2 Cm Dilated How Much Longer

The stages of labour and birth

If you’re having your 1st baby, this pushing stage should last no longer than 3 hours. If you’ve had a baby before, it should take no more than 2 hours.

Abstract

Background:

Early recognition of the signs and symptoms of preterm labor (PTL) is important in order to establish treatment. Our aim was to determine the relation between cervical dilatation and time interval from admission to delivery in women with preterm labor.

Materials and Methods:

A retrospective cohort study was conducted on 83 singleton gestations admitted for preterm labor between 24 weeks and 34 weeks, who subsequently delivered preterm. Women were categorized into three groups of cervical dilatation (0-2 cm, 3-6 cm, >6 cm) and the time interval from admission to delivery was compared. Cox regression analysis was performed to assess the association between cervical dilatation and time interval from admission to delivery. The other variables examined were gestational age (GA) at admission and length of the cervix, when performed.

INTRODUCTION

Preterm delivery (PTD), defined as birth before 37 weeks of gestational age, occurs with an incidence of 5-11% and is the leading cause of perinatal mortality and morbidity in developed countries.[1,2] Preterm delivery presents a complex etiopathogenesis, which consists of multiple pathological signalings and activation of one or more components of the common pathway of parturition.[3] One of the clinical conditions that often precedes spontaneous preterm delivery is threatened preterm labor (PTL), defined as the presence, between 24 weeks and 34 weeks, of the following symptoms: at least eight contractions per hour or four contractions in 20 min and documented cervical changes with intact membranes.[4] If spontaneous preterm birth can be predicted, effective therapeutic strategies can be used to improve neonatal outcomes.

Although over the years, many studies investigated the mechanisms involved in the cascade of preterm delivery and the methods for the prevention and early diagnosis of PTL, few studies have been performed on cervical dilation.[5,6,7,8,9] How et al.[5] found that dilatation of the cervix in women with threatened PTL was inversely associated with time from admission to delivery. In another study, the same inverse relation was shown for women with PTL treated with tocolytic agents.[6] Early recognition of the signs and symptoms of PTL is important in order to establish a tocolytic therapy and to allow antenatal steroids. Dilatation of the cervix is one of the parameters to be evaluated for the diagnosis of threatened PTL, and it may have an important role in the risk stratification of women presenting with PTL. On the basis of these considerations, the aim of this study was to evaluate the relation between dilatation of the cervix and time between threatened PTL and subsequent preterm delivery.

MATERIALS AND METHODS

This was a retrospective cohort study on patients admitted to the Department of Maternal and Child Health of Careggi University Hospital in Florence, Tuscany, Italy between 2010 and 2013, who delivered before 37 weeks. This hospital is a tertiary care center with approximately 3,500 deliveries per year. The local ethics committee approved this study.

Patients with singleton gestations presenting with spontaneous PTL between 24 weeks and 34 weeks and who delivered before 37 weeks were included. During the study period, 83 women who met the inclusion criteria were identified.

Preterm labor was defined as the presence of at least eight contractions per hour or four in 20 min and documented cervical changes with intact membranes.[4] Women with multiple gestations, premature rupture of membranes, and those who delivered preterm due to iatrogenic intervention for reasons other than active labor were excluded from the analysis. In addition, women admitted for threatened PTL who were then discharged from the hospital were excluded from the analysis as they represented cases of “false” PTL. Data were collected from the electronic medical records maintained by the Department of Maternal and Child Health. Data included demographics, medical and obstetric history, dilatation and effacement of the cervix at the time of admission, length of the cervix when available, treatment received, and delivery information. The length of cervix was measured by the physician using the appropriate technique.[10] This consists of the insertion of a clean transvaginal probe covered by a condom in the anterior fornix of the vagina after the woman has emptied her bladder. When a sagittal long-axis view of the entire endocervical canal is obtained, the image is enlarged until the cervix occupies at least two-thirds of the screen and both the external and internal os are seen. The length of the cervix is then measured from the internal to the external os along the endocervical canal, avoiding excessive pressure on the cervix. After obtaining three measurements, the shortest measurement in millimeters is recorded.

Gestational age estimation was based on the last menstrual period or on the ultrasound performed during the first trimester of pregnancy, when the discrepancy between the two dates was more than 7 days. At our institution, tocolytic therapy is usually administered when necessary only after 24 weeks and until 34 weeks, and it is associated with the administration of betamethasone for fetal lung maturity. Tocolysis is usually used for ≤48 h to allow betamethasone to act fully. Atosiban is our first-choice drug.

Statistical analysis

Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 20 (SPSS Inc., Chicago, IL, USA). Normality of continuous data was tested using the Shapiro-Wilk test. Women were categorized into three groups of cervical dilatation (0-2 cm, 3-6 cm, >6 cm). We first evaluated the time interval between admission and delivery in relation to dilatation of the cervix at admission. Cox regression analysis was performed to assess the association between cervical dilatation at admission and prolongation of pregnancy. Time interval from admission to delivery was used as a response in survival analysis; spontaneous delivery was the event. Curves were censored at 7 days. Other variables examined for their association with time interval to delivery were gestational age at admission (32 weeks) and length of the cervix (U test. Chi-square test was used to compare categorical variables. A p value

RESULTS

During the study period, 83 women who met the inclusion criteria were identified. Maternal demographic and obstetric characteristics are reported in Table 1. The median gestational age at admission was 29 weeks and at delivery was 30 weeks. The median interval between admission and delivery was 2 days. When the dilatation was less than 3 cm (n = 65), 23% of the women delivered in the first 24 h, 25% between 24 h and 48 h while 52% delivered after 48 h. When the dilatation was 3-6 cm (n = 14), 64% of the women delivered in the first 24 h, 21% between 24 h and 48 h, and the remaining 15% after 48 h. An interval of more than 7 days between admission and delivery was observed in 25% of the women with dilatation of the cervix less than 3 cm and only in 7% of the women with cervical dilation between 3 cm and 6 cm. Only four patients had a dilatation greater than 6 cm at presentation, and they delivered in the first 24 h.

Displays the pattern of time interval from admission to delivery of subjects with different cervical dilations (a), gestational ages (b) and cervical lengths (c). Curves are censored at 7 days. GA = Gestational age, CL = Cervical length

Women with a dilatation of the cervix between 0 cm and 2 cm had a median interval of 3 days between admission and delivery [interquartile range (IQR) 1-7.5] while women with a dilatation between 3 cm and 6 cm had a median interval of less than 1 day (IQR: 0-1.3); the difference was statistically significant (p = 0.01). Fifty-seven women (69%) received a tocolytic therapy. Tocolytic therapy was performed more frequently in women with p = 0.10).

When considering women presenting with PTL before 32 weeks (n = 62), univariate analysis showed that a more advanced dilatation and an earlier gestational age at admission were associated with a higher risk of delivering before 32 weeks (p = 0.002). After logistic regression analysis, dilatation of the cervix and gestational age at presentation remained independent predictors of delivery p = 0.01).

DISCUSSION

Dilatation of the cervix is one of the parameters that are systematically evaluated in women presenting with PTL. We aimed to evaluate the relation between dilatation of the cervix and pregnancy prolongation in women with PTL and subsequent preterm delivery. Our results showed that the time interval from admission to delivery was associated with dilatation of the cervix and gestational age at admission. These findings are in agreement with the results of previous studies.[5,6,7]

In our population, the median interval between admission and delivery was significantly higher (3 days) for women with dilatation of the cervix between 0 cm and 2 cm compared to women with a dilatation of 3-6 cm (less than 24 h). This time interval is of particular importance in view of the administration of antenatal steroids for pulmonary maturation in women with threatened PTL. Our results support the recommendation of some authors to limit tocolytic treatment to women with maximal cervical dilatation ≤5 cm,[11] because of the lower success rate in the presence of more advanced dilatation. However, data on tocolysis and advanced preterm labor are limited and the appropriate management is controversial.[12,13,14]

In our study, 48% of women presenting with 0-2 cm dilatation of the cervix delivered in the first 48 h, while 85% of women with a 3-6 cm dilatation delivered in the same time period. These percentages are higher than those reported in some previous studies[5,6,7] and indicate that a dilatation of 3-6 cm increases by two times the risk of delivery in the first 48 h compared to a lower dilatation. The high percentage of women delivering in the first 48 h is probably related to the fact that all women in our study had advanced preterm labor, thus constituting a group at a very high risk of delivering prematurely. Amon et al.[7] reported a high percentage of women with cervical dilatation of 3 cm or more for whom delivery was delayed by 24 h (75%) or 48 h (60%). Similarly, Guinn et al.[6] found that at 4 cm, 52% of the women remained undelivered at 48 h. All women enrolled in these studies received tocolytic therapy. In contrast to these studies, we selected women who were admitted to our Department and who subsequently delivered before 37 weeks during the same hospital admission, while we excluded women admitted for threatened PTL who were then discharged from the hospital and were considered cases of “false” PTL. Similar to our results on women with dilation 3-6 cm, a recent retrospective study reported that up to 60% of women presenting with advanced cervical dilatation prior to 34 weeks’ gestation gave birth within 24 h.[15]

Our study brings the attention on one aspect of PTL that often played only a marginal role in the prediction of preterm birth since it represents a late finding. Currently, the assessment of the length of the cervix alone or in combination with fetal fibronectin is used in clinical practice to predict preterm delivery.[16] Ultrasound measurement of cervical length is in fact the most accurate method.[10,17] We found no correlation between the length of the cervix at admission and time interval to delivery. This finding suggests that in women with an already dilated cervix, the ultrasound examination of the cervix for the prediction of PTD is unlikely to add information of clinical value, as confirmed by one previous study.[18] Other studies report a significant correlation between the length of the cervix and the time interval to delivery, in women with cervical dilatation

The correct identification of women at risk for giving birth prematurely after diagnosis of PTL would help to improve maternal and neonatal outcomes. In fact, estimating the risk of imminent delivery is important in order to determine the need for hospitalization, tocolytic therapy and steroids, or to consider maternal transfer to a high-risk center if delivery is not imminent. Our data provide new information for the counseling and obstetric management of women presenting with PTL. A dilatation of 3 to 6 cm doubles the risk of delivering in the next 48 h compared to a dilatation of 0 to 2 cm. Fifty-two percent of women who had preterm labor with cervical dilatation 0-2 cm can have delivery delayed by at least 48 h.

The main limitation of this study lays in its retrospective design. Therefore, some data that were not collected at time of admission are missing, such as the results of the fetal fibronectin (fFN) test, available in only a small number of patients. Among the numerous biomarkers studied in relation to PTD, fFN showed the best results, given its high negative predictive value (99%).[16,21] However, cervicovaginal fFN test is most accurate in predicting spontaneous PTD within 7-10 days of testing among women with symptoms of threatened PTL before advanced cervical dilatation.[16,22] For this reason, for most women in our cohort the test was not performed. Another limitation was that cervical length was available in only a small number of patients. Finally, quantitative measurement of strength of uterine contractions was not available, since such measurement is not routinely performed at our center.

CONCLUSION

Dilatation of the cervix and gestational age at admission are significantly associated with the interval between admission and delivery. The measurement of cervical length is unlikely to add information of clinical value in women with an already dilated cervix. Although dilatation of the cervix is an independent predictor of the time of delivery in women with preterm labor, its predictive accuracy as a single measurement is relatively limited. Further studies evaluating the combination of digital examination with other predictors, such as fetal fibronectin test, are necessary in order to increase our ability to predict preterm delivery.

Authors report no conflict of interests.

AUTHOR’S CONTRIBUTION

MDT contributed in the conception of the work, conducting the study, revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work. VS contributed in the conception of the work, drafting and revising the draft, analysis and interpretation of data for the work approval of the final version of the manuscript, and agreed for all aspects of the work. FV contributed in the conception of the work, conducting the study, revising the draft, acquisition of data for the work approval of the final version of the manuscript, and agreed for all aspects of the work. MC contributed in the conception of the work, revising the draft, acquisition of data for the work, approval of the final version of the manuscript, and agreed for all aspects of the work. MS contributed in the conception of the work, conducting the study, revising the draft, acquisition of data for the work, approval of the final version of the manuscript, and agreed for all aspects of the work. TS contributed in the conception of the work, revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work.

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Articles from Journal of Research in Medical Sciences : The Official Journal of Isfahan University of Medical Sciences are provided here courtesy of Wolters Kluwer — Medknow Publications

The stages of labour and birth

The latent stage of labour is where your cervix starts to soften and open (dilate) so your baby can be born.

You may begin to feel irregular contractions, but it can take many hours, or even days, before you’re in established labour. It’s usually the longest stage of labour.

At this stage, your contractions may range from being slightly uncomfortable to more painful. There’s no set pattern to how many contractions you get or how long they last.

During the latent stage, it’s a good idea to have something to eat and drink because you’ll need energy for when labour is established.

If your labour starts at night, try to stay comfortable and relaxed. Sleep if you can.

If your labour starts during the day, stay upright and gently active. This helps your baby move down into your pelvis and helps your cervix to dilate.

Breathing exercises, massage and having a warm bath or shower may help ease pain during this early stage of labour.

Established labour (1st stage of labour)

Established labour is where your cervix has dilated to about 4cm and your contractions are stronger and more regular.

When to contact a midwife

Call your midwife or maternity unit for guidance if:

• you think you’re in labour
• you’re having regular contractions coming every 5 minutes or more often
• you’re worried about anything

Call your midwife or maternity unit urgently if:

• your waters break
• you have vaginal bleeding
• your baby is moving less than usual
• you’re less than 37 weeks pregnant and think you might be in labour
• any of your contractions last longer than 2 minutes
• you’re having 6 or more contractions every 10 minutes

You can call 111 if you’re unable to contact your midwife or maternity unit.

Call 999 and ask for an ambulance if:

• you think your baby is coming now and you have a strong urge to push

If you go into hospital before your labour has become established, they may suggest you go home again for a while.

Once labour is established, your midwife will check on you from time to time to see how you’re progressing and offer you support, including pain relief if you need it.

You can either walk around or get into a position that feels comfortable to labour in.

Your midwife will offer you regular vaginal examinations to see how your labour is progressing. If you do not want to have these, you do not have to – your midwife can discuss with you why she’s offering them.

Your cervix needs to open about 10cm for your baby to pass through it. This is what’s called being fully dilated.

In a 1st pregnancy, the time from the start of established labour to being fully dilated is usually 8 to 18 hours. It’s often quicker (around 5 to 12 hours), in a 2nd or 3rd pregnancy.

When you reach the end of the 1st stage of labour, you may feel an urge to push.

Monitoring your baby in labour

Your midwife will monitor you and your baby during labour to make sure you’re both coping well.

This will include using a small handheld device to listen to your baby’s heart every 15 minutes. You’ll be free to move around as much as you want.

Your midwife may suggest electronic monitoring if there are any concerns about you or your baby, or if you choose to have an epidural.

Electronic monitoring involves strapping 2 pads to your bump. One pad is used to monitor your contractions and the other is used to monitor your baby’s heartbeat. These pads are attached to a monitor that shows your baby’s heartbeat and your contractions

Sometimes a heart monitor called a foetal scalp electrode can be attached to the baby’s head instead. This can give a more accurate measurement of your baby’s heartbeat.

You can ask to be monitored electronically even if there are no concerns. Having electronic monitoring can sometimes restrict how much you can move around. Your midwife can discuss this with you.

If you have electronic monitoring with pads on your bump because there are concerns about your baby’s heartbeat, you can take the monitor off if your baby’s heartbeat is shown to be normal.

A foetal scalp electrode will usually only be removed just as your baby is born, not before.

Speeding up labour

Labour can sometimes be slower than expected. This can happen if your contractions are not coming often enough, are not strong enough, or if your baby is in an awkward position.

If this is the case, your doctor or midwife may talk to you about 2 ways to speed up your labour: breaking your waters or an oxytocin drip.

Breaking your waters

Breaking the membrane that contains the fluid around your baby (your waters) is often enough to make contractions stronger and more regular. This is also known as artificial rupture of the membranes (ARM).

Your midwife or doctor can do this by making a small break in the membrane during a vaginal examination. This may make your contractions feel stronger and more painful, so your midwife will talk to you about pain relief.

Oxytocin drip

If breaking your waters does not work, your doctor or midwife may suggest using a medicine called oxytocin (also known as syntocinon) to make your contractions stronger. This is given through a drip that goes into a vein, usually in your wrist or arm.

Oxytocin can make your contractions stronger and more regular and can start to work quite quickly, so your midwife will talk to you about your options for pain relief.

You will also need electronic monitoring to check your baby is coping with the contractions, as well as regular vaginal examinations to check the drip is working.

2nd stage of labour

The 2nd stage of labour lasts from when your cervix is fully dilated until the birth of your baby.

Finding a position to give birth in

Your midwife will help you find a comfortable position to give birth in. You may want to sit, lie on your side, stand, kneel, or squat, although squatting may be difficult if you’re not used to it.

If you’ve had lots of backache while in labour, kneeling on all fours may help. It’s a good idea to try some of these positions before you go into labour. Talk to your birth partner so they know how they can help you.

Pushing your baby out

When your cervix is fully dilated, your baby will move further down the birth canal towards the entrance to your vagina. You may get an urge to push that feels a bit like you need to poo.

You can push during contractions whenever you feel the urge. You may not feel the urge to push immediately. If you have had an epidural, you may not feel an urge to push at all.

If you’re having your 1st baby, this pushing stage should last no longer than 3 hours. If you’ve had a baby before, it should take no more than 2 hours.

This stage of labour is hard work, but your midwife will help and encourage you. Your birth partner can also support you.

What happens when your baby is born

When your baby’s head is almost ready to come out, your midwife will ask you to stop pushing and take some short breaths, blowing them out through your mouth.

This is so your baby’s head can be born slowly and gently, giving the skin and muscles in the area between your vagina and anus (the perineum) time to stretch.

Sometimes your midwife or doctor will suggest an episiotomy to avoid a tear or to speed up delivery. This is a small cut made in your perineum.

You’ll be given a local anaesthetic injection to numb the area before the cut is made. Once your baby is born, an episiotomy, or any large tears, will be stitched closed.

Find out about your body after the birth, including how to deal with stitches.

Once your baby’s head is born, most of the hard work is over. The rest of their body is usually born during the next 1 or 2 contractions.

You’ll usually be able to hold your baby immediately and enjoy some skin-to-skin time together.

You can breastfeed your baby as soon as you like. Ideally, your baby will have their 1st feed within 1 hour of birth.

Read more about skin-to-skin contact and breastfeeding in the first few days.

3rd stage of labour

The 3rd stage of labour happens after your baby is born, when your womb contracts and the placenta comes out through your vagina.

There are 2 ways to manage this stage of labour:

• active – when you have treatment to make it happen faster
• physiological – when you have no treatment and this stage happens naturally

Your midwife will explain both ways to you while you’re still pregnant or during early labour, so you can decide which you would prefer.

There are some situations where physiological management is not advisable. Your midwife or doctor can explain if this is the case for you.

What is active management?

Your midwife will give you an injection of oxytocin into your thigh as you give birth, or soon after. This makes your womb contract.

Evidence suggests it’s better not to cut the umbilical cord immediately, so your midwife will wait to do this between 1 and 5 minutes after birth. This may be done sooner if there are concerns about you or your baby – for example, if the cord is wound tightly around your baby’s neck.

Once the placenta has come away from your womb, your midwife pulls the cord – which is attached to the placenta – and pulls the placenta out through your vagina. This usually happens within 30 minutes of your baby being born.

Active management speeds up the delivery of the placenta and lowers your risk of having heavy bleeding after the birth (postpartum haemorrhage), but it increases the chance of you feeling and being sick. It can also make afterpains (contraction-like pains after birth) worse.

What is physiological management?

No oxytocin injection is given, and the 3rd stage of labour happens naturally.

The cord is not cut until it has stopped pulsing. This means blood is still passing from the placenta to your baby. This usually takes around 2 to 4 minutes.

Once the placenta has come away from your womb, you should feel some pressure in your bottom and you’ll need to push the placenta out. It can take up to an hour for the placenta to come away, but it usually only takes a few minutes to push it out.

If the placenta does not come away naturally or you begin to bleed heavily, you’ll be advised by your midwife or doctor to switch to active management. You can do this at any time during the 3rd stage of labour.

Video: What positions are best for giving birth?

In this video, a midwife talks through some of the best positions to give birth.