THE ASSOCIATION BETWEEN PROTRACTED ACTIVE PHASE OF LABOR AND

NEONATAL OUTCOMES AMONG WOMEN WHO UNDERWENT TRIAL OF LABOR AT

MANILA DOCTORS HOSPITAL UNDER SOCIAL SERVICE

Ralph Laurence A. Dantes

Nelson Eliazar S. Pipit
Martin Luis Y. Reyes
Al-Ahjar M. Sumndad
Allain Joseph S. Templo
Aginaya Aggeen E. Tuguinay
Amille Joy S. Ty
Jeanne Therese Vergara
Marianne S. Wandag

Dr. Joy Bautista

A Research Proposal Submitted to the

Manila Doctors Hospital
Committee on Research

In Partial Fulfillment of the Requirements in

Post-Graduate Internship

April 2018
 INTRODUCTION AND BACKGROUND OF THE STUDY

Prolonged labor or dystocia is a common birth complication and constitutes the major indication of
instrumental deliveries and delivery by emergency caesarean section. Diagnosing prolonged labor is
inherently difficult and still remains a controversial issue in the practice of obstetrics.
Active-phase labor begins with a cervical dilatation of more than 4cm with regular uterine
contractions of more than 12 per hour. These uterine contractions should produce a cervical change which
will lead to full cervical dilatation at 10cm and 100% effacement which will eventually lead to
spontaneous delivery of the infant. However, not all delivery will proceed in this manner due to different
complications of dystocia.
Dystocia is multifactorial and maybe classified into three categories. First, it may be due to
abnormal expulsive force or insufficient uterine contraction to bring about dilatation and effacement of the
cervix or inadequate voluntary maternal muscle effort. Second maybe due to abnormal presentation,
positioning or abnormal growth and development of the fetus. Lastly, it may be due to diminished or
inadequate capacity of the pelvic bone. These abnormalities may bring about the slow progress of cervical
dilatation or its complete arrest.
The association between the length of active phase of labor and perinatal outcome remains largely
unclear and can be methodologically challenging to evaluate. Furthermore, there are only few literature
that tackle the association between dystocia in the active phase of labor and perinatal outcomes. Hence, the
proposal of the study.

STATEMENT OF THE PROBLEM

What is the association between adverse neonatal outcomes and protracted active phase of labor
among women who underwent trial of labor?

OBJECTIVES OF THE STUDY

General Objective:
To identify the association between adverse neonatal outcomes and protracted active phase of labor among
women who underwent trial of labor at the Manila Doctors Hospital from January 2014-December 2017.

Specific Objectives:
1. ​To describe the baseline characteristics of women who underwent protracted active phase of labor in
terms of:
a. ​Age – non-high risk (<36 y/o) vs. high risk pregnancy (​<​18 and ​>​ 36 y/o)
b. Parity – primigravid vs. < 4 multigravid vs ​>​ 4 multigravid
c. Prenatal care – none vs. <4 PNCU vs. ​>​ 4 PNCU
2. To describe the outcomes of neonates in terms of:
a. APGAR score – 7-9 (reassuring) vs 4-6 (mod. Abnormal) vs 0-3 (severely abnormal)
b. Need for resuscitation
c. Incidence of infection
d. Meconium aspiration syndrome
 e. Neurologic sequelae
f. Delayed rooming in
3. To determine the association between adverse neonatal outcomes and baseline characteristics of the
mothers with protracted active phase of labor.

SIGNIFICANCE OF THE STUDY

Practices in obstetrics vary. However, it has already been established that prolonging such labor
abnormalities will translate to adverse perinatal outcomes. Friedman described four abnormal patterns of
labor, and among them are present during the active phase of labor. However, only a few literature exists
regarding the association between dystocia in the active phase of labor and neonatal outcomes. This study
aims to evaluate the association of dystocia in the active phase of labor and adverse neonatal outcome
among patients who underwent trial of labor at the Manila Doctors Hospital. This study will also serve as
an eye opener to the practice of obstetrics regarding the said issue.

REVIEW OF RELATED LITERATURE

Normal Labor
Since 1955, obstetric practice has followed the description of normal labor stated in a study by Dr.
Emmanuel Friedman which described a characteristic sigmoid pattern for labor by graphing cervical
dilatation against time and a hyperbolic pattern for fetal descent against time, known as the Friedman’s
curve [1]. In this curve, the first stage of labor is divided into a latent phase, which appears as relatively
flat, and a rapidly progressive active phase starting at 4 cm and ends at 10 cm cervical dilatation [2] with
an average duration of 2.5 hours. The latter phase is further subdivided into acceleration phase, phase of
maximum slope and deceleration phase.
In a normal labor, parturients in the active phase should be dilating at a minimum rate of 1.2 cm/hr
for nulliparous and 1.5 cm/hr for multiparas. The minimum rate of descent starting at station +1 is 1 cm/hr
for nulliparous and 2 cm/hr for multiparas [1,2]. Dilatation and descent below the minimum rate is
considered as protracted active phase dilatation and protracted descent, respectively [1]. No appreciable
change in cervical dilatation in the active phase in the presence of adequate uterine contractions for more
than two hours is considered as labor arrest [3]. These definitions have been widely adopted and applied in
clinical practice.

Protracted Active Stage of Labor

Protracted labor is an abnormally slow cervical dilation or fetal descent during active labor.
Diagnosis is clinical. Protracted labor may result from fetopelvic disproportion (the fetus cannot fit through
the maternal pelvis), which can occur because the maternal pelvis is abnormally small or because the fetus
is abnormally large or abnormally positioned (fetal dystocia). Another cause of protracted labor is uterine
contractions that are hypotonic or occasionally hypertonic uterine dysfunction [6]. ​The characteristic sign
of active stage of labor is the presence of cervical dilatation of 3 to 5 cm or more, in the presence of uterine
contractions. Friedman subdivided active-phase problems into protraction and arrest disorders. Protraction
is defined as a slow rate of cervical dilation or descent, which for nulliparous was < 1.2 cm dilatation per
hour or < 1 cm descent per hour. For multiparas, protraction was defined as < 1.5 cm dilation per hour or <
2 cm descent per hour [1]. ​Interventions for protracted or arrested first stage of labor is oxytocin, operative
vaginal delivery, or cesarean delivery [5, 6].
The adverse effects of protracted active stage of labor on neonates is still understudied; In one
study made by Henry et al., they examined the association between active phase arrest and perinatal
outcomes. Active Phase Arrest (APA) is defined as no cervical change for two hours despite adequate
uterine contractions [7]. In this particular study, a retrospective cohort study of women with term,
singleton, cephalic gestations diagnosed with active phase arrest of labor was done. The result of the study
showed that with the efforts of achieving vaginal delivery in the setting of active phase arrest may reduce
the maternal risks associated with cesarean delivery without additional risk to the neonate. However, the
study did not include the relationship between protracted active stage of labor and risk of neonatal
morbidity [6].

Neonatal Outcome
Perinatal mortality was found to be three times greater with protracted active phase dilatation.
Long term outcomes were similarly poor among surviving babies born after these types of labor with twice
the frequency of abnormalities found in speech, language and hearing at 3yrs of age and in matched pair
analysis with significantly lower intelligence at 4 and 7 yrs of age [8]. ​Perinatal risk increased two fold
among those delivered from multiparas. Univariate analysis showed protracted labor patterns in nulliparas
were associated with a trend toward increased risk of perinatal deaths and significantly lower 5 minute
APGAR scores. Infants of multiparas showed even worse immediate effects, including perinatal mortality,
low 5 minute APGAR score, as well as long term adverse effects, including abnormal neurological
findings at 1 yr of age, and low mean intelligence quotient at 4yrs [8].
Another study showed the association of prolonged latent phase with maternal and neonatal
outcomes with results showing need for newborn resuscitation and 5-minute Apgar scores less than 7 were
significantly more frequent in association with a prolonged latent phase (RR 1.37 and 1.97, 95% CI
1.15-1.64 and 1.23-3.16, respectively) [9]. ​A study done by Maghoma and Buchmann in 2009 showed that
prolonged latent phase is associated with increased risks for obstetric intervention and poor fetal outcome,
with thick meconium staining of the amniotic fluid more frequent (15% vs. 5%; P <0·05), as were
5-minute Apgar scores less than 7 (17% vs. 3%; P <0·001) and admission to the neonatal unit (22% vs.
1%; P <0·0001) [10].
In the study of Harper et al. in 2014, a longer first stage of labor was associated with adverse
maternal and neonatal outcomes. Neonatal outcomes were a composite of the following: admission to level
2 or 3 nursery, 5 minute Apgar scores less than 3, shoulder dystocia, arterial cord pH of less than 7.0, and a
cord base excess of −12 or less. The composite adverse neonatal outcome, shoulder dystocia, and
admission to a higher-level nursery increased as the length of the first stage increased (P < .01). Apgar
score less than 3 at minutes, cord pH less than 7.0, and base excess of −12 or less were not associated with
increasing length of the first stage [11].

Maternal characteristics
Prenatal care is widely accepted as an important public health intervention; yet, its efficacy
remains largely unstudied and unproven. The current recommended American Congress of Obstetrics and
Gynecology (ACOG) prenatal visit schedule for uncomplicated first pregnancies consists of a visit every 4
weeks until 28 weeks, every 2 weeks until 36 weeks, and weekly until ​delivery. Historically, backloading
the majority of visits in the third trimester was done to detect maternal signs and symptoms of
preeclampsia. However, available data do not show whether this schedule, or any other prenatal visit
schedule, is adequate to improve maternal and neonatal outcomes [12].
In 1989, the US Public Health Service Expert Panel on Prenatal Care recommended that the
number of visits for low risk patients be reduced and become more “goal-oriented”. Several studies have
been done to validate these recommendations measuring outcomes such as patient satisfaction, cost
savings, and the rates of low birth weight infants, preterm deliveries, cesarean deliveries, and
preeclampsia. One study demonstrated that prenatal care visits could be reduced with no documented
change in perinatal outcome or patient satisfaction. Other studies show that the frequency of prenatal visits
can be significantly reduced with no change in perinatal outcomes but with less satisfaction with care [14].
It is still, therefore, unproven whether prenatal care has an effect with maternal labor and delivery and
neonatal outcome.
On the other hand, parity can also be contributory factor to labor and neonatal outcome. A study
by Worley et al regarding the prognosis for spontaneous labor in women with uncomplicated term
pregnancies shows that nulliparity was associated with significantly increased rates of umbilical artery
cord gas pH of 7.0 or less, intubation at delivery, and admission to the intensive care unit. The rates of
intrapartum fetal death and neonatal death were not affected by parity [15].

METHODOLOGY
STUDY DESIGN
This study utilizes a population-based retrospective cohort study that determines the association between
protracted active phase of labor and neonatal outcome among women who underwent trial of labor.

STUDY POPULATION
Subjects for this study include full term nulliparous and multiparous women aged 18 and above, with
single live intrauterine pregnancy who underwent trial of labor from January 2014 to December 2017 at
Manila Doctors Hospital under the Social Service. They will be subclassified into those who had (1)
normal labor progression, and (2) protracted active phase of labor. They will, however, be excluded from
the study if they have co-morbidities, multiple gestation, and abnormal ultrasound findings. For the
neonates, this study excludes those outcomes that were unrelated to prolonged maternal labor such as
breastfeeding jaundice, elective surgeries such as circumcision, iatrogenic conditions and the like.
Sample size computation: Using Epi Info Version 7, the minimum sample size is at least 73 based
on the incidence of APGAR <7 = 5%,​ ​with margin of error = 5%, and confidence level = 95%.

OPERATIONAL DEFINITION OF VARIABLES

Protracted active phase of labor: Maximum slope of less than 1.2cm/hour for nulliparous women and less
than 1.5cm/hour for multiparous women or a descent of <1cm/hour and <2cm/hour for nulliparous and
multiparous women, respectively, according to the subject’s partograph.
High Risk Pregnancy: Pregnancy that threatens the health of life of the mother or the fetus which requires
care. In this study, those who are more than 36 years of age will be considered.
Primigravid:​ A woman who has been pregnant once
Multigravid:​ A woman who has been pregnant at least once
Neurologic Sequelae: Neurological manifestations in the newborn related to decreased oxygenation to the
brain.
Neonatal Outcome: Measures of neonatal outcome including APGAR scores, maturity testing, need for
resuscitation, birth injuries, infections, meconium aspiration syndrome, neonatal pneumonia, sepsis,
admission to the Neonatal Intensive Care Unit (NICU), and other complications related to prolonged labor
as identified by MDH Records.
Full-term pregnancy: Pregnancy that reached at least 37 weeks age of gestation either by last menstrual
period or by early ultrasound.

DATA COLLECTION
Maternal and neonatal medical data records from January 2014 to December 2017 will be retrieved
from MDH’s Records Section, OB-Gyne Department, and Pediatrics Department upon approval of request
for research purposes. Data will be pooled anonymously.

DATA PROCESSING AND DATA ANALYSIS

Data analysis will be performed in Stata SE version 13. Quantitative variables will be summarized as mean
and standard deviation, while qualitative variables will be tabulated as frequency and percentage.
Association between protracted labor and neonatal outcomes will be analyzed using logistic regression
analysis. The level of significance will be set at 5%.

DUMMY TABLES

Table 1
Maternal Baseline Characteristics
Characteristics With Protracted Without Protracted p-Value
Labor Labor

Age
1. Non-High Risk
2. High Risk

Parity
1. Primigravid
2. <4 Multigravid
4. ​>​ 4 multigravid
 Pre-Natal Check-up
1. None
2. <4 PNCU
3. ​>​ 4 PNCU

Table 2
Neonatal Outcomes
Neonatal Outcomes Mean ​+​ SD

APGAR Score

Need for Resuscitation

Incidence of Infection

Meconium Aspiration Syndrome

Neurologic Sequelae

Delayed Rooming-In

Table 3
Association Between Protracted Active Phase of Labor and Adverse Neonatal Outcomes
Features With Adverse Without Adverse Odds Ratio p-Value
Neonatal Neonatal
Outcome Outcome
(n = ) (n = )

Protracted Labor

ETHICAL CONSIDERATIONS
For confidentiality purposes, approval letter to view charts will be sent to MDH’s Medical
Records, OB-Gyne Department, and Pediatrics Department.
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