2 cm, 8/10

Okay, so back in the 1980s and 1990s there were a bunch of crappy poorly controlled observational studies that showed that epidurals in labour were associated with a slowing of labour and an increase in caesarean deliveries.  The ACOG then came out with a statement that it would be better to wait to initiate epidural labour analgesia until 4-5 cm cervical dilation…then there were a couple of studies that randomized women to “early” (< 4 cm) or “late” (> 4 cm) epidural analgesia:

 

The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor

Cynthia A. Wong, M.D., Barbara M. Scavone, M.D., Alan M. Peaceman, M.D., Robert J. McCarthy, Pharm.D., John T. Sullivan, M.D., Nathaniel T. Diaz, M.D., Edward Yaghmour, M.D., R-Jay L. Marcus, M.D., Saadia S. Sherwani, M.D., Michelle T. Sproviero, M.D., Meltem Yilmaz, M.D., Roshani Patel, R.N., Carmen Robles, R.N., and Sharon Grouper, B.S.

N Engl J Med 2005; 352:655-665February 17, 2005

and….

Epidural Analgesia in the Latent Phase of Labor and the Risk of Cesarean Delivery: A Five-year Randomized Controlled Trial.  Wang, FuZhou; Shen, XiaoFeng; Guo, XiRong; Peng, YuZhu; Gu, XiaoQi; The Labor Analgesia Examining Group (LAEG).  Anesthesiology. 111(4):871-880, October 2009.

Both studies basically put the idea that delaying epidural analgesia has any benefits regarding length of labour or risk of c-section to bed for good.  The second study has almost 13000 women in it and was powered to detect a <3% difference in the c-section rate which would be a very small effect.

ACOG changed its tune and now, based on scientific evidence, they suggest providing analgesia to labouring women on request rather than on some magic, preselected, size of the cervical opening.

My personal feeling, is that when someone requests pain relief, you give pain relief.  However, I know that women seem to be really competitive and maybe we are programmed to compare ourselves to each other.  I admit it, I check out the bodies around me in the gym to see if I shape up.  My primary interest in the superbowl half time show was to see what Beyonce looked like post partum so I could imagine myself in a leather and lace lingerie inspired get-up and stiletto heels to see how I would compare.  Shallow, I know, but hey, I’m willing to admit it.

Pain tolerance in childbirth is another area, besides physical appearance, where I think women frequently fall into comparing themselves to others.  The language that is used frequently assumes that weakness is associated with labour analgesia….you hear things like, “I wanted to do it naturally but I gave in….at 6 cm….because I had back labour….because I was exhausted….”

You also hear things like “it’s just latent labour” and “latent labour shouldn’t hurt that much” or “I thought it would be easy to cope in early labour.”

BS.

BS BS BS BS BS BS BS!!!

What if you took a bunch of women who had decided that they wanted epidurals prior to going into labour….presuming, of course, that they would be free of any of this psychological baggage about having to prove that they are womyn enough or tough enough or that they should feel guilty about their choice…and looked to see when they made their first request for analgesia?

Well, have another look at Cynthia Wong’ study.  Her 728 women were healthy women at term carrying their first child who had either gone into labour spontaneously or had spontaneously ruptured their membranes.  They were also women who had made the decision to get an epidural at some point during labour.

Guess what the median cervical dilation was at time of first request…..

 

2 cm.

 

Yep.  The median was 2 cm.  That means that half of the women made a request at less than 2 cm dilation.

What was the median pain score at the time of first request?

8/10….with an interquartile range (which includes 75% of scores) of 7-9.   That indicates severe pain folks.  Severe.

So maybe, because these women had decided to get an epidural prior to labour they comprise a subset of women with extremely low pain tolerance.  Maybe.

Or maybe latent labour really does hurt and really does warrant treatment on request.

So if you feel bad that you only “made it” to 5 cm prior to asking for an epidural, or you feel guilty because you asked at 2 cm, maybe this will help you will realize that you are not alone in your desire for the pain to stop in “early” labour.  And if you feel overly boastful about the fact that you held out until 8 cm, you might stop and think, what the heck was I doing during those hours, dilating from 2 to 8 cm, during which the women who already had epidurals spent them sleeping peacefully or watching TV or playing board games with their toddlers and  if I had known that most women make their request earlier than I did, would I have made my request earlier too?

Just wondering.  Does this change your impression about labour pain, epidurals and other analgesic options for childbirth?  I will admit, that not only do I have an unhealthy  tendency to compare my body with the bodies of other women around me, I also have an unhealthy tendency to think of women that hold out in labour longer as real “troopers” – a value judgement that does absolutely no good at all and maybe keeping in mind “2 cm, 8/10” will help me get past that.

 

Advertisements

21 comments

  1. Yes, I’ve changed my mind, but it’s too late for me. I had mind-numbing triple peak contractions. Thankfully labor lasted less than five hours, and the result was a healthy baby. But he was 8 lbs 15 oz, it was mainly back labor, and I wonder if I would have enjoyed the experience more with pain relief. I remember that it was painful, but I can’t re-feel the pain. So what did it matter? What I remember is his body laying on me and my hand on his little butt, looking at each other.

    1. I meant too late as in I’m past child-bearing. I would support any friend who wanted an epi.

  2. I was not allowed my intrathecal until oh, about 14 hours of what really felt like severe labor, even though I couldn’t seem to make any progress in centimeters. “It’ll slow progress” sounds less and less convincing with every check showing things tight as Fort Knox.

    So this information is pretty gratifying, albeit about 11 years too late, LOL.

    cheers.

  3. Yep…this rings true with me. I desperately wanted to do it “naturally,” but simply wasn’t dilating. It took 26 hours from the onset of labor (the last 6 of which were so unfathomably painful that I actually hoped I’d pass out) for me to reach 3 cm (for any “natural” birthers reading this, YES, I did prenatal yoga. YES, I took natural birthing classes. YES, I “believed” in the power of my body. YES, I had a doula. YES, I did early labor at home. YES, I tried massage, music, a birthing tub…you name it). Those last 6 hours — the ones that I could barely stand — I didn’t dilate AT ALL. Once I got an epidural, I began to dilate in earnest, and delivered my baby within 10 hours. I am obviously a purely anecdotal case, but I know a few things from my experience, and suspect a few more. First, “early” labor (that is, early in dilation) can be terribly painful. In my case, my pain was likely preventing relaxation and as such, was actually slowing dilation and prolonging the experience. Getting an epidural earlier certainly would have made me better rested when she finally came…and based upon the speed with which I began to dilate once the epidural was in, I feel comfortable (if not scientifically certain) in saying that it would likely have sped the labor as well. The latter would have been beneficial not only to me (for reasons of discomfort and exhaustion), but to her. She was quite distressed and I was on oxygen and had a temp of 102 by the end of my labor due to the sheer exhaustion of my body’s effort.

  4. Okay now…I’m just not getting the validation I need from this post…am I seriously the only one that is interested in celebrity post baby bodies. Crap. I was hoping I wasn’t absolutely the shallowest person who ever read this web page….

    crap!

  5. I’ll admit a certain jealousy at moms who have the resources (home gym, nanny/grandparent, spouse – whatever) that enables them to hit the gym and get back to fighting form in short order….that being said, some gyms have child minding – so perhaps this is a lame excuse for my not quite back to fighting for post-partum belly (nearly 5 months now)….

    1. I never trusted the childminding at the gym – not for a baby anyway. I do have a trainer, however, and count myself quite lucky to have that hour of intense time every week. It is a bit of a splurge for sure. I found baby wearing was a great way to camouflage the residual belly – maybe that is why it’s become soooooooo popular! 😉

      1. Glad to hear I’m not the only one nervous about the childminding at the Gym. I’d prefer to work out first thing in the morning but my husband likes to go to work by 630 and getting up at 515 to get an hour in before he goes, well sleep is already a limited quantity. I do not seem to have the motivation to do it in the afternoon. Maybe I have to take up running and actually use that fancy all terrain stroller we have…in the meantime baby wearing – that might just work.

  6. Thanks,love your blog. I recently had my second bub, first to come out the “right” way, induced with hyperstimulation, and a big, posterior baby! I went unmedicated out of curiosity, I guess, although after only a few hours including those nasty triple peaked contractions, I was exhausted and found pushing very difficult (2 hours of not getting very far and ultimately needing ventouse). It makes me wonder whether I should have had the drugs so I would have had some energy left to push..?

    1. Whoever told you there was a “right” way and a “wrong” way for a baby to come out?

      1. The only “wrong way” is any way that is unnecessarily damaging to either mother or child….

      2. Agh, sorry, that was tongue-in-cheek

  7. I had an epidural first time round, at about 8 hours into labour. I was in a lot of pain, and my blood pressure was very elevated, (I was also being treated for pre-eclampsia and was on IV medication for that)
    My second time round, for personal reasons, I decided I wanted to try to be without pain meds (not to be a hero, or to prove I was better than anyone else, it’s too complicated to explain, it’s on my blog if anyone cares to read the full story) and actually I managed up until about 8-9cm, but then I NEEDED the pain relief. My son was very big, and it was incredibly intense. Unfortunately, I went from 8-10, to transition to him arriving within minutes of my requesting the epidural (which they wanted me to have, because they were concerned he was in distress and were prepping me for a c-section anyway) and he arrived very quickly. I am open minded about it next time, if I need pain relief, I know my limits. I now know what both a non medicated and medicated labour and delivery feel like, so I can hopefully make the choice best for me/the baby, if we have a 3rd.
    Apparently, Beyonce, so I’m told, uses Eucerin creams and ointments (they make creams/lotions for dry skin conditions etc) I’m off to buy stocks in them, and slather them all over me, in the hopes that my not quite what it was before 2 babies body will magically begin to look like hers! 😉

  8. Staceyjw · · Reply

    With #1, I asked for my epidural when I showed up. Not kidding. I was already at 4, and had been walking around at 2 for weeks, but never had any pain. I just didn’t see any reason to wait for the pain, I mean, who want to hurt and have to hold still to get the procedure done? Got a PCA right away, and have no regrets. That birth was 100% pain free, until a day after the CS (after 36 hours, and 4 hours of pushing. Stuck, massive, baby!).

    #2 was a preemie, and I had agreed to breifly try a VBAC TOL. I asked for the epidural when I thought I had lots of time. Got it, fell asleep, woke up a little later because it wasn’t working (felt cramps and was totally mobile) Turned out baby was coming out! I didn’t have time to get it fixed, but had no pain anyway (DD was 4#). 4 pushes later, 13 min, DD arrived.

    I have chronic pain that is medically managed, I didn’t want anymore, so I don’t feel at all bad about getting pain relief pre pain!

  9. Rachael · · Reply

    I was never anti-epidural, I was, “If I need it, I’m having it.” And I did, both times. The first time, I’m not sure where I was…2 or 3 cm, I think. And in so much pain that my mind wasn’t working other than to say, “Where the hell is my anesthesiologist?!” (In an emergency C-section, so I had to wait a bit.)

    Second time I got to the hospital at 5 cm after walking around for a week at 4, and had my epidural the second I decided I’d had enough walking about in pain. I’m no hero, and not remotely competitive about how long I can stand unnecessary pain.

  10. Kitti Y · · Reply

    A very nice post! I think it is great that epidurals exist and it is a shame that people seem to place value judgements on if a person got one or not. I didn’t have one for either of my births but that doesn’t make my experience any better than anyone else’s. The first one I just wanted to know just how much pain it would cause. My curiosity was satisfied after that and I figured I would get pain relief when things got intense the second time. I only made it to the hospital 20 minutes before #2 was born, so inspite of asking for pain relief, there obviously wasn’t time.

  11. Elaine · · Reply

    I had two natural births and after each I felt hugely superior to other moms who I thought had wimped out of womanhood by getting an epidural. I am so embarrassed of that now. I have spent a lot of time sorting through my emotions surrounding my birth experiences including my last. With him I got my epidural at 6cm. I have come to realize that my whole self worth is tied up in this mothering thing and with birth stories you can really flaunt around your numbers. Maybe you were in labor for 50 hours or didn’t get your epi until 9cm. Or you only pushed 3 times before your 11lb baby was born. Well folks, my sons birth was easy peasy. I had a relatively short birth and a short pushing stage. I did not tear, recovery was easy and my story is not much of a war story at all. I won’t tell you about my other births because they are nothing to brag about either. I will however brag about my son. He is of course the sweetest little man I’ve ever met with the brightest blue eyes. And I will tell you that I am a much better mother now than I was when I had those natural births. Oh, and if I have another baby I will ask for my epidural as early as they will give it to me.

    other than be a parent and

  12. Jocelyn · · Reply

    This definitely describes me. I began having contractions in the early afternoon (probably 1 or 2 pm) on a Tuesday, and they progressed steadily until they were about a 6 on the pain scale by 9 pm. At 11 pm, my husband and I arrived at the hospital. I was barely 1 cm dilated, and they wanted to make sure I was progressing before admitting me. So I waited in triage for an hour, while the pain of each contraction increased to probably a 8 or 9. They were really, really, really painful. And when the nurse checked me after that hour, I was still only at 1 1/2 cm. So, they sent me home with a shot of morphine, telling me to come back when I could feel the contractions through the morphine again. Well, I could stil feel every single contraction through the morphine, but it made them go back down to about a 7. I came back to the hospital at 3 am, when the contractions were back to a 9 or 10 on the pain scale. And when the nurse checked me – I was still only at 2 cm. So the hospital wouldn’t admit me, or give me an epidural. I wanted to cry. They let me sit there for three more hours, finally admitting me and giving me an epidural when I was 5 cm – after I’d been in labor for over 12 hours. Anyway, I harbor no ill feelings toward the staff, because they couldn’t admit me until they knew my cervix was really dilating, but I wish they would admit people sooner and give them epidurals sooner. I was in extreme pain for a very long time.

  13. I was always a fan of “get it when you need it/ask for it.” I went into the hospital in labor, figuring I’d ask for the epidural when I started to feel uncomfortable, which is what I did. I was already dilated to 4 upon admittance, and had been for 4wks due to pre-term labor, so that wasn’t driving my (or anyone else’s) decisions as to when to get pain relief. Eventually, they had to augment my labor with pitocin, and after a few hours of that, it started to bother me, especially in my back, so I asked for and received the epidural (turned out I was around 6 or 7 cm, but considering where I started, not especially trooper like, since it hadn’t been real painful up to that point either.) Anyway, it made the rest of labor quite comfortable, though didn’t really work for the pushing part.

  14. I really enjoyed this post! I was wondering, however, if you could point me to the study where women asked for (on average) an epidural at 2cm? I found Wong’s study comparing an epidural as soon as it was asked or narcotics until the second or third time they asked but I could not seem to find the research on when the women asked for them. I would love it if you could point me in the right direction. Thank you!

    1. In the body of the paper by Wong (not the abstract the full text) there is a table showing pain rating out of 10 and cervical dilation for each of the groups at the time of first request for analgesia. At first request the median dilitaton was 2 cm and pain was rated as 8/10. Like I say inmy post perhaps the group of women agreeing to the study were less motivated to endure pain compared to the general population. However I think it’s incredibly constructive to see that the pain of early or prodromal labour is rated to be severe.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: