Objective: To determine whether term nulliparas with an unengaged vertex presentation at onset of active labor have a higher risk for cesarean delivery.
Methods: A retrospective cohort of 1250 randomly chosen nulliparous patients at 37–42 weeks' gestation who delivered between 1988 and 1989 were selected. Four hundred forty-seven patients were excluded because of nonvertex presentation, cesarean delivery before active phase of labor, multiple gestation, delivery at less than 37 weeks' or greater than 42 weeks' gestation, induction of labor, or missing charts. For the purpose of this study, active labor was defined as regular contractions with cervical dilatation of at least 3 cm. The station at onset of active labor was recorded. Engagement was considered to be at station 0 or below.
Results: Of the 803 patients in the study group, 567 presented unengaged and 236 patients presented engaged. The cesarean rates differed significantly between the two groups: 14% of those unengaged compared with 5% of those engaged (χ2 = 11.9, P < .001). After adjusting for confounding variables, engagement at the time of onset of active labor was associated with lower risk of cesarean delivery (odds ratio .512, 95% confidence interval .285, .922).
Conclusion: Eighty-six percent of nulliparas with an unengaged vertex at onset of active labor delivered vaginally. Engaged vertex at the onset of active labor was associated with a lower risk of cesarean delivery.
In attempting to optimize patient management and identify women at risk for cesarean delivery, a few investigators have studied the impact of an unengaged vertex at the time of active labor on the rate of cesarean.1–5 Gabbe et al6 state that engagement often occurs before the onset of true labor, especially in nulliparas. Can engagement, then, be used as another clinical indicator for increased incidence of cesarean delivery in nulliparas?
Engagement has been defined as the stage at which the widest part of the fetal head has passed through the pelvic inlet.7 It refers to the descent of the biparietal plane of the fetal head to a level below that of the pelvic inlet. Williams7 states further that in nulliparas, engagement occurs commonly during the last few weeks of pregnancy. Friedman and Sachtleben1 found in their series of studies that there was a significant association between higher station at the onset of labor and the incidence of fetopelvic disproportion. The incidence of a prolonged latent phase, primary dysfunctional labor, and secondary arrest of dilatation all decreased with a lower station at the time of admission to labor and delivery; their combined incidence decreased from 20.9% above station +1 to 11.4% below +1 station.1 Friedman and Sachtleben1 state that engagement of the fetal presenting part in nulliparas is related to delivery outcome, the incidence of cesarean delivery with unengaged vertex being six to eight times that of patients with engaged fetuses. In their subsequent study of 253 nulliparas, they found arrest of descent associated with fetopelvic disproportion in 52%.2 Those with arrest of descent showed deviations from normal, including prolongation of each of the phases of labor and slowing of the maximum slopes of dilatation and descent. Labor progression was also related to station of the fetal presenting part at the time of arrest. The higher the station, the slower and more protracted a course of labor.2
This study presents findings from a cohort of 1250 nulliparous patients in which engagement of the fetal vertex at the time of onset of active labor and its relation to cesarean delivery were investigated.
Eighty-six percent of nulliparas with unengaged fetal heads at onset of active labor delivered vaginally.
Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Address reprint requests to: Daniel Roshanfekr, MD, St. Vincent's Medical Center, 153 West 11th Street, Smith 9, New York, NY 10011
Received June 15, 1998. Received in revised form September 9, 1998. Accepted September 17, 1998.
Materials and Methods
A retrospective cohort of 1250 nulliparous patients was selected randomly from a computerized database at our innercity university-based hospital between 1988 and 1989. The computer generated a random-ordered list of nulliparous patients. Their charts were then re-reviewed to determine the station at the onset of active labor, as this information was not a part of our standard database. Four hundred forty-seven patients (36% of the total) were excluded from the analysis because of a nonvertex presentation, cesarean delivery before the active phase of labor, multiple gestation, delivery at less than 37 weeks or greater than 42 weeks' gestation, induction of labor, incomplete data, or missing charts. The final study group comprised 803 patients.
For the purpose of this study, we defined active labor as regular contractions, with a cervical dilatation of 3 cm or more. Engagement was defined at station 0 or below. The station at the onset of active labor was recorded.
Statistical analysis was by the χ2 test, and logistic regression analysis was used to adjust for maternal or obstetric criteria that could bias the analysis. These include maternal body mass index (BMI), maternal weight gain, use of oxytocin, birth weight, use of epidural anesthesia, estimated gestational age, race, and maternal age.
Of 803 patients, 567 patients (71%) were unengaged at the onset of active labor. The remaining 236 patients (29% of the total) were engaged at the onset of active labor. Ten percent were at −3 station, 21% at −2, 40% at −1, 23% at 0, 5% at +1, and 1% at +2. A significant difference was found in the cesarean rate: 14% for the unengaged vertex compared with 5% for the engaged vertex group (χ2 = 11.9, P < .001). The cesarean rates for patients entering the active phase at stations −3, −2, and −1 were 13%, 17%, and 12%, respectively, and did not differ statistically. The cesarean rates at stations 0, +1, and +2 were 5%, 5%, and 0%, respectively, and did not differ statistically (Table 1).
The patient demographics showed a number of differences between the engaged and unengaged groups, which might have biased the results (Table 2). Logistic regression analysis was used to control for these confounding conditions. In the adjusted model, an association between engaged vertex at the onset of active labor and a lowered risk for cesarean delivery was demonstrated (odds ratio .512, 95% confidence interval .285, .922, P = .026). All confounders showed similar associations with cesarean delivery, as previously reported in the literature.8–14 Increased risk was associated with increasing maternal BMI, increasing pregnancy weight gain, use of oxytocin, increasing birth weight, use of epidural anesthesia, increasing estimated gestational age at term, and increasing maternal age. Decreased risk was associated with black race. Not all of these associations reached statistical significance in our sample (Table 3).
In response to increasing concerns over the rising rate of cesarean delivery, the National Consensus Conference on Aspects of Cesarean Birth, convened in 1985, made recommendations in three major areas: vaginal birth after cesarean delivery, dystocia, and breech presentation.15 The rate of repeat cesarean delivery decreased subsequently by 15%, with an increase of only 2.6% in vaginal deliveries. The discrepancy may be explained by a shift in the indication for cesareans.16
The leading indication of primary cesarean delivery is the diagnosis of dystocia.7 Station at time of arrest has been identified previously as a risk factor associated with increased rate of cesarean delivery.3 Other known risk factors affecting the rate of cesarean delivery include maternal BMI, pregnancy weight gain, birth weight, gestational age, the use of oxytocin, the use of epidural anesthesia, maternal race, and maternal age.8–14 This study demonstrated that after controlling for these risk factors, nulliparous patients with vertex term infants entering active labor at station 0 or lower have a lower risk for cesarean delivery. Additionally, cesarean rates did not differ among nulliparous patients with vertex term infants entering active labor at stations − 3, −2, and −1.
Evaluation of station is rather difficult, and the findings may vary from individual to individual. As multiple examiners evaluated stations in this study, some errors may have been introduced into the measurement. In spite of this potential error, a striking difference in cesarean rate between engaged and unengaged vertex presentation at the onset of active labor was demonstrated. The findings of a nonengaged vertex in a nulliparous patient with regular contractions and cervical dilation of 3 cm or more calls for careful evaluation of the patient's pelvis. Nonetheless, 86% of such patients in our population delivered vaginally.
Although many obstetricians believe that nulliparous patients present mostly with engaged fetal heads in active labor, this study and others4,5 indicate that most nulliparous patients present with an unengaged fetal head in active labor. Despite the fact that nulliparous patients who present with an unengaged fetal head have a longer first and second stage of labor, the majority deliver vaginally. This finding allows the clinician to be more optimistic regarding vaginal delivery of nulliparous patients who present with an unengaged vertex in active phase of labor and avoid hasty decisions toward cesarean delivery.
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