Alternative Approach to Monitoring Labor: Purple Line

doi:10.21203/rs.3.rs-4809385/v1

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Research Article

Alternative Approach to Monitoring Labor: Purple Line

https://doi.org/10.21203/rs.3.rs-4809385/v1

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Background

This study was conducted to evaluate the effectiveness of the purple line, a method for assessing labor progress.

Methods

Data for this methodological study were collected from 304 pregnant women who presented to a maternity hospital for delivery on the Anatolian side of Istanbul between May and November 2021. Data collection included demographic information, partograph records, and measurements of the purple line. Women were followed via the partograph during active labor, with the purple line measured hourly via a disposable tape measure until delivery. Descriptive analyses, including means and standard deviations, medians and interquartile ranges, and receiver operating characteristic (ROC) curves, were conducted for data analysis.

Results

The mean age of the participating women was 27.74 (4.81) years, with a mean parity of 1.92 (1.12) and a mean gestational age of 39.05 (1.59) weeks at delivery. The purple line was observed in 85.9% of the women. Among all the women with the most common dilatation of 6 cm during labor, 85.9% had a visible purple line, with a specificity of 86% and sensitivity of 65%. The cut-off point was determined to be 9.5 cm. During the active phase of labor, the measurements of the purple line length in the sacral region increased proportionally with cervical dilatation. The sensitivity was 56%, and the specificity was 65% when the fetal head descent reached the − 2 level.

Conclusions

In conclusion, the purple line in the sacral region can be used as a noninvasive method to assess the course of labor and can be applied in clinical settings.

Purple Line

Labor Monitoring

Labor Progress

Partograph

Midwife

Approximately 140 million births occur worldwide every year, with more than four births occurring every second (1,2). A positive childbirth experience is important for every woman worldwide. The World Health Organization (WHO) defines a positive birth as an experience that espouses women's sociocultural beliefs and meets their expectations (3). A systematic review and meta-analysis of 20 studies involving 22,800 participants from twelve countries indicated that support during childbirth, preparation for childbirth, and minimal interventions during labor were the most important factors leading to a positive birth experience (4).

Women can perceive their childbirth experiences as positive or negative or have mixed emotions about them. Negative childbirth experiences are attributed to various factors, such as a lack of knowledge, inability to use decision-making mechanisms, media influences, deficiencies in healthcare facilities, behaviors of healthcare personnel, cultural beliefs, and negative childbirth narrations by family elders (2). However, it is crucial to monitor the progress of labor carefully and offer compassionate care during childbirth for a positive childbirth experience (5,6).

The progress of labor can be monitored via a series of signs and symptoms, including cervical dilatation, cervical effacement, and fetal descent, along with the observation and measurement of the purple line in the sacral region, respiratory rate, changes in behavior, sounds, and movements (7–11). Although various methods are available for monitoring the progress of labor, vaginal examination (manual examination) is predominantly preferred for evaluating cervical dilatation, cervical effacement, and fetal descent in clinical settings (7). Several studies have shown that monitoring cervical dilatation increases concerns about the decisions made and interventions performed during labor (8,12–15). Furthermore, vaginal examination is described as an unpleasant, intrusive, embarrassing, and discomforting experience for women (16–19). The frequency of vaginal examinations and lack of care during the procedure lead to pain, discomfort, anxiety, and negative emotions such as fear, embarrassment, guilt, and weakness among women, thereby reducing childbirth satisfaction (18). Women with a history of sexual violence and posttraumatic stress disorder experience more stress during vaginal examinations (19). Additionally, there is a positive relationship between the number of vaginal examinations and the risk of puerperal sepsis and genital tract infections (20).

In recent years, research has focused on the incorporation of objective, noninvasive, or less invasive methods into the monitoring of labor progress. Accurate assessment tools for the progress of labor are essential to reduce unnecessary interventions during childbirth. Noninvasive methods have been used to monitor the progress of labor to minimize interventions during childbirth (15). Intrapartum ultrasound is used to determine the degree of cervical dilatation, fetal head position, and descent. The World Association of Perinatal Medicine published guidelines and recommendations on the use of ultrasound during childbirth in 2022. These guidelines suggest that the use of intrapartum ultrasound is an easy, simple, and noninvasive method that can serve as an adjunct that can correlate with digital vaginal examination findings. A recent systematic review recommended sonographic assessment of various fetopelvic parameters as a new gold standard for predicting the progress of labor, but further research is needed to confirm this finding (15). Additionally, in recent years, the measurement of the purple line visualized in the sacral region of women, depending on ethnic origin and skin tone, has emerged as a different method for evaluating the progress of labor (14,17,21).

During the progression of labor, the fetal head generates intrapelvic pressure as it moves through the birth canal. This pressure leads to congestion in the sacral region, resulting in the appearance of a purple line. The purple line extends upwards from the anal region along the sacral region during the first and second stages of labor (21). The direction of this progression is upwards along the intergluteal line between the sacrococcygeal joint, akin to the movement of a mercury column in a thermometer (5,21–23). Research has revealed a relationship between the length of the purple line and both cervical dilatation and fetal descent (5,23).

It has been reported in the literature that the purple line emerges in 48% − 86.5% of women (21). In a study conducted in Iran, the sensitivity, specificity, and accuracy rates of the emergence and progression of the purple line during childbirth were reported to be 87.91%, 39.53%, and 85.25%, respectively (22). In another study, the purple line was observed in 56% of the women, and 81% of the women were not bothered by the purple line (17). In a study analysing the diagnostic value of the purple line, the purple line was observed in 75.3% of women during active labor, and its appearance predicted the progress of labor with a sensitivity of 90.2%, specificity of 45.3%, and positive predictive value of 88.1% (5). A systematic review based on data from six studies involving a total of 982 women revealed that the purple line was observed in 77.3% of the women. A moderate positive correlation was found between the length of the purple line and both cervical dilatation (r = + 0.64; 95% CI: 0.41–0.87) and fetal descent (r = + 0.50; 95% CI: 0.32–0.68). For women who underwent spontaneous or induced labor, the average length of the purple line was reported to be greater than 9.4 cm when the degree of cervical dilatation was 9–10 cm and greater than 7.3 cm when the degree of cervical dilatation was 3–4 cm. Consequently, this systematic review indicated that the purple line could be used as a noninvasive method for assessing the progress of labor (21).

In a Cochrane systematic review, uncertainty exists regarding which methods are most effective or acceptable for assessing the progress of labor, and more evidence about the assessment of the sacral purple line is needed (15). Although studies have focused on the appearance and length of the purple line for monitoring the progress of labor, more information is needed regarding its use in determining the degree of fetal descent and cervical dilatation during labor.

Therefore, this study aimed to evaluate the diagnostic accuracy of the length of the purple line in the sacral region for determining cervical dilatation and fetal descent as a method for monitoring the progress of labor. Answers to the following questions were sought in the study.

What is the frequency of the occurrence of the purple line during the first and second stages of labor?

What are the sensitivity and specificity of purple line measurements for determining the degree of cervical dilatation?

What are the sensitivity and specificity of purple line measurements to determine the degree of fetal descent?

Research Methodology

A methodological approach was adopted for the research design.

Study population and sample

The study population consisted of women who underwent vaginal delivery at a maternal hospital located on the Anatolian side of Istanbul in 2021 (N = 1531 deliveries). Convenience sampling was adopted, and the study sample comprised pregnant women presenting to hospital for delivery between May and November 2021, were willing to participate in the study, and were 38–42 weeks of gestation. On the basis of the reported frequency of occurrence of the purple line during childbirth in the literature (10), the sample size was calculated via the OpenEpi program at 95% confidence interval, resulting in 275 participants. Considering the risk of data loss, the sample size was increased by 10% to 304 participants to ensure data adequacy.

The inclusion and exclusion criteria for the study were having 38–42 weeks of gestation, being admitted to the delivery room with the onset of spontaneous labor and being in the active phase of labor (having at least 4 cm of cervical dilatation) without any psychological or physical discomfort.

Independent variables

Independent variables included sociodemographic characteristics; personal information, such as body mass index (BMI); cervical dilatation, measured in centimeters (cm) during labor; the position of the fetal head over the pelvic bones or through vaginal examination, and contraction intensity.

Dependent Variable

The dependent variable was the length of the purple line observed in the sacral region of the women during childbirth and measured in centimeters (cm).

Data collection instruments

Five data collection instruments were employed in the study: an informed consent form, a personal identification form, a partograph form for labor monitoring, a purple line tracking measurement tool, and a postpartum evaluation form.

Personal identification form

Developed by researchers on the basis of the literature (7,14,22), this form consists of 32 questions regarding sociodemographic characteristics such as age, education, income, and obstetric features, including pregnancy, delivery, miscarriage, and abortion.

Partograph Form for Labor Monitoring

The partograph, developed as an essential tool for monitoring and evaluating the progress of labor within the scope of evidence-based medical practices, records the progress of labor and fetal developments continuously and in detail, aiding in the early detection of abnormal conditions and the diagnosis of prolonged labor (24).

Sacral Purple Line Measurement Record Form

Developed by researchers in light of the literature (5,23), this form was utilized to record the presence of the purple line in the sacral region, measured in cm using a measuring tape at hourly intervals during labor. A paper measuring tape with intervals of cm was used as the measurement tool (Fig. 1).

Intrapartum Assessment Form

Developed by researchers on the basis of the literature (26,27), this form consists of 12 questions about the mode of delivery, interventions applied during childbirth, and Apgar score.

Data collection procedure

The research team comprised academic and clinical midwives. The pregnant women who met the inclusion criteria and agreed to participate in the study were provided with an informed consent form upon admission to the delivery room. The personal identification form was subsequently completed, and labor progress was monitored through the partograph form and the sacral purple line measurement record form at hourly intervals. Vaginal examination was performed by the attending midwife, and the measurement of the purple line was conducted by the researcher. Findings from the vaginal examination and the length of the purple line were recorded by individuals who were blinded to the groups. All the pregnant women were routinely monitored, and the findings were recorded in the partograph. The length of the purple line was measured by a researcher blinded to the vaginal examination findings. The purple line was tracked by the same researcher. Purple line tracking continued hourly until the completion of labor. Labour progress was monitored via the partograph form, with data recorded at a maximum of four-hour intervals to avoid unnecessary interventions. After the completion of labor, the postpartum assessment form was completed.

Data analysis

The obtained data were analysed via the Statistical Package for the Social Sciences. The normality of the data was assessed via the Kolmogorov‒Smirnov test. Descriptive statistical methods (frequency, percentage, mean, standard deviation) were utilized for data evaluation. Receiver operating characteristic (ROC) curve analysis and sensitivity and specificity tests were conducted to analyse the diagnostic accuracy of the purple line as a diagnostic tool in medicine. p ≤ 0.05 was considered statistically significant.

Ethical considerations

Ethical approval for the research was obtained from the Clinical Research Ethics Committee of Zeynep Kamil Women and Children’s Diseases Training and Research Hospital (approval number: 109; approval date: 05.05.2021). Written informed consent was obtained from the pregnant women in accordance with the Helsinki Declaration.

The mean age of the women in the study was 27.74 ± 4.81 years, and the mean duration of marriage was 4.74 (4.12) years. Among all the women, 49% were high school graduates, and 69.4% were employed. The mean age at first pregnancy was 24.51 ± 4.30 years, the mean number of pregnancies was 1.92 ± 1.12, the mean number of living children was 1.23 ± 1.08, and the mean gestational age at delivery was 39.05 ± 1.59 weeks (Table 1).

Table 1

The Distribution of the Women by their Sociodemographic and Obstetric Characteristics (n = 304)
Variables		n	%
Age	Mean (SD) = 27.74 (4.81)	304	100
Marriage Duration	Mean (SD) = 4.74 (4.12)	304	100
Education Status	Illiterate	9	3.0
	Primary School	25	8.2
	Middle School	64	21.1
	High School	150	49.3
	Undergraduate and above	56	18.4
Employment Status	Not working	93	30.6
Employment Status	Working	211	69.4
Education Status of Spouse	Illiterate	2	0.7
	Literate	8	2.6
	Primary School	32	10.5
	Middle School	66	21.7
	High School	131	43.1
	Undergraduate and above	65	21.4
Spouse's Employment Status	Working	300	98.7
Spouse's Employment Status	Not working	4	1.3
Social Security Status	Insured	287	93,1
Social Security Status	Uninsured	21	6.9
Income Status	Good	106	34.9
	Centre	194	63.8
	Bad	4	1.3
Body Mass Index	Weak (< 18.5)	22	7.2
	Normal (18.5–24.9)	165	54.3
	Overweight (25-29.9)	79	26.0
	Obese (> 30)	38	12.5
Smoking status during pregnancy	Yes	274	90.1
Smoking status during pregnancy	No	30	9.9
Alcohol Drinking During Pregnancy	Yes	2	0.7
Alcohol Drinking During Pregnancy	No	302	99.3
Exercise Status in Pregnancy	Yes	189	62.2
Exercise Status in Pregnancy	No	115	37.8
Number of Pregnancy	Mean (SD) = 1.92 (1.12)	304	100
Age at First Pregnancy	Mean (SD) = 24.51 (4.30)	304	100
Number of Living Children	Mean (SD) = 1.23 (1.08)	304	100
Pregnancy Week in Trauma	Mean (SD) = 39.05 (1.59)	304	100
Abortion Status	Yes	4	1.3
Abortion Status	No	300	98.7
Spontan Abortion Status	Yes	40	13.2
Spontan Abortion Status	No	264	86.8
Mode of Conception	Spontaneous	292	96.1
	Treatment	10	3.3
	Accidentally	2	0.7
Total		304	100.0

Evaluation of the Purple Line According to Cervical Dilatation

The purple line was present in 85.9% of the women throughout labor. The frequency of observing the purple line was 67.4% in the first stage of labor and 32.6% in the second stage (Table 2).

Table 2

Presence of a Purple Line according to the Stages of Labor
Variable		Phase One		Phase Two		Total
Variable		(n)	%	(n)	%	n	%
Purple Line Presence	Available	176	67.4	85	32.6	261	85,9
Purple Line Presence	None	21	48.8	22	51.2	43	14,1

Analyses of the sensitivity and specificity of the purple line when cervical dilatation was between 4 and 10 cm revealed that the highest sensitivity was 0.962 at 5 cm dilatation, and the highest specificity was 0.651 at 6 cm dilatation (Table 3 and Fig. 2).

As the degree of cervical dilatation increased, the cut-off value of the purple line also increased proportionally. The cut-off values were 3.5 cm at 4 cm, 8.5 cm at 5 cm, 9.5 cm at 6 cm, 10.5 cm at 7 cm, 8 cm, 11.5 cm at 9 cm, and 13.5 cm at 10 cm (Table 3).

Table 3

Diagnostic values of the measurement values of the length of the purple line in the progression of labor according to the degree of cervical dilatation
Cervical Dilatation	ROC Area	Standard Error	p	Occurrence of purple line		Sensitivity	Specificity	Purple line Cut-off Value (cm)
Cervical Dilatation	ROC Area	Standard Error	p	n	%	Sensitivity	Specificity	Purple line Cut-off Value (cm)
3 cm Dilatation	,558	,051	,222	5	1.6	-	-	1.5
4 cm Dilatation	,713	,049	,0001	166	54.6	0,916	0,488	3.5
5 cm Dilatation	,969	,010	,0001	192	63.1	0,962	0,419	8.5
6 cm Dilatation	,775	,045	,0001	261	85.9	0,858	0,651	9.5
7 cm Dilatation	,733	,048	,0001	252	82.8	0,904	0,512	10.5
8 cm Dilatation	,737	,048	,0001	248	81.5	0,889	0,558	10.5
9 cm Dilatation	,642	,052	,003	233	76.6	0,927	0,326	11.5
10 cm Dilatation	,756	,046	,0001	197	64.8	0,881	0,605	13.5
p < 0.05, *p < 0.001

Evaluation of the Purple Line According to Fetal Head Descent

In the first stage of labor, the relationship between the sacral purple line length and the descent level of the fetal head was examined. When the fetal head descent was at level + 2, the average purple line length was greater than that at levels − 3, -2, and − 1. There was no significant correlation between fetal head descent at levels − 3 and + 2 and purple line length. However, a significant correlation was found between purple line length and fetal head descent at levels − 2, -1, 0, and + 1 (Table 4 and Fig. 3).

Table 4

Mean Purple Line Lengths and their Correlations with Fetal Head Descent Levels in Labor Progression
Fetal head descent	Purple Line Length				Pearson correlation coefficient
Fetal head descent	n	\(\:\stackrel{-}{\varvec{X}}\)	SS	Min- Max	Pearson correlation coefficient
-3	43-(32 − 11)	9.96	1.53	7.00–13.00	r = 1 -
-2	147 (116 − 31)	8.90	1.36	5.00–12.00	r = 0.488 p < 0.001
-1	157 (141 − 16)	8.89	1.31	6.00–12.00	r = 0.643 p < 0.001
0	157	8.40	0.93	5.00–10.00	r = 0.791 p < 0.001
1	44	8.0	0.00	8.00–8.00	r = 0.846 p < 0.001
2	18	12.5	1.00	12.00–14.00	r:1 -
*Min: minimum, Max: maximum

To determine the sensitivity and specificity of the purple line presence according to fetal head descent level, a value deemed significant (p < 0.05) was observed at the head level of -1, with a sensitivity of 0.563 and a specificity of 0.652 (Table 4, Table 5).

Table 5

Diagnostic values of the measurement values of the length of the purple line in the progression of labor according to the level of head descent
Fetal Head Descent	Fetal Head Descent	Fetal Head Descent	p	Occurrence of purple line		Sensitivity	Specificity	Purple line Cut-off Value (cm)
Fetal Head Descent	Fetal Head Descent	Fetal Head Descent	p	n	%	Sensitivity	Specificity	Purple line Cut-off Value (cm)
-3	,436	,093	,531	32	10.5	1,000	,875	3.6
-2	,493	,058	,924	141	46.4	1,000	,730	4.7
-1	,335	,073	,030	141	46.4	,563	,652	5.6
0	,313	,073	,221	40	13.2	1,000	,750	5.5
1	,111	,080	,009	12	4.0	1,000	1,000	3
2	-	-	-	-	-	-	-	-

This study was conducted to evaluate the diagnostic accuracy of the length of the purple line in the sacral region as a method for monitoring the progression of labor in determining cervical dilatation and the descent of the fetal head. The purple line was found to have diagnostic accuracy in determining dilatation, and at 4–10 cm dilatation, its lowest sensitivity and specificity were 0.858 and 0.326, respectively. It was also shown to have diagnostic accuracy in determining fetal head descent, and at a fetal head descent of -1, its sensitivity and specificity were 0.563 and 0.652, respectively. These findings suggest that the presence of a purple line may be considered an alternative to vaginal examination for evaluating cervical dilatation and descent of the head.

In this study, the purple line was detected in 67% of the women in the first stage of labor and 85% of the women in the second stage, with an overall detection rate of 85.9% for the entire active phase of labor. The purple line has been reported in 56%-85.9% of women during the active phase of labor (5,10,17,22,23,28). In a systematic review, the accuracy of the purple line length for monitoring labor progression was reported to be 81%-85%, potentially identifying more than 80% of women undergoing normal labor (29). These findings indicate that the purple line commonly appears during the active phase of labor.

In the present study, an analysis was conducted to determine the sensitivity and specificity of the purple line length for detecting cervical dilatation between 4–10 cm, with the highest sensitivity of 0.962 at 5 cm dilatation and the highest specificity of 0.651 at 6 cm dilatation. In a study by Farrag and Eltohamy, the appearance of the purple line during labor monitoring had a sensitivity of 87.91%, specificity of 39.53%, and accuracy of 85.25% (22). In the study by Kordi et al., the sensitivity and specificity of the purple line in women during the active phase of labor ranged from 68.57–87.91% and from 42.66–39.53%, respectively, with the purple line being more prominent in women with lighter skin tones than in those with darker skin tones (28). The sensitivity and specificity values above 0.60 in this study indicate the potential diagnostic utility of the purple line in labor progression. The high sensitivity identified in this study can be explained by the fact that all the participating women were Caucasian. Additionally, no studies have evaluated the sensitivity and specificity of purple line appearance in relation to the cervical dilatation length in centimeters. In fact, prior studies have focused on the overall appearance of the purple line.

In this study, the mean purple line length was 9.96 ± 1.53 at a fetal head descent of -3, 8.90 ± 1.36 at a fetal head descent of -2, 8.89 ± 1.31 at a fetal head descent of -1, 8.40 ± 0.93 at a fetal head descent of 0, 8 ± 0 at a fetal head descent of + 1, and 12.5 ± 1 at a fetal head descent of + 2. Unlike this study, Irani et al.’s study evaluating fetal head and purple line length revealed that the total purple line length was correlated with fetal head position, with mean values of 86.52 ± 23.61 at the − 3 level, 93.97 ± 20.7 at the − 2 level, 99.21 ± 24.21 at the − 1 level, 108.25 ± 19.27 at the 0 level, and 110.82 ± 16.84 at the + 1 level (7).

In this study, the analysis conducted to determine the sensitivity and specificity of the presence of the purple line in determining fetal head descent revealed that it had diagnostic value when head descent was − 1, with a sensitivity of 0.563 and specificity of 0.652. These results may indicate a moderate diagnostic value of purple line length in determining fetal head descent. However, the diagnostic value of the purple line at the − 3 and + 2 levels could not be interpreted. Positive correlations between fetal head descent at all levels and purple line length have been reported in the literature (7, 23). The correlation of purple line length with fetal head descent of -2, -1, 0, and + 1 and the lack of correlation of purple line length with fetal head descent of -3 and + 2 can be explained by increased pressure on the sacrum when the fetal head is at levels 2, -1, 0, and + 1, enhancing the visibility of the purple line.

Limitations of the Study

There are several limitations of this study. First, measurements and evaluations of cervical dilatation, fetal head descent, and the purple line may vary depending on the individual conducting the measurements. In this study, to minimize bias arising from the measurement process, all measurements were performed by the same researcher. The evaluation of the purple line was conducted on the basis of each degree of cervical dilatation and fetal head descent. However, prior studies have not revealed any results that are consistent with or conflicting with these findings. The data on the presence and length of the purple line in this study may have been influenced by the maternal pelvic bone measurements and the size of the fetal head. This highlights the need for studies evaluating the variation in the purple line according to pelvic bone and fetal head measurements.

Conclusion and recommendations

This study showed that the probability of observing the purple line is high, with moderate to high levels of diagnostic value for detecting cervical dilatation and moderate diagnostic value for detecting fetal head descent.

On the basis of these results, it can be recommended that as a noninvasive alternative method, the purple line should be used to determine the cervical dilatation level during labor surveillance in clinical practice. It can also be taught in undergraduate and in-service training programs for monitoring labor progression, thereby contributing to the improvement of positive birth experiences. Moreover, policies could be developed to integrate the use of the purple line for labor monitoring under midwifery leadership in maternity units. Additionally, further studies should focus on evaluating the satisfaction of women, maternal and neonatal outcomes, usability, and effectiveness of purple line-guided deliveries.

Ethics approval and consent to participate: Ethical permissions for the research were obtained from the Zeynep Kamil Women and Children Diseases Training and Research Hospital Clinical Research Ethics Committee (Decision:109, Date: 05.05.2021). In accordance with the Helsinki Declaration, informed consent forms were obtained from the pregnant women participating in the research. All participants were fully informed of the purpose and methods of the trial and signed informed consents.

Consent for publication: Not applicable.

Availability of data and materials: The data that support the findings of this study are available from [Tuğba Yılmaz Esencan]. Research data supporting this publication are available from the TUBITAK ULAKBIM on the aperta website with https://doi.org/10.48623/aperta.273792.

Data Access Statement: Demir Yıldırım, A., Yılmaz Esencan, T., & Ata, B. (2024, 31 July). Alternative Approach to Monitoring Labour: Purple Line. doi:10.48623/aperta.273792.

Competing interests: The authors declare no competing interests.

Conflict of Interest: Authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding: This research received no specific grants from any funding agency in the public, commercial or non-profit sectors.

Authors' contributions: A.D.Y. designed the study, A.D.Y. and T.Y.E. conducted literature searches and provided summaries of previous research studies. A.D.Y. conducted the statistical analysis. T.Y.E., A.D.Y., B.A. wrote the first draft of the manuscript and all authors contributed to and approved the final manuscript.

Acknowledgements: We would like to express our deep gratitude to Prof. Dr. Zekiye KARAÇAM, Midwife Betül Engin, Midwife Sena Nur Karadeniz, Midwife Döne Abbasoğlu, Midwife İpek Yıldız and Midwife Mervenur Kasap for her valuable contributions to the preparation of this article. Prof. Dr. Zekiye KARAÇAM made significant contributions throughout the process with her valuable technical assistance, guidance, and support, greatly enhancing the quality of our study. The authors would like to thank all the women who participated in the study.

Authors' information

Authors and Affiliations

Ayça DEMİR YILDIRIM, CM, DM, Ph.D., Department of Midwifery, Faculty of Health Sciences, Uskudar University, Istanbul, Turkey. Orcid: 0000-0001-8385-3954, [email protected].

Tuğba YILMAZ ESENCAN, CM, DM, Ph.D., Department of Midwifery, Faculty of Health Sciences, Uskudar University, Istanbul, Turkey. Orcid:0000-0002-8748-0793, [email protected].

Büşra ATA, CM, Master’s Student, Department of Midwifery, Faculty of Health Sciences, Uskudar University, Istanbul, Turkey. Orcid: 0000-0003-3013-5670, [email protected].

Corresponding author: Tuğba Yılmaz Esencan

Address: Department of Midwifery, Faculty of Health Sciences, Uskudar University, Istanbul, Turkey.Tel.: +905057084946, E-mail: [email protected].

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No competing interests reported.

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Alternative Approach to Monitoring Labor: Purple Line

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Abstract

Background

Methods

Results

Conclusions

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Background

METHOD

Research Methodology

Study population and sample

Data collection instruments

Data collection procedure

Data analysis

Ethical considerations

RESULTS

Evaluation of the Purple Line According to Cervical Dilatation

Evaluation of the Purple Line According to Fetal Head Descent

DISCUSSION

Limitations of the Study

Conclusion and recommendations

Declarations

References

Additional Declarations

Supplementary Files

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Version 1