Acta Obstetricia et Gynecologica.

2008; 87: 731
737

ORIGINAL ARTICLE

Sagittal suture overlap in cephalopelvic disproportion: Blinded and

non-participant assessment

ECKHART J. BUCHMANN1 & ELENA LIBHABER2

1
Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital and University of the Witwatersrand,
Johannesburg, South Africa, and 2Department of Cardiology, Chris Hani Baragwanath Hospital and University of the
Witwatersrand, Johannesburg, South Africa

Abstract
Objective. To determine the role of assessment of overlap of fetal skull bones (molding) in intrapartum prediction of
cephalopelvic disproportion (CPD). Design. Prospective cross-sectional study. Setting. South African high-risk obstetric unit
that receives referrals from other facilities. Population. Women of at least 37 weeks’ gestation in the active phase of labor,
with singleton vertex presentations and live fetuses, and without previous cesarean sections. Method. The researcher was
blinded to parity and previous clinical information on the women, and not involved in their obstetric care. The researcher
performed clinical assessments, including estimation of level of head, cervical dilatation, head flexion, position, overlap of
fetal skull bones, caput succedaneum and asynclitism. A single assessment was done on each woman. Main outcome measure.
CPD, defined as cesarean section for poor progress in labor. Results. The author examined 504 women, and CPD occurred
in 113 (22.4%). In multivariate logistic regression analysis, sagittal suture overlap was independently associated with CPD.
Other factors associated were maternal height, duration of labor, birth weight, and the interaction between caput
succedaneum and cervical dilatation at the time of examination. Lambdoid suture overlap was not significantly associated
with CPD, and could be determined in only 66.5% of examinations because of frequent head deflexion. Conclusion.
Assessment of sagittal suture overlap, but not lambdoid suture overlap, is useful for prediction of CPD. Knowledge of
sagittal suture overlap may assist in decisions on clinical management where there is poor progress in a trial of labor.

Key words: Molding, fetal skull, cephalopelvic disproportion, obstructed labor, intrapartum clinical assessment

Introduction and to a lesser degree at the lambdoid suture

Cephalopelvic disproportion (CPD) is a clinical
diagnosis made in a trial of labor, where there is
poor progress in the presence of adequate uterine
activity. CPD is especially common in sub-Saharan
Africa, where complications of obstructed labor
result in significant maternal and perinatal death
and morbidity. It has been stated that the best
evidence of CPD is failure of fetal head descent
with an increase in the grade of skull molding (1).
Molding involves change in the shape of the fetal
skull during labor, by flattening and overlap of the
skull bones (2). A study of laboring primigravidae in
Zimbabwe in the 1970s showed that overlap of skull
bones at the sagittal suture (parietal over parietal),
(parietal over occipital), was associated with CPD
(3). The predictive value of these observations can
be questioned because the clinicians who made the
observations also made the diagnoses of CPD,
raising the possibility of bias. In addition, the authors
did not perform statistical analysis to adjust for
confounding. The role of assessment of molding in
CPD remains unclear, with overlap of skull bones
considered by many to be a sign of normal labor
(2,4
6). A call was recently made for further studies
on the role of assessing grades of molding in
obstructed labor (7). The objective of this study
was to determine the role of assessment of overlap at
the sagittal and lambdoid sutures in intrapartum
prediction of CPD.

Correspondence: Eckhart J. Buchmann, Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Hospital, P O Bertsham, 2013 South Africa.
E-mail: eckhart.buchmann@wits.ac.za

(Received 30 March 2008; accepted 29 April 2008)

ISSN 0001-6349 print/ISSN 1600-0412 online # 2008 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.1080/00016340802179848
732 E.J. Buchmann and E. Libhaber
Material and methods
This was a prospective cross-sectional study, in
which the researcher performed intrapartum clinical
examinations without knowledge of the women’s
parities or previous clinical findings, and did not
participate in the obstetric care of the women. The
assessments were done at the time of the attending
clinicians’ labor rounds. Approval for the research
was given by the Human Research and Ethics
Committee of the University of the Witwatersrand.
The study was performed in the Chris Hani Bar-
agwanath Hospital labor ward, Johannesburg. This
high-risk unit receives referrals from midwifery
clinics and other hospitals. A frequent reason for
referral is poor progress in labor. The study popula-
tion was pregnant women of at least 37 weeks’
gestation in the active phase of labor (cervix 3 cm or
more dilated and fully effaced) with singleton live
fetuses and vertex presentations. Exclusion criteria
were previous cesarean section, maternal medical
conditions, known major fetal abnormality, and
evidence of fetal distress. A consecutive sampling
method was used on days where the researcher was
available to perform examinations. The required
sample size (n 352) was based on a pre-study
calculation that sought to show a difference in
positive predictive value for CPD of 45% for sagittal
suture overlap vs. 30% for lambdoid suture overlap,
assuming a significance level at P less than 0.05 and
a power of 80%. Data collection was done from mid-
2003 to the end of 2005.
About one hour before the scheduled clinician’s
ward round, the researcher approached each par-
turient woman to determine eligibility for inclusion
in the study. The study design did not allow him to
read the clinical notes as this would eliminate
blinding and allow biased clinical assessment. To
determine eligibility for the study, each woman was
asked if she: (1) was nine months pregnant with a
single live baby; (2) had labor pains; and (3) had a
previous cesarean section. The attending midwifery
and medical staff frequently assisted by reading the
notes on behalf of the researcher. If a woman was
possibly eligible, informed consent for examination
was obtained, and the researcher measured the
mother’s supine height with a stiff metal tape
measure. Arrival of the attending clinician was then
awaited. The clinicians were aware that their find-
ings should not be shared with the researcher, and
that the researcher would not reveal his findings to
them at the time of examination.
On arrival of the clinician, the researcher pro-
ceeded with abdominal examination and estimation
of level of head in fifths palpable above the pelvic
brim. The attending clinician then performed the
routine intrapartum examination. Amniotomy was
done if clinically indicated. Immediately after this,
before the woman turned back on her side, the
researcher performed vaginal examination. He re-
corded cervical dilatation to the nearest cm, overlap
at the sagittal and lambdoid sutures, caput succeda-
neum, fetal position, asynclitism and degree of head
flexion. Overlap was defined as grade 0 if the skull
bones were clearly separated, grade 1 if they were
touching, and grade 2 if there was overlap. Caput
was classified subjectively as grade 0 (absent), grade
1 (mild) and grade 2 (marked). Flexion was defined
as good if only the posterior fontanelle was easily felt,
moderate if both fontanelles were easily felt, and
poor if only the anterior fontanelle was easily felt.
Asynclitism was subjectively recorded if the sagittal
suture felt significantly displaced to the fetal right or
left resulting from lateral tilt of the head. Women
found to be in the latent phase of labor (cervix less
than 3 cm dilated or not fully effaced) were excluded
at this stage. After the clinician completed the
obstetric management plan, the researcher obtained
demographic and clinical information from the case-
notes. This included maternal weight at the first
prenatal visit. Later, or on the following day, the
researcher recorded the mode of delivery, need for
oxytocin augmentation, duration of labor, and birth
weight.
It is well known that clinicians have difficulty in
identifying fetal position (8
10). This may result in
misidentification of suture lines, and assignment of
overlap to the incorrect sutures. Just after mid-way
through the study the researcher performed
30 consecutive transabdominal suprapubic ultra-
sound scans on participant women immediately after
the clinical examinations. This was done to deter-
mine fetal position accurately for comparison with
the clinical findings, to provide assurance that he was
identifying suture lines correctly during clinical
assessment.
The main outcome measure was the presence or
absence of CPD, defined as cesarean section for poor
progress in labor. Normal vaginal delivery and
assisted vaginal delivery were accepted as evidence
of no CPD. The outcome was uncertain when
cesarean section was done for fetal distress (cardio-
tocographic findings suggestive of fetal hypoxemia),
and such women were excluded from analysis.
Database management and statistical analysis
were performed on SAS software version 9.1 (SAS
Institute Inc, Cary, NC). Descriptive statistics used
statements of frequencies with percentages and 95%
confidence intervals. Continuous data were pre-
sented using means and standard deviations (SDs).
 Sagittal suture overlap in cephalopelvic disproportion
To determine associations between independent
variables and CPD, separate analyses were done for
nulliparous and multiparous women. The tests used
were the Chi-squared test for comparison of fre-
quencies, and Student’s t test and the Mann

Whitney test, when applicable, for continuous vari-
ables. Positive and negative predictive values for
CPD were calculated for selected explanatory vari-
ables. Univariate and multivariate logistic regression
analyses were done to determine independent asso-
ciations with CPD, using odds ratios and 95%
confidence intervals. A logistic regression model
was developed to determine the association of
CPD with the following variables: maternal age
(years), parity (0,1,2 or greater), weight (kg), supine
height (cm), gestation (weeks), level of fetal head
above the brim (fifths), cervical dilatation at the time
of examination (cm), fetal membrane status (intact,
ruptured at time of examination, already ruptured at
time of examination) occipitoposterior (OP) position
(present or absent), sagittal suture overlap (grade),
caput succedaneum (grade), head flexion (good,
moderate, poor), asynclitism (present or absent),
duration of labor (hours) and birth weight (kg). To
build this model, univariate analysis with contin-
gency tables for each variable and logit plots for
continuous and ordinal variables was performed.
Backward and forward subset selection methods
were used to assess interactions among the explana-
tory variables. If significant interactions were de-
tected, a best subset selection method was used to
identify a plausible model. The significance level of
removal of variables was set at P B0.05, and all non-
significant interaction terms were removed to obtain
the final model, using backward logistic regression.
A likelihood ratio test for the model with main
effects plus interaction versus the main effects model
only was computed to decide if the interaction
should be entered into the model. For all tests,
statistical significance was accepted at a P value less
than 0.05.
Results
The researcher examined 504 women. Their mean
age was 25.095.8 years, with a range of 14 to 43
years, and 320 (63.5%) were nulliparous. There
were 493 indigenous African women (97.0%). The
mean gestational age was 39.3 91.6 weeks. Demo-
graphic and obstetric data are shown in Table I. The
mean cervical dilatation at examination was 5.991.9
cm, and the cervix was fully dilated in 37 women
(7.3%). The mean duration of the active phase of
labor was 8.795.1 hours. Nulliparae had longer
mean durations of labor (9.4 hours) than multiparae
733
(7.4 hours; P B0.0001). The mean birth weight was
31909436 g, with a range of 1880 to 4890 g. The
mean time interval between examination and deliv-
ery was 3.693.4 hours. There were three fresh
stillbirths, all related to intrapartum hypoxia, and
two early neonatal deaths, one related to intrapar-
tum hypoxia and one to antenatally undiagnosed
multiple congenital abnormalities. Ultrasound scans
for fetal position in 30 consecutive women showed
that 27 (90.0%) of the researcher’s assessments were
correct to within 45 degrees of rotation. Two were
incorrect by 90 degrees or more, and one clinical
assessment could not determine a position.
There were 346 normal vaginal deliveries (68.7%)
and 21 assisted vaginal deliveries (4.2%). According
to the study definition, all of these women were
classified as not having CPD. One hundred and
thirteen cesarean sections were done for poor pro-
gress (22.4%) and 24 were done for fetal distress
(4.8%). The latter 24 could not be defined as having
or not having CPD. This left 480 women in whom
prediction for CPD could be studied. Among
nulliparae with CPD, 73.8% received oxytocin
augmentation, and among multiparae with CPD,
48.5% received augmentation (Tables II and III).
Associations between CPD and clinical variables
were studied separately in nulliparous and multi-
parous women (Tables II and III). In nulliparae,
height (P 0.016), gestational age (P 0.004) and
birth weight (P 0.0001) were associated with CPD
(Table II). On intrapartum assessment, no signifi-
cant associations with CPD were observed for
lambdoid suture overlap (P 0.060), OP position
(P 0.92) and head flexion (P 0.11) (Table II).
CPD was significantly associated with higher level of
the head above the pelvic brim (P B0.0001), lesser
cervical dilatation at examination (P B0.0001), sa-
gittal suture overlap (P B0.0001), caput succeda-
neum (P 0.0007), asynclitism (P 0.002),
increased duration of labor (P B0.0001), and use
of oxytocin (P0.003) (Table II). Lambdoid suture
overlap could only be assessed in 201 cases (65.9%),
mostly because of head deflexion, with the suture
lines not accessible for palpation. Similar associa-
tions were shown in multiparous women (n 175),
although level of the head above brim (P0.21),
cervical dilatation (P 0.41) and use of oxytocin
(P 0.08) did not differ significantly between those
with and those without CPD (Table III). Lambdoid
suture overlap could be assessed in only 134 women
(76.6%).
The positive predictive value for CPD with sagittal
suture overlap, irrespective of parity (n 477), was
47.1% (41/87) with grade 2 overlap, and 34.5% (81/
235) with overlap of grade 1 or more. For lambdoid
734 E.J. Buchmann and E. Libhaber
Table I. Clinical data and labor outcomes for nulliparae and multiparae, and for the whole study sample, with findings at the time of clinical
examination; means9standard deviation (n 504).

Nulliparae Multiparae
(n 320) (n184) All (n 504)

Age (years) 22.393.9 29.795.6 25.095.8

Gestational age (weeks) 39.491.6 39.391.6 39.391.6
Weight (kg) (n 488) 66.3913.3 74.1913.4 69.2913.8
Supine height (cm) 162.196.3 162.996.5 162.496.4
Cervical dilatation (cm) 6.092.0 5.991.7 5.991.9
Membranes ruptured: n (%) 284 (88.8%) 152 (82.6%) 436 (86.5%)
Duration of labor (hours) 9.495.3 7.494.5 8.795.1
Oxytocin augmentation: n (%) 189 (59.1%) 66 (35.9%) 255 (50.6%)
Delivery: n (%)
Normal vaginal 204 (63.8%) 142 (77.2%) 346 (68.7%)
Assisted vaginal 21 (6.6%) 0 (0.0%) 21 (4.2%)
Cesarean for CPD 80 (25.0%) 33 (17.9%) 113 (22.4%)
Cesarean for fetal distress 15 (4.7%) 9 (4.9%) 24 (4.8%)
Birth weight (g) 3,1419411 3,2759465 3,1909436

suture overlap in those women in whom this could
be assessed (n 335), the corresponding positive
predictive values were 25.2% (54/214) for grade 2
overlap and 23.4% (68/291) for overlap of grade 1 or
more. The negative predictive value for CPD with a
finding of no sagittal suture overlap was 87.2% (211/
242). With a finding of no lambdoid suture overlap,
this was 90.9% (40/44).
Unadjusted logistic regression analysis (not
shown) demonstrated that CPD was significantly
associated with the following variables: maternal
height, gestation, cervical dilatation at examination,

Table II. Association of intrapartum clinical observations with CPD in nulliparae; means9standard deviation (n 305).

No CPD CPD
Number (n 225) (n 80) P value

Maternal weight (kg) 294 66.1911.7 66.6917.3 0.39

Supine height (cm) 305 162.596.2 160.696.5 0.016
Gestational age (weeks) 305 39.291.6 39.891.6 0.004
Cervical dilatation (cm) 305 6.392.1 5.291.4 B0.0001
Level of head above brim (fifths) 304 2.591.6 3.291.1 B0.0001
Sagittal suture overlap: n (%)
Grade 0 302 140 (62.8%) 23 (29.1%) B0.0001
Grade 1 57 (25.6%) 27 (34.2%)
Grade 2 26 (11.7%) 29 (36.3%)
Lambdoid suture overlap: n (%)
Grade 0 201 26 (16.7%) 2 (4.4%) 0.060
Grade 1 35 (22.4%) 8 (17.8%)
Grade 2 95 (60.9%) 35 (77.8%)
Caput: n (%)
Grade 0 305 144 (64.0%) 32 (40.0%) 0.0007
Grade 1 50 (22.2%) 27 (33.8%)
Grade 2 31 (13.8%) 21 (26.3%)
Occipitoposterior position: n (%) 299 85 (38.3%) 30 (39.0%) 0.92
Asynclitism: n (%) 305 9 (4.0%) 11 (13.8%) 0.002
Flexion: n (%)
Good 299 47 (21.3%) 22 (28.2%) 0.11
Moderate 95 (43.0%) 38 (48.7%)
Poor 79 (35.7%) 18 (23.1%)
Active phase labor duration (hours) 305 8.394.7 12.895.5 B0.0001
Oxytocin augmentation used: n (%) 305 123 (54.7%) 59 (73.8%) 0.003
Birth weight (g) 305 3,0819370 3,3299475 0.0001
 Sagittal suture overlap in cephalopelvic disproportion 735
Table III. Association of intrapartum clinical observations with CPD in multiparae; means9standard deviation (n175).

No CPD CPD
Number (n142) (n33) P value

Maternal weight (kg) 171 74.4913.4 73.3914.2 0.69

Supine height (cm) 175 163.696.6 160.395.6 0.009
Gestational age (weeks) 175 39.191.6 39.991.4 0.004
Cervical dilatation (cm) 175 6.091.7 5.791.7 0.41
Level of head above brim (fifths) 174 3.291.6 3.591.0 0.21
Sagittal suture Overlap: n (%)
Grade 0 175 71 (50.0%) 8 (24.2%) 0.003
Grade 1 51 (35.9%) 13 (39.4%)
Grade 2 20 (14.1%) 12 (36.4%)
Lambdoid suture overlap: n (%)
Grade 0 134 14 (13.1%) 2 (7.4%) 0.060
Grade 1 28 (26.2%) 6 (22.2%)
Grade 2 65 (60.7%) 19 (70.4%)
Caput: n (%)
Grade 0 175 104 (73.2%) 17 (51.5%) 0.046
Grade 1 26 (18.3%) 10 (30.3%)
Grade 2 12 (8.5%) 6 (18.2%)
Occipitoposterior position: n (%) 174 37 (26.2%) 10 (30.3%) 0.64
Asynclitism: n (%) 175 8 (5.6%) 9 (27.3%) 0.0002
Flexion: n (%)
Good 172 25 (18.0%) 5 (15.2%) 0.74
Moderate 61 (43.9%) 13 (39.4%)
Poor 53 (38.1%) 15 (45.5%)
Active phase labor duration (hours) 175 6.293.7 11.295.2 B0.0001
Oxytocin augmentation used: n (%) 175 46 (32.4%) 16 (48.5%) 0.08
Birth weight (g) 175 3,2409436 3,4739486 0.008

level of head in fifths, sagittal suture overlap, caput
succedaneum, asynclitism, duration of labor, and
birth weight. Backward logistic regression showed
that maternal height, sagittal suture overlap,
duration of labor, and birth weight were indepen-
dently associated with CPD (Table IV). Interaction
between caput and cervical dilatation was included
in the final model after achieving significance
(P0.006) when comparing the 2-log likelihood
values of the models with and without the interaction
(P0.004). No odds ratio was computed for the
interaction because caput was not constant with
different measures of cervical dilatation, and vice
versa. The interaction in this model indicates that a
high grade of caput at low measures of cervical
dilatation is independently associated with CPD.
offer new insight into the value of commonly
performed intrapartum observations, and have de-
monstrated the importance of sagittal suture overlap
in prediction of CPD. This had been suspected
previously based on radiological studies, (11,12) and
was suggested in one prospective study from the
1970s (3). The findings here also support the view
that lambdoid suture overlap is a normal intrapar-
tum phenomenon, (13,14) and should not be used
Table IV. Logistic regression model showing independent asso-
ciation between explanatory variables and cephalopelvic dispro-
portion.
Adjusted odds
Predictor ratio (95% CI) P value

Supine height (cm) 0.91 (0.87
0.96) 0.0001

Discussion Sagittal suture overlap (grade) 2.31 (1.60
3.38) B0.0001
Duration of labor (hours) 1.25 (1.18
1.32) B0.0001
The prospective blinded non-participant methodol- Birth weight (g) 1.002 (1.001
1.002) B0.0001
ogy allowed unbiased assessment of intrapartum Caput*cervical dilatation$ 0.006
clinical observations by the researcher for their
$Explanatory variable is the interaction between caput succeda-
association with delivery outcome. This method neum and cervical dilatation. Odds ratio not given because caput
has not been used previously in research on intra- is not constant with different measures of cervical dilatation, and
partum clinical assessment. The results therefore vice versa.
736 E.J. Buchmann and E. Libhaber
to justify a diagnosis of CPD. Lambdoid sutures
could only be palpated in about two-thirds of
examinations owing to deflexion of the fetal head.
Regarding correct identification of the sutures,
ultrasound verification of fetal position provided
assurance that the suture lines and fetal position
were correctly identified by the researcher in most
cases.
Other factors independently associated with CPD
were, predictably, poor labor progress (cervical
dilatation and duration of labor), maternal height,
and birth weight. Caput succedaneum, at low
cervical dilatation, was also significantly associated
with CPD. A number of clinical observations were
found to have no value in predicting CPD. Gesta-
tional age was associated with CPD only in un-
adjusted analysis. OP position was frequent in the
study sample and surprisingly showed no association
with CPD. However, this is in agreement with old
but classic clinical research from U.S.A. in the
1930s, where Calkins found the OP position to be
frequent (48%) in a large consecutive sample of
laboring women. There was no association between
OP position and operative delivery (15). Similar
findings were noted from South Africa in the 1980s
(16). The traditional view is that the OP position is
associated with CPD, and this is supported in
studies from North America, Africa and Europe
(17
19). The results here are strengthened by the
blinded non-participant methodology and the ultra-
sound verification of fetal position. Another surprise
was that the level of fetal head above the brim was
not an independent predictor for CPD. However, an
unengaged head in the first stage of labor is known to
be of questionable significance, (20,21) especially in
multiparae, (22) and in African women, (23,24)
where head descent typically occurs late in labor.
The true significance of failure of head descent in the
first stage may only be found in studies with a
longitudinal design where women are followed with
repeat examinations up to delivery.
Interpretation of these results must consider
certain limitations. The results are applicable to
women at risk for CPD in an African population.
Africans are considered to be at greater risk for
pelvic contraction than Caucasians (25,26). The
definition of CPD in this study may be questioned,
although it agrees with those of other researchers
(27
29). While vaginal delivery excludes absolute
CPD, the performance of cesarean section for poor
progress is not a guarantee that there was dispropor-
tion. It is possible that a number of cases of ‘CPD’
may simply have had poor uterine activity, although
a majority did receive oxytocin for augmentation of
labor. Intra-uterine pressure monitors were not used
and midwifery observations in the notes did not
provide sufficient detail for analysis of contraction
frequency and duration. The high rate of CPD
(22%) is explained by the high-risk nature of the
population studied in this referral institution. Re-
garding the single researcher doing all examinations,
this provides consistency but lacks evidence of
repeatability. Other observers may not have made
the same findings. However, the researcher is an
experienced consultant obstetrician with a long
record of teaching clinical skills in obstetrics. In
addition, the clinical findings observed by the
researcher were accessible to the attending clinicians
who were making the intrapartum assessments. If
they made the same findings as the researcher, and
used these findings to make their decisions, this
could eliminate the ‘non-participant’ element of the
study design. This may have occurred in a number of
cases.
This study has shown that overlap at the sagittal
suture is suggestive of CPD, although not necessarily
diagnostic. Lambdoid suture overlap has little clin-
ical value. Obstetric clinicians and midwives should
consider a finding of sagittal suture overlap in the
light of the intrapartum clinical picture, including
maternal height, estimated fetal weight, caput suc-
cedaneum, and, most important, progress in a
properly conducted trial of labor.
Acknowledgements
This research was funded by a grant from the South
African Society of Obstetricians and Gynaecologists,
toward Dr Buchmann’s PhD thesis.
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