Ultrasound Obstet Gynecol 2019; 53: 798–803

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.20152

Cervical consistency index and risk of Cesarean delivery

after induction of labor at term
F. MIGLIORELLI1 , C. RUEDA1 , M. A. ANGELES1 , N. BAÑOS1 , D. E. POSADAS1 ,
E. GRATACÓS1,2 and M. PALACIO1,2
1
BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clı́nic and Hospital Sant Joan de Déu), Fetal i+D Fetal
Medicine Research Center, IDIBAPS, University of Barcelona, Barcelona, Spain; 2 Center for Biomedical Research on Rare Diseases
(CIBER-ER), Barcelona, Spain

K E Y W O R D S: biomarkers; cervical assessment; cervical consistency index; Cesarean delivery; induction of labor; mode of
delivery; transvaginal ultrasound

ABSTRACT interobserver agreement were 0.81 (95% CI, 0.66–0.89)

Objective To evaluate the association between the cer-
vical consistency index (CCI) and the risk of Cesarean
delivery after planned induction of labor (IOL) at term.
Methods This was a prospective observational study
of women with a term singleton pregnancy admitted
for IOL due to maternal or fetal indication. Ultrasono-
graphic images were obtained before IOL and CCI was
calculated offline once recruitment was completed. The
main outcome was defined as Cesarean delivery due
to failed IOL or arrest of labor. Cesarean deliveries indi-
cated due to maternal or fetal compromise (Van Dillen’s
grade 1 or 2) were excluded from analysis. Univariate
statistical analysis was performed using Fisher’s exact test
and Student’s t-test for categorical and continuous vari-
ables, respectively. Multivariate analysis was performed
using logistic regression, including CCI and other vari-
ables related to the main outcome. Intraclass correlation
coefficients were used to estimate intra- and interobserver
agreement.
Results Of 510 women admitted for IOL during the study
period and for whom image quality was adequate, 46 were
excluded due to emergency Cesarean delivery leaving 464
pregnancies for analysis. Cesarean section due to failed
IOL or arrest of labor was performed in 100/464 (21.6%)
pregnancies. The mean CCI of women who underwent
Cesarean delivery was not significantly different from
that in those who had vaginal delivery after IOL (70.1 ±
12.3% vs 70.0 ± 13.1%; P = 0.94). Multivariate analysis
also showed absence of statistical association between
CCI and Cesarean delivery for failed IOL or arrest of
labor. Intraclass correlation coefficients for intra- and
and 0.86 (95% CI, 0.75–0.92), respectively.
Conclusion CCI does not seem to be associated with the
risk of Cesarean delivery after IOL. Copyright © 2018
ISUOG. Published by John Wiley & Sons Ltd.
INTRODUCTION
Induction of labor (IOL) is one of the most common
obstetric procedures1 . However, despite its high fre-
quency, it has not yet been possible to identify factors
that can predict accurately its outcome2 . Bishop score3
is still the most widespread method for preinduction
assessment4 , but several studies have concluded that it
is a poor predictor of IOL outcome5 . Research is thus
focusing on other biomarkers able to identify women at
risk of failed IOL, which are based mainly on ultrasono-
graphic features such as cervical angle, head position,
head-to-perineum distance or angle of progression6–9 .
Among these, the most evaluated parameter is cervical
length, although results regarding its value as a predictor
of IOL outcome are conflicting2,10 . Thus far, none of
these markers has succeeded in being included in current
clinical guidelines.
In an attempt to find new strategies to predict IOL
outcome, some researchers have turned their focus to
the assessment of the biomechanical properties of the
cervix, mainly evaluating its deformability after the
application of external pressure11 . This was achieved
by using vacuum-assisted devices12,13 or by evaluating
cervical elasticity using ultrasonography-based software
(elastography), and it was shown that cervical consistency
might be related to the success of IOL14–16 .

Correspondence to: Dr F. Migliorelli, BCNatal – Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clı́nic de Barcelona,
C/Sabino Arana 1, 08028 Barcelona, Spain (e-mail: fmiguore@clinic.cat)
Accepted: 8 October 2018

Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd. ORIGINAL PAPER
Cervical consistency index and induction of labor
Based on this idea, Parra-Saavedra et al. described a new
ultrasonographic tool for assessing the dynamic properties
of the cervix, the cervical consistency index (CCI)17 .
CCI is an estimate of cervical softness, calculated
by dividing the anteroposterior diameter of the cervix,
after applying pressure with the transvaginal probe until
maximum deformation is achieved, by the anteroposterior
diameter at rest. When the tissue is softer, the increasing
difference between these two measurements results in
lower CCI values; hence, CCI is directly proportional to
cervical toughness.
CCI seems to be correlated negatively with gestational
age. Low CCI values in the first and second trimesters
were shown to be risk factors for preterm delivery,
even allowing better prediction than cervical length17,18 .
However, the performance of this index has not yet been
assessed in the scenario of IOL.
Therefore, we conducted this prospective study with
the aim to evaluate the association between CCI and the
risk of Cesarean delivery after planned IOL.
METHODS
This was a single-center prospective observational study
of all women admitted to the Hospital Clı́nic de Barcelona
with maternal or fetal indication for IOL between January
and August 2016. Inclusion criteria were women over 18
years old with a live singleton pregnancy at term (i.e. > 37
weeks) and absence of uterine contractions at admission.
Women who declined participation or with inadequate
ultrasonographic images (i.e. when structures could
not be recognized) were excluded. The study protocol
was approved by the local Institutional Review Board
(Registry ID: HCP/2014/0407) and all participants
provided written and signed informed consent.
Patients were admitted to the hospital and, if they
met the inclusion criteria, they were asked to participate
in the study. Transvaginal ultrasonographic assessment
was performed in all included patients by one of the
authors before the IOL procedure. Women were asked to
empty their bladder before the examination. A set of two
images was obtained: (1) a sagittal view of the uterine
cervix on which the internal and external ora could be
identified clearly, obtained without exerting any pressure
with the probe (Figure 1a,c); and (2) the same sagittal view
obtained at maximum compression of the cervix using the
technique described by Parra-Saavedra et al.17 , according
to which pressure is applied with the transvaginal probe
on the cervix until no further deformation of the tissue is
identified (Figure 1b,d). All images were acquired using a
Voluson S6 (GE Healthcare Ultrasound, Milwaukee, WI,
USA) ultrasound machine equipped with a 2–10-MHz
transvaginal transducer. All patients and clinicians in
charge of the IOL were blinded to the ultrasound images
and findings. Images were collected and saved in their
original Digital Imaging and Communication in Medicine
(DICOM) format. We did not perform any measurement
at this stage.
Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
799
IOL was conducted following local guidelines19 . For
Bishop score > 6, oxytocin was indicated. If Bishop
score was ≤ 6, cervical ripening was attempted by
(1) oral administration of a misoprostol 50-µg tablet
(Cytotec®, Pfizer, New York, NY, USA) every 4 h (up
to three doses) or (2) application of dinoprostone 10-mg
vaginal insert (Propess®, Ferring Pharmaceuticals, Kiel,
Germany), depending on the risk of hyperstimulation19 .
Local protocol defines successful cervical ripening as
the accomplishment of cervical effacement and at least
4 cm dilatation. Any cervical ripening method was
stopped the morning after placement or following onset
of labor, which was defined as progression of local
cervical conditions in the presence of regular contractions.
Oxytocin was used subsequently at the discretion of
the attending physician, who adjusted administration to
achieve from three to five contractions every 10 min.
Cesarean delivery was performed following any of these
indications: (1) failed IOL (i.e. unsuccessful cervical
ripening after 12 h of oxytocin stimulation, with three
to five contractions every 10 min); (2) arrest of labor
(unmodified cervical conditions during 4 h after onset of
labor with adequate uterine activity); or (3) immediate
need for delivery (Van Dillen’s grade 1 or 220 ), after
maternal compromise or non-reassuring fetal status. Fetal
surveillance was performed using fetal cardiotocography
or fetal scalp blood pH testing.
The main variable for analysis was CCI. To obtain the
CCI value, one of the authors (C.R.) reviewed the images
using ImageJ 2.0 software (National Institutes of Health,
Bethesda, MD, USA) and reproduced the procedure
described by Parra-Saavedra et al.17 : (1) measurement
of cervical length, defined by a longitudinal line across
the cervix, from the internal to the external os, as
described previously21 ; (2) localization of the midpoint
of the cervical-length line; and (3) measurement of the
anteroposterior diameter of the cervix, perpendicular to
the cervical-length line, through its midpoint. The antero-
posterior diameter was measured on both images of each
set, i.e. before (AP) and after (AP′ ) pressure was applied,
and CCI was calculated as (AP′ /AP) × 100 (Figure 1).
Main outcome was Cesarean delivery due to failed IOL
or due to arrest of labor, as defined above. We excluded
from analysis all Cesarean deliveries indicated due to
maternal or fetal compromise (Van Dillen’s grade 1 or 2),
as we did not include any variable related to this situation.
In order to evaluate the association between CCI and
the main outcome in the presence of other variables,
we retrieved the following data from medical records:
maternal age, previous vaginal or Cesarean delivery,
body mass index before delivery, gestational age and
Bishop score at admission, ultrasonographic cervical
length (as measured on the images used to calculate
CCI), prelabor rupture of membranes and neonatal
weight at birth. All information was collected once
recruitment was completed, using a dedicated form. Data
were saved in a Microsoft Excel (Microsoft, Redmond,
WA, USA) password-protected anonymized database,
which was accessible by only the researchers. A full
Ultrasound Obstet Gynecol 2019; 53: 798–803.
800 Migliorelli et al.

CL = 35.4 mm CL′ = 35.8 mm

AP = 36.4 mm AP′ = 24.1 mm

Figure 1 Example of images acquired from each woman in order to evaluate cervical consistency index (CCI). Images (a) and (b) are clean
versions (saved during examination) of images (c) and (d), respectively, in which measurements are illustrated. (a,c) Sagittal view of uterine
cervix without application of external pressure; both internal and external cervical ora can be seen. (b,d) Sagittal view of uterine cervix after
applying pressure with transvaginal probe until it is no longer possible to identify deformation. Cross calipers are placed on internal and
external cervical ora and dashed line between them defines cervical length (CL). At midpoint of this line, anteroposterior diameter of cervix
before (AP) and after (AP′ ) application of pressure is measured perpendicularly in each image (solid line with dotted calipers). In this
example, CCI = (AP′ /AP) × 100 = (24.1 mm/36.4 mm) × 100 = 66.2%. Dotted line delimits uterine cervix.

set of data was available for all women included in
the study.
Sample-size estimation was performed before com-
mencement of recruitment. Assuming a Cesarean section
rate of 25%, α risk of 5% and power of 90%, we cal-
culated that 445 women were required to identify a CCI
difference of 5%.
Normality was evaluated visually using distribution
diagnostic plots and the Kolmogorov–Smirnov test.
Univariate statistical analysis was performed using
Fisher’s exact test for categorical variables and Student’s
t-test for continuous characteristics and results were
presented as n (%) and mean ± SD, respectively. Bishop
score and its components were compared using the
Wilcoxon rank-sum test and presented as median and
interquartile range. Multivariate analysis was performed
using logistic regression, including CCI and other
variables related to IOL outcome, and results were
presented as odds ratios with 95% CI. Assessment
of cervical consistency by vaginal exploration (within
Bishop score) and CCI agreement were compared using
weighted Cohen’s κ coefficient for ordered categories,
after categorizing CCI into terciles.
Inter- and intraobserver agreement was evaluated in
a set of 40 pairs of images selected randomly using
computer software. The author (C.R.) who performed the
initial measurements of CCI repeated the image analysis
6 months later. CCI was also calculated in these images
by another author (F.M.). Both observers were blinded to
the previous measurements. The results were compared
using intraclass correlation coefficient, with a two-way
random-effects model.
Statistical analysis was performed using Stata version
13.1 software (StataCorp LP, College Station, TX, USA).
The two-sided significance level was set at 0.05.

Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2019; 53: 798–803.
Cervical consistency index and induction of labor 801

RESULTS (46/141, 32.6%), diabetes (40/141, 28.4%), age > 40

years (29/141, 20.6%), medical conditions (18/141,
During the study period, a total of 510 women who 12.8%) or other (8/141, 5.7%). Fetal indications for
fulfilled the inclusion criteria were admitted to our IOL occurred in 69.6% (323/464) of pregnancies and
center for IOL, of whom 46 had emergency Cesarean comprised gestational age ≥ 41 weeks (164/323, 50.8%),
delivery due to maternal or fetal compromise (Van Dillen’s suspected growth restriction (51/323, 15.8%), prelabor
grade 1 or 2). Therefore, 464 pregnancies were included rupture of membranes (37/323, 11.5%), antenatal
for analysis. Figure 2 shows the flow of participants non-reassuring status (36/323, 11.1%) and other (35/323,
through the study. Demographic characteristics of the 10.8%).
study population are presented in Table 1. Mean CCI of the total cohort was 70.1 ± 12.9%.
Maternal indication for IOL occurred in 30.4% The main outcome (Cesarean delivery due to failed
(141/464) of the women, due to hypertensive disorders IOL or arrest of labor) occurred in 100/464 (21.6%)
pregnancies, and these women had a mean CCI of
70.1 ± 12.3%, which did not differ significantly from the
Admission for induction of labor
(January to August 2016)
mean CCI of the vaginal-delivery group (70.0 ± 13.1%;
(n = 526) P = 0.94). Furthermore, women who underwent Cesarean
section due to failed IOL (46/100, 46.0%) had a mean
Excluded (n = 16): CCI of 72.3 ± 10.9%, while those who had Cesarean
• Declined to participate (n = 2) delivery due to arrest of labor (54/100, 54.0%) had an
• Inadequate image quality average CCI of 68.3 ± 13.2% (P = 0.10). These values did
for analysis (n = 14)
not differ significantly from the mean CCI in women who
delivered vaginally (P = 0.26 and P = 0.36, respectively).
Adequate image quality
(n = 510)
Logistic regression analysis also showed lack of statistical
association between CCI and Cesarean delivery due to
failed IOL or arrest of labor (Table 2).
Excluded due to emergency
Cesarean delivery
Weighted Cohen’s κ coefficient for the agreement
(n = 46) between cervical consistency evaluated by vaginal exam-
ination and CCI was 0.04. Intraclass correlation coeffi-
Included in analysis cients for intra- and interobserver agreement were 0.81
(n = 464) (95% CI, 0.66–0.89) and 0.86 (95% CI, 0.75–0.92),
respectively. Power of the analysis, according to our sam-
ple size and findings, was 0.93.
Vaginal delivery Cesarean delivery
(n = 364) (n = 100)
DISCUSSION

Figure 2 Flowchart showing inclusion in study of women We performed this study to evaluate the association
undergoing planned induction of labor. between an ultrasonographic index based on dynamic

Table 1 Baseline characteristics of 464 women who underwent planned induction of labor (IOL) at term, overall and according to mode of
delivery

Mode of delivery
Characteristic All (n = 464) Vaginal (n = 364) Cesarean (n = 100) P

Maternal age (years) 33.9 ± 5.2 34.0 ± 5.3 33.3 ± 5.0 0.24
Previous vaginal delivery 132 (28.4) 125 (34.3) 7 (7.0) < 0.01
Previous Cesarean delivery 27 (5.8) 19 (5.2) 8 (8.0) 0.33
BMI before delivery (kg/m2 ) 28.7 ± 4.4 28.2 ± 4.2 30.5 ± 4.5 < 0.01
GA at admission (days) 280.5 ± 9.3 280.4 ± 9.4 280.9 ± 8.8 0.65
GA ≥ 41 weeks 164 (35.3) 129 (35.4) 35 (35.0) > 0.99
Indication for IOL
Maternal 141 (30.4) 108 (29.7) 33 (33.0) 0.54
Fetal 323 (69.6) 256 (70.3) 67 (67.0) 0.54
Bishop score at admission 3 (2–4) 3 (2–4) 2.5 (1–4) < 0.01
Cervical consistency (Bishop score) 1 (1–2) 1 (1–2) 1 (1–2) 0.30
Cervical length (mm) 23.1 ± 10.6 22.0 ± 10.2 26.9 ± 11.0 < 0.01
Prelabor rupture of membranes 38 (8.2) 31 (8.5) 7 (7.0) 0.84
Unripe cervix before induction 447 (96.3) 352 (96.7) 95 (95.0) 0.38
Cervical consistency index (%) 70.1 ± 12.9 70.0 ± 13.1 70.1 ± 12.3 0.94
Neonatal weight (kg) 3.33 ± 0.5 3.29 ± 0.5 3.50 ± 0.5 < 0.01

Data are given as mean ± SD, n (%) or median (interquartile range). BMI, body mass index; GA, gestational age.

Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd. Ultrasound Obstet Gynecol 2019; 53: 798–803.
802
Table 2 Multivariate logistic regression analysis for association
between cervical consistency index (CCI) and Cesarean delivery due
to failed induction of labor or arrest of labor (excluding urgent
indications) in presence of other variables related to outcome
Characteristic Odds ratio (95% CI)
CCI (in %) 0.988 (0.968–1.008)
Previous vaginal delivery 0.108 (0.045–0.258)
BMI before delivery (in kg/m2 ) 1.119 (1.058–1.184)
Bishop score at admission 1.010 (0.868–1.174)
Cervical length (in mm) 1.060 (1.031–1.090)
Neonatal weight (in kg) 2.769 (1.559–4.920)
BMI, body mass index.
measurements of the uterine cervix, the CCI, and the
risk of Cesarean delivery after attempted IOL. We
were not able to demonstrate an association between
CCI values and Cesarean delivery in our population.
However, we confirmed that measurement of this index
has adequate inter- and intraobserver reproducibility
(intraclass correlation coefficients of 0.86 and 0.81,
respectively, in the present study), as has been shown
in previous reports17,18 . Cervical consistency as assessed
by vaginal digital examination (Cohen’s κ coefficient of
0.04) was not reproducible. Furthermore, neither Bishop
score nor CCI showed relevant association with the
outcome of IOL on logistic regression analysis.
The mechanisms behind the modifications that allow
proper cervical effacement and dilatation before delivery
are not yet well understood. However, it seems that
remodeling begins early in pregnancy22–24 , leading to
progressive decrease of cervical stiffness, even before
cervical shortening occurs25 . Several researchers have
focused on the analysis of this biomechanical property
using aspiration devices13 or ultrasonographic tools.
Among the latter, elastography is the most evaluated
technique. This method evaluates quantitatively the
consistency of the tissue by inducing motion of the cervix
by applying pressure with the ultrasonographic probe.
However, although the technique seems reproducible26 ,
it lacks means of controlling the force applied to the
cervix, which makes standardization of the measurements
difficult. Consequently, even though relative comparison
of different regions is feasible, it is not possible to define
absolute values of cervical consistency27 .
To overcome this issue, Parra-Saavedra et al.17 designed
a dynamic index that compares the cervical anteroposte-
rior diameter at rest and on maximum compression, after
pressing the cervix with the transvaginal probe up to the
point at which it is not possible to further modify its
morphology. The ratio of the anteroposterior diameter at
maximum compression to that at rest is the CCI, which
can be defined roughly as the proportion of remain-
ing cervical thickness after compression. Therefore, the
index increases proportionally with the resistance of the
cervix to deformation, meaning that higher CCI values
represent tougher cervices. Although determination of
CCI has been shown to be reproducible17,18 , the force
required to compress the cervix cannot be quantified,
Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Migliorelli et al.
as is the case in elastography. However, the definition
of the index ensures standardization of its measure-
ment, as it requires achieving maximum deformation of
the cervix by applying pressure with the probe. Thus,
intermediate deformation would be irrelevant to the
measurement11,28 .
Cervical consistency has been a matter of interest
in the prediction of preterm birth or IOL outcome.
Low CCI was shown to predict spontaneous preterm
delivery and to have better predictive performance
than cervical-length measurements17,18 . With respect to
IOL, the use of elastography for cervical assessment
demonstrated promising results, correlating the stiffness
of the tissue surrounding the internal cervical os (as
quantified using the elasticity index) with the success of
IOL14 . We designed this study to evaluate the association
of cervical consistency, as quantified by CCI, with the
outcome of IOL, since this tool has not yet been tested
in this scenario. We found a mean CCI of 70.1% in our
cohort, which is higher than the 45.6% reported for the
third trimester17 . This difference might be attributed to
the definition of our study population, which included
women admitted for IOL (> 95% of them requiring
cervical ripening). This definition selects women who
will probably not have spontaneous onset of labor,
mostly represented by those admitted after 41 weeks of
pregnancy but also by those who were induced early
due to medical complications of pregnancy. However,
this assumption has to be confirmed by tracing normality
curves for term pregnancies together with the analysis of
the association between CCI and spontaneous onset of
labor.
Our findings did not show an association between
CCI and the risk of Cesarean delivery after IOL, even in
the presence of other variables that were correlated with
Cesarean delivery. These variables (parity, body mass
index, cervical length and neonatal weight) have been
studied previously and have been associated with IOL
outcome2,29–34 .
The main strength of this study is its prospective design,
with an adequate sample size to allow analysis of the
association between CCI and Cesarean delivery after IOL.
The study did not interfere with the decisions related to
IOL, as the women and the clinicians in charge of IOL
were both blinded to the results. To our knowledge, this
is the first work assessing the value of CCI in the context
of Cesarean delivery after IOL.
We acknowledge some limitations of our study. It
was performed in a single institution, which may confine
the results to our setting. Furthermore, the wide range
of indications, although representing clinical practice,
constitutes a heterogeneous population, in which women
who are expected to start labor spontaneously but are
admitted early for IOL (for maternal or fetal cause) are
combined with those who will eventually require IOL due
to lack of spontaneous onset of delivery. This might skew
the findings and could only be overcome by studying
normal distributions throughout varied term gestational
ages. The evaluation of the cervix was performed before
Ultrasound Obstet Gynecol 2019; 53: 798–803.
Cervical consistency index and induction of labor
triggering IOL, according to common practice; however,
this might represent a shortcoming for identifying the
usefulness of CCI in predicting IOL outcome. In fact,
the performance of CCI in a different phase of IOL has
not been assessed. For example, if the modifications
occurring after attempting cervical ripening are somehow
associated with the outcome of IOL, a second evaluation
of the cervix would have to be performed after this
process in order to evaluate the change in CCI.
Finally, there are limitations owing to the technique
of determining CCI. The angulation of the cervix may
interfere with the force vector, thereby impeding the
assessment of a true maximally compressed antero-
posterior diameter. Also, the absolute value of tissue
stiffness remains unknown and further studies are
required to evaluate complementary features (such as the
combination with shear wave elastography11 , in which
the applied force is known).
Future research should first focus on characterization
of the population and the normal distribution; then, we
would be able to assess more accurately the utility of this
tool and evaluate its contribution to predictive models.
In conclusion, CCI does not seem to be associated
with the risk of Cesarean delivery after IOL at term.
Further research is needed for a better understanding of
the distribution and determinants of CCI in women with
term pregnancy.
ACKNOWLEDGMENTS
This project was supported financially by the End
of Residence Award ‘Emili Letang’ project number
318_28_PFR_2014, granted by the Hospital Clı́nic
de Barcelona, Research, Innovation and Education
Directorate and by the Research grant in the area
of Maternal and Fetal Medicine given by the Fundación
Dexeus – Salud de la Mujer.
This publication was funded with support of the
Erasmus+ Program of the European Union (Framework
Agreement number: 2013-0040). This publication reflects
the views only of the authors, and the Commission cannot
be held responsible for any use that may be made of the
information contained herein.
REFERENCES
1. Martin JA, Hamilton BE, Osterman MJ, Driscoll AK, Drake P. National Vital
Statistics Reports: Births: Final Data for 2016. Natl Vital Stat Reports 2018; 67:
1–55.
2. Hatfield AS, Sanchez-Ramos L, Kaunitz AM. Sonographic cervical assessment to
predict the success of labor induction: a systematic review with metaanalysis. Am
J Obstet Gynecol 2007; 197: 186–192.
3. Bishop EH. Pelvic scoring for elective induction. Obstet Gynecol 1964; 24: 266–268.
4. Ramirez M, Ramin S. ACOG Practice Bulletin No. 107: Induction of labor. Obstet
Gynecol 2009; 114: 386–397.
5. Kolkman DGE, Verhoeven CJM, Brinkhorst SJ, Van Der Post JAM, Pajkrt E, Opmeer
BC, Mol BJ. The Bishop score as a predictor of labor induction success: A systematic
review. Am J Perinatol 2013; 30: 625–630.
6. Gokturk U, Cavkaytar S, Danisman N. Can measurement of cervical length, fetal
head position and posterior cervical angle be an alternative method to Bishop score
in the prediction of successful labor induction? J Matern Fetal Neonatal Med 2015;
28: 1360–1365.
Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
803
7. Pereira S, Frick AP, Poon LC, Zamprakou A, Nicolaides KH. Successful induction of
labor: Prediction by preinduction cervical length, angle of progression and cervical
elastography. Ultrasound Obstet Gynecol 2014; 44: 468–475.
8. Eggebø TM, Heien C, Økland I, Gjessing LK, Romundstad P, Salvesen KÅ.
Ultrasound assessment of fetal head–perineum distance before induction of labor.
Ultrasound Obstet Gynecol 2008; 32: 199–204.
9. Verhoeven CJM, Mulders LGM, Oei SG, Mol BWJ. Does ultrasonographic foetal
head position prior to induction of labour predict the outcome of delivery? Eur
J Obstet Gynecol Reprod Biol 2012; 164: 133–137.
10. Verhoeven CJM, Opmeer BC, Oei SG, Latour V, Van Der Post JAM, Mol BWJ.
Transvaginal sonographic assessment of cervical length and wedging for predicting
outcome of labor induction at term: A systematic review and meta-analysis.
Ultrasound Obstet Gynecol 2013; 42: 500–508.
11. Mazza E, Parra-Saavedra M, Bajka M, Gratacos E, Nicolaides K, Deprest J. In vivo
assessment of the biomechanical properties of the uterine cervix in pregnancy. Prenat
Diagn 2014; 34: 33–41.
12. Mazza E, Nava A, Bauer M, Winter R, Bajka M, Holzapfel GA. Mechanical
properties of the human uterine cervix: An in vivo study. Med Image Anal 2006; 10:
125–136.
13. Bauer M, Mazza E, Jabareen M, Sultan L, Bajka M, Lang U, Zimmermann R,
Holzapfel GA. Assessment of the in vivo biomechanical properties of the human
uterine cervix in pregnancy using the aspiration test: A feasibility study. Eur J Obstet
Gynecol Reprod Biol 2009; 144 (Suppl 1): 77–81.
14. Swiatkowska-Freund M, Preis K. Elastography of the uterine cervix: implications
for success of induction of labor. Ultrasound Obstet Gynecol 2011; 38:
52–56.
15. Swiatkowska-Freund M, Preis K. Cervical elastography during pregnancy: Clinical
perspectives. Int J Womens Health 2017; 9: 245–254.
16. Londero AP, Schmitz R, Bertozzi S, Driul L, Fruscalzo A. Diagnostic accuracy of
cervical elastography in predicting labor induction success: a systematic review and
meta-analysis. J Perinat Med 2016; 44: 167–178.
17. Parra-Saavedra M, Gómez L, Barrero A, Parra G, Vergara F, Navarro E. Prediction
of preterm birth using the cervical consistency index. Ultrasound Obstet Gynecol
2011; 38: 44–51.
18. Baños N, Murillo-Bravo C, Julià C, Migliorelli F, Perez-Moreno A, Rı́os J, Gratacos E,
Valentin L, Palacio M. Mid-trimester sonographic cervical consistency index to
predict spontaneous preterm birth in a low-risk population. Ultrasound Obstet
Gynecol 2018; 51: 629–636.
19. Migliorelli F, Peguero A, Hernández S, Palacio M, Figueras F, Arranz Á. Protocolo
inducción del parto y métodos de maduración cervical. Protoc Serv Med Matern Hosp
Clı́nic Barcelona 2014. https://medicinafetalbarcelona.org/protocolos/es/obstetricia/
inducci%C3%B3n%20del%20parto.pdf
20. van Dillen J, Diesch M, Schutte J, Zwart J, Wolterbeek R, van Roosmalen J.
Comparing grades of urgency for classification of cesarean delivery. Int J Gynecol
Obstet 2009; 107: 16–18.
21. Heath VCF, Southhall TR, Souka AP, Novakov A, Nicolaides KH. Cervical length
at 23 weeks gestation: relation to demographic characteristics and previous obstetric
history. Ultrasound Obstet Gynecol 1998; 12: 304–311.
22. Word RA, Li XH, Hnat M, Carrick K. Dynamics of cervical remodeling during
pregnancy and parturition: Mechanisms and current concepts. Semin Reprod Med
2007; 25: 69–79.
23. Timmons B, Akins M, Mahendroo M. Cervical remodeling during pregnancy and
parturition. Trends Endocrinol Metab 2010; 21: 353–361.
24. Feltovich H, Hall TJ, Berghella V. Beyond cervical length: Emerging technologies for
assessing the pregnant cervix. Am J Obstet Gynecol 2012; 207: 345–354.
25. Badir S, Mazza E, Zimmermann R, Bajka M. Cervical softening occurs early in
pregnancy: Characterization of cervical stiffness in 100 healthy women using the
aspiration technique. Prenat Diagn 2013; 33: 737–741.
26. Molina FS, Gómez LF, Florido J, Padilla MC, Nicolaides KH. Quantification of
cervical elastography: a reproducibility study. Ultrasound Obstet Gynecol 2012; 39:
685–689.
27. Hernandez-Andrade E, Hassan SS, Ahn H, Korzeniewski SJ, Yeo L, Chai-
worapongsa T, Romero R. Evaluation of cervical stiffness during pregnancy using
semiquantitative ultrasound elastography. Ultrasound Obstet Gynecol 2013; 41:
152–161.
28. Fruscalzo A, Schmitz R. Quantitative cervical elastography in pregnancy. Ultrasound
Obstet Gynecol 2012; 40: 612–613.
29. Rane SM, Pandis GK, Guirgis RR, Higgins B, Nicolaides KH. Pre-induction
sonographic measurement of cervical length in prolonged pregnancy: the effect of
parity in the prediction of induction-to-delivery interval. Ultrasound Obstet Gynecol
2003; 22: 40–44.
30. Rane SM, Guirgis RR, Higgins B, Nicolaides KH. The value of ultrasound in the
prediction of successful induction of labor. Ultrasound Obstet Gynecol 2004; 24:
538–549.
31. Kawakita T, Reddy UM, Huang C-C, Auguste TC, Bauer D, Overcash RT. Predicting
vaginal delivery in nulliparous women undergoing induction of labor. Am J Perinatol
2018; 35: 660–668.
32. Pevzner L, Rayburn WF, Rumney PJ, Wing DA. Factors predicting successful labor
induction with dinoprostone and misoprostol vaginal inserts. Obstet Gynecol 2009;
114: 261–267.
33. Prado CA de C, Araujo Júnior E, Duarte G, Quintana SM, Tonni G, Cavalli R de C,
Marcolin AC. Predicting success of labor induction in singleton term pregnancies by
combining maternal and ultrasound variables. J Matern Fetal Neonatal Med 2016;
29: 3511–3518.
34. Gibson KS, Waters TP. Measures of success: Prediction of successful labor induction.
Semin Perinatol 2015; 39: 475–482.
Ultrasound Obstet Gynecol 2019; 53: 798–803.