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OBSTETRICS

Maternal obesity and contraction strength

in the first stage of labor
Jeanette R. Chin, MD; Erick Henry, MPH; Calla M. Holmgren, MD; Michael W. Varner, MD; D. Ware Branch, MD
OBJECTIVE: The purpose of this study was to determine whether ma-

RESULTS: Although obese women were at significantly greater odds of cesar-

ternal obesity is associated with cesarean delivery and decreased contraction strength in the first stage of labor.

eandeliverythannormal-weightwomen(oddsratio,2.4;95%confidenceinterval, 1.93.1), they were equally able to achieve Montevideo units of 200.
Among women with a vaginal delivery, obese women had a longer first stage of
labor compared with normal-weight women (597 vs 566 min; P .003).

STUDY DESIGN: We studied a retrospective cohort of women who delivered within a single healthcare system from 2007-2009; we included
5410 women with an intrauterine pressure catheter during the last 2
hours of the first stage of labor and who either had a vaginal delivery or
cesarean delivery for dystocia. Logistic regression was used to determine how body mass index was associated with cesarean delivery or
mean Montevideo units of 200.

CONCLUSION: Obese women have longer labors but are equally able to

achieve adequate Montevideo units as normal-weight women.

Key words: contraction strength, labor, maternal obesity, Montevideo
units, pregnancy

Cite this article as: Chin JR, Henry E, Holmgren CM, et al. Maternal obesity and contraction strength in the first stage of labor. Am J Obstet Gynecol
2012;207:129.e1-6.

besity is an epidemic in many developed countries. More than onethird of all women in the United States are
obese (body mass index [BMI], 30 kg/
m2),1 with approximately 1-in-5 being
obese at the onset of pregnancy.2 Maternal
obesity is associated with multiple labor
abnormalities that include increased risks
for induction of labor, postdates preg-

From the Division of Maternal-Fetal Medicine,

Department of Obstetrics and Gynecology,
University of Utah School of Medicine (Drs
Chin, Holmgren, Varner, and Branch), and the
Division of Maternal-Fetal Medicine,
Department of Obstetrics and Gynecology,
Intermountain Healthcare (Mr Henry and Drs
Holmgren, Varner, and Branch), Salt Lake City,
UT.
Received Feb. 20, 2012; revised April 22,
2012; accepted June 18, 2012.
The authors report no conflict of interest.
Presented in poster format at the 58th annual
meeting of the Society for Gynecologic
Investigation, Miami Beach, FL, March 16-19,
2011.
Reprints: Jeanette R. Chin, MD, University of
Utah, Department of Obstetrics and
Gynecology, 30 N 1900 E, Room 2B200, Salt
Lake City, Utah 84124.
jeanette.chin@hsc.utah.edu.
0002-9378/$36.00
2012 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2012.06.044

nancy, prolonged labor, oxytocin augmentation, postpartum hemorrhage, and

cesarean delivery (CD).3-8 There is a dosedependent relationship between maternal
BMI and a risk for CD that is independent
of parity and infant birthweight.9-11 A recent study found that, for every 1 unit increase in BMI, the risk for CD increased by
5% for both nulliparous and multiparous
women without a previous CD.11 The increased rate of CD among obese women
appears to be confined to the first stage of
labor9 and is, in large part, due to failure to
progress or cephalopelvic disproportion.10
Furthermore, progression in the first stage
of labor is particularly slow among obese
women.8
Given that the initiation and maintenance of normal labor is complex (and
incompletely understood), the cause of
the increased CD rate among obese
women is likely multifactorial. However,
given the multiple labor abnormalities
that are seen more frequently among
obese women, a leading theory is that
obesity may be associated with impaired
myometrial contractility. This theory is
supported by multiple ex vivo and animal studies. Zhang et al12 found that
myometrial strips obtained from obese
women who undergo an elective CD at
term contracted with less force and frequency than strips that were obtained

from normal-weight women; however, a

subsequent study was unable to confirm
these findings.13 In 2 other studies, leptin14
and low-density lipoprotein cholesterol15
were found to inhibit the contractility of
human myometrial strips. In a recent
study that used a rat model, a high-fat,
high-cholesterol diet resulted in decreased
expression of certain myometrial contractile-associated proteins.16
Although these ex vivo and animal
studies indicate that myometrial contractility may indeed be impaired in the setting
of maternal obesity, data as to whether
these results translate into clinically measurable or meaningful differences in contractile strength during human labor are
limited. Buhimschi et al17 found that obese
women in the second stage of labor generate equivalent intrauterine pressures with
pushing compared with normal-weight
women. Nuthalapaty et al18 examined
whether uterine contraction strength in
the first stage of labor varies with BMI. Although maternal BMI was related inversely
to the rate of cervical change in the first
stage of labor, neither uterine responsiveness (as measured in Montevideo units
[MVUs]) nor rates of oxytocin administration differed by BMI.
Using a large and detailed electronic
obstetric database from a single integrated healthcare system, we sought to

AUGUST 2012 American Journal of Obstetrics & Gynecology

129.e1

Research

Obstetrics

determine whether maternal obesity is

associated with (1) an increased risk for
CD in the first stage of labor and (2) decreased uterine contractility in the first
stage of labor, as measured by intrauterine pressure catheters (IUPCs) and
MVUs.

M ATERIALS AND M ETHODS

Study population
University of Utah and Intermountain
Healthcare institutional review board
approval was obtained to access electronic data on women who delivered
from 2007-2009 at 10 hospitals within
Intermountain Healthcare (a single vertically integrated health care system).
Electronic data were from an Intermountain Healthcare-specific database
(StorkBytes) that captures maternal history, labor progression (fetal and uterine
tracings, cervical examinations, oxytocin
doses, and nurse charting), and delivery
data.
Only women who had a term (37
weeks gestation) vaginal delivery (VD),
or a CD in the first stage of labor (10
cm dilation) and who had an IUPC for at
least 2 hours before complete dilation or
CD were included. Because we sought to
focus on contraction strength in the first
stage of labor (at which time progression
is particularly slow among obese women)
and because maternal pushing efforts
might make the calculation of MVUs inaccurate, women who had a CD in the
second stage of labor were excluded.
Women with a multiple gestation, previous CD, major fetal anomaly, diagnosis
of chorioamnionitis, or diagnosis of preeclampsia that required magnesium sulfate treatment were excluded. To eliminate potential coding errors, women
with gestational weight gain (GWG) recorded as 0 or 75 lbs were excluded;
women with a gestational age at delivery
of 43 weeks were excluded, and
women with a recorded time in labor
that was a negative value were excluded.
Women with a listed CD indication that
included failed induction/augmentation, failure to progress, arrest of dilation/descent, or cephalopelvic disproportion were included in a category that
was designated as dystocia. Some
129.e2

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women had 1 indication listed for their
CD (for example, arrest of dilation and
non-reassuring tracing). If one of the indications was dystocia as defined earlier,
then they were placed in the dystocia category for the purposes of analysis.
Women with no recorded indication for
CD and women with a listed indication
of cord prolapse, malpresentation, compound presentation, or marginal previa
were excluded.

Measures
The primary predictor was prepregnancy BMI category that was defined in
the following manner: normal weight
(BMI, 25 kg/m2), overweight (BMI,
26-30 kg/m2), or obese (BMI, 30 kg/
m2). Prepregnancy BMI was calculated
on the basis of self-reported prepregnancy weight and height at the time of
admission to Labor and Delivery. The
primary outcome variables were CD and
mean MVUs of 200 (typically considered adequate in clinical practice) in the
last 2 hours of the first stage of labor (2
hours preceding complete dilation for
women with a VD and 2 hours preceding
delivery for women with a CD). When
prompted, a computer algorithm calculates MVUs over a 10-minute period.
These MVU values are then recorded
electronically by nurses. Variables that
were evaluated as potential confounders
of the association between prepregnancy
BMI and CD were maternal age, parity,
induction of labor, gestational age, admission cervical dilation, excessive GWG
as defined by Institute of Medicine 2009
criteria,19 and infant birthweight. In addition to these variables, maximum oxytocin
dosage in the last 2 hours of the first stage of
labor was included as a potential confounder when we evaluated the association
between BMI and mean MVUs.
Statistical analysis
One-way analysis of variance or the nonparametric Kruskal-Wallis test was used
in bivariate analyses. To evaluate for
potential colinearity among predictors,
correlation coefficients were calculated.
Multivariable logistic regression was
used first to determine how prepregnancy BMI category was associated with
CD. Logistic regression was then used to

American Journal of Obstetrics & Gynecology AUGUST 2012

determine how prepregnancy BMI category was associated with mean MVUs of
200 in the last 2 hours of the first stage
of labor. Because women who ultimately
had a CD may have had a more dysfunctional labor course than those with a VD
and because the phase of labor during
which MVUs were recorded would differ
for women with a CD vs VD, this analysis
was stratified by mode of delivery. We
hypothesized that women whose only indication for CD was dystocia (ie, not also
including nonreassuring tracing) represent a group for which clinicians would
be particularly aggressive in trying to
achieve adequate MVUs. For this reason,
we performed a subanalysis of the association of BMI with MVUs among this
group.
The logistic regression models are
summarized by odds ratios (ORs) with
corresponding 95% confidence intervals
(CIs). All statistical tests used a 2-sided
alpha of .05. Analysis was performed
with SAS software (version 9.2; SAS Institute Inc. Cary, NC).

R ESULTS
From a total of 69,857 women who delivered at these 10 hospitals during the
study period, 7611 women were identified who had a term singleton gestation
that resulted in a VD or primary CD in
the first stage of labor and who had an
IUPC during the last 2 hours of the first
stage of labor. Three women with no
listed indication for CD, 6 women who
had a listed indication of cord prolapse,
malpresentation, compound presentation, or marginal previa, and 443 women
who had a listed indication of a major
fetal anomaly, chorioamnionitis, or preeclampsia that required magnesium sulfate treatment were excluded. After additional exclusions for potential coding
errors (as described earlier), a total of
5410 women were included in the analysis (VD, 4772; CD in the first stage of
labor, 638). Most of the women (n
509; 79.8%) who had a CD had a recorded indication classified in the dystocia category. Four hundred ten women
who had a CD had only a dystocia indication. Two thousand eight hundred
eighteen of the women (52.1%) were

Obstetrics

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Research

TABLE 1

Characteristics of the study population (n 5410)

Characteristic
Age, y

Normal weight

Overweight

25.8 5.0

Obese

26.6 5.2

27.3 5.3

P value
.0001

................................................................................................................................................................................................................................................................................................................................................................................

Nulliparous, n (%)

1620 (57.5)

707 (50.6)

535 (44.8)

Parous, n (%)

1198 (42.5)

691 (49.4)

659 (55.2)

Induction of labor, n (%)

1444 (51.2)

824 (58.8)

735 (61.6)

Spontaneous labor, n (%)

1374 (48.8)

574 (41.1)

459 (38.4)

.0001

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

.0001

................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
a

Infant birthweight, g

3359.4 416.3

Excessive gestational weight gain, n (%)

1153 (40.9)

3430.1 429.4

3443.6 425.2

.0001

................................................................................................................................................................................................................................................................................................................................................................................

952 (68.1)

719 (60.2)

.0001

................................................................................................................................................................................................................................................................................................................................................................................
a

Admission dilation (per 1 cm)

2.4 1.3

2.4 1.3

2.3 1.3

.44

Gestational age, wk

39.1 1.1

39.1 1.1

39.0 1.1

.08

................................................................................................................................................................................................................................................................................................................................................................................
a
................................................................................................................................................................................................................................................................................................................................................................................

Cesarean delivery, n (%)

277 (9.8)

171 (12.2)

190 (15.9)

.001

................................................................................................................................................................................................................................................................................................................................................................................
a

Data are given as mean SD.

Chin. Obesity and contraction strength. Am J Obstet Gynecol 2012.

normal weight; 1398 of the women

(25.8%) were overweight, and 1194 of
the women (22.1%) were obese. As compared with normal-weight women, obese
women were significantly older and significantly more likely to be parous, to undergo an induction of labor, to have larger
infants, and to have excessive GWG (Table
1). Admission cervical dilation did not differ by BMI category.
After adjustment for maternal age, gestational age, birthweight, excessive GWG,
admission dilation, induction of labor, and
parity, overweight and obese women were
at significantly increased odds of having a
CD in the first stage of labor compared
with normal-weight women (overweight
women: odds ratio, 1.3 (95% CI, 1.0 1.6);
obese women: odds ratio, 2.4 (95% CI,
1.9 3.1).
The maximum dose of oxytocin did
not differ by BMI category either for
women who had a CD or for women
who had a VD. There was a mean of 1.9
(SD, 1.1) MVU values recorded per
woman, which did not vary by BMI category. Among women who had a CD,
281 women (44%) had mean MVUs of
200 in the 2 hours preceding delivery.
Among women who had a VD, 2287
women (47.9%) had mean MVUs of
200 in the last 2 hours of the first stage
of labor. The results of the final logistic
regression models that evaluated the association between BMI category and
MVUs are detailed in Table 2. Among

women who had a CD, the odds of mean

MVUs of 200 were actually greater for
obese women compared with normalweight women (OR, 1.76; 95% CI, 1.11
2.81). Among women who had a VD,
there was no significant association between BMI category and mean MVUs of
200. In both models, each 5 mU/min
increase in maximum oxytocin dose was
associated with decreased odds of mean
MVUs of 200.

Results of the subanalysis of the 410

women whose only listed indication for
CD was dystocia was similar to the results of the analysis of all women who
had a CD, with an odds ratio for mean
MVUs of 200 of 1.7 (95% CI, 1.0 3.1)
for obese women compared with normal-weight women.
Women who had a CD were delivered
at a mean of 5.5 2.0 cm cervical dilation, which did not differ by BMI cate-

TABLE 2

Final logistic regression models: adjusted association between BMI

category and mean Montevideo units >200
Cesarean delivery,a
OR (95% CI)

Predictor

Vaginal delivery,a
OR (95% CI)

Body mass index category

.....................................................................................................................................................................................................................................

Obese vs normal weight

1.76 (1.112.81)

1.16 (0.981.37)

Overweight vs normal weight

1.12 (0.731.73)

1.08 (0.931.26)

Maximum oxytocin dose (per 5 mU/min)

0.79 (0.690.90)

0.87 (0.840.90)

Excessive gestational weight gain (yes vs no)

1.31 (0.842.06)

1.03 (0.891.20)

Maternal age (per 5 y)

0.87 (0.741.03)

0.79 (0.740.84)

Gestational age (per 1 wk)

0.96 (0.821.11)

1.00 (0.941.07)

Infant birthweight (per 100 g)

0.98 (0.941.01)

0.96 (0.950.98)

.....................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

Parity (parous vs nulliparous)

1.10 (0.661.81)

1.07 (0.931.23)

Induction of labor (spontaneous vs induction)

0.85 (0.591.21)

0.67 (0.590.77)

Admission dilation (per 1 cm)

1.11 (0.981.27)

0.86 (0.820.90)

..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................

BMI, body mass index; CI, confidence interval; OR, odds ratio.
a

Deliveries that were included in the final models because of missing data for some predictor variables. Cesarean delivery, 623
women; vaginal delivery, 4675 women.

Chin. Obesity and contraction strength. Am J Obstet Gynecol 2012.

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TABLE 3

Time in labor and final dilation, stratified by mode of delivery

Mode of delivery

Normal weight

Overweight

Obese

P value

Vaginal (n 4772)

.......................................................................................................................................................................................................................................................................................................................................................................
a

Stage 1, min

566.1 (421.5760.4)

585.9 (423.0788.9)

597.2 (454.0794.0)

Stage 2, min

42.7 (20.893.1)

37.1 (16.383.0)

30.5 (16.071.4)

.0001

.0030

Nulliparous

80.9 (46.6130.0)

80.5 (49.1132.0)

81.0 (46.2126.3)

.69

Parous

21.0 (12.034.5)

18.8 (11.133.6)

19.7 (10.732.3)

.06

.......................................................................................................................................................................................................................................................................................................................................................................
a
b
..............................................................................................................................................................................................................................................................................................................................................................
..............................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................

Cesarean (n 638)

.......................................................................................................................................................................................................................................................................................................................................................................
c

Final dilation, cm

5.5 2.0

5.4 2.0

5.5 1.9

.90

.......................................................................................................................................................................................................................................................................................................................................................................
a

Stage 1, min

823.2 (651.01051.8)

895.8 (664.01126.8)

835.0 (625.21164.0)

.55

................................................................................................................................................................................................................................................................................................................................................................................
a

Data are given as median (25-75% interquartile range); No longer significant when stratified by parity; Data are given as mean SD.
b

Chin. Obesity and contraction strength. Am J Obstet Gynecol 2012.

gory (Table 3). Most women who had a

CD were nulliparous (n 548; 86%).
Time in labor did not differ by BMI category for women who had a CD (Table
3). Among women who had a VD, obese
women spent a median of 597 minutes in
the first stage of labor vs 585 minutes for
overweight women and 566 minutes for
normal-weight women (P .003; Table
3). To evaluate potential confounders of
the relationship between BMI and length
of the first stage of labor, we conducted
linear regression models (results not
shown) adjusting for the same covariates
as previously described. In these models,
obese women who had a VD still had a significantly longer first stage of labor compared with normal-weight women who
had a VD. However, among women who
had a CD, BMI category was not associated
with time in labor after adjustment for potential confounders.
Time in the second stage of labor for
women who had a VD was associated inversely with BMI category. However, the
duration of the second stage did not vary
according to BMI once the analysis was
stratified by parity (Table 3).

C OMMENT
Similar to other studies, we found that
the risk for CD among overweight and
obese women increased in a dose-dependent manner. We were then able to analyze contraction strength as measured in
MVUs among a relatively large number
of women who ultimately had a VD or
CD in the first stage, while adjusting for
129.e4

multiple potential confounders. Although

overweight and obese women were at increased risk for CD, they were equally able
to achieve adequate MVUs in the first stage
of labor. In a secondary analysis of data
from 509 women (104 of whom had a CD)
who were enrolled in an observational
study of a standardized labor induction
protocol, Nuthalapaty et al18 reported similar results. There was no significant difference between women in the highest and lowest weight quartiles in the mean maximum
MVUs that were achieved, which was 200
in both groups.
Although multiple studies have linked
maternal obesity to an increased risk for
labor abnormalities and CD, the underlying cause for these increased risks remains poorly defined. It has been proposed that increased fat deposits in the
pelvis may cause obstructed labor. However, such deposits would be expected to
impede the second phase of labor as well
as the first, which is not consistent with
either the existing data9 or our findings.
One of the most attractive theories is that
the altered metabolic profile of obese
women may impair myometrial contractility. Obesity in pregnancy is associated
with dyslipidemia.20 Cholesterol is an essential component of cell membranes and
is important in the control of smooth muscle contractility. Furthermore, oxytocin
receptors have been found to localize
within cholesterol-rich regions of the cell
membrane known as lipid rafts.21 The dyslipidemia among obese pregnant women
may alter the stability or efficacy of these

American Journal of Obstetrics & Gynecology AUGUST 2012

lipid rafts and thus impact myometrial

contractility.
It is evident that the traditional teaching
of performing a CD for failure to progress
after adequate MVUs for 2 hours in the active phase with no cervical change should
not be applied to the modern obstetric
population.22 A specific intrauterine pressure that is generated during contractions
among obese women may not translate
into the same molecular and/or structural
cervical changes as it might for normalweight women. It is also possible that adequate MVUs may vary with BMI. The
definition of adequate MVUs as 200
originated in small retrospective studies
that were conducted more than 20 years
ago that did not assess the BMI of study
subjects.23,24
Not only do obese women need more
time to progress in labor, but traditional
labor curves (such as the Friedman
curve) that define the onset of active labor at approximately 4 cm of dilation increasingly are being challenged. Vahratian et al8 found that progression from
4-10 cm of cervical dilation was significantly slower among obese women compared with normal-weight women (7.9
vs 6.2 hours) and that, for obese women,
labor was significantly slower up to 7 cm.
A recent analysis of data from the Consortium on Safe Labor found that, for
nulliparous women, there was no apparent inflection point in the labor curves
and that, for multiparous women, the inflection point for transition to the active
phase was approximately 6 cm.25 Multi-

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parous women with a BMI of 40 kg/m2
took an hour longer to reach 6 cm than
multiparous women with a BMI of 25
kg/m2.
We found that, although obese and
normal-weight women had a similar final cervical dilation (5.5 cm) and time
in labor before undergoing CD, obese
women who had a VD had a longer first
stage of labor than normal-weight
women who had a VD. These results indicate that most obese women who had a
CD were delivered before entering what
might now be considered the active
phase. Zhang et al26 found that, even in
spontaneous labor, it may take 6 hours
to progress from 4-5 cm and 3 hours to
progress from 5-6 cm. We speculate that
many of the obese women in our study
who had a CD may have been successful
in achieving a VD if allowed the additional time to progress. Consistent with
the idea that adequate MVUs may not be
equally effective at achieving cervical
change among obese women compared
with normal-weight women, the same
cervical dilation may fall at different
points on the labor curve for obese vs
normal-weight women.
The clinical study of uterine contractility is complicated by the multiple
potential confounders of MVUs, which
is the only objective measure of contraction strength available to us. With the use
of a large and detailed Labor and Delivery database, we were able to adjust for
the variables that are most likely to alter
the relationship between BMI and contraction strength. However, as with all
retrospective studies, there may be unmeasured confounders. For example, we
are unable to determine the decisionmaking of the clinicians who managed
each womans labor. Although MVU
values were not available for the entire
2-hour period, based on clinical experience, we believe that an MVU value was
most likely to be recorded when trying to
achieve or demonstrate adequacy of contractions. The recording of MVUs may
be inaccurate in the setting of malpositioned or malfunctioning IUPCs. However, this is unlikely to differ by BMI. We
are also not able to evaluate whether
obese women were more likely to have
dysfunctional contractile patterns such

as coupling (despite equivalent contraction strengths) compared with normalweight women. The contractile pattern
may be important in the determination
of the rate of cervical dilation and deserves attention in future studies. Maternal height, weight, and GWG are selfreported variables in this data set and
may be subject to recall bias that resulted
in the classification of women into inaccurate BMI or GWG categories.
The increase in the rates of obesity that
complicate pregnancy combined with
record-high CD rates in the United
States is creating the perfect storm for
women with the most comorbidities to
be at greatest risk of obstetric and surgical complications, which include placenta accreta spectrum, hysterectomy,
and thromboembolism. No significant
decrease in the rates of obesity among
reproductive-aged women is anticipated
in the immediate future. As a result, efforts should focus on decreasing the CD
rate among obese women. Research into
the improvement of metabolic parameters among obese pregnant women
(either by lifestyle or medication interventions) and into the determination of
whether there are specific labor induction or augmentation protocols that are
more effective among obese women are
important areas for investigation. However, an important first step is for obstetric providers to allow adequate time for
obese women to progress in the first
stage of labor, particularly when cervical
dilation is 6 cm in the setting of reasf
suring fetal status.
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