Cervical dilatation at diagnosis of active phase of labour determines the mode of delivery and peripartum outcomes: a retrospective study in a single tertiary centre in Malaysia

(2023) 23:221 Rosli et al. BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-023-05523-7 BMC Pregnancy and Childbirth Open Access RESEARCH Cervical dilatation at diagnosis of active phase of labour determines the mode of delivery and peripartum outcomes: a retrospective study in a single tertiary centre in Malaysia Anizah Aishah Rosli1,2, Azmawati Mohd Nawi3, Ixora Kamisan Atan1,2, Aida Mohd Kalok1,2, Shuhaila Ahmad1,2*, Nor Azlin Mohamed Ismail1,2, Zaleha Abdullah Mahdy1,2 and Rahana Abd Rahman1,2 Abstract Background There is an increasing trend of Caesarean section rate in Malaysia. Limited evidence demonstrated the benefits of changing the demarcation of the active phase of labour. Methods This was a retrospective study of 3980 singletons, term pregnancy, spontaneous labouring women between 2015 and 2019 comparing outcomes between those with cervical dilation of 4 versus 6 cm at diagnosis of the active phase of labour. Results A total of 3403 (85.5%) women had cervical dilatation of 4 cm, and 577 (14.5%) at 6 cm upon diagnosis of the active phase of labour. Women in 4 cm group were significantly heavier at delivery (p = 0.015) but significantly more multiparous women were in 6 cm group (p < 0.001). There were significantly fewer women in the 6 cm group who needed oxytocin infusion (p < 0.001) and epidural analgesia (p < 0.001) with significantly lower caesarean section rate (p < 0.001) done for fetal distress and poor progress (p < 0.001 both). The mean duration from diagnosis of the active phase of labour until delivery was significantly shorter in the 6 cm group (p < 0.001) with lighter mean birth weight (p = 0.019) and fewer neonates with arterial cord pH < 7.20 (p = 0.047) requiring neonatal intensive care unit admissions (p = 0.01). Multiparity (AOR = 0.488, p < 0.001), oxytocin augmentation (AOR = 0.487, p < 0.001) and active phase of labour diagnosed at 6 cm (AOR = 0.337, p < 0.001) reduced the risk of caesarean delivery. Caesarean delivery increased the risk of neonatal intensive care admission by 27% (AOR = 1.73, p < 0.001). Conclusions Active phase of labour at 6 cm cervical dilatation is associated with reduced primary caesarean delivery rate, labour intervention, shorter labour duration and fewer neonatal complications. Keywords 4 cm, 6 cm, Cervical dilatation, Active phase of labour, Caesarean section *Correspondence: Shuhaila Ahmad Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rosli et al. BMC Pregnancy and Childbirth (2023) 23:221 Page 2 of 7 Background Management of labour is challenging and as a result, partogram was created to guide obstetricians towards safe labour management [1]. Various training and labour protocols use Friedman’s original partogram. A normal labour is characterised by the latent phase which has a nearly flat slope and it is not related to the remaining part of labour. Accelerated cervical dilatation follows with major changes seen within 3.5 to 8.5 cm. However, it is important to diagnose arrested labour accurately as it may lead to unnecessary caesarean delivery (CD). World Health Organization (WHO) had set the optimal rate for CD at 10–15% rate of all births [2]. Over the decades, there is a rising trend of CD rate worldwide, including Malaysia. Karalasingam et al. reported increasing caesarean delivery rate from 21.8 to 25.3% from 2011 to 2015 [3]. The Robson criteria that was used to classify the births showed an increasing trend of CD amongst nulliparous and multiparas women at term in spontaneous labour. Although various attempts were made to reduce the CD rate, there has not been a tremendous reduction seen, most likely due to multiple factors. The decision for CD depends on the practice of different centres and individual obstetricians. This gives rise to a wide variation in the CD rate even for Malaysia [3]. In recent years, researchers had challenged the Friedman’s labour curve and partogram. Advancement in choice of painkillers, characteristics of labouring women and management methods contributed to the need in revising the partogram. In 2002, due to the difference in labour management particularly in the oxytocin use and epidural analgesia Zhang et al. had proposed a gradual transition from latent to active phase of labour. This is in contrast to the Friedman curve. It takes longer for the cervical os to progress from 4 cm to full dilatation of 10 cm. On the other hand, the rate of cervical dilatation doubled after 5 cm [4]. The median duration of labour prior to 6 cm was similar between nullipara and multipara women. Subsequently, multiparas progress faster than the nulliparas [5]. In view of these findings, the objective of this study is to compare the maternal and neonatal outcomes between women diagnosed in active phase of labour at 4 versus 6 cm cervical dilatation. data was extracted from the labour room central management system. The inclusion criteria were all pregnant women at and above 18 years old, singleton pregnancy with cephalic presentation admitted in spontaneous labour at 37 weeks gestation or more with cervical dilation of 4 and 6 cm with or without intact membranes. The exclusion criteria were medical disorders such as diabetes and hypertension, fetal complications such as small for gestational age, fetal growth restriction, oligohydramnios, polyhydramnios, patients who had labour induction and previous uterine scars. In our centre, women who achieved 4 cm or more would be sent to labour room according to the hospital protocol. Amniotomy is performed by the doctors if the membranes are still intact. This is followed by oxytocin infusion to augment labour when the contractions are not optimised after 2 h. We analysed information on maternal demographic and clinical characteristics such as maternal age, ethnicity, maternal weight at delivery, parity and gestational age at delivery, intr (...truncated)