Ultrasound Obstet Gynecol 2008; 31: 328–331
Published online 8 February 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.5254
Ultrasound assessment of cervical length in prolonged
pregnancy: prediction of spontaneous onset of labor and
successful vaginal delivery
P. VANKAYALAPATI, F. SETHNA, N. ROBERTS, N. NGEH, B. THILAGANATHAN and A. BHIDE
Fetal Medicine Unit, St. George’s Hospital, London, UK
K E Y W O R D S: postdates; prolonged pregnancy; ultrasound cervical length
ABSTRACT
Objectives To evaluate the usefulness of sonographic
assessment of cervical length in the prediction of
spontaneous onset of labor and of vaginal delivery.
Methods Two hundred and six women who attended a
dedicated postdates clinic at 41 + 3 weeks of pregnancy
and agreed to the assessment of cervical length using
transvaginal ultrasound imaging were included in the
study. Those who had not delivered at 42 weeks were
offered induction of labor. The labor details were recorded
prospectively, and the onset of spontaneous labor and
mode of delivery were correlated with cervical length data.
Results Women who underwent spontaneous onset of
labor (n = 112) had a significantly shorter cervical length
(mean (SD) 25.0 (8.3) mm) than had women whose labor
was induced (n = 67; mean (SD) 29.7 (8.5) mm). Logistic
regression analysis showed that cervical length was an
independent predictor of the likelihood of spontaneous
labor in nulliparous women, and of vaginal delivery in
both nulliparous and parous women. Parity had no inde-
pendent effect on the onset of spontaneous labor, but
was an independent predictor of the likelihood of vaginal
delivery.
Conclusions Sonographic assessment of cervical length is
a significant independent predictor of the likelihood of
the onset of spontaneous labor in nulliparous women,
and of successful vaginal delivery in both nulliparous and
parous women with prolonged pregnancy. Copyright 
2008 ISUOG. Published by John Wiley & Sons, Ltd.
INTRODUCTION
In a meta-analysis of randomized trials of the management
of prolonged pregnancy it was found that routine
Correspondence to: Dr A. Bhide, Fetal Medicine Unit, St George’s Hospital, 4th Floor, Lanesborough Wing, Blackshaw Road, London
SW17 0QT, UK (e-mail: abhide@sgul.ac.uk)
Accepted: 30 October 2007
Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd.
induction of labor after 41 weeks’ gestation reduces
perinatal mortality1 . Furthermore, the meta-analysis
suggests that approximately one in five women with
a prolonged pregnancy is likely to need a Cesarean
section, irrespective of the chosen management option1,2 .
Previous studies have shown that sonographic assessment
of cervical length is a predictor of successful induction
of labor3 – 7 . The purpose of this study was to investigate
the value of sonographic assessment of cervical length in
prolonged pregnancy as a predictor of spontaneous onset
of labor and successful vaginal delivery.
METHODS
This observational study was conducted between March
2005 and February 2006. Women booked for rou-
tine antenatal care who reached 41 weeks’ gestation
(287 days) were seen in the antenatal clinic, offered a cer-
vical sweep and booked to attend a dedicated postdates
clinic at 41 + 3 weeks (290 days). All pregnancies had
been dated by sonographic measurement of crown–rump
length between 11 and 14 weeks. At the postdates clinic,
fetal assessment with computed cardiotocography and an
ultrasound scan were conducted, and women were invited
to participate in the present study. Immediate induction
of labor was recommended if the ultrasound scan esti-
mated the fetal weight to be below the 5th centile, as
fetal growth restriction is independently associated with
increased perinatal mortality in prolonged pregnancies8 .
Women who had not delivered by 42 weeks (294 days)
were also offered induction of labor. Labor details were
recorded and the mode of delivery was correlated with the
cervical length data. Women who had a Cesarean section
in a previous pregnancy were not invited to participate in
this study. Written, informed consent was obtained before
ORIGINAL PAPER
Ultrasound assessment of cervical length in prolonged pregnancy 329

transvaginal ultrasound examination. Ethics committee
approval was obtained for the study.
Those agreeing to participate in the study underwent
transvaginal sonographic measurement of cervical length.
Transvaginal ultrasound imaging was carried out in the
dorsal lithotomy position. Women were requested to
empty the urinary bladder just before the scan. The
transvaginal probe (3–8 MHz) covered by a sterile probe
sheath was gently inserted into the lower part of the
vagina and advanced until the cervix was visualized in
sagittal plane. Care was taken to avoid using excessive
pressure on the cervix. The image was magnified until it
occupied most of the screen, and the internal os, external
os and cervical canal were clearly visualized. Cervical
length was measured from the internal os to the external
os in a straight line, only including the cervical canal
bordered by the endocervical mucosa9 . Fundal pressure
was not used and no attempt was made to measure angular
distance. A separate measurement was obtained from each
of three images of acceptable quality that were acquired.
An average of the three measurements was calculated and
used for analysis. All the images were stored electronically
on the hard disk of a central server. The images could
be retrieved for future review if required. The cervical
length measurements were not available to the clinicians
responsible for decision making.
Statistical analysis
All statistical calculations were carried out using SPSS
software version 11.5.0 (SPSS Inc., Chicago, IL, USA).
The distribution of continuous data was tested for
normality. Unpaired t-test or Mann–Whitney U-test was
used for comparison of data as appropriate. Chi-square
test was used for categorical data. The area under the
receiver–operating characteristics (ROC) curve and its
95% CI were calculated for cervical length. Logistic
regression analysis was used to explore the use of
ultrasound cervical length, parity and gestational age as
possible predictors of spontaneous onset of labor and of
successful vaginal birth. A forced entry method was used.
P < 0.05 was considered significant.
RESULTS
A total of 297 women were invited to participate
in the study. Ninety-one declined and cervical length
measurements were carried out in 206 women. Fourteen
women were excluded from the analysis because they
delivered elsewhere and the delivery data were not
available. Four women underwent a Cesarean section
without an attempt at labor induction. Nine women were
advised to undergo induction of labor before 42 weeks for
indications other than prolonged pregnancy. Data from
these nine women were not included in the analysis of the
association between cervical length and the spontaneous
onset of labor.
The characteristics of nulliparous and parous women
participating in the study are shown in Table 1.
The parous women had significantly fewer emergency
Cesarean sections (13%) than had nulliparous women
(35%). Table 2 shows a comparison of women who
had spontaneous onset of labor and those in whom

Table 1 Baseline characteristics of nulliparous and parous women

Characteristic Nulliparous (n = 125) Parous (n = 63) P

Maternal weight (kg) 64.8 ± 17.0 67.0 ± 15.8 NS*

Maternal height (cm) 165.8 ± 6.6 164.5 ± 6.3 NS*
Body mass index (kg/m2 ) 24.1 ± 4.4 24.6 ± 5.4 NS*
Gestational age at delivery (days, median (range)) 294 (290–305) 292 (290–306) 0.00025†
Birth weight (g) 3719 ± 439.9 3755 ± 431.9 NS*
Labor induction (% (n)) 44 (55) 30.1 (19) NS‡
Cervical length (mm) 26.8 ± 8.6 27.5 ± 8.4 NS*
Proportion having emergency Cesarean section (% (n)) 35.2 (44) 12.7 (8) 0.0015‡

Data are mean ± SD unless otherwise indicated. *Unpaired t-test. †Mann–Whitney U-test. ‡Chi-square test. NS, not significant.

Table 2 Comparison of women with spontaneous onset of labor and those with induction of labor

Characteristic Spontaneous (n = 112) Induced (n = 67)* P

Maternal weight (kg) 63.8 ± 14.2 66.9 ± 20.0 NS†

Maternal height (cm) 162.7 ± 22.8 160.9 ± 28.6 NS†
Body mass index (kg/m2 ) 23.7 ± 4.00 24.7 ± 5.6 NS†
Birth weight (g) 3737 ± 418.1 3778 ± 461.2 NS†
Gestational age at delivery (days) 293 (290–306) 295 (294–300) < 0.0001‡
Cervical length (mm) 25.0 ± 8.3 29.7 ± 8.5 0.001†

Data are mean ± SD or median (range). *Nine women whose labor induction was carried out before 294 days were not included. †Unpaired
t-test. ‡Mann–Whitney U-test. NS, not significant.

Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2008; 31: 328–331.
330 Vankayalapati et al.

Table 3 Comparison of women who had a standard vaginal delivery (SVD) or emergency Cesarean section according to parity

Nulliparous (n = 125) Parous (n = 63)

SVD Cesarean SVD Cesarean

Characteristic (n = 81) (n = 44) P (n = 55) ( n = 8) P

Maternal weight (kg) 63.7 ± 16.8 66.4 ± 17.1 NS* 66.3 ± 16.2 70.5 ± 9.6 NS*
Maternal height (cm) 161.4 ± 31.5 160.6 ± 25.1 NS* 164.3 ± 6.5 165.6 ± 5.6 NS*
Body mass index (kg/m2 ) 23.6 ± 4.3 25.0 ± 4.5 NS* 24.5 ± 5.5 25.6 ± 4.8 NS*
Birth weight (g) 3649 ± 410.2 3860 ± 458.4 NS* 3756 ± 412.9 6753 ± 635.5 NS*
Gestational age at delivery (days) 293 (290–305) 295 (290–299) NS† 292 (290–306) 292 (290–296) NS†
Cervical length (mm) 24.8 ± 8.5 30.9 ± 8.6 0.0002* 27.1 ± 8.9 30.7 ± 8.2 NS*

Data are mean ± SD or median (range). *Unpaired t-test. †Mann–Whitney U-test. NS, not significant.

labor was induced. Cervical length in women under-
going spontaneous labor (mean, 25 mm) was significantly
shorter than that in those who required induction of labor
(mean, 30 mm). Table 3 shows data for women achiev-
ing a vaginal delivery and those requiring an emergency
Cesarean section, grouped according to parity. The cer-
vical length was significantly shorter in nulliparous than
parous women.
Logistic regression analysis of the need for labor
induction and Cesarean section is shown in Table 4.
Cervical length was associated with both the likelihood
of spontaneous onset of labor and of successful vaginal
delivery, but parity was only associated with the likelihood
of successful vaginal delivery. Areas under the ROC curves
for ultrasound cervical length and predicting the onset
of spontaneous labor and successful vaginal delivery,
with 95% CI values, are shown in Table 5. Sonographic
Table 4 Results of logistic regression analysis for the prediction of
onset of spontaneous labor and successful vaginal delivery
according to parity and cervical length
Adjusted odds ratio
Variable (95% CI)
Decision to induce labor
Cervical length* 1.062 (1.024–1.101)
Cesarean delivery
Parity 0.214 (0.087–0.525)
Cervical length 1.079 (1.034–1.127)
Nulliparous coded as 1, parous coded as 0. *Nine women with
labor induction before 294 days were not included.
assessment of cervical length had the discriminatory
capacity to predict successful vaginal delivery in all
women, and to predict the spontaneous onset of labor
in nulliparous women.
DISCUSSION
The present data show that, in prolonged pregnancy, the
cervical length is significantly shorter in women entering
spontaneous labor than in those who require induction of
labor after 42 weeks’ (294 days’) gestation. Women with
a short cervix are also significantly more likely to deliver
vaginally than to require an emergency Cesarean section.
A correlation between ultrasound cervical length and
the spontaneous onset of labor at term10 – 12 and in
prolonged pregnancies13,14 has been reported previously.
Strobel et al. studied 97 women at 42 weeks and found
that cervical length is an independent predictor of the
spontaneous onset of labor13 . The data from the present
study show that the shorter the cervix, the sooner the
onset of spontaneous labor. The area under the ROC
curve for onset of labor within 4 days in the present
P study (0.683 nulliparous, 0.588 parous) was very similar
to that reported by Strobel et al. (0.706 nulliparous,
0.583 parous)13 . Our study also demonstrates that parity
0.001 has no independent effect on the spontaneous onset of
labor. Tables 4 and 5 show that, when the data are
< 0.001
analyzed according to parity, the ability of cervical
< 0.0002
length measurement to predict spontaneous onset of
labor disappears for parous women. In other words,
sonographic measurement of cervical length works only

Table 5 Ability of cervical length measured by transvaginal ultrasound to predict the outcome of delivery

Area under ROC curve

Prediction Parity (95% CI) P

Spontaneous onset of labor Nulliparous (n = 120) 0.683 (0.589–0.777) 0.001

Parous (n = 59) 0.588 (0.422–0.755) 0.303
Overall (n = 179) 0.645 (0.563–0.726) 0.001
Vaginal delivery Nulliparous (n = 125) 0.694 (0.600–0.788) 0.00032
Parous (n = 63) 0.724 (0.530–0.918) 0.042
Overall (n = 188) 0.674 (0.590–0.757) 0.00019

ROC, receiver–operating characteristics.

Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2008; 31: 328–331.
Ultrasound assessment of cervical length in prolonged pregnancy
for nulliparous women. However, the number of parous
women was half that of nulliparous women, and the lack
of significance may be due to low numbers.
Only one previous study has reported on the value of
sonographic cervical length measurement before induc-
tion of labor in prolonged pregnancy15 . The authors
reported on 382 women whose cervical length was mea-
sured just before induction of labor. The data from this
study showed that cervical length (odds ratio, 1.10) and
parity (odds ratio, 0.26) influenced the need for Cesarean
section. In our study, sonographic assessment was carried
out up to 4 days before either induction or spontaneous
labor. Therefore, these two studies are not comparable.
The present study reports an odds ratio of 1.079 for
cervical length and 0.214 for parity for the need for
Cesarean section. The likelihood of need for a Cesarean
section increased with cervical length, and being parous
reduced by fourfold the chance of a Cesarean section
being performed.
Routine induction of labor is recommended in pro-
longed pregnancy, mainly in order to reduce the risk of
stillbirth. There is some evidence that the risk of stillbirth
in prolonged pregnancy is significantly increased in nulli-
parous women, but not in parous women16 . The findings
of the present study indicate that cervical length, but not
parity, is significantly associated with the spontaneous
onset of labor after 41 weeks’ gestation. These findings
suggest that parous women and nulliparous women with
a short cervix are not only more likely to undergo spon-
taneous labor, but also to deliver normally. Given the
relative ineffectiveness of fetal assessment in prolonged
pregnancy to prevent unexplained stillbirth, particular
attention should be paid to all women with a long cervix.
In conclusion, cervical length is a significant indepen-
dent predictor of the onset of spontaneous labor in
nulliparous women, and of successful vaginal delivery
in nulliparous and parous women with prolonged preg-
nancy. Parity has no independent effect on prediction
of the onset of spontaneous labor, but has a significant
impact on the prediction of a successful vaginal birth.
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