paper aimed to assess in what percentage of women in labour a purple line was present, clear and measurable and to determine if any relationship existed between the length of the purple line and cervical dilatation and/or station of the fetal head. This longitudinal study observed 144 women either in spontaneous labour (n = 112) or for induction of labour (n = 32) from admission through to final VE. Women were examined in the lateral position and midwives recorded the presence or absence of the line throughout labour immediately before each VE. Where present, the length of the line was measured using a disposable tape measure. Within subjects correlation, chi-squared test for independence, and independent samples t-test were used to analyse the data. The purple line was seen at some point in labour for 109 women (76%). There was a medium positive correlation between length of the purple line and cervical dilatation (r = +0.36, n = 66, P = 0.0001) and station of the fetal head (r = +0.42, n = 56, P < 0.0001). The purple line does exist and there is a medium positive correlation between its length and both cervical dilatation and station of the fetal head. Where the line is present, it may provide a useful guide for clinicians of labour progress along side other measures. Further research is required to assess whether measurement of the line is acceptable to women in labour and also clinicians.
... In studies based on birth simulators, cervical dilation was determined precisely only in 56% of transvaginal digital assessments. What is more, the number of errors made by the same examiners exceeded 50% (4) . In other studies, using a model made of soft materials to make it more realistic, cervical dilation was assessed correctly only in 19% of simulated examinations (5) . ...
Article
Full-text available
For many years, the progress of labour has been traditionally evaluated almost exclusively by transvaginal digital assessment which, by its very nature, is an imprecise and, above all, subjective examination. Appropriate assessment of foetal head station and position in the birth canal is of critical importance for predicting further progress and safe completion of labour by instrumental or surgical intervention. In view of the deficiency of diagnostic methods available in the delivery room, attempts are undertaken to introduce intrapartum ultrasound performed using a transabdominal suprapubic or transperineal approach as a useful diagnostic tool. The examination is performed at the patient’s bedside, using a portable ultrasound unit equipped with a convex probe. The method comprises a range of parameters, of which the most common are the angle of progression (AoP), foetal head direction, headperineum distance or midline angle (MLA). Intrapartum sonography yields an array of data to evaluate with a high degree of precision the foetal head position and station in the birth canal. Intrapartum ultrasound may prove a very useful method complementing traditional obstetric examination in a number of clinical situations such as prolonged delivery and lack of certainty as to the way to end the labour. Increasingly, attention is being drawn to the role of the examination in predicting the efficacy of induction of labour, serving as visual biofeedback to increase the effectiveness of maternal pushing or accurately identify the beginning of labour. It has been highlighted that intrapartum ultrasound is easy to use, painless, and reproducible. Also, the method does not require specialist training. Despite promising research results and the development of recommendations on the application of the method, there is still insufficient evidence to elaborate definite algorithms for the interpretation of results, based on which clinical decisions could be made.
... However, vaginal examination has several limitations, in-cluding operator dependence with significant inter-and intraobserver variability [1,2]. In addition, repeated vaginal examinations can increase the risk of chorioamnionitis [3][4][5][6][7] and can cause significant discomfort [8,9]. ...
Article
Objectives: To evaluate the feasibility, reliability, and agreement of serial transperineal ultrasound (TPU) assessment of fetal head station (parasagittal angle of progression [psAOP], head-perineum distance [HPD], and head-symphysis distance [HSD]) and sonographic cervical dilatation (SCD), compared to fetal head station and cervical dilatation determined by vaginal examination, respectively. Methods: This was a prospective longitudinal study in singleton pregnancies undergoing induction of labor at term. Paired assessment of fetal head station and cervical dilatation by vaginal examination, with TPU assessment of psAOP, HPD, HSD, and SCD was made serially. Feasibility, correlation, reliability, and agreement were determined. Results: 1,139 paired measurements among 326 women were included. psAOP and HPD were achievable in all assessments. HSD was not achievable in 3.4% (11/326) due to high fetal head station. Fetal head station by vaginal examination was positively correlated with psAOP (rho = 0.70) but negatively correlated with HPD (rho = -0.57) and HSD (rho = -0.52). The feasibility to measure SCD reduced as cervical dilatation increased. Cervical dilatation and SCD were positively correlated (rho = 0.96) with strong agreement (concordant correlation coefficient = 0.925). Conclusions: Measurements of psAOP and HPD are feasible and correlate significantly with fetal head station by vaginal examination. Measurement of HSD is not feasible when fetal head station is high. Measurement of SCD is feasible, but it is more difficult in the advanced stage of labor. The correlation, reliability, and agreement between SCD and cervical dilatation by vaginal examination are high.
... However, this is a subjective method with high inter and intra observer variability, uncomfortable and less precise. [5][6][7][8] So obstetricians need an objective, painless, easy and precise method. ...
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Objective Our aim was (1) to evaluate a pre-induction ultrasound score for prediction of vaginal birth and compare it with the Bishop score in term nulliparous women, and (2) to formulate a prediction model to calculate probability of vaginal delivery for clinical use. Methods Ninety six nulliparous women between 36-41 weeks gestation were recruited. All subjects fulfilled the inclusion criteria of a live singleton pregnancy, vertex presentation, intact amniotic membrane, in the absence of active labour with no contraindication to vaginal delivery. The patients were assessed by our ultrasound score comprising of 3 cervical and 2 fetal head parameters. These parameters were fetal head position, fetal head symphysis pubis distance relation, cervical length, funnelling and posterior cervical angle. Each parameter was scored from 0-2,with a maximum score of 10.A second obstetrician blinded to the sonographic findings assessed the modified Bishop score. SPSS 20 was used for ROC curves plots and calculation of area under curve. Binary Logistic Regression model was prepared and probability of vaginal delivery for various scores was calculated. Results Out of 91, 61(67%) achieved active phase of labour and 54(59%) had vaginal delivery. Our pelvic ultrasound score showed better sensitivity and specificity in comparison to the Bishop score. At a cut off of ≥ 5, the ultrasound score showed sensitivity of 79.3%, specificity of 75.8%, whereas, the Bishop score showed sensitivity of 66.7% and specificity of 44.2%. Binary logistic regression model predicted 78.0% of the events correctly. Conclusion Our study shows that “Garg Ultrasound Score” can predict success of induction of labour in nulliparous women . This proposed pelvic ultrasound score, if validated in larger multicentre studies, could help clinicians provide evidence-based counselling for predicting probability of vaginal delivery. This in turn, may allow women make a more informed decision before undergoing induction of labour. Keywords Induction of Labour, Bishop Score, Garg Ultrasound Score, Induction Success, Prediction Model
... The 'gold standard' for assessing progress in labour is by performing vaginal examinations (VEs) and measuring cervical dilatation. 6 Multiple VEs after prelabour rupture of membranes has been reported as an independent predictor of neonatal sepsis. 7 Imseis et al. found a marked increase in the organisms isolated after VE in women with both ruptured and intact membranes. ...
Article
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Background: Early onset neonatal sepsis (EONS) is caused mainly by organisms present in the genital tract. Maternal risk factors increase the incidence of EONS. This study was done to find out the association between one such risk factor i.e., multiple vaginal examinations and EONS.Methods: Case control study. 114 patients with three or more vaginal examinations after rupture of membranes were taken as cases and 114 patients with less than three vaginal examinations after rupture of membranes were taken as controls. All these babies were followed up for the development of EONS.Results: Of the 114 cases, 6 babies developed EONS. None of the babies in the control group developed EONS. So, 3 or more vaginal examinations after rupture of membranes in labour is significantly associated with early onset neonatal sepsis with p-value of 0.01305.Conclusions: Multiple vaginal examinations after rupture of membranes is a risk factor for early onset neonatal sepsis.
... Even experienced hands were shown to exhibit a variability of up to 2 cm in the estimation of cervical dilatation. [6][7][8][9] Assessment of fetal head station is even more subjective and suffers from large errors. 10,11 Several instruments were designed for accurate measurements of cervical dilatation based on a variety of physical principles. ...
Article
The relationship between instantaneous changes in fetal head station and cervical dilatation within the individual contraction during the active stage of labor were studied and an index of labor progress was suggested. Cervix dilatation and fetal head station were measured continuously in 30 nullipara women (mean age 27.5, standard deviation 4.8). The continuous measurements enabled the analysis of each variable and the analysis of the relations between these two variables. The relationship between the head station and the cervical dilatation were demonstrated by plotting one against the other during a contraction. This led to the definition of a contraction vector that integrates the interaction between the two variables. The angle of this vector, that indicates this relation, was plotted against mean head station to demonstrate change along the delivery process regardless of time to normalize the progress and allow comparison between different women with different labor durations. This plot showed a sharp change from almost zero into a steep curve at about zero head station. A zero angle indicates that the cervix dilates during a contraction with little effect on head station while a steep angle indicates a significant effect of cervical dilatation on head station during the contraction. The contraction-vector angle reflects the changing intra-contraction relationship between head station and cervical dilatation. The angle of this vector may serve as an indicator of labor progress.
... 17 A short cervix is associated closely with subsequent spontaneous PTB 2 and a reliable sign of its latency. The lack of success of a digital examination in the prediction of PTB because of its subjectivity, high interobserver variability, 18 inaccuracy for evaluation of the internal os, 19 and nonspecificity 20 makes TVU CL far superior to manual examination of the cervix in PTB prediction. It is the internal os, which is visible only on ultrasound scanning, that first starts to open, and not the external os, which is the only cervical portion that is palpable by digital examination. ...
Article
Preterm birth remains a major cause of perinatal morbidity and mortality. A short cervix is strongly associated with spontaneous preterm birth. Professional organizations support cervical length screening for singleton gestations with a prior spontaneous preterm birth and second-trimester cervical length measurements between 16-24 weeks. All interventions used to decrease the risk of preterm birth in women with a short cervix are based on clinical trials that used transvaginal cervical length measurement, but transabdominal ultrasound has been shown to correlate well with transvaginal measurement in some observational studies. Transvaginal cervical length measurement is more accurate and more reliably obtained than the transabdominal approach. Conversely, transabdominal ultrasound could have the advantage of ease of implementation and, in general, is perceived by patients to be associated with less discomfort. Currently, there is no randomized clinical study that compares head-to-head the effectiveness of transvaginal vs transabdominal ultrasound for preterm birth risk screening. This point/counterpoint article summarizes the pros and cons of the 2 ultrasound approaches and debates whether transvaginal ultrasound should be used exclusively or if transabdominal ultrasound can be incorporated in cervical length screening for prevention of preterm birth.
Article
Since partographs were introduced into obstetric practice, more than 50 years ago, the appearance of cervicographs as their central section has not been significantly changed. The aims of this article are to assess whether the current characteristics of cervicographs represent the optimal solution with regard to the rules for plotting data and to suggest what that optimal solution might be. The literature was searched for papers containing reproductions of cervicographs to review their characteristics. According to the general rules for plotting data, values of three most important characteristics of cervicographs were defined. The characteristics of the majority of available cervicographs are: a dilatation scale smallest division 1 cm, a time scale smallest division 1 h and 1 cm/h dilatation rate line inclination less than 45 degrees. The optimal characteristics of cervicographs are: a dilatation scale smallest division 2 cm, a time scale smallest division 5 min and 1 cm/h dilatation rate line inclination of 45 degrees. The scale divisions on the proposed cervicograph form are in predefined relation to the accuracy of the measurements made. This enables improved portrayal of labour.
Article
To describe a two-dimensional (2D) ultrasound technique to measure cervical dilatation in labor, and to compare ultrasound with digital measurements. 2D transperineal ultrasound was performed in 21 nulliparous women in labor with a singleton fetus in cephalic presentation and cervical dilatation measured before or after a digital vaginal examination. The absolute difference was calculated and Bland–Altman analysis was used to assess the mean difference between digital vaginal examination and ultrasound examination of cervical dilatation. Pearson analysis was used to determine the correlation between digital and ultrasound measurements. Intraclass correlation coefficients (ICCs) with 95% CI were used to evaluate the reliability of the two methods. Satisfactory quality images of the cervix were obtained in 19 of 21 cases. There was positive correlation between 2D ultrasound measurement of cervical dilatation and digital vaginal examination (Pearson coefficient r = 0.821, n = 19, P < 0.001). Bland–Altman analysis showed a mean difference between digital and ultrasound measurements of 0.08 cm (95% limits of agreement: −1.83 to 2.00) and the mean absolute difference was 1.24 cm. The ICC between the two methods was 0.81 (95% CI, 0.58–0.92). Assessment and measurement of cervical dilatation by 2D transperineal ultrasound is feasible, with close agreement shown between the technique and digital vaginal examination. The technique that we describe could represent an important component of a ‘sonopartogram’ for ultrasound assessment of labor progress. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd.
Article
Oxytocin augmentation and cesarean rates among low-risk, term, nulliparous women with a spontaneous onset of labor in the United States approximate 50% and 26.5%, respectively. This indicates that the quality of obstetrical care is less than optimal in this nation. Exorbitant oxytocin use, the intervention most commonly associated with preventable adverse perinatal outcomes, jeopardizes birth safety while the high cesarean rate in this high-volume group compromises population health and increases health care costs. Dystocia, characterized by the slow, abnormal progression of labor, is the most commonly reported indication for primary cesareans, accounting directly for approximately 50% of all nulliparous cesareans and indirectly for most repeat cesareans. Diagnoses of dystocia are most often based on ambiguously defined delays in cervical dilation beyond which labor augmentation is deemed justified. Dystocia is known to be over-diagnosed which undoubtedly contributes to contemporary oxytocin augmentation and primary cesarean rates. Labor attendants would benefit from an evidence-based framework for homogenous labor assessment. To this end, we present a physiologically-based partograph for 'in-hospital' use in assessing the labors of low-risk, term, nulliparous women with spontaneous labor onset. This tool incorporates several evidence-based labor principles that combine to give needed clinical meaning to 'dystocia' as a diagnosis. It is hypothesized that our partograph will safely limit diagnoses of dystocia to only the slowest 10% of low-risk, nulliparous women. This should, in turn, safe-guard against unnecessary, injudicious, and potentially harmful use of oxytocin when labor is already adequately progressing while also indicating when its use may be justified. We further hypothesize that cesareans performed for dystocia in this population will decrease by ≥ 50%. No significant influence on other labor process or labor outcome variables is expected with partograph use. Widespread use of this physiologically-based partograph will be warranted if our hypotheses are supported.
Article
Our purpose was to prospectively evaluate the interobserver reliability of digital and endovaginal ultrasonographic cervical length measurements. Forty-three women were recruited from our antepartum clinic to participate in this study. Two independent and blinded digital cervical examinations were performed by the first author and a second examiner. Instructions were given to estimate the cervical length in millimeters. After micturition endovaginal ultrasonographic cervical length measurements were performed by two independent, blinded registered diagnostic medical sonographers. Cervical lengths were compared with the Student t test and Pearson's correlation coefficient. A kappa statistic was calculated for interobserver reliability at three levels of agreement +/- 1 mm, +/- 4 mm, and +/- 10 mm. Data are expressed as means +/- SD. Digital cervical lengths were not different between the two examiners (18.7 +/- 4.8 mm, 20.5 +/- 6.2 mm) nor between the two ultrasonographic measurements (38.6 +/- 6.1 mm, 39.2 +/- 5.4 mm). The digital cervical lengths agreed (+/- 1 mm) 35% of the time (R2 0.10, p = 0.02). The endovaginal ultrasonographic measurements agreed (+/- 1 mm) 74% of the time with a stronger correlation (R2 0.53, p = 0.0001). The kappa statistic for interobserver variability was marginal for both digital and endovaginal cervical length measurements when agreement was defined as +/- 1 mm. Endovaginal ultrasonography was significantly more reliable than digital examination when agreement between examiners was defined as either +/- 4 mm or +/- 10 mm. Although both digital and endovaginal ultrasonographic cervical length measurements show correlation between examiners, endovaginal ultrasonography is significantly more reliable when agreement is defined as > or = +/- 4 mm. Serial cervical length measurements to predict preterm labor will be enhanced by the interobserver reliability of endovaginal ultrasonography.
Article
This study was undertaken to evaluate the comparative value of sonographic cervical length and the Bishop score in predicting the type of delivery after induced labor. The Bishop score was determined by digital examination and cervical length by transvaginal sonography in 177 women. The best cut-off points for predicting type of delivery found with ROC curves were 25.2 mm for cervical length and 5 for the Bishop score. The Bishop score was not predictive of type of delivery. Cervical length was related to type of delivery in women with Bishop score ≤5. A logistic regression model showed that only cervical length ≥25.2 mm, parity, and body mass index significantly predicted the likelihood of cesarean delivery. Our study suggests that both Bishop score and sonographic cervical length can contribute to predicting type of delivery after labor induction, but cervical length is a better predictor of the risk of cesarean delivery.
Article
Our purpose was to compare the accuracy of ultrasonographic and manual cervical examinations for the prediction of preterm delivery. One hundred two singleton pregnancies at high risk for preterm delivery were followed up prospectively from 14 to 30 weeks with both serial cervical ultrasonography measurements and manual examinations of the length of the cervix. The primary outcome studied was preterm (< 35 weeks) delivery. Excluding six induced preterm deliveries, 96 pregnancies were analyzed. The mean cervical length measured by ultrasonography was 20.6 mm in pregnancies delivered preterm (n = 17) and 31.3 mm in pregnancies delivered at term (n = 79) (p = 0.003); the mean cervical lengths measured by manual examination were 16.1 mm and 18.6 mm in the same preterm and term pregnancies, respectively (not significant). The sixteenth- and twentieth-week ultrasonographic cervical lengths predicted preterm delivery most accurately (p < 0.0005). The 25th percentiles of ultrasonographic (25 mm) and manual (16 mm) cervical lengths showed relative risks for preterm delivery of 4.8 (95% confidence interval 2.1 to 11.1, p = 0.0004) and 2.0 (95% confidence interval 0.5 to 4.7, p = 0.1), respectively; sensitivity, specificity, and positive and negative predictive values were 59%, 85%, 45%, 91%, and 41%, 77%, 28%, and 86%, respectively. Cervical length measured by ultrasonography is a better predictor of preterm delivery than is cervical length measured by manual examination. Cervical ultrasonography in patients at high risk for preterm birth seems to be most predictive of preterm delivery when it is performed between 14 and 22 weeks' gestation.
Article
The aim of this study was to evaluate the role of Bishop score and cervical length in predicting the outcome of induced labor. A prospective observational study was performed during a year in women undergoing labor induction. Prior to the procedure, Bishop score was evaluated by transvaginal digital examination and cervical length was measured by transvaginal ultrasound. Demographic data and labor details were recorded. A total of 197 women were analyzed; 166 women had a vaginal delivery (84.3%) and 31 had a cesarean section (15.7%). On univariate analysis, nulliparity, Bishop score >5 and cervical length <30 mm were all associated with cesarean delivery. On multivariate analysis, only nulliparity remained significantly associated with cesarean delivery and the other characteristics did not achieve statistical significance. When women were stratified according to parity, there was a significant association between cesarean delivery and nulliparity, but not multiparity. Our results suggest that Bishop score and cervical length are good predictors of successful induction of labor, particularly in nulliparous women.
Article
To compare station and cervical dilation at the time of epidural placement for predicting cesarean delivery risk. This prospective cohort study included 275 women in labor with live, singleton fetuses at term in vertex presentations. We excluded women with preeclampsia or previous cesarean deliveries. A multiple logistic regression model evaluated demographic and labor-related variables' associations with cesarean risk. Fifty-nine of the 275 patients receiving epidural analgesia (21.5%) were delivered by cesarean, whereas 216 (78.5%) delivered vaginally. Variables that proved to be statistically significant in increasing the likelihood of cesarean were station at time of epidural placement (odds ratio [OR] 5.3; 95% confidence interval [CI] 2.6, 11.0; P < .001) and nulliparity (OR 3.8, 95% CI 1.8, 8.0; P < .001). Cervical dilation at the time of epidural placement was not a statistically significant predictor (OR 1.2, 95% CI 0.9, 1.6; P = .26). Cesareans were performed in 43 of 129 women (33.3%) who received epidurals with the vertex at a -1 station or higher, whereas only 16 of 146 women (11.0%) had cesareans if placement of the epidural was done after the vertex had reached at least a zero station. Station at the time of epidural placement was more accurate predicting cesarean risk than cervical dilation. Placement of the epidural after the fetal vertex has become engaged in the pelvis (at least a zero station) resulted in a substantially lower cesarean risk.
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Objective: In our study, we aimed to evaluate the knowledge, attitudes and behaviors of pregnant women about tetanus vaccine who admitted to our hospital. Methods: The pregnant women who admitted to our clinic between January 2019 and July 2019 were included in this cross-sectional study. All participants took a questionnaire evaluating tetanus vaccine rates during pregnancy and the knowledge, attitude and behaviors of pregnant women about tetanus vaccine. Results: A total of 227 pregnant women were included in the study. The mean age of the patients was 29.5±6.12, and the mean week of gestation was 30.79±7.49. It was found that 24 (52.1%) of the 46 (12.6%) patients who were not vaccinated for tetanus in their previous pregnancies believed that the vaccine was harmful for the baby and therefore they were not vaccinated. In addition, it was found that the physicians who carried out the follow-ups of 2 of these 46 patients, who stated that they were not vaccinated in their previous pregnancies, were also anti-vaxxers. It was found out that 172 (75.7%) patients learnt from the family practitioner’s nurse that they needed to be vaccinated. The number of the patients who learnt from the obstetriciangynecologist that they needed to get tetanus vaccine was only 2 (0.8%). While there were 177 (77.9%) patients who were / will be vaccinated for tetanus in this pregnancy, 47 (20.7%) patients were indecisive for being vaccinated or not. Also, 200 (88.1%) patients knew that tetanus vaccine does not have any side effect on pregnancy. Conclusion: The greatest obstacles to the vaccination are the belief that vaccine may harm the baby, and the lack of knowledge about vaccination. The greatest obstacle caused by the healthcare professionals is the lack of providing sufficient information about vaccine, not explaining the necessities of vaccine to patients and the perception of obstetricians in particular that only the primary healthcare organizations are responsible for tetanus vaccine
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Vaginal examinations have become a routine intervention in labour as a means of assessing labour progress. Used at regular intervals, either alone or as a component of the partogram (a pre-printed form providing a pictorial overview of the progress of labour), the aim is to assess if labour is progressing physiologically, and to provide an early warning of slow progress. Abnormally slow progress can be a sign of labour dystocia, which is associated with maternal and fetal morbidity and mortality, particularly in low-income countries where appropriate interventions cannot easily be accessed. However, over-diagnosis of dystocia can lead to iatrogenic morbidity from unnecessary intervention (e.g. operative vaginal birth or caesarean section). It is, therefore, important to establish whether or not the routine use of vaginal examinations is an effective intervention, both as a diagnostic tool for true labour dystocia, and as an accurate measure of physiological labour progress. To compare the effectiveness, acceptability and consequences of digital vaginal examination(s) (alone or within the context of the partogram) with other strategies, or different timings, to assess progress during labour at term. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 February 2013) and reference lists of identified studies. We included randomised controlled trials (RCTs) of vaginal examinations (including digital assessment of the consistency of the cervix, and the degree of dilation and position of the opening of the uterus (cervical os); and position and station of the fetal presenting part, with or without abdominal palpation) compared with other ways of assessing progress of labour. We also included studies assessing different timings of vaginal examinations. We excluded quasi-RCTs and cross-over trials. We also excluded trials with a primary focus on assessing progress of labour using the partogram (of which vaginal examinations is one component) as this is covered by another Cochrane review. However, studies where vaginal examinations were used within the context of the partogram were included if the studies were randomised according to the vaginal examination component. Three review authors assessed the studies for inclusion in the review. Two authors undertook independent data extraction and assessed the risk of bias of each included study. A third review author also checked data extraction and risk of bias. Data entry was checked. We found two studies that met our inclusion criteria but they were of unclear quality. One study, involving 307 women, compared vaginal examinations with rectal examinations, and the other study, involving 150 women, compared two-hourly with four-hourly vaginal examinations. Both studies were of unclear quality in terms of risk of selection bias, and the study comparing the timing of the vaginal examinations excluded 27% (two hourly) to 28% (four hourly) of women after randomisation because they no longer met the inclusion criteria.When comparing routine vaginal examinations with routine rectal examinations to assess the progress of labour, we identified no difference in neonatal infections requiring antibiotics (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.01 to 8.07, one study, 307 infants). There were no data on the other primary outcomes of length of labour, maternal infections requiring antibiotics and women's overall views of labour. The study did show that significantly fewer women reported that vaginal examination was very uncomfortable compared with rectal examinations (RR 0.42, 95% CI 0.25 to 0.70, one study, 303 women). We identified no difference in the secondary outcomes of augmentation, caesarean section, spontaneous vaginal birth, operative vaginal birth, perinatal mortality and admission to neonatal intensive care.Comparing two-hourly vaginal examinations with four-hourly vaginal examinations in labour, we found no difference in length of labour (mean difference in minutes (MD) -6.00, 95% CI -88.70 to 76.70, one study, 109 women). There were no data on the other primary outcomes of maternal or neonatal infections requiring antibiotics, and women's overall views of labour. We identified no difference in the secondary outcomes of augmentation, epidural for pain relief, caesarean section, spontaneous vaginal birth and operative vaginal birth. On the basis of women's preferences, vaginal examination seems to be preferred to rectal examination. For all other outcomes, we found no evidence to support or reject the use of routine vaginal examinations in labour to improve outcomes for women and babies. The two studies included in the review were both small, and carried out in high-income countries in the 1990s. It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings.The effectiveness of the use and timing of routine vaginal examinations in labour, and other ways of assessing progress in labour, including maternal behavioural cues, should be the focus of new research as a matter of urgency. Women's views of ways of assessing labour progress should be given high priority in any future research in this area.
Article
Objectif La mesure échographique par voie endovaginale du col utérin (EEV) fait aujourd’hui partie du bilan de toute menace d’accouchement prématuré (MAP). La recherche de fibronectine foetale (fFN) au niveau cervical a été proposée pour en améliorer son dépistage. Matériel et méthode Pour toute MAP, ont été réalisé: un toucher vaginal, un enregistrement des contractions utérines (CU), une mesure de l’EEV. Si cette dernière était comprise entre 15 et 25 mm une recherche de fFN était ajoutée. Les cliniciens étaient informés des différents résultats. Résultats Cent quatre-vingt huit patientes admises aux urgences pour MAP entre 24 et 34 SA présentaient un dossier complet. Parmi les différents examens, une EEV < 15 mm présente respectivement pour le dépistage de la prématurité < 37 SA ou un accouchement dans les sept jours une sensibilité de 56 et 79 %, une spécificité de 70 et 66 % et une valeur prédictive négative (VPN) de 81 et 98 %. En prenant 25 mm comme valeur seuil et en recherchant la fFN pour l’intervalle 15–25 mm, on obtient respectivement une sensibilité de 68 et 86%, une spécificité de 61 et 56%et une VPN de 84 et 98%. Les rapports de vraisemblance positifs et négatifs sont, quel que soit le test diagnostique significatif retenu et quel que soit le critère de jugement utilisé, très modestes. Conclusion Pour dépister la prématurité, la valeur seuil classique de 25 mm pour la mesure du col utérin est peu performante. Celle de 15 mm est plus intéressante, mais présente une faible sensibilité. L’adjonction de la recherche de fNF lorsque l’EEVest comprise entre 15 et 25 mm améliore les performances du dépistage de la prématurité.
Article
Prematurity is the chief cause of neonatal morbidity and mortality. The objective of this study is to review the different methods for predicting preterm delivery in asymptomatic pregnant women and in situations of threatened preterm delivery. A search of the Pubmed/Medline database was carried out for the years 1980-2012. We included studies for predicting preterm birth in asymptomatic and symptomatic patients. Models for predicting preterm delivery based on maternal factors, cervical length and obstetric history in 1st trimester of pregnancy is a valuable avenue of research. Nevertheless, prediction accuracy still needs to be improved. In the 2nd and 3rd trimesters, routine digital vaginal examination is of no value in asymptomatic women. Echography of the cervix is not useful except in patients with a history of late miscarriage or preterm delivery in order to offer them a preventive treatment. In symptomatic women, the combination of digital vaginal examination, cervical echography and fibronectin gives the best predictive results. Electromyography of the uterus and elastography of the cervix are interesting avenues for future research. Identifying patients at risk of preterm delivery should be considered differently at each stage of pregnancy.
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Introduction: Currently, vaginal examination is considered as the gold standard for assessing progress of labor. But, vaginal examination can be painful, embarrassing and unpleasant for women. The presence of a purple line during labor between buttocks is one of the non-invasive methods to assess progress of labor. This method can be used as an alternative or supplement for vaginal examinations. The objective of this study was to determine the relationship between the purple line and cervical dilatation in active phase of labor. Methods: This correlational study was conducted on 350 women who referred to "Ommolbanin" hospital in Mashhad between April to August 2012. First, in cervical dilatation of 3-4 cm, presence or absence of purple lines was observed in lateral position by researcher and its length was measured. Then, vaginal examination was performed to measure cervical dilatation in both groups (presence or absence of purple lines) by research assistant. These measurements were repeated until full cervical dilatation each one hour. Data were analyzed using SPSS software version 14 and statistical test such as Pearson correlation coefficient, chi square and t-test. P value less than 0.05 was considered statistically significant. Results: The mean age of women was 25.22±5 years. Of 350 women enrolled, 222 women (61.2%) were primigravida and 128 women (38.8%) were multigravida. The purple line was appeared in 75.3% of cases in active phase of labor. There were no significant difference between primigravida and multigravida in appearance of purple line (p<0.001). There was a positive correlation between purple line and cervical dilatation (r=0.44, p<0.001). Conclusion: There is a positive correlation between purple line and cervical dilatation. So this non-invasive method can be used as an alternative or supplement for vaginal examinations.
Article
Objective: To assess laboratory accuracy and precision of 'cervical dilatometer' in measuring cervical dilatation. Methods: Seven midwives in two groups of experimental phases were asked to measure cervix dilatation blindly in artificial simulators ranging from 40 to 100 mm by means of the device. Results were recorded and then after using a simple calculation, dilatations were reported. For the accuracy and precision of the instrument ICC (Inter-Class Correlation) between simulators and examiners reports, ICC between observers, Pearson's Correlation and Standard Error, all with 95% confidence interval, were used. Ninety-five examinations in 37 simulators were performed, none of the cases excluded. Results: According to the statistical analyses there were positive correlations between the instrument reports and simulators real sizes in either phases (ICC=0.968 in phase 1 and 0.834 in phase 2). Reliability of the instrument using Cronbach's Alpha was 0.995, inter-observer agreement due to ICC and Pearson's correlation was 0.995 and 0.697 in phase 1 and phase 2 respectively. Conclusion: Cervical Dilatometer qualifies accuracy, precision and reliability requirements to be used as a cervimetry instrument in laboratory phase. Further research is needed to determine those elements in clinical set-up.
Article
Introduction: Neal and Lowe developed a physiologic partograph to give clinicians an evidence-based, uniform approach to assessing active labor progress and diagnosing dystocia in high-resource settings. The aim of this pilot study was to examine the feasibility of implementing the Neal and Lowe partograph for in-hospital labor assessment. Methods: A descriptive study of low-risk, nulliparous women with spontaneous labor onset was performed at an academic medical center. Eight certified nurse-midwives from a single practice used the Neal and Lowe partograph for the assessment of labor progress. Descriptive statistics were used to summarize characteristics, interventions, and outcomes for women with partograph-assessed labors. Labors assessed by nurse-midwives (n = 83) or obstetricians (n = 75) using their usual assessment strategies were also described for the year prior to partograph introduction to contextualize partograph-assessed labor findings. Inferential statistical tests were not performed. Results: Thirty-one of 34 (91.2%) partographs were used correctly. Seventy-one percent (n = 22) of these women progressed to complete dilatation within expected physiologic time frames while the remaining women (n = 9) experienced labor dystocia. Similar proportions of women in the partograph and usual labor assessment groups received oxytocin during labor. The cesarean rate was lower in the partograph group than in the usual care groups. No cesareans were performed for dystocia in active labor for women whose labors were assessed via partograph. Discussion: Implementation of the Neal and Lowe partograph for in-hospital labor assessment is feasible. Incorrect plotting and/or interpretation of the partograph may be further minimized by providing clinicians opportunities for ongoing partograph training after implementation or through partograph software development. The Neal and Lowe partograph may assist clinicians in safely and significantly decreasing primary cesarean births performed for active labor dystocia in high-resource settings. Larger scale, hypothesis-testing studies of partograph implementation are now warranted.
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OBJECTIVE: Aim of this study was to evaluate whether routine vaginal examination during labour is associated with increased levels of anxiety and pain perception compared to transperineal assessment via ultrasound. STUDY DESIGN: This was a single blind, parallel, randomised controlled trial conducted in a tertiary care facility (Ankara University, Department of Obstetrics and Gynecology). Multiparous women without any known psychiatric condition were included. Participants had uneventful pregnancies and they were subjected to either routine vaginal examinations or transperineal assessment via ultrasound. Outcome measures were pain and anxiety levels during latent phase, during the beginning of active labor and during postpartum period. A sample size of 45 per group (N = 90) was planned to compare the interventions. RESULTS: From November 2015 to March 2016, 90 women were randomized 1:1 to allocated interventions. Pre-admission psychological distress levels as measured with the Symptom Checklist-90-R, anxiety levels as measured with State-Trait Anxiety Inventory (STAI) 2 were similar between two groups (P = 0.93, and P = 0.65, respectively). Most of the studied characteristics including duration of labor, number of examinations, analgesic administration during labor, episiotomy rate, interval between deliveries were similar between groups. Visual Analog Scale (VAS) scores have shown parturients' pain perception were reduced during both latent and active stages of labor [Mean differences in VAS scores -1.5(95%CI: -2.51 to -0.57) and -1.2(95% CI: -2.45 to -0.09), respectively] and during postpartum period [Mean difference in VAS score -0.5(95% CI: -1.02 to -0.06)] in transperineal assessment group compared to digital examination. STAI-1 scoring have shown anxiety levels were similar between two groups during latent phase, during active labor and during postpartum period (P = 0.07, P = 0.38 and P = 0.13, respectively). CONCLUSION: Pain perceptions were significantly reduced with use of transperineal assessment during latent stage of labor. Our results indicate transperineal assessment could be preferred to digital examination during this period. Digital examination has no clinically relevant effects on state-anxiety levels as measured with STAI-1 questionnaires. CLINICAL TRIAL REGISTRATION:www.clinicaltrials.gov, www.clinicaltrials.gov, NCT02599610. KEYWORDS:Anxiety; digital examination; labor; obstetric; pain; transperineal ultrasound
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Objective: To evaluate the accuracy and reliability of an automatic ultrasound technique for assessment of the angle of progression (AoP) during labor. Methods: Thirty-nine pregnant women in the second stage of labor, with fetus in cephalic presentation, underwent conventional labor management with additional translabial sonographic examination. AoP was measured in a total of 95 acquisition sessions, both automatically by an innovative algorithm and manually by an experienced sonographer, who was blinded to the algorithm outcome. The results obtained from the manual measurement were used as the reference against which the performance of the algorithm was assessed. In order to overcome the common difficulties encountered when visualizing by sonography the pubic symphysis, the AoP was measured by considering as the symphysis landmark its centroid rather than its distal point, thereby assuring high measurement reliability and reproducibility, while maintaining objectivity and accuracy in the evaluation of progression of labor. Results: There was a strong and statistically significant correlation between AoP values measured by the algorithm and the reference values (r = 0.99, P < 0.001). The high accuracy provided by the automatic method was also highlighted by the corresponding high values of the coefficient of determination (r2 = 0.98) and the low residual errors (root mean square error = 2°27' (2.1%)). The global agreement between the two methods, assessed through Bland-Altman analysis, resulted in a negligible mean difference of 1°1' (limits of agreement, 4°29'). Conclusions: The proposed automatic algorithm is a reliable technique for measurement of the AoP. Its (relative) operator-independence has the potential to reduce human errors and speed up ultrasound acquisition time, which should facilitate management of women during labor. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Background: The diagnosis of labor dystocia generally is determined by the deviation of labor progress, which is assessed by the use of a partogram. Recently, intrapartum transperineal ultrasound for the assessment of fetal head descent has been introduced to assess labor progress in the first stage of labor in a more objective and noninvasive way. Objective: The objective of the study was to determine the differences in labor progress by the use of serial transperineal ultrasound assessment of fetal head descent between women having vaginal and cesarean delivery. Study design: This was a prospective longitudinal study performed in 315 women with singleton pregnancy who were undergoing labor induction at term between December 2016 and December 2017. Paired assessment of cervical dilation and fetal head station by vaginal examination and transperineal ultrasonographic assessment of parasagittal angle of progression and head-perineum distance were made serially after the commencement of labor induction. According to the hospital protocol, assessment was performed every 24 hours and 4 hours, respectively, during latent and active phases of labor. The researchers and the clinical team were blinded to each other's findings. The repeated measures data were analyzed by mixed effect models. To determine the effect of mode of delivery on the association between parasagittal angle of progression and head-perineum distance against fetal head station and cervical dilation, the significance of the interaction term between each mode of delivery and fetal head station or cervical dilation was determined, which accounted for parity and obesity. Area under receiver-operating characteristic curve was used to evaluate the performance of serial intrapartum sonography in predicting women with cesarean delivery because of failure to progress. Results: The total number of paired vaginal examination and ultrasound assessments was 1198, with a median of 3 per woman. The median assessment-to-assessment interval was 4.6 hours (interquartile range, 4.3-5.1 hours). Women who achieved vaginal delivery (n=261) had steeper slopes of parasagittal angle of progression and head-perineum distance against fetal head station and cervical dilation than those who achieved cesarean delivery (n=54). Objectively, an additional decrease of 5.11 and 1.37 degrees in parasagittal angle of progression was observed for an unit increase in fetal head station and cervical dilation, respectively, in women who required cesarean delivery (P<.01; P=.01), compared with women who achieved vaginal delivery, after taking account of repeated measures from individuals and confounding factors. The respective additional increases in head-perineum distance for a unit increase in fetal head station and cervical dilation were 0.27 cm (P<.01) and 0.12 cm (P<.01). A combination of maternal characteristics with the temporal changes of parasagittal angle of progression for an unit increase in fetal head station achieved an area under receiver-operating characteristic curve of 0.85 (95% confidence interval, 0.76-0.94), with sensitivity of 79% and specificity of 80%, for the prediction of women who required cesarean delivery because of failure to progress. Conclusion: The differences in labor progress between vaginal and cesarean delivery have been illustrated objectively by serial intrapartum transperineal ultrasonographic assessment of fetal head descent. This tool is potentially predictive of women who will require cesarean delivery because of failure to progress.
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Bachelorarbeit | Angesichts hoher Interventionsraten bei Gebärenden mit niedrigem Ausgangsrisiko ist die Entscheidungsgrundlage für Interventionen neu zu hinterfragen. Die Beurteilung des Geburtsfortschrittes beeinflusst maßgeblich den Einsatz von Medikation und mechanischen Interventionen. Die vaginale Untersuchung als zentraler Parameter für das Voranschreiten der Geburt steht in der Fachwelt auf dem Prüfstand. Die Autorin identifiziert mögliche Alternativen zur Beurteilung des Geburtsfortschrittes und leitet Empfehlungen für die Geburtsbetreuung durch Hebammen ab.
Chapter
Transvaginal ultrasound cervical length assessment (TVU CL) has been reported to be the major predictor of spontaneous PTB as both a screening and a diagnostic tool. The knowledge of cervical length in women with threatened preterm labor is useful for supporting the diagnosis of true preterm labor and for guiding the obstetrician toward the proper management, with significant lower incidence of PTB and later gestational age at delivery. In case of PPROM and placenta previa, TVU CL has been shown to be a safe procedure and a good predictor of delivery latency and emergency delivery for antepartum bleeding, respectively, but there is still insufficient data to recommend routine TVU CL in these subset of women. TVU CL role in predicting delivery outcomes is similar to the Bishop score in case of IOL, and it is better tolerated than digital examination. TVU CL has also a good accuracy in predicting the onset of spontaneous labor in women at term.
Chapter
Friedman’s labor partogram is the central pillar for the clinical management of labor today. First published more than a half century ago in 1955 [1], the partogram charts labor progression by the dilatation of the uterine cervix and descent of fetal presenting part over time.
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Aim To measure the utility of the Simulation training model for training purposes over and above conventional methods of training for vaginal assessment during labour. Methods The study group included undergraduate trainees, and the control group included postgraduate trainees and qualified personnel, i.e. senior registrars and consultants. Participants from the study group were trained for vaginal assessment on the simulation training model. Then both the groups were tested on the model for accuracy in estimating each value of cervical dilatation and fetal station. Mean cervical dilatation and station accuracy scores were noted, and comparative analysis was done between the study and control groups. Results A total of 150 participants were included. The overall mean dilatation and station accuracy scores of a model trained study group participants were better than subjectively trained control group participants. Study group participants showed greater accuracy for smaller dilatations, i.e. 1, 2, 3, 4cm and middle dilatation, i.e. 5cm and 6cm (p value=<0.05). In contrast, comparing the two groups for higher dilatations from 6 to 10 cm did not show any statistical significance. Study group participants also showed greater accuracy for all the fetal stations except stations 0 and +1. Conclusions The simulation training model can be considered an in vitro training device to improve the trainees' understanding of cervical dilatation and fetal station and can be made a part of a routine obstetric teaching program.
Article
To evaluate the agreement within three pairs of observers regarding the Bishop score and an informal global evaluation of the cervix (favourable/unfavourable). We conducted a reliability study of the Bishop score. Three pairs of examiners (A-B, A-C and D-E) performed independently a cervical examination in 156 term pregnant women admitted for labour induction. We calculated the proportion of agreement and the Kappa coefficient. Perfect agreement between two observers for the Bishop score was found in 44 women (28%). Accepting a difference of one point between the observers, agreement increased to 66%. Weighted Kappa coefficients for the Bishop score were 69, 54 and 35% for each pair of observers. Kappa coefficients for the informal evaluation of the cervix were 64, 45 and 46, respectively. Agreement between two observers evaluating the cervix is fair to substantial. An informal evaluation of the cervix is as reliable as the Bishop score.
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