3. Evidence and recommendations
3.2 First stage of labour
3.2.5 Clinical pelvimetry on admission RECOMMENDATION 11
3. EVIDENCE AND RECOMMENDATIONS
3.2.5 Clinical pelvimetry on admission
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
Perinatal mortality: Evidence for this outcome is of very low certainty due to few events, study limitations and indirectness.
Additional considerations
Clinical pelvimetry involves a digital examination of the internal aspect of the bony pelvis, which may be very uncomfortable for the woman, particularly when she is experiencing labour pains (108).
However, the review did not evaluate any maternal experiences associated with this procedure.
A higher caesarean section rate in the absence of evidence of benefits on other outcomes is undesirable in view of the potential additional morbidity and increased health care costs associated with caesarean section.
The diagnostic accuracy of clinical pelvimetry is uncertain; however, findings from some observational studies suggest that it might help to predict cephalo-pelvic disproportion among nulliparous women in some low-resource settings with limited access to caesarean section and a need for timely referral to a higher-level facility (109, 110).
Values
Findings from a review of qualitative studies looking at what matters to women during intrapartum care (23) indicate that most women want a normal childbirth with good outcomes for mother and baby, but acknowledge that medical intervention may sometimes be necessary. Most women, especially those giving birth for the first time, are apprehensive about childbirth (high confidence in the evidence) and of certain interventions. Where interventions are introduced, women would like to receive relevant information from technically competent health care providers who are sensitive to their needs (high confidence in the evidence).
Additional considerations
Based on the findings of the review presented above, women might be unlikely to appreciate this medical intervention if it increases the chance of caesarean section without improving birth outcomes.
Resources
No review evidence on resource requirements or cost-effectiveness was found.
Additional considerations
The main cost of this intervention is staff time and, while the procedure itself may only take minutes, time is also required to counsel the woman on the reason for digital examination, to obtain her consent, and to explain the findings afterwards.
As the intervention could lead to increased risk of caesarean section without improving substantive perinatal outcomes, it is unlikely to be cost-effective.
Equity
No direct evidence on the impact of clinical pelvimetry on equity was found. However, indirect evidence from a review of barriers and facilitators to facility-based birth indicates that digital vaginal examinations by health workers in facilities, which are perceived by women to be uncomfortable and dehumanizing, are an important barrier to the uptake of facility-based birth by marginalized women in LMICs (high confidence in the
evidence) (8).
Additional considerations
Based on the indirect evidence above, clinical pelvimetry, which can be more uncomfortable than a standard pelvic examination for assessment of progress of labour, could deter disadvantaged women from giving birth in a facility and further reduce equity. In addition, given that pelvimetry might increase the use of caesarean section in privileged women assessed as having a contracted pelvis, disadvantaged women with similar findings may not be able to receive similar levels of care, even when medically indicated.
Acceptability
There is no specific evidence on clinical pelvimetry from the qualitative systematic review on women’s and providers’ experiences of intrapartum care.
Table 3.22 Main resource requirements for clinical pelvimetry
Resource Description
Training Practice-based training on how to perform clinical pelvimetry Supplies Supplies for standard digital pelvic examination
Equipment None
Staff time Time to counsel women, obtain their consent and perform the procedure Supervision and
monitoring Monitoring by the labour ward/clinic/facility lead as part of regular quality of care audit/
review
3. EVIDENCE AND RECOMMENDATIONS
However, general findings on women’s experiences suggest that women would rather avoid medical interventions unless their baby is at risk (high confidence in the evidence) (26). In addition, where an intervention is required, women would like to be informed about the procedure and treated by sensitive, kind and technically competent staff (high confidence in the evidence).
Additional considerations
Women may welcome a pelvic examination by the care provider, which provides reassurance about their chances of given birth vaginally. However, they may not readily accept clinical pelvimetry if the findings are likely to preclude them from undergoing a trial of labour, or heighten their fears of adverse events during labour.
Feasibility
There is no specific evidence on clinical pelvimetry from the qualitative systematic review on women’s
and providers’ experiences of intrapartum care (26).
However, general findings on providers’ experiences suggest that providers in certain contexts
(particularly LMICs) may lack the time, training and/
or resources to routinely perform clinical pelvimetry for all women presenting in labour (high confidence in the evidence).
Additional considerations
Clinical pelvimetry requires specific experience and expertise to examine with high certainty the internal diameters of the maternal pelvis in correlation with the size of the fetal head, to assess the likelihood of cephalo-pelvic disproportion during labour.
This expertise is generally limited to higher-level hospitals, experienced midwives and obstetricians, and may not be readily available in lower-level hospitals and resource-limited settings.
Table 3.23 Summary of judgements: Clinical pelvimetry compared with no clinical pelvimetry
Desirable
effects ✓
Don’t know –
Varies –
Trivial –
Small –
Moderate –
Large Undesirable
effects –
Don’t know –
Varies –
Large –
Moderate ✓
Small –
Trivial Certainty of
the evidence –
No included studies
Very low✓ –
Low –
Moderate –
High
Values –
Important uncertainty or
variability
Possibly ✓ important uncertainty or
variability
Probably no – important uncertainty or
variability
No important – uncertainty or variability Balance of
effects –
Don’t know –
Varies –
Favours no pelvimetry
Probably ✓ favours no pelvimetry
Does not – favour pelvimetry or no pelvimetry
Probably – favours pelvimetry
Favours – pelvimetry
Resources
required –
Don’t know –
Varies –
Large costs –
Moderate costs
✓ Negligible
costs or savings
Moderate – savings
Large savings–
Certainty of evidence of required resources
No included ✓ studies
Very low– –
Low –
Moderate –
High
Cost-effectiveness –
Don’t know –
Varies –
Favours no pelvimetry
Probably ✓ favours no pelvimetry
Does not – favour pelvimetry or no pelvimetry
Probably – favours pelvimetry
Favours – pelvimetry
Equity –
Don’t know –
Varies –
Reduced ✓
Probably reduced
Probably no – impact
Probably – increased
Increased–
Acceptability –
Don’t know ✓
Varies –
No –
Probably No –
Probably Yes –
Yes
Feasibility –
Don’t know ✓
Varies –
No –
Probably No
-Probably Yes –
Yes
WHO RECOMMENDATIONS: INTRAPARTUM CARE FOR A POSITIVE CHILDBIRTH EXPERIENCE
3.2.6 Routine assessment of fetal well-being on