Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : QC01 - QC05 Full Version

Role of Transvaginal Sonographic Parameters in Predicting Outcomes of Induction of Labour: A Prospective Observational Study


Published: October 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/58314.17011
Sangeeta Gupta, Neetika Pandey, Taru Gupta

1. Consultant and Associate Professor, Department of Obstetrics and Gynaecology, Esic Pgimsr Basaidarapur, New Delhi, India. 2. Senior Resident, Department of Obstetrics and Gynaecology, ESIC PGIMSR Basaidarapur, New Delhi, India. 3. Head, Department of Obstetrics and Gynaecology, ESIC PGIMSR Basaidarapur, New Delhi, India.

Correspondence Address :
Dr. Sangeeta Gupta,
Consultant and Associate Professor, Department of Obstetrics and Gynaecology, ESIC PGIMSR, Basaidapur, New Delhi, India.
E-mail: sangeetagupta58@hotmail.com

Abstract

Introduction: Induction of labour is an artificial method of initiating uterine contractions before the onset of spontaneous labour, which leads to progressive cervical dilatation and effacement followed by delivery. Bishop score is the most commonly used method for assessing the favourability of the cervix. However, this method is subjective and less accurate. Transvaginal ultrasonography (TVS) has been demonstrated to be more sensitive than the Modified Bishop score in predicting successful labour induction in recent years as it avoids interobserver variations.

Aim: To know the role of TVS parameters in predicting the outcome of induction of labour and to compare with the predictive power of the Modified Bishop score.

Materials and Methods: This was a prospective observational study conducted between October 2019 to April 2021 in the Department of Obstetrics and Gynaecology, ESIC PGIMSR, Basaidarapur, New Delhi, India. The study was conducted on 124 pregnant women. Preinduction TVS was performed using a transvaginal probe of 6 MHz and a transabdominal probe of 3.75 MHz. Ultrasound was used to determine cervical length, posterior cervical angle and foetal head position. Following the ultrasonographic examination, a digital examination of the cervix was done, and a score was assigned based on the Modified Bishop score. The induction of labour was performed as per hospital protocol. For the purpose of this study, the successful outcome was taken as a vaginal delivery within 24 hours from the start of induction. Data analysis was done by Statistical Package for Social Sciences (SPSS) version 25.0. McNemar’s test was used to compare sensitivity and specificity. Qualitative variables were correlated by the Chi-square test/Fisher’s exact test.

Results: A total of 124 patients were selected, who underwent induction of labour. Out of these 92 (74.2%) patients who delivered vaginally, 81 patients delivered within 24 hours of induction and 11 patients delivered after 24 hours of induction, rest 32 patients delivered by caesarean. So, the unsuccessful outcome was in 8.87% the of study population. Modified bishop score, TVS cervical length, posterior cervical angle and foetal head position, all were found significant in predicting the successful induction of labour. Cervical length measured by ultrasonography can be used as a significant predictor of the successful induction of labour (p<0.001) with an optimum cut-off of <3.65 with sensitivity and specificity of 99.1% and 79.5% respectively. The posterior cervical angle can also be used as a significant predictor of successful induction of labour. Modified bishop score can be used as a significant predictor of successful induction of labour (p<0.001) with an optimum cut-off of >2 with sensitivity and specificity of 98.13% and 82.35% respectively. Although, all ultrasound parameters when combined and compared with the Bishop score were found to be more significant in predicting successful induction of labour.

Conclusion: TVS parameters when combined were found to be more specific and sensitive as compared to the Modified Bishop score in predicting successful labour induction.

Keywords

Cervical length, Modified bishop score, Vaginal delivery

Induction of labour is an artificial method of initiating uterine contractions before the onset of spontaneous labour, leading to progressive cervical dilatation and effacement followed by delivery. Modified Bishop score is the most commonly used method for the evaluation of preinduction favourability of the cervix. However, it has a high inter and intraobserver variability and its sensitivity is 23-64% (1). TVS has been demonstrated to be more sensitive than the Modified Bishop score in predicting successful labour induction in recent years, as it avoids interobserver variations (2),(3).

The TVS measurement of the cervix could represent a more accurate assessment of the cervix than digital examination because the supra vaginal portion of the cervix usually comprises about 50% of the cervical length and it is very difficult to assess digitally the supravaginal part of the cervix (4). In addition, it is difficult to assess the effacement in a closed cervix, as effacement starts at the level of the internal os. Assessment of the cervix digitally is reported to be associated with fear of examination, pain, anxiety and discomfort (5). Yang SH et al., conducted a study and found that TVS assessment of cervical length is a better method in predicting induction of labour than the Bishop score (6).

Measurements of the angle between the posterior uterine wall and the cervical canal (posterior cervical angle), have been associated with successful labour induction prediction (7). A study by Rane SM et al., showed that, in women undergoing induction of labour, the posterior cervical angle is better than the Bishop score in the prediction of the outcome of labour (8).

Foetal head position is evaluated by placing the abdominal transducer transversely in the suprapubic region of the maternal abdomen. According to the study conducted by Akmal S et al., determining occiput position sonographically, during the early stages of active labour can help to estimate the risk of a caesarean section (9). Various other parameters like cervical funnelling, cervical wedging and translabial distance of foetal head have also been studied.

This study was done to determine the efficacy of combined as well as an individual TVS parameter in predicting the successful outcome of induction of labour and whether, is this a better tool than clinical assessment obtained by the Bishop score.

Material and Methods

This was a prospective observational study conducted between October 2019 to April 2021 in the Department of Obstetrics and Gynaecology, ESIC PGIMSR, Basaidarapur, New Delhi, India. This study was conducted after getting approval from the Ethical Committee (DM(A)H 19/14/17/IEC/2012PGIMSR). A total of 124 pregnant women who were admitted to labour room and Antenatal Clinic (ANC) ward and planned for induction of labour and gave consent were enrolled.

Inclusion criteria: Pregnant female with gestation from 37 completed weeks upto 42 weeks, singleton, live foetus, longitudinal lie, cephalic presentation with an intact amniotic membrane with reactive Non Stress Test (NST), and initial cervical examination showing ≤2 cm dilatation and ≤50% effacement that is Bishop score ≤6 were included in the study.

Exclusion criteria: Women with major foetal anomalies, previous uterine surgery, antepartum haemorrhage and contraindication to vaginal delivery were excluded from the study.

Sample size calculation: The study of Kanwar SN et al., observed that the sensitivity and specificity of bishop score were 34.43% and 93.88% respectively and cervical length was 57.38% and 100% respectively (10). Taking these values as a reference, the minimum required sample size with desired precision of 12.5%, 80% power of study, and 5% level of significance was 118 patients. To reduce the margin of error, the total sample size taken was 124 (Table/Fig 1).

Study Procedure

After a careful history, general and systemic examination, TVS was performed before induction of labour, using Philips clearVue350 machine with a transvaginal probe of 6 MHz and transabdominal probe of 3.75MHz.

Cervical distortion was avoided by placing the transducer, 3 cms proximal to the cervix. A sagittal view of the cervix was obtained and echogenic endocervical mucosa was visualised along the length of the endocervical canal. The image of the cervix was magnified to about 75% of the screen. The length of the cervix was measured from the internal os to the external os.

The posterior cervical angle was measured with a protractor applied to a hard copy picture taken in a sagittal plane at the level of the internal os and approximated to the nearest 10° (Table/Fig 2). For determination of foetal head position, the ultrasound transducer was first placed transversely in the suprapubic region of the maternal abdomen. The foetal orbits in the case of Occiput Posterior (OP) position, the midline cerebral echo in the case of Occiput Transverse (OT) positions and the cerebellum or occiput in the case of Occiput Anterior (OA) position served as landmarks for foetal head position (Table/Fig 3) (8). Following the ultrasonographic examination, an obstetrician who was blinded to the ultrasound measurements did a digital examination of the cervix with all aseptic precautions and a score was assigned based on the Modified Bishop score (11).

The induction of labour was performed in accordance with the hospital’s protocol. 0.5 mg dinoprostone gel was instilled into the cervix every six hours, for a total of three doses. If regular uterine contractions and cervical change did not occur six hours following the last prostaglandin dosage, an oxytocin infusion was given. Amniotomy with oxytocin infusion or oxytocin alone was started when Bishop’s score was more than 5. For the purpose of this study, a successful outcome was taken as a vaginal delivery within 24 hours from the start of induction.

Failed induction: was defined as failure to achieve regular uterine contraction even after insertion of 3 intracervical PGE2 gel at six hours intervals, and 12 hours of oxytocin administration after rupture of the membranes.

Failure to progress: was defined as no cervical dilatation during the active phase of the labour (≥4 cms) for the last two hours and no descent of the foetal head during 2nd stage of labour for atleast one hour despite adequate uterine contractions (12).

Statistical Analysis

The collected data were transformed into variables, coded and entered in Microsoft excel. Data were analysed and statistically evaluated using SPSS version 25.0. Quantitative data were expressed in mean±standard deviation (SD) or median with interquartile range. Difference between two comparable groups was tested by student’s t-test (unpaired). Qualitative data were expressed in percentage and statistical differences between the proportions were tested by Chisquare test. Receiver Operating Characteristic (ROC) curve was prepared using different parameters for prediction of successful induction of labour and based on cut-off value, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated. Pearson or Spearmann correlation coefficient was used to see the correlation between two quantitative variables. The p-value <0.05 was considered statistically significant.

Results

There were 74 (59.7%) primigravidas and 50 (40.3%) multigravidas in the study population (Table/Fig 4).

In present study, population maximum induction was done electively at term followed by Intrahepatic Cholestasis of Pregnancy (IHCP) (Table/Fig 5).

Around 15 (12%) patients underwent caesarean section due to foetal distress followed by Meconium-stained liquor 5 (4%) (Table/Fig 6).

Cervical length measured by TVS in the maximum number of patients ie 49 lies between 3.1-3.5 cms. Posterior cervical angle was <120o in 65.3% of patients. It was also found that the occiput anterior position is the most common presentation in 75% (Table/Fig 7).

It was found that the maximum number of patients fall in the category of Bishop score of 3-4 ie 84 and mean Bishop score was 3.61 and vaginal delivery was 72 with Bishop score of 0-4 (Table/Fig 8),(Table/Fig 9).

In women, delivered vaginally mean cervical length measured by TVS was 3.37±0.45 cms and by digital examination was 2.66±0.38 cms, significantly short as compared to those who required caesarean section (p-value <0.001) by Chi-square test.

It was found that for patients with TVS cervical length between 2-2.5 cm, 100% underwent normal vaginal delivery and for patients with a cervical length between 3.1-3.5 cm, 89.75% underwent normal vaginal delivery while 10.2% underwent caesarean section, while with the digitally measured cervical length between 1.5-2 cm 100% delivered vaginally while between 2.6-3 cm, 70.5% delivered vaginally while 29.4% delivered by caesarean section (Table/Fig 10).

The mean posterior cervical angle was117.97±9.35 cm in patients delivered vaginally which was significantly (p-value-0.001) higher as compared to those who underwent caesarean section. OA position was significantly associated with vaginal delivery 75 (80.6%) (Table/Fig 11).

It was observed that 54 (43.6%) of patients delivered within 12 hours of induction, 53 (42.7%) of patients delivered between 12-24 hours and 17 (13.7%) delivered in more than 24 hours.

Out of 107 cases where induction to the delivery interval was ≤24 hours, 81 (75.7%) cases were delivered vaginally and 26 (24.3%) underwent caesarean section. Out of 17 cases where induction to the delivery interval was >24 hours, 11 (64.7%) cases were delivered by the vaginal route and 6 (35.3%) by caesarean section. For the patients delivered vaginally the mean time duration from induction to active phase was 10.36±5.54 hours, the mean time duration from active phase to vaginal delivery was 3.72±1.11 hours and the mean time duration from induction to the delivery interval was 14.11±6.05 hours.

There was statistically very strong positive correlation between TVS cervical length in IOL to delivery interval (r-value=0.815, p-value <0.001) and strong positive correlation between IOL to active phase (r-value=0.793, p-value <0.001) (Table/Fig 12).

Combined Ultrasonography (USG) parameters were found to be more sensitive (100%, AUC-0.97%) as compared to single USG parameter or Bishop score (98.13%, AUC-0.93) (Table/Fig 13).

Discussion

In the present study, the successful outcome of induction was defined as; vaginal delivery occurring within 24 hours. This endpoint has been traditionally used in several studies to examine the efficacy of an inducing method, Pandis G et al., also demonstrated that cervical length by ultrasound performed better than Bishop Score to predict vaginal delivery within 24 hours of induction (13).

In the present study, the mean time duration from induction to the active phase was 10.36±5.54 hours. The mean time duration from the active phase to vaginal delivery was 3.72±1.11 hours. The mean time duration from induction to delivery interval was 14.11±6.05 hours. These findings were consistent with the study by Aggarwal K and Yadav A, in which the mean time duration from induction to active phase was 8.86±3.93 hours. The mean time duration from the active phase to vaginal delivery was 4.68±1.86 hours. The mean time duration from induction to the delivery interval was 13.26±4.98 hours (14). In the present study, cervical length was measured by digital examination and TVS and the mean sonographic cervical length was 3.37±0.4 cm and the mean cervical length measured by digital examination was 2.66±0.38. There was a significant difference of 0.7 cms in mean cervical length measured by the two methods. The difference in cervical length measured digitally and by USG is mainly due to the supravaginal portion of the cervix which cannot be measured digitally.

The digital examination can only measure the length between the external os to the cervicovaginal junction. Present study findings were consistent with the study conducted by Aggarwal K and Yadav A, which reported a mean sonographic cervical length of 3.4 cm and cervical length measured by digital examination as 2.6 cm (14).

In the present study, the best cut-off point for predicting successful induction of labour was ≤3.6 cm for cervical length measured by TVS.

Present study findings were consistent with the study conducted by Keepanasseril A et al., (15). In the ROC curve, the best cut-off point for predicting successful induction of labour was >2 for the modified Bishop score. The area under the ROC curve was 0.93 which were consistent with the study conducted by Aggarwal K and Yadav A (14).

The ROC curve of present study showed that as compared to TVS cervical length, the Modified Bishop score was the best parameter for predicting successful induction of labour (area under ROC curve of modified bishop score was more than the TVS cervical length). From the previous studies done on the prediction of successful labour induction, Paterson-Brown S et al., Aggarwal K and Yadav A and Chandra S et al., reported Bishop score as a better predictor than the transvaginal ultrasonographic assessment of cervical length (7),(14),(16).

Previous studies done by Elghorori MR et al., Ware V and Raynor BD, Rane SM et al., Pandis G et al., Keepanasseril A et al., and Gabriel R et al., reported transvaginal ultrasonographic cervical assessment as a better predictor than Bishop score for predicting successful labour induction (1),(4),(8),(13),(15),(17). In the study conducted by Athulathmudali SR et al., the primary outcome was taken as vaginal delivery within 24 hours and TVS cervical length, cervical volume and bishop score were compared (18). TVS cervical length was found to be a superior predictor to other parameters. In another study by Abdullah ZH et al., TVS cervical length and Bishop score was compared and they did not find much difference in the predictive value of both parameters (19). Ransiri PA et al., and Vince K et al., found the Bishop score to be a better predictor than TVS cervical length (Table/Fig 14) (20),(21).

In the literature, there are very few studies about the effect of posterior cervical angle in labour induction. In present study, posterior cervical angle >111 is having better predictive value for successful induction of labour with a sensitivity of 0.79 and specificity of 0.99 and AUC 0.95. Paterson-Brown S et al., reported that posterior cervical angle was more accurate than Bishop score in predicting vaginal delivery (7). Rane SM et al., performed transvaginal ultrasound in 604 patients, whose posterior cervical angle measurements were >120 and reported better responses to labour induction within 24 hours (8). In a study by Gokturk U et al., posterior cervical angle 120 appears to be a better predictive value for successful labour induction (22). But, in multiple regression analysis, it was not statistically significant.

So, if all three USG parameters are combined, they act as a better method in predicting successful induction as compared to the Modified Bishop score.

Limitation(s)

The present study includes only a population from a single medical centre and may not depict the rest of the population. Also, a single method of induction was used, different methods have different outcomes and labour duration. Authors did not include other sonographic parameters of the cervix such as the presence of wedging and distance of presenting part to external os, which may have additional value in predicting successful induction of labour. Further study in the future is needed to investigate the ultrasound parameter in predicting labour induction.

Conclusion

Combining all the TVS parameters is more sensitive and specific than Modified Bishop in preinduction cervical assessment, hence can be used as an alternative in predicting successful labour induction.

References

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DOI and Others

DOI: 10.7860/JCDR/2022/58314.17011

Date of Submission: Jun 07, 2022
Date of Peer Review: Jul 07, 2022
Date of Acceptance: Sep 20, 2022
Date of Publishing: Oct 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 12, 2022
• Manual Googling: Sep 09, 2022
• iThenticate Software: Sep 19, 2022 (20%)

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