Certeza Diagnostica de La Pelvimetría Externa y Altura Materna Para Predecir La Distocia en Mujeres...

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The diagnostic accuracy of external pelvimetryand maternal height to predict dystocia in

nulliparous women: a study in CameroonAT Rozenholc,a SN Ako,b RJ Leke,b M Boulvaina

a Unite de Developpement en Obstetrique, Department of Gynecology and Obstetrics, University Hospital, Geneva, Switzerlandb Maternite principale, Hopital Central, Yaounde, Cameroon

Correspondence: A Rozenholc, Unite de Developpement en Obstetrique, Department of Gynecology and Obstetrics, University Hospital,

Bd de la Cluse 32, Geneva 14 CH 1211, Switzerland. Email [email protected]

Accepted 14 January 2007.

Objective In many developing countries, most women deliver at

home or in facilities without operative capability. Identificationbefore labour of women at risk of dystocia and timely referral to

a district hospital for delivery is one strategy to reduce maternal

and perinatal mortality and morbidity. Our objective was to

assess the prediction of dystocia by the combination of maternal

height with external pelvimetry, and with foot length and

symphysis-fundus height.

Design A prospective cohort study.

Setting Three maternity units in Yaounde, Cameroon.

Population A total of 807 consecutive nulliparous women at term

who completed a trial of labour and delivered a single fetus in

vertex presentation.

Methods Anthropometric measurements were recorded at theantenatal visit by a researcher and concealed from the staff

managing labour. After delivery, the accuracy of individual and

combined measurements in the prediction of dystocia was

analysed.

Main outcome measures Dystocia, defined as caesarean section

for dystocia; vacuum or forceps delivery after a prolonged labour(>12 hours); or spontaneous delivery after a prolonged labour

associated with intrapartum death.

Results Ninety-eight women (12.1%) had dystocia. The

combination of a maternal height less than or equal to the 5th

percentile or a transverse diagonal of the Michaelis sacral

rhomboid area less than or equal to the 10th percentile resulted in

a sensitivity of 53.1% (95% CI 42.763.2), a specificity of 92.0%

(95% CI 89.793.9), a positive predictive value of 47.7% (95% CI

38.057.5) and a positive likelihood ratio of 6.6 (95% CI 4.89.0),

with 13.5% of all women presumed to be at risk. Other

combinations resulted in inferior prediction.

Conclusion The combination of the maternal height with the

transverse diagonal of the Michaelis sacral rhomboid area couldidentify, before labour, more than half of the cases of dystocia in

nulliparous women.

Keywords Cephalopelvic disproportion, dystocia, height,

pelvimetry, sensitivity, specificity.

Please cite this paper as: Rozenholc A, Ako S, Leke R, Boulvain M. The diagnostic accuracy of external pelvimetry and maternal height to predict dystocia in

nulliparous women: a study in Cameroon. BJOG 2007;114:630635.

Introduction

Maternal and perinatal mortality are very high in developing

countries. The worst figures show a maternal mortality 100times1 and a perinatal mortality 10 times2 those of developed

countries. Dystocia is the underlying cause of about one-third

of maternal deaths, the immediate cause being haemorrhage

due to uterine rupture or atony following prolonged labour,

or sepsis following prolonged rupture of membranes.3 Dys-

tocia can also lead to severe maternal morbidity (e.g. genital

fistula), perinatal death or severe morbidity in the neonate

(e.g. cerebral damage).4,5

Access to district hospitals to perform obstetrical inter-

ventions when needed is essential to reduce maternal and

perinatal mortality.6 Caesarean section can be life-saving for

both the mother and the infant in case of severe dystocia. Ascaesarean section can not be performed in peripheral health

centres, it is crucial to identify women at risk of dystocia

before labour, and to refer them for delivery in district

hospitals. This concerns mainly nulliparous women, as in

multiparous women, the best predictor of dystocia is poor

obstetrical history.7,8

Maternal height has been shown to be associated with dys-

tocia.9 This measurement is routinely used in most antenatal

630 2007 The Authors Journal compilation RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology

DOI: 10.1111/j.1471-0528.2007.01294.x

www.blackwellpublishing.com/bjogGeneral obstetrics


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clinics, despite a limited prediction. Symphysis-fundus

height,10 shoe size11,12 and clinical internal pelvimetry13,14

result in a prediction inferior to that of maternal height.

Some authors reported that external pelvimetry has a

limited value to identify women at risk of dystocia. 15,16 In

contrast, Liselele et al.17 showed that the addition of the

measurement of the transverse diagonal of the Michaelis

sacral rhomboid area (in short the Michaelis transverse,

Figure 1) to the maternal height could increase the sensitiv-

ity in predicting dystocia from 21% to 52%, with a positive

predictive value of 24%.

Our primary objective was to assess the accuracy of external

pelvimetry (specifically the addition of the measurement of

the Michaelis transverse to the maternal height) in the pre-

diction of dystocia in a different population. Our secondary

objective was to compare combinations of maternal height

with other external pelvic measurements, with the foot length

and the symphysis-fundus height, in order to identify nul-

liparous women at risk of dystocia.

Methods

Data were collected in one peripheral urban and the two referral

maternity units of Yaounde, the capital of Cameroon. All

centres offered antenatal and delivery care, including caesarean

section. Consecutive nulliparous women presenting at the ante-

natal clinics for a third trimester visit were included. A few

women with an obviously abnormal pelvis and women with

twin pregnancy were not included (exact number not recorded).

One research assistant (doctor or midwife) was trained to

perform the measurements in each centre. Maternal height,

pelvic and foot length measurements were performed at the

antenatal visit. Foot gauges were specially designed, fixing

a measuring tape on a wooden plank. Pelvic measurements

consisted of the antero-posterior diameter (also named Baude-

locque or external conjugate), the intertrochanteric diameter

and the Michaelis transverse (Figure 1). The Michaelis trans-

verse is defined by the distance between the two visible depres-

sions in the skin overfacing the sacro-iliac joints.

The antero-posterior and intertrochanteric diameters were

measured using a Breisky pelvimeter, while the Michaelis

transverse was measured using a tape measure. All measure-

ments were recorded to the nearest 0.5-cm interval. Results

were kept in a closed envelope attached to the antenatal file to

allow collection after delivery. These measurements were not

available to the clinician in charge of the delivery and thuswere not used for decision making during labour. Moreover,

the research assistants who performed the measurements were

not involved in the delivery. Symphysis-fundus height and

abdominal circumference were measured in the last 426

included women, at the admission for labour.

Information on mode of delivery and outcome was

obtained from the delivery room register. Exclusion criteria

at delivery were nonvertex presentation, birthweight less than

2500 g, elective caesarean section and caesarean section for

reasons other than dystocia.

Dystocia was defined as caesarean section for dystocia, as

assessed by the clinician in charge based on the partograph;

vacuum or forceps delivery after a prolonged labour (more

than 12 hours) or spontaneous delivery after a prolonged

labour associated with intrapartum death.

During the first phase of the study, data were collected

in the three centres, while during the second phase data

were collected only in one centre. During the first phase, the

antenatal measurements were performed by several observers

trained to perform the measurements by the principal inves-

tigator (A.R.) (phase 1, 467 women included), while during

the second phase, the antenatal measurements were per-

formed by a single observer who did not participate in this

training (phase 2, 340 women included).

Means were compared using the t-test. Cutoff values for allthe measurements were defined as the values closest to the 5th

and 10th percentiles of our population. These cutoffs were

chosen according to the results of the study by Liselele et al.17

Sensitivity, specificity, positive predictive value and the posi-

tive likelihood ratio (sensitivity divided by [1 specificity])

with their 95% confidence intervals (CI) were calculated

using these thresholds. Various combinations of maternal

height with pelvic, foot length and symphysis-fundus height

Figure 1. Intertrochanteric diameter (A); antero-posterior diameter (B);

blue bar: transverse diagonal of the Michaelis sacral rhomboid area (C).

Modified from Liselele HB, et al. BJOG 2000;107:94752. 17

Pelvimetry and height to predict dystocia

2007 The Authors Journal compilation RCOG 2007 BJOG An International Journal of Obstetrics and Gynaecology

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measurements were assessed. As an example, in the combina-

tion of the maternal height with the Michaelis transverse,

women at risk were either those with a maternal height infe-

rior or equal to the cutoff, or those with a Michaelis transverse

inferior or equal to the cutoff. The prediction of dystocia by

the different measurements and combinations was compared

when one or several observers performed the measurements.

Data management and analysis were performed using EpiInfo

version 6 (CDC, Atlanta, GA, USA) and Medcalc version 7.4

(MedCalc software, Mariakerke, Belgium).

Assuming a prevalence of dystocia of 10% and a proportion

of positive test results of 10%, we calculated that a sample size

of 610960 women was needed to obtain a precision of 10%

in the evaluation of sensitivity and predictive value of the test

ranging between 20% and 80%.

All participants gave oral informed consent. The study pro-

tocol was approved by the ethics committee of the Yaounde

University and by the authorities of the hospitals involved in

the study.

Results

Between March 2002 and April 2004, we included 893 women

at the antenatal clinics. After delivery, 86 women were

excluded for nonvertex presentation (n = 22); birthweight less

than 2500 g (n = 38); elective caesarean section (n = 2) and

caesarean section for reasons other than dystocia (n = 24).

Thus, the analysis included 807 nulliparous women who com-

pleted a trial of labour and delivered a single fetus in vertex

presentation weighing at least 2500 g (Figure 2).

The proportion of deliveries complicated by dystocia was

12.1% (98/807). There were 7.7% (62/807) caesarean section

for dystocia, 2.1% (17/807) vacuum or forceps after a pro-

longed labour and 2.3% (19/807) spontaneous deliveries after

a prolonged labour associated with intrapartum death. Over-

all, there were 62 perinatal deaths (77 per 1000 births) of

which 40 were associated with dystocia.

Maternal height, all pelvic measurements and foot length

were smaller in the dystocia group than in the normal delivery

group. Conversely, symphysis-fundus height and birthweight

were higher in the dystocia group. Abdominal circumference

was similar in the two groups (Table 1).

There was no significant difference in the distribution of

maternal height between women included during phase 1

(measurements performed by several observers) or phase 2(measurements performed by a single observer). The 5th per-

centile was 150 cm and the 10th percentile was 153 cm. In

contrast, there was a significant difference in the distribution

of the other measurements. The values, in centimetres, cor-

responding to the 10th percentile in phase 1 and phase 2 were,

respectively: Michaelis transverse 9.0 and 10.0; intertrochan-

teric diameter 20.0 and 23.0; antero-posterior diameter 18.0

and 17.0 and foot length 20.5 and 19.5. The different values

893 nulliparouswomen

Antenatal anthropometricmeasurements

Test positive, n = 109 Test negative

, n = 698

Excluded after delivery*n = 86

807 completed trials of labour

Dystocia,n = 52

No dystocia,n = 57

Dystocia,n = 46

No dystocia,n = 652

Figure 2. Stard flow diagram. *Excluded after delivery for: non-vertex

presentation (n = 22); birthweight less than 2500 g (n = 38);

elective caesarean section (n = 2); caesarean section for reasons

other than dystocia (n = 24). Test positive if maternal heigtht = 5th

percentile or Michaelis transverse = 10th percentile. Test negative

if maternal heigtht > 5th percentile and Michaelis transverse > 10th

percentile.

Table 1. Comparison of maternal characteristics and birthweight

between groups

Variables Normal

delivery

(n 5 709)

Dystocia

(n 5 98)

Pvalue*

Height 162.2 (5.7) 155.4 (6.3) , 0.001

Michaelis transverse 10.9 (1.1) 10.1 (1.6) , 0.001

Intertrochanteric diameter 25.1 (2.9) 23.9 (2.9) , 0.001

Antero-posterior diameter 21.2 (3.4) 19.4 (2.3) , 0.001

Foot length 22.9 (2.4) 21.4 (2.0) , 0.001

Symphysis-fundus height** 33.5 (2.7) 34.9 (2.9) , 0.001

Abdominal circumference** 94.5 (5.9) 94.5 (5.2) 0.997

Birthweight 3173 (404) 3463 (400) , 0.001

All measurements in centimetres, except birthweight in grams.

Values are given as means (SD).

*Computed by t-test.

**Measurements were performed in 426 women.

Rozenholc et al.



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corresponding to the tenth percentile in each phase were used

in the overall analysis. Therefore, cutoffs are reported as per-

centiles instead of centimetres.

Maternal height and the Michaelis transverse had the

highest sensitivity, specificity, positive predictive value and

positive likelihood ratio (Table 2). The intertrochanteric

diameter, the antero-posterior diameter, the foot length and

symphysis-fundus height did not predict as well. The combi-

nation of a maternal height less than or equal to the 5th

percentile or a Michaelis transverse less than or equal to the

10th percentile resulted in the best sensitivity, specificity, posi-

tive predictive value and positive likelihood ratio (Table 3).

The addition of a symphysis-fundus height superior or equal

to the 90th percentile to the above combination increased the

sensitivity, at the cost of an increased proportion of women

presumed to be at risk.

The prediction of perinatal death associated with dystocia

by the combination of maternal height with the Michaelis

transverse (sensitivity of 55.0% and specificity of 88.7%)was similar to the prediction of all cases of dystocia.

The prediction by all individual and combined measure-

ments was within the same range in the two phases of the

study (Table 4).

Discussion

This study confirms that the combination of the measure-

ments of the maternal height with the transverse diagonal

of the Michaelis sacral rhomboid area is a valuable method

to screen nulliparous women during pregnancy for the occur-

rence of dystocia at delivery.

The proportion of dystocia was 12.1%, within the range of

4.022.0% reported in sub-Saharan Africa.8,1821 The propor-

tion of caesarean section for dystocia was 7.7%, within the

range of 1.58.5% reported in the same countries.22 The pres-

ent work considered not only caesarean section, but other

outcomes of labour likely associated with dystocia and

focused on nulliparous women. These two factors contributed

to a relatively high percentage of dystocia. The proportion ofperinatal death among all deliveries and the fraction due to

Table 2. Prediction of dystocia by maternal height, external pelvimetry, foot length and symphysis-fundus height: univariate analysis

Sensitivity Specificity Positive predictive value Positive likelihood ratio

Height 5th percentile 28.6 (19.938.6) 98.4 (97.299.2) 71.8 (55.185.0) 18.4 (9.635.3)

Michaelis transverse 10th percenti le 45.9 (35.856. 3) 92.7 (90.594.5) 46.4 (36.256. 8) 6.3 (4.48.7)

Intertrochanteric diameter 10th percentile 26.5 (18.136.4) 88.9 (86.391.1) 24.8 (16.934.1) 2.4 (1.63.5)

Antero-posterior diameter 10th percentile 16.3 (9.625.2) 88.7 (86.190.9) 16.7 (9.825.6) 1.4 (0.92.3)Foot length 10th percentile 24.5 (16.434.2) 9 2.1 (89.994.0) 30.0 (20.341.3) 3.1 (2.04.7)

Symphysis-fundus height 90th percentile 28.3 (17.441.4) 89.1 (85.492.1) 29.8 (18.443.4) 2.6 (1.64.2)

Values are given as % (95% CI).

Table 3. Prediction of dystocia by combinations of maternal height with the Michaelis transverse, intertrochanteric diameter, foot length and symphysis-

fundus height

Combinations Women at risk Sensitivity Specificity Positive

predictive value

Positive

likelihood ratio

Height 5th percentile or Michaelis

transverse 10th percentile

13.5 53.1 (42.763.2) 92.0 (89.793.9) 47.7 (38.057.5) 6.6 (4.89.0)

Height 5th percentile or

intertrochanteric diameter 10th percentile

16.6 46.9 (36.857.3) 87.6 (84.989.9) 34.3 (26.343.0) 3.8 (2.85.0)


foot length 10th percentile

12.8 42.9 (32.953.2) 91.4 (89.193.4) 40.8 (31.250.9) 5.0 (3.56.9)


symphysis-fundus height 90th percentile

11.6 43.9 (33.954.3) 92.8 (90.694.6) 45.7 (35.456.3) 6.1 (4.38.6)


Michaelis transverse 10th percentile or

symphysis-fundus height 90th percentile

19.7 64.3 (54.073.7) 86.5 (83.788.9) 39.6 (32.047.7) 4.7 (3.76.0)

Values are given as % (95% CI).



633


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dystocia were comparable to those usually reported in sub-

Saharan Africa.4,8

A meta-analysis of the value of maternal height as a risk

factor for dystocia showed the 5th percentile to have a sensi-

tivity of 21.0%, a specificity of 95% and a positive likelihood

ratio of 4.2.9 The prediction by the maternal height obtained

in our study was slightly higher. In our setting, clinicians may

have had a tendency to diagnose dystocia excessively when

caring for short women.

The prediction by the Michaelis transverse that we found

was very close to that by Liselele et al.,17 who reported a

sensitivity of 42.9%, a specificity of 91.1% and a positive

likelihood ratio of 4.8 for the 10th percentile. Likewise, the

sensitivity, specificity and likelihood ratio of the combina-

tion of a maternal height less than or equal to the 5th per-

centile or a Michaelis transverse less than or equal to the 10th

percentile obtained here were similar to those obtained by

Liselele (respectively, 52.4%, 87.0% and 4.0). The positive

predictive value was higher in our study, because of a higher

percentage of dystocia and possibly because of the overesti-mation of the positive predictive value of the maternal

height. The high specificity would result in a limited per-

centage of unnecessary referrals, minimising the burden on

district hospitals.

Significant variations in the distribution of the Michaelis

transverse measurement between phase 1 and 2 question the

reproducibility of this measurement. Agreement was not

evaluated in this study. Nevertheless, this measurement had

similar prediction when performed by several observers or by

a single observer, provided that the cutoff was determined as

a percentile of the distribution in each phase, instead of a sin-

gle value in centimetres in the whole population. The observ-

ers performing the measurements during phase 1 were

instructed to measure the distance between the middle points

of the two depressions defining the Michaelis transverse. Dur-

ing phase 2, the observer, who was not instructed specifically,

measured the distance between the lateral edges of the depres-

sion. This difference in the measurement technique likely

corresponds to the overestimation noticed during phase 2.

This emphasises the need for standardisation of the measure-

ment technique, which would allow the determination of

a single cutoff for a population measured by several observers,

as in phase 1.

The measurements of the intertrochanteric and antero-pos-

terior diameters, and the foot length either separately or in anycombination did not result in improved prediction. The sym-

physis-fundus height, which was the only measurement related

to the fetal component of dystocia, was also unhelpful.

The value in centimetre corresponding to the 10th per-

centile of the Michaelis transverse in phase 1 was the same in

our population than in the study by Liselele et al.17 in Zaire.

This suggested that, as for maternal height (less than or

equal to 150 cm), a cutoff for the Michaelis transverse (lessTable

4.

Comparisonofpred

ictionbymeasurementsperformedduringpha

se1(severalobservers)orphase2(oneobserv

er)

Sensitivity

Specificity

Positive

predictive

value

Positive

likelihood

ratio

Phase

1

Phase

2

Phase

1

Phase

2

Phase

1

Phase

2

Phase

1

Phase

2

Height

5thpercentile

35.4

(22.250.5

)

22.0

(11.536.0

)

98.1

(96.399.2

)

99.0

(97.099.8

)

68.0

(46.585.0

)

78.6

(49.295.3

)

18.5

(8.539

.8)

21.3

(6.668.6

)

Michaelistransverse

10thp

ercentile

50.0

(35.264.8

)

42.0

(28.256.8

)

91.4

(88.393.9

)

94.5

(91.296.8

)

40.0

(27.653.5

)

56.8

(39.572.9

)

5.8

(3.88.7

)

7.6

(4.313.4

)

Height

5thpercentileor

Michaelistransverse

10th

percentile

58.3

(43.272.4

)

48.0

(33.762.6

)

90.5

(87.293.1

)

94.1

(90.896.5

)

41.2

(29.453.8

)

58.5

(42.173.7

)

6.1

(4.18.8

)

8.2

(4.714.0

)

Valuesaregivenas%

(95%

CI).

Rozenholc et al.



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than or equal to 9.0 cm) may be applicable in different

populations.

The size of the Michaelis transverse is associated with the

transverse pelvic capacity. Among black women, the propor-

tion of anthropoid pelvises, characterised by a reduction in

the pelvic transverse diameters, is twice that in white

women.23 Therefore, in black women, the transverse pelvic

capacity may be more critical during labour, and the Michae-

lis transverse may be more associated with dystocia than in

white women. Anyhow, most white women live in the West-

ern world where caesarean section during labour is readily

available, limiting the interest of screening for dystocia. In

Chinese women, the proportion of anthropoid pelvises is

intermediate between white and black women,24 and this

method could be useful.

The effects of the implementation of this screening method

should be evaluated in a randomised controlled trial.

Conclusion

This simple antenatal screening method could be imple-

mented in centres without operative capability, for timely

referral of women at risk, for delivery in district hospitals. It

must be underlined that all referred women should be allowed

a trial of labour, as this is a screening and not a diagnostic test.

Acknowledgements

We thank Professor Fritz Baumann, for his help throughout

the study and Prof. Guillaume Atchou for his support during

the visits in Cameroon.

Funding

Fondation Suisse pour la Sante Mondiale, Thonex,

Switzerland. j

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