0utcom.e of normal and dysfunctional different racial groups MARGARET K.

H.

lablor in

THOM

K. CHAN

J. W.

W.

STUDD

Londo?L,

England

Spontaneous labor in patients of different racial groups has been studied relating progress and outcome to whether labor was dysfunctional as defined by the partogram and action line. Forty-three percent of primigravidas and 17.6 to 25.8% of multigravidas passed the action line and had a lower admission cervical dilatation and a longer observed first stage than those patients whose labor progress remained to the left of the action line. White and black primigravidas whose labor progressed to the right of the action line had lower 1 and 5 minute Apgar scores and delivered heavier babies than those to the left. The cesarean section rates were 1.6% and 1.4% (left) and 7.6% and 18.2% (right) in white and black primigravidas, respectively. The cesarean section rate was significantly higher in black primigravidas irrespective of the relationship to the action line due to the high incidence of the complications of hypertension such as fetal distress and abruptio placentae in those in normal labor as well as those in dysfunctional labor due to cephalopelvic disproponion in those patients whose cervimetric progress went to the right of the action line. (AM. J. OHSTET. GYNECOL. 135:495, 1979.)

NORMAL labor in different racial groups’, ’ has been shown to have cervical dilatation time curves similar to those of normal white parturiants.3, 4 The practical value of these curves used as an action line in the recognition of abnormal labor in conjunction with Philpott’s partogran? has been reported.6 The aim of the present study was to ascertain what proportion of white, black, or Asian patients who begin labor spontaneously pass the labor nomogram and require acceleration in order to correct the dysfunctional labor and also to establish whether any high-risk characteristic exists in any particular ethnic subpopulation.

Patients and methlods A total of 1,643 consecutive patients who went into spontaneous labor with a singleton, cephalic fetus at King’s College and Dulwich Hospitals during 1976 were studied. The racial groups studied were those of European and Caucasian origin: “white,” those of Afro-Caribbean origin: “black” and those of IndoFrom

King’s

College Hospital.

Received for publicntion Accepted December

August

15, 1978.

12, 1978.

Reprint requests: Dr. Margaret H. Thorn, King’s Hospital, London S.E.5, United Kingdom. 0002-9378/79/200495+04$00.40/O

College

0 1979 The C. V. Mosby'Co.

Pakistani or Bangladeshi origin who were designated “Asian,” a simple classification used previously in the study of normal spontaneous labor.’ There were 588 white primigravidas and 699 multigravidas; 127 black primigravidas and 194 multigravidas; 26 Asian primigravidas and 34 multigravidas. Five Chinese patients were excluded from the study as their numbers were considered too small for meaningful conclusion. All patients had a vaginal examination after selfadmission in labor and this result was plotted at zero time on the partogram and the expected cervimetric progress drawn in plencil using the labor stencil.” Examinations were then repeated once every four hours or more frequently if the patient’s condition indicated. Patients whose progress remained to the left of the stencilled action line were not usually stimulated, but acceleration of labor using a dilute intravenous solution of Syntocinon was implemented when the patient’s cervimetric progress reached two hours to the right of the action line. For future discussion those patients maintaining progress to the left of the action line were designated “left,” and the dysfunctional groups, whether stimulated or not, “right.” Epidural analgesia was available to those requesting it. This method of selection of patients for augmentation of labor has 495

496

Ghan,

?-hGt?l,

Table

and Studd

1. &lgmentation,

Sumber

epidurals,

“n” (per cent)

Augmented

“n”

1% of

patients to R) Epidural “n’i (number augmented) Lesarean section “n” (per cent\ Venteuseiforceps “n” (per cent)

Ro:ational forceps .‘n” (per

cent)

and operative

Left Right Right

322 (57.;) 236 (42.3)

Left

65 103 5 18 55 25 17

Right

Left Right Left Right

Left Ri&ht

187 (79.2) (20) (89) (1.6)* (7.6) (17.1) (10.6) (5.3)

18 (7.6)

deliveries

72 (56.7) 55 (43.3) 42 (76.4)

15 (37.7) I1 (42.3) 11 (100)

9 (1)

2 (2) 6 (6)

20 (5) I 10 6 10 2

(1.4i? (18.2) (8.3) (IS.?) (2.8)

6 (10.9)

: (36.4) 2 (13.3) 2 (18.2) 1 (6.7)

l(9.1)

565 (80.8) 134 (19.2) 83 (6i.9) 43 34 3 7 13 15 7 3

(13) (27) (0.5)$ (3.2) (2.3) (11.2) (1.2) (2.2)

I44 (74.2) 50 (25.8) 38 pm) 9 13 10 4 41 2 0 I

(:) (12) (6.9)s i8! (2.8) (4.0) (2.01

28 (82.4) 6 ii7.q ‘1 (66.7) 2 ! 0 0 1 2 0 0

(1) (1)

(3.6) (33.3)

*! curd accident, 1 placenta previa, 3 fetal distress. tAbruptio placentae. f 1 placenta previa, 2 hypertension.

$1 abruptio placentae, 9 hypertension. Table II. Percentage analgesia

in each group

given epidural

Primigravida White

Black .-San

?/Iultipavida N’hite

20.2 12.5 13.3

7.6

43.6 36.4 54.5

I!Ai~k

6.2

25.3 26.0

Asian

7.1

16.7

previously been reported,’ although in this series some patients (23 primigravidas and I5 multigravidas) augmented to the left of the line following early membrane rupture or some individual variation in management. obstetric and neonatal details were coded on discharge from the hospital.

A total of 42.3% of white and Asian primigravidas, and 43.3% of black primigravidas cross the action line compared with 19.2% of white, 25.8% of black, and 17.6% of Asian multigravidas. The slight difference in the percentage of multigravidas in each group who passed the line was not significant. The number augmented with Syntocinon and receiving lumbar epidural analgesia is shown in Table I and the percentage in each group given epidurai analgesia is shown in Tabie II. In all groups at least twice as many patients in dysfunctional labor required or requested epldural anesthesia. The overall cesarean section rate was 3.8%-5.3% for primigravidas and 2.6% for multigravidas. As Table I shows, patients in the “right’? groups had

higher cesarean secrios rates than the urhers, but the most striking fmdin# was the high Cesarean sec:ion rate in black multigravidas: 6.Y% in parients to the ieft of the line in apparently normal labor and 8% to ibe right. due to the complications of hypertension and cephalopelvic disproportion, respecti>&y. Details of maternal age, height, admission dilatatior:, and “observed” first stage (from admission in labor) fetal maturity, birth weight and Apgar scores, and the statistical significances calculated using Student : test of any differences between left and right groups are shown in Table III. Age. Black primigravidas were significantly younger (2 1.3 !ears) than both white and Asian primigravidas, whether to the left or right of the action line. This difference was not found in multigravid patients. Weight. Asian primigravidas were the shortest at 157 cm. Black primigravidas (right) are significantly shorter than black primigravidas (left), but maternal height was not related to partographic progress in the other parit) or ethnic groups. Admission dilatation. In all subgroups the admission dilatation was greater in patients who maintained progress to the left indicating a more effrcienl labor, The only interracial difference is that black multigravidas (right) have a greater admission dilatation (4.4 cm) than white multigravidas (right) (3.4 cm) (p < 0.005). Qbserved first stage. Tbe observed first stage taken from the time of self-admission in labor was between cwo to three times more prolonged in patients ir! the right group, and in a!1 cases this difference was highly significant. For example, white primigravidas bad a first stage of five hours (left) and 10.7 hours (right) and white multigravidas had a first stage of three hours

Volume Number

135 4

Table

III.

Normal

Characteristics

Side oj action line

Characteristic Number

Age W-J Maturity (wk.) Height (cm) Admission

dilatation

“Observed” first stage (hr.) Apgar score at 1 min. Apgar Weight

score at 5 min. (gm)

of,women

(cm)

Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right Left Right

in spontaneous

and dysfunctional

labor

groups

497

Multigravidas

White

Black

Asian

322 236 i3.4 5 24.2 2 39.5 i 39.8 -t162.0 f 161.0 k 4.3 f 2.9 f 5.0 t 10.7 A 8.1 f 7.7 t 9.6 + 9.4 7t 3,186 + 3,296 k

72 55 2 2 2 -c f k f t 2 t it +ik k

15

21.3 21.9 38.6 39.5 161.5 159.6 4.4 2.8 4.7 11.9 8.2 7.2 9.7 8.9 2,866 3,276

racial

labor and fetal outcome

Prim@auzdas

4.7 5.0 2.1 1.7 6.4 6.6 2.2 * 1.6 2.9 * 4.4 1.6 1.9 + 0.9 1.4 $ 560$ 482

in different

4.7 4.5 2.6 1.5 5.9 7.0 2.2 1.6 3.1 5.6 1.6 2.3 0.8 1.8 554, 476

*, *

+ +

white

565 164. 24.E 5.1 26.6 k 4.‘7 26.9 -t- 4.3 26.6 k 4.8 38.7 i 1.8 39.5 f 2.4 38.2 + 5.0 39.5 + 1.8 156.6 2 4.6 162.0 +- 6.2 157.3 + 4.0 161.0 c 6.0 5.1 k 2.6 5.2 f 2.4 * 2.5 +- 1.4 + 3.4 + 1.8 4.4 -r- 2.8 .+ 3.5 ? 2.5 * 12.3 c 3.0 8.2 + 3.7 7.9 f 2.0 8.3 + 1.6 8.2 rf- 2.1 8.0 i 1.7 9.7 + 0.6 9.6 2 1.10 9.7 -c 0.9 9.6 i 0.8 2,715 2 554 3,329 -c 512 2,811 t 805 3,325 f 516

Black 145 49 26.7 & 27.8 i39.1 + 39.4 i159.5 k 160.6 + 5.4 f 4.4 -t 3.4 t 11.4 t 8.2 k 7.7 ? 9.7 2 9.2 + 3,196 + 3,338 k

A&an

5.7 6.0 2.0 2.4 13.2 5.7 2.6 2.1 2.7 * 3.4 1.5 2.2 $ 1.0 1.7 504 584

27.4 28.8 39.4 40.2 155.0 155.5 5.7 3.3 3.6 10.3 8.6 7.5 9.8 9.5 3,048 3,308

28 6 2 4.8 i 3:8 +- 1.0. +- 1.0 t 5.5 1?I 9.2 + 2.5 k 1.8 -+ 2.8 * f 6.0 f 1.0 t 1.9 $ 2 0.5 t 1.2 k 651 ? 559

*p < 0.0005. ip < 0.005. $p < 0.05.

(left) and 8.2 not seen in (right) spent hours) than (p < 0.0005).

hours (right). Interracial differences were primigravidas, but black multigravidas longer in labor before full dilatation (11.4 white multigravidas (right) (8.2 hours)

Fetal wdight. Whim and black primigravidas who crossed to the right of the action line had significantly larger babies than those who maintained normal progress and there was no such difference in the multigravid group, although in each subpopulation, babies born to multigravid patients were significantly heavier than those born to primigravid patients. Asian babies were smaller than those two ethnic groups. Apgar scores. The 1 and 5 minute Apgai scores of primigravidas were lowest in black parturiants whose labor passed the action line. In multigravidas this difference was evident in the black and Asian groups at one minute, but not at five minutes. There was no other interracial difference in primigravidas or multigravidas to the left of the line, but for those, in abnormal dysfunction labor (right), white primigravidas had higher Apgar scores at one (p < 0.05) and five (p < 0.01) minutes than black primigravidas. Asian primigravidas (right) had higher Apgar scores than black primigravidas (right) (p < 0.0605) at 5 minutes. The only interracial difference in multigravid patients was that white multigravidas (right) had significantly higher Apgar scores than black multigravidas (right) (p < 0.025). Perinatal loss. There were six stillbirths among the

primigravidas and tw-o among the multigravidas, giving a stillbirth rate of 4.9 per 1,006. These were all to the left of the action line in patients in apparently normal labor. Two were of birth weights less than 1,000 gm, one anencephalic, and one abrdptio placentae. In four patients the fetal heart was not heard on admission in labor, which occurred spontaneously from 35 to 40 weeks’ gestation. There were 11 neonatal deaths, of which seven were to the left of the line. Of the latter, two were less than 1,000 gm, one less than 1,500 gm, and one had had an abruptio placentae. There was one prolapsed cord, one multiple abnormality, a.nd one baby died following rotational forceps and fetal distress. Of the remaining four patients (right) one was premature, less than 1,000 gm, one had gross abnormalities, and two had avoidable factors, one of unrecognized acute fetal distress, and the other baby died following a difficult rotational forceps. The perinatal mortality rate was 11.6 per 1,000. Comment It has previously been demonstrated that the cervimetric progress of the first stage of spontaneous labor, uncomplicated by oxytocin stimulation, epidural analgesia, and instrumentation, is identical regardless of racial group and parity.’ The present study investigated the outcome and complications of spontaneous labor in 1.643 consecutive singleton patients with a cephalic presentation.

498

Thorn,

Ghan, and Studd

Dysfunctional labor has been defined according to the cervimetric progress of the first stage of uncomplicated labor” using the principles described by Friedman’and Philpott and Castle.R The same proportion of primigravidas-43%~suffer from dysfunctional labor regardless of racial group and the mean length of the first stage is also identical. There is also no difference in the mean length of the first stage in the normal patients to the left of the action line. In spite of this the overall cesarean section rate in black primigrav-idas (8.7%) is more than twice that of white primigravidas. Comparison cannot be made with the Asian patients because of the small number reported. The behavior of the multigravid patients is a little different in that 17.6 to 25.8% pass the action line; 25.8% of black multigravidas pass the line and have the longest first stage in any of-the ethnic groups, and these have a statistically significant increase in cesarean section rate (8%). There were also more biack primigravidas having abdominal deliveries for cephalopelvic disproportion than white or Asian primigravidas in spite of the similar incidence of augmentation. There is also a recurrent increase in operative delivery, as it is our experience that elective cesarean section in subsequent pregnancies is performed more commonly in black patients, because of the association of previous cesarean section and high head at term. Both black and white primigravidas in dysfunctional labor to the right of the action line had significantly heavier babies than those who progressed normally, but this difference was not found in multigravidas. The most surprising observation is the high inci-

I. Duignan, 2.

E. M., Studd, J. W. W., and Hughes, A. 0.: Br.

1. Obstet. Gvnaecol. %n, M. A., ‘Wang,

82:593.

1975.

7. Friedman, E. A.: Labour-Clinical agement,

W. P., and Sinnathuray, T. A.: Br. J. Obstet. Gynaecol. 84:600, 1977. 3. Hendricks, C. H., Brenner, W. E., and Kraus, G.: AM. J. OBSTET.GYKECOL. 106:1065, 1970. 4. Studd. J. W. W.: Br. Med. J. 4:451. 1973. 5. Philuott. R. H.: Br. Med. I. 4:351. 1972. 6. St&d, J. W. W.. Clegg: D. R.,’ Sanders, Hughes, A. 0.: Br. Med. J. 2:545. 1975.

dence of cesarean section in black muingt-avidas In a?parently normal labor to the left of the action lxx. These operative deliveries were due to complications of hypertension such as fetal distress and abruptio platentae. IL is known that chronic hypertension is more common in black women” which may present as eclampsia or masquerade as pre-eclampsia in the primigravid patient, ia but in the multigravid patient recur. rent hypertension is a major obstetric problem. However, one British report” found that the incidence of pre-eclampsia in the black patient was less than that in the white, although it was usually of a more fuiminating type, and the incidence of eclampsia was twice that of the white patient. They found no difference in the incidence of antepartum hemorrhage between white and black patients. This contrasts with our findings. The stillbirths in the study all occurred in patients to the left of the action line due to prematurity, fetal abnormality, or hypoxia after an abnormal anteparrum history. These causes of perinatal death will only be diminished by more intensive monitoring of fetal health in the latter part of pregnancy and the commencement of fetal heart monitoring in the critical first hours of labor. The routine use of the action line to recognize dysfunctional labor has abolished prolonged labor 25 a cause of stillbirth, but the two neonatal deaths following rotational forceps are reminders that the benefits of acceleration in the first stage of labor may be lost if difficult instrumentation is allowed in the second stage, particularly if the cervicograph reveals a delay in dilatation from 7 to 10 cm.i2

ed. 2. New

York,

1978,

Evaluation Meredith.

and Man-

8. Philpott, R. II., and Castle, W. M.: Br. J. Obstet. Gynaecol. 79:592, I972 9. Finnerty,

F. A.: J.A.M.A.

216:1634,

1971.

10. Davies, A. M.: 1sr.J. Med. Sci. 7:6, IYiI. Il. Barron, S. L., and Vesey, M. P.: Br. Med.J. ::I I89, iY66, R. R..

and

12. Davidson, A. C., Weaver, J. B.; Davies. I’., and Pearson, F.; Br. J. Obstet. Gynaecol. 833282, 1976.

J.

Outcome of normal and dysfunctional labor in different racial groups.

0utcom.e of normal and dysfunctional different racial groups MARGARET K. H. lablor in THOM K. CHAN J. W. W. STUDD Londo?L, England Spontaneo...
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