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A Light-hearted Tribute to Dr. Michael Klein

March 7th, 2013 by avatar

 

© Michael Klein

Dr. Michael Klein,  M.D., C.C.F.P., F.C.F.P., F.A.A.P. (Neonatal/Perinatal), F.C.P.S.,is a pediatrician/neonatologist and family physician researcher and educator based at Children’s & Women’s Hospital and the Centre for Developmental Neurosciences & Child Health of the Child and Family Research Institute in Vancouver British Columbia Canada.

Dr. Klein is also an occasional contributor to Science & Sensibility.  He is best known for his randomized controlled trial of routine episiotomies that demonstrated that they increased the very trauma that they were intended to prevent.

At the recent North American Primary Care Research Group, a tribute to Dr. Klein’s significant contribution to research on episiotomies was presented to those in attendance.  Lucky for us, this presentation was also recorded.  Clever, accurate and incredibly funny,  I hope that you enjoy this clip as much as I did.

Thank you, Dr. Klein for your years of researching, supporting and sharing evidence based birth practices with us.  It is very much appreciated.

Resources for some of Dr. Klein’s publications on episiotomies

Klein MC et al. Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? First North American Trial of Episiotomy.Inaugural issue: On-Line Journal of Current Clinical Trials. American Association Advancement Science. 1992;1:July 1 (Doc 10).

Klein MC. From routine episiotomy to routine Cesarean section: how society came from rejecting one to embracing another. Bear Bones Publication of the Department of Family Practice University of British Columbia. 2010. Spring 10 (1): 12-17.

Klein M: Studying Episiotomy: When Beliefs Conflict with Science. J Fam Practice 1995; 41(5):483-488.

Klein MC.What do episiotomy and cesarean have to do with Copernicus, Galileo and Newton? Birth. March 2010; 37(1): 1-2.

Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK: Physician Beliefs and Behaviour within a Randomized Controlled Trial of Episiotomy: Consequences for Women under their Care. Can Med Assoc J, 1995; 153(6):769-779.

Evidence Based Medicine, Maternity Care, Medical Interventions , ,

What Is the Evidence for Perineal Massage During Pregnancy to Prevent Tearing?

December 18th, 2012 by avatar

By Rebecca Dekker, PhD, RN, APRN of Evidence Based Birth

Do you talk about perineal massage with your students, clients and patients and state that perineal massage during pregnancy will/will not reduce tearing during birth?  today, Rebecca Dekker, of Evidence Based Birth takes a look at the research on perineal massage during pregnancy and provides information on the outcomes for women who practiced this and those who didn’t.  Does the research support what you have been saying? – Sharon Muza, Community Manager

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http://flic.kr/p/5XmJtL

Tearing during childbirth is a common occurrence among women who have a vaginal birth. In studies where the use of episiotomies was restricted, the rate of spontaneous tearing was recorded to be anywhere from 44-79% (Soong and Barnes 2005; Dahlen, Homer et al. 2007). Studies have consistently shown that women are more likely to experience tearing during a first vaginal birth and with forceps and vacuum assistance (Aasheim, Nilsen et al. 2011).

Spontaneous tears can be classified as first, second, third, or fourth degree tears. First degree tears involve only the perineal skin, while second degree tears involve both the skin and the perineal muscle. Third degree tears involve the anal sphincter, while fourth degree tears involve the anal sphincter and tissues. Third and fourth degree tears happen at 0.25% to 2.5% of spontaneous vaginal births (Byrd, Hobbiss et al. 2005; Groutz, Hasson et al. 2011).

Women are more likely to have a third or fourth degree tear if they are giving birth vaginally for the first time, if a baby is in the posterior position or has a heavier birth weight, and if forceps, vacuum, or episiotomy are used (Christianson, Bovbjerg et al. 2003; Groutz, Hasson et al. 2011; Hirayama, Koyanagi et al. 2012).

What is perineal massage?

It is thought that massaging the perineum during pregnancy can increase muscle and tissue elasticity and make it easier for a mother to avoid tearing during a vaginal birth. Typically, women are taught to spend about 10 minutes per day doing perineal massage, starting at about 34-35 weeks of pregnancy. Women are taught to insert 1-2 lubricated fingers about 2 inches into the vagina and apply pressure, first downward for 2 minutes, and then sideways for 2 minutes. The massage can be done by the woman or her partner, and sweet almond oil is sometimes used for lubrication (Labrecque, Eason et al. 1999).

What is the evidence for perineal massage?

In 2006, Beckmann and Garrett combined the results from four randomized, controlled trials that enrolled 2,497 pregnant women. Three of these studies involved only women without a previous vaginal birth (mostly first-time moms). One study enrolled women with and without a previous vaginal birth. All four of the studies were of very good quality.

Beckmann and Garrett found that women who were randomly assigned to do perineal massage had a 10% decrease in the risk of tears that required stitches (aka “perineal trauma”), and a 16% decrease in the risk of episiotomy—but these findings were only true for first-time moms.

It is important for you to understand that this is a 10% reduction in relative risk, and relative risk is different than absolute risk. Let me give you an example. Say you are a first-time mom, and let’s pretend your absolute risk of perineal trauma is 50%. A 10% decrease in relative risk means that your absolute risk decreases by 5% (because .5 X .1 = .05). So for you, doing perineal massage reduces your absolute risk of perineal trauma from 50% to 45%.

*As a side note, all of the numbers I am reporting below are changes in relative risk.

Importantly, for second-time moms who had already had a vaginal birth, prenatal perineal massage did not reduce the risk of perineal trauma (any tearing requiring stitches). However, second-time moms who massaged did report a 32% decrease in the risk of ongoing perineal pain at 3 months post-partum.

Surprisingly, Beckmann and Garrett found that the more frequently women used perineal massage, the less likely they were to see any benefits. Women who massaged an average of 1.5 times per week had a 17% reduced risk of perineal trauma and a 17% reduced risk of episiotomy. Women who massaged between 1.5-3.4 times per week had an 8% reduced risk of perineal trauma.

http://flic.kr/p/8pLkpV

Interestingly, women who massaged > 3.5 times per week experienced NO benefits and had a longer pushing phase of labor by an average of 10 minutes. So basically the finding was: the less frequent the massage, the better off the outcomes. However, this finding was unexpected, and the researchers had a hard time explaining it. I think we should interpret this result with caution, because in the largest clinical trial on perineal massage (included in Beckmann and Garrett’s review), Labrecque et al. (1999) found that the more often women did the massage, the more likely they were to avoid any tears.

Other results: 

There were no differences between women who did prenatal perineal massage and those who did not with regard to:

  • • First degree tears
  • • Second degree tears
  • • Third or fourth degree trauma
  • • Use of forceps or vacuum during delivery
  • • Sexual satisfaction 3 months post-partum
  • • Pain with sexual intercourse 3 months post-partum
  • • Uncontrolled loss of urine or bowel movements 3 months postpartum

Wait, I’m confused. You say that there was a significant decrease in perineal trauma requiring suturing. But there was no difference in 1st, 2nd, 3rd, or 4th degree tears. How can this be?

It’s important for you to understand that perineal trauma is an “umbrella” category that means all types of trauma requiring stitches, including episiotomies. Perineal massage during pregnancy decreased the overall risk of perineal trauma (the umbrella outcome), but the effect was too weak to see any difference with each of the individual outcomes (first degree, second degree, etc.). Also, the researchers think that the overall decrease in perineal trauma may have been due to the decreased episiotomy rate in the perineal massage group.

Why would perineal massage during pregnancy reduce the rate of episiotomies, but not tears?

The researchers guess that the women who were trained in perineal massage were highly motivated to birth with an intact perineum, so maybe they were more likely to refuse an episiotomy. Fewer episiotomies would then mean fewer incidents of trauma requiring stitches.

So what can we learn from the evidence?

During pregnancy, massage of the perineum can reduce the risk of tearing requiring stitches, but this benefit is only seen in moms giving birth vaginally for the first time. It is thought that most of the decreased risk of perineal trauma was due to a decrease in the episiotomy rate. In the largest study included in this review (Labrecque et al., 1999), there was an overall episiotomy rate of 38%. In the U.S., 25% of women have an episiotomy during a vaginal birth (Declercq, Sakala et al. 2007), and rates are even lower for some providers.  It is possible that these research findings might not apply to birth settings where episiotomies are extremely rare.

Second time moms who use perineal massage will not see any decrease in their risk of tearing, but they may reduce their risk of ongoing perineal pain at 3 months postpartum.

So in summary, for first-time moms only:

Perineal massage during pregnancy

Decreased risk of episiotomy

Decreased risk of trauma requiring stitches

If women choose to use perineal massage during pregnancy, there is no consensus on the amount of massage needed to reduce the risk of tearing.

Questions for discussion: Do you recommend prenatal perineal massage to others? Have your thoughts about this intervention changed after reading this article? 

References

Aasheim, V., A. B. Nilsen, et al. (2011). “Perineal techniques during the second stage of labour for reducing perineal trauma.” Cochrane Database Syst Rev(12): CD006672.

Beckmann, M. M. and A. J. Garrett (2006). “Antenatal perineal massage for reducing perineal trauma.” Cochrane Database Syst Rev(1): CD005123.

Byrd, L. M., J. Hobbiss, et al. (2005). “Is it possible to predict or prevent third degree tears?” Colorectal Dis 7(4): 311-318.

Christianson, L. M., V. E. Bovbjerg, et al. (2003). “Risk factors for perineal injury during delivery.” Am J Obstet Gynecol 189(1): 255-260.

Dahlen, H. G., C. S. Homer, et al. (2007). “Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial.” Birth 34(4): 282-290.

Declercq, E. R., C. Sakala, et al. (2007). “Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences: Conducted January-February 2006 for Childbirth Connection by Harris Interactive(R) in partnership with Lamaze International.” J Perinat Educ 16(4): 9-14.

Groutz, A., J. Hasson, et al. (2011). “Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium.” Am J Obstet Gynecol 204(4): 347 e341-344.

Hirayama, F., A. Koyanagi, et al. (2012). “Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study.” BJOG 119(3): 340-347.

Labrecque, M., E. Eason, et al. (1999). “Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy.” Am J Obstet Gynecol 180(3 Pt 1): 593-600.

Soong, B. and M. Barnes (2005). “Maternal position at midwife-attended birth and perineal trauma: is there an association?” Birth 32(3): 164-169.

About Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style.

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On Our Radar…Tocophobia and its Consequences

September 26th, 2011 by avatar

The Research
Several interesting studies have recently been published in the Scandinavian journal, Acta Obstetricia et Gynecologica Scandinavica (some of which I will cover in a subsequent post)The greatest one of interest, which has garnered much media attention lately is the study about fear of childbirth which, according to researchers, has a drastic affect on increasing instrumental deliveries (51%), labor inductions (17%), and requests for elective cesarean deliveries (30%) when compared to women not suffering from this intense form of childbirth-based fear termed “tocophobia.”

The results of this relatively small study (cases=353, controls =579) out of  University Hospital in Linköping, Central Sweden, are not necessarily surprising to many of us, but reiterate what many having been talking about for decades: fear has a very real affect on the process of labor and birth.  In fact,  in the most extreme cases, tocophobia may result in avoidance of pregnancy all together.  But for our purposes, as childbirth professionals, we need to be thinking about how we approach the topic of fear pertaining to birth in our interactions with our students/patients/clients.

Take the cascade of interventions, for example: For the woman who is increasingly anxious about what will happen during labor and birth–who asks for an elective labor induction to “just get it over with,” some of the difficulties she may be most afraid of, become a self-fulfilling prophecy when her labor is complicated by the effects of labor induction (increased pain, intensity and frequency of contractions…potential negative effects of epidural analgesia when assistance with her intense pain is requested…fetal heart rate concerns…maternal blood pressure concerns…potential advancement to cesarean surgery).

Application for Childbirth Educators
Carefully and sensitively bringing up the topic of fear related to childbirth is imperative for childbirth educators:  it gives our students the opportunity to express concerns which they might otherwise keep to themselves–thinking they are “the only ones” harboring such anxiety.   It is not about inducing or encouraging fear, rather it is about presenting the opportunity and encouraging dialogue on this topic–offering positive perspectives and coping strategies that the woman/couple may not have come up with on their own.

Don’t be Afraid to Refer
In the event we find ourselves interacting with a woman whose fear pertaining to pregnancy and/or birth is deeper than that which we feel poised to handle in class (or in clinic), referring the woman locally to a trained professional adept at counseling her through this challenge becomes a must.  Tocophobia is a very real phenomena.  This study published in Clinical Obstetrics and Gynecology, 2004 (47:3) describes tocophobia as occurring in 20% of pregnancies with disabling fear occurring in 6%.

As childbirth educators and maternity care professionals, we may not have the training or skill set to appropriately handle and solve every challenge that faces an expectant woman.  And when we don’t immediately posses those skill sets, we must invite the assistance of other professionals trained to do so.  In the mean time, proactively delivering evidence-based information that empowers (rather than frightens or degrades) expectant women can go a long way toward building confidence and reducing fear.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

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Why Transparency in Maternity Care Matters

January 26th, 2010 by avatar

I’m going to be on Momotics Blog Talk Radio tomorrow evening at 10pm EST discussing the issue of transparency in maternity care with Danielle from Momotics. You can listen here.  For the occasion, I thought I would dig up this fact sheet I wrote for Lamaze a couple of years ago when we first got involved in advocacy on this issue.  I’ve learned a lot since then and have thought for a while that this fact sheet needs to be revised and updated. I’d love thoughts from readers, especially those involved in ongoing efforts to collect and publicize facility data for The Birth Survey. What would you change? What messages need to be more clear? What else do I need to include? Feedback, please!

Why Transparency in Maternity Care Matters: A Fact Sheet for Birth Advocates

What is Transparency?

A pregnant woman asks her care provider, “What is your episiotomy rate?” Her doctor responds, “I only do them when it is necessary.” On her tour of the hospital maternity center, another woman asks about the hospital’s cesarean rate and is told, “We take care of many high risk patients, so you can’t compare our cesarean section rate with the hospital across town.”

What are the consequences when women can’t objectively evaluate the quality of their maternity care options? How do we help women make sense of intervention rates? How can women make fair comparisons?

Transparency means providing health care consumers with the information they need – and the means to interpret it – in order to evaluate the quality of care provided by individual providers and institutions. Transparency is the missing ingredient to truly informed choice.

Are Intervention Rates Important Quality Measures?

A growing body of research shows that among the most important factors influencing a woman’s risk of obstetric interventions, especially cesarean surgery and episiotomy, are where and with whom she gives birth. A recent study of over 41,000 low-risk women having their first babies in 20 California hospitals found cesarean rates for this population ranging from 11% – 30%. Statistical analysis revealed that obstetric practices – not clinical or demographic factors – accounted for over half of the variation across hospitals (1). Two studies conducted in Washington State found that the individual physician was an independent risk factor for cesarean section in both induced and spontaneous labors (2, 3). Several studies have shown that episiotomy is more common in private obstetric practices versus public or university-affiliated practices (4-6). Rates varied from 6% to 60%, but at least one university hospital maintains an episiotomy rate of 1% (7).

Excess use of obstetric interventions, in turn, increases the likelihood that the woman or her baby will be injured, experience complications such as infection, suffer pain, or have negative birth experiences (8). So, in short, a woman who goes to a provider or hospital with a high cesarean section rate is more likely to end up with cesarean surgery – and to suffer its potential consequences. If she goes to a provider with a high episiotomy rate, she is more likely to have an episiotomy – and to suffer its potential consequences. And so on… However, in most states, maternity care providers and facilities are not required by law to publicly report intervention rates or other outcome indicators, nor to help the public interpret data that are available.

Women can not make informed choices about their maternity care if they do not have access to the information that is most likely to influence their outcomes. They can not decrease their exposure to injury from injudicious use of interventions without knowing where and with whom intervention rates are too high. Without transparency, our health care system gives women a false sense of choice.

Can Transparency Improve the Quality of Maternity Care?

Yes! While most of the research on transparency and public reporting relates to other areas of health care, a few studies have looked at maternity care in particular and have found that public reporting of intervention rates and outcomes, whether alone or in combination with other quality improvement programs, translates into better care (9-11). In fact, an experiment conducted in Wisconsin suggests that the quality of obstetric care improves more in response to public reporting than other medical or surgical specialties (9). This may have been because there was more “room for improvement” in maternity care – more hospitals had low scores on obstetric indicators than on cardiac or surgical indicators. In the same study, hospitals included in a public report were more likely than those that were not to undertake quality improvement efforts. These efforts appeared to be effective – maternity units that improved their quality scores were more likely than those that stayed the same or did worse to have begun quality improvement efforts shortly after the public report was released. In other words, public reporting prompted hospitals to work to improve the areas where they scored poorly, and these efforts were effective at improving the quality of care.

Apples and Oranges: How Do We Make Fair Comparisons?

The question of which indicators to measure and how these should be reported complicate efforts to ensure transparency in maternity care. This is particularly problematic when it comes to interpreting cesarean section rates. The overall cesarean section rate (number of cesareans divided by the number of all births) may not be comparable across settings because some hospitals take care of many high risk women while others take care of low-risk women. The rate of cesarean section in high risk women may be higher for good reason. The same is true at the provider level; some providers, including many midwives, specialize in the care of low-risk women while others care for a mixed-risk population or specialize in high risk pregnancies. Similarly, factors such as parity (whether the woman has previously given birth) and age may naturally affect rates of obstetric interventions as well as outcomes.

Healthy People 2010, the federal program that sets goals for various health indicators, measures the cesarean section rate in nulliparous women (those having their first babies), with term (>37 weeks), singleton (one baby), vertex (head down) pregnancies (12). This is abbreviated as the “NTSV cesarean rate” and is used as a proxy for the cesarean section rate in low-risk first time mothers. It has been shown to be highly sensitive to variations in obstetric practices (1), so quality improvement programs should therefore be effective at safely lowering the NTSV cesarean rate. It is also a good measure because, if we can safely prevent the first cesarean, we can prevent repeat cesareans, as well as poor pregnancy outcomes resulting from accumulating many cesarean scars, such as placenta previa, preterm birth, and placenta accreta. As advocates for improvements in maternity care, we should recognize the NTSV cesarean rate as an effective quality indicator, and should educate the public to ask for and know how to interpret NTSV cesarean rates.

However, perfect indicators that can be compared easily across birth settings and providers will not be available in every community. Even when they are, the total rates of cesarean section, episiotomy, and other interventions are important quality measures. In the case of cesarean surgery, many studies have shown that rates can safely be less than 15% in mixed-risk populations, including those where considerable proportions of women have medical problems or are at risk because of poverty, age, or other factors (8, 13, 14). So, while the likelihood of requiring a cesarean will vary with individual circumstances, women with care providers whose rates are 15% or less can trust the their practitioner’s judgment should they recommend a cesarean in their case.

How Can Birth Advocates Promote Transparency?

Ensuring transparency in maternity care will require a major shift from the status quo, with buy-in and participation from hospitals, care providers, insurance companies, government, and consumers. As advocates for mother-friendly maternity care, we can help influence transparency efforts in our communities. In some areas, transparency initiatives are well underway and mother-friendly birth advocates can work to help consumers access and make sense of publicly available information. In communities where there is resistance to transparency, advocates can work to influence legislative efforts, create consumer demand for transparency, or work with the media, hospital administrators, local opinion leaders, or others to promote change. By maintaining a focus on quality improvement and safety rather than penalizing providers or facilities, transparency advocates are likely to gain greater acceptance and involvement from key stakeholders.

References

1. Main, E. K., Moore, D., Farrell, B., Schimmel, L. D., Altman, R. J., Abrahams, C., et al. (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. American Journal of Obstetrics and Gynecology, 194(6), 1644-51.

2. Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. American Journal of Obstetrics and Gynecology, 191(5), 1511-1515.

3. Luthy, D. A., Malmgren, J. A., Zingheim, R. W., & Leininger, C. J. (2003). Physician contribution to a cesarean delivery risk model. American Journal of Obstetrics and Gynecology, 188(6), 1579-85; discussion 1585-7.

4. Goode, K. T., Weiss, P. M., Koller, C., Kimmel, S., & Hess, L. W. (2006). Episiotomy rates in private vs. resident service deliveries: A comparison. The Journal of Reproductive Medicine, 51(3), 190-192.

5. Howden, N. L., Weber, A. M., & Meyn, L. A. (2004). Episiotomy use among residents and faculty compared with private practitioners. Obstetrics and Gynecology, 103(1), 114-118.

6. Robinson, J. N., Norwitz, E. R., Cohen, A. P., & Lieberman, E. (2000). Predictors of episiotomy use at first spontaneous vaginal delivery. Obstetrics and Gynecology, 96(2), 214-218.

7. Albers, L. L., Sedler, K. D., Bedrick, E. J., Teaf, D., & Peralta, P. (2005). Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial. Journal of Midwifery & Women’s Health, 50(5), 365-372.

8. Goer, H., Leslie, M. S., & Romano, A. (2007). The evidence basis for the 10 steps of mother-friendly care: Step 6: Does not routinely employ practices, procedures unsupported by the scientific evidence. The Journal of Perinatal Education, 16(1 Suppl), 32-64.

9. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). Hospital performance reports: Impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-1160.

10. Hibbard, J. H., Stockard, J., & Tusler, M. (2005). It isn’t just about choice: The potential of a public performance report to affect the public image of hospitals. Medical Care Research and Review, 62(3), 358-371.

11. Wirtschafter, D. D., Danielsen, B. H., Main, E. K., Korst, L. M., Gregory, K. D., Wertz, A., et al. (2006). Promoting antenatal steroid use for fetal maturation: Results from the California perinatal quality care collaborative. The Journal of Pediatrics, 148(5), 606-612.

12. Healthy People 2010. (2000). Objective 16-9. reduce cesarean births among low-risk (full term, singleton, vertex presentation) women. Retrieved 7/16/2007, from http://healthypeople.gov/document/html/objectives/16-09.htm

13. Haire, D. B., & Elsberry, C. C. (1991). Maternity care and outcomes in a high-risk service: The north central Bronx hospital experience. Birth, 18(1), 33-37.

14. Leeman, L., & Leeman, R. (2002). Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. The Journal of Family Practice, 51(2), 129-134.

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Baby it hurts: birth practices and postpartum pain

November 6th, 2009 by avatar

Ask a bunch of expectant women what worries them about labor, and chances are many of them will say, “the pain.”  Much is made about pain in labor. Women prepare for it, nurses constantly assess it, anesthesiology departments exist to eliminate it, and so on. But while there are many experiences of labor pain, just about the only universal truth about it is that labor pain ends once the baby is out.

FACES Pain Scale

But a 2008 report from Childbirth Connection suggests that, for many women, pain is an ongoing problem after birth. The report also suggests that two common labor interventions - cesarean surgery and episiotomy – are highly associated with ongoing pain.

According to their national survey of mothers, reported in New Mothers Speak Out, 22% of mothers who gave birth by cesarean said that pain interfered “quite a bit” or “extremely” with their daily activities in the first two months. That’s compared to only 10% of women who had vaginal births. Mothers who had vaginal births without episiotomies were the least likely to report that pain interfered at all with daily living. Episiotomy also increased the likelihood of painful intercourse in the first two months.

At six months, nearly 1 in 5 (18%) of mothers who had a cesarean still experienced pain at the incision site, versus only 2% of women who had vaginal births reporting continuing problems with perineal pain.

The Childbirth Connection survey did not ask about endometriosis, a common cause of chronic pelvic pain, but a growing number of case reports strongly suggest that cesarean surgery is associated with new-onset endometriosis.

ResearchBlogging.orgThis week I happened upon a study that reveals another aspect of labor and birth care that may affect postpartum pain. Researchers analyzed data from nearly 13,000 UK mothers of singleton, term, live-born babies. Participants were recruited into the study prenatally and answered questions about back pain in two postnatal surveys – one at 8 weeks and another at 8 months. The researchers set out to find out if mode of birth (spontaneous vaginal, instrumental vaginal, elective cesarean, or unscheduled cesarean) affected the likelihood of postpartum back pain. They concluded that it did not.

But here’s an interesting gem that I almost missed [emphasis mine]:

A higher proportion of women who had an emergency caesarean section reported 8-week postnatal back pain compared with those who delivered spontaneously… Adjusting for the factors associated with emergency caesarean section and back pain decreased this association. By 8 months, the prevalence of back pain fell, but remained higher amongst emergency caesarean sections. Epidural analgesia and ‘in preferred position in labour’ were the two most influential confounders.

What does this mean? I had to go back to an earlier study that reported outcomes from the same dataset in order to figure out what “in preferred position” was referring to.  It turns out researchers asked women how much of their labor was spent in their preferred labor position. Options were, “no/hardly,” “sometimes,” or “always.”  The results of this earlier trial showed that being in the preferred position in labor reduced the risk of cesarean surgery. The fact that the researchers in the new study controlled for it tells us that being in one’s preferred position in labor also was protective against postpartum back pain. It also tells us that having an epidural in labor increased the likelihood of postpartum back pain, although this finding has been inconsistent in other studies.

What other labor and birth practices could affect postpartum pain? What about skin-to-skin contact after birth? Only one tiny study involving only 20 mother/baby pairs has looked at whether skin-to-skin care affects nipple soreness and it did not find an association. Another small study (not published but included in the Cochrane systematic review) looked at breast engorgement pain and did find that skin-to-skin contact was protective. A much larger body of literature shows that skin-to-skin contact in the hour or so after birth increases the duration of breastfeeding, which lends additional support to the possibility that skin-to-skin care reduces breastfeeding-related pain (a common cause of early weaning).

Another Cochrane systematic review tells us that upright pushing positions are associated with a much lower rate of episiotomy. Although no study has evaluated pushing position and its direct effect on postpartum pain, anything that reduces episiotomy will in turn reduce postpartum perineal pain and painful intercourse.

In the same vein, practices that reduce operative delivery will in turn reduce postpartum pain associated with these modes of birth. These practices include letting labor begin on its own, providing continuous labor support, and reducing the use of interventions such as epidural analgesia and routine continuous electronic fetal monitoring.

It seems to me that we overemphasize the physiologic pain related to labor and completely ignore the pathological pain related to interventions and injuries in childbirth, many of which could be averted.  My question to my readers is this: how do we reframe the conversation about childbirth-related pain to look more holistically at pain throughout the childbearing year and beyond?

Citations:
Moore ER, Anderson GC, & Bergman N (2007). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane database of systematic reviews (Online) (3) PMID: 17636727

Gupta JK, & Hofmeyr GJ (2004). Position for women during second stage of labour. Cochrane database of systematic reviews (Online) (1) PMID: 14973980

Moore ER, & Anderson GC (2007). Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. Journal of midwifery & women’s health, 52 (2), 116-25 PMID: 17336817

Patel RR, Peters TJ, & Murphy DJ (2007). Is operative delivery associated with postnatal back pain at eight weeks and eight months? A cohort study. Acta obstetricia et gynecologica Scandinavica, 86 (11), 1322-7 PMID: 17851815

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