Int. J. Med. Sci. 2018, Vol.

15 549

Ivyspring
International Publisher International Journal of Medical Sciences
2018; 15(6): 549-556. doi: 10.7150/ijms.23505
Research Paper

Cervical Dilatation Curves of Spontaneous Deliveries in

Pregnant Japanese Females
Yusuke Inde1, Akihito Nakai1, Atsuko Sekiguchi1, Masako Hayashi1, Toshiyuki Takeshita2
1. Department of Obstetrics and Gynecology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
2. Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan

 Corresponding author: Prof. Akihito Nakai, Department of Obstetrics and Gynecology, Nippon Medical School Tama-Nagayama Hospital, 1-7-1 Nagayama,
Tama, Tokyo 206-8512, Japan. E-mail: [email protected], TEL: +81-42-371-2111, FAX: +81-42-372-7372

© Ivyspring International Publisher. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY-NC) license
(https://creativecommons.org/licenses/by-nc/4.0/). See http://ivyspring.com/terms for full terms and conditions.

Received: 2017.10.26; Accepted: 2018.02.07; Published: 2018.03.09

Abstract
Background: Although cervical dilatation curves are crucial for appropriate management of labor
progression, abnormal labor progression and obstetric interventions were included in previous and
widely-used cervical dilatation curves. We aimed to describe the cervical dilatation curves of normal
labor progression in pregnant Japanese females without abnormal labor progression and obstetric
interventions.
Methods: We completed retrospective obstetric record reviews on 3172 pregnant Japanese females
(parity = 0, n = 1047; parity = 1, n = 1083; parity ≥ 2, n = 1042), aged 20 to 39 years old at delivery, with
pregravid body mass indices of less than 30. All patients underwent spontaneous deliveries with term,
singleton, cephalic and live newborns of appropriate-for-gestational age birthweight, without adverse
neonatal outcomes. We characterized labor progression patterns by examining the relationship between
elapsed times from the full dilatation and cervical dilatation stages, and labor durations by examining the
distribution of time intervals from one cervical dilatation stage, to the next, and ultimately to the full
dilatation.
Results: Fastest cervical changes occurred at 6 cm (primiparas) and 5 cm (multiparas) of dilatation. The
95%tile of labor progression took over 3 hours to progress from 6 cm to 7 cm (primiparas), and over 2
hours to progress from 5 cm to 6 cm (multiparas). The 5%tile of traverse time to the full dilatation, during
the active phase, was less than 1 hour (primiparas) and 0.5 hours (multiparas). At the end of the active
phase, no deceleration phase was observed.
Conclusions: Active labor may not start until 5 cm of dilatation. At the beginning of the active phase,
cervical dilatation was slower than previously described. These results may reduce opportunities for
obstetric interventions during labor progression.
Key words: cervical dilatation, first stage of labor, labor curve, labor management, spontaneous delivery

Introduction
Cervical dilatation curves serve as clinical showed definite criteria for labor progression and
reference for appropriate management of labor duration [3, 4]. However, abnormal labor progression
progression. Inaccurate diagnosis of protracted or and obstetric interventions were included in these
arrested labor may lead to inappropriate obstetric previous, widely-used cervical dilatation curves.
interventions including cesarean section (CS) Past theories on labor progression and duration
deliveries. Considering risks associated with primary may no longer be applicable to those in current
CS and adverse CS-related implications for obstetric practice [5]. Friedman established mean
subsequent pregnancies, primary CS should be labor curves that considered various exogenous, and
avoided if possible [1]. Friedman was the first to depict endogenous, maternal and fetal factors. Besides
the preliminary labor curve [2], and two landmark changes in maternal and fetal characteristics, obstetric
labor curves of primiparas and multiparas which interventions and statistical procedures have impro-

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ved [3, 4]. Recent labor curves by Zhang et al. and anesthesia, oxytocin use, cephalopelvic disproportion,
Suzuki et al. markedly differ from Friedman’s labor placental abruption, non-AGA birthweight, congen-
curves, featuring slower cervical dilatation in the ital anomaly, birth injury, 5-minute Apgar scores
acceleration phase and lack of the deceleration phase lower than 7, neonatal intensive care unit (NICU)
[6, 7]. Their study designs also included variations in admission, and perinatal death. To investigate the
maternal and fetal backgrounds, and included abno- natural history of spontaneous labor progression, we
rmal labor progression and obstetric interventions. established no exclusion criteria for cervical dilatation
Establishment of referential labor curves for at admission or labor duration from admission to
spontaneous deliveries is necessary for appropriate delivery. Among the multiparas, we selected the first
management of labor progression. Various factors delivery to avoid intrapersonal correlation.
which may affect labor progression and duration Clinical definitions were as follows: Gestational
included maternal race and age [8], maternal and fetal age was determined from the first day of the patient’s
body sizes [9], gestational age at delivery [10], twin last menstrual period, and reconfirmed with fetal
gestations [11], obstetric anesthesia [12], oxytocin use crown-rump length, measured by transvaginal
[3, 4], obstetric complications [3, 4], and complicated ultrasound in the first trimester. Fetal presentation
pregnancies [13]. Obstetric anesthesia and oxytocin was assessed before and at admission by transabdo-
use are often considered as optional obstetric minal ultrasound. Onset of labor was defined as onset
interventions during spontaneous deliveries [3–13]. of labor pains, which continued to delivery, with ≤ 10
To develop referential labor curves for normal labor minutes interval between contractions, or ≥ 6 times
progression and duration, we describe spontaneous the number of contractions per hour. Midwives and
cervical dilatation curves, based on standard maternal obstetricians performed cervical dilatation
and fetal populations. measurements in centimeters, commonly at onset of
labor pain, not during intervals between labor pains,
Materials and Methods as directed by institution care standards or guided by
We retrospectively reviewed 3172 obstetric obstetric events such as admission, rupture of the
records of 1047 primiparous and 2125 multiparous membranes, intensive constructions, fetal heart rate
(1083 of parity = 1 and 1042 of parity ≥ 2) pregnant pattern changes, breathing changes, or spontaneous
Japanese females. All patients had spontaneous pushing. However, we could not completely clarify
deliveries with live newborns of appropriate-for- whether all pelvic examinations were taken at onset of
gestational age (AGA) birthweight between January labor pain. Non-pharmacological approaches (e.g.,
2008 and December 2015. Maternal characteristics and nipple stimulation, castor oil and herbs) were not
perinatal outcomes were obtained from six primary conducted. Episiotomy required maternal or fetal
obstetric institutions [Berun Forest Clinic (N = 759), indications. There was no major difference in the
Belier Hill Clinic (N = 413), Ladies Clinic Concerto (N management of labor among the study centers and
= 153), Machida Obstetrics and Gynecology during the study period.
Nanohana Clinic (N = 56), Higashi-Fuchu Hospital (N We analyzed the normality of continuous
= 128) and Yamaguchi Women’s Hospital (N = 343)] variables using the Shapiro-Wilk W-test. Medians and
and one university hospital [Nippon Medical School 95% confidence intervals were calculated for
Tama-Nagayama Hospital (N = 1320)]. All sites non-normally distributed continuous variables.
agreed to participate in this study. The ethics Statistical differences in maternal characteristics and
committee of Nippon Medical School approved this perinatal outcomes between primiparas and
retrospective study, which conformed to the multiparas (parity = 1 and ≥ 2) were analyzed using
principles established by the Declaration of Helsinki. the Mann-Whitney U-test or Kruskal-Wallis test for
We extracted continuous time-stamped cervical non-normally distributed continuous variables and
dilatation measurements, after onset of labor, from the χ2 test for categorical variables. Differences of P <
labor charts. A single researcher posted obstetric 0.05 were considered significant. We used the JMP®
records from parturition ledgers and a trained 12.0 software (SAS Institute Japan Co., Ltd, Tokyo,
researcher checked for posting errors. All researchers Japan) for statistical analyses.
maintained anonymity of all participants. Major statistical analyses were conducted as
Exclusion criteria included: non-Japanese, mult- previously reported [6, 7]. We characterized labor
iple pregnancies, maternal age less than 20, or 40 and progression patterns by examining the relationship
over at delivery, pregravid body mass index (BMI) 30 between elapsed times from the full dilatation and
and over, prior CS delivery, prior enucleatic myomec- cervical dilatation stages. Because participants were
tomy, preterm or post-term delivery, malpresentation, admitted at various cervical dilatation stages, which
instrumental or CS delivery, malrotation, obstetric ultimately reached 10 cm, we performed reverse

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regression analyses, with 10 cm of dilatation as the (0.75) vs. 0.15 (0.55) hours at the second stage for
starting point and moving backward in time. parity = 0, 1 and ≥ 2]. Median cervical dilatations at
Repeated measures regressions with sixth-degree admission were 4 cm (primiparas) and 5 cm
polynomial models fit the cervical dilatation values (multiparas). Neonatal body size increased with
best. We characterized labor durations by examining increasing parity. Although several newborns showed
the distribution of time intervals from one cervical low umbilical artery pH and low Apgar scores at
dilatation stage, to the next, and ultimately to the full 1-minute, no newborns were admitted to NICU and
dilatation. Labor durations have skewed distributions no adverse neonatal outcomes were observed.
that lean left, resembling log-normal distributions. Figure 1 and Figure 2 describe averaged cervical
Every participant contributed interval-censored dilatation curves for the primiparas and multiparas.
values at given cervical dilatation stages. We calculat- The primiparous labor curve shows slow cervical
ed the time interval series, between those two cervical dilatation during the acceleration phase with no
dilatation stages for each participant. definite inflection point, whereas the multiparous
labor curves appear to accelerate around 5 cm of
Results dilatation. Labor progresses faster with increasing
Table 1 and Table 2 show maternal characteri- parity, and in the multiparous labor curves, the active
stics and perinatal outcomes of the primiparas and phase begins earlier in parity ≥ 2, compared to parity
multiparas. Maternal age at delivery and body mass = 1. At the end of the active phase, we observe no
increased with increasing parity. Premature rupture deceleration phase. As multiparas were admitted at
of the membranes was associated with primiparas. more advanced cervical dilatation stages than
Labor durations decreased with increasing parity primiparas, the median records of most multiparas
[median (95%tile) 7.75 (18.71) vs. 4.07 (10.07) vs. 3.75 had less information on cervical dilatation
(9.91) hours at the first stage and 0.72 (2.34) vs. 0.20 measurements prior to 4 cm.

Table 1. Maternal characteristics of primiparous and multiparous females.

Primiparous females Multiparous females
N = 1047 Parity = 1, N = 1083 Parity ≥ 2, N = 1042 P value
Maternal age at delivery 30 (23–37)* 32 (25–38)‡ 34 (27–39) ＜0.0001
Maternal age of 20–29 at delivery 475 (45.4%)* 247 (22.8%)$ 172 (16.5%) ＜0.0001
Gestational age at delivery (weeks) 39.6 (37.9–40.9)¶ 39.4 (37.9–40.7) 39.4 (37.7–40.9)# ＜0.0001
Height (cm) 158.0 (150.0–169.0) 158.0 (150.0–167.0) 158.5 (150.0–167.0) NS
Pregravid body weight (kg) 50.0 (42.0–62.6)$ 50.0 (42.0–63.6)† 51.0 (43.0–65.0) ＜0.005
Body weight at admission (kg) 59.6 (50.2–72.5)$ 59.9 (50.1–72.1)‡ 60.9 (52.0–74.0) ＜0.0001
Total weight gain (kg) 9.7 (4.6–15.1) 9.0 (4.2–13.8)* 9.9 (4.3–14.8) ＜0.0001
Pregravid BMI 19.8 (16.8–24.0)‡# 20.0 (17.3–24.5) 20.2 (17.5–25.4) ＜0.0001
Normal (25.0 > BMI ≥ 18.5) 768 (73.4%)† 830 (76.6%) 808 (77.5%) NS
Lean (18.5 > BMI) 241 (23.0%)$** 203 (18.7%) 172 (16.5%) ＜0.001
Overweight (30.0 > BMI ≥ 25.0) 38 (3.6%)† 50 (4.6%) 62 (6.0%) ＜0.05
BMI at admission 23.7 (20.2–28.5) 23.6 (20.6–28.2) 24.2 (21.1–29.0)* ＜0.0001
BMI, body mass index; NS, not significant
Categorical variables are shown as number of patients (%), and numerical variables are shown as median (5%tile–95%tile).
*P < 0.0001, in relation to all other groups; ‡P < 0.0001, in relation to multiparous females (parity ≥ 2); $P < 0.0005, in relation to multiparous females (parity ≥ 2); ¶P < 0.0001, in relation to

multiparous females (parity = 1); #P < 0.005, in relation to multiparous women (parity = 1); †P < 0.05, in relation to multiparous females (parity ≥ 2); **P < 0.05, in relation to multiparous
females (parity = 1)

Table 2. Perinatal outcomes of primiparous and multiparous females.

Primiparous females Multiparous females
N = 1047 Parity = 1, N = 1083 Parity ≥ 2, N = 1042 P value
Premature rupture of the membranes 282 (26.9%)‡ 164 (15.1%) 179 (17.2%) ＜0.0001
Total labor durations (hr)* 8.48 (3.10–19.98)‡ 4.37 (1.47–10.43)$ 3.97 (1.27–10.12) ＜0.0001
Labor durations at the first stage (hr) 7.75 (2.43–18.71)‡ 4.07 (1.24–10.07)¶ 3.75 (1.05–9.91) ＜0.0001
Labor durations at the second stage (hr) 0.72 (0.17–2.34)‡ 0.20 (0.03–0.75)# 0.15 (0.03–0.55) ＜0.0001
Total labor durations < 3 hr 46 (4.4%)‡ 294 (27.1%)† 335 (32.1%) ＜0.0001
Times of vaginal examinations 6 (3–10)‡ 4 (3–8)# 5 (3–8) ＜0.0001
Cervical dilatation stage at admission (cm) 4 (2–9)‡ 5 (2–9)$ 5 (2–9) ＜0.0001
Episiotomy 353 (33.7%)‡ 113 (10.4%)# 39 (3.7%) ＜0.0001
Total blood loss including amnion (g) 344 (114–1017)‡ 250 (90–835) 255 (100–829) ＜0.0001
Umbilical arterial pH 7.280 (7.170–7.371)‡ 7.310 (7.200–7.415)# 7.328 (7.211–7.440) ＜0.0001
Umbilical arterial pH < 7.100 10 (0.9%) 6 (0.6%) 4 (0.4%) NS
Umbilical cord entanglement 364 (34.8%)† 361 (33.3%) 318 (30.5%) NS
Neonatal characteristics

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Primiparous females Multiparous females

N = 1047 Parity = 1, N = 1083 Parity ≥ 2, N = 1042 P value
Female 508 (48.5%) 537 (49.6%) 527 (50.6%) NS
Birthweight (g) 2962 (2443–3420)‡ 3004 (2523–3520)# 3080 (2574–3630) ＜0.0001
Height (cm) 49.0 (46.0–51.5) 49.0 (46.0–51.5) 49.5 (47.0–52.0)‡ ＜0.0001
Head circumference (cm) 33.0 (31.0–35.0)‡ 33.0 (31.0–35.0)† 33.5 (31.5–35.0) ＜0.0001
Apgar score at 1 minute < 7 4 (0.4%) 4 (0.4%) 2 (0.2%) NS
Apgar score at 5 minute < 7 0 (0.0%) 0 (0.0%) 0 (0.0%) –
NS, not significant
Categorical variables are shown as number of patients (%), and numerical variables are shown as median (5%tile–95%tile).
*Total labor duration consists of the labor durations at first and second stages.

‡P < 0.0001, in relation to all other groups; $P < 0.005, in relation to multiparous females (parity ≥ 2); ¶P < 0.01, in relation to multiparous females (parity ≥ 2); #P < 0.0001, in relation to

multiparous females (parity ≥ 2); †P < 0.05, in relation to multiparous females (parity ≥ 2)

Figure 1. Cervical dilatation curves of primiparous and multiparous females with 90% reference intervals. A. Primiparous females. B. Multiparous
females (parity=1). C. Multiparous females (parity ≥ 2). Primiparous labor curve consists of 4339 vaginal examinations [coefficient of determination (R2) = 0.71] and
multiparous labor curves consist of 3439 (parity = 1, R2 = 0.75) and 3459 (parity ≥ 2, R2 = 0.73) vaginal examinations, respectively. Dots are data, the solid lines are
the fitted curves and dotted lines are the 90% reference intervals.

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median changes of expected time intervals

between two consecutive cervical dilatation
stages, occurred in 6 cm (−0.52 cm/hr) and 5
cm (−0.37 cm/hr and –0.33 cm/hr for parity =
1 and ≥ 2) of dilatation in the primiparas and
multiparas, respectively. Among the primipa-
ras and multiparas in the 95%tile, labor
progression took over 3 hours (primiparas)
and over 2 hours (multiparas) to progress from
6 cm to 7 cm, and from 5 cm to 6 cm, respecti-
vely. All labors resulted in spontaneous
deliveries without abnormal labor progression
and obstetric interventions.
Table 4 shows traverse times, by cervical
dilatation stage from one centimeter to the full
dilatation, in the primiparas and multiparas.
Labor progression developed faster with
increasing parity and cervical dilatation stage
(from 4 cm to 10 cm, median 3.75 vs. 2.33 vs.
2.00 hours for parity = 0, 1 and ≥ 2). In the
active phase, the traverse times to the full
Figure 2. Cervical dilatation curves of primiparous and multiparous females. dilatation 5%tile were less than 1 hour and 0.5
This figure describes cervical dilatation curves of spontaneous deliveries by parity with term,
singleton, vertex, and live newborns of appropriate-for-gestational age birthweight without hours for the primiparas and multiparas,
adverse perinatal outcomes. respectively (0.58 hours from 6 cm to 10 cm for
parity = 0; 0.42 vs. 0.28 hours from 5 cm to 10
Table 3 shows expected time intervals, by cm for parity = 1 and ≥ 2). Even in the latent phase, it
cervical dilatation stage from one centimeter to the could be less than 1 hour (0.77 hours from 5 cm to 10
next, in the primiparas and multiparas. Labor cm for parity = 0; 0.67 vs. 0.42 hours from 4 cm to 10
progressed faster with increasing parity and cervical cm for parity = 1 and ≥ 2).
dilatation stage. Fastest cervical changes, i.e., maximal

Table 3. Expected time intervals, from one cervical dilatation stage to the next, for primiparous and multiparous females.
Multiparous females
Cervical Primiparous females Parity = 1 Parity ≥ 2
dilatation (cm) median N 5%–95%tile median N 5%–95%tile median N 5%–95%tile P value
From 2 to 3 2.62* 168 1.00–8.31 1.17 81 0.15–5.51 1.00 92 0.11–3.24 ＜0.0001
From 3 to 4 2.24* 333 0.78–8.00 0.87‡ 201 0.09–4.01 0.83 237 0.15–4.48 ＜0.0001
From 4 to 5 1.83* 374 0.50–5.81 0.50 282 0.09–2.25 0.50 313 0.08–2.39 ＜0.0001
From 5 to 6 1.31* 351 0.42–4.67 0.38‡ 292 0.07–2.25 0.31 300 0.06–2.12 ＜0.0001
From 6 to 7 1.05* 329 0.33–3.13 0.29 325 0.05–1.75 0.25 307 0.04–1.74 ＜0.0001
From 7 to 8 1.00* 328 0.33–3.31 0.28 278 0.04–1.67 0.26 276 0.06–1.55 ＜0.0001
From 8 to 9 0.76* 476 0.17–2.17 0.25$ 389 0.04–1.32 0.19 383 0.04–1.02 ＜0.0001
From 9 to 10 0.52* 504 0.08–2.19 0.25 312 0.07–1.16 0.25 276 0.06–1.17 ＜0.0001
*P < 0.0001, in relation to all other groups; ‡P < 0.05, in relation to multiparous females (parity ≥ 2); $P < 0.001, in relation to multiparous females (parity ≥ 2)

Table 4. Time to the full dilatation, by cervical dilatation stages, for primiparous and multiparous females.
Multiparous females
Cervical Primiparous females Parity = 1 Parity ≥ 2
dilatation (cm) median N 5%–95%tile median N 5%–95%tile median N 5%–95%tile P value
From 2 to 10 6.67* 168 2.35–16.85 4.12 81 1.09–10.52 4.12 92 1.39–11.51 ＜0.0001
From 3 to 10 5.08* 333 1.33–13.54 3.50‡ 201 0.92–8.97 2.75 237 0.66–8.02 ＜0.0001
From 4 to 10 3.75* 374 0.89–10.21 2.33 282 0.67–6.68 2.00 313 0.42–6.31 ＜0.0001
From 5 to 10 3.00* 351 0.77–8.91 1.67$ 292 0.42–5.25 1.42 300 0.28–5.53 ＜0.0001
From 6 to 10 2.25* 329 0.58–6.14 1.17$ 325 0.25–4.33 0.95 307 0.17–4.03 ＜0.0001
From 7 to 10 1.75* 328 0.42–5.29 0.75 278 0.17–3.17 0.72 276 0.12–3.00 ＜0.0001
From 8 to 10 1.03* 476 0.17–3.18 0.50‡ 389 0.08–2.08 0.42 383 0.08–1.58 ＜0.0001
From 9 to 10 0.52* 504 0.08–2.19 0.25 312 0.07–1.16 0.25 276 0.06–1.17 ＜0.0001
*P < 0.0001, in relation to all other groups; ‡P < 0.005, in relation to multiparous females (parity ≥ 2); $P < 0.05, in relation to multiparous females (parity ≥ 2)

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Preliminary analyses showed that labor accelerated after 6 cm [5]. Another study of 26838
durations increased at the second stage and did not deliveries, from 1959 to 1966, revealed that multiparas
increase at the first stage in the cases with atonic consistently seemed to progress at a faster pace than
bleeding after childbirth. In Japan, the total blood loss primiparas [15]. Demographic transition might affect
90%tile at singleton vaginal delivery is 800 mL. Labor labor progression and duration [3, 4, 8–13]. Epidural
durations at the second stage between the cases with analgesia and weak pains during oxytocin use may
and without atonic bleeding after childbirth were as lengthen the active phase [2–4, 12]. Because Zhang’s
follows; median 0.95 vs. 0.70 hours for parity = 0, 0.27 study included a substantial number of participants
vs. 0.20 hours for parity = 1 and 0.20 vs. 0.15 hours for with oxytocin use and epidural analgesia [5], their
parity ≥ 2. We aimed to describe averaged cervical labor progression developed more gradually than our
dilatation curves in the first stage. Because atonic labor progression.
bleeding after childbirth is the abnormal labor The 95%tile of labor progression took over 3
progression after the third stage, these cases have hours to progress from 6 cm to 7 cm (primiparas), and
been not excluded. over 2 hours to progress from 5 cm to 6 cm of
dilatation (multiparas). Considering labor augment-
Discussion ation in the active phase, cervical dilatation of ≤ 1.2
We examined pregnant Japanese females cm/hr and ≤ 1.5 cm/hr for primiparas and multiparas
without abnormal labor progression and obstetric were defined as protracted disorders of labor [3, 4].
interventions to describe cervical dilatation curves Previously in Japan, 2-hour and 1-hour thresholds
that characterized normal labor progression. Our were usually used for diagnosing arrested disorders
results demonstrated that labor progression was of labor, for primiparas and multiparas, after 4 cm,
faster with increasing parity and the active phase of which was considered as “in the active phase” in
labor may not start until 5 cm of dilatation. The results Friedman’s curves [3, 4]. These criteria may be too
also suggested that at the beginning of the active short before 6 cm [15], considered as “in the latent
phase, cervical dilatation was slower than previously phase” in present curves [6, 7]. Our participants
described, and at the end of the active phase, no achieved spontaneous deliveries even if their labor
deceleration phase was observed. These findings may durations exceeded the 95%tile of expected time
provide useful information for obstetric management, intervals, which exceeded those thresholds. Diagnosis
potentially reducing the need for medical intervene- of protracted or arrested labor should be based, not
tions during labor. only on research definitions, but also on maternal and
Fastest cervical changes occurred at 6 cm fetal conditions [5]. Offering reassurance of maternal
(primiparas) and 5 cm (multiparas) of dilatation. and fetal statuses, within a normal labor duration
These results were different from Friedman’s curves range, may allow patients to continue spontaneous
with definite inflection points around 4 cm [2–4]. labor progression. To optimize the opportunities for
Friedman’s study included many abnormal labor appropriate management of labor and improve
progression and obstetric interventions; e.g., in the perinatal prognoses, prospective studies are needed
primiparas, 20.8% exhibited malrotation and 51.2% to establish clinical thresholds for diagnosing
required vacuum extraction delivery [3]. Further- protracted or arrested labor. The upper limit of the
more, labor curve synthesis methods were not clearly normal range, i.e., the 95%tiles of expected durations,
described [2–4]. Peisner and Rosen analyzed 1060 may be the useful reference for these types of
primiparas and 639 multiparas and reported that prospective studies.
non-complicated patients with 5 cm of dilatation The 5%tile of traverse times to the full dilatation,
should be in the active phase [14]. This finding agrees during the active phase, was less than 1 hour
with our data. Patients enter the active phase at (primiparas) and 0.5 hours (multiparas). Natural
different stages, and with different rates. Due to history of the normal active phase, during the first
interpersonal variation, the average labor curve tends stage of labor, predicted labor progression. Recent
to appear flattened [6]. Consistent labor progression reports of labor curve creation [6, 7] included
patterns in the active phase were not observed, inclusion criteria of cervical dilatation < 7 cm at
particularly among the primiparas, and our labor admission and labor duration, from admission to
progression was slower than those reported by delivery, of > 3 hours. Based on these criteria, most
Friedman [3, 4]. Zhang et al. analyzed 62415 precipitate labors could be excluded. Sheiner et al.
deliveries, from 2002 to 2008, and reported that observed no significant differences in perinatal
primiparas and multiparas seemed to progress at a complications, but higher rates of maternal
similar pace, before 6 cm, and cervical dilatation rate complications, associated with precipitate labor [16].

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During precipitate labor progression, newborns may body mass (not shown). Mean maternal age of
fall onto hard surfaces, or suffer unexpected injuries primiparous patients was 30 and over, associated with
without the benefit of delivery assistance. Intense advancing late birth. Overweight females are less
contractions may cause other perinatal complications. common, and lean females are more common, in
In our study, the prevalence of precipitate labor was Japan. Considering these tendencies, new clinical
21.3% (4.4% vs. 29.6% for parity = 0 and ≥ 1), which references for appropriate management of labor
was higher than 14.3% (6.9% vs. 21.5% for parity = 0 progression are needed.
and ≥ 1) reported from a prior Japanese study [17]. This study had a number of limitations. First, we
These prevalence rates were markedly higher than did not determine the reliability of intrapersonal and
2.1%, reported in a study out of the United States [18]. interpersonal cervical dilatation measurement, and
As mentioned above, in Japan, onset of labor is prospective, hourly vaginal examinations were not
defined as the presence of regular contractions performed, as described by Friedman [2–4]. Second,
separated by ≤ 10 minutes, as reported by the patient. because constructions were assessed by the attending
Suzuki noted that the high incidence of precipitate obstetricians and midwives, the reliability of
labor may result from differing definitions, or from intrapersonal and interpersonal labor diagnosis was
diagnosis of regular contractions by clinical not assessed. Third, we acknowledge that selection
monitoring devices, and not the patient’s declaration bias, related to the exclusion criteria, might
[17]. underestimate the normal ranges, i.e., the 5%tile and
No deceleration phase was observed at the end 95%tile of various measurements. Finally, the current
of the active phase. Friedman noted that it maintains database likely reflects a comparatively urban
maximum dilatation rate until 8 cm to 9 cm of Japanese population. However, we believe that our
dilatation and the dilatation rate appears to slow results accurately depict the cervical dilatation curves,
down, but acknowledged, “In actually, normally of spontaneous deliveries in pregnant Japanese
nothing slows.” [19] We rarely observed the females. These curves provide useful information for
deceleration phase in the majority of participants, nor obstetric management and may reduce the need for
had been observed in previous studies [6, 7]. obstetric interventions during labor progression.
Deceleration phase marks the time in labor when the
process of fetal descent becomes maximized, and is Acknowledgements
often short or absent, probably because it is merely We thank Dr. Saburo Kogi, Dr. Yong-soon Kim,
not being observed [6, 19]. However, Friedman’s labor Dr. Norihiro Matsushita and Dr. Hideki Iwamoto
curves included 25.6% of primiparas and 6.4% of (Berun Forest Clinic and Belier Hill Clinic), Dr.
multiparas, with the deceleration phase longer than 1 Hiroshi Ohmura (Ladies Clinic Concerto), Dr.
hour and 0.5 hours, respectively [3, 4]. Labor curve Toshimasa Machida (Machida Obstetrics and
associated with prolonged deceleration phase due to Gynecology Nanohana Clinic), Dr. Masako Juzoji
dystocia has a prolonged active phase and low (Higashi-Fuchu Hospital), Dr. Satoru Yamaguchi
maximum slope [3], which will significantly affect the (Yamaguchi Women’s Hospital), and Ms. Mizue
mean labor curve. Lack of the deceleration phase in Hagiwara (Nippon Medical School Tama-Nagayama
the present study may be caused by excluding cases Hospital) for their patience in medical record
with dystocia. preparation.
Maternal and neonatal characteristics have
clearly changed over the past 60 years, and this can Competing Interests
affect labor progression patterns. Average maternal The authors have declared that no competing
age is rising, and the first stage of labor progresses interest exists.
more quickly with increasing maternal age [8].
Average maternal body mass is also increasing, and References
the first stage of labor progresses more slowly in 1. Spong CY, Berghella V, Wenstrom KD, et al. Preventing the first cesarean
delivery: summary of a Joint Eunice Kennedy Shriver National Institute of
patients with BMIs of 30 or more [9]. According to the Child Health and Human Development, Society for Maternal-Fetal Medicine,
Ministry of Health, Labour and Welfare, maternal and American College of Obstetricians and Gynecologists Workshop. Obstet
Gynecol. 2012; 120: 1181-93.
characteristics in the present study were not different 2. Friedman EA. The graphic analysis of labor. Obstet Gynecol. 1954; 68: 1568-75.
from those of the averaged Japanese females. For 3. Friedman EA. Primigravid labor; a graphicostatistical analysis. Obstet
Gynecol. 1955; 6: 567-89.
instance, in 2015, average maternal age at delivery of 4. Friedman EA. Labor in multiparas; a graphicostatistical analysis. Obstet
primiparas and multiparas (parity = 1 and ≥ 2) were Gynecol. 1956; 8: 691-703.
5. Zhang J, Landy HJ, Branch DW, et al. Consortium on Safe Labor.
30.7, 32.5 and 33.5, respectively [20]. We also observed Contemporary patterns of spontaneous labor with normal neonatal outcomes.
that labor progressed quickly with increasing Obstet Gynecol. 2010; 116: 1281-7.
6. Zhang J, Troendle JF, Yancey MK. Reassessing the labor curve in primiparous
maternal age, and slowly with increasing maternal women. Am J Obstet Gynecol. 2002; 187: 824-8.

http://www.medsci.org
Int. J. Med. Sci. 2018, Vol. 15 556
7. Suzuki R, Horiuchi S, Ohtsu H. Evaluation of the labor curve in primiparous
Japanese women. Am J Obstet Gynecol. 2010; 203: 226.e1-6.
8. Zaki MN, Hibbard JU, Kiminiarek MA. Contemporary labor patterns and
maternal age. Obstet Gynecol. Obstet Gynecol. 2013; 122: 1018-24.
9. Norman SM, Tuuli MG, Odibo AO, et al. The effects of obesity on the first
stage of labor. Obstet Gynecol. 2012; 120: 130-5.
10. Feghali M, Timofeev J, Huang CC, et al. Preterm induction of labor: predictors
of vaginal delivery and labor curves. Am J Obstet Gynecol. 2015; 212: 91.e1-7.
11. Leftwich HK, Zaki MN, Wilkins I, et al. Labor patterns in twin gestations. Am
J Obstet Gynecol. 2013; 209: 254.e1-5.
12. Alexander JM, Sharma SK, McIntire DD, et al. Epidural analgesia lengthens
the Friedman active phase of labor. Obstet Gynecol. 2002; 100: 46-50.
13. Timofeev J, Huang CC, Singh J, et al. Spontaneous labor curves in women with
pregnancies complicated by diabetes. J Matern Fetal Neonatal Med. 2012; 25:
20-6.
14. Peisner DB, Rosen MG. Transition from latent to active labor. Obstet Gynecol.
1986; 68: 448-51.
15. Zhang J, Troendle J, Mikolajczyk R, et al. The natural history of the normal
first stage of labor. Obstet Gynecol. 2010; 115: 705-10.
16. Sheiner E, Levy A, Mazor M. Precipitate labor: higher rates of maternal
complications. Eur J Obstet Gynecol Reprod Biol. 2004; 116: 43-7.
17. Suzuki S. Clinical significance of precipitous labor. J Clin Med Res. 2015; 7:
150-3.
18. Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2006. Natl Vital
Stat Rep. 2009; 57: 1-102.
19. Friedman EA. The labor curve. Clin Perinatol. 1981; 8: 15-25.
20. [Internet] Ministry of Health, Labour and Welfare: Tokyo, Japan. Vital
statistics in Japan: Trends up to 2015. Published March 2017. http://www.
mhlw.go.jp/toukei/list/dl/81-1a2.pdf

http://www.medsci.org