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\begin{document}

\title{OBSTETRIC OUTCOMES AMONG LOW RISK PARTURIENTS WHEN ACTIVE PHASE OF LABOR
IS DEFINED AT A CERVICAL DILATATION OF 6 VERSUS 4 CENTIMETRES AT
KENYATTA NATIONAL HOSPITAL, KENYA}



\author[1]{okoth francis}%
\author[1]{Alfred Osoti}%
\author[1]{Omondi Ogutu}%
\author[1]{Anne Pulei}%
\author[2]{Peter Michoma}%
\affil[1]{University of Nairobi College of Health Sciences}%
\affil[2]{Kenyatta National Hospital}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: Neal et al. suggested that active labor started at 6
centimeters (cm) cervical dilatation which differs from Friedman's labor
curve of 4cm. The feasibility and risk of adverse obstetric outcomes
when active labor starts at 4cm compared to 6cm dilatation has not been
studied amongst African women. Objective: Compare incidences of adverse
obstetric outcomes among low-risk parturients when active labor starts
at 6cm versus 4cm dilatation. Methodology:180 low-risk parturients in
spontaneous labor between 37-42 weeks gestation with a singleton fetus
in cephalic presentation and reassuring fetal status were recruited,
allotted to 4 cm or 6 cm arms and intrapartum and immediate postpartum
outcomes recorded. Demographic characteristics were summarized and
Chi-square tests used to evaluate relationships between study arms.
P-value was considered significant at \textless{}0.05 at the 95\% level
of confidence. Results: Between January and April 2019, 90 parturients
each were recruited to the 4cm and 6cm arms. Demographic and
reproductive characteristics were comparable on admission. Defining
active labor at cervical dilatation of 4 cm versus 6 cm was not
associated with adverse maternal and neonatal outcomes. However, the
need for amniotomy and oxytocin was 1.44 (1.09-1.96) and 1.42
(1.07-1.88) times higher when active labor was defined as cervical
dilation of 4 cm than 6 cm (P\textless{}0.05). Conclusion: Defining
active labor at cervical dilatation of 4 cm versus 6 cm was not linked
with adverse obstetric outcomes. However, defining active labor at 4 cm
than 6 cm increased the risk of amniotomy and oxytocin administration
1.44 and 1.42-fold.%
\end{abstract}%



\sloppy


\section*{Introduction}

{\label{introduction}}

Labor onset can be spontaneous or induced with regular or rhythmic
uterine contractions. Prolonged labor, especially latent phase, has been
associated with increased risk of caesarian deliveries, need for
intrapartum interventions, adverse fetal outcomes such as poor APGAR
scores at 5 minutes, and admission to newborn intensive care units
(NICU) {[}2,3{]}. There are some inconsistencies in defining the active
phase of labor. In 1978, Friedman observed that active labor started
when there is a significantly increased rate of change in cervical
dilation {[}4{]}. In the 2003 American College of Obstetrics and
Gynecologists (ACOG) practice bulletin on approaches to limit
intervention during labor and birth, it has been noted that most
clinicians defined the active phase of labor at 3 or 4 cm cervical
dilation {[}5{]}. Also, the 1998 World Health Organization partograph
defined the beginning of an active phase of labor at 3 cm with a
cervical dilation rate of at least 1 cm per hour {[}6{]}. However,
recent evidence suggests that defining active labor at cervical
dilatation of 5 or 6 centimeters may have similar obstetric outcomes as
cervical dilatation happens substantially slower than originally
reported by Friedman in his 1978 published book {[}7{]}. Zhang et al. in
2002 reported a substantially slower rate of dilation from 4-10 cm (5.5
hours) compared to what was reported by Friedman (2.5 hours) in 1978,
with the 3-4 cm diagnostic criteria for active labor found to be too
stringent for nulliparous parturients {[}8{]}. A follow-up study by
Zhang et al. (2010) and Laughon et al. (2014) also reported
substantially lower rates of dilation (0.5-0.7 cm per hour) compared to
Friedman's (1 cm per hour) {[}8,9{]}, supporting earlier findings that
the 3-4 cm diagnostic criteria for active labor might be too stringent.
Guided by this new evidence, ACOG released a new diagnostic criterion
for the active phase of labor in an obstetric care consensus statement
in 2014, which advocated for adopting 6 cm cervical dilation as the
threshold for the onset of the active phase of labor for most women
{[}10{]} and late r on supported by the World Health Organization (WHO)
in 2018 {[}11{]}. However, the feasibility and obstetric outcomes of
defining the active phase of labor at cervical dilation of 6 compared to
4 centimeters in low-resource settings have not been evaluated. This
study sought to compare the obstetrics outcomes of parturients whose
active stage of labor was defined at a cervical dilation of 4 cm
compared to 6 cm in Kenya.

\section*{Methodology}

{\label{methodology}}

\subsection*{Study design}

{\label{study-design}}

This was a prospective cohort study that compared obstetrics outcomes of
term parturients among whom active stage of labor was defined at a
cervical dilation of 4 cm versus 6 cm at Kenyatta National Hospital, the
largest teaching, and referral hospital in Kenya.

\subsection*{Power and sample size
calculation}

{\label{power-and-sample-size-calculation}}

Power and sample size calculation was estimated according to Charan and
Biswas (27) at an \selectlanguage{greek}α \selectlanguage{english}of 1.96 at 95\% confidence interval, statistical
power of 80\%, and an anticipated incidence of oxytocin administration
of 36.6\% at 6 cm and 58.5\% at 4 cm. The incidence data were obtained
from Kauffman et al., 2002 {[}12{]}. Assuming a recruitment ratio of
1:1, 162 participants (81 at 4 cm and 81 at 6 cm) were required. After
adjustment by a factor of 10\% to cover loss to follow up, 180
participants, 50\% at 4 cm cervical dilation and 50\% at 6 cm cervical
dilation were required.

\subsection*{Study procedures}

{\label{study-procedures}}

Eligible parturients were those in spontaneous labor at term (37-42
weeks) gestation and having a cervical dilation of either 4 or 6 cm,
cephalic presentation, reassuring fetal heart rate. Parturients with a
previous uterine scar, multiple gestations, and medical comorbidities
such as cardiac disease in pregnancy, diabetes mellitus, chronic
hypertension, and HIV/AIDS with unknown viral loads were excluded. On
admission, the cervical dilatation was assessed by a skilled trained
midwife by performing a sterile vaginal examination which was confirmed
using the cervical dilation and effacement chart. Informed consent was
obtained from those at 4 cm and 6 cm cervical dilatation respectively
until the required sample size (180) was reached. Enrolled participants
were then monitored up to 24 hours postpartum and outcome data obtained.

\subsection*{Data collection}

{\label{data-collection}}

Interviewer administered questionnaires were used to collect data on
sociodemographic and reproductive characteristics. Additional data was
obtained from parturient's medical records. Outcome data such as number
of vaginal examinations and intrapartum interventions including
amniotomy and oxytocin administration, and mode of delivery were
obtained from medical records. Records of adverse maternal outcomes
including cervical tears, primary PPH, early onset of sepsis, and
adverse neonatal outcomes such as low 5-minute APGAR scores, need for
resuscitation and oxygen administration, neonatal sepsis, and NBU
admissions were also obtained from maternal and newborn medical records.

\subsection*{Statistical analysis}

{\label{statistical-analysis}}

Categorical data were summarized as proportions and compared using the
Chi-square or Fisher's exact test. Continuous data were summarized as
means with standard deviations and compared using the t-test if
distributed normally and Mann Whitney U test if skewed. The association
between cervical dilatation at a definition of the onset of active labor
and obstetric outcomes was evaluated by a test for fitness in relation
to expected risks and the corresponding 95\% confidence intervals.
P-value \textless{} 0.05 was considered statistically significant. Data
were analyzed using Statistical Package for Social Scientists Software
version 25.

\section*{Results}

{\label{results}}

Between January 1 and May 31, 2019, 203 parturients were screened for
eligibility. Of these, 180 (88.7\%) consenting parturients were enrolled
(figure 1). The 23 (11.3\%) were ineligible due to refusal to provide
informed consent (n=12), twin gestations diagnosed during labor (n=3),
newly diagnosis of HIV/AIDS (n=2), and withdrawal of consent (6). Of
those enrolled, half (n=90) were at cervical dilation of 4 cm and the
rest (n=90) at 6 cm of cervical dilatation.

The baseline sociodemographic and reproductive health characteristics
are described in table 1. The mean age for parturients recruited at 4cm
versus 6cm was similar at 25 (SD=5) years. Similarly, education level,
employment status, parity, criteria for determination of gestation,
state of membranes, number of living children, number of Ante-Natal Care
(ANC) visits, and gestation in weeks were also comparable between the
two groups.

Maternal and neonatal outcomes are presented in table 2. More
parturients received oxytocin in the 4 cm (5) versus 6 cm (\%) groups.
Administration of oxytocin was 39\% statistically significantly higher
when active labor was defined at 4 cm compared to 6cm (RR 95\% CI =1.39
(1.03-1.84), P=0.01). A higher proportion of parturients underwent
amniotomy in the 4 cm vs the 6cm groups. The need for amniotomy was 54\%
statistically significantly greater when active labor was defined at 4cm
compared to 6cm (RR 95\% CI =1.54 (1.08-2.30), P=0.01). More vaginal
examinations (VE) were performed among those recruited at 4 vs 6.
Defining active labor at 4 cm was associated with statistically
significantly higher average number of VE 4 (SD=1) compared to 6 cm 3
(SD=1), P\textless{}0.01). Although the risk of episiotomy was 18\%
lower when active labor was 4 cm (17.7\%) compared to 6 cm (22.2\%),
this was not statistically significant. The risk of delivery via
caesarian section was 19\% higher when active labor was defined at 4 cm
compared to 6 cm but this was not statistically significant P=0.308).
Similarly, the risk of primary PPH was 31\% higher, perineal tears were
9\% lower when active labor was defined at 4 cm compared to 6 cm and
these were not statistically significant. Neonatal outcomes when active
labor starts at 4 cm versus 6 cm, show that the APGAR scores at 5- and
10-minutes P-0.802 and 0.875, were comparable when active labor was
defined at 4 cm and 6 cm. The mean birth weight was higher when active
labor was defined at 4 cm (3355 grams (SD=417 grams) compared to 6 cm
(3310 grams (SD=464 grams). However, the results were statistically
insignificant.

\section*{Discussion}

{\label{discussion}}

In this, we found that parturients among whom active labor was defined
at 4 cm had a significant P-value of 0.1 higher chances of risk of
undergoing amniotomy. This finding is comparable to that by Onah et al.,
2015 {[}13{]} in a randomized clinical trial found associations of early
amniotomy compared to fetal membrane conservation reduced the duration
of labor and need for oxytocin augmentation among term singleton
pregnant women. Oxytocin was significantly the drug to choose with a
P-value of 0.1 comparable to Ajadi et al., 2006 {[}14{]}, and was also
complimented by Onah et al., 2015 {[}13{]}. Episiotomy in the study was
also found statistically significant P-value of 0.1 lower when active
labor was 4 cm (17.7\%) compared to 6 cm in parturients though unknown
or not common. In the study, vaginal examinations had a high impact and
were statistically significant by a P-value less than 0.01, this is
comparable to the findings by Shepherd A and Cheyne H, 2013 {[}15{]}.
Moreover, the average number of vaginal examinations performed
intrapartum was higher when active labor was defined as 4 cm compared to
6 cm cervical dilation. A cross-sectional study of 5167 women in India
{[}16{]} reported similar results.

Definition of active labor as 4 cm compared to 6 cm cervical dilation
was statistically not associated with a higher risk of caesarian
deliveries. Incidences of caesarian section and their predisposing
factors were not statistically significantly different when active labor
was at 4 cm compared to 6 cm cervical dilation. Mikolajczyk et al.
{[}17{]} reported a higher risk of cesarean deliveries before 4 cm
cervical dilation, which reduced at 4 cm cervical dilation. In a study
by Spong et al., in 2012, the high risk of cesarean deliveries during
early labor was associated with failure of physicians to account for
non- linearity of cervical dilation in early labor, as they expected the
parameters of early cervical dilation to mimic those of late or optimal
cervical dilation. When parameters of early labor clashed with the
action lines of the partograph, cesarean deliveries were done even when
uncalled for. This calls for an audit of the available clinical
standards at KNH and design strategies that can improve the care offered
by in- house obstetric staff during labor and delivery. We also
recommend a review of the pre-existing labor assessment protocols of
labor to improve decision- making on cesarean deliveries when active
labor starts at 4 cm compared to 6 cm cervical dilatation.

Defining active labor at 4 cm compared to 6 cm cervical dilation was
associated with an increased risk of intrapartum interventions.
Administration of oxytocin and amniotomy was significantly statistically
increased when active labor was defined at 4 cm cervical dilatation
compared to 6 cm. In another cross-sectional study of 216 low-risk
nulliparous parturients in Nepal {[}19{]}, active labor defined at 4 cm
cervical dilation had increased need for labor augmentation with
oxytocin. Oxytocin is shown to restore cardiorespiratory homeostasis
during labor and delivery, but close to 26.4\% of its administration is
done without a clear indication. Administration of oxytocin before 5cm
dilatation might be inappropriate as it does not change the outcomes of
labor as envisaged {[}18, 21{]}. During labor, parturients should be
individualized after evaluation and interventions done with a clear
indication.

Defining active labor at 4 cm compared to 6 cm cervical dilation was not
associated with a statistically significant increase in the risk of
adverse maternal and neonatal outcomes among term parturients. The risk
of PPH, cervical and perineal tears was similar, while APGAR scores at
1, 5, and 10 minutes were normal and comparable when active labor was
defined at 4 cm and 6 cm cervical dilation. A Cochrane review {[}22{]}
reported similar results in 2018, in which cervical dilation was a poor
predictor for birth outcomes, necessitating a review of the partograph
alert time of 1 cm per hour. Degani and and Sikich {[}23{]} found no
significant association between the arrest of labor at 6 cm dilation and
associated complications in an evidence-based analysis in 2015. We
propose a review of existing labor assessment protocols to improve
decision-making for labor and delivery disorders.

\section*{Conclusions}

{\label{conclusions}}

Among term parturients, defining active labor at cervical dilatation of
6cm compared to 4cm had comparable obstetrics outcomes but reduced
amniotomy, administration of oxytocin, and some vaginal examinations.

\section*{Funding}

{\label{funding}}

The study was self-sponsored

\section*{Author contributions}

{\label{author-contributions}}

O-AF, OO, OA, PA, and PM contributed to the design of the study. O- AF
handled recruitment

and data collection. O-AF, OO, OA, PA, and PM wrote and edited the
manuscript.

\section*{Ethics declarations}

{\label{ethics-declarations}}

\subsection*{Ethics approval}

{\label{ethics-approval}}

Ethical review and approval were obtained from the UoN/KNH Ethical
Review Committees: number P749/10/2018, valid from
6\textsuperscript{th}December 2018 to 5\textsuperscript{th} December
2019.

\subsection*{Consent to participate}

{\label{consent-to-participate}}

Participants provided informed consent before recruitment. Printed
consent forms in English and Kiswahili were provided to parturients to
read. Participants who could not read were read for verbatim by the
research assistant in the presence of a next of kin before signing.
Thumbprints were acceptable for illiterate participants. Parturients
were free to withdraw from the study at any given point without
prejudice. Moreover, the confidentiality of our participants was upheld
during and after this study by de-identifying questionnaires. Signed
consent forms and questionnaires were filed and stored in a lockable
cabinet and databases password protected.

\subsection*{Consent for publication}

{\label{consent-for-publication}}

Consent for publication was attained from study participants and
collaborators. Competing interests

The authors have declared no non-financial or financial conflict of
interest.

\subsection*{Acknowledgements}

{\label{acknowledgements}}

Sincere appreciation to Dr. Osoti Alfred, Professor Omondi Ogutu, Dr.
Anne Pulei and Dr. Michoma Peter for their tireless efforts in
supervision and guidance. Appreciation to Kenyatta National Hospital
labor ward.

\textbf{8.5 List of tables}

Table1: Baseline demographic and reproductive health characteristics of
parturients whose active phase of labor is defined at a cervical
dilatation of 6 versus 4 centimeters

Table 2. Maternal and neonatal outcomes of parturients whose active
phase of labor is defined at a cervical dilatation of 6 versus 4
centimeters

\textbf{8.6 Figure Legends}

Figure 1. Flow chart showing the recruitment procedure of participant

\section*{References}

{\label{references}}

{[}1{]}. Hanley GE, Munro S, Greyson D, Gross MM, Hundley V, Spiby H, et
al. Diagnosing onset of labor: a systematic review of definitions in the
research literature. BMC Pregnancy Childbirth. 2016 Dec;16{[}1{]}:71.

{[}2{]}. Maghoma J, Buchmann EJ. Maternal and fetal risks associated
with a prolonged latent phase of labor. J Obstet Gynaecol {[}Lahore{]}.
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{[}3{]}. Chelmow D, Kilpatrick SJ, Laros RK. Maternal and neonatal
outcomes after prolonged latent phase. Obstet Gynecol. 1993
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{[}4{]}. Friedman E. Labor: Clinical Evaluation and Management. New
York: Appleton-Century Crofts; 1978.

{[}5{]}. The American College of Obstetricians and Gynecologists.
Approaches to Limit Intervention During Labor and Birth, Number 766
{[}Internet{]}. 2019. Available from:
https://www.acog.org/clinical/clinical-guidance/committee-
opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth

{[}6{]}. World Health Organization. Division of Family Health. Maternal
Health and Safe Motherhood Programme Preventing prolonged labor: A
practical guide. The partograph Part I: Principles and Strategy. Geneva;
1994.

{[}7{]}. Friedman EA. Labor: Clinical Evaluation and Management. New
York+: \selectlanguage{english}Appleton- Century-Crofts; 1978.

{[}8{]}. Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in
nulliparous women. In: American Journal of Obstetrics and Gynecology.
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{[}9{]}. Laughon SK, Berghella V, Reddy UM, Sundaram R, Lu Z, Hoffman
MK. Neonatal and maternal outcomes with a prolonged second stage of
labor. In: Obstetrics and Gynecology.2014. p. 57--67.

{[}10{]}. American College of Obstetricians and Gynecologists. Obstetric
Care Consensus No. 1. Obstet Gynecol. 2014 Mar;123{[}3{]}:693--711.

{[}11{]}. WHO. WHO recommendation on definitions of the late nt and
active first stages of labor. 2018;{[}February{]}:1--9.

{[}12{]}. Kaufman DW, Kelly JP, Rosenberg L, Anderson TE, Mitchell AA.
Recent patterns of medication use in the ambulatory adult population of
the United States: The Slone survey. J Am Med Assoc. 2002;

{[}13{]}. Onah LN, Dim CC, Nwagha UI, Ozumba BC. Effect of early
amniotomy on the outcome of spontaneous labor: A randomized controlled
trial of pregnant women in Enugu, south- east Nigeria. Afr Health Sci.
2015;

{[}14{]}. Ajadi MA, Kuti O, Orji EO, Ogunniyi SO, Sule SS. The effect of
amniotomy on the outcome of spontaneous labor in an uncomplicated
pregnancy. J Obstet Gynaecol {[}Lahore{]}. 2006;

{[}15{]}. Shepherd A, Cheyne H. The frequency and reasons for vaginal
examinations in labor. Women and Birth. 2013;

{[}16{]}. Anant M, Bindra V, Mukherji J. The impact of cervical dilation
at admission on labor outcomes. Int Res J Pharm. 2016
Nov;7{[}11{]}:43--6.

{[}17{]}. Mikolajczyk RT, Zhang J, Grewal J, Chan LC, Petersen A, Gross
MM. Early versus Late Admission to Labor Affects Labor Progression and
Risk of Cesarean Section in Nulliparous Women. Front Med. 2016 Jun;3.

{[}18{]}. Spong CY, Berghella V, Wenstrom KD, Mercer BM, Saade GR.
Preventing the first cesarean delivery: summary of a joint Eunice
Kennedy Shriver National Institute of Child Health and Human
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of Obstetricians and Gynecologists Workshop. Obstet Gynecol. 2012
Nov;120{[}5{]}:1181 --93.

{[}19{]}. Neal JL, Lowe NK, Ahijevych KL, Patrick TE, Cabbage LA, Corwin
EJ. ``Active Labor'' Duration and Dilation Rates Among Low-Risk,
Nulliparous Women With Spontaneous Labor Onset: A Systematic Review. J
Midwifery Women's Heal. 2010;55{[}4{]}:308--18.

{[}20{]}. Oladapo OT, Souza JP, Fawole B, Mugerwa K, Perdon\selectlanguage{ngerman}á G, Alves D,
et al. Progression of the first stage of spontaneous labor: A
prospective cohort study in two sub-Saharan African countries. PLoS Med.
2018;15{[}1{]}.

{[}21{]}. Oláh KS, Steer PJ. The use and abuse of oxytocin. Obstet
Gynaecol. 2015 {[}4{]}:265--71.

{[}22{]}. Souza J, Oladapo O, Fawole B, Mugerwa K, Reis R,
Barbosa-Junior F, et al. Cervical dilatation over time is a poor
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{[}23{]}. Degani N, Sikich N. Caesarean Delivery Rate Review: An
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2015;15{[}9{]}:1--58.

Table 1\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
& & Cervical Dilation & Cervical Dilation &\tabularnewline
\midrule
\endhead
& & 4cm (90) & 6cm (90) & P value\tabularnewline
Age in years & Mean (SD) & 26 (5) & 26 (5) & 0.239\tabularnewline
Education & Primary & 22 (24.4) & 22 (24.4) & Reference\tabularnewline
& Secondary & 38 (42.2) & 36 (40.0) & 0.887\tabularnewline
& Tertia ry & 30 (33.3) & 32 (35.6) & 0.870\tabularnewline
Employment & Employed & 48 (53.3) & 37 (41.1) & 0.101\tabularnewline
& Unemployed & 42 (46.7) & 53 (58.9) & 0.101\tabularnewline
Parity & Primigravida & 39 (43.3) & 41 (45.6) & 0.764\tabularnewline
& Multigravida & 51 (56.7) & 49 (54.4) & 0.764\tabularnewline
Determination Gestation & Dates & 74 (82.2) & 76 (84.4) &
Reference\tabularnewline
& Scan & 16 (17.8) & 12 (13.3) & 0.448\tabularnewline
& Palpation & 0 (0.0) & 2 (2.2) &\tabularnewline
Status of Membrane & Absent & 18 (20.0) & 19 (21.1) &
Reference\tabularnewline
& Flat & 59 (65.6) & 39 (43.3) & 0.226\tabularnewline
& Bulging & 13 (14.4) & 32 (35.6) & 0.066\tabularnewline
Number of living Children & Mean (SD) & 1 (1) & 1 (1) &\tabularnewline
Number of ANC Visits & Mean (SD) & 5 (2) & 4 (2) &\tabularnewline
\vtop{\hbox{\strut Gestational age in completed}\hbox{\strut Weeks)}} &
Mean (SD) & 39 (1) & 39 (2) &\tabularnewline
*SD: Standard deviation, ANC: Antenatal clinic & *SD: Standard
deviation, ANC: Antenatal clinic & *SD: Standard deviation, ANC:
Antenatal clinic & *SD: Standard deviation, ANC: Antenatal clinic & *SD:
Standard deviation, ANC: Antenatal clinic\tabularnewline
\bottomrule
\end{longtable}

Table 2\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Cervical Dilation\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Cervical Dilation\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 cm (90)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 cm (90)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
RR (95\% CI)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
P-value\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Oxytocin\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38 (43.3)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
24 (26.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.39 (1.03-1.84)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Amniotomy\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
70 (77.8)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
55 (61.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.54 (1.08-2.30)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Episiotomy\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
15 (16.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
20 (22.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.82 (0.52-1.19)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.34\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vaginal Examinations\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
3 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mode of Delivery\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Vaginal\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
76 (84.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
80 (88.9)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Reference\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Caesarian\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
14 (15.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (11.1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.19 (0.77-1.64)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.308\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Perineal Tears\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
42 (46.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
38 (42.2)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.09 (0.81-1.46)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.549\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Cervical Tears\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
4 (4.4)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0 (0.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Post-Partum Hemorrhage (PPH)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (10.0)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
5 (5.6)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.31 (0.77-1.82)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.266\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
APGAR Score after five minutes\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
(Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
9 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.802\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
APGAR Score after ten minutes (Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
APGAR Score after ten minutes (Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
10 (1)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
0.875\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
NBU admission\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (6.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
6 (6.7)\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
1.000\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Bight Weight of Babies in grams (Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Bight Weight of Babies in grams (Mean (SD)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3355 (417)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3310 (464)\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
0.501\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/ERC-approval/ERC-approval}

\end{center}
\end{figure}

\textbf{Hosted file}

\verb`flow chart showing recruitment of participants.docx`  available at \url{https://authorea.com/users/726281/articles/708882-obstetric-outcomes-among-low-risk-parturients-when-active-phase-of-labor-is-defined-at-a-cervical-dilatation-of-6-versus-4-centimetres-at-kenyatta-national-hospital-kenya}

\selectlanguage{english}
\FloatBarrier
\end{document}

