Research ajog.

org

OBSTETRICS
A model to predict vaginal delivery in
nulliparous women based on maternal
characteristics and intrapartum ultrasound
Tørbjorn Moe Eggebø, MD, PhD; Charlotte Wilhelm-Benartzi, PhD; Wassim A. Hassan, MD;
Sana Usman, MD; Kjell A. Salvesen, MD, PhD; Christoph C. Lees, MD

OBJECTIVE: Accurate prediction of whether a nulliparous woman will
have a vaginal delivery would be a major advance in obstetrics. The
objective of the study was to develop such a model based on maternal
characteristics and the results of intrapartum ultrasound.
STUDY DESIGN: One hundred twenty-two nulliparous women in
the first stage of labor were included in a prospective observa-
tional 2-centre study. Labor was classified as prolonged ac-
cording to the respective countries’ national guidelines. Fetal
head position was assessed with transabdominal ultrasound and
cervical dilatation by digital examination, and transperineal ul-
trasound was used to determine head-perineum distance and the
presence of caput succedaneum. The subjects were divided into
a testing set (n ¼ 61) and a validation set (n ¼ 61) and a risk
score derived using multivariable logistic regression with vaginal
birth as the outcome, which was dichotomized into no/cesarean
delivery and yes/vaginal birth. Covariates included head-perineum
distance, caput succedaneum, and occiput posterior position,
which were dichotomized respectively into the following: 40
mm, >40 mm, <10 mm, 10 mm, and no, yes. Maternal age,
gestational age, and maternal body mass index were included as
continuous covariates.
RESULTS: Dichotomized score is significantly associated with vaginal
delivery (P ¼ .03). Women with a score above the median had greater
than 10 times the odds of having a vaginal delivery as compared with
those with a score below the median. The receiver-operating char-
acteristic curve showed an area under the curve of 0.853 (95%
confidence interval, 0.678e1.000).
CONCLUSION: A risk score based on maternal characteristics and
intrapartum findings can predict vaginal delivery in nulliparous women
in the first stage of labor.
Key words: cesarean delivery, head-perineum distance, prediction
model, transperineal

Cite this article as: Eggebø TM, Wilhelm-Benartzi C, Hassan WA, et al. A model to predict vaginal delivery in nulliparous women based on maternal characteristics and
intrapartum ultrasound. Am J Obstet Gynecol 2015;213:362.e1-6.

P rolonged nulliparous labor is

responsible for 30% of all cesarean
deliveries.1 Although risk factors such as
induction of labor and occiput posterior
position increase the likelihood of
cesarean delivery,2 there is no way of
predicting this outcome with precision
based on clinical examination alone.
Digital vaginal examination is the key
method used worldwide to define the
diagnosis of labor and its progress, the
findings being plotted manually on a
graphical representation of the progress
of labor: a partogram. The partogram has
been developed to aid the recognition of

From the Department of Obstetrics and Gynecology, Stavanger University Hospital, Stavanger (Dr Eggebø), and National Center for Fetal Medicine,
Trondheim University Hospital (St Olav’s Hospital) (Dr Eggebø), and Department of Laboratory Medicine, Children’s and Women’s Health, Norwegian
University of Science and Technology (Dr Salvesen), Trondheim, Norway; ICTU-Cancer Clinical Trials Unit, Department of Surgery and Cancer, Imperial
College London (Dr Wilhelm-Benartzi); the Department of Cancer and Surgery, Imperial College London, Centre for Fetal Care, Queen Charlotte’s and
Chelsea Hospital, Imperial College Healthcare National Health Service Trust, London (Drs Usman and Lees); Department of Fetal Medicine, Rosie
Maternity Hospital, Addenbrooke’s Hospital, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge (Dr Hassan), United
Kingdom; and Department of Development and Regeneration, KU Leuven, Belgium (Dr Lees).
Received Dec. 15, 2014; revised April 25, 2015; accepted May 20, 2015.
The views expressed are those of the author(s) and not necessarily those of the National Health Service, the National Institute for Health Research, the
British Medical Association, or the Department of Health.
The Helen Lawson Grant, funded by the British Medical Association, has supported S.U.; C.C.L. is supported by the National Institute for Health Research
Biomedical Research Centre, based at Imperial College Healthcare National Health Service Trust and Imperial College London.
The authors report no conflict of interest.
Corresponding author: C. C. Lees, MD. christoph.lees@imperial.nhs.uk
0002-9378/$36.00  ª 2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2015.05.044

362.e1 American Journal of Obstetrics & Gynecology SEPTEMBER 2015

ajog.org
FIGURE 1
HPD on transperineal ultrasound
The head-perineum distance (HPD) is the
measurement between the fetal skull and the
perineum in the transverse section, in this image
showing the HPD of 34 mm.
Reproduced, with permission, from Tørbjorn Moe Eggebø.
Eggebø. Predicting vaginal delivery in nulliparous labor.
Am J Obstet Gynecol 2015.
failure to progress in labor3-5 and has
formed the basis for national guidelines.6
However, there is much discussion
regarding its applicability,7-9 resulting in
the American Association of Obstetri-
cians and Gynecologists issuing guide-
lines on labor management10 in 2014.
Digital vaginal examination is also
intrusive,11 subjective,12 inconsistent,13
and associated with infection.14 Our group
has recently described an ultrasound-
based partogram (sonopartogram) based
on nonintrusive intrapartum ultrasound
observations,15 using transabdominal
and transperineal ultrasound.
Transabdominal ultrasound can be
used to determine the fetal head position
in labor with a higher degree of accuracy
than by classical clinical palpation.16
Transperineal ultrasound, first des-
cribed in the mid-1990s,17 is a 2-
dimensional, noninvasive, objective,
simple method of scanning, placing a
transducer outside the vagina.18 It can
be used to determine the angle of pro-
gression of the fetal head,15,19-21 head-
perineum distance (HPD),22 and the
degree of caput succedaneum.15,23,24
Increasingly, models including maternal
characteristics and ultrasound findings
are used in risk prediction with womens’
health, for example in prenatal Down’s
syndrome screening,25 and in pre-
eclampsia risk prediction.26 Recently
fetal Doppler assessment of the cere-
broumbilical ratio prior to the onset of
labor has been shown to identify those
fetuses at high risk of emergency cesar-
ean delivery because of fetal distress.27
Knowledge of the likelihood of cesarean
delivery, especially in prolonged labor,
has the potential to inform obstetric care
and expectations of a woman in labor.
Taking basic maternal characteristics,
clinical and ultrasound observations, we
aimed to develop a model for prediction
of vaginal birth in the nulliparas in the
first stage of labor.
M ATERIALS AND M ETHODS
A prospective observational 2-center
study investigating the clinical value of
ultrasound in labor was performed at
Stavanger University Hospital (Sta-
vanger, Norway) and at Addenbrooke’s
Hospital (Cambridge, United Kingdom)
in 2012e2013.
Nulliparous women with a live
singleton pregnancy and cephalic pre-
sentation in the first stage of labor at
term (37 weeks) were eligible for the
study. Clinical results from the study
population have been published previ-
ously24,28 with respect of the individual
component measurements. For this
study, patients were included in which all
measurements were available specifically
in this case including caput succeda-
neum measurements. Ethics Committee
approval was obtained in Norway (REK
2011/731) and in the United Kingdom
(11/EE/064), and all women gave written
consent.
Prolonged first stage of labor was
defined according to national guidelines.
World Health Organization recommen-
dations were used in Norway when cer-
vical dilatation crossed the action line
(4 hours from the alert line).29 In the
United Kingdom, National Institutes of
Health and Clinical Excellence guide-
lines (dilatation of <2 cm in 4 hours)
were used.6
Gestational age was calculated from a
second-trimester scan in Norway and
from the first-trimester scan in the
United Kingdom. Maternal age was
taken as age at the time of labor and
SEPTEMBER 2015 American Journal of Obstetrics & Gynecology
Obstetrics Research
FIGURE 2
Transperineal ultrasound
measurement of caput
succedaneum
In the sagittal view, a vertical line is drawn from
the fetal skull to the uppermost edge of the cutis.
Reproduced, with permission, from Tørbjorn Moe Eggebø.
Eggebø. Predicting vaginal delivery in nulliparous labor.
Am J Obstet Gynecol 2015.
booking maternal body mass index
(BMI) was entered in the predictive
model. Vaginal delivery included spon-
taneous and assisted operative deliveries
using vacuum extraction and/or forceps.
During the ultrasound examination,
women were in the supine position with
flexed hips and knees, membranes had
ruptured and the bladder was empty as
previously described.28 The birth atten-
dant (midwife or doctor) performed a
digital vaginal examination assessing
cervical dilatation and fetal head descent.
The descent was categorized using the
World Health Organization classification
of fetal head station with the ischial
spines as reference point 0, e5 at the
pelvic inlet, and þ5 at the pelvic outlet.29
An obstetrician or midwife performed
all the ultrasound examinations using
Voluson i (GE, Zipf, Austria) with a
3.5e7.5 MHz three-dimensional curved
multifrequency transabdominal trans-
ducer in Norway and Samsung Medison
Accuvix XG (Samsung Medison, Medical
Imaging Systems Ltd, London, UK)
equipment with a 4e6 MHz convex
transabdominal transducer in the United
Kingdom. Birth attendants were blinded
to the ultrasound findings and these
findings were also not disclosed to the
parents.
Fetal position was assessed with a
transabdominal scan and recorded with
half-hourly divisions. Positions >03.30
362.e2
Research Obstetrics ajog.org

and <08.30 were recorded as the occiput

posterior position and other positions as TABLE 1
the nonocciput position.30 Thereafter Univariate and demographic characteristics by whole study set
the transducer was placed trans- Test Set Validation Set
perineally at the level of the posterior Characteristic (n [ 61) (n [ 61) P valuea
fourchette in a transverse position, and Maternal age, mean (SD) 29.6 (5.1) 29.2 (5.3) .69
the HPD was measured as previously Gestational age, mean (SD) 40.0 (1.3) 40.3 (0.83) .16
described (Figure 1).22 Caput succeda-
Maternal BMI, mean (SD) 24.9 (3.9) 25.0 (4.2) .96
neum was measured by the skin-skull
distance in a transperineal scan24 with Cervical dilation, mean (SD) 6.3 (1.6) 6.1 (1.6) .53
the probe held sagittally (Figure 2). Vaginal birth
Cesarean delivery (0) 20 9 .04b
Statistical analyses
A predictive model was tested using R Vaginal birth (1) 41 52
version 2.15, which included known Head perineum distance 40 mm
variables at the time of the ultrasou- 40 mm (0) 26 24 .85
nd examination such as maternal age
>40 mm (1) 35 37
and BMI. First, the study population
(n ¼ 122) was split into a testing set Caput 10 mm
(n ¼ 61) and a validation set (n ¼ 61) <10 mm (0) 34 29 .47
using blocked randomization to ensure
10 mm (1) 27 32
an equal number of prolonged labor
cases in both sets. This was to make our Occiput posterior position
model more externally generalizable No (0) 37 42 .99
because our study population had an
Yes (1) 18 19
overrepresentation of women with pro-
longed labor. Unknown 6 0
Table 1 shows the demographic and Prolonged labor
covariate information by study set as
No (0) 16 16 1.00
well as basic univariates comparing the
distribution of patients by set using Yes (1) 45 45
Pearson’s c2 test for categorical varia- BMI, body mass index.
bles and a Student 2-sample t test with a
Using Pearson’s c2 test and Student 2-sample t test with equal variance as appropriate; b Denotes statistical significance at
the P < .05 level.
equal variance for continuous variables.
Eggebø. Predicting vaginal delivery in nulliparous labor. Am J Obstet Gynecol 2015.
Vaginal birth was dichotomized into no/
cesarean delivery and into yes/vaginal
birth. Head perineum distance, caput,
occiput posterior position, and pro- The logistic regression model co- receiver-operating characteristic (ROC)
longed labor were all dichotomized into efficients were used to construct a risk curve and corresponding area under the
the following, respectively: 40 mm; score such that: curve were generated using the pROC
>40 mm; <10 mm; 10 mm; no, yes; log(risk score) ¼ 18.52 þ 1.58 package in R to determine how well the
and no, yes. (HPD) þ 1.62 (caput) e 0.57 (occiput continuous score predicts vaginal birth
Maternal age, gestational age, clini- posterior position) þ 0.07 (maternal in the validation set (Figure 3).
cally assessed cervical dilation, and age) e 0.05 (maternal BMI) e 0.51
maternal BMI were all kept as contin- (gestational age) e 1.31 (prolonged R ESULTS
uous variables for the prediction model. labor) þ 0.27 (cervical dilation) The mean gestational age was 40 weeks
A risk score was constructed in the Final risk score ¼ exp(log[risk score]). in both groups and maternal character-
testing set using multivariable logistic The risk score was applied to all pa- istics were similar. Vaginal birth was
regression with vaginal birth as the tients in the validation set (n ¼ 61) so unevenly distributed by study set
outcome. The covariates included in the that every patient had a risk score (P ¼ .04) (Table 1), and the occiput
model included the head perineum dis- (Table 2). The score was then dichoto- posterior position data were missing on
tance, caput, occiput posterior position, mized at its median (2.91) and a logistic 6 patients in the test group. Eighty
prolonged labor, maternal age, gesta- regression model run to see whether percent of the study population was
tional age, cervical dilation, and continuous and dichotomized scores augmented with oxytocin.
maternal BMI as described in the previ- were significantly associated with vaginal The dichotomized score was signifi-
ous text. delivery in the validation set (Table 3). A cantly associated with vaginal delivery

362.e3 American Journal of Obstetrics & Gynecology SEPTEMBER 2015

ajog.org
TABLE 2
Model predicting vaginal birth in test set (n [ 61)
Covariate
Intercept
Head perineum distance 40 mm
Caput succedaneum <10 mm
Occiput posterior position
Continuous maternal age
Continuous maternal BMI
Gestational age
Prolonged labor
Cervical dilation
BMI, body mass index; CI, confidence interval.
Eggebø. Predicting vaginal delivery in nulliparous labor. Am J Obstet Gynecol 2015.
(P ¼ .03), with patients having a score
above the median having >10 times the
odds of having a vaginal delivery as
compared with patients with a score
below the median (Table 3). The ROC
curve showed an area under the curve of
0.853 (95% confidence interval,
0.678e1.000) (Figure 1). The continuous
score did not predict vaginal delivery in
the validation set (P ¼ .10). The odds
ratios for vaginal delivery based on head-
perineum distance of 40 mm or less and
caput succedaneum less than 10 mm were
4.85 (P ¼ .07) and 5.08 (P ¼ .06),
respectively, in the test set (Table 2).
C OMMENT
Principal findings
With cesarean delivery rates approach-
ing 30% in many European countries,1
the associated morbidity and additional
staff resources required for operative
deliveries, a more informed assessment
TABLE 3
Score as a prediction of vaginal birth in the validation set
Covariate Beta coefficient
Intercept 0.79
Continuous score 0.30
Intercept 1.01
Dichotomized score 2.39
CI, confidence interval.
Eggebø. Predicting vaginal delivery in nulliparous labor. Am J Obstet Gynecol 2015.
Obstetrics Research
FIGURE 3
ROC between the dichotomized
Beta coefficient Odds ratio P value 95% CI score and prediction of vaginal
delivery
18.52 .16
1.58 4.85 .07 0.9e29.71
1.62 5.08 .06 1.02e32.59
0.57 0.57 .50 0.11e3.31
0.07 1.07 .42 0.91e1.27
0.05 0.96 .67 0.77e1.18
0.51 0.60 .12 0.29e1.09
1.31 0.27 .22 0.02e1.93
0.27 1.31 .27 0.82e2.21
The ROC curve illustrates the association be-
of delivery mode than relying on clinical
tween the continuous score and prediction of
expertise alone is perhaps overdue. In
vaginal delivery.
this proof-of-concept study, we report
AUC, area under the curve; ROC, receiver-operating
that variables shown in previous studies characteristic.
to be predictors of vaginal birth20,28,31-33 Eggebø. Predicting vaginal delivery in nulliparous labor.
can be pooled to assess the overall like- Am J Obstet Gynecol 2015.
lihood of vaginal birth in nulliparous
laboring women. Where vaginal birth is
predicted based on a risk score above and in predicting vaginal birth, this may be
below the median, women above the due to low study power (61 patients in
median score had a 10-fold risk of ce- each set). Furthermore, head-perineum
sarean delivery (Table 3). distance of 40 mm and caput succe-
daneum <10 mm had odds ratios of 4.85
(P ¼.07) and 5.08 (P ¼.06), respectively,
Clinical significance
so are potentially individually good
We have previously described a simple
predictors of vaginal birth (Table 2).
method using 2-dimensional trans-
perineal ultrasound of assessing cervical Strengths and limitations
dilatation, head-perineum distance, and This model represents a proof of concept
caput comparable with vaginal exami- and can be refined further. Despite
nations18 and that HPD of 40 mm is an the small number of patients, we have
independent factor in predicting a shown that the model is feasible
vaginal birth.28 Although a continuous when applied to the validation set. We
score did not show statistical significance measured cervical dilatation clinically
using digital vaginal examination with its
high inter- and intraobserver vari-
ability.34,35 With ultrasound-measured
cervical dilatation likely to be more ac-
Odds ratio P value 95% CI curate,36 adding this component to the
2.21 .12 0.83e6.17 model may improve the predictive model
for vaginal birth. Furthermore, although
1.36 .10 1.05e2.18
the majority of women had prolonged
2.75 .01 1.27e6.58 labor, some were in normal labor, and in
10.91 .03 1.81e210.08 these the ultrasound assessment was
performed as a spot assessment.
Although it is intuitive that a low HPD
and advanced cervical dilatation is likely
SEPTEMBER 2015 American Journal of Obstetrics & Gynecology 362.e4
Research Obstetrics
to lead to vaginal delivery irrespective of
time from onset of labor, standardizing
the time at which the ultrasound mea-
surement is made is likely to enhance the
accuracy of the model.
Potential limitations are whether the
model, developed from a cohort of
nulliparous women with prolonged and
normal labor, will apply to laboring
women in other birth settings or can be
adjusted for women of mixed parity. We
did not seek to change the schedule of
obstetric observations or management
in this study; it is certainly true that
applying a strict management protocol
might improve the predictive accuracy of
the model. Although vaginal birth was
unevenly distributed by study set because
the model was used to predict this vari-
able, it is unlikely to have had an impact
on our study results. Furthermore, there
is a relationship between maternal BMI
and HPD, but this relationship is weak22
and unlikely to have been of material
significance in developing the model.
Strengths of the study are that both
midwives and doctors performed ob-
servations in 2 sites in Europe and
Scandinavia, and maternal baseline
characteristics were similar at both sites.
Bias is unlikely to have been an issue
because caregivers were blinded to the
ultrasound findings.
Research implications
This study illustrates that a predictive
model is feasible, even in a relatively
small sample of laboring nulliparous
women and predicts vaginal delivery.
A longitudinal model with repeated
observations is likely to add further
precision to prediction and indicative
information on likely length of labor.
We caution that knowledge of the risk
scores derived from this model should
not change obstetric decision making
currently. However, further refinement
of the model is likely to provide impor-
tant information that is not currently
available for counseling women and
their birth partners while also informing
health care professionals on the chance
of vaginal delivery or cesarean delivery.
This would allow appropriate in-
terventions at the right time.
362.e5 American Journal of Obstetrics & Gynecology SEPTEMBER 2015
Conclusion
Whereas this model might (if validated
in a large study set) lead to earlier
intervention by cesarean delivery in
women with prolonged labor and unfa-
vorable chance of vaginal delivery, it
might just as well lead obstetricians to
persevere in which vaginal delivery is
likely. Furthermore, a major issue is
staffing and resourcing delivery units
for predicted activity: the model that
we describe might allow a scientific
approach to this in real time by pre-
dicting the likelihood of cesarean de-
livery for women in labor. This would
for the first time enable prospective
decisions to be made to enable resourc-
ing and staffing of delivery settings as
well as giving realistic and evidence-
based expectations to women and their
partners. - 16. Akmal S, Kametas N, Tsoi E, Hargreaves C,
ACKNOWLEDGMENTS
We thank all the staff at the 2 sites, Norway and
the United Kingdom, for recruitment, data
collection, and analysis. We especially thank the
patients for participating in the study.
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