In a recent poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology, Dr. Beilin and Diana Mungall presented data from Mt. Sinai Hospital in New York. Term, nulliparous (women giving birth for the first time) women in labor were asked to rate their pain on a scale of 1-10. The women were grouped into three categories: low pain (0-3), medium pain (4-6), and high pain (7-10). The investigators then examined whether there were differences in the c-section rate or operative vaginal delivery rate (forceps or vacuum) between the three groups.
Dr. Beilin reported that the differences in c-section rates between the three groups were not statistically significant. The c-section rate was 41% for the low-pain group; 36% for the moderate-pain group; and 34% for the high-pain group. I find this conclusion very interesting for the following reasons:
- The investigators collected data on 555 term, nulliparous women admitted to a single hospital between July 2005 and September 2oo8. In 2006, the national primary c-section rate (meaning the first c-section for a woman) was 20.6%.¹ It would have been interesting to be able to know the study hospital’s overall c-section rate. If it was average, at about 20.6%, all three groups had primary c-section rates that were much higher than the national average.
- I am unclear as to why the investigators state the differences between the three groups are not statistically significant. This was a retrospective study, which limits the application of the results, and no information was given as to how the data were analyzed.
- The conclusion the investigators reached is that epidural anesthesia can be safely placed in women with varying degrees of labor pain.² This is a strange conclusion. Modern medicine is constantly telling women that c-sections are safe, even to the point of allowing women to choose a primary c-section rather than to labor. What would have indicated to the investigators that timing of epidural placement could make birth unsafe? If c-section truly is such a safe mode of delivery, any rate should be acceptable.
- They do not tell us anything about cervical dilation at the time of epidural placement. However, I would speculate that higher degrees of pain most likely correlated with more advanced dilation. If I were entering this hospital as a woman in labor, I would certainly prefer to know that receiving my epidural when my pain level was low might mean I had a 41% chance of a c-section as opposed to a 34% chance if I waited until my pain was high. What might my risk of c-section be if I did not receive an epidural at all?
I am disappointed in the study’s conclusion and the fact that no one questioned why the c-section rates were so high in the first place, and whether epidural anesthetic might be a factor in the higher than average primary c-section rate. Once again, modern obstetrics demonstrates its ability to normalize deviance.
1. Childbirth Connection. Retrieved 1/4/10 from: http://www.childbirthconnection.org/article.asp?ck=10554
2. Labor pain intensity at epidural doesn’t affect delivery mode. Retrieved 1/4/10 from http://www.obgynnews.com