|Year : 2022 | Volume
| Issue : 2 | Page : 123-130
Ultrasonographic foetal head circumference and cheek-to-cheek diameter at term as predictors of labour outcomes
Michael Ademola Agbaje1, Abayomi Ibukun Alao2, Kola Musliudin Owonikoko3
1 Department of Obstetrics and Gynaecology, Lagoon Hospitals, Ikeja, Lagos, Nigeria
2 Department of Obstetrics and Gynaecology, James Cook University Hospital, Middlesbrough, United Kingdom
3 Department of Obstetrics and Gynaecology, LAUTECH Teaching Hospital, Ogbomoso, Oyo State, Nigeria
|Date of Submission||08-Nov-2021|
|Date of Decision||20-Jan-2022|
|Date of Acceptance||23-Jan-2022|
|Date of Web Publication||23-Apr-2022|
Abayomi Ibukun Alao
Department of Obstetrics and Gynaecology, James Cook University Hospital, Middlesbrough
Source of Support: None, Conflict of Interest: None
Background: The clinical uses of ultrasonography have varied and increased over time, especially the ability of ultrasonographic measured parameters to predict the outcomes of labour. The proper understanding of the association between these ultrasonographic parameters, mode of delivery, adverse maternal and foetal outcomes will further improve patient counselling as well as the planning of intrapartum care. Aim: The study explored the ultrasonographic measurement of foetal head circumference (HC) and cheek-to-cheek diameter (CCD) at term as predictors of labour outcomes. Methodology: Eligible pregnant women at term were recruited from the antenatal clinic and had obstetric ultrasound scans done with HC and CCD measured. Maternal and foetal outcomes were measured and included progress in labour, obstetric lacerations, mode of delivery and suspected foetal distress. Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 20. Results: One hundred and thirty-two patients were recruited into the study. Foetal HC measurements ≥35 cm were closely associated with caesarean delivery odds ratio - 2.40 (95% confidence interval - 1.02–5.66. P = 0.046). Neither CCD nor CCD/HC ratio was predictive of the modes of delivery. The occurrence of perineal lacerations and poor progress of labour were observed more frequently with increasing HC and CCD. Conclusions: HC performed well in predicting caesarean delivery as well as perinatal outcomes among parturients. The ultrasonographic measured HC (≥35 cm) is associated with a higher incidence of both obstetric interventions for poor progress of labour and adverse perinatal outcomes in comparison to CCD. The association between HC and labour dystocia was found to be linear. The CCD did not perform well as a predictor of the mode of delivery.
Keywords: Cheek-to-cheek diameter, foetal, head circumference, labour outcomes, ultrasound
|How to cite this article:|
Agbaje MA, Alao AI, Owonikoko KM. Ultrasonographic foetal head circumference and cheek-to-cheek diameter at term as predictors of labour outcomes. Niger Postgrad Med J 2022;29:123-30
|How to cite this URL:|
Agbaje MA, Alao AI, Owonikoko KM. Ultrasonographic foetal head circumference and cheek-to-cheek diameter at term as predictors of labour outcomes. Niger Postgrad Med J [serial online] 2022 [cited 2022 Jul 1];29:123-30. Available from: https://www.npmj.org/text.asp?2022/29/2/123/343738
| Introduction|| |
The accurate estimation of foetal weight remains a challenge to obstetricians as several decisions are made based on it. However, the ultrasonographic estimation of foetal weight are not always accurate and attempts have been made to improve this. Assessing foetal weights has become an essential part of obstetric care / antenatal care (ANC) as extremes of birth weight are recognised risk factors for several obstetric and neonatal complications, including prolonged labour, caesarean delivery, operative vaginal delivery, maternal and neonatal birth trauma.,,
The occurrences of maternal as well as foetal morbidities associated with the labour process have been noted to be closely associated with foetal anthropometric parameters., The popularity and use of ultrasonography in the measurement of foetal parameters have significantly increased and become a norm in current obstetric practice., During obstetric ultrasonographic examinations, the foetal head circumference (HC) is frequently measured in combination with other sonographic parameters such as femur length, abdominal circumference and biparietal diameter as components of several formulae used in estimating foetal weight. Studies have suggested a correlation between HC in the neonate, the route of delivery as well as with maternal and neonatal outcomes.,
At term, the foetal body fat accounts for about 14% (14%) of the birth weight in neonates. Bearing this in mind, the ultrasonographic measurement of foetal subcutaneous/adipose tissue was found to further increase the accuracy of ultrasound estimated foetal weight (EFW) and by extension, the ability to predict outcomes of labour., The regions of subcutaneous tissue measured by ultrasound include the foetal face (cheek), arm, leg, buttocks and abdomen. Studies have demonstrated that the incorporation of subcutaneous tissue, exemplified by the cheek-to-cheek diameter (CCD) into sonographic foetal evaluation have increased the accuracy of foetal weight estimation. These studies also suggested the cheek-to-cheek diameter (CCD) was a good indicator of subcutaneous tissue mass, a reflection of foetal body fat content and a good predictor of the mode of delivery in parturients.,, A CCD value >7.9 cm was noted to be associated with a higher risk of caesarean delivery.
The foetal head is adjudged to be the best pelvimeter, its dimensions and orientations are noted to be one of the most important determinants of labour outcomes. The use of HC in Ultrasound scanning (USS) has mostly been used for the purpose of EFW. It must be borne in mind that the foetal bony dimensions as measured may not be the only factors that determine the course of labour, the foetal subcutaneous fat/adipose tissue and its distribution, in particular, may have a major role in determining weight and more specifically foetal presenting dimensions. Cases of labour dystocia, difficult deliveries and cephalopelvic disproportion (CPD) of foetuses whose weights were not excessive may be explained by this.
While studies have demonstrated the improved accuracy of ultrasonographic measurements of foetal subcutaneous fat (CCD) and HC in EFW,,, the combination of both parameters are suggested to improve further the accuracy of estimation of foetal weight and the prediction of outcomes of labour than either method alone.,,
This study assessed HC and cheek-to-cheek (CCD) and their ability to predict maternal and foetal outcomes of labour.
| Methodology|| |
The study was carried out between March and August 2018.
The study was carried out in the Obstetrics and Gynaecology Department of LAUTECH Teaching Hospital Ogbomoso, located in Oyo State of South Western Nigeria. It is a fully equipped tertiary health facility with various medical and surgical specialities.
All consenting booked women at gestational age 37–41 weeks, who had singleton pregnancies with the cephalic presentation, planned for vaginal deliveries and eventually had their deliveries in LTH.
All women with uncertain gestational age, foetal anomalies involving head, neck and face, foetal growth restriction and all cases scheduled to have elective caesarean section for either maternal or foetal indications were excluded. Women with medical disorders in pregnancy; pre-eclampsia, diabetes, renal, liver or cardiac diseases as well as multiple gestations were also excluded.
This was a longitudinal prospective cohort study. A total of 132 participants who met inclusion criteria were recruited into the study and were divided into two groups of 66 each based on HC; HC <35 cm and HC ≥35 cm. Systematic random sampling technique was used. Recruitment of the participants at the antenatal clinic was done by the principal investigator and two other research assistants who were of the same cadre with the principal investigator.
All study participants had ultrasound scanning done at no cost to them after their ANC consultations. Participants who were not delivered within 1 week of ultrasound scanning had a repeat scan with the same ultrasonographic parameters noted.
Participants were followed up in labour and delivery in the labour ward. Outcomes of interest (mode of delivery, foetal distress, perineal lacerations and poor progress of labour) were collected after delivery with respect to the independent variables (HC and CCD).
Sample size determination
The minimum sample size “n” for the study was calculated using:
n = (Zα/2 + Zβ) 2 × [p1 (1 − p1) + p2 (1 − p2)]/(p1 − p2) 2.
Zα/2 - critical value of the Normal distribution at α/2 (for a confidence level of 95%, α is 0.05) = 1.96
Zβ - critical value of the Normal distribution at β (for a power of 80%, β is 0.2) = 0.84)
p1 = 56% (proportion of normal CCD who had caesarean delivery.)
p2 = 80% (proportion of abnormal CCD who had caesarean delivery.)
n = 60 in each group. Total sample size = 120
Anticipating a dropout rate of about 10%, the sample size was increased to 132.
Instrument of data collection
Quantitative method using the pro forma
The instrument of the survey was a pro forma which was interviewer administered and comprised sections A-E which highlighted sociodemographic data, antenatal history, antenatal foetal ultrasound parameter, labour findings, maternal outcomes and morbidity and foetal outcomes and morbidity, respectively.
All ultrasound measurements were performed using 2-dimensional trans-abdominal scanning via ultrasound unit; Acuson-Sequoia 512 model with a 4 MHz abdominal probe manufactured by Siemens Healthcare GmbH, Germany.
Data collection methods
Data collection with the pro forma
Recruited participants signed informed consent and provided information filled into a pro forma through the interview method for sections A and B of the pro forma. Ultrasound scanning was done with the foetal parameters obtained used to fill section C. The patient's antenatal card was labelled with a serial number indicating participation in this study. The filled pro forma were kept with the Principal Investigator in a secure location.
Procedure for scanning
Ultrasound scanning was performed by the principal investigator and research assistants at the obstetric scan unit located adjacent to the antenatal clinic. The participants were positioned appropriately on the examination couch with adequate exposure (exposure from xyphisternum to the pubic symphysis). For each participant, the standard scanning procedure took about 10 min for routine scanning with an additional 3–4 min for the CCD.
Collection of data after delivery
Enrolled participants who presented in established labour were identified by serial numbers on the case note. The serial number was entered onto the pro forma form and data collected on sections D-F noting the outcomes; both maternal and foetal. The obstetric team managing labour cases were not aware of the antenatal measured ultrasound parameters.
Ultrasonographic HC was measured utilising trans-abdominal 2-dimensional B mode scanning obtained in the transthalamic plane. The CCD was measured utilising trans-abdominal 2-dimensional B mode scanning in the coronal view of the foetal face using the method described by Abramowicz et al.,
Standard protocol for the management of all labour cases was followed. Participants admitted in labour had investigations requested; a packed cell volume, urinalysis and patients requiring emergency caesarean delivery had 2 units of blood grouped and cross-matched.
Diagnoses were made and treatment instituted in line with standard protocols.
Augmentation of labour was used judiciously in cases of poor progress secondary to inadequate uterine contractions. Cases of failure to progress secondary to CPD were managed by emergency lower segment caesarean section conducted by the labour ward team.
All perineal lacerations or episiotomies were repaired in layers under good illumination and appropriate analgesia with absorbable sutures; polyglactin (Vicryl).
All cases of suspected foetal distress were managed by emergency caesarean section or instrumental vaginal delivery (IVD) via outlet forceps or vacuum extraction as indicated.
All babies delivered via CS or IVD and diagnosed with birth asphyxia were admitted into the Neonatal intensive care unit for further care.
Data were entered into the Statistical package for the Social Sciences (SPSS) version 20 (IBM, Armonk, New York, USA). Baseline initial frequency tables and charts were generated for univariate analysis. At the bi-variate level, Chi-square test was used to determine the association between categorical variables, while Student's t-test was used to test for statistical difference between means of two continuous variables. Any significant association was subjected to multivariate analysis. Chi-squared test was analysed at a 5% level of significance to determine the factors that are significantly associated with independent variables. Values that are significant were entered into a logistic regression model to determine predictors of the outcome variables analysed at 95% confidence interval (CI).
Ethical clearance was obtained from the Ethical Review Committee of LTH Ogbomoso, Oyo State with Protocol Number LTH/OGB/EC/2016/139 via approval letter dated 29 March 2017. Permission was obtained from the Head of Department and Consultant staff of the Department of Obstetrics and Gynaecology to enrol their patients. Written informed consent was obtained from participants. Participation was voluntary with no consequences for non-participation and confidentiality of all information was assured.
| Results|| |
A total of 132 participants were recruited into the study and were divided into two groups (66 in each group), based on HC; HC <35 cm and HC ≥35 cm. With regard to the obstetric and perinatal outcome characteristics [Table 1], the USS EFW was higher in the HC ≥35 cm group (3.61 ± 0.25 kg as compared to the HC <35 cm group 3.31 ± 0.21 kg) and there was a statistically significant difference in the two groups (t = −7.72, P = 0.001). The mean gestational age at delivery was higher in the HC ≥35 cm (39.30 ± 1.15 weeks) than in the HC <35 cm group (38.80 ± 1.06 weeks) and this was statistically significant (t = −2.60, P = 0.010). The mean birth weight of foetuses with HC ≥35 cm was larger; 3.53 ± 0.28 kg as compared to 3.28 ± 0.30 kg of the HC <35 cm group and there was a statistically significant difference (t = −5.01, P = 0.001).
|Table 1: Obstetric and perinatal outcome characteristics among respondents|
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The labour and perinatal outcomes in the study groups [Table 2] showed analgesia was more often used in parturients (58.3%) than not with the HC <35 cm group accounting for most (68.2%), there was a statistically significant difference between the two groups (χ2 = 5.27, P = 0.022). Augmentation of labour was performed in <27% of parturients with majority occurring in the HC <35 cm than HC ≥35 cm group, there was a statistically significant difference between the two groups, (χ2 = 11.24, P = 0.001). Overall, IVD was the method least used to achieve deliveries (6.1%) with 3% occurring in the HC <35 cm group and 9.1% in the HC ≥35 cm. There was no statistically significant difference in the three modes of delivery (P = 0.194).
The majority of the perineal lacerations occurred in the HC ≥35 groups (56.1%) with a statistically significant difference between the two groups (χ2 = 7.87, P = 0.005). The occurrence of foetal distress was noted more in the HC <35 cm group (15.2%) as compared to the HC ≥35 cm group (4.5%), this was statistically significant P = 0.036.
The clinical characteristics and modes of delivery [Table 3] revealed the mean HC was larger in parturients delivered via IVD (35.88 ± 0.96 cm) compared to vaginal delivery and caesarean section. There was statistically significant differences between group means as determined by one-way ANOVA (F [2,(29) = 3.615, P = 0.030). A Tukey post-hoc test revealed that there was statistically significantly difference in the mean HC of the SVD and IVD groups (34.73 ± 1.13 cm vs. 35.88 ± 0.96 cm, P = 0.024). There was no statistically significant difference between the SVD and CS groups (P = 0.714) as well as between the IVD and CS groups (P = 0.095).
|Table 3: Clinical characteristics and modes of delivery of study subjects|
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The mean CCD/HC was marginally different but highest in the CS group. There was a statistically significant difference between group means as determined by one-way ANOVA (F ( [2,129) = 26.98, P = 0.001). A Tukey post-hoc test revealed statistically significantly difference in the mean CCD/HC in the SVD and IVD groups (P = 0.001) as well as in the CS and IVD groups (P = 0.001). There was no statistically significant difference between the SVD and CS groups (P = 0.460). The mean duration of labour in the SVD group was higher (7.74 ± 1.53 h) than in the other two modes of delivery. There was a statistically significant differences between group means as determined by one-way ANOVA (F (2,129) = 6.45, P = 0.003). A Tukey post-hoc test revealed statistically significantly difference in the mean duration of labour in the SVD and CS groups (7.74 ± 1.53 h vs. 6.69 ± 1.26 h, P = 0.002). The mean Apgar score at 5th min was higher in the IVD group (9.50 ± 0.53) and this was statistically significant P = 0.007
The distribution of the modes of delivery per unit cm of CCD [Table 4] showed vaginal delivery occurred most often in the CCD range 7.5–7.9 cm (46.7%). IVD occurred only in the CCD range 7–7.4 cm and 8.0–8.4 cm. Caesarean section occurred more often in the CCD range 7.5–7.9 cm (44.1%) and least in the 8.5–9.0 cm range (5.9%).
|Table 4: Distribution of modes of delivery among range of cheek-to-cheek diameter|
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Vaginal deliveries occurred more often as mode of delivery among all the ranges (per unit cm) of HC. IVD occurred more frequently in foetuses with HC range 36–36.9 cm (50%). Caesarean section occurred more in foetuses with HC range 33–33.9 cm (26.5%) and most in the HC range 36–36.9 cm (32.4%) [Table 5].
|Table 5: Distribution of modes of delivery among range of head circumference|
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A logistic regression of factors influencing mode of delivery (caesarean delivery) showed HC (odds ratio [OR] of 2.40 at 95% CI, 1.02–5.66, P = 0.046) and augmentation of labour were statistically significant (OR of 0.32 at 95% CI, 0.14–0.76, P = 0.010). Analgesia was also statistically significant P = 0.011 [Table 6].
| Discussion|| |
In this study, a geometric correlation between HC and EFW, gestational age as well as actual birth weight was noted, larger HC appears to correlate with bigger babies and subsequently impact upon the outcomes of interest viz mode of delivery and perinatal outcomes. This agrees with findings in other studies of larger biometric parameters resulting in larger measurement of EFW and birth weight of babies.
In this study, vaginal delivery was achieved more often with foetuses with smaller HC in comparison to when HC >35 cm. The vaginal delivery rate was similar to a study by carried out in Israel. A similar trend was observed with respect to CCD with vaginal deliveries more often achieved in babies with smaller CCD measurements, the mean values here were less than those found in the Abramowicz study which was conducted among Caucasians. These differences could be ascribed to the larger biometric parameters observed in Caucasians in comparison to this region., These findings may suggest that larger parameters result in larger babies, however, this is not always the case as large HC does not always accompany big babies. It may be expected that smaller diameters (HC and CCD) of the cephalic presenting foetus are likely to make navigating the maternal pelvis easier than larger one and resulting in less intervention and easier vaginal deliveries.
In this study, IVD with forceps accounted for a small number of all deliveries. This was similar to a range of 0.9%–6% found in Nigeria across Nigeria and 6.9% in Israel. This was however lower when compared to 15% obtained by Elvander et al. in Sweden and 10.5% reported by Mujugira et al. in the United States of America. However, these other studies recorded both vacuum and forceps were used in instrumental delivery and were retrospective case studies carried out in the Caucasian populations in developed countries. Interestingly, in this study, all the cases of IVD occurred in the multipara. This could allude to the occurrence of larger babies and invariably larger HC and CCD occurring more in the multipara with a resultant increased intervention in the course of labour.
From this study, there is a low utilisation of forceps in the course of labour. This reduction in the use of instrumental deliveries could be ascribed to the reduced training in its use, the non-availability or provision of the instruments, better anaesthesia, increased training in caesarean delivery as well as perceived fear of medical litigation associated with possible neonatal morbidities in the outcomes making caesarean delivery more attractive and rewarding than instrumental delivery.
Significant parameters were entered into a logistic regression model, HC ≥35 cm was closely associated with caesarean delivery. This was similar to study by Mujugira et al. who noted a 2-fold increase in CS with large HC. This may lend credence to the fact that wider presenting part circumference (HC) might make navigating the maternal pelvis more difficult, result in CPD, difficult deliveries, and hence may be predictive of caesarean deliveries.
Birth weight has also been looked into as a predictor of the mode of delivery, In this study, the mean birth weights across the modes of delivery were smaller for vaginal delivery (3.39 ± 0.32 kg) as compared to IVD (3.48 ± 0.23 kg) and highest for CS (3.43 ± 0.32 kg) with no statistically significant difference between the modes of delivery. In comparison to the birth weight which was neither significant nor predictive of caesarean delivery, foetal HC fared better as a predictor of caesarean delivery than both birth weight and CCD. The study by Abramowicz et al. noted a statistically significant difference in the birth weight between foetuses who were delivered vaginally (3.56 ± 0.550 kg) and by caesarean section (3.927 ± 0.520 kg). They also noted that CCD performed as well as birth weight in the prediction of the mode of delivery. However, their study was carried out among the Caucasian population who have larger foetal weight than in this environment. The differences obtained in birth weight and modes of delivery may be due to regional as well as racial differences.
CCD and CCD/HC ratios were not statistically significant (P = 0.496 and P = 0.733 respectively), they were not entered in the regression model and hence not predictive of the mode of delivery. This was contrary to the study by Abramowicz et al. where foetuses with large CCD were predictive of caesarean delivery. Hence, while CCD was suggested as a good assessor of foetal subcutaneous fat, it may not significantly affect the dimensions of the foetal presenting part and predict the outcome of labour.
While the benefits of analgesia in labour in terms of maternal pain relief and satisfaction are noted, the impact with regard to the progress of labour and mode of delivery has been a crucial subject of debate and remained a contentious issue in obstetrics.
In our study, analgesia in labour was found to be statistically significant between the modes of delivery (vaginal and caesarean) as well as between the control and study groups (HC). The use of analgesia in labour was found to increase the likelihood of caesarean delivery. This finding seemed to be corroborated by Sosa et al. who found that the administration of parenteral opioids was of no benefit in labour progress and to be avoided in cases of cervical dystocia. This was however contrary to findings in a study by Halpern and Abdallah who noted there was no increase in the incidence of caesarean section with analgesia in labour (both parenteral as well as neuroaxial analgesia). However, their study was performed in a developed country where a majority of analgesia in labour is epidural. The finding in this study could be due to the greater use of parenteral analgesia being the commonest option of analgesia in labour in this region and most developing countries.
In this study, augmentation of labour was found to be statistically significant between the control and study groups and was associated with a reduced likelihood of caesarean delivery with an odds ratio of OR = 0.320, (95% CI = 0.135–0.758). This was similar a recommendation by the World Health Organisation where there was a trend towards a modest reduction in caesarean section when augmentation was used as part of active management of labour. This was however contrary to a study by Davey and King who noted an increased risk of caesarean delivery when augmentation with oxytocin was used in labour. These differences in the findings could be due to the study region and practice/utilisation of epidural analgesia as the choice mode of labour analgesia. The option of analgesia used in this study was parenteral only.
Augmentation of labour is known to increase the process of moulding which significantly reduces both HC and biparietal diameter., and in effect can reduce the diameters of the cephalic presenting circumference making vaginal delivery more feasible/likely. Findings in this study support this occurrence.
Poor progress in labour/CPD accounted for more than half of the indication for caesarean delivery with more than 70% of these occurring when foetal HC ≥35 cm. This agreed with previous studies where it was demonstrated that there was an increase in the odds of poor progress of labour/prolonged labour occurring with increasing HC.,
Our study found that increasing CCD was also observed to result in an increasing incidence of poor progress in labour, especially when the CCD value was ≥7.5 cm. The study by Abramowicz et al. did not examine the outcomes of labour in this regard. These findings may lend credence to facts that large HC and CCD may be predictive of adverse labour outcomes and failure to progress in labour due to CPD.
The total incidence of foetal distress was 9.8%, while as the indication for CS, it was 38.2%. The HC <35 cm group had foetal distress accounting for 76.9% of the indication for CS as against 23.1% in HC ≥35 cm group. It could be expected that increasing HC would result in increasing occurrence of suspected foetal distress as supported by Aviram et al. and Elvander et al. both of whom noted a higher incidence of birth asphyxia and foetal distress in larger HC groups. However, this was not observed in this study, findings here were similar to a study by Mujugira et al. who did not find an association between large FHC and foetal distress.
Perineal lacerations occurred in 43.9% of all cases with perineal lacerations occurring more often when HC ≥35 cm. This was similar to the study by Valsky et al. However, this was at variance with studies carried out by Jangö et al. who found increasing HC was protective of anal sphincter injury and invariably perineal laceration.
The occurrence of perineal lacerations may be due to several factors; soft tissue/perineal resistance, deflexion of the foetal head, judicious utilisation of episiotomy and as demonstrated in this study, an increasing HC and CCD. The skill of the accoucheur managing the second stage of labour may also affect this. Despite moulding of the foetal head as a characteristic of the labour which reduces the HC, due consideration could be given to the other characteristics of the foetal presenting part; the thickness/size of the adipose tissue of said presenting part which subsequently leads to a wider dimension of the presenting part/head.
Strength of the study
Strengths of this study are in the prospective and randomised nature of the study and a larger sample size than in prior studies.
Parity might have been a confounding factor as a majority of the participants were multipara. Further studies may need to be carried out in smaller subsets, for example, primigravida to further corroborate the findings in this study. Neonates were not followed not beyond the immediate delivery period; other adverse outcomes such as palsy or neonatal deaths associated with the labour could have been missed.
Clinical pelvimetry was not evaluated in this study population; inadequate pelvis might have been used as an exclusion criterion. Nevertheless, these findings remain valid and generalizable since pelvic diameters are not routinely measured during pregnancy.
| Conclusions|| |
From the findings of the study, the present results indicate that ultrasonographic measured HC ≥35 cm is associated with a higher incidence of both obstetric interventions for the prolonged second stage of labour and adverse perinatal outcomes in comparison to other parameters such as CCD and even foetal weight. The association between HC and labour dystocia might be linear. CCD as a measure of foetal fat/subcutaneous distribution did not perform well as a predictor of mode of delivery as previously stated in other studies.
In patients undergoing labour, antepartum measurement of the HC may be an important factor to consider in cases of labour dystocia. The decision during the management of labour cases either to allow labour progress or possible intervention via instrumental delivery or caesarean delivery can be made based on the progress of labour and antenatal measured HC.
Large multicentre study will be required for a more definite statement on the predictive role of ultrasonographic parameters with consideration for foetal subcutaneous fat measurement.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]