Thai Journal of Obstetrics and Gynaecology April 2010, Vol. 18, pp.

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OBSTETRICS

Diagnosis of Cephalopelvic Disproportion or Failure to Progress of Labor in Rajavithi Hospital Compare with The Criteria of Royal Thai College of Obstetricians and Gynaecologists
Ekachai Kovavisarach MD*, Paweena Buddeewong MD**.
* Department of Obstetrics and Gynecology, Rajavithi Hospital, 2 Phayathai Road, Rajathevee, Bangkok 10400,Thailand ** College of Medicine Rangsit University

ABSTRACT Objective: To evaluate the correlation of the clinical criteria for cephalapelvic disproportion (CPD) or failure to progress of labor (FPL) in women underwent cesarean delivery with the criteria endorsed by the Royal Thai College of Obstetricians and Gynaecologists. (RTCOG) Material and Method: Two hundred and sixty one women underwent cesarean section due to CPD or FPL in Rajavithi Hospital from June 1st 2008 to May 31st, 2009 were retrospectively enrolled. The correlation between both criteria were analyzed using the criteria endorsed by RTCOG. Results: The correlation rate of the clinical criteria for diagnosis of CPD or FPL in women underwent cesarean section due to CPD or FPL with the criteria endorsed by the RTCOG was 82.00%. The correlation in private cases was significantly lower than those in ward cases. (53.2% vs 85.5%, p < 0.01). Maternal age, Bishop score, cervical dilatation when diagnosis of CPD or FPL by clinical or RTCOG criteria were statistic significant difference between groups. Conclusion: The correlation of clinical criteria and RTCOG criteria for diagnosis of CPD or FPL was higher (82.00%)The correlation rate in private cases was lower than those in ward cases. (53.2 % vs 85.5%, p < 0.01) Keywords: cesarean section, cephalopelvic disproportion, correlation, failure to progress of labor

Introduction
Cesarean section was growing up especially in the past few decade(1). Cephalapelvic disproportion (CPD) was the most common indication for cesarean section in Rajavithi Hospital varied from 31.39% in 1996 to 33.72% in 2000(2). Trend of cesarean section was still rising from 30.0% in 2004 to 35.98% in 2008(3) and CPD was the most common indication in

both period. The Royal Thai College of Obstetricians and Gynaecologists (RTCOG) recommended criteria for diagnosis of CPD.(4) However, some obstetricians in Rajavithi Hospital did not strictly follow these criteria. The aim of this study was to evaluate the correlation between the clinical criteria for diagnosis of CPD or failure to progress of labor in women underwent cesarean section with criteria endorsed

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by the RTCOG (4)

by individual obstetricians in the labor record in Rajavithi Hospital

Materials and Methods

Medical records of two hundred and sixty one pregnant women underwent cesarean delivery due to CPD or FPL in Rajavithi Hospital from June 1st 2008 to May 31st 2009 were reviewed, after approval of the Hospital Ethics Committee. Then they were re-evaluated the diagnosis of CPD or FPL using the criteria endorsed by RTCOG(4 ). Cases which met the RTCOGs criteria were classified as correlation while those did not met the RTCOGs criteria were classified as non correlation . Correlation of the clinical criteria for diagnosis of CPD of FPL was analyzed. The qualitative data were analyzed using the Chisquare test and the One-Way ANOVA. The quantitative data were analyzed using arithmetic mean, median, standard deviation and unpaired ttest. All data were collected and analysis by using SPSS for Windows Version 11.5 (SPSS, Chicago, IL).

Inclusion criteria
Women underwent cesarean section due to CPD or FPL in Rajavithi Hospital

Exclusion criteria
Incomplete medical records Elective cesarean section due to CPD

Results
The correlation rate between the clinical criteria for diagnosis of CPD or FPL and RTCOG was 82.0%. The correlation rate in private cases was lower than those in ward cases (53.19 % vs 85.5%), respectively (Table1). Table 2 shows the obstetric characteristic of patients. Maternal age, Bishop score before induction of labor and cervical dilatation when diagnosis of CPD or FPL were significant difference. Obstetric complications are shown in Table 3. Postpartum hemorrhage was the most common complications in every group. The severe neonatal complications were found in 1.9% and in ward correlated groups only. One cases might had more than one complication. Severe birth asphyxia at 1 minute was found only in 1 case (0.4%), mild birth asphyxia at 1 minute in 2 cases (0.8%), Meconium stained amniotic fluid in 2 cases (0.8%). Other complications 3 cases (1.2%) were transient tachypnea of the newborn (TTNB) and neonatal jaundice.

Definitions
Cephalopelvic disproportion (CPD): Obstructed labor resulting from disparity between the dimensions of the fetal head and maternal pelvis such as to preclude vaginal delivery (4) Lack of progression or failure of progress of labor (FPL): Ineffective labor, include lack of progressive cervical dilatation or lack of fetal descent (4) Clinical criteria of CPD in Rajavithi Hospital: Clinical findings at the time of final diagnosis of CPD

Table1. Correlation rate between the clinical criteria for diagnosis of CPD or FPL and RTCOGs criteria Correlation Case Private Ward Total * = Statistically significant difference

Correlation 25 183 208

Non-correlation 22 31 53

Total 47 214 261

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Table2. Obstetric characteristics of cases diagnosed CPD or FPL by clinical criteria and RTCOGs criteria Correlation (N=208) Ward(N=183) Age (yr) Mean SD min-max BMI(kg/M ) Mean SD
2

Non correlation(N=53) Ward (N= 31) 26.103.75 18 - 35 23.184.13 15.9 - 33 1 13 0 01 0 01 39 32 - 41 5.522.09 Private (N= 22) 29.734.88 21 - 39 21.613.78 15.8 33.3 1 14 0 02 0 01 38 36 41 5.322.51

Private(N=25) 31.08 3.22 25 - 38 21.312.90 17.4 - 30 1 13 0 02 0 02 39 34 - 41 6.722.44

p-value

27.905.51 16 - 44 22.653.96 13.3 - 36 1 16 0 03 0 05 39 29 42 7.382.31

0.02* 0.196

min-max Gravid (Median) min-max Para (Median) min-max Abortion(Median) min-max GA(wk) (Median) min-max Bishop score before induction of labor MeanSD min-max Cervical dilatation (When diagnosis of CPD or FPL) MeanSD min-max Estimate fetal weight(gram) MeanSD min-max Birthweight (gram) MeanSD min-max

<0.01*

0 12 7.02 2.27

2 - 11 5.201.78

09 2.611.14

1 - 10 2.311.17 <0.01*

3 10 3196.69370.60

3 10 3041.56307.81

06 3196.77379.02

05 3122.73258.07 0.196

1400- 4500 3291.56431.42 1250-4245

2000-3400 3204.40437.21 1890-3945

2300-4200 3211.48389.50 2155-4175

2800-3800 3156.59379.05 2455-4125 0.369

*= Statistically significant difference

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Table 3. Obstetric complications of cases diagnosed CPD or FPL by clinical criteria and RTCOGs criteria Maternal complication PPH Uterine atony Cesarean hysterectomy NA = not available Correlation 22(8.46%) Ward (N=183) 21 (9.81%) 8(3.73%) 1(0.47%) Private(N=25) 1(2.13%) 0 0 Non correlation 7(2.68%) Ward (N=31) 1(0.47%) 0 0 Private(N=22) 6(12.77%) 4(8.51%) 0

p-value 0.224 0.713 NA

Discussion
RTCOGs criteria(4) is recommended for diagnosis of CPD and FPL. However some obstetricians in Rajavithi Hospital did not strictly follow this criteria and did not have clinical practice guideline for CPD or FPL. They used individual clinical criteria for diagnosis. Results from this research found the correlation group was higher than non-correlation group (82.0% VS18.0%). When these patients were subdivided as private and ward cases. Ward cases had higher correlation rate compared with private cases 85.5 % vs 53.19 % for indication of CPD or FPL. The authors supposed that only single obstetricians care for private case all the time until delivery, sometime produce time constraint because the doctor should have the routine job to do. So sometime CPD or FPL might be early and overdiagnosed for rapid termination of delivery especially in the case whose clinical practice guideline (CPG) had not been established. This research found that cervical dilatation when diagnosis of CPD or FPL in correlation group was in active phase of labor but in non-correlation group was in latent phase of labor. Noncorrelation group in ward cases had good uterine contraction and had disorder of dilatation and descent but cervical dilatation was in latent phase of labor. But in non- correlation group in private cases did not meet proper all of criteria. Petchmanee P et al(5) studied for effect of CPG on cesarean section by the indication of CPD in Songklanagarind Hospital and found that the correlated group was 84.6% similar to those in this study in Rajavithi Hospital (82.0%). Chittithavorn S et al(6) studied for CPG for cesarean section due to CPD in Songklanagarind Hospital. They found obstetrician

diagnosis correlated CPG were 83% and ward cases were higher than private cases similar to those in this research too. In conclusion, the correlation rate of clinical criteria and RTCOG criteria for diagnosis of CPD or FPL was high (82.0%). The correlation rate in private cases was lower than those in ward cases. (53.19% vs 85.5%). Maternal age, Bishop score, cervical dilatation when diagnosis of CPD or FPL by clinical or RTCOG criteria were statistically significant difference between groups.

References
1. Royal Thai collage of obstetrician and gynaecologists. Cesarean section : rate of cesarean section. Ob Gyn Bull. 2001;10:1-14. Tansupasiri A, Kovavisarach E, Saenhorm P. Cesarean section rate at Rajavithi hospital from 1996-2000. Bull Dept Med Serv 2002;27:443-8. Statistic of obstetric and gynaecologic patient 2004 2008 Department of Obstetric and gynecologi, Rajavithi hospital, Rajathevee, Bangkok 10400. Royal Thai collage of obstetricians and gynaecologists .Clinical practice guideline for cesarean section due to cephalopelvic disproportion or failure to progress of labor. Obstet Gynaecol Bull 2001;10:17-22. Petmanee P, Kengpol C, Pinjaroen S, Krisanapan O. Effect of clinical practice guideline on cesarean section by the indication of cephalopelvic disproportion. Int J Qual Health Care 2004;16:327-32. Chittithavorn S, Suwanrath C, Pinjaroen S, Soonthornpun K. Clinical practice guideline for cesarean section due to cephalopelvic disproportion. J Med Assoc Thai 2006;89:735-40. Athisuk R,Boriboonhiranyasarn D,Jirojkul V. Sample size. In:Athisuk R,Boriboonhiranyasan D, Rattikarnsukka, editors. Research methodology 4th ed. Bangkok : Royal Thai College of Obstetricians and Gynecologists,1999 :423-45.

2.

3.

4.

5.

6.

7.

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: : 261 1 ..25 5 1 31 ..25 5 2 : 82 53.2 85 .5 , , : 8 2 53 .2 85.5

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