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Received: 10 October 2018    Revised: 26 February 2019    Accepted: 4 July 2019    First published online: 29 July 2019

DOI: 10.1002/ijgo.12906

CLINICAL ARTICLE
Obstetrics

Assessment of labor progression by intrapartum

ultrasonography among term nulliparous women

Anubhuti Mohan1,* | Pratima Mittal1 | Rekha Bharti1 | Shabnam Bhandari Grover1 | 

Jyotsana Suri1 | Usha Mohan2

1
Vardhman Mahavir Medical College and
Safdarjung Hospital, New Delhi, India
2
Shishu Mangal Maternity and Fertility
Clinic, New Delhi, India
*Correspondence
Anubhuti Mohan, B-2/30 A, Yamuna Vihar,
Delhi-110053, India.
Email: anubhutimohan@gmail.com
Abstract
Objective: To assess cervical dilation, fetal head station, and fetal head position by
intrapartum ultrasonography and to compare the approach with digital vaginal
­examination (DVE).
Methods: An observational study conducted from October 2015 to January 2017
among term nulliparous women in active labor at a tertiary hospital in Delhi, India.
Cervical dilation, head station, and head position were assessed by DVE, followed by
ultrasonography within 10 minutes. The women's preference was also evaluated.
Results: Overall, 458 observations were obtained for 215 women. Cervical dilation
measured by DVE was strongly correlated with ultrasonography findings (intraclass cor-
relation coefficient, 0.945; 95% confidence interval, 0.932–0.956; κ=0.837; P<0.001).
Data for fetal head station and head position showed a fair correlation (κ=0.353 and
κ=0.554, respectively; both P<0.001). The majority of women (186/215, 87%) reported
a preference for ultrasonography over DVE for assessment of labor progression in a
future pregnancy.
Conclusion: Intrapartum ultrasonography was preferred as an objective assessment tool
for labor progression among term nulliparous women and therefore should be practiced
in all labor rooms. Further studies on interobserver variation are recommended to
establish the reproducibility of intrapartum assessment by ultrasonography.

KEYWORDS
Cervical dilation; Head position; Head station; Sonopartograph; Transperineal ultrasound

1 | INTRODUCTION
Monitoring the progress of labor is important to prevent maternal and
1
fetal complications. There is huge variation in the duration of labor
among women. It is recommended that women should be allowed
to labor for longer durations so that vaginal delivery can be accom-
2
plished. Currently, monitoring the progress of labor is done by digital
vaginal examination (DVE). Although there are no guidelines on the
frequency of DVE in active labor, it is often repeated at 2–4-­hour inter-
vals. Women with slow progression of labor may undergo more DVEs
as compared with those with fast progression. Repeated DVEs may
cause physical pain and psychologic trauma to the laboring woman.3
Despite being the “gold standard” for obstetric practice, DVE is a
subjective evaluation with several limitations and is dependent on the
clinician's skill.4 In addition, it is subjective, imprecise, and associated
with interobserver variations, and it carries the risk of infection when
done repeatedly.5,6 For example, the risk of chorioamnionitis has been
reported to vary from 4% for 2 DVEs to 10% for 13 DVEs.6 Therefore,
the WHO has recommended that the number of DVEs for assessment
of labor progression should be restricted.1 International societies have
also recommended the need for further research aiming to reduce the
number of DVEs in labor.7
Intrapartum ultrasonography is available in most labor units and
is currently being used for confirmation of fetal presentation in early

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© 2019 International Federation of Int J Gynecol Obstet 2019; 147: 78–82
Gynecology and Obstetrics
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labor, for localization of fetal heart and placenta, and more recently
for accurate assessment of fetal head station and fetal head position
before instrumental vaginal delivery.8,9 It has also been proposed as a
tool for assessing labor progression by extending its use to determine
cervical dilation, and fetal head station and position. 10
With the use of
ultrasound, labor monitoring may be more objective and less intrusive.
The primary aim of the present study was therefore to evaluate
the application of ultrasonography to the measurement of cervical
dilation, fetal head station, and fetal head position among nulliparous
women in active labor and to compare the findings with those of DVE.
A secondary aim was to evaluate the women's preference for ultraso-
nography in relation to DVE during labor.
2 | MATERIALS AND METHODS
The present analytical observational study was conducted among
women in labor attending Safdarjung Hospital, New Delhi, India, a ter-
tiary care center, between October 1, 2015, and January 31, 2017.
Study approval was obtained from the Ethics Committee of Vardhman
Mahavir Medical College and Safdarjung Hospital, Government of India.
All participants provided written informed consent before enrollment.
During the 16-­month study period, women in active labor were
recruited on two fixed days each week. The study included nulliparous
women with a term singleton pregnancy and cephalic presentation in
active labor (cervical dilation, ≥4 cm by DVE). Women with language
problems or learning impairment, fetal macrosomia, intrauterine death,
or previous cervical surgery (e.g., cone biopsy, cervical cerclage), and
those with a medical emergency (e.g., eclampsia, heart disease NYHA
grade 3 or 4, severe respiratory distress) requiring immediate attention
and/or delivery were excluded.
For assessment of labor progression, participants were laid in the
dorsal position with hips and knees flexed. With all aseptic precau-
tions, dilation of the cervix, fetal head station, and fetal head position
were assessed, first, by DVE performed by the attending obstetrician;
and second, by ultrasonography performed within 10 minutes of DVE.
The pelvic examinations were repeated after 4 hours and thereafter
every 2 hours until the participant delivered. The DVE findings were
used to manage the participants.
For measurement of fetal head station by DVE, the relation of
the leading part of the fetal head (vertex) to the ischial spine was
recorded as follows: each centimeter above the ischial spine was
taken as −1, and each centimeter below as plus 1 (i.e., from −5 to
+5, with 0 at the ischial spine). For the purpose of comparing the
DVE and ultrasonography findings, the head station result from
DVE was converted to the distance between the leading part of the
fetal head and the perineum in centimeters, where −5 was taken
as 10 cm, 0 as 5 cm, and +5 as 0 cm. For measurement of the fetal
head position by DVE, the position of the posterior fontanelle was
recorded in the form of a 12-­hour clock with the examiner facing
the perineum (Table 1).
After the completion of DVE, ultrasonography was performed
within 10 minutes. All examinations were performed by the same
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      79
T A B L E   1   Position of fetal head by 12-­h clock system.
Time on clocka Position of fetal head
11:30–12:30 Occiputo-­anterior position (OA)
12:30–2:30 Left occiputo-­anterior position (LOA)
2:30–3:30 Left occiputo-­transverse position (LOT)
3:30–5:30 Left occiputo-­posterior position (LOP)
5:30–6:30 Occiputo-­posterior position (OP)
6:30–8:30 Right occiputo-­posterior position (ROP)
8:30–9:30 Right occiputo-­transverse position (ROT)
9:30–11:30 Right occiputo-­anterior position (ROA)
a
Position of the occiput with the examiner facing the perineum.
sonographer (AM), who was blind to the results of DVE, using an
SSA640 A instrument (Toshiba, Delhi, India) with a 3–5-­Hz probe.11
The details of the examination were recorded on a pre-­prepared pro-
forma and the observations were plotted on a WHO partograph.
Transabdominal examination was performed with a 3–5-­Hz two-­
dimensional ultrasonography probe using the fetal spine as a land-
mark and assuming occiput to be on the same side as the fetal spine.
The fetal head position was recorded by the 12-­hour clock system
(Table 1). The probe was then covered with a sterile latex glove and
ultrasound jelly, and placed in an antero-­posterior direction on the
perineum. The anterior lip of the cervix was identified, and the probe
was rotated in a transverse direction keeping the anterior lip of cervix
in view. Cervical dilation was measured in two planes by keeping the
cursors on the inner rim of the cervix on either side, and the mean of
the two observations was recorded (Supplementary Fig. S1). A slight
tilting of the probe revealed the fetal head position; the head sta-
tion was assessed by measuring the shortest distance between the
outer bony limit of the fetal skull and the perineal skin in centimeters
(Supplementary Fig. S2).
The participants’ preference for ultrasonography or DVE was
evaluated by asking the women which method they would prefer for
assessment of labor progression in a subsequent pregnancy.
The data were analyzed by using SPSS version 21.0 (IBM, Armonk,
NY, USA). Categoric variables were presented as number (percentage)
and continuous variables as mean ± SD (range). Qualitative variables
were correlated by using χ2 test. κ coefficient was used to measure
the agreement between DVE and ultrasonography for cervical dilation,
fetal head station, and fetal head position. A P value of less than 0.05
was considered to be statistically significant.
3 | RESULTS
During the study period, 215 women were enrolled. Among these
women, 20 delivered after the first labor assessment, 162 after the
second, 18 after the third, and 15 after the fourth. Thus, a total of 458
observations were obtained by both DVE and ultrasonography.
The mean ± SD age of the women was 23.1 ± 2.7 years (17–
32 years), and the mean gestational age was 38+3 weeks (SD, 2 days;
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80       Mohan ET AL.

T A B L E   2   Characteristics of women undergoing DVE and T A B L E   3   Agreement between DVE and ultrasonography findings.
ultrasonography examination.
No. (%) of observations
Characteristic Value (n=215) Measurement in agreement (n=458)

Maternal age, y Cervical dilation, cm

≤20 37 (17.2) Agree within ± 1.0 341 (74.5)
21–25 144 (67.0) Agree within 1.1–2.0 103 (22.5)
26–30 32 (14.9) Agree within 2.1–3.0 13 (2.8)
>30 2 (0.9) Differ by >3.0 1 (0.2)
BMI Fetal head station, cma,b
18.5–22.9 148 (68.8) 0–2.0 (n=134) 120 (89.5)
23.0–24.9 57 (26.5) 2.1–4.0 (n=125) 108 (86.4)
25.1–29.9 10 (4.7) 4.1–6.0 (n=124) 45 (36.2)
Gestational age, wk >6.0 (n=75) 0 (0)
+0 +6
37 –37 46 (21.4) Fetal head position
+0 +6
38 –38 64 (29.8) Agree completely 353 (77.1)
+0 +6
39 –39 63 (29.3) Agree within ± 45° 23 (5.0)
+0 +6
40 –40 35 (16.3) Differ by >45° 38 (8.3)
>41 7 (3.2) Not assessed by DVE 44 (9.6)
Birthweight, kg Abbreviations: DVE, digital vaginal examination; USG, ultrasonography.
a
<2.5 50 (23.2) None of the 75 observations where fetal head was >6 cm on DVE was in
agreement with the findings of ultrasonography.
2.5–3.5 159 (74.0) b
n is the number of observations with mentioned fetal head station on
>3.5 6 (2.8) DVE and no. of observations agreeing with USG in each row is mentioned
Type of labor in 2nd column.

Spontaneous 173 (80.5)

Induced 42 (19.5)
ultrasonography in all cases. In 376/458 (82.1%) observations, the
Abbreviation: DVE, digital vaginal examination.
head position on ultrasound was within 45° of the DVE assessment
(Table 3). The agreement between the two techniques was fairly well
range 37–42 weeks). Labor was spontaneous for 173 (80.4%) women correlated (κ=0.554; P<0.001).
and induced owing to maternal and fetal indications for 42 (19.5%) The women's preference for type of examination was evaluated.
women (Table 2). There were 11 (5.1%) operative vaginal deliveries Overall, 186 (86.5%) of the 215 women would prefer ultrasonog-
and 6 (2.7%) cesarean deliveries. The proportion of cesarean delivery raphy over DVE for the assessment of labor progression in a future
was lower than that of the study institution (28%) due to the study ­pregnancy (Table 4).
population of low-­risk nulliparous women in active labor.
All 458 observations included measurement of cervical dilation
by both DVE and ultrasonography, and the majority of measure- 4 | DISCUSSION
ments (341/458; 74.5%) were within ± 1 cm (Table 3). The intraclass
correlation coefficient (ICC) for the two methods showed a high The present study investigated the use of intrapartum sonography to
association (ICC, 0.945; 95% confidence interval [CI], 0.932–0.956) monitor the progress of labor. The study found a strong correlation
and the agreement between DVE and ultrasonography was strong between DVE and ultrasonography findings for cervical dilation (ICC,
(κ=0.837, P<0.001).
Similarly, fetal head station was measured by both DVE and ultra- T A B L E   4   Patient's preference for ultrasonography and digital
sonography in all 458 observations. Even for women with a finding vaginal examination.
of +2 to +3 caput succedaneum, fetal head station could be assessed
No. (%) of
without any difficulty by ultrasonography. The agreement between Preference women (n=215)
DVE and ultrasonography observations of fetal head station is summa-
Ultrasonography 186 (86.5)
rized in Table 3. The strength of agreement between two techniques
DVE 15 (7.0)
was fair (κ=0.353, P<0.001).
Equivocal 9 (4.2)
The fetal head position could not be determined by DVE in
44/458 (9.6%) observations owing to the presence of caput. By No comment 5 (2.3)

contrast, fetal head position was determined by transabdominal Abbreviation: DVE, digital vaginal examination.
Mohan ET AL.
0.945; 95% CI, 0.932–0.956; κ=0.837, P<0.001), whereas the cor-
relation for fetal head station (κ=0.353, P<0.001) and head position
(κ=0.554, P<0.001) was fair. Most of the women (186/215, 86.5%)
reported a preference for ultrasonography over DVE for the assess-
ment of labor progression in a future pregnancy.
At the assessment on enrollment, cervical dilation was deter-
mined to be less than 4 cm by transperineal ultrasonography for
37 (17.2%) women; this value was below the DVE cutoff of 4 cm or
more used for participant recruitment. In 192 assessments, cervical
dilation was less than 6 cm and there was no difficulty in measur-
ing it by ultrasonography because the whole of the cervical rim was
clearly visible. For a cervical dilation of 6–8 cm, 50%–75% of the
cervical rim was visible; and for 8–9 cm, only 25% of the rim was
visible (the anterior and posterior lips). The cervix was not visualized
by ultrasonography in 127 (27.7%) assessments and was recorded
as fully dilated. Of these, 8 (6.2%) women had a cervical dilation of
8 cm by DVE, 31 (24.4%) had one of 9 cm, and 88 (69.2%) had a fully
dilated cervix by DVE. The inability to measure cervical dilation by
ultrasound in up to one-­third of assessments has been reported in
other studies.10,12 Benediktsdottir et al.12 were also unable to mea-
sure cervical dilation by ultrasonography for 65% of women with
12
dilation of 8 cm or more.
In the present study, 341 (74.4%) observations of cervical dilation
on ultrasonography were within ± 1 cm of the reading obtained on
DVE. Benediktsdottir et al.12 similarly reported that a high percent-
age of ultrasound measurements of cervical dilation were within 1 cm
of DVE. The present study found a strong correlation between DVE
and ultrasonography for cervical dilation (ICC, 0.945; 95% CI, 0.932–
0.956; κ=0.837, P<0.001). A significant correlation between DVE and
13,14
ultrasound findings has been reported in other studies.
The mean difference between the DVE and ultrasound measure-
ment for cervical dilation was 0.2 cm (95% CI, −1.3 to 1.7). This differ-
ence was less than that reported by Hassan et al.10 (1.16 cm; 95% CI,
13
−0.76 to 3.08) and Yuce et al. (10 mm; 95% CI, −36 to 16). However,
in a pilot study, Hassan et al.14 reported a difference of 0.08 cm (95%
CI, −1.83 to 2.00) between DVE and ultrasound measurements of
­cervical dilatation.14
Assessment of fetal head station by ultrasonography has been
proposed as a tool to ascertain whether descent of the head has
failed, and thereby predict the mode of delivery. Various ultrasound
measurements have been described to assess head station including
angle of progression, head to perineum distance, and head to sym-
physis distance. Head to perineum distance was used in the present
study because it is relatively easy to measure as compared with other
parameters.15 Indeed, fetal head station was measured by sonogra-
phy without difficulty in all 458 assessments; the measurement was
possible even in for women with +2 to +3 caput succedaneum. Of
134 assessments with a head to perineum distance of less than 2 cm
by ultrasonography, 120 (89.5%) showed the same distance on DVE.
Furthermore, there was 100% agreement between ultrasonography
and DVE findings when the head to perineum distance was less than
1 cm. The strength of agreement between DVE and ultrasonography
was found to be fair (κ=0.353, P<0.001). Hassan et al.10 also observed
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moderate correlation of head to perineum distance measured by ultra-
sonography and DVE (r2=0.33, P<0.001). By contrast, Tutschek et al.16
reported a weak correlation of DVE and intrapartum translabial ultra-
sonography measurements for head station (head to perineum dis-
tance, angle of progression, and head to symphysis distance).
Ultrasonography has been found to be superior to DVE for accu-
rately determining fetal head position.17,18 The position of the fetal
head was measured by transabdominal ultrasound in all 458 assess-
ments in the present study, whereas the position of the fontanelle
could not be determined by DVE in 44 (9.6%) observations. In 27
(61.4%) of these cases, the sagittal sutures were felt but the exact
position of head could not be determined. In the other 17 (38.6%)
cases, even the position of sagittal sutures could not be determined
due to presence of a large caput. Chou et al.19 reported finding fetal
head position accurately in 71.6% of DVEs versus 92.0% of ultrasound
examinations. Hassan et al.10 obtained fetal head position in 98% of
ultrasonography examinations but only 46% of DVEs.10 Akmal et al.20
and Souka et al.21 also failed to define fetal head position in 33.5%
and 60.7% DVEs, respectively. In the present study, fetal head posi-
tion was determined in a higher proportion of DVEs as compared with
previous studies probably because the majority of assessments in pre-
vious studies were performed by midwives, whereas all DVEs were
performed by the attending obstetrician in the present study. This is
in agreement with a study reporting that the rate of correct identifi-
cation of fetal position by DVE was higher for obstetricians than for
midwifes (50% vs 30%).22
In the present study, absolute agreement for fetal head posi-
tion between ultrasonography and DVE was observed in 77.1% of
assessments; this increased to 82.1% for agreements within ±45°.
The ultrasound findings correlated fairly well with DVE (κ=0.554,
P<0.001). Souka et al.21 reported a similar correlation for fetal head
position (κ=0.59).
The majority of the study women (186, 86.5%) found ultrasonog-
raphy to be less distressing than DVE and expressed a preference for
ultrasound assessment during their next labor. Previous studies have
also found intrapartum ultrasonography to be less painful than DVE
and have described the potential advantage of ultrasonography in
labor units where routine epidural analgesia is not used.11,13
The main strengths of the study were that all of the study
women underwent both DVE and ultrasonography and that all
ultrasound examinations were performed by the same observer.
The main limitations of the study were the small sample size and
the fact that the DVEs were not performed by the same observer.
In addition, the outcomes of labor among women undergoing only
DVE and those undergoing only ultrasonography for labor progres-
sion were not compared.
In conclusion, intrapartum ultrasound was found to be a use-
ful tool for monitoring labor progression during the active phase
among term nulliparous women. The agreement between DVE and
ultrasound findings was strong for cervical dilation, and fair for fetal
head station and head position. Most laboring women reported that
ultrasonography is less distressing and preferred it over DVE for
assessment of labor.
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82       Mohan ET AL.
AUTHOR CONTRI B UTI O N S
AM contributed to study conception and design, and data acquisi-
tion, analysis, and interpretation. PM and RB contributed to study
conception and design, and data analysis and interpretation. SB
and JS contributed to data analysis and interpretation. UM contrib-
uted to study conception and data analysis. All authors contributed
to drafting the manuscript and revising it critically for important
intellectual content.
CO NFLI CTS OF I NTE RE ST
The authors have no conflicts of interest.
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S U P P O RT I NG I NFO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
Figure S1. Measurement of cervical dilation by transpe-
rineal ultrasonography.
Figure S2. Measurement of fetal head station by ultrasonography as
head to perineum distance.