Accepted Manuscript

Descent of the Fetal Head (Station) During the First Stage of Labor

Emily F. Hamilton, MD, Gabrielle Simoneau, MSc, Antonio Ciampi, PhD, Philip
Warrick, PhD, Kathleen Collins, RN, Samuel Smith, MD, Thomas J. Garite

PII: S0002-9378(15)01268-5
DOI: 10.1016/j.ajog.2015.10.005
Reference: YMOB 10701

To appear in: American Journal of Obstetrics and Gynecology

Received Date: 6 July 2015

Revised Date: 24 September 2015
Accepted Date: 6 October 2015

Please cite this article as: Hamilton EF, Simoneau G, Ciampi A, Warrick P, Collins K, Smith S, Garite TJ,
Descent of the Fetal Head (Station) During the First Stage of Labor, American Journal of Obstetrics and
Gynecology (2015), doi: 10.1016/j.ajog.2015.10.005.

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 ACCEPTED MANUSCRIPT

Descent of the Fetal Head (Station) During the First

Stage of Labor

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Emily F HAMILTON MD 1,2, Gabrielle SIMONEAU MSc 3, Antonio CIAMPI PhD 3, Philip WARRICK PhD 2,
Kathleen Collins RN 4, Samuel SMITH MD 5,6, Thomas J Garite 2,7,8

1. Department of Obstetrics and Gynecology, McGill University, Montreal, QC Canada

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2. PeriGen, Cranbury, NJ and Westmount, QC, Canada
3. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC,
Canada

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4. Department of Obstetrics and Gynecology, MedStar Washington Hospital Center, Washington, DC
5. Department of Obstetrics and Gynecology, MedStar Franklin Square Medical Center and
6. Department of Obstetrics and Gynecology, MedStar Harbor Hospital, Baltimore, MD
7. University of California Irvine, Orange, CA

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8. Pediatrix Medical Group, Sunrise, FL
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Disclosure statement:
Samuel Smith MD and Kathleen Collins RN, Gabrielle Simoneau MSc and Antonio Ciampi PhD have no
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conflict of interest. Emily Hamilton MD, Philip Warrick PhD, and Thomas Garite MD are employed by
PeriGen.
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This work was supported financially by PeriGen, Cranbury, NJ.

Reprints will not be available.

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Word count: text 2157 abstract 414

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Corresponding Author

Emily F. Hamilton MD
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PeriGen
245 Victoria Avenue, Suite 600
Westmount, QC, Canada H3Z 2M6
Tel 514.488.3461 ext 226 email emily.hamilton@perigen.com

Figure 2. for inclusion in the print version

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Condensation
Fetal descent occurs during the first stage and is generally related to advancing cervical dilation in a
linear fashion.

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Short Title

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First Stage Fetal Descent

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Abstract

Background: High station at specific points in the first stage of labor, such as a floating head on
admission, or at 4 cm dilation or when arrest of dilation occurs, is associated with higher rates of failure
to deliver vaginally. Therefore it could be useful to know if station is within an expected range at a given

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dilation during first stage. Arrest of descent disorders have been defined thus far on criteria applicable
in the second stage.

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Statistical modeling is an attractive methodology to characterize the relationship between station and
dilation because the resulting mathematical expressions could be used as a reference for comparison in

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the future. In addition, they can be used to produce a finely graded assessment of descent using
numerical terms such as percentile rankings.

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A two-step approach to potentially improving the assessment of station could be to develop a statistical
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model that describes the general relationship between station and dilation in the first stage of
uncomplicated births and then determine if such a model would have identified births with
complications related to poor labor progress.
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Given the complex nature of labor data, especially the imprecision of dilation and station measurement,
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it is not immediately evident that such a model is identifiable or what its precision would be.
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Objective: To characterize in mathematical terms the relationship of station to dilation during the first
stage of labor for nulliparous and multiparous women with spontaneous vaginal births.
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Study Design: This retrospective cohort study included 28,121 exams from 5555 women with
singleton cephalic presentations at 37 weeks or more gestation with EFM tracings, who delivered
vaginally without instrumentation and had 5 minute Apgar scores >6 at two academic community
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referral hospitals in 2012 and 2013. Women with a previous cesarean birth were excluded. We used
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longitudinal statistical techniques suitable to biological data that was irregularly sampled with repeated
measures over time.

Results: A linear relationship was observed between station and dilation. For both nulliparous and
multiparous women the final model was a linear regression with random effects for intercept and slope
and a first-order auto-regressive correlation structure. The 5th to 95th range of station at any given
dilation spanned about 3 to 4 cm.

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Conclusions: Our results demonstrate a general trend of increasing descent of the presenting part as
dilation advances during the first stage of labor in women who delivered vaginally without
instrumentation. We propose that the mathematical expressions describing this relationship may be
valuable in the assessment of first stage labor progression.

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Introduction
High station in the first stage can be a harbinger of cesarean or difficult birth. Several clinical studies
have reported that high station at certain points in the first stage of labor, such as a floating head on
admission, or at 4 cm dilation or when arrest of dilation occurs, is associated with higher rates of failure

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to deliver vaginally. (1-7). Therefore it could be useful to know if station is within an expected range at
specific dilations during the first stage. Although descent begins during the first stage, arrest disorders
of descent are essentially “pass-fail” criteria applicable in the second stage only. (8-11).

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A two-step approach to potentially improving the assessment of descent could be to develop a

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statistical model that describes the general relationship between station and dilation in the first stage of
labor in uncomplicated births and then determine if such a model could identify births with

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complications related to labor progress disorders. Statistical modeling is an attractive methodology
because the resulting mathematical expressions may be used as a reference for comparison in the
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future. In addition, they can be used to produce a finely graded assessment of descent using numerical
terms such as percentile rankings.
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The relationship between dilation and station in the first stage has been shown indirectly by plotting
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both dilation and station over time on the same graph as in the classic Friedman or contemporary labor
curves. (12-14) A statistical model of the relationship between station and dilation has not been
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reported previously.
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The objective of this study was to create a mathematical expression describing the relationship between
station and dilation during the first stage for nulliparous and multiparous women with spontaneous
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vaginal deliveries.
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Materials and Methods

In this retrospective cohort study, de-identified data was extracted from the departmental electronic
perinatal database for the clinical variables on all births between January 1, 2012 and December 31,
2013 at two acute care, academic community teaching hospitals and regional referral centers in the
Baltimore Washington corridor, MedStar Franklin Square Medical Center and MedStar Washington

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Hospital Center. The inclusion criteria were all labors with singleton cephalic presentations at 37 weeks
or more gestation with EFM tracings, who delivered vaginally without instrumentation and had 5
minute Apgar scores >6. Women with a previous cesarean birth were excluded.

All clinical data including cervical dilation, effacement and station and data were extracted from the
perinatal EMR, PeriBirth (PeriGen, Cranbury, NJ.) Dilation and station were measured in cm where

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station values could range from -5 to +5.

First we examined the data using scatter plots, trajectory plots and variograms.

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Based on the observation of these plots and inherent biological variation in the process of labor, we

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chose a modeling approach from the Extended Linear Mixed Model (ELMM) family. We fit our data to
several models of increasing complexity within the ELLM family, and chose the final model using the

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Akaike Information Criterion. (15)
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Since both fetal station and cervical dilation are closely related to time, we also tested the effect of time
by adding minutes-elapsed as a covariate to the model.
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We checked the final model regarding assumptions of normality.

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All statistical analyses were conducted using R version 3.0.2. (16)

This study was reviewed and approved by the MedStar Research Institute.
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GLOSSARY OF SELECTED TERMS IN THE CONTEXT OF THIS STUDY

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AUTO-REGRESSIVE: The term autoregressive refers to the fact that in labor, station measured at one
examination depends in part upon the most recent values and the time
between examinations.

CORRELATION: Correlation refers to the interdependence between factors.

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GOODNESS OF FIT: The goodness of fit is a measure that describes how well a statistical model
matches a set of real observations based on the discrepancies between actual
values and the values produced by the model.

FIXED EFFECTS: Parameters in a model describing the average behavior of a population.

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RANDOM EFFECTS: Parameters in a model describing the variation around a fixed effect due to
heterogeneity of individuals

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STATISTICAL MODEL: An equation describing the relationship between station and dilation in the first
stage of labor

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MIXED MODEL: A statistical equation that accounts for both fixed and random effects

TRAJECTORY PLOT: A graph showing the path of an individual’s measurements over time.

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VARIOGRAM: A specific type of graphical display that helps to visualize how much of the
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variation in station relative to dilation is related to a: measurement inaccuracy,
b: autoregressive effects, c: natural biological variation among subjects.
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Results
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The study sample included data from 5555 labors and 28,121 exams recorded during the 24-hour period
ending with spontaneous vaginal birth. Characteristics of the study population are summarized in Table
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1.

We excluded 210 examinations because either dilation or station values were missing, 441 examinations
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that were in the second stage, 83 examination with obvious date and time errors, and 13 examinations
with obvious sign errors that were influential points. For example, after a labor with progressive descent
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in a multiparous patient a station value was entered as -4 and the baby delivered vaginally 20 minutes
later. The final dataset included 5535 labors with 27,374 observations. There were 14,320 observations
in 2507 nulliparous births, and 13,054 observations in 3028 multiparous births. Figure 1 shows the
percentage of examinations at each level of station.

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The preliminary analysis with scatter plots showed a clear relationship between dilation and station.
Trajectory plots of station or dilation over time suggested a linear relationship. The trajectories were
roughly parallel. That is, not every labor progressed with the same rate of descent (slope) or had exactly
the same values of station relative to dilation (intercept). These observations of variation among
individuals suggested that that a random slope term and random intercept term could be beneficial

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additions to the model.

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Variogram plots showed strong serial correlation between dilation and station in both parity groups
indicating that the model should account for this correlation.

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ଶ ଶ
The inter- (ߪ௜௡௧௘௥ ) and intra-subject (ߪ௜௡௧௥௔ ) variability of station was 4.62 and 2.01 for nulliparous

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women and was 3.92 and 1.93 for multiparous women, strongly supporting the choice of a mixed effect
approach.
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The choice of a covariance structure was based on the results from a cross-correlation plot of residuals
which demonstrated a first order auto-regressive correlation pattern between observations taken on a
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same woman.
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Table 2 shows Akaike Information Criterion values for models with progressively more terms. Akaike
Information Criterion is a statistical measurement that reflects both the goodness of fit of the model and
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the complexity of the model. Lower values are preferable.

The coefficient associated with the time factor did not improve the performance of the model,
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suggesting that time does not influence the relation between fetal descent and cervical dilation. That is
to say, fetal descent and cervical dilation both varied in a similar way with respect to time.
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The final model for nulliparous and multiparous women was a random intercept and random slope
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linear regression with correlated random effects and a first-order auto-regressive correlation structure.

The assumption of normally distributed errors was clearly confirmed by graphical inspection, as
suggested in Pinheiro & Bates. (15)

The equations are shown below.

For nullipara

Station = 0.427(dilation) - 3.295

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For multipara

Station = 0.466(dilation) - 3.941

The models are shown graphically in Figures 2 and 3. Although the model is a population-average

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prediction model, the 5th and 95th percentiles in these graphs account for the subject-specific variability
in station.

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In nullipara, the widest 5th to 95th percentile range was 3.7 cm, and found at the lowest dilation. This
range reached a minimum of 3.0 cm at a dilation of 6.5 cm and then diverged to 3.2 cm at full dilation.

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In multipara, the widest 5th to 95th percentile range was 3.8 cm also seen at the lowest dilation. This
range reached a minimum of 3.1 cm at a dilation of 5 cm and then diverged again to 3.6 cm at full
dilation.
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Comment:
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The creation of a model of station versus dilation is challenging. There are several factors that affect the
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relationship between station and dilation. There is natural biological variation in how descent occurs.
Clinical measurements of dilation and station are inexact and prone to variation especially with
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inexperienced trainees. (17, 18) Individual women enter hospital at different points in labor and have
repeated examinations at irregular intervals. There is a correlation between an individual woman’s
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neighboring exam results that can be affected by the time between examinations. Finally there will be
influences that we have not measured at all. It is possible that even if the station-dilation relationship
could be represented mathematically, that the range of variation would be very large. A large range
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would severely limit its potential clinical utility. For example if the 5th to 95th percentile range of
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station at every dilation was -5 to +5 in normal labor, then station could not possibly be useful as a
potential indicator of abnormal labor progression.

Given the complex nature of labor data, especially the imprecision of dilation and station measurement,
it was not immediately evident that such a model could be identified or what its precision would be.

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Principal Findings
We observed a linear relationship between station and dilation. That is, there was a general trend of
descent of the fetal presenting part with increasing dilation during the first stage of labor. This is the first
report of an equation describing the general relationship between station and dilation in the first stage
of labor, derived from contemporary women who delivered vaginally without instrumentation. In

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addition, the graphs show the range of variation from the 5th to 95th percentile that spanned roughly 3-4
cm. While a specific woman may have experienced a trajectory that was different at times, 90% of the

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examinations fell within this percentile range.

The relationship between station and dilation is consistent with the findings of Zhang et al and Graseck

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et al. (12, 13) who reported graphs of dilation and station versus time. From their graphs it is possible to
extract their station values at each dilation value and superimpose their results on our graph of station

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versus dilation. Attention must be given to reconcile measuring station in thirds (-3 to +3) or in cm (-5 to
+5) when comparing these curves. Figure 4 shows the relationship between station and dilation for
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nulliparous women re-expressed from their publications and superimposed on our findings. Note that all
station measurements in Figure 4 are expressed in cm in the -5 to +5 system and the horizontal axis is
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dilation not time. Our findings closely follow the values published by Zhang et al. (12)

Clinical Implications
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The clinical implications of the mathematical expressions describing the general relationship between
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these two factors are that they can be used to quantify a specific patient’s station relative to dilation.

Research Implications
Further research with larger or different datasets could result in improvements. Newer ultrasound
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based techniques could reduce measurement errors. The incorporation of other influential factors like
BMI or epidural use that were unmeasured in this exercise, could potentially improve the precision of
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the model. Research examining the outliers or specific subsets could also produce insights leading to
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further improvements. Finally it is possible that a different relationship could be described with better
clinical discrimination.

Strengths and Limitations

Generalizing these results to other centers must be considered with caution for several reasons. The
cesarean rates were higher than the national average. Maryland and DC where the data originated
ranked 7th and 9th amongst all US states for cesarean rates in nulliparous women with singleton term

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vertex presentations in the US in 2013 (19). Other patient and health care differences can make
particular centers different and the models described here to be less representative for them. That said
the close similarity between observations by Zhang et al for nulliparous women in spontaneous labor
and this model provides reassurance about generalization of this model. Like the study of Graseck et al,
our study included a similar percentage of women with induction and augmentation of labor. We also

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did not include a small number of mothers (26) with 5 minute Apgar scores ≤6 which can be a
complication of abnormal labor.

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It is important to emphasize that a statistical range of values found in a “normal” population does not
necessarily translate to limits defining clinical abnormality. In fact, the definition of percentile ensures

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that 10% of the examinations in this “normal” population will fall beyond the thresholds of 5 and 95. The
selection of limits defining increased risk of a specific clinical abnormality would require an examination

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Conclusions
Our results demonstrate a general linear trend of increasing descent of the presenting part as dilation
advances during the first stage of labor in women who delivered vaginally without instrumentation. We
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propose that the mathematical expressions describing this relationship may be valuable in the
assessment of first stage labor progression.
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Acknowledgements
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We wish to thank Dr. Omer Ben-Yoseph of PeriGen, (Israel), who gave his time and expertise for data
extraction.
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Table 1. General characteristics of the study population

Number
Nulliparity 2510 45.2%
Multiparity 3045 54.8%
Diabetes 251 4.5%

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Hypertension 546 9.8%
Induction 2055 37.0%
Augmentation 1121 20.2%

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Epidural Anesthesia 3325 59.9%
Median IQR
Gestational age 39.6 38.9-40.3

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Birthweight 3320 3037-3610
BMI 30.8 27.4-35.3

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Table 2. Akaike Information Criterion values with the addition of more complexity to the models

Akaike Information Akaike Information Criterion

Criterion in Nulliparous in Multiparous Women
Women
Simple linear regression 41151 37115
+ Random Intercept 37901 34643

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+ Imposed correlation structure for the errors 36014 33494
+ Random slope 35832 33212

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+ Time as a covariate 35860 33239

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Figure 1. Percentage of examinations at each level of station.

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25

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% of Examinations

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-5 -4 -3 -2 -1 0 1 2 3 4 5
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Station (cm)
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Figure 2. Graphical display of the final model showing station versus dilation in nulliparous women

Median
5th percentile
95th percentile

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-6

-5

-4

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-3
Station cm

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Dilation cm
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Figure 3. Graphical display of the final model showing station versus dilation in multiparous women.

Median
5th percentile
95th percentile

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-6

-5

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Station cm

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Dilation cm
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Figure 4. Graphical display of the final model showing station versus dilation in nulliparous women with
extracted values extracted and superimposed from two other studies.

Median
5th percentile
95th percentile
Zhang

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Graseck

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-6

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Station cm

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0 1 2 3 4 5 6 7 8 9 10
Dilation cm
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