Labour progression patterns of low-risk women

The physiologic pattern of normal labour progression

J Zhang,a T Duanb
a b
Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China Shanghai First Maternity and
Infant Hospital, Shanghai Tongji University, Shanghai, China

Linked article: This is a mini commentary on OT Oladapo et al., pp. 944–954 in this issue. To view this article visit
https://doi.org/10.1111/1471-0528.14930

Published Online 3 November 2017.

The escalating frequency of obstetric
interventions such as oxytocin aug-
mentation and caesarean delivery has
raised concerns for practitioners and
the public. Although maternal conse-
quences of caesarean section are well
recognised by obstetricians, the impact
of caesarean birth on child health has
come under the spotlight in recent
years. Mounting evidence links cae-
sarean birth with childhood allergic
disorders, such as asthma, childhood
obesity, and neurodevelopmental dis-
orders (Cho et al. Am J Obstet Gynecol
2013;208:249–54; Kuhle et al. Obes
Rev 2015;16:295–303; Curran et al. J
Child Psychol Psychiatry 2015;56:500–
8), even though it is still under debate
whether these associations are causal.
Regardless, oxytocin augmentation and
caesarean section will continue to be
essential when labour protraction and
arrest are diagnosed. But how to define
labour abnormalities quantitatively
remains a challenge, partly because of
our lack of understanding of normal
labour.
It has been taught for decades that
normal labour should progress at a
speed of at least 1 cm cervical dilatation
per hour, starting at 3–4 cm of dilation.
Labour that progresses at a rate slower
than that is often considered abnormal;
however, more recent evidence suggests
that the above notions may not be appli-
cable to a substantial number of parturi-
ents. The systematic review conducted
by Oladapo et al. (BJOG 2018;125:944–
54) highlights the following points. (1)
The active phase of the first stage of
labour, characterised by accelerating
dilatation of the cervix, may not start
until the dilation reaches 5–6 cm. Slow
progression before 6 cm of dilation may
not, therefore, represent labour protrac-
tion. (2) Cervical dilatation in normal
labour can be slower than 1 cm per
hour, and although this labour might
last for a much longer time than previ-
ously taught it still ends in vaginal deliv-
ery and normal perinatal outcomes. (3)
The cervix does not dilate in a linear
fashion even in the active phase of
labour; it is more likely to be hyperbolic.
These observations depict a physiologic
pattern of normal labour that differs
materially from the Friedman curve;
however, it should be noted that this is
an average labour pattern at the popula-
tion level. An individual labour trajec-
tory can deviate substantially from the
above pattern. In addition, the data in
the original studies were often ‘contami-
nated’ by patient selection, labour aug-
mentation, epidural analgesia, and other
obstetric interventions.
Understanding the physiologic
pattern of labour only makes the first
step toward optimal labour manage-
ment. The more difficult part is to define
labour abnormality. This review con-
firms that there are wide individual vari-
ations in labour patterns. As such,
choosing the 95th percentile of the distri-
bution of normal labour duration is a
reasonable approach to define abnormal
labour, because the distribution has
taken the wide individual variation into
account. Still, 5% of women who could
end in a vaginal delivery if more time is
given may be misdiagnosed as labour
protraction or arrest. Finally, cervical
dilation is only one of the parameters
measuring labour progression. A multi-
dimensional approach may be needed to
provide better accuracy in identifying a
woman in true labour protraction and
arrest. The search still continues.
Disclosure of interests
None declared. Completed disclosure
of interests form available to view
online as supporting information.&

© 2017 Royal College of Obstetricians and Gynaecologists 955