STUDY ON COMPARISON OF TRANSVAGINAL

CERVICAL LENGTH AND BISHOP SCORE IN

PREDICTING SUCCESSFUL LABOUR INDUCTION
By
Dr. Sr. REEJA M. MATHEW, M.B.B.S

A Dissertation Submitted to the
Rajiv Gandhi University Of Health Sciences, Bangalore,
Karnataka,
In partial fulfillment
Of the requirement for the degree of

M.S.OBSTERTRICS &GYNAECOLOGY
Under the guidance of
Dr .C.N. SHEELA, M.D,

DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
ST.JOHNS MEDICAL COLLEGE & HOSPITAL
BANGALORE- 560 034
2011

DECLARATION BY THE CANDIDATE



I hereby declare that this dissertation entitled Study On comparison of trans
vaginal cervical length and bishop score in predicting successful labour
induction is a bonafide and genuine research work carried out by me under
the guidance of Dr. C.N.Sheela MD, Professor , Department of obstetrics and
gynaecology, St. Johns Medical College & Hospital, Bangalore.





Dr.Sr. Reeja M. Mathew,
Post Graduate Student,
Department of OBG,
Date: St.Johns Medical College & Hospital, Bangalore.
Bangalore.




CERTIFICATE BY THE GUIDE


This is to certify that this dissertation titled Study on comparison of
transvaginal cervical length and bishop score in predicting successful labour
induction is a bonafide research work done by Dr. Sr. Reeja M. Mathew,
Postgraduate MS student in the Department of Obstetrics & Gynaecology at
St.Johns Medical College & Hospital, Bangalore, in partial fulfillment of the
requirement for the degree of M.S in Obstetrics & Gynaecoloy.


Date:

Bangalore

Dr.C.N.Sheela,
Professor,
Department of OBG,
St. Johns Medical College & Hospital,
Bangalore.













ENDORSEMENT BY THE HOD, PRINCIPAL/ HEAD OF THE INSTITUTION


This is to certify that this dissertation titled Study on trans vaginal cervical
length and bisop score in predicting successful labour induction is a
bonafide research work done by Dr Sr. Reeja M. Mathew, Postgraduate MS
student in the Department of Obstetrics And Gynaecology, St.Johns Medical
College & Hospital, Bangalore, under the guidance of Dr. C.N. Sheela MD,
Professor , Department of Obtetrics and Gynaecology, St.Johns Medical College
and Hospital, Bangalore.





Dr Prem Pias, MD DR Annamma Thomas MD
Dean, Professor ,
St Johns Medical College Department Of Obstetrics & Gynae,
Bangalore,560034 St Johns Medical College


Date: Date:
Place:Bangalore. Place: Bangalore.




COPY RIGHT



DECLARATION BY THE CANDIDATE




I hereby declare that the Rajiv Gandhi University of Health Sciences, Karnataka
shall have the rights to preserve, use and disseminate this dissertation / thesis in
print or electronic format for academic/ research purpose.


Dr.Sr Reeja M. Mathew,
Post Graduate student,
Department of OBG,
St.Johns Medical College & Hospital,
Bangalore





Date:
Place:Bangalore.




ACKNOWLEDGEMENT ACKNOWLEDGEMENT ACKNOWLEDGEMENT ACKNOWLEDGEMENT


I express my sincere and heartfelt gratitude to my respected Professor and guide
Dr. Dr. Dr. Dr.C.N. C.N. C.N. C.N. Sheela Sheela Sheela Sheela, professor,Department of Obstetrics And Gynaecology St. Johns Medical
College & Hospital for his invaluable guidance, constant support and encouragement at every
stage of this work . Indeed I am fortunate to get the benefit of her vast experience and advise
at every step of my study.
I am extremely grateful to Dr Dr Dr Dr Annamma Thomas, DR. Rita Mhaskar, Annamma Thomas, DR. Rita Mhaskar, Annamma Thomas, DR. Rita Mhaskar, Annamma Thomas, DR. Rita Mhaskar, Dr A Dr A Dr A Dr Arun Mhaskar run Mhaskar run Mhaskar run Mhaskar
and all my teachers in the department of Obtestrics & Gynaecology, for their support and
valuable suggestions at every stage of my study.
I express my sincere thanks to Department Of Radiology Department Of Radiology Department Of Radiology Department Of Radiology for their help and support in
completing my study
With deep sense of gratitude, I thank my colleagues, and my fellow postgraduates.
I will be ever thankful to my statistician Dr Dr Dr Dr.TINKU .TINKU .TINKU .TINKU SARAH SARAH SARAH SARAH for her guidance and help.
Above all, I thank all my patients patients patients patients who were the subjects of my dissertation and without whose
co-operation; this study would not have been possible.
I will always be grateful to sisters of F.C.C. F.C.C. F.C.C. F.C.C.family family family family, my parents, my friends parents, my friends parents, my friends parents, my friends and Th Th Th The Almighty e Almighty e Almighty e Almighty
in helping me complete this work. in helping me complete this work. in helping me complete this work. in helping me complete this work.
Reeja Reeja Reeja Reeja Mathew Mathew Mathew Mathew

ABBREVIATIONS
FFN -Fetal Fibronectin
MMP -Matrix Metalloproteinase
TVU -Trans Vaginal Ultrasound
TVU CL -Trans Vaginal Ultrasonic Cervical Length
PTB -Preterm Birth
PPROM -Pre term Premature Rupture Of Membrane
LIF - Light Induced Fluorescence
FHR -Fetal Heart Rate
PGF2 -Prostaglandin F2
PGE2 -Prostaglandin E2
IOL - Induction of Labor
MU -Montevideo Unit
kPas -kilo Pascal second












ABSTRACT


Objectives: To compare the predictive value of the Bishop Score and Transvaginal
ultrasonographic cervical length in successful labour induction
To estimate the most useful cutoff points for the two methods
Study design: It is a prospective observational study.In this study 100 primigravida with
gestational age of 37-42 weeks of gestation admitted for induction of labour ,the cervical length
was measured by transvaginal ultrasound and then Bishop Score was assessed by digital
examination. Predictive values for successful labour induction was detected and compared.
Results: Using Spearmans rho correlation both TVS cervical length and Bishop score have
significant correlation in predicting the success of induction of labour. Cervical length is the
better predictor of the likelihood of delivering vaginally within 24hrs. In the receiver operating
characteristic curves,the best cutoff points for the prediction of successful induction was 26mm
for cervical length and 4 for the Bishop Score. However, cervical length appears to be a better
predictor than the Bishop Score, with a sensitivity of 58.1% and a specificity of 100% compared
to 70.3% and 45.5% respectively.
Conclusion : Transvaginal sonographic measurement of cervical length is a better predictior of
the likelihood of vaginal delivery within 24hrs of induction when compared to Bishop Score.







CONTENTS




1. INTRODUCTION. 1

2. AIMS AND OBJECTIVES..3

3. REVIEW OF LITERATURE...5

4. MATERIALS AND METHODS.......39

5. RESULTS.42

6. DISCUSSION........57

7. CONCLUSION.63

8. BIBLIOGRAPHY 64

9. ANNEXURE 75

PROFORMA.........75

KEY TO MASTER CHART.77

MASTER CHART..80




Page No
LIST OF TABLES

SL.No. TITLE Page
No.

1. Age distribution


42
2. Distribution of gestational age


43
3. Indications for induction of labour


44
4. Distribution of the Bishop Score


45
5. Distribution of TVS cervical length


46
6. Mode of delivery


47
7. Indications for LSCS


48
8. Fetal outcome variable


49
9. Percentage of NICU admission


49
10. Primary outcome measures


50
11. Mean Bishop Score &TVS length


50
12. Correlation of outcome measures


50
13. Predictive values

55
14. Comparison of predictive values


56
LIST OF FIGURES
SL.No.


TITLE Page No.
1. Age distribution


42
2. Indications for induction


44
3. Distribution of Bishop Score


45
4. Distribution of cervical length


46
5. Mode of delivery


47
6. Indications for LSCS


48
7. Mean Bishop score


51
8. Mean cervical length


52
9. ROC Curve for correlation of Bishop Score


53
10. ROC Curve for correlation of cervical length


54

1


INTRODUCTION

Induction of labour is carried out in approximately 20% of pregnancies.
1
The commonest
indication for induction is prolonged pregnancy, and several studies have shown that induction,
compared to expectant management, is associated with a substantial reduction in perinatal
mortality.
2-4
The traditional method of predicting whether an induced labour will result in
successful vaginal delivery is based on the pre-induction favorability of the cervix as assessed by
the Bishop score. However, this assessment is subjective and several studies have demonstrated a
poor predictive value for the outcome of induction especially in women with a low Bishop
socre.
5

Transvaginal ultrasonography has gained increasing application in obstetric in the area of
induction of labor. Transvaginal cervical length measurement has primarily focused on detecting
cervical changes in women at risk for preterm delivery.
6
Theoretically, transvaginal
ultransonographic measurement of the cervix could represent a more accurate assessment of the
cervix than digital examination, because the supra vaginal portion of the cervix usually
comprising about 50% of the cervical length is very difficulty to asses digitally in a closed
cervix. In addition, the assessment of the effacement which starts at the internal OS will be
difficult to predict in a closed cervix. In contrast sonographic measurement of the cervical length
is quantitative and easily reproducible method of assessing the cervix which can be achieved
easily with minimal discomfort to the patient.
This study was undertaken, to determine if transvaginal ultrasound, with its ability to
objectively measure the cervical length, could predict the outcome of induction better than
2

clinical assessment obtain by the Bishop score, if so, transvaginal ultrasonographic measurement
of cervical length can be used as an adjunct tool to the traditional Bishop score and add yet
another dimension of information in the field of successful induction of labour.




















3

OBJECTIVES OF THE STUDY

1. To compare the predictive value of the Bishop score and transvaginal ultrasonography in
successful labour induction.
2. To estimate the most useful cutoff points for the two methods.


















4

NEED FOR THE STUDY:
Labour induction is one of the common interventions in obstetric practice. Assessment of
cervix has been used as a prediction of the successful vaginal delivery. Traditionally, the bishop
score has been used to assess the cervix. Bishop originally observed that nulliparous women
undergoing induction of labour with a cervical score >8 had the same likelihood of vaginal
delivery as did women in spontaneous labour.
7
Labour induction with a low cervical score has
been associated with failure of induction, prolonged labour, and a high rate of cesarean
deliveries.
Recently transvaginal ultrasonographic measurement of cervical length has been linked
with the risk of preterm delivery.
8
Cervical shortening, as seen in sonograms, has been proposed
as representative of the process of cervical effacement.
9

A text book of obstetric described a successful labour induction as the initiation of
labour.
10
Active labour, represented by cervical dilatation of 3-4cem or greater in the presence of
uterine contractions, is usually considered a reasonable threshold for diagnosis of labour because
of the uncertainties in diagnosing true labour during earlier stages of cervical dilation.
This study is designed to investigate transvaginal ultrasonographic cervical measurement
as a predictor of duration of labor and successful induction resulting in vaginal delivery and also
compare the performance of ultransonographic cervical measurement with that of the Bishop
score in predicting the outcome of labour induction.




5

REVIEW OF LITERATURE
Pre induction scoring to predict successful labour induction- Historic Perspectives:
More than 12 different pelvic or cervical scoring schemes have been described during the
past 70 years, but the semi quantitative clinical scoring system described by the bishop is the
most widely employed (Bishop 1964)
Fetal Fibronectin (FFN) concentrations in the cervical transudate represent a laboratory
approach and have been shown to correlate with induced labour outcome with concentration
<50mcg /ml associated with a favorable cervix ( Ekman et al 1995)
A positive FFN was associated with significantly shorter delivery intervals than when a
negative FFN result is obtained (Kiss et al.2000)
Ultrasound assessment of the cervix has been investigated as a way of predicting the
likely outcome of induced labour as an alternative to clinical digital examination. Studies have
explored possible relationships between cervical length, internal cervical OS shape and
assessment of the angle between the cervical axis and the wall of the inferior segment of the
uterus (Chandra et al.2001)
Electrical impedance measurements across the surface of the cervix using a 8mm
tetrapolar pencil probe have been used to investigate correlations with clinical examination to
assess cervical favorability (OConnell et al 2003). A statistically significant association was
found with the resistivity and the favorability of the cervix
Serum nitrite /nitrate levels also has been assayed in nullipara undergoing prostraglandin
induction of labour and using multiple regression analyses significantly lower levels of each
were found in woman who delivered within 15 hrs of labour induction compared with those
delivering over a longer period (Facchinetti et al. 1998)
6


ANTOMY AND PHYSIOLOGY OF THE UTERINE CERVIX
The human uterine cervix is a complex and heterogeneous organ that undergoes extensive
changes throughout gestation and parturition.
11
It is a unique valve responsible for keeping the
fetus inside the uterus until the end of gestation and for its safe passage to the outside world
during labor
.


The cervix is dominated by fibrous connective tissue. It is composed of an extracellular
matrix consisting predominately of collagen with elastin and proteoglycans, and a cellular
portion consisting of smooth muscle and fibroblasts, epithelium and blood vessels. The relative
7

ratio of connective tissue to smooth muscle is not uniformly distributed throughout the length of
the cervix. The distal portion has a greater ratio of connective tissue to smooth muscle than the
upper cervical portion closer to the myometrium.
12
Extracellular Matrix:
Collagen is the predominant component of the extracellular matrix. Cervical collagen
consists of type I (70%) and type III (30%).
13
Collagens arranged as a triple helix. It can cross
linked into fibrils, fibers, and bundles. Collagen fibers must be at least 20 m in length to
maintain tensile strength
14
peptidyl lysine oxidase is the enzyme that cross links collagen.
Copper and vitamin C are cofactors.
Another important molecule involved in collagen structure within the human cervix is the
presence of a small molecular weight proteoglycan, decorin
15
cervical cells produce decorin
during pregnancy. When the ratio of decorin to collagen increases, it causes a dispersal of
collagen fibrils leading to disorganization of the collagen fibers.
16
Collagen is degraded by
collagenases both intracellularly, to remove structurally defective procollagen to prevent the
formation of weak structural collagen, and extracellularly, to slowly weaken the collagen matrix
to allow delivery of the pregnancy.

Elastic Component:
Elastic fibrers are organized parallel to and between collagen fibers. They assemble in a
band 20-30m thick.
17
These thin sheets are capable of being stretched in any direction. With
mechanical stress, the elastin component can distend to twice its length to allow the cervix to
dilate for parturition. The elastin fibers appear broken and fragmented compared with samples
from women with full term pregnancies that revealed elastin oriented in a band like manner.
18
8

ELASTICCOMPONENT


Cellular Component:
Smooth muscle cells and fibroblasts make up the cellular component of the human
uterine cervix. Early in gestation, turnover of both smooth muscle and fibroblast is initiated. The
cervix undergoes hyperplasia as these cells proliferate. As the pregnancy advances, physiologic
cell death occurs. Decorin suppress the further cell proliferation, which accounts for further
increases in decorin levels; a process that helps to disperse collagen fibrers. This disorganization
of collagen then aids in an influx of water and aids in increasing the ability of the cervix to
distend.
19




9

CELLULARCOMPONENT



Elements Affecting Cervical Ripening:
The various elements implicated include decorin, hyaluronic acid, hormones, cytokines
and proteases. These factors are responsible for increasing the water content in the cervix,
decreasing the collagen concentration, and collagen restructure. Decorin causes tight alignment
of collagen fibrils and the ratio of decorin to collagen correlates in an inverse manner with the
softness of the cervix.
Second mechanism is enzymatic degradation of the extracellular matrix. Collagenases,
matrix metalloproteinases (MMP I & 8) which cleave the collagen helices and elastases are the
enzymes involved in this late restructuring of the cervix.
10

Hyaluronic acid has also been shown to stimulate the synthesis of proteolytic enzymes by
cervical fibroblasts.
20
Hyaluronic acid level increases with cervical ripening and increase
dramatically in the cervix with the onset of labour. It has got an important role in increasing the
water content of the cervix at term. It also has a role in neovascularization, a process noted with
cervical ripening. Hyaluronic acid increases the chemotactic response of neutrophils.
21

Human cervical connective tissue contains both estrogen and progesterone receptors. As
term approaches, there is down regulation of both estrogen and progesterone receptors, which
may be caused by increased turnover of the receptor proteins
22
. Estrogen and its precursors have
been shown to stimulate collagenase production in the pregnant human cervix.
23
Progesterone
inhibit cervical tissue from producing intrleukin-8.

CERVIX ANATOMY:
The cervix is about 5.0cm long and projects into the vagina to form the fornices. It has a
supravaginal and an infravaginal part or portio vaginals. The supravaginal part is covered by
peritoneum posteriorly. The ureter runs very close to the cervix and is about 1.2cm away from
the supravaginal cervix. The cervix has a cervical canal which extends from the internal OS
above to the external OS below. The external OS in a nullipara is a circular opening, whereas in
a multiparous women it appears as a transverse slit, thus creating the anterior and posterior lips
of the cervix.




11




CERVIX




Cervical length is normally distributed and remains relatively constant until the
third trimester.
24
Heath found at 23 weeks a mean length of 38mm.
25
Iams found a mean length
at 24 weeks of 35mm and at 28 weeks 34mm.
26
If funneling is present, the measurement should
exclude the funnel and be taken from the funnel tip to the external OS Isthmus.
27

It is the portion where the cervix joins the uterus,the area between the anatomical internal
OS and the histological internal OS is called the isthmus and is of special obstetric significance
12

as it develops into the lower uterine segment in pregnancy. The histological internal OS is the
point at which the epithelium of the uterus changes to that of the cervix.

PRE INDUCTION CERVICAL ASSESSMENT:
The rate of labour progression relates to certain identifiable prelabour characteristics of
the cervix. The validity of scoring systems for predicting the course of induced labors has been
reported in terms of time from start of induction until onset of labor, and the rate of operative
delivery.
In 1964, Bishop described a scoring system for determining a patients suitability for
elective induction of labor.
28
This pelvic score, which has become known as the Bishop score,
was based on those factors that had been previously found to correlate with ripeness.

Parameters Score
0 1 2 3
Cervical
dilatation
Closed 1-2 cm 3-4 cm 5 cm
Length 3 2 1 0
Consistency Firm Medium Soft
Position Posterior Mid position Anterior
Head station -3 -2 -1,0 +1, +2



13

Modifiers:
Add 1 point to score for:
1. Preeclampsia
2. Each prior vaginal delivery

Subtract 1 point from score for:
1. Post dated pregnancy
2. Nulliparity
3. Premature or prolonged rupture of membranes.
Total score is sum of all points for each parameter.
The meaning of the score:
7 or less: Do not attempt induction without ripening the cervix first.
9 or more: Favorable to attempt induction
12 or More: She is quite ready for labour or in early labour; a little encouragement should
get her going.

CERVICAL EXAMIANTION
The degree of cervical effacement usually is expressed in terms of the length of the
cervical canal compared with that of an uneffaced cervix. When the cervix becomes as thin as
the adjacent lower uterine segment, it is completely, or 100% effaced. Cervical dilatation is
determined by estimating the average diameter of the cervical opening by sweeping the
examining finger from the margin of the cervical opening on one side to that on the opposite
side. The diameter traversed is estimated in centimeters. The cervix is said to be dilated fully
14

when the diameter measures 10cm, because the presenting part of a term size new born usually
can pass through a cervix this widely dilated.
The position of the cervix is determined by the relationship of the cervical OS to the fetal
head and is categorized as posterior, mid position, or anterior: Along with position, the
consistency of cervix is determined to be soft, firm, or intermediate between these two.
The level or station of the presenting fetal part in the birth canal is described in relationship to
the ischial spines, which are halfway between the pelvic inlet and pelvic outlet. When the
lowermost portion of the presenting fetal part is at the level of the spines, it is designated as
being at zero station. In 1989, the American College of Obstetricians and Gynecologists adopted
the classification of station that divides the pelvis above and below the spines into fifths. Each
fifth represents a centimeter above or below the spines. Thus, as the presenting fetal part
descents from the inlet toward the ischial spines, the designation is -5, -4, -3, -2, -1 then 0
stations. Below the spines, as the presenting fetal part descends, it passes +1, +2, +3, +4 and +5
stations to delivery. Station +5 corresponds to the fetal head being visible at the introitus.
29

Modifications of the Bishop Score:
Modifications of the Bishop score were proposed in an effort to increase its predictability
for successful induction and decrease morbidity rates associated with induction.
Burnett Modification of the Bishop score:
Burnett proposed a modified score system. This allocated a maximum score of 2 to each
Bishops five categories; yielding a total maximum score of 10, and considered effacement in
terms of length.
30


15

BURNETT MODIFICATION
Factors Score
0 1 2
Dilatation (cm) <1.5 1.5 3 >3
Station -2 or higher -1 0 or lower
Position Posterior Mid Anterior
Head station 1.5 or more Intermediate 0.5 or less
Consistency Firm Intermediate Soft
Burnett considered a previous term birth and cephalic presentation to be prerequisites to
induction of labor. He considered previous uterine surgery a contraindication to this procedure.

When patients had a score of 9 or 10 on this modified scale, Burnett found that all
patients could be delivered within 4 hrs, most within 2hours. Additionally, 90% of patients with
sores of 6 to 8 delivered within 6 hours. He found that the outcome of patients having scores less
than 6 was unpredictable.
31


Friedman et al
32
modified the Bishopscore in a different way. They evaluated 408
multiparas undergoing labor induction and found that the latent phase, but not the active phase,
of the first stage of labor was inversely related to the preinduction cervical score. The factors
considered in determining the Bishop score did not equally influences the length of the latent
phase. They proposed that cervical dilation should be allocated twice the influence as of
consistency, station, and effacement and four times that of positio

16


Fields system for Rating Readiness for induction
33

Factor Score
0 1 2
Timing of induction
versus EDC (wks)
Uncertain or >3
previous
1-3 previous Within1
Attitude toward
induction
Objects or fears Hesitates, accepts Enthusiastic
Estimated fetal weight
(gms)
<2,500 Uncertain >2,500
Uterine tone on
palpation
Flaccid Some tone Firm, contraction
Softness of cervix Firm Some what soft Soft
Effacement (%) <80 80 >80
Position of cervix Posterior 45
o
to vaginal axis Toward vulva
Station of presenting
part (cm)
-2 or higher -1 to 0 +1 or lower
Dilation (cm) 0-1 2-3 >3
Recent vaginal
discharge
No change Increased Blood tinged

17

The same group of investigators proposed two weighted scoring system based on these
findings.
34
However, even in the authors own analysis, performance of neither of these weighted
scoring systems was different enough from the raw Bishop score to be clinically significant.
Weighted Bishop score proposed by Friedman et al
Factors Unweighted Simple weighing Complete
weighting
Dilatation 0-3 x2 X4
Effacement 0-3 X1 X2
Station 0-3 X1 X2
Consistency 0-2 X1 X2
Position 0-2 X0 X1
Range of scores 0-13 0-14 0-30

Evaluation of the Bishop score:
Several groups have reported evaluations of the Bishop score. In 1977, Harrison et al
35

evaluated Bishop score of patients at 36 weeks gestation and again at 40 weeks gestation. They
found a significant increase in scores during the last month of pregnancy. They also confirmed
the association between the Bishop score and the duration of induced labor. Patients with a score
of 7 or more delivered in less than 9 hours 87% of the time, whereas patients having score of 4 or
less delivered within this interval only 44% of the time.
Lange et al
36
, in 1982, evaluated 1,189 patients who underwent successful induction of
labor for obstetric or medical indications. They confirmed that the Bishop score, as used in
Denmark with effacement expressed as centimeters of cervical length correlated well with the
18

likelihood of successful induction. They found that cervical dilation was at least twice as
important as the other factors considered in the Bishop score.
Based on these findings, Lange et al proposed another modification of Bishops scoring
system.
Pelvic score proposed by Lange et al
Factors Score Multiply By
0 1 2 3
Dilation (cm) 0 1-2 3-4 >4 X2
Length (cm) 3 2 1 0 X1
Station (cm) -3 -2 -1 or 0 +1 / +2 X1

This simpler scoring system predicted successful induction equally as well as the Bishop
score.
A study by Hughey et al
37
evaluated the comparative performance of the scoring system
proposed by Bishop, Fields, Burnett and Friedman. The increased likelihood of successful
induction with increasing scores was confirmed for all of these system. It is interesting that these
authors suggested adding modifiers to whichever scoring system was used in an attempt to
optimize the systems prediction accuracy.

They proposed adding points for preeclampsia, each previous delivery, and elective
induction. Points were substracted for premature rupture of membranes, postdatism or
nulliparity. In their study, these modification, improved the accuracy of all scoring systems.

19


ULTRASOUND ASSESSMENT OF THE CERVIX
In more recent years, ultrasound assessment of preinduction cervical characterists has
been evaluated. In 1986, OLeary and Ferrell
38
proposed what they called as semi quantitative
ultrasound scoring system and evaluated this system against the modified Bishop score. This
scoring system, which apparently used trans abdominal ultrasound, evaluated the thickness and
contour of the lower uterine segment, the length and dilation of the cervix, and the station of the
presenting part. The authors found that the ultrasound scoring system correlated well with the
modified Bishop score and that a favorable result with either digital or ultrasound assessment
was associated with a high likelihood of successful induction.

ULTRASOUND MECHINE WITH TRANS VAGINAL PROBE




20


TRANS ABDOMINAL CERVICAL MEASUREMENT
Ultrasound assessment of the cervix was initially Trans abdominal, but specific
disadvantages led to a preference for the transvaginal examination.
39




1. Trans abdominal ultrasound requires filling the bladder to assess the cervix adequately,
but this may spuriously lengthen the cervix by opposing the anterior and posterior lower
uterine segments, concealing cervical shortening or funneling. In contrast, transvaginal
ultrasound is performed with the bladder empty.
40

2. Trans abdominal resolution is hampered significantly by maternal obesity, shadowing
from fetal parts and the need for lower frequently transducers.
21

3. The long distance from the probe to the cervix does not allow for clear visualization of
the cervix.
41


TRANS PERINEAL ULTRASOUND
Transperineal ultrasound also known as translabial. This technique involves having the
women lie on the table with the hips and knees flexed, while a gloved transducer is positioned on
the perineum in a sagittal orientation between the patients labia majora. This technique is not
impaired by obstruction from fetal parts, and does not require bladder filling, achieving close to
100% visualization.
Advantages:
1. The transducer is closer to the cervix; but does not enter the vagina (so no pressure can be
exerted on the cervix).
2. It does not require an additional transducer.
3. It is well accepted by pregnant women.

Drawbacks:
1. Gas shadow in the rectum can hamper visualization of the cervix, especially the external
OS.
2. This technique is difficult to master, probably because of the poor visualization usually
achieved compared with transvaginal ultrasound.



22

TRANS VAGINAL ULTRASOUND MEASUREMENT
The First studies of the human cervix using trans vaginal ultrasound also date back to the
1980s. this technique share the advantages of translabial ultrasound but the probe is even closer
the cervix, and the problem of obscuring bowel gas is eliminated. It has thus become the
preferred, gold standard method of evaluating the cervix in most clinical settings.





Current recommendations for the performance of TVU of the cervix are as follows:
42

1. Have the patient empty her bladder;
2. Prepare the clean probe covered by a condom;
3. Insert the probe (probe can be inserted by patents for more comfort).
23

4. Place the probe in the anterior fornix of the vagina
5. Obtain a sagittal view of the cervix, with the long axis view of echogenic endocervical
mucosa along the length of the canal.
6. Withdraw the probe until the image is blurred and reapply just enough pressure to restore
the image (avoid excessive pressure on the cervix which can elongate it).
7. Enlarge the image so that the cervix occupies at least 2/3 of the image, and external and
internal OS are well seen;
8. Measure the cervical length from the internal to the external OS along the endocervical
canal.
9. Obtain at least 3 measurements, and record the shortest best measurement in millimeters;
10. Apply transfundal pressure for 15 seconds and record any changes in cervical length or
funneling.

For Best Results:
1. The internal OS should be flat or at an isosceles angle with respect to the uterus and the
external OS should be visible and appear symmetric.
2. The whole length of the cervix should be visualized, so that the endocervical canal is
visible from the internal to external OS.
3. A symmetric image of the external OS should be obtained, so that the distance from the
surface of the posterior lip to the cervical canal should be equal to the distance from the
surface of the anterior lip to the cervical canal.
4. There should not be any increased echogenicity in the cervix (a sign of excessive
pressure)
43

24


Although TVU of the cervix is usually straight forward there is some anatomic or technical
difficulty encountered in about one forth of patients.
44

Anatomic:
Focal myometrial contraction: may obscure the internal OS and make the cervix appear
longer than it is:
Endocervical mucus or polyps: may appear to separate the anterior and posterior borders
of the endocervical canal and make the cervix measure shorter than it is.
Rapid cervical change (dynamic cervix): CL may fluctuate during an examination. This is
itself a risk factor for preterm delivery, especially if the shortest cervical measurement is
below 15mm.
Technical:
Vaginal probe orientation: because the cervical canal has width (usually less than 1 cm in
the axial plane) the manual examination may show a greater dilatation than the TVU CL
in just the sagittal plane. In addition, in experienced hands, it is possible to obtain several
diagnonal angles through the cervix all giving a shorter CL than the true sagittal plane.
Pressure distortion: even minimal pressure on the cervix falsely elongates the CL
measurement. Increased echogenicity within the cervix or just posterior to it usually
indicates excessive probe pressure.




25

Normal Cervical length by ultrasound:
Ultrasound measurement of the cervical canal in the second and early third trimester has
been reported to range from 10 to 50 mm. Iams et al
45
measured cervical length at 24 and 28
weeks gestation in nearly 3000 women not selected for risk of preterm delivery. At 24 weeks
mean cervical length in nulliparous women were 34 7.8mm and 36 8.4mm in parous
women. At 28 weeks, the cervix shortened slightly to 32.6 8.1mm in nulliparous women
and 34.5 8.1mm in parous women. The tenth percentiles cervical length measurement at 24
weeks was found to be 25 mm and this increased the risk of preterm delivery six fold.

Other uses of ultrasound Cervical Assessment:
Prediction of Preterm Birth
Studies that have evaluated the usefulness of TVU for predicting PTB, found that the
shorter the cervix, the higher the risk of PTB. Using different cut-offs for CL ranging from
15mm to 34mm, the positive predictive values ranged from 6% to 44%.
46
This relatively low
value is likely due at least in part to the low incidence of PTB in these studies (0.8% - 15%).
A recent study well designed blinded multicenter study of Maternal Fetal Medicine Units
Network of the National Institute of Child Health and Human Development on TVU in
patients with a history of PTB <23 weeks demonstrated that the best predictive accuracy was
achieved with serial TVUs, and including the shortest cervix ever after spontaneous or
transfundal pressure elicited changes. The sensitivity and positive predictive value reached
69% and 55% respectively.
47



26

Twins:
In a preterm prediction study in twin gestation, Goldenberg found that a cervical length
25mm at 24 weeks gestation to be the best of all the predictors of PTB that they evaluated,
including fetal fibronectin and bacterial vaginosis.
48
Compared with singleton pregnancies,
twin pregnancies that deliver at term have been shown to have a similar TVU CL at 14 to 19
weeks; but have a progressively much shorter cervix starting after 20 weeks gestaton.
49
Since
cervical shortening occurs after 20 weeks gestation even in twin pregnancies destined to
delivery at term, sonographic examination of the cervix before 20-24 weeks may lead to
better prediction of PTB. A recent study found that the predictive value of sonographic CL
determination in twins between 24-34 weeks gestation was low.
50


Women with Cerclage:
TVU of the cervix has been evaluated in patients with prophylactic, therapeutic or
emergent cerclage in place. Most studies have shown that transvaginal cerclage is placed in
the middle part of the cervix in a majority of cases.
51
Evaluation of pre-and post cerclage
TVU CL has shown that CL usually increases post cerclage, and that an increase in CL is
associated with a higher rate of term delivery.
52

Several studies have evaluated the accuracy of TVU for predicting PTB in patients with
cerclage.
53
These studies show that TVU cervical parameters are predictive of PTB CL
<25mm and upper cervix (the closed portion above the cerclage) <10mm are probably the
two best predictive parameters.


27

Evaluation of patients with suspected preterm labor:

TVU of the cervix has been studied extensively as a predictor of PTB in patients with
symptoms of PTL. While inclusion criteria in these studies were all slightly different, all
showed a statistically significant predictive accuracy of TVU for PTB. Zalar
54
reported a
decrease in incidence of birth weight <2,500gms when TVU of the cervix was used to triage
patients to bed rest and tocolysis, compared with historic controls. Rageth
55
showed that
using TVU in symptomatic patients for management could decrease the incidence of
hospitalization and costs, but did not decrease PTB.

Predicting latency in PPROM:
Three studies have examined the utility of TVU of the cervix in patients with preterm
premature rupture of membranes (PPROM). Carlan
56
demonstrated in a randomized trial the
safety of performing TVU in this group. In patients studied between 24-34 weeks, he found
that the latency was 2 days shorter if the CL was 30 mm. Rizzo
57
studied 92 women with
PPROM between 24 and 32 weeks and showed that a CL 20 mm was associated with a
latency of 2 days versus 6 days if the CL was >20mm.

CERVICAL RIPENING
Cervical ripening is a chronic process, which begins within the first trimester of
pregnancy and progressively proceeds until term, and is usually described as softening,
effacement and dilation of the cervix. Softening must be considered a vital process because
effacement and dilation cannot occur without remodeling of the cervix during the softening
phase. Effacement and dilation are often associated with or contributed to uterine
28

contractions, but it is evident that softening occurs independent of contractions. Throughout
most of gestation the cervix remains rigid and closed to secure the products of conception. A
dramatic functional shift occurs during parturition as it dilates through a cervical destructive
process. The cascade responsible for the process of cervical ripening, and which finally
enables uterine contractions to efface and dilate the cervix, is still not fully understood.
Studies in cervical resistance and light induced Fluorescence (LIF) have measured these
changes in rats.
58

Many studies show that hormones seem to control cervical ripening although the
mechanisms and effects on each step in ripening are not clear. Because antiprogestins induce
cervical ripening, this process seems to be controlled at least in part by hormones including
progesterone and estrogen
59
relaxin and androgens.
60
The gene is involved in androgen
production, and the parturition defect can be overcome by treatment with 5 reduced
androgens. The enzyme plays an essential role in progesterone catabolism in the cervix
inhibiting the conversion of testosterone to dihydrotestosterone resulting in localized failure
of progesterone withdrawal. The physiologic decrease in the concentration of progesterone
during the third trimester of pregnancy initiates a cascade that is analogous to an
inflammatory response with influx of polymorphonuclear cells
61
and release of matrix
metalloproteinases into the cervical stroma, culminating in the degradation is mostly
probably due to decreased sensitivity of the hormone receptor.
The nervous system has significant involvement in the process of reproduction and could
also be involved in cervical ripening. Sensory, sympathetic and para sympathetic fibers are
numerous in the cervix
62
. The seonsory component largely comes from the pelvic nerves L6-
S1 dorsal root gandglia and terminates in the cervix as unmyelinated, small, capsaisin
29

sensitive sensory neurons. These synthesize neurotransmitters such as vasoactive
neuropeptides, calcitonin gene related peptide, substance P, and secretoneurin, which are
locally released n the cervix and act through their receptors to induce inflammatory like
cervical changes with vasodilatation, vascular leakage and plasma and leukocyte
extravasations.
Very little is known about how cervical ripening can be prevented or inhibited. Recently,
it has been found that oral administration of a platelet activating factor receptor antagonist in
rats significantly increases the duration of parturition
63
platelet activating factor antagonist
WEB 2170 effectively inhibits preterm cervical ripening induced by lipopolysaccharides in
an in vivo animal model.

Measurements of Cervical Softening:
Evaluation of the first common step, cervical softening, has been hypothesized to be
useful for the early evaluation of alternations in cervical ripening either spontaneously
occurring or medically induced. Collascope is a device, used for quantitative estimation of
cervical ripening. It uses the light induced fluorescence of cross linked collagen to permit the
attending physician to differentiate between the labour versus the non labour state of the
cervix.

Fluorescence Spectroscopy of Collagen:
Fluorescence spectroscopy can reveal molecular and physical states.
64
Fluorescence
spectra offer important details on the structure and dynamics of macromolecules and their
30

location at microscopic levels. It has been used to examine collagen content of a variety of
tissues including cancers.
65


Cervical LIF (Light Induced Fluorescence)
One study involving cervical collagen was conducted to investigate gestational changes
of cervical LIF, an index for cross linked collagen, and to estimate whether LIF correlates
with the time to delivery interval and is predictive of delivery within 24 hours.
66
Cervical
LIF was obtained noninvasively by using the collascope. Patients who delivered within less
than 24 hours of measurement had significantly lower LIF than those who delivered more
than 24 hours later.

INDUCTION OF LABOR:
The goal of induction labor is to achieve vaginal delivery by stimulating uterine
contractions before the spontaneous onset of labor. Induction of labor has merit as a
therapeutic option when the benefits of expeditious delivery outweigh the risk of continuing
the pregnancy. The benefits of labor induction must be weighed against the potential
maternal and fetal risks associated with this procedure.
67
The goal of cervical ripening is to
facilitate the process of cervical softening, thinning and dilating with resultant reduction in
the rate of failed induction and induction to delivery time. Cervical remodeling is a critical
component of normal parturition. Observed changes not only include collagen breakdown
and rearrangement but also changes in the glycosaminoglycans, increased production of
cytokines and white blood cell infiltration.
68


31

Labor Induction Terminology:
At a 2008 workshop sponsored by American College of Obstetricians and Gynecologists
for Maternal Fetal Medicine on Intrapartum electronic FHR monitoring renewed the existing
classification systems for FHR patterns
69
in particular, it was determine that the terms
hyperstimulation and hypercontractility should be abandoned. It was recommended that the
term tachysystole, with or without corresponding FHR decelerations, be used instead.

Uterine Contractions:
Uterine contractions are quantified as the number of contractions present in a 10 minute
window, averaged over 30 minutes. Contraction frequency alone is a partial assessment of
uterine activity. Other factors such as duration, intensity, and relaxation time between
contractions are equally important in clinical practice. The following represents terminology
to describe uterine activity.
Normal: Five contractions or less in 10 minutes, averaged over a 30 minute window.
Tachsytole: More than 5 contractions in 10 minutes, averaged over a 30 minute window.
Listed characteristics of uterine contractions:
1. Tachysystole should always be qualified as to the presence or absence of associated FHR
decelerations.
2. The term tachysystole applies to both spontaneous and stimulated labor. The clinical
response to tachysystole may differ depending on whether contractions are spontaneous
or stimulated.


32

ACOG Recommendations for Indication of Labor Induction:
Abruptio placenta
Chorioamnionitis
Fetal demise
Gestational hypertension
Preeclampsia, eclampsia
Premature rupture of membranes
Post term pregnancy
Maternal medical conditions. (Diabetes mellitus, renal disease, chronic pulmonary
disease, chronic hypertension, antiphospholipid syndrome).
Fetal compromise (eg: severe fetal growth restriction, isoimmunization,
oligohydramnios).
Contraindications of Labor Induction:
Vasa previa or complete placenta previa
Transverse fetal lie
Umbilical cord prolapse
Previous classical cesarean delivery
Active genital herpes infection.
Previous myomectomy entering the endometrial cavity.

Criteria should be met before the cervical ripening:
Assessment of gestational age and consideration of any potential risk to the mother or
fetus are of paramount importance for appropriate evaluation and counseling before initiating
33

induction. The patient should be counseled regarding the indications for induction, the agents
and methods of labor stimulation and the possible need for repeat induction or cesarean delivery.
Labor progression differs significantly for women with an elective induction of labor compared
with women who have spontaneous onset of labor.
70
Allowing at least 12-18 hours of latent labor
before diagnosing a failed induction may reduce the risk of cesarean delivery.
71


Cervical ripening with PGE2:
The first use of a Prostaglandin for the induction of labor was reported by Karim et al in
1968. the PG used was PGF2. PGE2 and PGF2 both stimulate contractions of the pregnant
uterus and cause similar side effects in terms of nausea, vomiting and diarrhea, and they have a
number of opposite actions on different organ systems.
72
PGE2 is a vasodilator, it causes
hyperthermia. PGF2 is a vasoconstrictor. PGE2 is 5o to 10 times more potent than PGF2 on
the pregnant uterus. PGE2 is available in solution, oral tablets, vaginal tablets, vaginal pessaries,
gels and slow release vaginal inserts containing different amounts of PGE2. PGE2 in gel form is
available as 0.5mg dose for endocervical application and 1 or 2 mg doses for vaginal use (prostin
E2), where as vaginal pessaries exist in 3 and 20mg formulations.

Routes of PGE2 administration:
Intravenous PGE2
Systemic reviews of the literature on intravenous infusion of PGE2, the earliest and now
abandoned route of administration, indicated that it offered no advantages over intravenous
oxytocin.
73
The main problem was the small margin between doses that stimulated contractions
and those that produced hyper stimulation and a large differential in cost for no benefit.
74
The
34

most bothersome, in terms of non uterine effects, was hyperthermia because of the difficulty of
differentiating this PGE2 effect on thermoregulation from signs of chorioamnionitis, particularly
as PGE2 and some PG analogs also stimulate leucocytosis.

Extra amniotic PGE2:
Initially administered as an extra amniotic infusion was the method, used when ripening
effects of PGE2 on the uterine cervix was first identified. This was later replaced by insertion in
a viscous gel.
75
By inserting endocervical gel preparations well above the internal OS, which
partially explains the large differences in uterine response observed among studies using the
same endocervical preparations.
76


Oral PGE2:
Oral administration of PGE2 became popular in several European Countries in the 1970s
predominantly because of the freedom of movement that it offered compared with an intravenous
line. It was thought to be less dependent on concomitant amniotomy to enhance its effectiveness
that induction with oxytocin. The induction trials comparing oral PGE2 with intravenous
oxytocin with amniotomy, in both arms, in neither arm, or in the oxytocin arm only, showed little
difference between the methods compared except for a reduction in the rate of operative
delivery, probably related to ambulation, that just reached statistical significance.
77
The total
amount of PGE2 administered, mostly at hourly intervals, was higher than that needed with any
other route of administration and vomiting was common with repeat episodes occurring in upto
10% women depending on the doses used.
78


35

Endocervical PGE2:
A large number of studies has been conducted with endocervical gels either locally
prepared or commercially available as prepedil or cerviprost, the latter both containing 0.5mg
PGE2 but in different gels. The endocervical approach is sometimes referred to as intracervical, a
notion that should be reserved for injection into the body of the cervix, a procedure that has been
used to reduce cervical resistance to mechanical dilatation both outside pregnancy and in early
pregnancy, but also for induction of labor in late pregnancy.
79
It initiate labor and abolish the
need for further induction in more than 40% of women and reduce the risk of failed induction.
80

The use of oxytocin alone is more likely to result in failed induction and absence of vaginal birth
within a reasonable interval than the use of endocervical PGE2 alone or pretreatment with
endocervical PGE2.
81

Hyperstimulation is an issue that has drawn considerable attention probably more so with
endocervical PGE2 that with other routes of PGE2 administration.

Vaginal PGE2:
Initially assessed explicitly for ripening the cervix in nulliparous women,
82
the use of
vaginal PGE2 soon spread to both ripening and induction. Current dose ranges from 1 to 3mg per
dose. A trial induced 260 nulliparous and parous women all with Bishop score of 6 or more,
women in the amniotromy arm received oxytocin after 4 hour if not in labor, whereas women in
the PGE2 group had amniotomy after 4 hours and oxytocin another 2 hours later, if not in
established labor. Despite including only women with a favourable cervix, the need for oxytocin
supplementation was 3 times higher in amniotomy group (44% vs 15%). Rates of pyrexia and
epidural analgesia in the amniotomy group were twice those with PGE2, with no cases of
36

hyperstimulation and no differences in other outcomes including cesarean section (4.2%)
between the 2 treatment regimens.
83
This trial is included in a Cochrane systematic review of
amniotomy for induction of labor, which comments that the time allowed for amniotomy to work
on its own, without the secondary intervention may have been too short.
84


FAILED LABOR INDUCTION:
Definition: Failure to achieve dilation 4 cm after trial of oxytocin to a maximum of 20
mu/min.
85

Failure to enter the active phase of labor within 12 hours after IOL was begun
86
and
failure to enter the active phase of labor (Bishop score >8) after 24 hours.
87

Adequate contractions for 2 hours without cervical change.
88

Failed induction occurred when painful, regular contractions with cervical change were
not achieved and the patient was delivered by cesarean with failed induction.
89

Failure to achieve the active phase after a maximum of 12 hour of oxytocin
administration.
90

Failure to deliver within 24 hours of induction
91


Components of Definition:
From Friedmans studies, in the most general sense, induction failure can be best
characterized by the failure to transition from the latent to the active phase of labor. Because
the duration of the active phase is the same or shorter in induced compared to spontaneous
labors.
92
We would argue that the criteria by which this transition can be judged to have
37

occurred might plausibly depend on the combination of labor duration cervical dilation and
uterine activity.
Labor Duration:
Peisner and rosen
93
studied 2479 women admitted with a cervical dilation of <5cm of the
factors analyzed, cervical dilation on admission was the most important determinant of latent
phase duration; with a mean latent phase of a and a half hours for those dilated 0 to 2cm on
admission. 3% of women studied had a latent phase longer than 20 hours. Admitting cervical
dilation did not predict those at risk for latent phase prolongation.
Induction of labor with an unfavorable cervix increases the length of the latent phase
94
.
Those who begin their induction with a Bishop score of <6 progress more slowly than
women in spontaneous labor. As the length of the latent phase increases, the risk of adverse
maternal and neonatal outcomes rises.
95

Cervical Dilation:
Friedman defined the start of the active phase as the point along the labor curve when the
slops begins to change. Peisner and Rosen in a prospective descriptive study of 1060
nulliparus and 639 parous women attempted to define the transition from latent to active
phase by cervical dilatation. Women enrolled in the study presented in spontaneous labor and
were dilated 4 cm or less. Entry into the active phase of labor was demarcated by a rate of
cervical change of at least 1.2cm/hour. Patients with documented labor dystocia, whose
transition to the active phase was difficult to pinpoint. There were 727 cases of either an
active phase protraction or arrest. A 4cm cutoff with 90% effacement or a 5cm cut off
regardless of effacement would capture the majority of women who have entered the active
phase during labor induction.
38


Uterine activity:
In 1950
96
, Caldeyro-Barcia and his colleagues devised a novel method by which to
measure intrauterine pressure. They inserted a thin polyethylene catheter into the amniotic
sac through the anterior abdominal wall. The device was designed to record changes in the
amniotic fluid pressure that arose as a result of uterine contractions. A Montevideo Unit
(MU) was a measure of uterine activity that was the product of the intensity (amplitude) of
each contraction and the frequency (number of contractions in 10 min). Caldeyro-Barcia
illustrated that before 30 weeks of gestation the uterus maintained a resting tone of 20
mmHg. As the pregnancy progressed, the uterus becomes more responsive to oxytocin. A
very small uterine contractions were characteristic and these contractions typically remained
localized.
After 30 weeks, contractions were noted to increase in intensity, frequency and
coordination. The beginning of labor is usually characterized by uterine activity between 80
and 120MU. Uterine coordination is important with the strongest portion of the contraction at
the fundus. From there, it self propagates to the lower uterine segment. In normal labor
uterine activity ranges between 75 and 375 MU.
The other most widely used method
97
is the uterine activity integral. The uterine activity
integral incorporates measures of contraction frequency, duration and strength in its
calculation. It is the integral of the pressure above baseline tone with time and is taken over a
period of 15 minutes its units are kilo Pascal second (kPas). Mean active pressure is the most
important variable in determine the rate of cervical dilation.

39

MATERIALS AND METHDOS

STUDY DESIGN Prospective Observational study
SAMPLE SIZE AND SOURCE OF DATA
100 primi gravida with gestational age ranging between 37-42 weeks who are admitted
for labour induction under Obstetrics and Gynecology in St. Johns Medical College Hospital.
A minimum sample size of 100 is planned.
DURATION OF STUDY
1
st
September 2009 to 1
st
March 2011.
INCLUSION CRITERIA
1. Nulliparous patients
2. Singleton pregnancy
3. Live fetus with vertex presentation
4. Intact amniotic membranes
5. Gestational age between 37-42 weeks
6. Reassuring NST pattern before induction
7. No contraindications for vaginal delivery
8. Patients who are willing to give consent for the study
9. Bishop score 6
EXCLUSION CRITERIA
1. Vaginal bleeding
2. Allergic to prostaglandins
3. Patients in active phase of labour
40

4. History of uterine surgery like previous LSCS, myomectomy
5. Presence of severe maternal or fetal compromise such as Severe PIH, Severe IUGR,
Cardiac disease etc.

METHOD OF COLLECTION OF DATA
All patients who are willing to participate in this study will be included in the study
baseline characters such as age, gestational age at induction & indication for induction are noted.
. After informed consent is obtained, Transvaginal ultrasonographic measurement of cervical
length is performed with the standard longitudinal view of the cervix while the patients bladder
is empty. GE VOLUSON 730 PRO TVS Probe IC5-9 H instruments with 5-9 MHz is using to
measure the cervical length. Cervical length is measured by keeping the proble 3cm away from
the posterior fornix. The cervical length is defined as the length between the internal and external
OS.
After sonography the Bishop Score is determine by the digital examination by the
resident physician responsible for the induction. Physicians were masked to the cervical length
measurement.
Induction of labour is carried out according to the standard protocol of our hospital.
Prostaglandin E2 gel is inserted into the cervical canal within 1 hour of cervical assessment. The
patient is reassessed after 12 hours. If she did not exhibit regular uterine contractions and
cervical change, a second dose of PG E2 is administrate intracervically. Maximum of 3 doses
can be repeated. Subsequent dose is withheld if;
a) The patient is in active labour
b) Rapture of membrane
41

c) If cervical effacement >60% and OS 3 cm.
d) Regular uterine contractions 2-3 in 10 minutes.

Augmentation of labour is done as per labour room protocol.
Active phase of labour is diagnosed as 3-4 contractions in every 10 minutes, each lasting
for 45 to 60 seconds. And the cervix is dilated 3cm and the effacement of cervix is 80% or
greater. Successful induction of labour is defined as active labour occurring at the end of
induction protocol (12 hrs from the last dose)
Failed induction is defined as an inability to achieve the active phase of labour
corresponding to cervical dilatation of 3 cm within 12 hours from the last dose of PG E2.
Failure to progress is defined as no cervical dilation during the active phase of labour for
the last 2 hours or no descent of the fetus head during the second stage of labour for at least 1
hour despite adequate uterine contractions. This is considered as an indication for cesarean
delivery for failure to progress.

Primary outcome measures assessed are
1. Induction to delivery interval < 24 hrs

Secondary outcome measures assessed are:
1. Induction Active phase interval < 12hrs
2. Number of vaginal deliveries <48 hrs


42

RESULTS

Hundred primigravida with gestational age between 37-42wks who are admitted for
induction of labour were enrolled in the study. Demographic variables (age distribution,
gestational age & indication for induction) are summarized
TABLE 1
AGE DISTRIBUTION WOMEN
AGE IN YEARS


NUMBER (%)
15-20

33 (33%)
21-25

49 (49%)
26-30

17 (17%)
31-35

1 (1%)
TOTAL

100 (100%)

FIGURE 1



43


TABLE 2
DISRIBUTION OF GESTATIONAL AGE

STUDY PARAMETER


GESTATIONAL AGE IN DAYS
MEAN SD
GESTATIONAL AGE BY LMP


273.28 8.172( 250- 290)
GESTATIONAL AGE BY USG


262.50 10.755(238- 287)

































44


INDICATION FOR INDUCTION
TABLE 3
INDICATION



Number (%)
POST DATISM


23 (23%)


MILD P I H


18 (18%)
PROLONGED LATENT PHASE


50 (50%)
DECREASED A F I <8CM


7 (7%)
DECREASED FETAL MOVEMENTS

2 (2%)
TOTAL


100 (100%)

FIGURE 2




45


TABLE 4
BISHOP SCORE TOTAL
BISHOP SCORE
Number (%)
1 4 (4%)

2 7 (7%)

3 17 (17%)

4 20 (20%)

5 26 (26%)

6 26 (26%)


FIGURE3









46


TABLE 5
TRANS VAGINAL CERVICAL LENGTH
TVS cervical length
In cm
NUMBER (%)


<2 cm 12 (12%)


2.1- 2.5 cm 31 (31%)


2.6 cm 67 (67%)





FIGURE 4

Women with trans vaginal cervical length <2cm were 12%, 31% of women were with cervical
length between 2.1- 2.5cm and 67% were with cervical length of 2.6cm.






47


MODE OF DELIVERY
TABLE 6
MODE OF DELIVERY


NUMBER (%)
VAGINAL


85 (85%)
CESERIAN


15 (15%)


FIGURE
5
Vaginal delivery occurred in 85% of women and in 74% of these, delivery was within
24hrs of induction. There were 15%deliveries by caesarean section





48


INDICATIONS FOR LSCS
TABLE 7
INDICATION



NUMBER (%)
FETAL DISTRESS


8 (8%)
NON PROGRESSION OF LABOR

6 (6%)
THICK MSL


1 (1%)
TOTAL 15




FIGURE 6

Out of 100 study patients 85 delivered vaginally, and 15 underwent LSCS. Out of 15
eight were for fetal distress and 6 were for non progression of labour (40%)





49


FETAL OUT COME
TABLE 8
VARIABLE


MEANSD
BIRTH WEIGHT


2.87 0.3629(2.01-3.8kg)
APGAR @ 5 MINUTE


8.90 0.414 (6 9)
NICU Admission 7 (7%)




NICU ADMISSION
TABLE 9
ICU ADMISSION



Number (%)
YES


7 (7%)
NO


93 (93%)
TOTAL


100 (100%)

7% of neonates required NICU admission, 6 for respiratory distress and 1 with congenital
malformation












50

TABLE 10
PRIMARY OUTCOME MEASURES
OUTCOME MEASURES


NUMBER (%)
Number of patients with Induction to Delivery
interval < 24hrs

74 (74%)
Number of patients with Induction to active
phase interval < 12hrs

55 (55%)
Number of vaginal deliveries < 48 hrs


85 (85%)


TABLE 11
VARIABLE MEAN SD


BISHOP SCORE


4.04 0.99

CERVICAL LENGTH(TVS)


2.85 0.46

CORRELATION OF THE OUTCOME MEASURES WITH MEAN BISHOP
SCORE & CERVICAL LENGTH
TABLE 12
OUTCOME MEASURES


BISHOP SCORE CERVICAL LENGTH
In cms
Induction to delivery interval
<24hrs(74)

4.1 1 2.5 0.4
Induction to active phase
interval <12hrs (55)

4.6 0.7 2.4 0.3
Total number of vaginal
deliveries

4.01 2.60.5





51

The mean Bishop score was 4.84 (1-6) and the distribution shown in figure 7

FIGURE 7



There was a significant association between the bishop score and the induction to
delivery interval (p<0.0001). Furthermore, the likely hood of vaginal delivery within 24hr
increased with increasing bishop score








52

The mean Trans vaginal cervical length was 2.74cm, and the distribution is shown in figure 8

FIGURE 8


There was a significant association between cervical length and the Induction to delivery
interval (p<0.0001). The likely hood of vaginal delivery within 24hrs increased with decreasing
cervical length








53

Receiver operating characteristic curves for the correlation of bishop score and
Induction to delivery interval <24 hrs
FIGURE 9


Area under the curve is 0.638
A correlation between -1 to +1 is significant
Using Spearmans rho correlation induction to active phase interval correlation
Coefficient is -0.607. Correlation is significant at the 0.01 level (2-tailed)











54

Receiver operating characteristic curves for the correlation of transvaginal
cervical length and induction to delivery interval
FIGURE 10


The area under the curve is - 0.967
A correlation between -1 to +1 is significant
Using Spearmans rho correlation induction to active phase interval correlation
coefficient is 0.908. Correlation is significant at the 0.01 level (2-tailed)
However, cervical length appears to be a better predictor than the Bishop Score with a
sensitivity of 0.703 and a specificity of 0.82 compared to 0.9 and 0.94 respectively
In the receiver operating characteristic curves, the best cut-off point for the prediction of
successful induction was 2.6cm cervical length and 4 for the bishop score.

55

Bishop score around 4 and transvaginal cervical length around 2.6 are found to be best
cut-off values for the pre induction cervical condition. Taking Bishop Score 4 and Cervical
length 2.6 as the cut off and taking successful induction of labour as delivery within 24hrs.The
predictive values were compared and shown in Table 13.
TABLE 13
VARIABLE SENSITIVITY SPECIFICITY PPV NPV PREDICTIVE
VALUE

BISHOP
SCORE
4

70.3% 45.5% 89.7% 18.5% 0.296
TVS
CERVICAL
LENGTH
2.6
58.1% 100% 100% 26.2% <0.001


Though Bishop score has more sensitivity than cervical length , specificity and positive
predictive value of the trans vaginal cervical length is 100%. Significant predictive value is
obtained for cervical length <0.001. P value for Bishop Score is 0.296. So trans vaginal cervical
length found to be better predictor of successful induction of labour in terms of delivery within
24hrs when compared to Bishop Score.













56


TABLE 14
COMPARISON OF NUBER OF WOMEN UNDELIVERED AT 24hrs


VARIABLE NO. OF
DELIVERIES
WITHIN 24hrs
NO. UNDELIVERED
AT 24hrs
TOTAL

BISHOP SCORE 4

68 (90%) 6 (10%) 74
TVS Length 2.6


74 (100%) 0 (0%) 74

Further comparing the prediction of women who remained undelivered at 24hrs, we
found that 10% of women with Bishop Score 4 remained undelivered when compared to none
with a TVS cervical length of 2.6cm
This points towards TVS cervical length being a better predictive of successful labour
induction compared to Bishop Score.


























57

DISCUSSION

This study has demonstrated that, in primi singleton pregnancies undergoing induction of
labor with dinoprostone gel at 37-42 wks, successful vaginal delivery within24hrs of induction
occured in approximately 74%. The study has also demonstrated that induction to delivery
interval is significantly associated with both the preinduction bishop score and the
sonographically measured cervical length, higher the Bishop score and lesser the cervical length
better the likelihood of vaginal delivery. TVS cervical length was a better predictor of successful
labour induction in terms of delivery within 24hrs of induction.
Previous studies on the value of pre induction sonographic measurement of cervical
length have reported conflicting results. Paterson Brown et al
98
. examined 50 pregnancies before
induction and reported that, although the Bishop Score correlated significantly with successful
vaginal delivery, the score fell well short of being a satisfactory predictor of successful
induction. In addition they found that sonographically measured cervical length was not
significantly associated with either the Bishop Score or the induction to delivery interval.
Boozarjomehri et al
99
. Examined 53 women before induction and reported that , although
sonographically measured cervical length was correlated with the duration of the latent phase of
the labour , there was no significant association with the induction to delivery interval or to
cervical effacement measured by digital examination
Watson et al
100
. Examined 109 women before induction and reported a significant
association between sonographically measured cervical length and clinical assessment of cervical
effacement; however, neither of the two provided a useful prediction of the length of the latent
phase of labour. Gonen et al
101
examined 86 women before induction and reported significant
association between both the Bishop Score and sonographically measured cervical length with
58

successful induction and induction to delivery interval. Ware and Raynor
102
examined 77women
before induction and found that both sonographically measured cervical length and Bishop score
predicted induction-to-delivery interval and likelihood of vaginal delivery. In a logistic
regression model, only cervical length and parity were independent predictors of vaginal
delivery.
Pandis et al
103
. Conducted a study on 240 women with singleton pregnancies at 37-
42wks of gestation Vaginal delivery occurred in 194(80.8%) women and in 142(73.2%) of these
delivered within 24hrs of induction. In our study 85% delivered vaginally and 74% delivered
within 24hrs. Table 15 shows the comparison of the primary outcome measures in our study with
the other study
COMPARISON OF THE PRIMARY OUTCOME MEASURES WITH OTHER STUDY
OUTCOME MEASURES PANDIS ET AL (Total
No.240) No. (%)
THIS STUDY (Total No. 100)
No. (%)
Number of vaginal delivery

194 (80.4%) 85 (85%)
Number of LSCS 46 (19.2%) 15 (15%)

Number delivered within
24hrs
142 (73.2%) 74 (74%)

In our study we defined successful induction of labour as vaginal delivery occurring
within 24 hrs. This end point has been traditionally used in several studies to examine the
efficacy of an inducing method. P Rozenberg et al
104
compared the Bishop score and
59

sonographically assessed cervical length for the prediction of successful induction as delivery
within 24 hrs of induction. Pandis et al. also demonstrated that cervical length by ultrasound
performed better than Bishop Score to predict vaginal delivery wihin 24hrs of induction.
Both sonographic cervical assessment and the Bishop Score successfully predicted
vaginal delivery within 24 hrs. As the cervical length increases the likelihood of delivering
within 24hrs decreases whilst, as bishop score increase, the likelihood of delivering within 24hrs
increases. However, the receiver operating characteristic curves for the two variables showed
that, the sensitivity of sonologically measured cervical length in predicting successful induction
of labour was higher than that for the Bishop Score.ROC curves were constructed to determine
appropriate cut off for bishop score and trans vaginal cervical length in predicting the labour
induction, shown 4 is the best cut off for Bishop Score and 2.6 is for trans vaginal cervical
length.
Sujata et al
105
. Conducted study on 122 patients and their ROC curves failed to identify
an appropriate cut off for continuous variables relating to sonographic cervical measurements.
These variables were, therefore, analyzed as continuous variables in the regression model .
Independent predictors of vaginal delivery included Bishop Score, cervical position, and
maternal age. In their study trans vaginal ultrasound does not predict successful labour
induction as well as digital cervical examination
In our study though the sensitivity of the Bishop Score in predicting the successful labour
induction is higher (70.3%) compared with that of cervical length measured trans vaginally
(58.1%) the specificity and positive predictive value for the cervical length was 100% compared
with the Bishop Score ( 45.5% and 89.7% are respectively)
60

Two larger studies have been published, which compared Bishop Score and transvaginal
ultrasound in preinduction cervical assessment. In a study of 109 women,Watson et al
100
. Used
regression modelling to determine factors associated with successful induction. They determined
that only cervical dilatation, as assessed by clinical examination, was a predictor of induction
success. Likewise, Gonen et al
101
. prospectively evaluated 86 study subjects and found that only
Bishop Score and parity were independent predictors of vaginal delivery in induced labour.
Interestingly, a recent randomised study comparing use of transvaginl sonographic
assessment and Bihop Score to guide preinduction cervical ripening with prostaglandins has
shown a reduction in prostaglandin use without affecting successful labour induction with trans
vaginal ultrasonography.
The survival analysis demonstrated better discriminatory results in favour of cervical
length without any women in short cervix (0-1.8cm)remaining undelivered after 24hrs compared
to 10% of women in the high Bishop Score group (5-8). 67% of the long cervix group (3.2-5cm)
remained undelivered after 24 hrs compared to 33% of women in the low Bishop Score group.
These findings suggest that sonographic cervical length is a better test than the Bishop Score for
predicting successful induction of labour
But the limitations for obtain TVS cervical length are that the expensive equipment and
also the technical expertise in measuring the cervical length in standard and reproducible manner
is required, so as to avoid the errors in the measurement. It is also an expensive test
In the setting where Transvaginal sonographic measurement of cervical length can be
achieved easily, correctly and with minimal discomfort to the patient, it provides a useful
prediction of the likelihood of vaginal delivery within 24 hrs of induction and of the induction to
delivery interval. It helps in counseling the women regarding the outcome of labour induction.
61

Women with a cervical length of less than 2.6 cm can be counseled that delivery will possibly
occur within 24 hrs of induction , whereas those with cervical length of 3cm can be advised that
they have an approximately 67% chance of remaining undelivered after this interval.
Bishop score still remains a useful test in the setting where the equipment and experts are
not available as it is a simple, inexpensive test and does not required technical expert.


















62

LIMITATIONS OF THE STUDY

1. Did not analysis the different components of bishop score separately to see which factor can
contribute to the successful prediction in induced labour
2. Did not include the other parameters of the transvaginal cervical assessment like dilation,
presence of wedging, or cervical angle which could have probably added in the predictability
obtained by cervical length alone
3. Association of other factors like maternal weight, maternal age, are not considered in our
study. It can be independent predictors in successful labour induction














63


CONCLUSION


Bishop score and transvaginal cervical length both are good predictors of successful
induction of labour. Transvaginal cervical length provides a better prediction of the likelihood of
vaginal delivery within 24hrs of induction. TVS cervical length could be used as a better
alternative to Bishop Score for successful labour induction in the setting where the appropriate
equipment and expertise are available.






















64

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75

PROFORMA
NAME : AGE:
OP/IP No:
OCCUPATION:
LMP: EDD:
GA at intervention
Indication for induction of labour:
Obstetric Complications:
Medical Complications:
USG Findings:
Gestational Age:
Expected Fetal Weight:
Amniotic Fluid Index:
Trans vaginal cervical length:
BISHOP SCORE
Dilatation Effacement Station

Cervical
consistency
Cervical
position




TOTAL SCORE


76

Induction to active phase interval :
Induction to delivery interval :
Mode of delivery :
A) Vaginal :
B) Vaginal instrumental :
C) LSCS :
Indication for LSCS :
Indication for instrumental delivery :
Fetal outcome
a) Birth weight :
b) Apgar score
1 minute :
5 minute :
Neonatal ICU Admission :
Indication for ICU Admission :








77

KEY TO MASTER CHART
AGE 1=15-20yrs
2=21-25yrs
3=26-30yrs
4=31-35yrs
5=36-40yrs
OCCUPATION
1-Professional
2-House wife
INDICATION FOR INDUCTION OF LABOUR
1-Post datism
2-Mild PIH
3-Prolonged latent Phase
4-Decreased AFI
5-Decreased fetal movements
BISHOP SCORE
DILATATION
0= Closed
1=1-2cm
2=3-4cm
3=5cm


78

EFFACEMENT
0=3cm
1=2cm
2=3cm
3=0cm
STATION
0= -3
1= -2
2= -1
3=+1,+2
CERVICAL CONSISTANCY
0-firm
1-medium
2-soft
CERVICAL POSITION
0-posterior
1-mid position
2-anterior
MODE OF DELIVERY
1-Vaginal
2-Vaginal Instrumental
3-LSCS

79


NICU ADMISSION
1-yes
2-No
INDICATION FOR NICU ADMISSION
1-Respiratory distress
2-Grunting
3-Cyanosed
4-Malformation











































I II I
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O OO O
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R RR R
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M MM M
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M MM M
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D DD D
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C CC C
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B BB B
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A AA A
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p pp p
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name age OP no occupation GA indication for induction complications
GA EFW AFI cervicallength dialatation effacement station cervical consistency
sathya anusurya 2 2673444 2 281 1 decreased AFI(6.5) 266 3.14 6.5 3.4 1 0 0 2
syeda shamama 2 2752162 2 276 3 nil 242 2.6 13 2.3 0 0 1 2
chandrakala 2 2749267 2 280 1 nil 266 3 9 2.8 1 0 0 2
sowmya shekar 1 2748465 2 274 2 nil 266 2.6 12 2.7 1 0 1 2
shantha 2 2663325 2 281 1 nil 252 2.6 7 2.3 1 1 1 2
pavithra 2 2743356 2 280 5 nil 273 2.7 11.5 2.4 1 0 0 2
pushpa 2 2750260 2 278 3 nil 273 3 16 3.4 1 1 0 0
renuka dinesh 3 2641779 2 278 3 nil 261 2.9 10 3.6 0 0 0 2
shiva kumari 2 2643636 1 281 1 Rh-ve,hypothyroidism 259 2.4 12 3.4 1 1 1 2
shalini 1 2741776 2 280 4 anemia 266 2.8 6 3.2 1 0 0 2
pushpa 2 2750260 2 278 2 nil 273 3 16 3.4 1 1 0 2
reshma 2 2758605 2 285 1 nil 280 3.2 12 2 0 0 0 2
clari josephine 3 2729087 1 280 4 AFI(7) 259 2.6 7 3.2 1 0 1 2
roopa s 1 2759031 2 276 3 nil 252 2.8 8.2 2.4 1 1 1 2
rajalakshmi 1 2759721 2 260 2 nil 259 2.8 7.2 2.8 1 1 0 2
ranjitha e 1 2759979 2 282 1 nil 256 3.088 8 2.7 1 1 1 2
pushpa 1 2735231 2 273 2 mild PIH 259 2.7 12 3.6 1 0 1 2
mamatha 2 2761020 2 280 1 nil 280 3 10.2 3.8 1 0 1 2
bhagyamma 2 2761568 2 263 2 nil 259 2.8 12 2 1 1 2 2
mamatha 1 2683285 2 274 5 nil 266 2.7 12 2 1 1 2 2
manjula 2 2678682 2 278 3 nil 248 2.5 8 2.6 1 1 1 2
sushmita chatri 1 2725239 2 282 1 nil 271 3.2 9 3 1 1 1 2
radha 2 2767366 2 282 1 Rh-ve 259 3 10.5 2 1 2 1 2
devi 1 2766162 2 260 2 nil 245 2.4 9.3 3.2 1 1 0 2
veena j 3 2766627 2 271 3 nil 245 2.4 9 2 1 1 1 2
jamuna 3 2697164 2 277 1 nil 280 3.2 7 4 0 0 0 2
swetha 1 2685341 2 279 2 nil 268 2.88 11 2.8 0 0 1 2
gomathy 2 2674432 2 281 1 nil 280 2.6 10 2.8 1 0 1 2
sunitha 2 2669096 2 280 1 mild PIH 273 2.5 10 2.4 0 0 1 2
usha s 1 2697481 2 261 3 nil 266 2.8 12 2 1 1 1 2
saraswathi 2 2770981 2 268 3 nil 252 2.9 8.3 2.4 1 1 0 2
padmini 1 2765843 2 269 2 nil 243 2.5 10 2.8 1 0 0 2
subashini 2 2691474 2 253 3 nil 252 2.7 7 3.4 0 0 1 2
aneesha s 2 2662327 2 261 2 impaired GTT 252 2.4 16 2.2 1 1 1 2
shilpa rani 2 2691016 2 263 4 nil 256 2.9 7 3.2 1 0 1 2
ramya 2 2761925 2 264 2 nil 256 2.9 10.5 2.3 2 1 1 2
yasmeen 2 2631498 2 269 2 nil 255 2.7 12.5 2.5 1 0 1 2
jyothi 1 2716804 2 271 3 nil 266 2.6 10.5 2.8 1 1 0 2
mubin taj 2 2514995 2 277 3 nil 266 2.4 12.5 3 1 0 0 2
seema misra 3 2679276 2 258 4 nil 238 2.1 7 3 1 0 0 0
leelekshi 2 2511089 2 267 3 hypothyroidism 255 2.6 12 2.5 1 0 0 2
saraswathi 2 2740847 2 284 1 PTB 259 2.9 10 2.6 1 1 0 2
girija 1 2698296 2 277 4 anemia 266 2.8 10 2.2 1 1 0 2
pushpa k 3 2502515 2 271 3 nil 259 3.096 10 2.4 1 0 0 2
mala 1 2771579 2 281 1 nil 245 2.5 8.2 3.5 1 0 1 2
selvi r 2 2681735 2 281 1 nil 273 2.6 12.5 2 0 0 1 2
niyamata 2 2741510 2 278 4 nil 259 2.7 10 2.5 1 1 1 2
ahalya sahoo 3 2681566 2 280 3 nil 269 3.5 10 3.6 0 0 1 2
yashoda 2 2777052 2 250 4 nil 240 2.4 7 2.2 1 1 1 2
poovalazi 1 2772343 2 270 3 hyperthyroidism 259 2.7 10.5 2.4 1 1 1 2
sharmila kumari 3 2787887 2 263 3 nil 245 2.2 10 2.4 1 1 0 2
khushnuu a 1 2787853 2 279 3 nil 273 2.8 7 2.4 1 1 1 2
saritha 2 2732850 2 278 2 anemia 273 2.9 10 2.6 1 1 1 2
kokila 3 2588720 2 273 3 hypothyroidism 266 2.8 8 2.8 1 0 0 2
sridevi 3 2120525 2 276 3 nil 276 2.8 9 2.3 0 0 1 2
shailaja 1 2693403 2 259 2 nil 259 2.8 7.3 2 0 0 1 2
kavitha 2 2777182 2 278 3 nil 266 2.7 15 2.8 1 1 1 2
usha s 1 2696219 2 267 3 nil 273 2.5 12 3 1 1 1 2
ramya g 1 2696282 2 278 3 nil 273 2.7 8.5 3.2 1 0 0 2
bishopscore USG FINDINGS
jainey raju 4 2784433 2 269 3 nil 266 2.6 9.6 2.6 1 0 1 2
pavithra hs 1 2789560 2 287 1 nil 259 2.8 10 3 1 0 2 0
narayanamma 1 2772558 2 270 3 nil 252 2.3 12 3.6 0 0 0 2
chadramma 2 2198598 2 277 3 nil 238 2 8 2.8 1 1 0 2
priya 1 2709779 2 262 2 nil 252 2.4 11 2.6 1 1 1 2
nirmala 2 2787431 2 277 3 nil 273 3.5 13 3.6 0 0 0 2
sukanya 1 2728173 2 264 3 nil 252 2.6 8 2 1 1 1 0
jayarani 3 2805499 2 290 1 nil 277 3.2 6 2.4 1 1 1 2
mohanarani 2 2451702 2 275 3 abnormal OGCT 273 2.7 12 2.4 1 1 1 2
rajeswari 2 2801072 2 276 3 nil 262 3.2 10 3 1 1 0 2
asha 2 2794407 2 276 3 nil 266 3 10.4 2.2 1 2 0 2
ambika 1 2701556 2 281 1 nil 273 2.8 9 3.2 1 0 0 2
subhashini 3 1219811 2 271 2 nil 266 3 12 2 0 0 1 2
ramya 2 2728220 2 268 3 nil 273 3.3 11 3 0 0 1 2
pushpa 2 2803811 2 264 3 nil 238 2.16 10 2.1 0 0 1 2
swetha 3 2662335 2 281 3 nil 273 2.7 11 4.2 1 0 0 2
devi 1 2797254 2 283 3 nil 266 2.5 13 3.8 1 0 1 2
sripriya 2 2804704 2 266 3 nil 259 2.4 12 2.3 1 1 1 2
lavanya 2 2810651 2 273 3 nil 266 3.1 11 2 1 1 1 2
asha 3 2642300 2 283 1 nil 273 3.1 20 3.4 0 0 0 2
rani 1 2779285 2 252 3 nil 248 2.58 9 2.4 1 1 1 2
shanthamma 3 2779051 2 275 3 nil 266 2.5 10 2.3 1 1 1 2
babitha 1 2810882 2 273 2 nil 259 2.4 12 2.6 1 1 1 2
bhavani 1 2752835 2 266 3 Rh negative 259 3 8 2 0 0 0 0
jayapradha m 2 2715758 2 279 3 nil 266 3.4 14 3 1 1 1 2
suma 2 2790307 2 281 1 nil 273 3 11 3.8 0 0 1 0
dhanalakshmi 3 2767597 2 267 3 nil 266 2.5 8 2.4 1 1 1 2
latha 3 2808181 2 285 1 nil 287 3 8 3.8 0 0 0 0
shwetha 1 2790333 2 281 1 nil 283 2.8 16.5 2.2 1 1 1 2
riziya sulthana 2 2134442 2 266 3 nil 259 2.4 12 2.6 1 1 1 2
shilpa 1 2804372 2 270 2 nil 259 2.7 8 2.8 1 0 1 2
nazni banu 2 2714633 2 266 3 nil 259 2.7 10 3 1 0 1 0
uma 2 2751072 2 272 3 nil 259 2.9 8 2.5 1 0 0 2
manjula p 2 2802007 2 264 3 nil 252 2.6 16 3 1 0 1 2
vasantha kumari 2 2749192 2 281 1 nil 273 2.5 9 3.5 0 0 0 2
nithya bharathi 2 2805255 2 266 3 nil 259 2.7 10 2.4 1 1 1 2
kavitha 2 2810443 2 278 3 nil 266 3.5 10 3 1 1 1 2
subha 2 2674214 2 271 2 nil 266 3 10 2.4 0 0 0 0
devi 1 2129515 2 276 3 nil 276 2.8 9 2.3 0 0 1 2
roopa s 1 2828230 2 266 3 nil 273 3.3 11 3 0 0 1 2
Priya 2 2704803 2 266 3 nil 259 2.4 12 2.3 1 1 1 2
induction to active phase interval induction to delivery interval MOD indication for LSCS NICUadmission indication for ICU admission
cervicalposition TOTAL birth weight
1 minute 5 minute
0 3 20 23 1 3.4 4 6 1 1
1 4 2 3 1 2.51 8 9 2
1 5 5 8 1 3.25 8 9 1 2
1 5 6 8 1 2.39 8 9 1 2
0 5 1 4 1 2.74 7 9 1 3
0 3 13 15 1 2.71 8 9 2
0 2 21 23 1 3.235 7 9 2
0 2 25 3 fetal distress 3.055 8 9 2
0 5 48 3 NPL 2.68 8 9 2
0 3 14 17 1 2.83 8 9 2
1 5 30 33 1 3.235 7 8 2
2 4 3 5 1 3.43 8 9 2
0 4 12 15 1 2.97 8 9 2
1 6 5 8 1 2.66 8 9 2
0 4 15 18 1 3.05 8 9 2
0 5 12 14 1 3.03 7 9 2
1 6 25 28 1 2.37 8 9 2
1 5 40 45 1 3.12 8 9 2
2 6 5 7 1 2.97 8 9 2
0 6 5 8 1 2.855 8 9 2
1 6 12 14 1 2.62 8 9 2
0 5 8 13 1 3.1 8 9 1 2
0 6 4 10 1 2.89 8 9 2
1 5 23 26 1 2.77 8 9 2
0 5 5 8 1 2.01 8 9 2
1 3 34 38 1 3.48 8 9 2
0 3 10 15 1 2.93 8 9 2
1 5 12 3 fetal distress 2.95 8 9 2
0 3 8 14 1 2.82 8 9 2
1 6 3 5 1 2.98 8 9 2
1 5 5 7 1 2.805 8 9 2
0 3 18 22 1 2.65 8 9 2
0 3 20 26 1 2.91 8 9 2
1 6 3 6 1 2.45 8 9 2
1 5 24 3 NPL 3.055 8 9 2
0 6 3 5 1 2.56 8 9 2
0 4 14 16 1 3.455 8 9 2
0 4 6 8 1 3.02 8 9 2
1 4 13 15 1 2.72 8 9 2
1 2 16 20 1 2.2 8 9 2
0 3 12 14 1 2.9 8 9 2
0 4 13 16 1 3.115 8 9 2
1 5 5 7 1 2.865 8 9 2
0 3 4 6 1 2.73 8 9 2
1 5 12 20 1 2.8 8 9 2
1 4 2 4 1 3.06 8 9 2
1 6 4 7 1 2.3 8 9 2
0 3 28 3 NPL 3.115 8 9 2
1 6 4 5 1 2.36 8 9 2
0 5 6 8 1 3.05 8 9 2
0 4 4 8 1 2.6 8 9 2
1 6 5 8 1 2.5 8 9 2
1 6 6 8 1 2.94 8 9 2
0 3 16 18 1 2.23 8 9 2
1 4 3 5 1 2.55 8 9 2
1 4 2 4 1 2.9 7 8 2
0 5 7 9 1 3.06 8 9 2
0 5 10 12 1 2.66 8 9 2
1 4 20 24 1 2.82 8 9 2
fetaloutcome
apgar score
1 5 8 10 1 3.08 8 9 2
0 3 17 22 1 2.64 8 9 2
1 3 29 3 fetal distress 2.5 8 9 2
1 5 7 10 1 2.5 8 9 2
1 6 6 10 1 2.97 8 9 2
0 2 23 3 thick MSL 3.01 7 8 1 2
0 3 2 3 1 2.54 8 9 2
1 6 4 3 fetal distress 2.44 8 9 2
1 6 4 6 1 3.33 8 9 1 4
1 5 10 3 fetal distress 3 8 9 2
1 6 4 8 1 3.38 9 9 2
1 4 26 28 1 3.42 8 9 2
1 4 2 4 1 3.085 9 9 2
1 4 18 24 1 3.8 8 9 2
1 4 2 3 1 2.4 6 7 2
0 3 40 3 NPL 2.93 8 9 2
1 5 26 30 1 2.84 8 9 2
1 6 3 6 1 2.57 8 9 2
1 6 2 4 1 3.19 8 9 2
0 2 22 27 1 2.88 8 9 2
0 5 5 9 1 2.353 8 9 2
1 6 4 8 1 2.4 8 9 2
1 6 8 12 1 2.1 8 9 2
1 1 2 4 1 3.037 8 9 2
1 6 10 3 fetal disterss 3.58 8 8 2
0 1 32 3 fetal distress 3.605 8 9 2
0 5 6 10 1 2.515 8 9 2
1 1 30 3 fetal distress 3.3 6 8 2
1 6 3 8 1 2.9 6 9 2
0 5 8 10 1 2.6 8 9 2
1 5 8 12 1 2.85 8 9 2
1 3 12 16 1 2.81 8 9 2
0 4 8 12 1 3 9 9 2
2 6 8 12 1 3 8 9 2
0 2 21 3 NPL 3.02 8 9 2
1 6 7 10 1 2.8 8 9 2
1 6 10 3 NPL 3.6 8 9 2
1 1 3 7 1 3 8 9 2
1 4 2 5 1 2.5 8 9 2
1 4 13 18 1 3.8 8 9 2
1 6 3 6 1 2.57 8 9 2