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.