British Journal of Obstetrics and Gynaecology

August 2000, V01107, pp. 947-952

Maternal height and external pelvimetry to predict

cephalopelvic disproportion in nulliparous African
women: a cohort study
*$Hubert B. Liselele Researcher, tMichel Boulvain Epidemiologist, *Kalala C. Tshibangu Professor,
SSylvain Meuris Professor
*Department of Gynaecology and Obstetrics, University of Kinshasa, Democratic Republic of Congo; tPublic Health School, Free
University Bruxelles, Belgium: $Research Laboratory for Reproduction, Faculty of Medicine, Free University Brussels, Belgium

Objective To assess external pelvimetry and maternal height, as predictors of cephalopelvicdisproportion.

Design Prospective cohort study.

Setting Four hospitals in Zaire.

Population Six hundred and five nulliparous women.
Methods Maternal height and external pelvimetry were assessed during the third trimester antenatal
visit. Cut off values for considering women at risk for cephalopelvic disproportion were height
< 150 cm and external pelvic distances < 10th centile for the population. Logistic regression analysis,
combining height and pelvic measurements, was performed to predict women at risk for
cephalopelvic disproportion.
Main outcome measure Cephalopelvicdisproportion was considered when there was caesarean section
for failure to progress, vacuum or forceps delivery or intrapartum stillbirth.
Results Cephalopelvic disproportion was present in 42 women. In univariate analysis, height,
intertrochanteric diameter and the transverse diagonal of Michaelis sacral rhomboid area were found
to be associated with cephalopelvic disproportion. Logistic regression analysis showed that maternal
height < 150 cm and/or transverse diagonal < 9.5 cm were the variables most associated with
cephalopelvic disproportion. The adjusted odds ratios were 2.2 (95% CI 0.9 to 5.4) and 6.5 (95% CI
3.2 to 13.2), respectively. The positive predictive value and likelihood ratio were 24% and 4.0 (95%
CI 2-8to 5-8),respectively.The addition of transverse diagonal to maternal height increased the sensitivity in predicting cephalopelvicdisproportion from 21% to 52% .
Conclusion In addition to height, transverse diagonal measurement is able to predict one out of two
cases of cephalopelvic disproportionin nulliparous women. After validation in a separate cohort, this
simple predictive method may be used in peripheral centres for timely referral of pregnant women at
risk for cephalopelvic disproportion.

INTRODUCTION
Maternal mortality remains a major concern in developing countries. Recent estimates suggest that about
600,000 women die each year of pregnancy related
complications'. Among these deaths, 20% to 30% are
attributable to the complications of cephalopelvic disproportion'4. Those who survive are at significant risk
of morbidity, including postpartum haemorrhage, perineal tears, genital prolapse and obstetric fistulae3".

Correspondence: Professor S. Mewis, Research Laboratory on

Reproduction, Facult6 de M6decine (CPi 626), Universie Libre
de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium.
Q RCOG 2000 British Journal of Obstetrics and Gynaecology

Risks for the fetus include asphyxia, septicaemia,neurological damage and perinatal death6.
In the majority of cases of cephalopelvic disproportion, caesarean section represents the best treatment
for both the mother and the fetus. Detection of women
at risk for cephalopelvic disproportion is therefore one
of the main goals of antenatal clinics. This is particularly crucial in settings where caesarean section is not
feasible, so that women at high risk for cephalopelvic
disproportion may be referred to a district hospital
equipped with an operating theatre prior to the onset
of labour. At present, most antenatal care programs
rely only on maternal height to identify women at risk
for cephalopelvic disprop~rtion~-'~.
Maternal height has
been shown, however, to have limited predictive value'.
947

948

H . B . LISELELE ET A L .

External pelvimetry was the first technique used to

predict cephalopelvic disproportion"-". Few studies on
pelvimetry are available and the prediction of
cephalopelvic disproportion by this method was not
adequately assessed'"*'. The objective of our cohort
study was to evaluate external pelvimetry, in addition to
maternal height, to predict cephalopelvic disproportion
in nulliparous women.

METHODS
Four obstetricians from the Maternity Hospital of the
Kinshasa University were trained to measure external
pelvic distances. They were posted for a six-month
period between 1986 and 1989 in one of four hospitals
of the former Republic of Zaire (Kinshasa, Boende,
Mbuji-Mayi and Mambasa). These hospitals served
mixed urban and rural Bantu populations. Routinely,
pregnant women have a single prenatal visit during
the third trimester. All nulliparous women (n = 646)
presenting during the period that the visiting obstetrician was there were included in the study. More than
95% of included women were delivered in the same
hospital. Women who were limping or who had an
obvious asymmetrical pelvis were excluded from the
study. Nulliparous women who were delivered of
twins ( n = 8), a fetus weighing < 2000 g ( n = 30) or a
non-vertex presentation ( n = 3 ) were also excluded.
The analysis included 605 nulliparous women who
were delivered of a single fetus weighing 2 2000 g in
vertex presentation.
Maternal height and external pelvic measurements
were performed by visiting obstetricians during the
antenatal visit. Height was measured using a height
gauge with the woman standing erect in bare feet. The
antero-posterior diameter (also named external conjugateI8 or Baudelocque diameter), the distance between
the anterior superior iliac spines (intercrestal), between
the anterior inferior iliac spines (interspinous), between
the femoral trochanters (intertrochanteric) and the intertuberous diameter were measured using a Breisky
pelvimeter (Fig. 1). The vertical and transverse diagonals of the Michaelis sacral rhomboid area were measured using a measuring tape (Fig. l). Height and pelvic
measurements were recorded to the nearest 0.5 cm interval. Results of height and pelvic measurements were
recorded in a file separate from the antenatal record.
Pelvic measurements were not used for decision making
and the visiting obstetricians who did the pelvimetry
were not involved in the management of delivery.
Information on delivery was recorded by the local
medical staff in the obstetric register and collected
everyday by the visiting obstetrician. Cephalopelvic disproportion was considered under the following conditions: caesarean section for failure to progress, vacuum

or forceps delivery or vaginal delivery complicated by

intrapartum stillbirth. All uncomplicated vertex births
were considered as the reference group. Another group
comprising complicated deliveries ('other complicated
deliveries' group) included women who had caesarean
section for fetal distress, placenta praevia or insufficient
uterine contractions. These conditions were not considered as related to cephalopelvicdisproportion,because a
trial of labour could not be completed.
The mean (SD) were compared using analysis of variance (ANOVA), followed by a Scheffe test. As usually
accepted, a maternal height c 150 cm was used as cut off
to identify women at risk for cephalopelvic disproportion7-'". Cut off values for pelvic distances were defined
as the values closest to the loth centile of our population. Sensitivity, specificity, positive predictive values
and the positive likelihood ratio [sensitivity divided by
(1-specificity)] with their 95% confidence intervals (CI)
were calculated using these thresholds. Logistic regression models (forced entry method) were constructed,
with cephalopelvic disproportion as a dependent variable, to assess the independent predictive properties of
various combinations between maternal height and
pelvic measurements.
The study protocol was approved by the authorities of
the hospitals involved in the study and by academic
authorities of the Kinshasa University.

RESULTS
Among included women, the proportion of deliveries
complicated by cephalopelvic disproportion, as defined
above, was 7.0% (42/605). Among these deliveries,
there were 26 caesarean section (including two stillbirths), nine vacuum or forceps (includingone stillbirth)
and seven vaginal deliveries complicated by intrapartum stillbirth. The proportion of women with
cephalopelvic disproportion did not differ between the
four maternity hospitals. The proportion of other complicated deliveries was 2.5% (15/605). There were no
maternal deaths in the study group.
Mean maternal age did not differ between the
cephalopelvic disproportion and normal delivery (n =
548) groups (Table 1). Maternal height and most of the
pelvic measurements were smaller in the cephalopelvic
disproportion group than in the normal delivery group.
The intertuberous diameter was similar between the two
groups. Maternal measurements were similar between
the 'other complicated deliveries' group and the normal
delivery group (Table 1).
The proportion of women with height < 150 cm was
7.3% (Table 2). The proportion of women with pelvic
measurements below the chosen cut off levels ranged
from 8.1% to 12.5% . All anthropometricmeasurements
displayed high specificity ranging from 89.1% to
0 RCOG 2000 Br J Obstet Gynaecol 107,947-952

P R E D I C T I O N OF C E P H A L O P E L V I C D I S P R O P O R T I O N

949

Fig. 1. External intercrestal (IC), interspinous (IS), intertrochanteric (IT) and intertuberous (ITb) transverse pelvic diameters
(a); antero-posterior external conjugate or Baudelocque diameter (b); and transverse (BD) and vertical (AC) diagonals of the Michaelis
sacral rhomboid area (c); Breisky pelvimeter (d).

Table 1.Comparison of maternal characteristics between groups. Values are given as means (SD).

Variables

Normal delivery
(n = 548)

Cephalopelvic
disproportion
(n = 42)

Other complicated
deliveries
(n = 15)

P*

19.1 (3.3)
161.9 (7.3)

19.6 (4.3)
157.6 (8.8)'

19.5 (4.8)
166.8 (7.2)'

0.748
< 0.001

21.8 (2.8)
27.5 (3.5)
23.3 (3.4)
32.0 (3.6)
9.4 (1.5)

20.6 (2.2)'
24.8 (2-5)'
21-4(2.0)'
29.0 (3.0)'
9.3 (1.3)

22.6 (1.5)
27.3 (2.4)
22-4(2.4)
32.5 (2.3)
9.9 (1.0)

0.003
0.001
0.002

11.9 (2-1)
10.7 (1.1)

10.9 (1.8)+
9.8 (1.5)'

13.0 (1.6)'
11.1 (1.2)

Age (years)
Height (cm)
External pelvic dimensions (cm)
Baudeloque diameter
Intercrestal diameter
Interspinous diameter
Intertrochanteric diameter
Intertuberous diameter
Michaelis sacral rhomboid area (cm)
Vertical diagonal
Transverse diagonal

*Computed by ANOVA.
+Significantlydifferent from the normal delivery group at the 0.05 level (Scheffetest).
0 RCOG 2000 Br J Obstet Gynaecol 107,947-952

< 0~001
0.470

0.001

< 0.001

950

H . B. LISELELE ET AL.

Table 2. Prediction of cephalopelvic disproportion by maternal height and external pelvimetry: univariate analysis. Values are given as %
(nh,,,), unless otherwise indicated.
Cut off value
at risk
Height (cm)
External pelvic dimensions (cm)
Baudeloque diameter
Intercrestal diameter
Interspinous diameter
Intertrochantericdiameter
Intertuberous diameter
Michaelis sacral rhomboid area
Vertical diagonal
Transverse diagonal

Women
at risk

Sensitivity

Specificity

Positive
Positive likelihood
predictive value
ratio (95% CI)

< 150

7.3 (43/590)

21.4 (9/42)

93-8 (514/548)

20.9 (9/43)

3.5 (1-8-6.8)

< 18.5

10.8 (64/590)
9.6 (56/590)
8.1 (48/590)
12.5 (74/590)
10.7 (63/590)

19.0 (8/42)
14.3 (6/42)
9.5 (4/42)
38.1 (16/42)
7.1 (3/42)

89.8 (492/548)
90.9 (498/548)
92.0 (504/548)
89.4 (490/548)
89.1 (4881548)

12.5 (8/64)
10.7 (6/56)
8.3 (4/48)
21.6 (16/74)
4.8 (3/63)

1.9 (1.0-3.7)
1.6 (0.7-3.4)
1.2 (0.5-3.1)
3.6 (2.3-5.7)
0.7 (0.2-2.0)

10.8 (64/590)
11.7 (67/590)

21.4 (9/42)
90.0 (493/548)
42.9 (18/42) 91.1 (499/548)

14.1 (9/64)
26.9 (18/67)

2.1 (1.1-4.0)
4.8 (391-7.4)

< 23.0
< 20.0

< 27.5
< 8.0
< 9.5

< 9.5

93.8%. In univariate analysis, maternal height,

intertrochanteric diameter and the transverse diagonal
of the Michaelis sacral rhomboid area had the highest
sensitivity, positive predictive value and positive likelihood ratio (Table 2).
These predictors were included in four logistic regression models (Table 3). According to the predictive properties derived from these models, women at highest risk
for cephalopelvic disproportion were those with a height
< 150 cm and/or a transverse diagonal of Michaelis area
c 9-5 cm (model 2 in Table 3). The adjusted odds ratios
of maternal height and transverse diagonal were 2.2
(95% CI 0.9 to 5.4,P = 0.089) and 6.5 (95% CI 3.2 to
13.2, P < 0.001), respectively. The positive predictive
value and likelihood ratio of this model were 24% (95%
CI 16 to 34) and 4.0 (95% CI 2.8 to 58), respectively.
The sensitivity of the two combined tests to identify
women who subsequently had a delivery complicated by
cephalopelvicdisproportion was 52% (95% CI 37 to 68).
To achieve a similar sensitivity (55%) using maternal
height alone, a cut off level of 159 cm should be used.
This would result in a referral rate of 3 1% (190/605) and
a positive predictive value of 13%.
Mean (SD) birthweight was higher in the
cephalopelvic disproportion group [3129 g (425)] than
in normal delivery group [2976 g (395); P = 0.0151.
Among women identified as being at risk by the model,

those having cephalopelvic disproportion were delivered

of larger babies [true positives; n = 22; mean (SD) birthweight 3019 g (369)] than women who had an uncomplicated vaginal delivery [false positives; n = 71; mean
(SD) birthweight 2840 g (396); P = 0.061.Birthweight
was also higher in women not identified by the model but
having cephalopelvic disproportion [false negatives; n =
20; mean (SD) birthweight 3251 g (457)]than among
women with normal delivery [true negatives; n = 477;
mean (SD) birthweight 2996 g (391);P = 0.0041.
In order to evaluate the fetal component of
cephalopelvic disproportion on the predictive properties
of the proposed model, birthweight was added to the
model. The adjusted odds ratios for maternal height, the
transverse diagonal of Michaelis area and birthweight
L 3500 g (90th centile) were 2.1 (95% CI 0.8 to 5.2; P =
0.112), 7.2 (95%CI 3-5to 14-9;P c 0.001) and 2.7 (95%
CI 1.2 to 6.3, P = 0-019), respectively. The sensitivity,
positive predictive value and positive likelihood ratio
were 67% (95% CI 50 to 80), 18% (95% CI 13 to 25)
and 2.9 (95% CI 2-2 to 3.7), respectively.

DISCUSSION
Cephalopelvic disproportion is a major risk factor for
maternal and perinatal morbidity and mortality. Accurate prediction of women at risk for cephalopelvic

Table 3. Logistic regression analysis: prediction of cephalopelvicdisproportion by models combining maternal height (HT), intertrochanteric
diameter (IT) and transverse diagonal of the Michaelis area (TD). Values are given as % (n/ntom,),unless otherwise indicated.
Logistic regression models

Women at risk

Sensitivity

Specificity

Positive
predictive value

Positive likelihood
ratio (95% CI)

Model 1: (HT < 150 cm)or (IT < 27.5 cm)

Model 2: (HT < 150 cm) or (TD < 9.5 cm)
Model 3: (IT < 27.5 cm) or (TD < 9.5 cm)
Model 4: (HT < 150 c m r (IT < 27.5 cm)
or (TD < 9.5 cm)

16.1 (95/590)
15.8 (93/590)
19.3 (1141590)

42.9 (18/42)
52.4 (22/42)
54.8 (23/42)

85.9 (4711548)
87.0 (4771548)
83.4 (457/548)

18.9 (18/95)
23.7 (22/93)
20.2 (23/114)

3.1 (2.0-4.6)
4.0 (2.8-5.8)
3.3 (2.4-4.6)

22.0 (130/590)

59.5 (25/42)

80.8 (443/548)

19.2 (25/130)

3.1 (2.3-3.7)

0 RCOG 2000 Br J Obstet Gynaecol 107,947-952

P R E D I C T I O N O F C E P H A L O P E L V I C DISPROPORTION

disproportion would permit early referral to district hospitals for trial of labour under safe conditionsz1. If
cephalopelvic disproportion is not predicted by health
centres which are not equipped to perform a caesarean
section, long referral distances and poor local transport
may lead to obstructed labour and uterine rupturez4.
Conversely, in a resource limited setting, prediction of
cephalopelvic disproportion in women at risk must be
sufficiently specific to avoid unnecessary referral.
In the present study the proportion of cephalopelvic
disproportion in nulliparous women was in the range of
4% to 15%, reported in developed and developing countries6.Variations in the proportion of cephalopelvic disproportion are due to genetic factors, nutritional factors
and differences in the definition of cephalopelvic disp r o p ~ r t i o n ~ , 'The
~ . ~complications
~~~.
included in our
definition of cephalopelvic disproportion are likely to be
caused by an absolute or relative mechanical disparity
between the fetal size and the birth
Women's height is correlated to pelvic size and is curIn
rently used to predict cephalopelvic disprop~rtion~-'~.
our study women who had cephalopelvic disproportion
were shorter than those having a normal delivery. However, the sensitivity related to a maternal height cut off
for risk set at c 150 cm was low. Our results confirm
previous studies showing the limitations of maternal
height to predict cephalopelvic dispr~portion~.~.
Pelvic measurements, performed either by external
pelvimetry or by X-ray techniques, can provide markers of the risk for cephalopelvic disproportion. External pelvic measurements have been found to be
correlated with internal pelvic measurements by Xr a ~ ' ~ , 'In
~ . our study, the majority of external pelvic
measurements were smaller among women having
cephalopelvic disproportion than among women with
uncomplicated vaginal delivery. The antero-posterior
diameter (Baudelocque diameter) is the only external
distance associated with the pelvic anterior posterior
size6~18~z6.
Its sensitivity, positive predictive value and
likelihood ratio remained lower than those of maternal
height. The intercrestal, interspinous and intertrochanteric diameters can be used to determine pelvic
shape and transverse ~ a p a c i t y ~ .*Am
' ~ ongthem,the
~'~*~~
intertrochanteric diameter was the best predictor of
cephalopelvic disproportion. The intertuberous diameter was not related to cephalopelvic disproportion. This
distance, nevertheless, is usually described as related
to outlet d y ~ t o c i a ' ~ ? ' ~ .
Abnormal size and shape of the Michaelis sacral
rhomboid area, first described in 1851, was reported to
be associated with abnormal p e l v i ~ ' ~ . 'Our
~ . study
shows that the transverse diagonal of this sacral area
was the strongest anthropometric predictor for
cephalopelvic disproportion. Moreover, the clinical
algorithm obtained by the addition of this risk factor to
0 RCOG 2000 Br J Obstet Gynaecol 107,947-952

951

the maternal height was found to be the best model to

identify women at risk for cephalopelvic disproportion.
This model identified more than half of the cases of
cephalopelvic disproportion among nulliparous women,
with a proportion of women presumed to be at risk of
16% . It is important to note that in order to achieve a
similar sensitivity using only maternal height, a cut off
value of 159 cm should be used. Using this cut off value
will lead to referral of 31% of nulliparous women,
which is not acceptable in most settings. The proposed
model greatly reduced the referral rate to a limit that
may be more suitable in a resource limited setting.
However, a lower cut off may be chosen (e.g. 5th centile for both measures) to minimise the number of
women referred.
Large babies are at higher risk of dystocia6. In our
study, mean birthweight was higher in the
cephalopelvic disproportion group than in the group
having a normal delivery. Babies born to women who
had normal height and transverse diagonal and who
subsequently had a cephalopelvic disproportion (false
negatives) were larger. Conversely, babies born to
false positive women were smaller and thus the mothers might have been able to deliver normally despite
having a smaller pelvis. After addition of birthweight
in the logistic regression model, the association
between transverse diagonal and cephalopelvic disproportion remained high. Consequently, as birthweight
and fundal height are correlated2', it may be of great
interest to assess the prediction of cephalopelvic disproportion by fundal height and/or abdominal circumference measurement, in addition to external
pelvimetry and maternal height.
The results of our study should be validated prospectively in a separate cohort before implementing them in
routine practice. Acceptability of referral based on the
proposed model must also be evaluated. The advantage
of the proposed measurements are that only measurements that can be performed easily during a routine
antenatal visit by health workers, using a simple and
widely available measuring tape, are needed.
In conclusion measurements of maternal height and
the transverse diagonal of the Michaelis sacral rhomboid area using a measuring tape may represent a simple
method to detect nulliparous women at risk for
cephalopelvic disproportion. This method, after being
validated in other populations, may be very useful in
peripheral antenatal clinics to identify pregnant women
at risk for cephalopelvic disproportion and to refer them
to district hospitals before the onset of labour.

Acknowledgements
The authors would like to thank Drs J. E. Mboloko, J. K.
Kizonde, and D. Nk. Ndidwa, obstetricians at the

952 H . B. LISELELE ET AL.

maternity hospital of the University of Kinshasa. Local

medical staffs at Boende, Mbuji-Mayi and Mambasa are
greatly thanked for recruiting the participants. They
would also like to thank Drs D. Walker and S. Ako for
their help in editing the manuscript. Mr S. Meuris is a
research director from the Belgium National Fund for
Scientific Research.
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Accepted 1 March 2000

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