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OBSTETRICS
ternal obesity is associated with cesarean delivery and decreased contraction strength in the first stage of labor.
eandeliverythannormal-weightwomen(oddsratio,2.4;95%confidenceinterval, 1.93.1), they were equally able to achieve Montevideo units of 200.
Among women with a vaginal delivery, obese women had a longer first stage of
labor compared with normal-weight women (597 vs 566 min; P .003).
STUDY DESIGN: We studied a retrospective cohort of women who delivered within a single healthcare system from 2007-2009; we included
5410 women with an intrauterine pressure catheter during the last 2
hours of the first stage of labor and who either had a vaginal delivery or
cesarean delivery for dystocia. Logistic regression was used to determine how body mass index was associated with cesarean delivery or
mean Montevideo units of 200.
CONCLUSION: Obese women have longer labors but are equally able to
Cite this article as: Chin JR, Henry E, Holmgren CM, et al. Maternal obesity and contraction strength in the first stage of labor. Am J Obstet Gynecol
2012;207:129.e1-6.
besity is an epidemic in many developed countries. More than onethird of all women in the United States are
obese (body mass index [BMI], 30 kg/
m2),1 with approximately 1-in-5 being
obese at the onset of pregnancy.2 Maternal
obesity is associated with multiple labor
abnormalities that include increased risks
for induction of labor, postdates preg-
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women had 1 indication listed for their
CD (for example, arrest of dilation and
non-reassuring tracing). If one of the indications was dystocia as defined earlier,
then they were placed in the dystocia category for the purposes of analysis.
Women with no recorded indication for
CD and women with a listed indication
of cord prolapse, malpresentation, compound presentation, or marginal previa
were excluded.
Measures
The primary predictor was prepregnancy BMI category that was defined in
the following manner: normal weight
(BMI, 25 kg/m2), overweight (BMI,
26-30 kg/m2), or obese (BMI, 30 kg/
m2). Prepregnancy BMI was calculated
on the basis of self-reported prepregnancy weight and height at the time of
admission to Labor and Delivery. The
primary outcome variables were CD and
mean MVUs of 200 (typically considered adequate in clinical practice) in the
last 2 hours of the first stage of labor (2
hours preceding complete dilation for
women with a VD and 2 hours preceding
delivery for women with a CD). When
prompted, a computer algorithm calculates MVUs over a 10-minute period.
These MVU values are then recorded
electronically by nurses. Variables that
were evaluated as potential confounders
of the association between prepregnancy
BMI and CD were maternal age, parity,
induction of labor, gestational age, admission cervical dilation, excessive GWG
as defined by Institute of Medicine 2009
criteria,19 and infant birthweight. In addition to these variables, maximum oxytocin
dosage in the last 2 hours of the first stage of
labor was included as a potential confounder when we evaluated the association
between BMI and mean MVUs.
Statistical analysis
One-way analysis of variance or the nonparametric Kruskal-Wallis test was used
in bivariate analyses. To evaluate for
potential colinearity among predictors,
correlation coefficients were calculated.
Multivariable logistic regression was
used first to determine how prepregnancy BMI category was associated with
CD. Logistic regression was then used to
determine how prepregnancy BMI category was associated with mean MVUs of
200 in the last 2 hours of the first stage
of labor. Because women who ultimately
had a CD may have had a more dysfunctional labor course than those with a VD
and because the phase of labor during
which MVUs were recorded would differ
for women with a CD vs VD, this analysis
was stratified by mode of delivery. We
hypothesized that women whose only indication for CD was dystocia (ie, not also
including nonreassuring tracing) represent a group for which clinicians would
be particularly aggressive in trying to
achieve adequate MVUs. For this reason,
we performed a subanalysis of the association of BMI with MVUs among this
group.
The logistic regression models are
summarized by odds ratios (ORs) with
corresponding 95% confidence intervals
(CIs). All statistical tests used a 2-sided
alpha of .05. Analysis was performed
with SAS software (version 9.2; SAS Institute Inc. Cary, NC).
R ESULTS
From a total of 69,857 women who delivered at these 10 hospitals during the
study period, 7611 women were identified who had a term singleton gestation
that resulted in a VD or primary CD in
the first stage of labor and who had an
IUPC during the last 2 hours of the first
stage of labor. Three women with no
listed indication for CD, 6 women who
had a listed indication of cord prolapse,
malpresentation, compound presentation, or marginal previa, and 443 women
who had a listed indication of a major
fetal anomaly, chorioamnionitis, or preeclampsia that required magnesium sulfate treatment were excluded. After additional exclusions for potential coding
errors (as described earlier), a total of
5410 women were included in the analysis (VD, 4772; CD in the first stage of
labor, 638). Most of the women (n
509; 79.8%) who had a CD had a recorded indication classified in the dystocia category. Four hundred ten women
who had a CD had only a dystocia indication. Two thousand eight hundred
eighteen of the women (52.1%) were
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Research
TABLE 1
Normal weight
Overweight
25.8 5.0
Obese
26.6 5.2
27.3 5.3
P value
.0001
................................................................................................................................................................................................................................................................................................................................................................................
Nulliparous, n (%)
1620 (57.5)
707 (50.6)
535 (44.8)
Parous, n (%)
1198 (42.5)
691 (49.4)
659 (55.2)
1444 (51.2)
824 (58.8)
735 (61.6)
1374 (48.8)
574 (41.1)
459 (38.4)
.0001
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
.0001
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
a
Infant birthweight, g
3359.4 416.3
1153 (40.9)
3430.1 429.4
3443.6 425.2
.0001
................................................................................................................................................................................................................................................................................................................................................................................
952 (68.1)
719 (60.2)
.0001
................................................................................................................................................................................................................................................................................................................................................................................
a
2.4 1.3
2.4 1.3
2.3 1.3
.44
Gestational age, wk
39.1 1.1
39.1 1.1
39.0 1.1
.08
................................................................................................................................................................................................................................................................................................................................................................................
a
................................................................................................................................................................................................................................................................................................................................................................................
277 (9.8)
171 (12.2)
190 (15.9)
.001
................................................................................................................................................................................................................................................................................................................................................................................
a
TABLE 2
Predictor
Vaginal delivery,a
OR (95% CI)
.....................................................................................................................................................................................................................................
1.76 (1.112.81)
1.16 (0.981.37)
1.12 (0.731.73)
1.08 (0.931.26)
0.79 (0.690.90)
0.87 (0.840.90)
1.31 (0.842.06)
1.03 (0.891.20)
0.87 (0.741.03)
0.79 (0.740.84)
0.96 (0.821.11)
1.00 (0.941.07)
0.98 (0.941.01)
0.96 (0.950.98)
.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
1.10 (0.661.81)
1.07 (0.931.23)
0.85 (0.591.21)
0.67 (0.590.77)
1.11 (0.981.27)
0.86 (0.820.90)
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
BMI, body mass index; CI, confidence interval; OR, odds ratio.
a
Deliveries that were included in the final models because of missing data for some predictor variables. Cesarean delivery, 623
women; vaginal delivery, 4675 women.
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TABLE 3
Normal weight
Overweight
Obese
P value
Vaginal (n 4772)
.......................................................................................................................................................................................................................................................................................................................................................................
a
Stage 1, min
566.1 (421.5760.4)
585.9 (423.0788.9)
597.2 (454.0794.0)
Stage 2, min
42.7 (20.893.1)
37.1 (16.383.0)
30.5 (16.071.4)
.0001
.0030
Nulliparous
80.9 (46.6130.0)
80.5 (49.1132.0)
81.0 (46.2126.3)
.69
Parous
21.0 (12.034.5)
18.8 (11.133.6)
19.7 (10.732.3)
.06
.......................................................................................................................................................................................................................................................................................................................................................................
a
b
..............................................................................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
Cesarean (n 638)
.......................................................................................................................................................................................................................................................................................................................................................................
c
Final dilation, cm
5.5 2.0
5.4 2.0
5.5 1.9
.90
.......................................................................................................................................................................................................................................................................................................................................................................
a
Stage 1, min
823.2 (651.01051.8)
895.8 (664.01126.8)
835.0 (625.21164.0)
.55
................................................................................................................................................................................................................................................................................................................................................................................
a
Data are given as median (25-75% interquartile range); No longer significant when stratified by parity; Data are given as mean SD.
b
C OMMENT
Similar to other studies, we found that
the risk for CD among overweight and
obese women increased in a dose-dependent manner. We were then able to analyze contraction strength as measured in
MVUs among a relatively large number
of women who ultimately had a VD or
CD in the first stage, while adjusting for
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parous women with a BMI of 40 kg/m2
took an hour longer to reach 6 cm than
multiparous women with a BMI of 25
kg/m2.
We found that, although obese and
normal-weight women had a similar final cervical dilation (5.5 cm) and time
in labor before undergoing CD, obese
women who had a VD had a longer first
stage of labor than normal-weight
women who had a VD. These results indicate that most obese women who had a
CD were delivered before entering what
might now be considered the active
phase. Zhang et al26 found that, even in
spontaneous labor, it may take 6 hours
to progress from 4-5 cm and 3 hours to
progress from 5-6 cm. We speculate that
many of the obese women in our study
who had a CD may have been successful
in achieving a VD if allowed the additional time to progress. Consistent with
the idea that adequate MVUs may not be
equally effective at achieving cervical
change among obese women compared
with normal-weight women, the same
cervical dilation may fall at different
points on the labor curve for obese vs
normal-weight women.
The clinical study of uterine contractility is complicated by the multiple
potential confounders of MVUs, which
is the only objective measure of contraction strength available to us. With the use
of a large and detailed Labor and Delivery database, we were able to adjust for
the variables that are most likely to alter
the relationship between BMI and contraction strength. However, as with all
retrospective studies, there may be unmeasured confounders. For example, we
are unable to determine the decisionmaking of the clinicians who managed
each womans labor. Although MVU
values were not available for the entire
2-hour period, based on clinical experience, we believe that an MVU value was
most likely to be recorded when trying to
achieve or demonstrate adequacy of contractions. The recording of MVUs may
be inaccurate in the setting of malpositioned or malfunctioning IUPCs. However, this is unlikely to differ by BMI. We
are also not able to evaluate whether
obese women were more likely to have
dysfunctional contractile patterns such
as coupling (despite equivalent contraction strengths) compared with normalweight women. The contractile pattern
may be important in the determination
of the rate of cervical dilation and deserves attention in future studies. Maternal height, weight, and GWG are selfreported variables in this data set and
may be subject to recall bias that resulted
in the classification of women into inaccurate BMI or GWG categories.
The increase in the rates of obesity that
complicate pregnancy combined with
record-high CD rates in the United
States is creating the perfect storm for
women with the most comorbidities to
be at greatest risk of obstetric and surgical complications, which include placenta accreta spectrum, hysterectomy,
and thromboembolism. No significant
decrease in the rates of obesity among
reproductive-aged women is anticipated
in the immediate future. As a result, efforts should focus on decreasing the CD
rate among obese women. Research into
the improvement of metabolic parameters among obese pregnant women
(either by lifestyle or medication interventions) and into the determination of
whether there are specific labor induction or augmentation protocols that are
more effective among obese women are
important areas for investigation. However, an important first step is for obstetric providers to allow adequate time for
obese women to progress in the first
stage of labor, particularly when cervical
dilation is 6 cm in the setting of reasf
suring fetal status.
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