ABSTRACT Cephalopelvic disproportion (CPD) is a common and serious obstetric condition, especially in sub-Saharan Africa. Recognition relies on clinical observations, such as cervical dilatation, head descent, moulding, and size of fetus, all made in a trial of labour. No prospective studies have investigated intrapartum clinical observations and their predictive value for CPD. The objectives of this research were 1) to determine the association of intrapartum clinical findings, especially level of head and moulding, with the outcome of CPD, 2) to determine inter-observer agreement of these findings between clinicians, and 3) to compare intrapartum clinical palpation with symphysis-fundal height (SFH) measurement in the prediction of birth weight. A prospective cross-sectional comparative study was done in the Chris Hani Baragwanath labour ward, a large referral centre. The subjects were women at term, in the active phase of labour, with vertex presentations. The author, blinded to previous clinical or ultrasound findings, performed clinical assessments at the same time as the women’s attending clinicians. His observations were not divulged to the clinicians and he did not participate in obstetric management of the women. The primary outcome measures were CPD, defined as caesarean section for poor progress, and birth weight. Five hundred and eight women were examined, of whom 113 (22.2%) had CPD. Multivariate analysis identified short maternal stature, increased SFH, lesser cervical dilatation, long duration of labour, high degree of parieto-parietal moulding, and high degree of caput succedaneum as independent predictors for CPD. Fetal position and occipito-parietal moulding were not predictive, and level of head, by fifths and by station, was poorly predictive. Inter-observer agreement between the author and attending clinicians was moderate for cervical dilatation, engagement of the head in fifths, and caput succedaneum, and poor for engagement of the head by station. SFH measurement was a slightly better predictor of birth weight than clinical fetal weight estimation. The clinical observations that were shown to be predictive for CPD may be useful adjuncts in the management of a trial of labour. Inter-observer agreement of these findings is at best moderate. Measurement of SFH deserves more attention as an intrapartum predictor of birth weight.

Females of childbearing age are overrepresented in the population of the Kellis 2 cemetery (100-450 AD) in the Dakhleh Oasis, Egypt (Wheeler 2009). The demographic overrepresentation found here may be the result of complications related to childbirth. Clinical literature demonstrates that fetal size is rarely an explanation for failed labor (Cunningham et al. 2001) and the fetuses buried in the Kellis 2 Cemetery at the Dakhleh Oasis were not larger than average (Tocheri et al. 2005), directing the focus to dimensions of the maternal pelvis for evidence of obstetrical issues, such as abnormally compressed pelvises. To formulate a test for this hypothesis, a total of 50 adults, 24 of which are female, were examined for this study. The sample consisted of individuals from an archaeological population from the Dakhleh Oasis, Egypt as well as from six populations housed in the American Museum of Natural History (NYC). These include archaeological populations from the sites of El Hesa and Sai Island in the Sudan, also South Africa, Nubia, and India, as well as a medical collection from North America. Pelvic dimension and asymmetry was determined through nine measurements of the pelvis and sacrum. Kruskal-Wallis tests were used to analyze variance and assess whether the younger females in this group may have been at a higher risk of death during childbirth due to fetal-pelvic disproportion. Mann-Whitney-Wilcoxan nonparametric tests were used to assess differences in asymmetry in young and old groups. A MANOVA test assessed overall variation in the population. Results indicate significant differences between young and old females in pelvic outlet anteroposterior diameter, a measure of midpelvic contraction, as young females had smaller pelvic outlet anteroposterior diameters. There were also significant differences between iv young and old females in alar-pubis length asymmetry; the young females were more asymmetric. These differences were not found in the male groups. It is suggested that these differences could impact childbirth as a contracted midpelvis, such as that found in the young female group, can cause transverse arrest of the fetal head (Cunningham et al. 2010) and pelvic asymmetry can contribute to obstetrical complications (Campbell et al. 2011).