Our observational study failed to suggest differences in client expectations between the 2 hospitals. Features of labor management did differ, however, in that women in Burnaby ambulated more, had fewer types and numbers of caregivers in labor and were less often offered an epidural. Nurses in Burnaby may have offered epidural less often because they were aware that anesthetists had to come to the delivery suite from elsewhere in the hospital or from outside the hospital. Alternatively, a cohort study has reported that nurses grouped according to cesarean rate quintiles differed in their recording of psychosocial data and other aspects of nursing care.19 Aspects of nursing practice may influence use of epidural analgesia. Our phase II study is limited by its small size, and other additional effects of nursing practice on labor cannot be ruled out. A large randomized controlled study is under way to examine the association of aspects of nursing care (including consistency of nursing caregiver) with cesarean delivery rates.20 Ultimately, the decision to undertake a cesarean delivery resides with the obstetrician. It is possible that in the smaller community hospital physicians may practice with a greater degree of cohesion, perhaps influenced more readily by the philosophy of opinion leaders who advocate a more conservative approach to cesarean delivery. In addition, the presence of obstetric and family practice residency programs at BC Women’s may have encouraged use of interventions, including cesarean the delivery.
The role of ambulation in cesarean delivery remains controversial. A randomized trial failed to demonstrate an association of ambulation with cesarean delivery, but this study had a 22% crossover rate and enrolled women after they had attained a cervical dilatation rate of 3 to 5 cm, when early ambulation may have already exerted a positive effect.21 Among low-risk parturients cared for by midwives and not requiring either augmentation of labor or epidural analgesia, ambulation has been associated with a reduction in cesarean delivery rates.22
Limitations
Our study is limited by lack of knowledge of women’s levels of anxiety and pain during their labor. This would have allowed us to gauge whether less frequent use of epidural analgesia at Burnaby was associated with a cost of diminished satisfaction with the childbirth experience.
We were fortunate in being able to study 2 institutions that were only 20 minutes’ driving distance apart and that served populations from which we were able to sample women who were demographically comparable. Our retrospective cohort analysis identified use of an epidural as the main predictive factor differentiating cesarean delivery rates between the hospitals. It is not possible to determine cause and effect from this retrospective study design, however, and use of epidural analgesia may be a proxy for other unmeasured variables, such as physician practice, anxiety level among patients, or level of education. Direct observation of intrapartum care in a follow-up study failed to differentiate clients attending either hospital in terms of preparation for or expectations of the labor experience. Differences in some aspects of caregiving, however, including more frequent offering of epidural for pain management, may explain the increased use of epidural at BC Women’s. Factors influencing use of epidural need to be studied more thoroughly to support its appropriate place in an overall strategy for pain management in labor.
Related Resources
- Society of Obstetricians and Gynaecologists of Canada (SOGC) http://www.sogc.org/SOGCnet
- College of Family Physicians of Canada www.cfpc.ca
- Canadian Paediatric Society www.cps.ca