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.