Accuracy of non-invasive methods for assessing the progress of labor in the first stage: a systematic review and meta-analysis

Abstract

Background: The World Health Organization in recent years has emphasized reducing the possibility of unnecessary interventions in natural childbirth, but little is known about the accuracy of non-invasive methods when assessing the progress of labor. This paper presents a literature review to assess strategies that support non-invasive methods for labor during the first stage. It evaluates the available evidence to provide the most suitable assessments and predictions that objectively identify the progress of low-risk labor during the first stage of labor.

Methods: A search for relevant literature was conducted using the electronic databases of PubMed, CINAHL, Web of Sciences, the Cochrane Library, Scopus, Medline (OVID), and CEPS, with publications up to November 2021. Records were screened against pre-specified inclusion/exclusion criteria and the potential papers from Google Scholar were examined to identify additional papers that may have been missed. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to appraise the methodological quality of the included studies. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Two independent investigators extracted the review's characteristics, and discrepancies were resolved by consensus. This review calculated individual and pooled sensitivity, specificity, and positive predictive values, which were exported to STATA (version 14; Stata Corp., College Station, TX) to represent the performance of diagnostic testing.

Results: Our search returned 2283 reports of which 13 fulfilled the inclusion criteria, accounting for 2594 women. The subjects were divided into groups according to the diagnostic tests used to assess the progress of their labor, including appearance assessment and sonographic imaging parameters (head perineum distance, HPD; angle of progression, AOP, and other parameters). HPD pooled sensitivity was 0.74 (0.65-0.82), and specificity was 0.77 (0.69-0.84). The pooled diagnostic odds ratio (DOR) was 8.21 (4.67-14.41) and 10.34 (5.02-21.27), respectively. The results of subgroup analysis showed that the summary sensitivity and specificity were of medium accuracy overall. The quality of evidence as assessed with GRADE was low.

Conclusion: Vaginal examination is an intrinsic element in the use of the partogram, while transperineal ultrasound can also be used as an auxiliary tool. However, the presence of publication bias within the parameters of ultrasound indicates that the diagnostic performance may be overestimated. Thus, randomized controlled trials or large-scale prospective cohort studies are necessary.

Keywords: Intrapartum ultrasound; Meta-analysis; Purple line; Sensitivity; Specificity; Systematic review; Vaginal examination.

Fig. 1

PRISMA 2020 Flowchart

Fig. 2

QUADAS-2 quality assessment of included studies

Fig. 3

The OSA, HPD, AOP, HD and HSD of ultrasound parameters. OSA, occiput-spine angle; HPD, head-perineum distance; AOP, angle of progression; HD fetal head direction; HSD, head symphysis distance

Fig. 4

HSROC curve for the diagnostic accuracy of HPD and AOP

Fig. 5

Forest plots for the diagnostic accuracy of HPD and AOP. DOR: diagnostic odds ratio; I2: percentage of total variation across studies due to heterogeneity rather than chance

Fig. 6

Deeks’ funnel plot of publication bias of HPD and AOP. ESS, effective sample size