Brüggemann 

et al.
BMC Pregnancy and Childbirth (2022) 22:408
https://doi.org/10.1186/s12884-022-04710-2

RESEARCH Open Access

Labor dystocia and oxytocin

augmentation before or after six centimeters
cervical dilatation, in nulliparous women
with spontaneous labor, in relation to mode
of birth
Cecilia Brüggemann1, Sara Carlhäll1, Hanna Grundström2 and Marie Blomberg1* 

Abstract 
Background:  The effects of diagnosing and treating labor dystocia with oxytocin infusion at different cervical dilata-
tions have not been fully evaluated. Therefore, we aimed to examine whether cervical dilatation at diagnosis of dys-
tocia and initiation of oxytocin infusion at different stages of cervical dilatation were associated with mode of birth,
obstetric complications and women’s birthing experience.
Methods:  A retrospective cohort study, including 588 nulliparous term women with spontaneous onset of labor and
dystocia requiring oxytocin augmentation. The study population was divided into three groups according to cervi-
cal dilatation at diagnosis of dystocia and initiation of oxytocin-infusion (≤ 5 cm, 6–10 cm, fully dilated) with mode
of birth as the primary outcome. Secondary outcomes were obstetrical and neonatal complications and women´s
experience of childbirth. Statistical comparison between groups using Chi-square and ANOVA was performed. The risk
of operative birth (cesarean section and instrumental birth) was assessed using binary logistic regression with suitable
adjustments (maternal age, body mass index and risk assessment on admission to the labor ward).
Results:  The cesarean section rate differed between the groups (p < 0.001); 12% in the ≤ 5 cm group, 6% in the
6–10 cm group and 0% in the fully dilated group. There was no increased risk for operative birth in the ≤ 5 cm group
compared to the 6–10 cm group, adjusted OR 1.28 95%CI (0.78–2.08). The fully dilated group had a decreased risk of
operative birth (adjusted OR 0.48 95%CI (0.27–0.85). The rate of a negative birthing experience was high in all groups
(28.5%, 19% and 18%) but was only increased among women in the ≤ 5 cm group compared with the 6–10 cm
group, adjusted OR 1.76 95%CI (1.05–2.95).
Conclusions:  Although no difference in the risk of operative birth was found between the ≤ 5 cm and 6-10 cm
cervical dilatation-groups, the cesarean section rate was highest in women with dystocia requiring oxytocin augmen-
tation at ≤ 5 cm cervical dilatation. This might indicate that oxytocin augmentation before 6 cm cervical dilatation

*Correspondence: marie.blomberg@liu.se
1
Department of Obstetrics and Gynecology in Linköping, Department
of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
Full list of author information is available at the end of the article

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Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 2 of 9

could be contra-productive in preventing cesarean sections. Further, the increased risk of negative birth experience in
the ≤ 5 cm group should be kept in mind to improve labor care.
Keywords:  Oxytocin augmentation, Active labor, Labor dystocia, Cesarean section, Birth experience

Introduction It is still not clear whether diagnosing and treat-

Labor dystocia is a common complication in nulliparous ing labor dystocia with oxytocin before 5–6  cm cervi-
women and is strongly related to cesarean section (CS) cal dilatation increases the risk of CS compared with
and instrumental vaginal birth [1–3]. The majority of after 5–6  cm [17]. Some studies, show decreased rate
women diagnosed with labor dystocia receive oxytocin of CS performed due to labor dystocia by changing the
infusion to enhance uterine contractions [4, 5]. Cur- recommendations of active labor [18] while others have
rently, the definition of labor dystocia at different stages not found the same compelling connection [19]. Most of
of labor is about to change. The American College of these studies have been performed in countries with a
Obstetricians and Gynecologists (ACOG) [6] and the generally high rate of CS [18, 19]. An important question
World Health Organization (WHO) [7, 8] suggests that that arises is whether the positive results in lowering the
active labor starts at 5 or 6 cm cervical dilatation, com- CS rate by changing the recommendations on labor dys-
pared with the traditional definition by Friedman [9] stat- tocia from studies performed in a high CS rate context
ing 3–4 cm as the threshold for the start of active labor. could be extrapolated to settings with relatively low num-
Besides that active labor seems to start at a higher cervi- bers of CSs? A change in the definition of active labor and
cal dilatation than previously assumed [10, 11], the view permitting a slower labor progress during active labor
of what is normal labor progress is debated and new cut need to be thoroughly evaluated in relation to mode of
offs for protracted labor at different cervical dilatations birth and other outcomes in different contexts before
has been suggested [7]. the definition is fully implemented. Since the CS rate in
The WHO and ACOG both changed their definitions Region Östergötland is low among women in the TGCS
of the start of active labor (recommendations) to stem the group 1, studying this group regarding degree of cervical
rising CS rates, as too much focus on cervical progression dilatation at labor dystocia in relation to mode of birth
in early labor was viewed as a risk factor for CS and other would enable an evaluation in a new context (with low
interventions in labor that may negatively affect maternal CS rate) compared with previous studies.
and neonatal outcomes [6, 7]. Recommendations in Swe- We hypothesized that a diagnose of labor dystocia and
den still adhere to Friedman’s’ definition of active labor start of oxytocin infusion before 6 cm cervical dilatation
(4 cm cervical dilatation and expected cervical dilatation increased the risk of cesarean section and instrumental
rate of 1  cm/hour from 4  cm with some slight modera- birth, compared to labor dystocia diagnosed after 6  cm
tions) [12], as do the Swedish recommendations for when cervical dilatation in the TGCS group 1.
to diagnose labor dystocia and initiate labor augmenta- Thus, the primary aim of this study was to evaluate
tion [5]. cervical dilatation at diagnose of labor dystocia and ini-
The CS rates in nulliparous women with a singleton tiation of oxytocin infusion for labor augmentation in
term (≥ 37 + 0 gestational weeks) pregnancy, sponta- relation to mode of birth, in the TGCS group 1. Second-
neous onset of labor and vertex presentation, e.g. the ary outcomes were obstetrical and neonatal adverse out-
Ten Group Classification System (TGCS) group 1 [13, comes and women´s experience of childbirth.
14] are relatively low in Sweden (range in 2020, 3–11%)
compared with many other countries [15]. In Sweden, Methods
Region Östergötland has one of the lowest CS rates (5.9% Study setting and participants
in 2020) as an effect of an active improvement project, This retrospective cohort study included nulliparous
focusing on increasing the rate of spontaneous vaginal women with a singleton and term (≥ 37 + 0 gestational
births in TGCS group 1 women. The TGCS group 1 was weeks) pregnancy, spontaneous onset of labor and vertex
targeted for the improvement project as this relatively presentation, TGCS group 1 [14], who gave birth from
large group of women had much to gain by avoiding the March to November 2018 at two hospitals in the Region
first cesarean section. An increased vaginal birth rate in Östergötland, which has approximately 5000 births per
this group would reduce the risk of complications associ- year combined. Further inclusion criteria were a docu-
ated with CS both during the first birth and subsequent mented risk classification on admission to the labor ward,
pregnancies and births [16]. a diagnosis of labor dystocia and initiation of oxytocin
 Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 3 of 9

infusion in labor. A flowchart of the study population is the following two hours, in accordance with the Swedish
presented in Fig. 1.  national recommendations [12]. Also in accordance with
Swedish national guidelines, diagnosis of labor dystocia
Guidelines and recommendations and initiation of oxytocin infusion was indicated when
The participating hospitals followed the same national there was a delay in the expected cervical progress of
clinical guidelines concerning risk classification, active one cm/hour for more than three hours, no progress in
labor care, diagnosis of labor dystocia and oxytocin infu- descent of the fetal head for one hour when fully dilated,
sion initiation. Maternal and fetal risk classification was or no progress after pushing actively for 30 min [5].
performed on admission to the labor ward using three
risk categories: low, medium or high risk (Appendix 1). Data collection and definition of variables
Active labor was defined as 4  cm of cervical dilatation, Maternal, obstetric and neonatal data were prospec-

records (Obstetrix®) by the midwives and the physicians

or one cm of cervical dilatation and a completely effaced tively recorded in standardized electronic medical
cervix, painful, regular contractions and/or rupture of
the membranes and progress of cervical dilatation within responsible for the care of the women. The maternal

Fig. 1  Flowchart of the study population 

Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 4 of 9

characteristics assessed were age and height, weight diagnosis of labor dystocia and start of oxytocin infusion
in early pregnancy, smoking during pregnancy, diabe- (≤ 5 cm, 6 -10 cm and fully dilated).
tes mellitus, hypertension, and asthma/lung disease.
Maternal height and weight were measured at the first Sample size estimation
antenatal visit in gestational weeks 8–12, which enabled The sample size calculation using Fischer´s exact test
calculation of early pregnancy Body Mass Index (BMI, was based on rates of operative birth in TGCS group 1
kg/m2). The obstetric characteristics that were extracted in 2017 at the hospitals. With 183 women in each group
were: gestational age at birth, active labor time estimates, (cervical dilatation ≤ 5  cm and 6–10  cm) a difference in
cervical dilatation at the start of oxytocin augmentation, rate of operative births (8 vs 17%) could be detected with
epidural analgesia, mode of birth, occurrence of obstet- a 0.05 level of significance at a power of 80%.
ric anal sphincter injury (OASI), postpartum hemor-
rhage (PPH) and women’s birthing experience according Statistical analyses
to the visual analog scale (VAS). At the postnatal ward, All analyses were performed using SPSS Statistical pack-
all women were asked by the midwife in charge at the age version 25.0 (IBM Corporation 1989, 2017). Categori-
postnatal ward to assess their overall birthing experi- cal data is presented as number and per cent. Continuous
ence as a VAS-score ranging from 1 to 10, where 1 is a data is presented as mean and one standard deviation
very negative experience and 10 is a very positive experi- (SD) or median and inter quartile range (IQR) if not nor-
ence. This assessment of childbirth experience by VAS is mally distributed. Maternal characteristics and obstetric
a well-established routine in the postnatal care at the par- and neonatal outcomes were analyzed using a C ­ hi2 test
ticipating delivery units included in this study. A value of for categorical variables and when appropriate Fischer´s
VAS 1–4 was considered a negative birthing experience exact test, and a one-way ANOVA (Analysis of Variance)
according to the Swedish Pregnancy Registry [20]. for continuous variables. A p-value of < 0.05 was consid-
Furthermore, the documented risk classification, ered statistically significant. Binary logistic regression
assessed by the attending midwife on admission to the was performed to calculate odds ratios (ORs), adjusted
labor ward as low, medium or high (Appendix 1), was odds ratios (aORs) and 95% confidence intervals (95%
also extracted. The risk classification partly assesses the CIs) for primary and secondary outcomes. The reference
risk of labor dystocia by including parameters such as group was set at 6–10 cm according to the definition of
first trimester BMI ≥ 30, prolonged latent phase of labor, active labor by ACOG [6]. In the binary logistic regres-
maternal psychological well-being, hypertensive disor- sion, CS and instrumental vaginal birth were merged into
ders and preeclampsia, and fetal well-being (i.e., risk for the outcome operative birth since there was no CS in the
infections in the newborn, intra uterine growth retarda- fully dilated group. The results were adjusted for mater-
tion, non-reassuring CTG (cardiotocography) and heav- nal age at birth, BMI in early pregnancy and risk classi-
ily meconium-stained waters). The neonatal variables fication on admission to the labor ward, using a binary
assessed in the medical file were fetal birth weight and logistic regression model.
Apgar score < 7 at five minutes and umbilical cord arte-
rial pH < 7.10. Data was extracted from the electronic Results
medical records, except data concerning cervical dilation A total number of 588 women were included in the study.
at diagnosis of labor dystocia and the risk classification The women eligible for the study and the women who
on admission to the labor ward which were manually were excluded are presented in Fig. 1. A total number of
extracted from each medical record and added to the 242 (41%) women were classified as low risk on admis-
dataset. All variables were retrospectively extracted. sion to the labor ward and 346 (59%) as medium risk.
None of the women were risk-classified as a high risk.
Primary and secondary outcomes In the study population 34.5% had a diagnosis of labor
The primary outcomes were mode of birth (spontane- dystocia and oxytocin infusion initiated at ≤ 5  cm cer-
ous vaginal birth, instrumental vaginal birth, or CS) vix dilatation, 31.1% at 6–10  cm of cervical dilatation,
and a composite outcome of operative birth (CS and and 34.3% at fully dilated cervix. The three groups were
instrumental birth). Secondary outcomes were the similar in terms of maternal characteristics, apart from
use of epidural anesthesia, OASI grades III and IV, a statistically significant difference in height, BMI in
PPH > 1,000  mL, negative childbirth experience defined early pregnancy and risk classification on admission to
as VAS 1–4 and Apgar score < 7 at five minutes and cord the labor ward (Table 1). No women had pre-pregnancy
arterial pH < 7.10. The outcomes were compared between hypertension, renal disease, preeclampsia, diabetes mel-
the groups defined according to cervical dilatation at litus or heart disease.
 Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 5 of 9

The primary outcome, mode of birth in relation to cer- 78.7% in the 6–10 cm group and 88.6% in the fully dilated
vical dilatation at diagnosis of dystocia and initiation of group. All instrumental vaginal births (n = 77) were vac-
oxytocin infusion, is presented in Tables 2 and 3. uum extractions. The occurrence of instrumental birth
did not differ significantly between the groups (14.3%,
Analog scale 14.8% and 11.4%) (Table 2). The corresponding outcome
The overall CS rate in the study population was 6.3%, rates in the three dilatation groups (≤ 5  cm, 6-10  cm,
13.4% had an instrumental vaginal birth and 80.4% a fully dilated) for low-risk women (n = 242) were as fol-
spontaneous vaginal birth. The CS rate differed signifi- lows, spontaneous vaginal birth 78.0%, 83.3%, 88.6%, and
cantly between the women with a diagnosis of dystocia CS 6.8%, 2.6%, 0%.
and start of oxytocin infusion at cervical dilatation ≤ 5 cm Women diagnosed with dystocia and initiated oxy-
(12.3%) compared to the women with a cervical dilata- tocin infusion when fully dilated had a decreased risk of
tion of 6–10 cm (6.6%) and the fully dilated group (none) operative birth (CS or instrumental vaginal birth) com-
(p < 0.001) (Table 2). Concurrently, there was a significant pared with women in the 6–10  cm cervical dilatation
difference between the groups in women having a spon- group (aOR 0.48 95% CI 0.27–0.85) even after adjusting
taneous vaginal birth with 73.4% in the ≤ 5  cm group, for maternal age at birth, BMI in early pregnancy and risk

Table 1  Maternal and obstetric characteristics of the study population

Cervix dilatation at diagnosis of dystocia and start of  ≤ 5 cm 6–10 cm Fully dilated P-value
oxytocin infusion n = 203 n = 183 n = 202

Age (years) mean [SD] 28.5 [4.8] 28.9 [4.3] 29.4 [4.3] 0.177
Smoking during pregnancy n (%) 5 (3) 5 (3) 1 (0.5) 0.202
Height (cm) mean [SD] 164.8 [6.0] 166.2 [6.0] 167.6 [6.1]  < 0.001
BMI (kg/m2) mean [SD] 25.7 [5.1] 25.8 [5.2] 24.5 [4.1] 0.013
Asthma/lung disease n (%) 21 (11) 8 (4) 18 (9) 0.075
Gestational age in days mean [SD] 283 [7.1] 282 [7.4] 281 [7.0] 0.14
Risk assessment on admission n (%)  < 0.001
   Low risk 59 (29) 78 (43) 105 (52)
   Medium risk 144 (71) 105 (57) 97 (48)
   High risk 0 0 0
Active phase of first stage of labor in minutes, median [IQR] 736 [515–958] 790 [619–968] 604 [451–764]  < 0.001
Second stage of labor in minutes, median [IQR] 36 [21–49] 31,5 [21–50] 37 [24–57] 0.114
Data is presented as mean and [standard deviation] or median and [inter quartile range] for continuous variables and number and (percent) for categorical variables.
Percent was calculated within dilatation groups. p < 0.05 was considered statistically significant
BMI Body mass index, IQR Inter quartile range

Table 2  Outcomes according to cervix dilatation groups at diagnosis of dystocia and start of oxytocin infusion
Cervix dilatation at diagnosis of dystocia and  ≤ 5 cm 6–10 cm Fully dilated P-value
start of oxytocin infusion n = 203 n = 183 n = 202

Spontaneous vaginal birth n (%) 149 (73.4) 144 (78.7) 179 (88.6)  < 0.001
Instrumental vaginal birth n (%) 29 (14.3) 27 (14.8) 23 (11.4) 0.569
Cesarean section n (%) 25 (12.3) 12 (6.6) 0 (0.0)  < 0.001
Need of epidural anesthesia n (%) 178 (88) 162 (89) 142 (70)  < 0.001
OASI grade III + IV n (%) 13 (6) 10 (5) 11 (5) 0.89
PPH (> 1000 mL) n (%) 14 (7) 10 (6) 14 (7) 0.80
Apgar < 7 at 5 min n (%) 8 (4) 4 (2) 1 (0.5) 0.06
Umbilical cord arterial pH < 7.10 n (%) 19 (12.2) 14 (10.3) 15 (9.7) 0.76
Negative birth experience (VAS 1–4) n (%) 53 (28.5) 33 (19.0) 34 (18.0) 0.03
Data is presented as number and percent. Percent was calculated within dilatation groups. p < 0.05 was considered statistically significant
OASI Obstetric Anal Sphincter injury, PPH Postpartum hemorrhage, VAS Visual Analog Scale
Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 6 of 9

Table 3  Crude and adjusted odds ratios for obstetric and neonatal outcomes
Crude OR (95% CI) Adjusted ­OR* (95% CI)

Primary outcome
Operative birth
  ≤ 5 cm 1.34 (0.84–2.14) 1.28 (0.78–2.08)
 Fully dilated 0.47 (0.27–0.83) 0.48 (0.27–0.85)
Secondary outcome
 Need of epidural
   ≤ 5 cm 0.92 (0.5–1.71) 0.91 (0.48–1.73)
  Fully dilated 0.31 (0.18–0.53) 0.28 (0.16–0.50)
OASI grade III + IV
  ≤ 5 cm 1.18 (0.51–2.77) 1.18 (0.50–2.81)
 Fully dilated 0.10 (0.41–2.40) 1.07 (0.44–2.60)
PPH (> 1000 ml)
  ≤ 5 cm 1.28 (0.56–2.96) 1.39 (0.60–3.28)
 Fully dilated 1.29 (0.56–2.98) 1.36 (0.58–3.17)
Apgar score < 7 at 5 min
  ≤ 5 cm 1.86 (0.55–6.27) 1.57 (0.45–5.46)
 Fully dilated 0.23 (0.03–2.01) 0.22 (0.02–2.00)
Negative birth experience VAS 1–4
  ≤ 5 cm 1.70 (1.04–2.79) 1.76 (1.05–2.95)
 Fully dilated 0.94 (0.55–1.60) 1.01 (0.58–1.75)
Cervical dilatation at diagnosis of dystocia and start of oxytocin augmentation and the risk of operative birth (instrumental vaginal birth or cesarean section), adverse
obstetric and neonatal outcomes and risk of negative birthing experience. Cervical dilatation of 6–10 cm at diagnosis of dystocia and start of oxytocin augmentation
was set as reference
OR Odds Ratio, OASI obstetric anal sphincter injury, VAS Visual Analog Scale, PPH postpartum hemorrhage
*
Adjusted for maternal age at birth, BMI in early pregnancy and risk assessment at admission to the labor ward

classification on admission to the labor ward (Table  3). shown in the ≤ 5 cm group in comparison to the 6–10 cm
The secondary outcomes in relation to cervical dilata- group. Furthermore, women with a diagnosis of dystocia
tion at diagnosis of dystocia and initiation of oxytocin and start of oxytocin infusion at ≤ 5 cm had an increased
infusion are shown in Tables 2 and 3. The use of epidural risk of a negative birth experience.
anesthesia and negative birth experience (VAS 1–4) dif- These results are in line with a study by Häggsgård et al.
fered significantly between the three cervical dilatation who compared mode of birth among women in the TGCS
groups (Table  2). Women with a diagnosis of dystocia group 1 according to the degree of cervical dilation when
and start of oxytocin infusion at ≤ 5 cm of dilatation, had initiating labor augmentation with oxytocin. They found,
an increased risk of reporting a negative birth experience in 464 women, that the more dilated the cervix was when
(VAS 1–4), compared to women in the 6–10  cm group initiating oxytocin augmentation, the higher the likeli-
(aOR 1.76 95% CI 1.05–2.95) (Table  3). Women in the hood of a vaginal birth, and concluded that women who
fully dilated group had a decreased risk for having epi- had oxytocin infusion initiated at ≤ 4 cm cervical dilata-
dural anesthesia compared with women in the 6–10 cm tion had the highest risk of CS (13.6%) [21]. In this con-
group (aOR 0.28 95% CI 0.16–0.50) (Table 3). text it is also of interest to look at studies comparing
mode of birth outcome according to cervical dilatation
Discussion degree when active labor starts. Results from the present
This cohort study, including 588 women in the TGCS study are in line with results from a French study, where
group 1, showed significant differences between the the definition of active labor was changed from 4 to 6 cm
three cervical dilatation groups (≤ 5  cm, 6–10  cm, fully cervical dilatation, in which women who were diagnosed
dilated) in rates of spontaneous vaginal births and CS, with labor dystocia and had oxytocin infusion was ini-
but no difference in rates of instrumental birth. The risk tiated before 7  cm had an increased risk of CS [18]. On
of operative birth (cesarean and vacuum extraction) was the other hand, when the Norwegian LaPS trial clus-
significantly lower in the fully dilated group compared ter-randomized women in the TGCS group 1 to active
with the 6–10 cm group, but no increased risk could be labor defined as either 4 or 6  cm of cervical dilatation,
 Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 7 of 9

they found no difference in mode of delivery. However, restricts women’s mobility during labor and birth due to
the total CS rate in both groups decreased during the the increased need of continuous CTG, but also increase
trial, from 9–10% to 6% [19]. One reason for the current the risk of more discomfort, pain and need for epidural
study’s incoherence with the LaPS-trial might be due to analgesia [27].
the differences in study design. More studies are needed
to evaluate both mode of birth and neonatal outcomes in Strengths and limitations
women with and without interventions due to labor dys- This study has certain strengths and limitations. One
tocia at low cervical dilatation degrees. strength is the large study population of term nulliparous
In the present study population 34.5% were diagnosed women with spontaneous onset of labor and oxytocin
with dystocia and received oxytocin infusion when the augmentation initiated during labor, enabling evaluation
cervix dilatation was ≤ 5  cm and were thus in the latent of outcomes in three cervical dilatation groups with cut-
phase of labor according to the ACOG definition [6] but offs customized to the latest definitions on start of active
not according to the Swedish criteria of active labor [12]. labor. Another strength is the cohort design, where all
We found that in the ≤ 5 cm group the CS rate was twice women during a specified period of time were included
as high as in in the 6–10  cm group. With the proposed in the study, which minimized the risk of selection bias.
definition of start of active labor at a cervical dilatation The detailed prospectively collected data on baseline
of 6  cm [6, 11], oxytocin infusion before that would be evaluation of maternal comorbidity and socioeconomic
classified as induction of labor in the latent phase of factors, enabled adjustment for possible confounding
labor, instead of spontaneous onset and labor augmen- factors. Another strength is the availability of manu-
tation due to labor dystocia. It is well described that the ally extracted risk assessments, which made it possible
rates of CS increase when labor is induced compared to to adjust outcomes for the woman´s individual risk on
spontaneous onset of labor [22], and the increased rate of admission to the labor ward.
CS in the ≤ 5 cm group in the present study might have The retrospective design of a study is always a limi-
been because these women were still in the latent phase tation as the researcher has no control over the data
of first stage of labor when diagnosed with labor dysto- entered into the electronic medical records. Also, addi-
cia and oxytocin infusion was initiated. As women enter tional data that would have been valuable in the analysis
the active stage of labor the cervical collagen structure (e.g. cervix dilatation on admission or time from start of
transforms to become softer and more prone to dilata- oxytocin infusion to birth) was not available. The choice
tion [23]. If the contractions are reinforced with oxytocin of confounding factors was based on previous simi-
infusion before the cervix has changed its structure and lar research and clinical experience, but there might be
thus remains firm, it might not be able to dilate and unknown confounding factors that could have biased our
thereby there is no progress of labor. results. Another drawback arose when it became appar-
The current study found that almost one-third of the ent that no CS were performed in the group which had
women that were diagnosed with labor dystocia and had oxytocin initiated when cervix was fully dilated. A com-
oxytocin augmentation initiated at ≤ 5  cm of dilatation posite outcome of CS and instrumental birth was there-
had a negative birthing experience measured by VAS, fore created and named “operative birth”, enabling the
compared to one out of five women with start of augmen- data to be further analyzed using binary logistic regres-
tation at 6–10 cm cervical dilatation. A negative birthing sion. The context in which this study was performed has
experience has in earlier studies been associated with a a long tradition of high use of oxytocin but also high fre-
long duration of labor and CS [1, 24, 25], oxytocin aug- quencies of spontaneous vaginal births, a fact that might
mentation during the first stage of labor [24, 26], instru- reduce the generalizability to other populations with
mental birth and PPH [24]. Satisfaction with childbirth higher incidence of CS.
experience is a measure of quality and should be a sig-
nificant endpoint according to the WHO, alongside the Conclusion
outcome of healthy mother and healthy baby. WHO fur- This study on nulliparous women with spontaneous
ther states that the increased medicalization of normal onset of labor and labor dystocia, performed in a low
childbirth deprives women of their own birthing capabili- CS setting, showed a significant difference in mode of
ties and contributes to a higher risk of a negative child- birth rates among the three cervical dilatation groups.
birth experience [8]. The individual parts of the cascade The fact that the highest rate of CS occurred when
of interventions in women with diagnosed labor dysto- labor dystocia was diagnosed and oxytocin was initi-
cia have not been evaluated in relation to the women’s ated before ≤ 5 cm of cervical dilatation might indicate
birth experience in the current study. Factors of impor- that oxytocin augmentation before 6 cm could be contra
tance could be that the use of oxytocin infusion not only productive in preventing CS. Additionally, the higher
Brüggemann et al. BMC Pregnancy and Childbirth (2022) 22:408 Page 8 of 9

risk for a negative birth satisfaction among the women were contacted. All methods were carried out in accordance with relevant
guidelines and regulations.
in the ≤ 5 cm of cervical dilatation group, calls for cau-
tion when considering augmenting labor at ≤ 5  cm of Consent for publication
cervical dilatation. The results from the present study Not applicable.
support the shift toward a definition of active labor at Competing interests
a higher cervical dilatation degree, minimizing inter- The authors declare that they have no competing interests.
ventions in early stages of labor, and thus potentially
Author details
increasing both the number of spontaneous vaginal 1
 Department of Obstetrics and Gynecology in Linköping, Department
births and women´s satisfaction with childbirth. These of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden.
results should be considered when designing new rec- 2
 Department of Obstetrics and Gynecology in Norrköping, Department of Bio-
medical and Clinical Sciences, Linköping University, Linköping, Sweden.
ommendations on labor care.
Received: 20 January 2022 Accepted: 22 April 2022

Abbreviations
ACOG: American College of Obstetricians and Gynecologists; ANOVA: Analysis
of Variance; aORs: Adjusted odds ratios; BMI: Body Mass Index (kg/m2); CIs:
Confidence intervals; CS: Cesarean section; CTG​: Cardiotocography; IQR: Inter References
Quartile Range; OASI: Obstetric anal sphincter injury; ORs: Odds ratios; PPH: 1. Selin L, Wallin G, Berg M. Dystocia in labour–risk factors, management
Postpartum hemorrhage; TGCS: Ten Group Classification System; WHO: World and outcome: a retrospective observational study in a Swedish setting.
Health Organization. Acta Obstet Gynecol Scand. 2008;87(2):216–21.
2. Cheng YW, Shaffer BL, Bryant AS, Caughey AB. Length of the first stage of
Supplementary Information labor and associated perinatal outcomes in nulliparous women. Obstet
Gynecol. 2010;116(5):1127–35.
The online version contains supplementary material available at https://​doi.​ 3. Nyfløt LT, Stray-Pedersen B, Forsén L, Vangen S. Duration of labor and the
org/​10.​1186/​s12884-​022-​04710-2. risk of severe postpartum hemorrhage: a case-control study. PLoS ONE.
2017;12(4): e0175306.
Additional file 1: Appendix 1. Risk assessment on admission to the labor 4. Selin L, Almström E, Wallin G, Berg M. Use and abuse of oxytocin for
ward.  augmentation of labor. Acta Obstet Gynecol Scand. 2009;88(12):1352–7.
5. Socialstyrelsen. Indikation för värkstimulering med oxytocin under aktiv
förlossning (Indication for augmentation with oxytocin during active
Acknowledgements labor). 2011 2011 08/01 Report No 2011 18
The authors would like to thank Lars Valter, Forum Östergötland, Linköping 6. Caughey AB, Cahill AG, Guise J-M, Rouse DJ, American College of
University and Region Östergötland, Linköping, Sweden for assistance with Obstetricians and Gynecologists. Safe prevention of the primary cesarean
statistics. delivery. Am J Obstet Gynecol. 2014;210(3):179–93.
7. World Health Organization. WHO labour care guide: user’s manual.
Authors’ contributions Geneva; 2020.
Authors CB and MB designed the study. CB extracted all data from medical 8. World Health Organization. WHO recommendations: intrapartum care for
records. CB did the statistical analyses. CB, HG, SC, and MB contributed to a positive childbirth experience. Geneva; 2018.
the analysis and interpretation of data for the work. CB and MB wrote the 9. Friedman EA. The graphic analysis of labor. Am J Obstet Gynecol.
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final approval and agreed to be accountable for all aspects of work ensuring 10. Lundborg L, Åberg K, Sandström A, Discacciati A, Tilden EL, Stephans-
integrity and accuracy.  son O, et al. First stage progression in women with spontaneous onset
of labor: A large population-based cohort study. PLoS ONE. 2020;15(9):
Funding e0239724.
Open access funding provided by Linköping University. This work was sup- 11. Zhang J, Landy HJ, Branch DW, Burkman R, Haberman S, Gregory KD,
ported by the ALF (Avtal om Läkarutbildning och forskning) grants, Region et al. Contemporary patterns of spontaneous labor with normal neonatal
Östergötland (grant no. RÖ-938175). The funder was not involved in the outcomes. Obstet Gynecol. 2010;116(6):1281.
development of the study from the idea to the project plan, the analysis of 12. Perinatal ARG och svenska Barnmorskeförbundet. Definition av etablerat
data or writing the manuscript. förlossningsarbete (Definition of active labor). 2015.
13. World Health Organization. Robson Classification: Implementation
Availability of data and materials Manual. Geneva; 2017.
The datasets generated and/or analyzed during the current study are not 14. Robson M. The Ten Group Classification System (TGCS)–a common start-
publicly available due to restrictions in Swedish law (Offentlighets- och ing point for more detailed analysis. BJOG. 2015;122(5):701.
sekretesslag (SFS 2009:400)/Public Access to Information and Secrecy Act (SFS 15. Boerma T, Ronsmans C, Melesse DY, Barros AJ, Barros FC, Juan L, et al.
2009:400)) but are available from the corresponding author on reasonable Global epidemiology of use of and disparities in caesarean sections.
request. Lancet. 2018;392(10155):1341–8.
16. Blomberg M. Avoiding the first cesarean section–results of structured
organizational and cultural changes. Acta Obstet Gynecol Scand.
Declarations 2016;95(5):580–6.
17. Caughey AB, editor Is Zhang the new Friedman: How should we evaluate
Ethics approval and consent to participate the first stage of labor? Semin Perinatol; 2020: Elsevier.
The Regional Ethical Review Board in Linköping, Sweden approved the study 18. Thuillier C, Roy S, Peyronnet V, Quibel T, Nlandu A, Rozenberg P. Impact
and the extraction of data from patient medical records on June ­14th, 2017 of recommended changes in labor management for prevention of the
(Dnr. 2017–277-31) and on February ­19th, 2019 (Dnr. 2019–01059). Upon col- primary cesarean delivery. Am J Obstet Gynecol. 2018;218(3):341-e1 e9.
lection, all data was de-identified. According to statement from the Regional 19. Bernitz S, Dalbye R, Zhang J, Eggebø TM, Frøslie KF, Olsen IC, et al.
Ethical Review Board, informed consent was not needed as no individuals The frequency of intrapartum caesarean section use with the WHO
partograph versus Zhang’s guideline in the Labour Progression Study
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