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:
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
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!!!
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…..
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.