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Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.
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Published in final edited form as:

Obstet Gynecol. 2016 March ; 127(3): 489–495. doi:10.1097/AOG.0000000000001299.

Association of Cervical Effacement With the Rate of Cervical

Change in Labor Among Nulliparous Women
Elizabeth S. Langen, M.D., Steven J. Weiner, M.S., Steven L. Bloom, M.D., Dwight J. Rouse,
M.D., Michael W. Varner, M.D., Uma M. Reddy, M.D., M.P.H., Susan M. Ramin, M.D., Steve N.
Caritis, M.D., Alan M. Peaceman, M.D., Yoram Sorokin, M.D., Anthony Sciscione, D.O.,
Marshall W. Carpenter, M.D., Brian M. Mercer, M.D., John M. Thorp Jr., M.D., Fergal D.
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Malone, M.D., Jay D. Iams, M.D., and for the Eunice Kennedy Shriver National Institute of
Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU)
Network*
From the Departments of Obstetrics and Gynecology of Stanford University, Stanford, CA
(E.S.L.); University of Texas Southwestern Medical Center, Dallas, TX (S.L.B.); University of
Alabama at Birmingham, Birmingham, AL (D.J.R.); University of Utah Health Sciences Center,
Salt Lake City, UT (M.W.V.); The University of Texas Health Science Center at Houston-Children’s
Memorial Hermann Hospital, Houston, TX (S.M.R.); University of Pittsburgh, Pittsburgh, PA
(S.N.C.); Northwestern University, Chicago, IL (A.M.P.); Wayne State University, Detroit, MI (Y.S.);
Drexel University, Philadelphia, PA (A.S.); Brown University, Providence, RI (M.W.C.); MetroHealth
Medical Center- Case Western Reserve University, Cleveland, OH (B.M.M.); University of North
Carolina at Chapel Hill, Chapel Hill, NC (J.M.T.); Columbia University, New York, NY (F.D.M.); The
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Ohio State University, Columbus, OH (J.D.I.); and the George Washington University Biostatistics
Center, Washington, DC (S.J.W.); and Eunice Kennedy Shriver National Institute of Child Health
and Human Development, Bethesda, MD (U.M.R.)

Abstract
Objective—To assess the association of cervical effacement with the rate of intrapartum cervical
change among nulliparous women.

Methods—We conducted a secondary analysis of a prospective trial of intrapartum fetal pulse

oximetry. For women who had vaginal deliveries, interval censored regression was used to
estimate the time to dilate at one centimeter intervals. For each given centimeter of progressive
cervical dilation, women were divided into those who had achieved 100% cervical effacement and
those who had not. The analysis was performed separately for women in spontaneous labor and
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those who were given oxytocin.

Results—Three thousand nine hundred two women were included in this analysis, 1,466 (38%)
who underwent labor induction, 1,948 (50%) who underwent labor augmentation (combined for
the analysis), as well as 488 (13%) who labored spontaneously. For women in spontaneous labor,
the time to dilate 1 cm was shorter for those who were 100% effaced starting at 4 cm of cervical

Corresponding Author: Elizabeth S. Langen, MD, Obstetrics and Gynecology, Floor 9 Room 109 VVWH, 1540 W. Hospital Drive,
SPC 4264, Ann Arbor, MI 48109-4264, (650) 799-8784, [email protected].
*For a list of other members of the NICHD MFMU Network, see Appendix 1 online at http://links.lww.com/xxx.
Presented at the Society for Maternal-Fetal Medicine, San Francisco, California, February 11–16, 2013.
 Langen et al. Page 2

dilation (P = 0.01 to P < 0.001). For women who received oxytocin, the time to dilate 1 cm was
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shorter for those who were 100% effaced throughout labor (P < 0.001).

Conclusion—The rate of cervical dilation among nulliparous women is associated with not only
the degree of cervical dilation, but also with cervical effacement.

Clinical Trial Registration—ClinicalTrials.gov, www.clinicaltrials.gov, NCT00098709.

Précis
Achievement of 100% cervical effacement is associated with a shorter median time of dilation
among nulliparous women.

Introduction
In recent years, the Consortium on Safe Labor (CSL) labor curves have replaced the
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traditional labor curve proposed by Friedman (1–3, 4). The importance of understanding
normal labor progression was highlighted by Rouse and colleagues in 1999 when they
challenged the idea that arrest of labor could be diagnosed after only 2 hours of inadequate
cervical change (5). Rouse and colleagues found that 60% of women who were given 2
additional hours to demonstrate cervical change went on to deliver vaginally. This
observation highlighted that an inappropriate model of normal labor can lead to an over
diagnosis of arrest disorders of labor and subsequently unnecessary cesarean deliveries. The
American College of Obstetrics and Gynecology and the Society for Maternal-Fetal
Medicine consensus statement on the Safe Prevention of the Primary Cesarean Delivery
recommends using the CSL labor curves to define normal labor progress (6).

The CSL labor curve emphasizes the notion that active labor may not begin until 6 cm of
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cervical dilation. The CSL labor curve does not specifically address the role of cervical
effacement in predicting normal rates of cervical change. Cervical effacement, however, has
been used by many authors as a traditional part of the definition of active labor (7) and
clinical experience would suggest that cervical effacement plays a role in labor progress.
The current study assesses the association of cervical effacement with the rate of intrapartum
cervical change among nulliparous women.

Materials and Methods

We conducted a secondary analysis of a prospective trial of fetal pulse oximetry conducted
by the National Institute of Child Health and Human Development Maternal-Fetal Medicine
Units Network (8). In the original study, women were eligible to participate if they were
nulliparous with a singleton, cephalic, living fetus at or beyond 36 weeks of gestation.
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Exclusion criteria included a planned cesarean delivery, maternal temperature ≥38°C,

maternal HIV or hepatitis infection, maternal heart or renal disease and diabetes mellitus
requiring insulin. Women were enrolled with cervical dilations between 2 and 6 cm. Labor
was managed according to the usual clinical practice at the participating centers. The
original study was approved by the institutional review board at each participating Maternal-
Fetal Medicine Units Network center and written informed consent was obtained from each
participant. Data were collected by trained research nurses.

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For the current study, we included all participants who had a vaginal delivery of a live-born
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infant. There were no stillbirths. A separate analysis included those participants who had a
cesarean delivery for an arrest disorder. We abstracted data on patient race, body mass index,
use of epidural anesthesia, use of oxytocin for labor induction or augmentation, use of
cervical ripening agents, and details of labor progression including cervical dilation and
effacement at each exam.

When comparing demographic and other patient characteristics between those with induced
or augmented labor to those with spontaneous labor, the Wilcoxon rank-sum test was used to
compare continuous variables, and categorical variables were compared by means of the chi-
square or Fisher's exact test, as appropriate. Analyses are presented separately for those with
induced or augmented labor and those with spontaneous labor. Cervical effacement was
recorded as a percentage of effacement (0–100%). Given that measurements of cervical
effacement can often vary significantly by observer (9, 10) as well as the presumed clinical
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importance of achieving 100% cervical effacement, women were stratified into those who
had achieved 100% cervical effacement and those who had not at each cervical exam. We
used interval-censored regression to estimate the time to progress from one integer
centimeter dilation to the next, assuming a log-normal distribution (11). Since cervical
exams are often irregularly spaced, an individual may have progressed several centimeters of
dilation from one exam to the next. Therefore, interval-censoring allows an estimation of the
time between any two one-centimeter measurements (e.g., from 4 cm to 5 cm), even when
those precise measurements were not observed for all patients. The median, 5th percentile,
and 95th percentile were calculated for the time to progress between every two successive
dilations, and the times for those at 100% effacement versus less than 100% effacement
were compared with a Wald test using procedure LIFEREG in SAS Version 9.3. Using these
same methods, a model was constructed with the covariates of 100% cervical effacement
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(yes vs. no), use of regional anesthesia (yes vs. no), maternal BMI, age, and race (white vs.
all others). To calculate the cumulative time from 4 cm, 5 cm, and 6 cm to complete cervical
dilation, right-censored regression assuming a log-normal distribution was used, with
effacement assessed at the initial cervical dilation. Among women whose labor was induced,
a model was constructed with additional terms for mechanical ripening, medical ripening,
and their interactions with 100% cervical effacement. Finally, these analyses were repeated
for the women who had cesarean deliveries for arrest disorders.

Results
The original trial randomized 5,341 women. Of these, 1,439 women had a cesarean delivery,
leaving 3,902 women with vaginal deliveries in this analysis. There were no stillbirths. The
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current cohort included 1,466 (38%) women who underwent labor induction and 1,948
(50%) who underwent labor augmentation with oxytocin (combined for the analysis), as
well as 488 (13%) women who labored spontaneously. Women in spontaneous labor were
different from those women who were augmented or induced in most baseline
characteristics, though the absolute magnitude of the differences was small (Table 1).
Missing information on cervical effacement was rare. Fewer than 1% of cervical
examinations were missing an effacement measurement.

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For women who received oxytocin during labor, the time to dilate from each centimeter to
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the next was significantly shorter for women who were 100% effaced compared with those
who were not (Table 2). For women who had spontaneous labor, the time to dilate from 2 to
3 cm and 3 to 4 cm did not differ by effacement, while the time to dilate from 4 to 5 cm, 5 to
6 cm, 6 to 7 cm, 7 to 8 cm, 8 to 9 cm and 9 to 10 cm was significantly shorter for those who
were 100% effaced vs. those who were not (Table 2). When potential confounders including
maternal race, age, BMI at the time of delivery, and use of regional anesthesia were
considered in the model, the trend remained unchanged (Table 3).

For women who received oxytocin during labor, the time to reach 10 cm of cervical dilation
from 4, 5, and 6 cm respectively was longer for those women who had not yet achieved
100% cervical effacement at the starting dilation. For women in spontaneous labor, this was
true for 4 and 5 cm of cervical dilation. However, the 100% cervical effacement at 6 cm
dilation was not associated with a significantly shorter duration to reach 10 cm dilation
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(Table 4).

Among women whose labors were induced, 370 (25.2%) were medically ripened and 243
(16.6%) were mechanically ripened. Medical ripening shortened the time to dilate from 6 to
7 cm beyond the effect of 100% effacement (p=0.03), but not at other dilations. Mechanical
ripening shortened the time to dilate from 9 to 10 cm beyond the effect of 100% effacement
(p=0.01), but not at other dilations.

From the 1,439 women who had a cesarean delivery, we performed an analysis of the 985
who delivered by cesarean for an arrest disorder in the first (n=773) or second (n=212) stage
of labor, despite the use of oxytocin. Those women with 100% effacement had consistently
faster rates of cervical dilation compared with those at less than 100% (Tables 5–6).
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Discussion
Labor is defined as “uterine contractions that bring about demonstrable effacement and
dilation of the cervix.” (12) While labor involves both dilation and effacement, existing labor
curves demonstrate only the rate of cervical change in relationship to cervical dilation (1–4).
We sought to investigate how cervical effacement might influence expectations of the rate of
cervical change. In this large cohort of nulliparous women, the rate of cervical dilation in
labor was significantly associated with achieving 100% cervical effacement.

Much attention has been paid to when the transition to active labor begins. The CSL data
suggest that active labor may not begin until 6 cm (1, 6). This strict criterion, however, has
been challenged by Cohen and Friedman who “discouraged the use of any specific degree of
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dilation for the identification of the active phase” (13). They argue that the timing of active
labor depends on assessment of the individual patient, but is typically between 3 and 6 cm.
Our observations suggest that combining the assessment of cervical dilation with cervical
effacement may allow us to better define the beginning of active labor. If our findings are
confirmed, future labor guidelines may wish to include the combination of cervical dilation
and effacement when defining active labor.

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Our analyses consistently demonstrated that achievement of 100% cervical effacement was
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associated with faster labor progression. Even when the comparisons did not reach statistical
significance, the trend was in this direction. The instances that were not statistically
significant occurred in those with spontaneous labor, which were a minority of our cohort. In
particular, the availability of data at earlier dilations was scarce in this group, likely
secondary to fewer women in spontaneous labor having been admitted to labor and delivery
prior to more advanced cervical dilations. Overall, these smaller numbers do limit our ability
to comment on this group.

Strengths of this study include the prospective collection of data from a large number of
nulliparous women from multiple institutions. However, measuring the rate of labor progress
was not the focus of the study, and there was no protocol regarding the frequency of
examinations or the experience level of those performing them. The uneven frequency is
partially addressed through our statistical methods, but potential observer errors are not. By
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separating women into those who were 100% effaced vs. not, we hoped to eliminate some of
the inter-observer variability that is inherent in measuring cervical effacement (9, 10). This
decision was designed to provide more-reproducible results, while allowing us to provide
insight into how cervical effacement is associated with labor progression.

While those who have cesarean deliveries for arrest disorders have slower labor progression,
we wished to address the basic question regarding cervical effacement in this group as well.
Therefore, we repeated the analysis in this group and found that the pattern of more rapid
cervical dilation was associated with achievement of 100% cervical effacement in these
women as well. While the absolute range of time to dilate from one centimeter to the next
may differ between those with a vaginal or cesarean delivery, the association between rate of
cervical change and 100% cervical effacement was consistently observed.
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Our study is applicable only to women who share characteristics with the women in the
original study. We do not have data on multiparous women or diabetic women. Also, our
analysis was limited to those who arrived at the hospital and agreed to participate in the
randomized trial before reaching 7 cm dilation. Those missed would include women whose
labor was progressing more quickly and therefore without sufficient opportunity to enroll in
the trial. The result is an unknown lengthening of the time we report for labor progression.
Lastly, those who chose to participate in the randomized trial may be different from those
who did not.

Finally, our analysis combined women who had labor inductions with those who had labor
augmentations. This was done because the distinction between these groups can be difficult
to make and there is likely substantial overlap. The combination of these two groups is
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supported by the findings by Harper and colleagues who analyzed the labor progress of
women with augmented and induced labors and found them to be similar (14).

Labor involves a complex process of both cervical dilation and effacement. As we strive to
safely reduce the number of unnecessary cesarean deliveries, we hope that an understanding
of how cervical effacement may impact the expected rate of cervical change in labor will
allow clinicians to more appropriately diagnose arrest disorders.

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Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The authors thank Allison Todd, M.S.N., R.N. for protocol development and coordination between clinical research
centers; Elizabeth Thom, Ph.D. for protocol development, data management and statistical analysis; and Kenneth J.
Leveno, M.D. and Catherine Y. Spong, M.D. for protocol development and oversight.

Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development
(NICHD) [HD21410, HD27860, HD27869, HD27915, HD27917, HD34116, HD34136, HD34208, HD40485,
HD40500, HD40512, HD40544, M01 RR00080 (NCRR); HD40545, HD40560, and HD36801]. Comments and
views of the authors do not necessarily represent views of the NICHD.

References
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1. Zhang J, Troendle JF, Yancy MK. Reassessing the labor curve in nulliparous women. Am J Obstet
Gynecol. 2002; 187(4):824–828. [PubMed: 12388957]
2. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD, et al. Contemporary
patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol. 2010; 116(6):1281–
1287. [PubMed: 21099592]
3. Laughon SK, Branch DW, Beaver J, Zhang J. Changes in labor patterns over 50 years. Am J Obstet
Gynecol. 2012; 206(5):419.e1–419.e9. [PubMed: 22542117]
4. Friedman EA. The graphic analysis of labor. Am J Obstet Gynecol. 1954; 68:1558–1575.
5. Rouse DJ, Owen J, Hauth JC. Active-phase labor arrest: Oxytocin augmentation for at least 4 hours.
Obstet Gynecol. 1999; 93(3):323–328. [PubMed: 10074971]
6. Caughey AB, Cahill AG, Guise JM, Rouse DJ. ACOG, SMFM. Safe prevention of the primary
cesarean delivery. Am J Obstet Gynecol. 2014; 210(3):179–193. [PubMed: 24565430]
7. Laughon SK, Zhang J, Troendle J, Sun J, Reddy UM. Using a simplified Bishop score to predict
vaginal delivery. Obstet Gynecol. 2011; 117(4):805–811. [PubMed: 21383643]
Author Manuscript

8. Bloom SL, Spong CY, Thom E, Varner MW, Rouse DJ, Weininger S, et al. Fetal pulse oximetry and
cesarean delivery. N Engl J Med. 2006; 355(21):2195–2202. [PubMed: 17124017]
9. Holcomb WL, Smeltzer JS. Cervical effacement: variation in belief among clinicians. Obstet
Gynecol. 1991; 78(1):43–45. [PubMed: 2047066]
10. Huhn KA, Brost BC. Accuracy of simulated cervical dilation and effacement measurements among
practitioners. Am J Obstet Gynecol. 2004; 191:1797–1799. [PubMed: 15547567]
11. Vahratian A, Troendle FJ, Seiga-Riz AM, Zhang J. Methodological challenges in studying labour
progression. Paediatr Perinat Epidemiol. 2006; 20:72–78. [PubMed: 16420344]
12. Cunnigham, GF.; Leveno, KJ.; Bloom, SL.; Spong, CY.; Dashe, JS.; Hoffman, BL., et al. Williams
Obstetrics. 24th. New York (NY): McGraw Hill Education; 2014.
13. Cohen WR, Friedman EA. Perils of the new labor management guidelines. Am J Obstet Gynecol.
2015; 212(4):420–427. [PubMed: 25218127]
14. Harper LM, Caughey AB, Odibo AO, Roehl KA, Zhao Q, Cahill AG. Normal progress of induced
labor. Obstet Gynecol. 2012; 119(6):1113–1118. [PubMed: 22569121]
Author Manuscript

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Table 1

Patient demographics and labor characteristics *

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Characteristic Overall Induced/Augmented Spontaneous p-value†

(n=3.902) (n=1,466/1.948) (n=488)

Maternal race <0.001

Black or African American 1,190 (30.5%) 1,051 (30.8%) 139 (28.5%)
White 2,041 (52.3%) 1,856 (54.4%) 185 (37.9%)
Other 671 (17.2%) 507 (14.9%) 164 (33.6%)
Ethnicity
Hispanic/Latina 952 (24.4%) 756 (22.1%) 196 (40.2%) <0.001

Maternal age (years) 23.0 ± 5.2 23.3 ± 5.3 21.6 ± 4.6 <0.001

BMI at end of pregnancy <0.001

(kg/m2)
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18.5–24.9 500 (12.9%) 405 (12.0%) 95 (19.6%)

25–29.9 1,452 (37.5%) 1,263 (37.3%) 189 (39.1%)
30–34.9 1,152 (29.8%) 1,026 (30.3%) 126 (26.0%)
>=35 767 (19.8%) 693 (20.5%) 74 (15.3%)
Mean/s.d. 30.9 ± 5.9 31.1 ± 5.9 29.8 ± 5.8

Gestational age at delivery 39.7 ± 1.3 39.7 ± 1.3 39.5 ± 1.2 <0.001
(weeks)

Regional anesthesia 3,695 (94.7%) 3,302 (96.7%) 393 (80.5%) <0.001

Initiated before 3,349 (85.8%) 3,027 (88.7%) 322 (66.0%) <0.001
randomization

Delivery method 0.002

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Spontaneous vaginal 3,122 (80.0%) 2,708 (79.3%) 414 (84.8%)

Forceps 456 (11.7%) 403 (11.8%) 53 (10.9%)
Vacuum 324 (8.3%) 303 (8.9%) 21 (4.3%)

Dilation at first exam (cm) 3 [2–4] 2 [1–3] 4 [3–4] <0.001

Effacement at first exam (%) 75 [50–90] 75 [50–90] 90 [80–100] <0.001

Number of cervical exams per 6 [5–8] 7 [5–8] 5 [4–6] <0.001

patient

Time from one exam to the 89 [52–140] 90 [52–140] 80 [45–125] <0.001

next (mins)

Birth weight (grams) 3,315 ± 445 3,323 ± 448 3,265 ± 421 0.001
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BMI, body mass index

*
Data are mean ± standard deviation, n (%), or median [interquartile range]
†
Comparing induced and augmented vs. spontaneous labors. Continuous variables compared using the Wilcoxon rank-sum test and categorical
variables using the chi-square test.

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Table 2

Median time (minutes) to increase to the next centimeter cervical dilation, comparing those completely effaced with those less than completely effaced.*

Induced/Augmented Labor Spontaneous Labor

(n=3,414) (n=488)
Langen et al.

Cervic
al 100% <100% 100% <100%
dilatio effaced effaced effaced effaced
n median median median median
interva (5th–95th (5th–95th (5th–95th (5th–95th
l (cm) N† percentile) N† percentile) p-value‡ N† percentile) N† percentile) p-value‡
2–3 90 34.8 1655 90.6 <0.001 16 39.6 77 37.6 0.89
(5.2–232.6) (13.6–605.5) (10.2–154.1) (9.7–146.2)

3–4 293 38.5 2385 84.1 <0.001 47 32.7 180 40.2 0.39
(6.9–216.5) (15.0–472.6) (8.0–134.5) (9.8–165.5)

4–5 707 40.8 2533 80.6 <0.001 137 41.4 258 59.5 0.01
(6.9–242.3) (13.6–477.9) (8.0–215.2) (11.4–309.0)

5–6 1194 38.2 2191 72.7 <0.001 223 32.1 243 56.7 <0.001
(6.0–243.4) (11.4–463.7) (6.0–173.5) (10.5–306.1)

6–7 1720 31.5 1693 61.6 <0.001 321 33.7 167 57.2 <0.001
(4.9–203.1) (9.5–397.7) (6.8–168.1) (11.5–285.2)

7–8 1974 24.5 1440 52.2 <0.001 339 27.0 149 43.6 <0.001
(3.4–174.4) (7.3–371.6) (4.6–157.9) (7.5–254.8)

8–9 2285 19.2 1129 44.8 <0.001 376 22.4 112 41.8 <0.001
(2.6–140.2) (6.1–327.0) (3.8–130.4) (7.2–243.4)

9–10 2738 17.5 676 44.2 <0.001 427 15.9 61 47.4 <0.001
(2.3–132.2) (5.9–333.2) (2.4–106.4) (7.1–317.8)

*
Effacement assessed at the earlier of any two successive examinations.

Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.

†
Represents the number of women with available cervical measurement data at the specified range of cervical dilation and level of effacement. Note that the effacement was assessed at the earlier of any two
successive examinations, and therefore may have been measured before the lower end of the interval if no examination was performed at the lower end itself.
‡
Compares those completely effaced with those not yet completely effaced using interval-censored regression and a Wald test.
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Table 3

Median time (minutes) to increase to the next centimeter cervical dilation, comparing those completely effaced with those less than completely effaced,
with adjustment for maternal body mass index, race, age, and use of epidural anesthesia.*
Langen et al.

Induced/Augmented Labor Spontaneous Labor

(n=3,387)† (n=484)†

Cervic
al
dilatio 100% <100% 100% <100%
n effaced effaced effaced effaced
interva median median median median
l (5th–95th (5th–95th p- (5th–95th (5th–95th p-
(cm) N‡ percentile) N‡ percentile) value§ N‡ percentile) N‡ percentile) value§
2–3 90 36.2 1645 92.5 <0.001 16 39.5 76 36.3 0.93
(5.6–234.5) (14.3–598.8) (10.8–143.7) (10.0–132.4)

3–4 293 39.4 2363 85.4 <0.001 47 33.6 179 39.4 0.23
(7.2–216.5) (15.6–468.6) (9.0–126.2) (10.5–147.8)

4–5 703 42.5 2510 83.0 <0.001 135 41.5 257 60.6 0.01
(7.5–241.0) (14.6–470.9) (8.2–210.4) (12.0–307.0)

5–6 1186 40.1 2172 75.4 <0.001 220 33.0 242 58.3 <0.001
(6.6–242.8) (12.5–456.3) (6.3–171.9) (11.2–303.6)

6–7 1705 32.4 1681 62.7 <0.001 317 35.9 167 59.0 <0.001
(5.2–203.2) (10.0–394.1) (7.7–167.7) (12.6–276.0)

7–8 1956 25.2 1431 53.1 <0.001 335 29.0 149 44.9 0.001
(3.6–174.1) (7.7–367.6) (5.3–158.8) (8.2–245.4)

8–9 2264 19.6 1123 45.3 <0.001 372 24.0 112 42.9 <0.001
(2.7–140.7) (6.3–324.7) (4.4–131.3) (7.8–234.5)

9–10 2713 17.9 674 44.8 <0.001 423 16.5 61 48.4 <0.001
(2.4–132.7) (6.0–332.3) (2.5–106.7) (7.5–313.7)

Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.

*
Effacement assessed at the earlier of any two successive examinations.
†
Thirty-one women (27 with induced or augmented labor; 4 with spontaneous labor) are not included in this analysis due to missing data for maternal body mass index.
‡
Represents the number of women with available cervical measurement data at the specified range of cervical dilation and level of effacement. Note that the effacement was assessed at the earlier of any two
successive examinations, and therefore may have been measured before the lower end of the interval if no examination was performed at the lower end itself.
§
Compares those completely effaced with those not yet completely effaced using interval-censored regression and a Wald test.
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Table 4

Median time (minutes) to reach 10 cm of cervical dilation from 4, 5, and 6 cm respectively, comparing those completely effaced versus less than
completely effaced.*
Langen et al.

Induced/Augmented Labor Spontaneous Labor

(n=3,414) (n=488)

Cervic 100% <100% 100% <100%

al effaced effaced effaced effaced
dilatio median median median median
n (5th–95th (5th–95th (5th–95th (5th–95th p-
change percentil percentil p- percentil percentil value
(cm) N† e) N† e) value‡ N† e) N† e) ‡
4–10 591 304.0 1881 370.4 <0.001 117 299.0 192 340.1 0.01
(122.1– (148.8– (144.2– (164.1–
757.0) 922.3) 619.6) 704.8)

5–10 849 224.4 1139 255.3 <0.001 142 199.5 117 238.3 0.005
(79.4– (90.3– (87.0– (103.9–
634.2) 721.7) 457.7) 546.5)

6–10 1079 150.3 663 178.0 <0.001 230 145.6 84 167.9 0.07
(45.9– (54.3– (52.5– (60.5–
492.7) 583.3) 403.8) 465.7)

*
Effacement assessed at the earlier of any two successive examinations. Each row of the table includes only those women with a cervical measurement at the starting dilation (i.e., 4, 5, or 6 centimeters).
†
Represents the number of women with available cervical measurement data at the specified range of cervical dilation and level of effacement. Effacement is classified per the examination at the start of the
dilation interval.
‡
Compares those completely effaced with those not yet completely effaced using right-censored regression and a Wald test.

Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.

Page 10
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Table 5

Median time (minutes) to increase to the next centimeter cervical dilation among 985 women with induced or augmented labor who had a cesarean
delivery for dystocia, comparing those completely effaced with those less than completely effaced.*
Langen et al.

Cervical
dilation 100% effaced <100% effaced
interval median median
(cm) N† (5th–95th percentile) N† (5th–95th percentile) p-value‡
2–3 28 50.0 601 111.4 0.007
(7.1–353.2) (15.8–786.7)

3–4 89 48.6 741 102.4 <0.001

(8.5–279.6) (17.8–589.2)

4–5 201 80.3 626 108.4 0.001

(15.8–407.1) (21.4–549.8)

5–6 264 55.7 376 86.0 <0.001

(9.2–335.9) (14.3–518.3)

6–7 290 46.8 180 78.5 <0.001

(7.9–276.4) (13.3–463.9)

7–8 260 38.5 104 63.0 0.001

(6.5–227.6) (10.7–372.3)

8–9 241 26.5 53 61.6 <0.001

(4.4–158.4) (10.3–367.8)

9–10 199 32.5 13 100.5 <0.001

(5.8–182.1) (18.0–562.5)

*
Cesarean delivery for arrest disorders from both the first and second stages of labor. Effacement assessed at the earlier of any two successive examinations.
†
Represents the number of women with available cervical measurement data at the specified range of cervical dilation and level of effacement. Note that the effacement was assessed at the earlier of any two
successive examinations, and therefore may have been measured before the lower end of the interval if no examination was performed at the lower end itself.

Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.

‡
Compares those completely effaced with those not yet completely effaced using interval-censored regression and a Wald test.
Page 11
 Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Table 6

Median time (minutes) to increase to the next centimeter cervical dilation among 974 women who had a cesarean delivery for dystocia, comparing those
completely effaced versus with those than completely effaced, with adjustment for maternal body mass index, race, age, and use of epidural anesthesia.*
Langen et al.

Cervical
dilation 100% effaced <100% effaced
interval median median p-
(cm) N† (5th–95th percentile) N† (5th–95th percentile) value‡
2–3 28 54.0 593 116.2 0.01
(8.0–364.0) (17.2–783.3)

3–4 87 49.2 733 102.5 <0.001

(8.6–280.6) (18.0–583.9)

4–5 197 82.1 620 109.6 0.002

(16.6–406.5) (22.1–542.9)

5–6 259 58.2 372 88.8 <0.001

(10.1–334.4) (15.4–510.2)

6–7 286 48.4 178 79.4 <0.001

(8.5–276.6) (13.9–453.5)

7–8 256 39.5 103 63.1 0.003

(6.8–228.9) (10.9–365.9)

8–9 237 26.4 53 61.5 <0.001

(4.4–158.9) (10.2–369.8)

9–10 196 31.9 13 100.1 0.001

(5.6–180.4) (17.7–565.6)

*
Cesarean delivery for arrest disorders from both the first and second stages of labor. Effacement assessed at the earlier of any two successive examinations. Body mass index was unavailable for 11 women,
and as a result do not appear in this table.
†
Represents the number of women with available cervical measurement data at the specified range of cervical dilation and level of effacement. Note that the effacement was assessed at the earlier of any two
successive examinations, and therefore may have been measured before the lower end of the interval if no examination was performed at the lower end itself.

Obstet Gynecol. Author manuscript; available in PMC 2017 March 01.

‡
Compares those completely effaced with those not yet completely effaced using interval-censored regression and a Wald test.
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