Ultrasound Obstet Gynecol 2015; 45: 358–362

Published online 29 January 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.14742

How to . . . .
Practical advice on imaging-based techniques and investigations with
accompanying slides and videoclips online

How to measure cervical length

K. O. KAGAN* and J. SONEK†‡
*Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen, Germany; †Fetal Medicine Foundation USA, Dayton, OH,
USA; ‡Division of Maternal Fetal Medicine, Wright State University, Dayton, OH, USA

BACKGROUND It has been shown that only 15% of symptomatic

Cervical-length measurement using transvaginal sono-
graphy (TVS) is an essential part of assessing the risk
of preterm delivery. At mid-gestation, it provides a
useful method with which to predict the likelihood
of subsequent preterm birth in asymptomatic women.
In women who present with threatened spontaneous
preterm labor, TVS measurement of cervical length
can help to distinguish between ‘true’ and ‘false’
spontaneous preterm labor. Additionally, there is some
evidence that measurement of the cervix at the 11+0
to 13+6-week scan can help to establish the risk of
preterm birth1,2 .
To et al.3 reported on cervical-length measurement
between 22 and 24 weeks’ gestation in 39 000 women
with a singleton pregnancy. The cervical length was
found to be distributed normally, with a mean length
of 36 mm. In about 1% of the women, the length was
15 mm or less. This cut-off is generally used to define the
high-risk group in interventional studies4 . In most studies
focusing on asymptomatic twin pregnancies at 20 to 24
weeks, a cut-off of 25 mm is applied5 . Celik et al.6 used
cervical-length measurements obtained between 20 and
24 weeks’ gestation, along with maternal history, in more
than 58 000 women to create computed risk models for
preterm delivery. They compared patients who delivered
before 28 weeks, between 28 and 30 weeks, between 31
and 33 weeks, and between 34 and 36 weeks’ gestation.
For a 10% false-positive rate, the sensitivities were 81%,
59%, 53% and 29%, respectively. In a Health Technology
Assessment report, Honest et al.7 summarized the results
of five studies that used cervical-length measurements
between 20 and 24 weeks, with cut-offs of 20–30 mm,
to predict preterm birth before 34 weeks’ gestation. The
resultant positive likelihood ratios ranged from 2.3 for
30 mm to 7.6 for 20 mm.
patients presenting with preterm contractions will actually
deliver within the next 7 days8 . Cervical length can be used
to distinguish between ‘true’ and ‘false’ labor. Sotiriadis
et al.9 summarized six studies, including about 1800
women, that assessed the risk for preterm delivery within
1 week, based on cervical length at the time of admission.
With a cut-off of 15 mm, the sensitivity was about 60%
for a false-positive rate of about 10%. The respective
positive and negative likelihood ratios were 5.7 and 0.5.
With cut-offs of 20 and 25 mm, the sensitivities increased
to 75% and 80%, but at the expense of false-positive
rates of 20% and 30%, respectively.
Recent work10 has shown that cervical length at 11–13
weeks’ gestation, in combination with maternal history,
can detect about half of the pregnancies that result in
preterm delivery before 34 weeks, for a false-positive
rate of 10%. However, the difference between the
median cervical length of the normal group and that
of the preterm-birth group was only 5 mm (32.5 mm
vs 27.5 mm)10 , which raises doubts as to whether this
technique can be used for general screening.
PRACTICAL POINTS
There are essentially four methods that can be used
to evaluate the uterine cervix: digital examination,
transabdominal ultrasound, transperineal ultrasound
(TPS) and TVS. It is the digital examination that provides
the most comprehensive evaluation of the cervix, assessing
dilatation, position, consistency and length. However, this
examination suffers from being subjective. It is limited
especially in its ability to establish accurately the cervical
length. It also cannot detect reproducibly any changes
at the internal cervical os and the upper portion of the
cervical canal. Ultrasound, with its ability to penetrate the

Correspondence to: Prof. K. O. Kagan, University of Tuebingen, Calwerstrasse 7, 72076 Tübingen, Germany (e-mail: KOKagan@gmx.de)

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. HOW TO...
How To . . .
Figure 1 Transvaginal ultrasound image of a normal cervix,
showing the most commonly used method of cervical length
measurement (double-headed arrow). In a curved cervix, the length
is underestimated with a straight line. If the cervix is curved and the
straight-line cervical length measurement is short, measurement
obtained in two or more segments provides a more accurate
estimation of length14 . However, in patients with a pathologically
short cervix, the cervical canal will be straight and this adjustment
in measurement technique is unnecessary.
cervical tissue and display its anatomy, makes an ideal
modality with which to address both of these issues. Both
TVS and TPS are performed with the patient in a dorsal
lithotomy position. In order for the measurement to be
accurate and reproducible, the following factors need to
be taken into account (Figure 1 and Videoclip S1):
Maternal bladder should be essentially empty
The patient having a full bladder can increase artificially
the cervical length. To et al.11 showed that the mean
difference between cervical length measured when the
patient’s bladder is empty and that measured when the
bladder is full is about 4 mm. In addition, a full bladder
can obscure the presence of cervical funneling by com-
pressing the two halves of the funnel together (Figure 2).
A longitudinal view of the cervix should be obtained
The cervix should be measured along its longitudinal axis,
which may be different from the patient’s longitudinal
axis. The cervical canal, in most cases, is a fairly thin
line. It may have a thin layer of hypoechoic contents. This
is true especially in the third trimester. In all likelihood,
it represents accumulation of mucus, and needs to be
differentiated from a thin cervical funnel. This is best
done by delineating the course of the fetal membranes:
if they are not prolapsing into the cervical canal and are
located at the level of the internal cervical os, the presence
of a true funnel is unlikely (Figure 3).
The cervical canal and surrounding cervical mucosa need
to be identified
In order to avoid inclusion of the isthmus into the
cervical-length measurement, care must be taken to
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
359
identify the internal, as well as the external, cervical
ora. The external os is identified as the point at which the
anterior and posterior lips of the cervix come together.
Identification of the location of the internal os can be more
challenging. In order to do so, the cervical mucosa must
be identified. This is usually hypoechoic, with respect to
the surrounding stroma, though occasionally it can be
slightly hyperechoic. A thin line of demarcation between
the stroma and the cervical mucosa can generally be
identified on ultrasound. The point at which the cervical
mucosa ends is considered to be the internal cervical os.
Of note, the mucosa of the lower uterine segment is much
thinner than is the cervical mucosa and is usually difficult
to identify on ultrasound (Figure 4).
Magnification of the ultrasound image needs to be
appropriate
The image should be magnified sufficiently so that the
morphology of the cervix is easily identifiable. The cervix
should occupy approximately 50–75% of the image.
Pressure from the probe on the cervix should be as little
as possible
If excessive pressure is applied on the cervix by the probe,
the cervix appears artificially to be longer and the presence
of a funnel will be obscured. Generally, in order to identify
the relevant structures, it is helpful to put some pressure
on the cervix initially. However, subsequently this should
be reduced to the minimum that is required in order to
view the cervix adequately (Videoclip S2).
Duration of the examination should be 3–5 min
The cervix is not a static structure and the length can
vary, for example due to uterine contractions or to
different positions of the patient (Videoclip S3). Therefore,
sufficient time should be allowed for the examination to
detect these changes. It may be helpful to press manually
on the uterus or to ask the patient to push downwards
to assess the cervical stability. Some even suggest that
during the examination the patient stands, with the
ultrasound probe inside the vagina. Several (at least three)
measurements should be obtained during the course of
the examination and the shortest measurement should be
used for counseling.
Calipers should be placed correctly
Cervical measurement is obtained by placing calipers at
the external and the internal ora (Figure 1). In 95% of
cases, the difference between two measurements obtained
by the same sonographer or by two different sonographers
is about 4 mm12 . If there is funneling, the caliper should
be placed at the apex of the funnel. If the cervix exceeds
25 mm in length, it will be curved in more than 50% of
cases13 . The standard method of measurement, using a
Ultrasound Obstet Gynecol 2015; 45: 358–362.
360 How To . . .

27mm 14mm

Figure 2 Transvaginal ultrasound measurement of cervical length in the same patient, with a full bladder (a) and with an empty bladder (b).

Figure 3 Transvaginal ultrasound image of a cervix with Figure 5 Transvaginal ultrasound image of a short cervix with
accumulation of mucus. Amniotic membranes are indicated funneling.
(arrow), showing that funneling is not present.

Figure 4 Transvaginal ultrasound image of a cervix, showing

cervical mucosa as a homogeneous and hypoechoic structure Figure 6 Transvaginal ultrasound image of amniotic fluid sludge
compared to the surrounding stroma. (arrow).

Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2015; 45: 358–362.
How To . . .
Figure 7 Transvaginal ultrasound Doppler image of vasa previa (a) and gray-scale image of placenta previa (b).
Figure 8 Transperineal (a) and transabdominal (b) ultrasound images of the cervix in the same patient. The cervical canal is indicated
(arrows).
straight line between the internal and the external ora, will
underestimate the cervical length in these cases. However,
this is of little clinical significance as these patients are
at low risk regardless of the exact measurement. In the
high-risk group of patients with a cervical length < 16 mm,
the cervix will always be a straight line.
In the first trimester, the difference in cervical length
between patients who are at risk for preterm birth and
those who are not is extremely small; therefore, it would
seem appropriate to correct for cervical curvature by
obtaining the measurement either in segments or by
tracing the canal14 .
Identification of additional significant findings at the
time of the cervical scan
• Funneling, defined as protrusion of the amniotic
membranes into the cervical canal, is considered by
some as an additional risk factor for preterm delivery
(Figure 5). Various criteria for the diagnosis of true
funneling have been published15,16 . However, using a
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
361
logistic regression analysis that includes both funneling
and cervical length, funneling has been shown not to
be an independent risk factor for spontaneous preterm
delivery17 .
• Amniotic fluid sludge can be found as echogenic aggre-
gates close to the internal os or within a funnel. This
appears to be associated with microbial invasion of
the amniotic cavity18,19 . Sludge is an independent risk
factor for spontaneous preterm delivery, preterm rup-
ture of membranes and histological chorioamnionitis
in asymptomatic patients at high risk for spontaneous
preterm delivery (Figure 6, Videoclip S4).
• Vasa previa, placenta previa or low-lying placenta can
be diagnosed20 (Figure 7).
Other approaches
In general, the cervix should be assessed by TVS. In
cases in which this should be avoided, such as in those
with preterm prelabor rupture of membranes, the cervical
length can be measured by TPS: the transducer is placed
on the perineum and rotated until the complete cervical
Ultrasound Obstet Gynecol 2015; 45: 358–362.
362
canal and the internal and external ora can be identified.
The placement of the probe is further away from the
cervix than it is on TVS; therefore, there is a reduction in
the detail in which the cervix is seen. In 95% of cases, the
difference between TVS and TPS measurements is within
± 5 mm21 . Assessment of cervical length by TAS can be
used as an initial evaluation but it should be borne in
mind that, especially in cases with a short cervix, this
modality tends to overestimate the true cervical length.
Therefore, a proper risk assessment should be based on a
TVS or TPS measurement (Figure 8).
REFERENCES
1. Kagan KO, To M, Tsoi E, Nicolaides KH. Preterm birth: the
value of sonographic measurement of cervical length. BJOG
2006; 113 (Suppl): 52–56.
2. Sonek J, Shellhaas C. Cervical sonography: a review. Ultrasound
Obstet Gynecol 1998; 11: 71–78.
3. To MS, Skentou CA, Royston P, Yu CKH, Nicolaides KH.
Prediction of patient-specific risk of early preterm delivery using
maternal history and sonographic measurement of cervical
length: a population-based prospective study. Ultrasound
Obstet Gynecol 2006; 27: 362–367.
4. Fonseca EB, Celik E, Parra M, Singh M, Nicolaides KH,
Fetal Medicine Foundation Second Trimester Screening Group.
Progesterone and the risk of preterm birth among women with
a short cervix. N Engl J Med 2007; 357: 462–469.
5. Conde-Agudelo A, Romero R, Hassan SS, Yeo, L. Transvaginal
sonographic cervical length for the prediction of spontaneous
preterm birth in twin pregnancies: a systematic review and
meta-analysis. Am J Obstet Gyneco. 2010; 203: 128.e1–12.
6. Celik E, To M, Gajewska K, Smith GCS, Nicolaides KH, On
behalf of the Fetal Medicine Foundation Second Trimester
Screening Group. Cervical length and obstetric history predict
spontaneous preterm birth: development and validation of a
model to provide individualized risk assessment. Ultrasound
Obstet Gynecol 2008; 31: 549–554.
7. Honest H, Forbes CA, Durée KH, Norman G, Duffy SB,
Tsourapas A, Roberts TE, Barton PM, Jowett SM, Hyde CJ,
Khan KS. Screening to prevent spontaneous preterm birth:
systematic reviews of accuracy and effectiveness literature with
economic modelling. Health Technol Assess 2009; 13: 1–627.
8. Kenyon SL, Taylor DJ, Tarnow-Mordi W. Broad-spectrum
antibiotics for spontaneous preterm labour: the ORACLE II
randomised trial. Lancet 2001; 357(9261): 989–994.
9. Sotiriadis A, Papatheodorou S, Kavvadias A, Makrydimas G.
Transvaginal cervical length measurement for prediction of
Slides summarizing practical points, with
accompanying illustrations and videoclips,
are provided as supporting information
online.
Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
How To . . .
preterm birth in women with threatened preterm labor: a
meta-analysis. Ultrasound Obstet Gynecol 2010; 35: 54–64.
10. Greco E, Gupta R, Syngelaki A, Poon LCY, Nicolaides KH.
First-Trimester Screening for Spontaneous Preterm Delivery
with Maternal Characteristics and Cervical Length. Fetal Diagn
Ther 2012; 31: 154–161.
11. To MS, Skentou C, Cicero S, Nicolaides KH. Cervical
assessment at the routine 23-weeks’ scan: problems with
transabdominal sonography. Ultrasound Obstet Gynecol 2000;
15: 292–296.
12. Heath VC, Southall TR, Souka AP, Novakov A, Nicolaides
KH. Cervical length at 23 weeks of gestation: relation to
demographic characteristics and previous obstetric history.
Ultrasound Obstet Gynecol 1998; 12: 304–311.
13. To MS, Skentou C, Chan C, Zagaliki A, Nicolaides KH.
Cervical assessment at the routine 23-week scan: standardizing
techniques. Ultrasound Obstet Gynecol 2001; 17: 217–219.
14. Retzke JD, Sonek JD, Lehmann J, Yazdi B, Kagan KO.
Comparison of three methods of cervical measurement in the
first trimester: single-line, two-line, and tracing. Prenat Diagn
2013.
15. Rust OA, Atlas RO, Kimmel S, Roberts WE, Hess LW. Does
the presence of a funnel increase the risk of adverse perinatal
outcome in a patient with a short cervix? Am J Obstet Gynecol
2005; 192: 1060–1066.
16. Grimes-Dennis J, Berghella V. Cervical length and prediction of
preterm delivery. Current Opinion Obstet Gynecol 2007; 19:
191–195.
17. Owen J, Yost N, Berghella V, Thom E, Swain M, Dildy GA,
Miodovnik M, Langer O, Sibai B, McNellis D, National Insti-
tute of Child Health and Human Development, Maternal-Fetal
Medicine Units Network. Mid-trimester endovaginal sonogra-
phy in women at high risk for spontaneous preterm birth. JAMA
2001; 286: 1340–1348.
18. Kusanovic JP, Espinoza J, Romero R, Gonçalves LF, Nien
JK, Soto E, Khalek N, Camacho N, Hendler I, Mittal P,
Friel LA, Gotsch F, Erez O, Than NG, Mazaki-Tovi S,
Schoen ML, Hassan SS. Clinical significance of the presence
of amniotic fluid ‘‘sludge’’ in asymptomatic patients at high risk
for spontaneous preterm delivery. Ultrasound Obstet Gynecol
2007; 30: 706–714.
19. Espinoza J, Gon alves LF, Romero R, Nien JK, Stites S,
Kim YM, Hassan S, Gomez R, Yoon BH, Chaiworapongsa
T, Lee W, Mazor M. The prevalence and clinical significance of
amniotic fluid sludge in patients with preterm labor and intact
membranes. Ultrasound Obstet Gynecol 2005; 25: 346–352.
20. Oyelese Y, Smulian JC. Placenta previa, placenta accreta, and
vasa previa. Obstet Gynecol 2006; 107: 927–941.
21. Cicero S, Skentou C, Souka A, To MS, Nicolaides KH.
Cervical length at 22–24 weeks of gestation: comparison
of transvaginal and transperineal-translabial ultrasonography.
Ultrasound Obstet Gynecol 2001; 17: 335–340.
Ultrasound Obstet Gynecol 2015; 45: 358–362.