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Research

Obstetrics

www.AJOG.org

Radiographic measures of the mid pelvis to predict cesarean


delivery
Lorie M. Harper, MD, MSCI, Anthony O. Odibo, MD, MSCE, David M. Stamilio, MD, MSCE, George A. Macones, MD, MSCE
OBJECTIVE: The purpose of this study was to determine whether

RESULTS: Four hundred twenty-six women were included. Subjects with

x-ray measures of the mid pelvis can be used to predict cesarean


delivery.
STUDY DESIGN: Women were enrolled prospectively; x-ray pelvimetry
was performed after delivery; the readers were blinded to the outcome.
Groups were determined by mid pelvis measures (transverse diameter,
anteroposterior diameter, and circumference 10th percentile. The
primary outcome was cesarean delivery. Univariable, stratified, and
multivariable analyses were performed to estimate the effect of mid pelvis measures on cesarean delivery. Receiver operator characteristics
curves were created to estimate the predictive value of mid pelvis measures of cesarean delivery.

anteroposterior diameter or circumference 10th percentile were at


greater risk of cesarean delivery (risk ratio for anteroposterior diameter, 4.8;
95% confidence interval, 3.9 5.8; risk ratio for circumference 10th percentile, 3.8; 95% confidence interval, 3.1 4.8). Transverse diameter
10th percentile was not associated with an increased risk of cesarean
delivery. The area under the receiver operator characteristics curves for anteroposterior diameter, circumference 10th percentile, and transverse
diameter were 0.88, 0.85, and 0.69, respectively (P .01).
CONCLUSION: Simple radiographic measures of the mid pelvis on x-ray
can provide a useful adjunct to clinical information in the determination
of who should attempt a vaginal delivery.

Cite this article as: Harper LM, Odibo AO, Stamilio DM, et al. Radiographic measures of the mid pelvis to predict cesarean delivery. Am J Obstet Gynecol
2013;208:460.e1-6.

B ACKGROUND AND O BJECTIVE


Studies of radiographic pelvimetry have
had a limited number of patients, have
been subject to bias because of a lack
of blinding, and have been used as arbitrary cut-off points of adequate vs
contracted pelvis. Women who have
had a previous cesarean delivery and no
previous vaginal delivery already may
have demonstrated that their pelvis was
not adequate. Because most morbidity
from a trial of labor after cesarean delivery (TOLAC) is due to a failed TOLAC, it
would be ideal to identify the women
who will have a failed TOLAC before
they attempt it.

From the Department of Obstetrics and


Gynecology, Washington University in St. Louis
School of Medicine, St. Louis, MO
Supported by a grant from the Eunice Kennedy
Shriver National Institute of Child Health and
Human Development (R01HD039441 to G.A.M.;
T32HD055172 and UL1RR024992 to L.M.H).
The authors report no conflict of interest.
Presented at the annual meeting of the Society
for Gynecologic Investigation, Miami, FL,
March 16-19, 2011.
0002-9378/free
2013 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2013.02.050

460

Therefore, we sought to determine the


utility of radiographic measures of the
mid pelvis to predict cesarean delivery.

M ATERIALS AND M ETHODS


This is a secondary analysis of a multicenter prospective cohort study that
was designed to evaluate the use of the
fetal pelvic index for the prediction of cesarean delivery. Women were eligible
if they had a viable singleton intrauterine
pregnancy at 36 weeks gestation and
vertex presentation and planned to attempt vaginal delivery. Women were excluded if they had a multiple gestation;
breech presentation; planned cesarean
delivery; previous low vertical, classic, or
unknown cesarean scar, or other maternal contraindications to vaginal delivery.
X-ray pelvimetry was obtained after
delivery with the Colcher-Sussman technique. In the lateral view, the anteroposterior diameter (APD) of the mid pelvis
was measured from S3 to the pubic symphysis. In the anteroposterior view, the
transverse diameter of the mid pelvis was
measured at the level of the ischial
spines. Each measure was determined by
2 independent radiologists who were
blinded to mode of delivery. The average
measurement was used.

American Journal of Obstetrics & Gynecology JUNE 2013

The exposure group was defined by


APD, transverse diameter, and mean circumference 10th percentile. The primary outcome was cesarean delivery in
labor. A planned secondary analysis was
performed that defined the exposure as
mid pelvis measures of 5th percentile.
An analysis was performed to determine
whether mid pelvis measures of 90th
percentile could predict successful vaginal delivery. Multivariable logistic regression models were developed to better estimate the independent effect of
mid pelvis measures of 10th percentile
on the risk of cesarean delivery.

R ESULTS
Of 652 women in the cohort, 426
women met inclusion criteria. The 2
groups are similar with respect to age,
gravidity, previous vaginal delivery, previous cesarean delivery, birthweight, and
labor type. Subjects with a mid pelvis circumference of 10th percentile were
more likely to be black or Asian.
A transverse diameter of the mid pelvis
10th percentile was not associated with
an increased risk of cesarean delivery
(positive predictive value, 45.5%; adjusted odds ratio, 2.0; 95% confidence
interval [CI], 1.0 3.8; Table). An APD
of 10th percentile was associated

Obstetrics

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strongly with cesarean delivery; 98% of
women with an APD of 9.5 cm required cesarean delivery (positive predictive value, 98%; adjusted odds ratio,
112.7; 95% CI, 14.9 854.1). Of the 28
subjects with an APD of 5th percentile,
all were delivered by cesarean delivery
(positive predictive value, 100%). The
sensitivity of an APD of 10th percentile
to detect subjects who require cesarean
delivery was low at 39%; however, the
specificity of the test was 99.7%.
An APD measurement of 90th percentile decreased the risk for cesarean
delivery (adjusted odds ratio, 0.1; 95%
CI, 0.03 0.4), as did a circumference of
90th percentile (adjusted odds ratio,
0.2; 95% CI, 0.04 0.82). No upper
threshold of radiographic measurements
existed above which every subject delivered vaginally.

Research

TABLE

Risk of cesarean delivery by measures of the mid pelvis

Exposure group

Cesarean
delivery, Risk ratio
(95% CI)
n (%)a

Adjusted odds
ratio (95% CI)b

P value

Transverse diameter

.....................................................................................................................................................................................................................................

10th (9.0 cm; n 77)

35 (45.5) 1.7 (1.32.3)

10th (9.0 cm; n 349)

92 (26.3) Reference

5th (8.0 cm; n 24)

13 (54.2) 1.9 (1.32.8)

2.0 (1.03.8)

.04

.....................................................................................................................................................................................................................................

Reference

.....................................................................................................................................................................................................................................

2.0 (0.75.5)

.19

.....................................................................................................................................................................................................................................

5th (8.0 cm; n 402)

114 (28.4) Reference

Reference

..............................................................................................................................................................................................................................................

Anteroposterior diameter

.....................................................................................................................................................................................................................................

10th (9.5 cm; n 51)

50 (98.0) 4.8 (3.95.8) 112.7 (14.9854.1) .01

10th (9.5 cm; n 375)

77 (20.5) Reference

5th (9.0 cm; n 28)

28 (100) 4.0 (3.44.8)

5th (9.0 cm; n 398)

99 (24.9) Reference

.....................................................................................................................................................................................................................................

Reference

.....................................................................................................................................................................................................................................
c

.....................................................................................................................................................................................................................................
c

..............................................................................................................................................................................................................................................

Circumference

.....................................................................................................................................................................................................................................

10th (29.8 cm; n 47)

41 (87.2) 3.8 (3.14.8)

10th (29.8 cm; n 379)

86 (22.7) Reference

5th (29.0 cm; n 20)

19 (95.0) 3.6 (3.04.3)

19.3 (6.953.6)

.01

.....................................................................................................................................................................................................................................

Reference

.....................................................................................................................................................................................................................................
c

C OMMENT
Our study demonstrated an almost
100% specificity of the APD of the mid
pelvis at 9.5 cm (10th percentile) for
the determination of the need for cesarean delivery. No subject delivered vaginally with an APD of 9 cm. Women
with APD of 90th percentile had a
much lower risk of cesarean delivery.
The inability to identify a threshold
above which every woman delivered vaginally was probably because a multitude
of factors, rather than the pelvic passage
alone, contribute to a vaginal delivery.
This information could be clinically
useful, particularly when counseling patients regarding TOLAC. A simple
method of predicting who will ultimately
have a failed trial of labor could decrease the morbidity of TOLAC. Radiographic pelvimetry with an APD of
10th percentile could be used to identify women who will require repeat cesarean delivery.
Our study has several strengths. The
large sample size allowed us to investigate a relatively infrequent exposure. Because radiography was performed after
delivery, physicians were unable to make
decisions regarding mode of delivery or
the use of vacuum or forceps based on
the measurements, thus limiting bias.

.....................................................................................................................................................................................................................................
c

5th (29.0 cm; n 406)

108 (26.7) Reference

..............................................................................................................................................................................................................................................
a

The percentage of cesarean deliveries represents the positive predictive value (10th, 5th) or the negative predictive value
(10th, 5th) of the pelvic measurement; b Adjusted for previous cesarean delivery, labor induction; c Adjusted analysis not
performed.

Harper. Radiographic pelvimetry. Am J Obstet Gynecol 2013

Bias was further limited by having the


radiologists blinded to the mode of delivery; therefore, their interpretation
could not be influenced by knowledge of
the clinical scenario and outcome.
One limitation of the study was that
approximately 25% of subjects enrolled
in the third trimester were lost to follow
up and did not have either pelvimetry
or delivery information available, which
left the potential for selection bias. These
women were similar to those who were
included in the cohort in most characteristics, although they were slightly more
likely to be black. Consequently, this potential source of bias was unlikely to have
affected the findings. In addition, our
study population was largely black (approximately 60%), which potentially
limited the generalizability of our findings to other populations. Body mass index, a known risk factor for cesarean delivery, was not available for all subjects in
this cohort. Pelvic measurements are unlikely to be affected by body mass index;
thus, the unadjusted analyses are valid.

Despite these limitations, our study


has clinically relevant findings. The APD
of the mid pelvis was highly specific
for the requirement of cesarean delivery;
a minimum APD of the mid pelvis of
9 cm was required for a vaginal delivery.
This information may be clinically useful, particularly in patients with a previous cesarean delivery for arrest or
cephalopelvic disproportion who are
considering TOLAC. Further prospective studies to confirm our findings are
necessary before this strategy is implemented widely.

CLINICAL IMPLICATIONS

A minimum anteroposterior diameter of the mid pelvis of 9 cm was required for vaginal delivery.
Further prospective evaluations of radiographic pelvimetry to predict cesarean delivery are necessary.
f

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