Incidence and Predictors of Dystocia of Active First Stage of Labor at Debremarkos Comprehensive Specialized Hospital Amhara, North West Ethiopia, 2022/2023

doi:10.21203/rs.3.rs-3132594/v1

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Incidence and Predictors of Dystocia of Active First Stage of Labor at Debremarkos Comprehensive Specialized Hospital Amhara, North West Ethiopia, 2022/2023

https://doi.org/10.21203/rs.3.rs-3132594/v1

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Background

Dystocia of active first stage of labor `has a notable contribution to maternal and fetal and / or neonatal morbidity and mortality. It is a main reason for the increasing rate of cesarean delivery in the world. Majorities of the determinants of dystocia in active first stage of labor could be modifiable, and may vary across the settings and over time trend. So, contextual scientific studies in this regard are imperative for evidence-based interventions. However, there was a dearth of evidence about extent and contributing factors of dystocia of active first stage of labor in Ethiopia.

Objective

This study aimed to assess the incidence and predictors of dystocia of active first stage of labor among laboring women at debremarkos comprehensive specialized hospital Amhara, northwest Ethiopia, 2022/23.

Methods

Prospective cohort study was conducted among 656 laboring women from October 20 to January 4/2023. The study participants were selected by using a systematic random sampling technique. Data were collected through observation, interview using a pretested structured questionnaire, and document review. Both descriptive and inferential analyses were carried out. Binary Logistic Regression was fitted and the level of significance was declared based on Adjusted Odds Ratio (AOR) with its 95% Confidence Interval (CI) and p-value of ≤ 0.05.

Result

The overall incidence of dystocia of AFSOL was 35.3%( 95%CI: 31.9, 39.2). Induction of labor (AOR: 2.5; 95%CI: 1.23. 5.42), admitting of laboring mother with cervical dilation of < 4cm (AOR: 2.9; 95%CI: 1.72, 4.93), poor health care provider support (AOR: 7.5; 95%CI: 4.18, 13.67), and caffeine intake > 200mg (≥ 3cup of coffee) (AOR: 3.7; 95%CI: 1.80, 7.74), Drinking of linseed (AOR: 0.28; 95%CI: .14, .55), ANC follow up (AOR: .24; 95%CI: .09, .63), and ambulation during AFSOL (AOR: 0.31; 95%CI: .13, .69) were predictors of dystocia of active 1st stage of labor.

Conclusion

The incidence of DAFSOL was high. Having ANC follow up, eating/drinking of linseed at the onset of labor pain and ambulating during active first stage of labor, drinking of three or more cup of coffee per day during pregnancy, induction of labor, poor health care provider support during AFSOL and admitting of the laboring mothers while cervical dilation < 4cm were predictors of DAFSOL. Adopting WHO labor care guide and encouraging health care providers to practice evidence based practice regarding the management of active 1st stage of labor and good patient handling during the laboring process is recommended to minimize the diagnosis of DAFSOL and its unnecessary interventions.

Dystocia

first stage

induction of labor

incidence

Active first stage of labor (AFSOL) is defined as the period in which the greatest rate of cervical dilation occurs(1). Dystocia of AFSOL is defined as difficult labor or abnormally slow progress of labor in the active first stage(2). There are two main type of dystocia of AFSOL. The first category is slow progress of labor (i.e., cervical dilatation of less than 1 centimeter per hour); it is also termed as protracted AFSOL. The second type is cessation of AFSOL (i.e., no change on cervical dilation for 2–6 hours, which is also named as arrest of AFSOL (2–5).

Dystocia of active first stage of labor is the comments types of abnormal labor accounting 48.8% of all types of abnormal labor (6). Active-phase abnormalities have been reported to occurs in 25–37% of nulliparous and 15% of multiparous labors (4, 7). Secondary arrest of AFSOL complicates 5–10% of labors (8). A retrospective observational study done in Swedish showed that the dystocia of active phase of labor were occurred in 21% of deliveries of these 16.7% were end up with cesarean delivery compared to 1.7% of deliveries without dystocia (9). Another retrospective study in Sweden concluded that dystocia of active phase of labor were occurred in 22.5% of primiparous and 10.4% of multiparous laboring women(10).

Active first stages of labor disorder are associated with the increasing incidence of cesarean delivery (CD), the numbers of vaginal examinations, increased risk of operative delivery, postpartum hemorrhage and blood transfusion, maternal fever, endomyometritis, chorioamnionitis, shoulder dystocia, neonatal infection, increased admission to neonatal intensive care unit and neonatal death and exposed oxytocin with their complications (7, 11–16). Dystocia is responsible for more than 34–50% of primary cesarean deliveries (17, 18). Many evidence including in Ethiopia suggest that 13% -23.97% of unjustified cesarean delivers was performed due to abnormal progress of labor especially arrest of cervical dilation (14, 19–21).

The commonest factors that are associated with dystocia of AFSOL is anthropometric related factors like (pre-pregnancy body mass index, maternal height), pregnancy related factors like (hypertension, gestational diabetes, gravidity and parity, anemia), intrapartum related factors like (Induction of labor, Dehydration, Labor analgesia, Women preference of mode of delivery, Cervical dilation at admission, Fetal descent at admission, Health care providers support during AFSOL, Anxiety, Ambulation during labor, Presence of companionship during labor) and socio-demographic related factors (6, 9, 11, 17, 22). The determinants of dystocia of AFSOL may not be limited to the aforementioned factors and may vary across the settings (i.e., sensitive to contexts) and over time trend, and most of these determinants are modifiable. Thus, the burden of dystocia of AFSOL could be alleviated if evidence-based actions are implemented by taking the contextual and modifiable determinants into consideration.

World health organization (WHO) develops partograph and in order to reduce maternal and neonatal adverse outcomes related to dystocia of active phase of labor and recommends augmentation of labor and CD as management principles as indicated (5, 23). However, it doesn’t reduce the incidence and identifies the contributing factors of dystocia of AFSOL rather it only shows weather the active phase progress normally or not that is way dystocia of labor still a concerns of many clinicians even if the incidence are not known in our country(7, 24). So, knowing the incidence and the preventable risk factor of dystocia of AFSOL is unsparing to reduce direct complication and adverse effect related to unintended intervention for dystocia.

Despite of dystocia of active 1st stage of labor contributed to maternal and neonatal morbidity and mortality directly or indirectly, there is no study in this aspect in Ethiopia as to the investigators’ best knowledge. Therefore, this study is designed to investigate the incidence and pre-labor and during labor predictors of dystocia of active phase of labor that are more likely to be modifiable, in debremarkos comprehensive specialized hospital. This contributes for reduction of maternal and neonatal morbidity and mortality during the laboring process.

Study design, period and setting

Prospective cohort study was conducted from October 20/2022 to January 4, 2023 at Debremarkos comprehensive specialized hospital. Debremarkos hospital established in 1957 by emperor Haileslassie and it named as liuel Mekonnen primary hospital. It serve as zonal hospital up to 2002ec, then become referral hospital up to 2011 now to comprehensive specialized hospital serving for more than 5 million catchment population(25). The department of Obstetrics and Gynecology has a labor ward with six beds in the first stage room, four delivery couches in the second stage, and 37 beds in the maternity ward. The ward is staffed by seven obstetric and gynecological specialists, 46 midwives, one emergency surgeon, two clinical midwifery specialist, 14 general practitioners, and interns(26). Based on three consecutive years hospital report (2012–2014) it provides averagely 969 antenatal cares, 6712 delivery service for regular and referral cases, of these 2260 had cesarean delivery.

Population

All laboring mothers who were in the active first stage of labor at Debremarkos comprehensive specialized hospital during the study period.

Eligibility criteria

Inclusion criteria

Laboring mothers who were in the active first stage of labor at Debremarkos comprehensive specialized hospital during the study period was included.

Exclusion criteria

Those women who were eclamptic and not regained their consciousness in active first stage of labor at the time of data collection were excluded from the study.

Sample size determination and sampling procedure

Sample size determination

We calculated the sample size by double population proportion formula using factors related to dystocia of active first stage of labor through Epi-Info v-7.2.5.0. Based on the following table the sample size can be:

Table 1

Sample size determination of dystocia of active first stage of labor and its predictor among laboring mothers at debremarkos referral hospital Amhara,.(data obtained from study in Israel(27).
Predictors of dystocia of AFSOL		Ratio	% of CI	Power	Proportion of dystocia	Sample size
Parity	Primiparous	1:1	95%	80%	53.4%	104
Parity	multipara	-	-	-	24.9%	104
Sex of the neonate	Male	1:1	-	-	55.4	596
Sex of the neonate	Female	-	-	-	43.6	596

Thus, the calculated sample size was 596 and we take it as a final sample size by adding 10% non-response rate, the final sample size is calculated to be 655.6 ≈ 656.

Sampling technique and procedures

We used systematic random sampling technique to select the study participants from laboring mothers attended in debremarkos comprehensive specialized hospital (DMCSH) by using client’s card as order of arrangement. The average number of laboring women attended in DMCSH within two month equivalent to the study period estimated to be 1200. Thus, the interval of selection was “K”= 1400 (study population) ÷ 656 = 2, k = 2. Then after we selected the random number (1–2) with lottery method, finally we selected all the study participants every” 2^th” interval.

Variables of the study

Dependent variable

Dystocia of active first stage of labor (present/absent)

Independent variables

Maternal age, marital status, occupation and educational status of the mother, Passive cigarette smoker (exposure to cigarette smoking), Coffee drinker and feeding of linseed or flax, maternal height, height to fundal height ratio, Parity, Gestational age, Presence of obstetrical complication (Premature rapture of membrane, hypertension during Pregnancy, Gestational diabetics, and oligo/polyhydraminos), Inter-pregnancy interval, previous history of cesarean delivery and anemia, Induction of labor, Labor analgesia, Women preference of mode of delivery, Cervical dilation at admission, Fetal descent at admission, Women satisfaction by health care providers (support by health care providers), Anxiety, Height to fundal height ratio, Ambulation during labor and Presence of companionship during labor, health care provider Qualification.

Operational definitions

Active phase

The phase of labor after 4cm of cervical dilatation to the full cervical dilatation (28).

Dystocia of active first stage of labor

Slow or cessation of the labor progress in active first stage (4).

Protracted disorder of labor

Slow progress of cervical dilation averagely less than 1centimeter per hour over 4hr and cross the alert line of the cervicogram in the active first stage of labor(3).

Arrest disorder of active phase of labor

Cessation of progress of labor in the active first stage averagely after 2hr over 4hr and the cervicogram crosses the alert line(3).

Passive smoker

Exposure to two or more cigarettes per day on average during the pregnancy is considered as passive smoking(29).

Anxiety

Spielberg’s State Anxiety Inventory Scores 20–40 are regarded as mild anxiety, 41–54 as moderate anxiety, and ≥ 55 as severe anxiety(29, 30).

Healthcare providers support

Measured by childbirth Satisfaction rating scale that contains 5 point licker scales. Those who gave answers above the mean of the total score were considered as received a good support from health care providers (31, 32)

Spontaneous onset of labor: If the woman achieved active first stage of labor without any artificial stimulation of labor onset (23).

Induced labor

If the onset of labor was artificially stimulated, by administering oxytocin or prostaglandins to the pregnant woman, artificially rupturing the amniotic membranes or applying a balloon catheter into the cervix(23).

Neonatal asphyxia

Failure to initiate and sustain breathing at birth(33).

Gestational age

The age of the pregnancy/fetus in weeks(5). It is assessed by last normal menstrual period or early ultrasound. If both are present we taken early ultrasound.

Ambulation

When the parturient moving around in 15 minute interval with 10 minuet duration and the cycle repeated at least 6times(34, 35).

Inter-pregnancy interval

Is the time elapsed between the birth of one live child and the conception of subsequent pregnancies(36).

Labor companion

Any person chosen by a woman to accompany her consistently during active first stage of labor (37).

Data collection tool and procedure

The data were collected by interview guided structured questionnaire, observation and follow up and chart review. The questionnaire was adapted with some modifications from different literature and it contains socio-demographic variables, obstetric and intrapartum related variables. It also includes partograph to diagnose active phase disorder, Spielberg’s State Anxiety Inventory questionnaire to assess anxiety (It is a 20-item self-report questionnaire with minimum and maximum total scores of 20–80. Each item is scored by 1 “not at all,” 2 “same what,” 3 “moderately so,” and 4 “very much so.” Almost half of the items are scored inversely (1, 2, 5, 8, 10, 11, 12, 16, 19 and 20), Childbirth Satisfaction rating scale (5 point licker scale from not at all satisfied to completely satisfied) to measure support of the laboring women by the health care providers during active first stage of labor. Some variables or information were retrieved from patient cards. Height of the mother was measured by tape mater. The data were collected day and night by 4 bachelor of degree midwifes and supervised by 2 MSc midwife. The cervical status was assessed by health care provider who works at the hospital and who follow the laboring mothers at the time being. The questionnaire was filled by the data collectors.

Data quality control

The questionnaire were prepared in English and translated to a common spoken language Amharic and then retranslated back in to English properly to keep its consistency. A pretest of the questionnaire was done on 5% (33) of the sample population at Finote Selam general hospital in order to check the simplicity and understandability of the questionnaire. The data collectors and the supervisors were received training on how to collect the data correctly and appropriately and how to supervise the data collection process closely. The principal investigator was overseeing the entire data collection process and work closely with the supervisors. Data were collected each day and night by the data collectors and the principal investigator and the supervisors were checked the data for completeness and whether it fills appropriately or not in order to tack early appropriate measures.

Data processing and analysis

The data were checked, coded and entered through Epi- data v. 4.2 and then export to the statistical package for social sciences (SPSS v.26) for analysis. Cross tabulation and descriptive statistics were carried out to clean the data, to check completeness of the data and to identify missing value and unusual or outlier data. Bivariable analysis was done to identify factor associated with dystocia of active first stage of labor. Those variables with p-value of < 0.25 were entered and analyzed with multivariable analysis in order to control potential confounders and to identify significant variables (p-value < 0.05) that are associated with dystocia. Finally the result was presented by tables, charts and with texts appropriately.

Socio demographic and behavioral characteristic

A total of 656 laboring mothers in debremarkos comprehensive specialized hospital were enrolled in this study with 96.2% of response rate. The median age of the study participants were 27 (IQR = 6). Majority of the study participants 354(57.1%) were in the age group of 25–34 year. Almost all of the study participants 612(98.7%) followed orthodox religion. Most of the study participants 613(98.9%) were married. Majority of the respondent 420(67.7%) were urban residence (Table 2).

Table 2

Socio demographic and behavioral characteristics of study participant at debremarkos comprehensive specialized hospital, 2022/23(n = 620).
Variables	Category	Frequency (%)
Age	15–24	192(31%)
	25–34	354(57.1%)
	35–49	74(11.9%)
Religion	Orthodox	612(98.7%)
	Muslim	5(0.8%)
	Protestant	3(0.5%)
Marital status	Married	613(98.9%)
	Divorced	3(0.5%)
	Single	4(0.6%)
Occupation	House wife	232(37.5%)
	Government employee	133(21.5%)
	Private business	79(12.7%)
	Merchant	25(4%%)
	Farmer	151(24.4%)
Educational status	Can`t read & write	94(15.2%)
	Read & write	59(9.5%)
	1–8 grade	137(22.1%)
	9–12 grade	160(25.8%)
	Collage and above	170(27.4%)
Residence	Urban	420(67.7%)
Residence	Rural	200(32.3%)
No. of cup of coffee you drank per day	Not at all	304(49.0%)
	< 3 cup	189(30.5%)
	≥ 3 cup	127(20.5%)
Eat or drank Linseed at the onset of labor pain	Yes (eat or drank)	160(25.8%)
Eat or drank Linseed at the onset of labor pain	No	460(74.2%)

Pregnancy related history of the study participant

Most of 442(71.3%) of the study participants were multigravida. Same of the study participants 71(11.5%) had previous history of abortion. Few of the study participant 18(2.9%) were gave birth through caesarean delivery previously. Almost all 597(95.6%) of the laboring mothers wants there pregnancy. Most of the study participants 577(93.1%) were at least one ANC follow up in the current pregnancy. Majority of the study participant 228(36.8%) had optimal birth interval (24–60 month). Few of the laboring mothers in Debremarkos comprehensive specialized hospital 13 (2.1%) were anemic. Most of the study participant 544(87%) were planned to give birth through vagina (Table 3).

Table 3: pregnancy related history of laboring mothers in Debremarkos comprehensive specialized hospital 2022/23 (n=620).

Variables	Category	Frequency (%)
Gravidity	Prime gravid	178(28.7%)
Gravidity	Multi gravid	442(71.3%)
Parity	Null Para	199(32.1%)
Parity	Multi Para	421(67.9%)
Previous mode of delivery	Vaginal	387(62.4%)
	Cesarean delivery	18(2.9%)
	Instrumental	16(2.6%)
Adverse outcomes of previous pregnancy	Abortion	71(11.5%)
	Still birth	11(1.8%)
	Neonatal death	9(1.5%)
	Gross congenital anomaly	4(0.6%)
Type of pregnancy	Planned	593(95.6%)
Type of pregnancy	Unplanned	27(4.4%)
ANC follow up	Yes	577(93.1%)
ANC follow up	No	43(6.9%)
Gestational age	Preterm	35(5.6%)
	Term	451(72.7%)
	Post term	47(7.6%)
	Unknown	87(14%)
Hemoglobin	<11gm/dl	13(2.1%)
Hemoglobin	≥11gm/dl	607(97.9%)
Inter pregnancy interval	Short (<24 month)	113(18.2%)
	Optimal (24-60month)	228(36.8%)
	Long (>60 month)	66(10.6%)
Plan of mode of delivery	Vaginal	544(87.7%)
	C/D	14(2.3%)
	Not planned	62(10%)

Some of the study participants 47(7.6%) were complicated with pre-labor rapture of amniotic membrane in the current pregnancy (Fig. 1).

Intrapartum related history of the study participant

Regarding to the intrapartum history of the parturient that was on active first stage of labor at DMCSH 291(46.9%) of them were admitted in the intrapartum ward with cervical dilation of less than 4cm. more than half of the fetal heart beat of the study participants were monitored by fetoscope. Most of the laboring process of the respondent 524(84.5%) was started spontaneously. Some of the laboring mothers 141(22.7%) were ambulating during active first stage of labor. Almost half 315(50.8%) of the study participant were on intravenous fluid while on active first stage of labor (Table 4).

Table 4

Intrapartum history of the laboring mother who was on active first stage of labor in DMCSH, 2022/23 (n = 620).
Variables	Category	Frequency (%)
Cervical dilation at admission	< 4cm	291(46.9%)
Cervical dilation at admission	≥ 4cm	329(53.1%)
Fetal heart bit (FHB ) during AFSOL	Positive	612(98.7%)
Fetal heart bit (FHB ) during AFSOL	Negative	8(1.3%)
Method of FHB monitoring	CEFM	270(43.5%)
Method of FHB monitoring	Fetoscope	342(55.2%)
Health care provider who follow the parturient	Midwife	259(41.8%)
	MSc midwife	202(32.6%)
	Intern	159(25.6%)
Fetal presentation	Vertex	603(97.3%)
	Breech	15(2.4%)
	Face	2(0.3%)
Onset of labor	Spontaneous	524(84.5%)
Onset of labor	Induced	96(15.5%)
Ambulation during AFSOL	Yes	141(22.7%)
Ambulation during AFSOL	No	479(77.3%)
Companion during AFSOL	Yes	99(16%)
Companion during AFSOL	No	521(84%)
Fluid intake during AFSOL	IV	315(50.8%)
	Oral	286(46.1%)
	Nothing at all	19(3.1%)
Health care provider support during AFSOL	Good	297(47.9%)
Health care provider support during AFSOL	Poor	323(52.1%)
Anxiety during AFSOL	Mild	343(55.3%)
	Moderate	235(37.9%)
	Sever	42(6.8%)

Incidence of dystocia of active first stage of labor

From 620 laboring mothers in Debremarkos comprehensive specialized hospital 35.3% (95%CI: 31.9, 39.2) of them have experienced abnormal progress (dystocia) of labor in active first stage. Of these 135(21.8%) were protracted and 84(13.5%) were arrest of cervical dilation.

More than half of (51.1%) dystocia of AFSOL was diagnosed at cervical dilation of 6cm followed by 5cm cervical dilation (26.5%) (Fig. 2).

Predictors of dystocia of active first stage of labor

Based on the output of bivariable logistic regression parturient who eat or drank linseed/flax during the onset of labor pain, those who had ANC follow up, parturient whose fetal heart bit monitored by EFM, those followed by interns, induction of labor, those who hand companion during AFSOL, ambulation during AFSOL, those who were on intravenous fluid, male fetus, parturient on age group of 15–24 year, those who drank coffee three or more cup per day, laboring mothers who exposed to two or more cigarette per day during pregnancy, parturient admitted to intrapartum with cervical dilation of < 4cm, being primigravida and primipara, maternal height to fundal height ratio of < 4, those who had severely anxious at AFSOL and poor health professional support during AFSOL were identified as significant predictors of dystocia of AFSOL.

In multivariable logistic regression seven variables i.e. laboring mothers who eat or drank linseed at the onset of labor pain, those parturient who drank three or more cup of coffee per day, who had ANC follow up with the current pregnancy, admitted to the intrapartum ward with cervical dilation of < 4cm, parturient who ambulate during active first stage of labor, who satisfied on health care providers support and care and induced labor were statistically significant.

Dystocia of AFSOL was reduced by 72% among parturient who eat/drank linseed since the onset of pushing down pain compared to those who didn’t eat or drank (AOR: 0.28; 95%CI: 0.14,0 .55). Likewise, laboring mothers who drank ≥ 3 cup of coffee were 3.7 times more likely to develop dystocia of AFSOL compared to those who drank < 3 cup of coffee per day (AOR: 3.7; 95%CI: 1.80, 7.74). Similarly, abnormal progress of AFSOL was minimized by 76% among laboring mothers who had ANC follow up during this pregnancy compared to their counterpart(AOR: .24; 95%CI: 0.09, 0.63).

The odds of abnormal progress of active first stage of labor were 2.9 times more likely to occurred among parturient who was admitted in intrapartum while she was in latent 1st stage compared to their counterpart (AOR: 2.92: 95%CI: 1.7, 4.93). Dystocia of active first stage of labor was 2.5 times common with induced labor compared to spontaneously Onsted labor (AOR: 2.5: 95%CI: 1.23, 5.42). Ambulation during AFSOL labor reduced dystocia of AFSOL by 69% compared to bed restriction (AOR: 0.31: 95%CI: 0.13, 0.69). Moreover, Laboring mothers who got poor support from health care providers during AFSOL were 7.5 times more likely to have dystocia of AFSOL compared to those who satisfied with health care providers (AOR: 7.: 95%CI: 4.18, 13.67) (S1 Table 1).

This study aimed to assess the incidence and predictors of dystocia of active first stage of labor. The overall incidence of dystocia of active first stage of labor (protracted and arrest disorder of cervical dilation) was 35.3% (95%CI: 31.9, 39.2). The major identified predictors of dystocia of AFSOL are, ANC follow-up, induction of labor, linseed/flax, good health care provider support, drinking of coffee > 3cup per day, cervical dilation at admission < 4cm and ambulation during AFSOL.

This is consistent with prospective follow up study done in Sweden (37%) and other retrospective observational study conducted in Sweden (32.5%)(7, 10).

While it is significantly higher than retrospective observation study conducted in United States (20.8%), Swedish (21%), a population based follow up study conducted in Israel (1.3%) (14, 24, 27, 38). The reason of these great discrepancies might be different in study population as well as health care providers who follow the parturient. Beside this, some studies excluded laboring mother with scared uterus. But, this study included it and based on this, around 67% of parturient with scared uterus is admitted in labor ward with cervical dilation of < 4cm. As the current and other studies showed that, DAFSOL is predicted by admitting of parturient in labor ward with cervical dilation of < 4cm. So, the higher incidence of dystocia of active 1st stage of labor in the current study might be attributable to composition of the study participants that is including parturient with scared uterus. These all mentioned explanation possibly could answer why dystocia of active 1st stage of labor in our study was higher.

Dystocia of AFSOL is decreased by 76% among laboring mothers who had ANC follow up during this pregnancy compared to those who don’t have ANC follow up during this pregnancy. This may be due to the fact that women who had ANC follow up are counseled on birth preparedness and complication redness, so they may be well prepared psychologically, economically and on different aspect to give birth.

This study revealed that laboring mothers who drank ≥ 3 cup of coffee per day (estimated to > 200mg of caffeine) during antenatal period are 3.7 times more likely to develop dystocia of AFSOL compared to those who drank < 3 cup of coffee per day. This is in line with study conducted in United States of America(24). This can be explained as Caffeine decreased the uterine contractility through inhibiting the activity of phosphodiesterase, which increase the intracellular cyclic adenomonophosphate (cAMP) level. cAMP induce uterine relaxation via activation of specific protein kinase which phosphorylates and inhibits myosin light chain kinase (MLCK) which oppose calcium pathway. Alterations in myosin light chain phosphorylation decrease force of contraction, and content of contractile proteins in human myometrium (39–42).

Our study conclude that abnormal progress (protracted or arrest) of active first stage of labor are 2.9 times more likely to occurred among parturient who admitted in intrapartum ward when cervical dilation is < 4cm compared to those who are admitted with cervical dilation of > 4cm. Which agree with study done in California and Portland(22, 43). This might be when laboring mothers admitted to intrapartum while in latent stage, first, she may be psychologically stressed when she saw those active women on pain and second, she may restrict in the bed.

Based on our study dystocia of active first stage of labor is 2.5 times more common in artificially stimulated (induced) labor compared to spontaneously Onsted labor. This is consistent with study conducted in Portland, Israel, Norway and Iran (22, 27, 29, 44). One reason can be induced labor is more painful than natural labor, so the laboring mothers become stressful, it causes excessive production of catecholamine from adrenal gland (dopamine, epinephrine and norepinephrine) which acts on alpha- and beta-adrenergic receptors of the uterus then uterine contraction can be ineffective(45, 46). Other reason might be induction can be started with unfavorable cervix.

Our study elucidated that parturient who got poor support (dissatisfied with intrapartum care in AFSOL) from health care providers are 7.5 times more likely to have dystocia of AFSOL compared to those who got good health care providers support (satisfied with intrapartum care). That is in line with study conducted in Iran and Portland(22, 29). This can be due to parturient who get poor support from health care provider may worry on laboring process and may become anxious; this may affect effectiveness of uterine contraction.

The result of our study implies that laboring mothers who ambulating during AFSOL labor is 69% less likely to be complicated with dystocia of AFSOL compared to laboring mothers who are restricted in the bed. The result is consistent with prospective study done in, Egypt, Tunisia and India (34, 35, 47). The reason for these can be Ambulation helps for early descent of the fetus by gravity influence during labor, increases uterine contraction intensity and frequency by increasing uterine blood flow in this way it helps for the progression of active labor. It also reduces labor pain.

Surprisingly our study revealed that dystocia of AFSOL is around 72% less likely to occur among those parturient who eat or drank linseed in 3rd trimester or at the onset of labor pain compared to those who didn’t eat or drank. This might be due to linseed/flaxseed is rich in, linoleic acid, alpha linoleic acid, fiber lignans (which contained estrogen & antioxidant),different macro and micro nutrients and it contained detectable levels of cadmium, a heavy metal that activates the estrogen receptors. Therefore, if the pregnant woman consumes linseed especially after third trimester it leads to cervical ripening, increase intensity of uterine contraction by increasing myometrium oxytocin and prostaglandin receptors. In addition, Flaxseed in itself has the ability to increase the production of cervical fluids for delivery and, therefore, this facilitates the delivery of the baby and reduces the intensity of pain in the birth canal since it will be well lubricated. In this sense, flaxseed will make childbirth simpler and faster. Likewise, the baby will be able to slide out more easily. Even it may leads to preterm birth if she eat or drank in second and early third trimesters, but it needs randomized control trails (48–53).

Strength and limitation of the study

The data were collected day and night which provided us more representative data for the laboring mothers who were on labor at debremarkos comprehensive specialized hospital. And the data were collected prospectively which bring more appropriate and trustful information. This study was conducted in one institution. Because of the feasibility issue restrained us to conduct the study in one comprehensive specialized hospital which restrained its generalization. In this study, the measurement of some variables might have been committed to recall bias. Even though we executed certain efforts to minimize such potential recall biases. During data collection we give extended time for the study participants to think over it. And we provide training for our data collectors on how to approach the mother to collect each study variables.

The finding of our study concluded that the incidence of dystocia (abnormal progress) of active first stage of labor is higher compared to most of literatures conducted in different countries. Having ANC follow up, eating/drinking of linseed and ambulating during active first stage of labor is identified as protective factors for dystocia of active first stage of labor. Whereas, drinking of three or more cup of coffee, induction of labor, poor health care provider support during AFSOL and admitting of the laboring mothers while cervical dilation < 4cm are positive predictors of dystocia of active first stage of labor.

AFSOL: Active First Stage of Labor, ANC: Antenatal Care, CD: Cesarean Delivery, CEFM: Continuous Electronic Fetal Monitoring, CI: Confidence Interval, DMCSH: Debre-Markos Comprehensive Specialized Hospital, DAFSOL: Dystocia of Active First Stage of Labor, OR: Odds Ratio, SPSS: Statistical Package of Social Science, WHO: World Health Organization

Ethics approval and consent to participate

Ethical clearance was obtained from University of Gondar, college of medicine and health science school of midwifery institutional review board under the delegation of the university institutional ethical review board with Ref. number MIDW/30/2015E.c. The study was in accordance with the Ethiopian Health Research Ethics Guideline and the declaration of Helsinki. And formal letter of study approval was obtained from the debremarkos specialized hospital administrators. Finally written and oral consent was taken from each individual study participants after informed about the important of the study, how the Study carried out, the potential risks and benefits and all about the study. Participants address, names and signs couldn’t be included in order to keep participants confidentiality. Since all of our study participants were in the age of 18 and above and we didn’t use sample of human tissue for this study, Informed consent from a parent and/or legal guardian was not tacked. So, Informed consent from a parent and/or legal guardian is not relevant for this study.

Consent for publication

Not applicable.

Data sharing statement

The datasets collected and analyzed for this study are available from the corresponding author and it was attached in the supplementary file.

Competing interests

The authors declare that they have no conflict of interest in this work.

Funding

The authors received no specific funding for this research.

Author Contributions

TNK and MSM designed the study, developed data collection tools, performed the analysis and interpretation, and drafted the paper. GA participated in developing the study proposal, analysis, and interpretation, revised drafts of the paper, and revised the final version of the manuscript. All authors read and gave final approval of the version to be published, have agreed on the journal to which the article has been submitted and agree to be accountable for all aspects of the work.

Acknowledgement

We would like to thank University of Gondar for providing the ethical clearance of this study. Our gratitude likewise drives all data collectors and study participants. Finally, we are glad to Debre Markos comprehensive specialized hospital administrators for writing the permission letter.

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Incidence and Predictors of Dystocia of Active First Stage of Labor at Debremarkos Comprehensive Specialized Hospital Amhara, North West Ethiopia, 2022/2023

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Abstract

Background

Objective

Methods

Result

Conclusion

Figures

Introduction

Methods and materials

Study design, period and setting

Population

Eligibility criteria

Inclusion criteria

Exclusion criteria

Sample size determination and sampling procedure

Sample size determination

Sampling technique and procedures

Variables of the study

Operational definitions

Data collection tool and procedure

Data quality control

Data processing and analysis

Results

Socio demographic and behavioral characteristic

Pregnancy related history of the study participant

Intrapartum related history of the study participant

Incidence of dystocia of active first stage of labor

Predictors of dystocia of active first stage of labor

Discussion

Strength and limitation of the study

Conclusion

Abbreviations

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References

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