Objective
We sought to study the association between mode of delivery and persistent pelvic girdle syndrome (PGS) (pain in anterior and bilateral posterior pelvis) 6 months postpartum.
Study Design
We followed up 10,400 women with singleton deliveries in the Norwegian Mother and Child Cohort Study who reported PGS in pregnancy week 30 (1999 through 2008). Data were obtained by 3 self-administered questionnaires and linked to the Medical Birth Registry of Norway.
Results
Planned cesarean section was associated with the presence of severe PGS 6 months postpartum (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4–3.9). In women who used crutches during pregnancy, emergency (adjusted OR, 2.0; 95% CI, 1.0–4.0) and planned (adjusted OR, 3.3; 95% CI, 1.9–5.9) cesarean section were each associated with severe PGS.
Conclusion
The results suggest an increased risk of severe PGS 6 months postpartum in women who underwent a cesarean section vs women who had an unassisted vaginal delivery.
Cesarean section is one of the most common surgical procedures worldwide. Cesarean section rates are consistently increasing, and the trend has partially been explained by maternal requests for planned cesarean section without medical or obstetrical indication. In a Norwegian study, the 2 most important indications for planned cesarean section were previous cesarean delivery and maternal request. Obstetricians may be willing to perform a cesarean section on maternal request, but the woman’s right to choose the procedure is debated.
See related editorial, page 242
One in 5 women report pelvic girdle pain during pregnancy, and the majority experience regression of the pain postpartum. Nevertheless, 2-3% of all women report significant symptoms 1 year after delivery. Pelvic girdle pain during pregnancy has been associated with increased planned cesarean section rates and with maternal preference for cesarean section. Some women with severe pelvic girdle pain may fear the consequences of labor pain, and therefore lack confidence in their ability to give birth vaginally. Others may fear that a vaginal delivery will cause additional harm to an already painful pelvis, and therefore be more prone to request a planned cesarean section. Whether or not mode of delivery affects the prognosis of pelvic girdle pain after delivery has been insufficiently studied, and previous studies suffer from methodological limitations such as unclear diagnostic criteria and small sample sizes. Cesarean section has been associated with an increased risk of gynecological pelvic pain and chronic pain. Hence, mode of delivery may affect the process of recovery from pelvic girdle pain.
Cesarean section may increase the risk of complications for the mother and the newborn in pregnancies with no medical or obstetrical indication, compared with vaginal delivery. In particular, the complication risk in subsequent pregnancies is increased. Also, the additional costs to society due to increased cesarean section rates may be substantial. Decisions about planned cesarean section should be based on solid evidence. Therefore, knowledge about the impact of mode of delivery on the prognosis of pelvic girdle pain is needed. Our aim was to study the association between mode of delivery and persistent pelvic girdle syndrome (PGS) (defined as pain in the anterior pelvis and in the bilateral posterior pelvis) 6 months after delivery.
Materials and Methods
Study design, study population, and follow-up
During the years 1999 through 2008, all pregnant women scheduled to give birth at 50 hospitals in Norway were targeted for recruitment into the Norwegian Mother and Child Cohort Study ( www.fhi.no/morogbarn ), conducted by the Norwegian Institute of Public Health. The women were recruited in connection with the routine ultrasound examination in pregnancy weeks 17-18. This examination is part of the public antenatal care program, and is offered to all pregnant women. The study had no exclusion criteria, and 38.5% of all eligible women who gave birth in Norway agreed to participate. The current study is based on quality-assured data files released for research in 2010. The Norwegian Mother and Child Cohort Study is described in detail elsewhere.
Data were obtained through 3 self-administered questionnaires, which were sent and returned by mail. The first questionnaire, which was completed during the second trimester (mean, 17.2 weeks; SD, 2.2 weeks), included questions about sociodemographic factors, general health, and reproductive history. The women completed the second and third questionnaires during the third trimester (mean, 30.5 weeks; SD, 1.4 weeks) and at 6 months after delivery (mean, 28.0 weeks; SD, 3.0 weeks), respectively. These questionnaires included questions about maternal health status during pregnancy and after delivery. Information regarding mode of delivery was obtained by linkage to the Medical Birth Registry of Norway, which contains information about all births in Norway after pregnancy week 16 through compulsory notification.
The response rate was 91.6% at pregnancy week 30 and 90.5% 6 months after delivery. A total of 71,992 women with singleton deliveries completed all 3 questionnaires and had available information from the Medical Birth Registry of Norway. We included the 14.6% (10,491/71,992) who reported PGS at pregnancy week 30 and excluded the 91 women lacking information about type of cesarean section (planned vs emergency), leaving 10,400 women in our study sample. The women lost to follow-up after delivery reported somewhat more severe PGS at pregnancy week 30, but did not differ with respect to mode of delivery compared to the women constituting our study sample.
Study factors
The location of pelvic girdle pain was classified on the basis of answers to the following questions at 30 weeks of pregnancy and at 6 months after delivery: “Do you have pain in the pelvic girdle?” and “If you have pain in the pelvic girdle, where is the pain located?” One or more locations could be specified: the frontal part of the pelvis, one side of the rear part of the pelvis, and both sides of the rear part of the pelvis. Pain intensity was scored as mild or severe at each location. PGS was defined as combined anterior pelvic pain and bilateral posterior pelvic pain. PGS was subdivided according to reported pain intensity; the presence of severe pain in all 3 locations was designated as severe PGS. Functional disability during pregnancy week 30 was addressed by the following question: “Do you use crutches because of pelvic girdle pain?”
Information about mode of delivery was obtained from the Medical Birth Registry of Norway and coded: unassisted vaginal delivery (reference), instrumental vaginal delivery (vacuum- or forceps-assisted delivery), emergency cesarean section, and planned cesarean section. Planned cesarean deliveries included cesarean deliveries with or without medical indication that were planned >8 hours before delivery. Emergency cesarean deliveries included all other cesarean deliveries.
In the multivariate statistical models, we included factors associated with mode of delivery, as well as body mass index (BMI) and emotional distress, which have previously been associated with PGS after delivery. Information about obstetric complications, birthweight, parity, and maternal age was obtained from the Medical Birth Registry of Norway. Obstetric complications (coded as present or not) included preeclampsia, eclampsia, HELLP syndrome (hemolytic anemia, elevated liver enzymes, and low platelet count), gestational diabetes, placenta previa, placental abruption, preterm delivery (<37 gestational weeks), and breech presentation. Birthweight was coded as <3000 g, 3000-4449 g, and ≥4500 g. Parity was dichotomized (para 0 and para ≥1), and maternal age was coded as <25 years, 25-34 years, and ≥35 years.
Educational level, as obtained from the Norwegian Mother and Child Cohort Study, was coded as ≤12 years, 13-16 years, ≥17 years, and missing. BMI in pregnancy week 17 was calculated as weight/height 2 (kilograms per square meter) and coded as <25, 25-29, ≥30, and missing. Emotional distress during pregnancy was measured using a short version of the Hopkins Symptom Checklist-25, namely the Symptom Checklist-5, in pregnancy weeks 17 and 30. We defined a mean score ≥2.0 as the presence of emotional distress. In our data analyses, the presence of emotional distress in pregnancy was coded as follows: no emotional distress (at either time point), emotional distress at 1 time point (in pregnancy week 17 or in week 30), emotional distress at both time points in pregnancy, and missing. Information about other pain conditions (coded as present or not) included low back pain before the first pregnancy, rheumatic diseases, fibromyalgia, migraine, and endometriosis. Maternal preference for a cesarean section was based on the question “If I could choose, I would have a cesarean section” in pregnancy week 30; the answers were coded as yes (agree completely, agree, and agree somewhat) and no (disagree somewhat, disagree, and disagree completely).
Statistical methods
Mode of delivery and maternal preference for cesarean section according to functional disability (use of crutches) in pregnancy week 30 are presented as proportions (%). Group differences were examined by χ 2 tests. The associations of mode of delivery with the presence of PGS and severe PGS 6 months after delivery were estimated as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) using logistic regression analyses. Both PGS and severe PGS were used as the dependent variable. We studied the associations in all 10,400 women, and we also performed separate analyses according to functional disability in pregnancy week 30. A 5% significance level was chosen for the analyses. The statistical software package Predictive Analytics Software version 17.0 was used for the statistical analyses (SPSS Inc., Chicago, IL).
Ethical considerations
The Norwegian Mother and Child Cohort Study was approved by all Regional Committees for Medical Research Ethics in Norway and by the Norwegian Data Inspectorate. All participants signed an informed consent form.
Results
In this follow-up study of women reporting PGS in pregnancy (14.6% of all women), the mean maternal age was 30.1 years (SD, 4.5 years; range, 14–46 years) at delivery and 30.6% were first-time mothers ( Table 1 ). One of 4 women (25.1%) used crutches in pregnancy week 30. The proportion of women with preference for a cesarean section was 35% higher in women with PGS during pregnancy than in women without PGS (11.9% vs 8.8%, P < .001) and remained stable during the study period (1999 through 2008). Six months after delivery, 9.3% (972/10,400) reported PGS and 1.3% (140/10,400) reported severe PGS. Women with persistent PGS after delivery had higher BMI at inclusion in pregnancy week 17 and reported higher levels of emotional distress during pregnancy than women who did not report PGS.
| Characteristics | No. (%) | Mean (SD) |
|---|---|---|
| Maternal age, y | 30.1 (4.5) | |
| Body mass index in pregnancy wk 17, a kg/m 2 | 26.1 (4.6) | |
| Parity | ||
| Para 0 | 3187 (30.6) | |
| Para ≥1 | 7213 (69.4) | |
| Mode of delivery | ||
| Unassisted vaginal delivery | 8307 (79.9) | |
| Instrumental vaginal delivery | 695 (6.7) | |
| Emergency cesarean section | 753 (7.2) | |
| Planned cesarean section | 645 (6.2) |
A total of 79.9% of the women had unassisted vaginal deliveries, 6.7% had instrumental vaginal deliveries, 7.2% had emergency cesarean sections, and 6.2% had planned cesarean sections ( Table 1 ). The proportion of women who had a planned cesarean section was higher among women using crutches in pregnancy week 30 than among women not using crutches ( P < .001) ( Table 2 ). Accordingly, the proportion of women who reported preference for cesarean section was higher among women using crutches than among women not using crutches ( P < .001).
| Variable | No use of crutches | Use of crutches | P value | ||
|---|---|---|---|---|---|
| n | % | n | % | ||
| Mode of delivery | |||||
| Unassisted vaginal delivery | 6256 | 80.4 | 2051 | 78.4 | < .001 |
| Instrumental vaginal delivery | 547 | 7.0 | 148 | 5.7 | |
| Emergency cesarean section | 543 | 7.0 | 210 | 8.0 | |
| Planned cesarean section | 439 | 5.6 | 206 | 7.9 | |
| Preference for cesarean section | |||||
| No | 6775 | 87.0 | 2190 | 83.7 | < .001 |
| Yes | 875 | 11.2 | 363 | 13.9 | |
| Missing | 135 | 1.7 | 62 | 2.4 | |
The prevalence of PGS 6 months after delivery was 9.1% in women who had unassisted vaginal delivery and 11.4% in women who had instrumental vaginal delivery (crude OR, 1.3; 95% CI, 1.0–1.6) ( Table 3 ). The association remained after adjustment for obstetric complications, other pain conditions, birthweight, emotional distress, BMI, parity, maternal age, educational level, and use of crutches. Neither planned cesarean section nor emergency cesarean section was associated with increased prevalence of PGS. However, planned cesarean section was associated with severe PGS; 3.1% of women who underwent planned cesarean section reported severe PGS compared to 1.1% of women who had unassisted vaginal delivery (crude OR, 2.8; 95% CI, 1.7–4.6) ( Table 3 ). The association remained after adjustment for the other study factors (adjusted OR, 2.3; 95% CI, 1.4–3.9). Instrumental vaginal delivery and emergency cesarean section were also associated with increased prevalence of severe PGS, although not significantly. Obstetric complications and birthweight were not associated with persistence of PGS or with severe PGS 6 months after delivery. In addition, nonrecovery could not be explained by maternal age, parity, or educational level.
| Variables | No. persons | Pelvic girdle syndrome | Severe pelvic girdle syndrome | ||||||
|---|---|---|---|---|---|---|---|---|---|
| No. cases (%) | Crude OR (95% CI) | Adjusted OR a (95% CI) | Adjusted OR b (95% CI) | No. cases (%) | Crude OR (95% CI) | Adjusted OR a (95% CI) | Adjusted OR b (95% CI) | ||
| Mode of delivery | |||||||||
| Unassisted vaginal delivery | 8307 | 755 (9.1) | 1.0 | 1.0 | 1.0 | 94 (1.1) | 1.0 | 1.0 | 1.0 |
| Instrumental vaginal delivery | 695 | 79 (11.4) | 1.3 (1.0–1.6) c | 1.3 (1.0–1.7) c | 1.4 (1.1–1.8) c | 11 (1.6) | 1.4 (0.7–2.6) | 1.3 (0.7–2.4) | 1.3 (0.7–2.5) |
| Emergency cesarean section | 753 | 67 (8.9) | 1.0 (0.8–1.3) | 0.9 (0.7–1.2) | 0.8 (0.6–1.1) | 15 (2.0) | 1.8 (1.0–3.1) c | 1.6 (0.9–2.8) | 1.5 (0.8–2.6) |
| Planned cesarean section | 645 | 71 (11.0) | 1.2 (1.0–1.6) | 1.1 (0.8–1.4) | 1.0 (0.8–1.3) | 20 (3.1) | 2.8 (1.7–4.6) d | 2.6 (1.6–4.3) d | 2.3 (1.4–3.9) e |
| Obstetric complications | |||||||||
| No | 8990 | 841 (9.4) | 1.0 | 1.0 | 1.0 | 121 (1.3) | 1.0 | 1.0 | 1.0 |
| Yes | 1410 | 131 (9.3) | 1.0 (0.8–1.2) | 0.9 (0.7–1.1) | 0.9 (0.7–1.1) | 19 (1.3) | 1.0 (0.6–1.6) | 0.7 (0.4–1.2) | 0.8 (0.4–1.3) |
| Other pain conditions | |||||||||
| No | 6284 | 466 (7.4) | 1.0 | 1.0 | 1.0 | 67 (1.1) | 1.0 | 1.0 | 1.0 |
| Yes | 4116 | 506 (12.3) | 1.8 (1.5–2.0) d | 1.7 (1.5–1.9) d | 1.6 (1.4–1.8) d | 73 (1.8) | 1.7 (1.2–2.3) d | 1.5 (1.1–2.1) d | 1.3 (0.9–1.9) |
| Birthweight, g | |||||||||
| <3000 | 911 | 89 (9.8) | 1.1 (0.8–1.3) | 1.1 (0.9–1.4) | 1.1 (0.9–1.5) | 12 (1.3) | 1.0 (0.5–1.7) | 1.0 (0.5–1.8) | 1.0 (0.5–1.9) |
| 3000-4499 | 8842 | 826 (9.3) | 1.0 | 1.0 | 1.0 | 122 (1.4) | 1.0 | 1.0 | 1.0 |
| ≥4500 | 647 | 57 (647) | 0.9 (0.7–1.2) | 0.9 (0.7–1.2) | 0.9 (0.6–1.2) | 6 (0.9) | 0.7 (0.3–1.5) | 0.6 (0.3–1.4) | 0.6 (0.3–1.4) |
| Emotional distress | |||||||||
| No | 8653 | 756 (8.7) | 1.0 | 1.0 | 1.0 | 98 (1.1) | 1.0 | 1.0 | 1.0 |
| Yes, at 1 time point | 1059 | 128 (12.1) | 1.4 (1.2–1.8) d | 1.4 (1.1–1.7) e | 1.3 (1.0–1.6) c | 24 (2.3) | 2.0 (1.3–3.2) e | 1.8 (1.2–2.9) c | 1.6 (1.0–2.6) c |
| Yes, at 2 time points | 484 | 72 (14.9) | 1.8 (1.4–2.4) d | 1.7 (1.3–2.3) d | 1.6 (1.2–2.1) e | 15 (3.1) | 2.8 (1.6–4.8) d | 2.4 (1.4–4.2) d | 2.0 (1.1–3.5) c |
| Missing | 204 | 16 (7.8) | 0.9 (0.5–1.5) | 0.8 (0.5–1.4) | 0.8 (0.5–1.3) | 3 (1.5) | 1.3 (0.4–4.1) | 1.2 (0.4–4.0) | 1.2 (0.4–3.7) |
| Use of crutches wk 30 | |||||||||
| No | 7785 | 451 (5.8) | 1.0 | 1.0 | 43 (0.6) | 1.0 | 1.0 | ||
| Yes | 2615 | 521 (19.9) | 4.0 (3.5–4.6) d | 3.8 (3.3–4.4) d | 97 (3.7) | 6.9 (4.8–10.0) d | 6.4 (4.4–9.3) d | ||
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